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Effects of Lumbar Core Stability Exercise Programme on Knee Pain, Range of Motion, and Function Post Anterior Cruciate Ligament Reconstruction
Journal of Orthopaedics, Trauma and Rehabilitation 23 (2017) 39e44
Contents lists available at ScienceDirect
Journal of Orthopaedics, Trauma and Rehabilitation Journal homepages: www.e-jotr.com & www.ejotr.org
Research Study
Effects of Lumbar Core Stability Exercise Programme on Knee Pain, Range of Motion, and Function Post Anterior Cruciate Ligament Reconstruction 腰部核心穩定性訓練方案對前十字韌帶重建手術後的膝關節疼痛,活動範 圍及功能的影響 Panchal Priyanka a, *, Bedekar Nilima a, Sancheti Parag b, Shyam Ashok b a b
Department of Musculoskeletal Physiotherapy, Sancheti Institute College of Physiotherapy, Pune, Maharashtra, India Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 March 2016 Received in revised form 19 September 2016 Accepted 10 October 2016
Purpose: To study the additional effects of lumbar core stability on knee pain, range of motion and function post ACL reconstruction. Methods: An experimental comparative study was undertaken at a tertiary orthopaedic and rehabilitation centre with a total of 60 patients with ACL reconstruction, randomly allotted into two groups. Both groups were given institutional rehabilitation protocol; and additional lumbar core stability exercise programme was given to experimental group. Intervention period was 4 weeks. Pain on VAS, range of motion (ROM) and function using Modified Lysholm Scoring Scale (MLSS) and Tegner Activity Level (TAL) were the outcome measures. Results: Between group analyses of MLSS and TAL by Mann Whitney U test showed a statistically significant difference (p ¼ 0.038) and statistically non-significant difference (p ¼ 1.00), respectively. Conclusion: Institutional conventional exercise protocol is effective in reducing pain and improving the ROM post and lumbar core stability exercise programme is effective in improving function, post ACL reconstruction.
Keywords: ACL reconstruction core stability function rehabilitation
中 文 摘 要 目的: 研究額外的腰部核心穩定性訓練對前十字韌帶重建手術後的膝關節疼痛,活動範圍及功能帶來的影響。 方法: 本研究是在屬於第三層轉介中心的骨科和康復醫院進行的單盲隨機對照試驗,共有 60 例前十字韌帶重 建手術的患者,隨機分為兩組。兩組均給予平常的復康訓練,而實驗組接受額外的腰部核心穩定性訓練方案。訓 練期是 4 周。評核成果是疼痛分數 VAS,活動範圍 (ROM) ,並以修改 Lysholm 評分 (MLSS) 和 Tegner 活動水準 (TAL) 來側定的功能。 結果: 由曼惠特尼U測試(Mann Whitney U test)的結果,發現兩組之間的MLSS 評分有統計學上的明顯差異 (p ¼ 0.038)。TAL 則沒有統計學上的明顯差異 (p ¼ 1.00)。 結論: 在前十字韌帶重建手術後,平常的復康訓練有效地減輕疼痛,改善關節活動範圍。額外的腰部核心穩定性 訓練方案則有效地改善術後功能。
Introduction Knee joint injuries are common in daily life as well as in sports. Pain, instability, swelling, difficulty in climbing stairs, etc. could be
* Corresponding author. E-mail: [email protected].
the consequences of damage to anterior cruciate ligament (ACL) and related structures.1e3 Generally, arthroscopic reconstruction is performed either by hamstring tendon graft or bone patellar bone tendon graft. Postsurgical rehabilitation focuses on reducing the pain, swelling, stiffness, instability, regaining full range of motion (ROM), strength, and normal functional activities.3,4 Various rehabilitation protocols post anterior cruciate ligament reconstruction
http://dx.doi.org/10.1016/j.jotr.2016.10.003 2210-4917/Copyright © 2016, Hong Kong Orthopaedic Association and the Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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P. Panchal et al. / Journal of Orthopaedics, Trauma and Rehabilitation 23 (2017) 39e44
(ACLR) have been studied, which emphasise on open versus closed chain exercises, early versus delayed weight bearing status, use of brace post operatively, accelerated versus nonaccelerated rehabilitation, supervised versus unsupervised rehabilitation along with strength training, balance training, and criteria for return to play.5e8 “Lumbar core”, also known as the lumbo-pelvic-hip complex, comprising muscular boundaries in three-dimensional space, produces a corset-like stabilisation of the trunk and spine.9 It acts as a connecting medium and force transferor between the upper and the lower limbs.10 Therefore, stability of this core is vital for such a force transfer. Core stability and strengthening is increasingly gaining importance in the sports rehabilitation and fitness sector.11 It is not only incorporated for strengthening and optimising performance but has also gained importance in injury prevention.8,11 Core stability demonstrates a negative correlation with the incidence of ACL injury.12 To accelerate recovery, core exercises should be made an integral part of ACL rehabilitation.12 However, there are few studies stating the effect of core stability on various functional impairments, such as ROM and pain, and activity limitation following ACLR. Incorporation of lumbar core stability exercise programme to the ACL rehabilitation protocol was undertaken to know its additional effects. Methods A single-blinded (all the outcome measurements were undertaken by another research physiotherapist blinded to treatment allocation), randomised controlled trial was undertaken. Subjects with ACLR with or without medial and/or lateral partial meniscal excision and/or trephination were equally allotted to each group (Table 1) by stratified random sampling using chit method. Ethical approval was obtained from the Institutional Review Board. All subjects gave informed consent before participation. The sample size for this study was calculated using a margin of error of 0.178 on a type 1 error of 0.05 and power of 0.08.13 Participants Male or female participants, in the age range 20e40 years, who had undergone ACLR were included in the study. All the participants were operated as per the institutional surgical protocol using the 4-fold hamstring tendon auto-graft harvested from the limb to be operated. Participants with associated fracture, history of previous knee surgery and fracture, dislocation, acute infection, and other conditions like lumbar radiculopathy, neurological
Table 1 Allocation of the participants to each group based on the sex and injury/surgery Surgery
No. of participants in the rehabilitation group
Number of participants in the core stability group
ACLR ACLR þ MM excision ACLR þ LM excision ACLR þ MM trephination ACLR þ LM trephination ACLR þ LM excision þ MM excision ACLR þ LM trephination þ MM excision ACLR þ LM excision þ MM trephination
15 males; 1 female 5 males 2 males 1 male; 1 female 2 males 1 male; 1 female
15 males; 2 females 5 males 3 males e 2 males 1 male; 1 female
1 male
d
d
1 male
ACLR ¼ anterior cruciate LM ¼ lateral meniscus.
ligament
reconstruction;
MM ¼ medial
meniscus;
conditions, such as upper motor neuron lesions and previous nerve injury of lower limbs, were excluded. Outcome measures Pain, ROM, and function were the outcome measures selected for this study. Pain was measured using the visual analogue scale (VAS).14,15 ROM was measured in degrees using the mobile goniometer application named Goniometer Records.16 This application was validated for android and iPhone devices.17 In this study, an iPhone device was used to measure the ROM. Function was measured using the modified Lysholm scoring scale (MLSS) and Tegner activity level (TAL).18,19 Intervention Participants of the experimental group were assessed for lumbopelvic stability using the Stabilizer Pressure Biofeedback Unit (Chattanooga Group Inc. of DJO Global, Guildford Surrey, United Kingdom) by doing the progressive leg loading test emphasising on abdominals (Table 2).20e23 For this, the pressure biofeedback unit cuff was placed under the lumbar spine, participants were asked to obtain the neutral pelvic tilt position in modified crook lying position (operated leg straight in the long knee brace and unoperated leg bent at 40 of hip flexion and 80 of knee flexion), and the cuff was inflated to 40 mmHg.20 The participants were then asked to perform drawing in manoeuvre and hold it for 10 seconds allowing a rise of > 2 mmHg (up to 10 mmHg). The core stability level was checked thrice with a rest period of 2 minutes in between. The level of core that the participants obtained was followed as the treatment protocol for the 1st week as one set of 10 repetitions of 10 seconds hold, twice daily for 6 days a week. A weekly progression in the level of limb loading was made from 2nd through 4th week. From the 2nd week, treatment protocol was given as three sets of 10 repetitions of 10 seconds hold, twice daily for 6 days. Both the groups received the institutional conventional rehabilitation exercises (Table 3); the experimental group additionally received the lumbar core stability exercise programme (Table 2). The participants in both the groups received standard medication and rehabilitation protocol during the hospital stay. The rehabilitation protocol was thoroughly explained and demonstrated to the participants and to their family members. It was followed by all the participants of both the groups as Home Exercise Programme (HEP) after discharge. Data collection The participants' general evaluation was documented, and demographic data was collected (Table 4). Measurement of pain on VAS was noted before the treatment. Both the groups received treatment from the researcher therapist until the day of discharge. On the day of discharge, ROM was measured. After 4 weeks of intervention, pain and ROM were re-evaluated. Assessment of the function using MLSS and TAL was performed. Data analysis Data was analysed using SPSS version 20, Windows 7 OS. Within group, analysis for pain on VAS for both the groups was done using the Wilcoxon sign ranked test and for ROM for both the groups was done using paired samples t test. Between group analysis for pain on VAS was done using the ManneWhitney U test and for ROM, it was done using Independent samples t test. Between group analysis for MLSS and TAL between both the groups was done using the ManneWhitney U test.
P. Panchal et al. / Journal of Orthopaedics, Trauma and Rehabilitation 23 (2017) 39e44
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Table 2 Progressive limb loading Progressive limb loading A. Lift leg to 90 hip flexion Minimum external support Maximum external support
Level Level Level Level Level Level
1: 2: 3: 4: 5: 6:
core activation A, A, A, A,
B, or C B or C B, or C B, or C
B. Slide heel to extend knee
C. Lift straight leg to 45
Draw in and hold 10 s Opposite LE on mat; bent leg fall out Opposite LE is on table Hold opposite LE at 90 of hip flexion with UE Hold opposite LE at 90 of hip flexion (no UE assistance) Bilateral LE movement
Minimum external support LE ¼ lower extremity; UE ¼ upper extremity. Note. (Adapted from Kisner C and Colby L, pg 516)20
Table 3 Institutional conventional rehabilitation protocol 1st week (1 set of 10 repetitions, twice a day) Ankle toe movements Static quadriceps exercise Static hamstrings exercise Patellar mobilisation Knee bending with heel slides Supine hip abduction-adduction with LKB Icing 25% weight bearing walking with walker with LKB 2nd week (3 sets of 10 repetitions, twice a day) Static quadriceps exercise Static hamstrings exercise Patellar mobilisation Knee bending with heel slides Straight leg raising with LKB Side lying hip abduction Standing hamstring curl Icing 25% weight bearing walking with walker with LKB 3rd week (3 sets of 10 repetitions, twice a day) Continue 2nd week exercises Icing 50% weight bearing walking with walker with LKB 4th week (3 sets of 10 repetitions, twice a day) Continue 3rd week exercises Icing 100% weight bearing walking with walker with LKB
10 s hold 10 s hold
20 min, 2e4 times a day
Discussion
1 set of 10 repetition 20 min, 2e4 times a day
With 10 s hold 20 min, 2e4 times a day
With 10 s hold 20 min, 2e4 times a day
LKB ¼ long knee brace. Institute Protocol.
Table 4 Demographic data
Age Sex
At 4 weeks, a statistically significant improvement was noted in VAS and ROM (Table 6) in both the groups. The mean value of improvement in the total ROM of the rehabilitation group was 75.06 [95% confidence interval (CI) ¼ 81.5e68.6) and that of the core stability group was 66.4 (95% CI ¼ 73.4e59.4). There was no statistically significant difference noted in VAS, ROM, and TAL on between group analyses (Table 7). Mean difference in the total ROM between the groups was 8.67 (95% CI ¼ 0.62e18). Statistically significant result was obtained in the MLSS score on between group analyses.
Rehabilitation group mean ± SD)
Core stability group (mean ± SD)
29 ± 5.3 27 Males 3 Females
29 ± 5.5 27 Males 3 Females
Table 6 shows statistically significant improvement in pain (p ¼ 0.001 in rehabilitation group; p ¼ 0.001 in core stability group) and ROM (p ¼ 0.001 in rehabilitation group; p ¼ 0.001 in core stability group) in both the groups, respectively. Postoperatively, immediately inflammatory process starts because of the surgical incision, and there is pain and joint effusion due to the inflammatory mediators. Muscle setting exercises help to improve the local circulation, which pumps nutrition and oxygen through blood. This washes out the inflammatory metabolites and contributes to reduction in pain. Cold therapy is known to decrease postoperative pain and improve ROM after immediate application over the painful operated joint. It also has its beneficial disinhibition effects on the quadriceps muscle, resulting in improved quadriceps contraction and extension ROM post arthroscopic knee surgeries.24,25 Active-assisted heel slides in the early rehabilitation phase with the patellar mobilisation also helps improve the ROM and prevent adhesions.26 Therefore, optimal quadriceps contraction and medial-lateral and superior-inferior patellar mobility results in both improved extension and flexion ROM. Bed side sitting allows the gravity to act on the limb and passively attributes to increase ROM up to 90 . Standing hamstring curls helps in gaining the active flexion ROM. A statistically nonsignificant difference in pain and ROM between the groups (Table 7: p ¼ 0.511 and p ¼ 0.067, respectively) suggests that lumbar core stability exercise has no additional effect
Results There were no statistically significant baseline differences in clinical parameters between the groups under study as seen in Table 5. Seven participants from the rehabilitation group and eight participants from the core stability group did not follow-up. 60 participants were analysed (Figure 1). Baseline characteristics for those who completed the intervention and follow-up were calculated.
Table 5 Baseline Values Baseline Parameter
Rehabilitation Group (mean ± SD)
Core stability Group (mean ± SD)
p
Baseline Pain Baseline available total range of motion
4.67 ± 2.29 35.9 ± 16.2
4.27 ± 2.72 42.8 ± 16.9
0.478 0.108
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134 participants assessed for eligibility
57 participants excluded: 47 did not fulfil the inclusion criteria 9 declined to participate 1 was an overseas participant
Enrolment
75 participants randomized
Allocation 37 allocated to rehabilitation group 37 received allocated intervention
38 allocated to core stability group 38 received allocated intervention
Follow-Up 30 participants reassessed:
30 participants reassessed:
6 had follow-up in a different city
6 had follow-up in a different city
1 discontinued intervention due to medical illness during the study
2 discontinued intervention due to medical illness during the study
Analysis 30 participants reassessed
30 participants reassessed
30 participants analysed
30 participants analysed Figure 1. Study flow chart.
Table 6 Within group analysis of pain and ROM in both the groups Outcome measure
Group
1st reading (mean ± SD)
2nd reading (mean ± SD)
p
Pain (VAS) ROM (Total available)
Rehabilitation group Core stability group Rehabilitation group Core stability group
4.67 ± 2.29 4.27 ± 2.72 35.9 ± 16.2 42.8 ± 16.9
1.99 ± 2.23 0.94 ± 1.20 110.93 ± 17.02 109.23 ± 19.06
0.001 0.001 0.001 0.001
ROM ¼ range of motion; VAS ¼ visual analogue scale.
on the experimental group in improving the pain and ROM. Gain in the ROM in both the groups can be attributed to the conventional exercise protocol. Statistically significant difference in the MLSS score (Table 7; p ¼ 0.038) suggests that lumbar core stability exercises have brought about the change in the MLSS functional scale. MLSS in the rehabilitation group showed a poor result, whereas a fair result in the core stability group was obtained. Core stability is an important component of every gross motor activity, and postural support is a
Table 7 Between the group analysis of pain, ROM, MLSS, and TAL Outcome measures
Rehabilitation group (mean ± SD)
Core stability group (mean ± SD)
p
Improvement in pain score Improvement in the total available ROM MLSS post Rx TAL post Rx
2.68 ± 3.37 75.06 ± 17.21 62 ± 15.7 0.4 ± 0.6
3.33 ± 2.57 66.4 ± 18.68 71.5 ± 7.67 0.4 ± 0.6
0.511 0.067 0.038 0.999
MLSS ¼ modified Lysholm scoring scale; ROM ¼ range of motion; TAL ¼ Tegner activity level.
P. Panchal et al. / Journal of Orthopaedics, Trauma and Rehabilitation 23 (2017) 39e44
prerequisite for initiation of voluntary extremity movements. This was proved by electromyographic studies, demonstrating that trunk muscle activity, specifically the transversus abdominis, occurs before the prime limb mover.27,28 This implies that there is a proper force generation and distribution in the kinetic chain and that core provides proximal stability for distal mobility. Medeni et al29 compared the effects of core stabilisation exercises and conventional rehabilitation exercises in 16 weeks postoperative ACLR. They found a positive outcome in the core stabilisation exercise group in terms of single-limb postural stability compared with the conventional rehabilitation exercise group, and similar results for knee laxity, muscle strength, and functional tests were obtained. The results state that outcomes will be positive if core stability exercises are included in the rehabilitation protocol. In the present study, core stability is introduced in the early intervention and positive outcome has been noted in terms of function. Manske et al30 in a systemic review of the latest evidence regarding ACL rehabilitation, incorporated a phase-wise rehabilitation protocol starting from the immediate rehabilitation to more than 6 months postoperative rehabilitation and home-based rehabilitation as compared to the supervised therapy by physical therapist. The studies in the above systemic review suggested that home-based therapy may produce similar outcomes as clinicalbased programs. At the same time, it was stressed that ACL rehabilitation may not require the need for continuous supervision and it was counted as a safe and effective rehabilitation programme. In the current study too, the immediate postoperative rehabilitation was a supervised physiotherapy session until the patients were discharged from the hospital, post which they followed the HEP. Also, a fortnightly follow-up was maintained to monitor the function, patient education, and progression of the treatment plan. Nonsignificant result in the TAL is suggestive that the core stability exercises did not bring about a change in the activity level of the individual. But it is worth mentioning here that the immediate postoperative phase is the maximum protection phase; therefore, a reduced level of activity was noted in both the groups. Studies have shown that lower extremity injuries may diminish core stability measures and a pre-existing core deficiency may increase the risk of lower extremity injury implying a negative correlation of core stability with the incidence of ACL injury. It is suggested in the literature that identification of these deficits and appropriately addressing these individuals with intervention for diminished core stability measures may reduce the incidences of ACL injury and prepare these individuals for better functional performance.12,27 As noted in this study, lumbar core stability exercise programme showed a favourable result over conventional exercise programme post ACLR in terms of function. Therefore, the clinical implication would be the incorporation of core stability exercise programme in the rehabilitation post ACLR from the early postoperative phase itself. Conclusion In our study, we found that both the institutional rehabilitation protocol with or without additional core stability exercises helped in reduction of pain and improving ROM and the activity levels. Our study provides empirical evidence of use of core stability exercises in the rehabilitation protocol for improvement in the function. However, lumbar core stability exercise programme did not bring about any additional change in terms of pain, ROM, and TAL. The limitation of this study is that patients were given home exercise programme and advised to continue the same; however, a longterm follow-up was not within the scope of the study. This study invites scope for future research and urges the readers and
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researchers to perform similar studies to determine the effect of core stability post ACLR on various other outcome measures for correlating the pretreatment core stability level and the duration of injury, for correlating the pretreatment core stability level and occurrence of re-injury post ACLR with or without core stability training, and to perform studies with a larger sample size. Ethics approval Ethics approval was obtained from the Institutional Review Board of Sancheti Institute for Orthopedics and Rehabilitation, Pune. Reference No. IRB-SIOR/ Agenda 035/ 04. Conflicts of interest The authors have no conflicts of interest to declare. Funding/support None Acknowledgements The authors are thankful to Dr. Rachana Dhabadgav for her help with statistical analysis. References 1. Norris CM. Sports injuries diagnosis and management. 3rd ed. Oxford: Butterworth-Heinemann; 2004. 2. Cooper R, Morris H, Arendt L. Acute knee injuries. In: Buckner P, Khan K, editors. Clinical sports medicine. New Delhi: Tata McGraw-Hill publishing company Ltd; 2008. p. 461. 3. Colby L, Kisner C, Dewitt J. The knee. In: Kisner C, Colby L, editors. Therapeutic exercise foundations and techniques. New Delhi: Jaypee Brothers Medical Publishers Ltd; 2012. p. 802. 4. Biggs A, Jenkins WL, Urch SE, et al. Rehabilitation for patients following ACL reconstruction: a knee symmetry model. N Am J Sports Phys Ther 2009;4:2e12. 5. Glass R, Waddell J, Hoogenboom B. The effects of open versus closed kinetic chain exercises on patients with ACL deficient or reconstructed knees: a systematic review. N Am J Sports Phys Ther 2010;5:74e84. 6. Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 2012;94:1737e48. 7. Beynnon BD, Uh BS, Johnson RJ, et al. Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med 2005;33:347e59. 8. Hartigan EH, Axe MJ, Snyder-Mackler L. Time line for noncopers to pass returnto-sports criteria after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2010;40:141e54. 9. Huxel Bliven KC, Anderson BE. Core stability training for injury prevention. Sports Health 2013;5:514e22. 10. Akuthota V, Ferreiro A, Moore T, et al. Core stability exercise principles. Curr Sports Med Rep 2008;7:39e44. 11. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med 2006;36:189Y198 (Abstract). 12. Shi DL, Li JL, Zhai H, et al. Specialized core stability exercise: a neglected component of anterior cruciate ligament rehabilitation programs. J Back Musculoskelet Rehabil 2012;25:291e7. 13. Cochran WG. Sampling techniques. 2nd ed. New York: John Wiley and Sons, Inc; 1963. 14. Boonstra AM, Schiphorst Preuper HR, Reneman MF, et al. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res 2008;31:165e9. 15. Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983;16:87e101. 16. Bedekar N, Suryawanshi M, Rairikar S, et al. Inter and intra-rater reliability of mobile device goniometer in measuring lumbar flexion range of motion. J Back Musculoskelet Rehabil 2014;27:161e6. 17. Available from: http://www.iorg.co.in/2013/05/goniometer-records-mobileapp/ [Last cited on 19th April 2016]. 18. Rodkey W, Briggs K, Lysholm J, et al. 25 years later: reliability, validity and responsiveness of patient-administered Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee. J Bone Joint Surg Br 2010;92:505e6.
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19. Sgaglione NA, Del Pizzo W, Fox JM, et al. Critical analysis of knee ligament rating systems. Am J Sports Med 1995;23:660e7. 20. Kisner C, Thorp J. The spine: exercise and manipulation interventions. In: Kisner C, Colby L, editors. Therapeutic exercise foundations and techniques. New Delhi: Jaypee Brothers Medical Publishers Ltd; 2012. p. 516e7. 21. Gilleard WL, Brown JM. An electromyographic validation of an abdominal muscle test. Arch Phys Med Rehabil 1994;75:1002e7. 22. Hagins M, Adler K, Cash M, et al. Effects of practice on the ability to perform lumbar stabilization exercises. J Orthop Sports Phys Ther 1999;29:546e55. 23. Hubley-Kozey CL, Vezina MJ. Muscle activation during exercises to improve trunk stability in men with low back pain. Arch Phys Med Rehabil 2002;83:1100e8. 24. Shaw T, Williams MT, Chipchase LS. Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. Aust J Physiother 2005;51:9e17. 25. Dambros C, Martimbianco ALC, Polachini LO, et al. Effectiveness of cryotherapy after anterior cruciate ligament reconstruction. Acta Ortopedica Brasileira 2012;20:285e90.
26. Mariani PP, Cerullo G, Iannella G, et al. Anterior cruciate ligament lesions; Chap 16. Football traumatology. Springer. 2015. p. 151. Available from: https://books. google.co.in/books?id¼FvNUCgAAQBAJ&pg¼PA151&dq¼exerciseþdecreasesþ painþfollowingþACLþreconstruction&hl¼en&sa¼X&redir_esc¼y#v¼ onepage&q¼exercise%20decreases%20pain%20following%20ACL% 20reconstruction&f¼false [Last cited: 22 Nov 2015]. 27. Willson JD, Dougherty CP, Ireland ML, et al. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg 2005;13: 316e25. 28. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther 1997;77:132e42. € 29. Medeni OÇ, Bayramlar K, Baltacı G, et al. Core stabilization training After anterior cruciate ligament reconstruction. Orthop J Sports Med 2014;2. 2325967114S00150. 30. Manske RC, Prohaska D, Lucas B. Recent advances following anterior cruciate ligament reconstruction: rehabilitation perspectives: critical reviews in rehabilitation medicine. Curr Rev Musculoskelet Med 2012;5:59e71.
Contents lists available at ScienceDirect
Journal of Orthopaedics, Trauma and Rehabilitation Journal homepages: www.e-jotr.com & www.ejotr.org
Research Study
Effects of Lumbar Core Stability Exercise Programme on Knee Pain, Range of Motion, and Function Post Anterior Cruciate Ligament Reconstruction 腰部核心穩定性訓練方案對前十字韌帶重建手術後的膝關節疼痛,活動範 圍及功能的影響 Panchal Priyanka a, *, Bedekar Nilima a, Sancheti Parag b, Shyam Ashok b a b
Department of Musculoskeletal Physiotherapy, Sancheti Institute College of Physiotherapy, Pune, Maharashtra, India Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 March 2016 Received in revised form 19 September 2016 Accepted 10 October 2016
Purpose: To study the additional effects of lumbar core stability on knee pain, range of motion and function post ACL reconstruction. Methods: An experimental comparative study was undertaken at a tertiary orthopaedic and rehabilitation centre with a total of 60 patients with ACL reconstruction, randomly allotted into two groups. Both groups were given institutional rehabilitation protocol; and additional lumbar core stability exercise programme was given to experimental group. Intervention period was 4 weeks. Pain on VAS, range of motion (ROM) and function using Modified Lysholm Scoring Scale (MLSS) and Tegner Activity Level (TAL) were the outcome measures. Results: Between group analyses of MLSS and TAL by Mann Whitney U test showed a statistically significant difference (p ¼ 0.038) and statistically non-significant difference (p ¼ 1.00), respectively. Conclusion: Institutional conventional exercise protocol is effective in reducing pain and improving the ROM post and lumbar core stability exercise programme is effective in improving function, post ACL reconstruction.
Keywords: ACL reconstruction core stability function rehabilitation
中 文 摘 要 目的: 研究額外的腰部核心穩定性訓練對前十字韌帶重建手術後的膝關節疼痛,活動範圍及功能帶來的影響。 方法: 本研究是在屬於第三層轉介中心的骨科和康復醫院進行的單盲隨機對照試驗,共有 60 例前十字韌帶重 建手術的患者,隨機分為兩組。兩組均給予平常的復康訓練,而實驗組接受額外的腰部核心穩定性訓練方案。訓 練期是 4 周。評核成果是疼痛分數 VAS,活動範圍 (ROM) ,並以修改 Lysholm 評分 (MLSS) 和 Tegner 活動水準 (TAL) 來側定的功能。 結果: 由曼惠特尼U測試(Mann Whitney U test)的結果,發現兩組之間的MLSS 評分有統計學上的明顯差異 (p ¼ 0.038)。TAL 則沒有統計學上的明顯差異 (p ¼ 1.00)。 結論: 在前十字韌帶重建手術後,平常的復康訓練有效地減輕疼痛,改善關節活動範圍。額外的腰部核心穩定性 訓練方案則有效地改善術後功能。
Introduction Knee joint injuries are common in daily life as well as in sports. Pain, instability, swelling, difficulty in climbing stairs, etc. could be
* Corresponding author. E-mail: [email protected].
the consequences of damage to anterior cruciate ligament (ACL) and related structures.1e3 Generally, arthroscopic reconstruction is performed either by hamstring tendon graft or bone patellar bone tendon graft. Postsurgical rehabilitation focuses on reducing the pain, swelling, stiffness, instability, regaining full range of motion (ROM), strength, and normal functional activities.3,4 Various rehabilitation protocols post anterior cruciate ligament reconstruction
http://dx.doi.org/10.1016/j.jotr.2016.10.003 2210-4917/Copyright © 2016, Hong Kong Orthopaedic Association and the Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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P. Panchal et al. / Journal of Orthopaedics, Trauma and Rehabilitation 23 (2017) 39e44
(ACLR) have been studied, which emphasise on open versus closed chain exercises, early versus delayed weight bearing status, use of brace post operatively, accelerated versus nonaccelerated rehabilitation, supervised versus unsupervised rehabilitation along with strength training, balance training, and criteria for return to play.5e8 “Lumbar core”, also known as the lumbo-pelvic-hip complex, comprising muscular boundaries in three-dimensional space, produces a corset-like stabilisation of the trunk and spine.9 It acts as a connecting medium and force transferor between the upper and the lower limbs.10 Therefore, stability of this core is vital for such a force transfer. Core stability and strengthening is increasingly gaining importance in the sports rehabilitation and fitness sector.11 It is not only incorporated for strengthening and optimising performance but has also gained importance in injury prevention.8,11 Core stability demonstrates a negative correlation with the incidence of ACL injury.12 To accelerate recovery, core exercises should be made an integral part of ACL rehabilitation.12 However, there are few studies stating the effect of core stability on various functional impairments, such as ROM and pain, and activity limitation following ACLR. Incorporation of lumbar core stability exercise programme to the ACL rehabilitation protocol was undertaken to know its additional effects. Methods A single-blinded (all the outcome measurements were undertaken by another research physiotherapist blinded to treatment allocation), randomised controlled trial was undertaken. Subjects with ACLR with or without medial and/or lateral partial meniscal excision and/or trephination were equally allotted to each group (Table 1) by stratified random sampling using chit method. Ethical approval was obtained from the Institutional Review Board. All subjects gave informed consent before participation. The sample size for this study was calculated using a margin of error of 0.178 on a type 1 error of 0.05 and power of 0.08.13 Participants Male or female participants, in the age range 20e40 years, who had undergone ACLR were included in the study. All the participants were operated as per the institutional surgical protocol using the 4-fold hamstring tendon auto-graft harvested from the limb to be operated. Participants with associated fracture, history of previous knee surgery and fracture, dislocation, acute infection, and other conditions like lumbar radiculopathy, neurological
Table 1 Allocation of the participants to each group based on the sex and injury/surgery Surgery
No. of participants in the rehabilitation group
Number of participants in the core stability group
ACLR ACLR þ MM excision ACLR þ LM excision ACLR þ MM trephination ACLR þ LM trephination ACLR þ LM excision þ MM excision ACLR þ LM trephination þ MM excision ACLR þ LM excision þ MM trephination
15 males; 1 female 5 males 2 males 1 male; 1 female 2 males 1 male; 1 female
15 males; 2 females 5 males 3 males e 2 males 1 male; 1 female
1 male
d
d
1 male
ACLR ¼ anterior cruciate LM ¼ lateral meniscus.
ligament
reconstruction;
MM ¼ medial
meniscus;
conditions, such as upper motor neuron lesions and previous nerve injury of lower limbs, were excluded. Outcome measures Pain, ROM, and function were the outcome measures selected for this study. Pain was measured using the visual analogue scale (VAS).14,15 ROM was measured in degrees using the mobile goniometer application named Goniometer Records.16 This application was validated for android and iPhone devices.17 In this study, an iPhone device was used to measure the ROM. Function was measured using the modified Lysholm scoring scale (MLSS) and Tegner activity level (TAL).18,19 Intervention Participants of the experimental group were assessed for lumbopelvic stability using the Stabilizer Pressure Biofeedback Unit (Chattanooga Group Inc. of DJO Global, Guildford Surrey, United Kingdom) by doing the progressive leg loading test emphasising on abdominals (Table 2).20e23 For this, the pressure biofeedback unit cuff was placed under the lumbar spine, participants were asked to obtain the neutral pelvic tilt position in modified crook lying position (operated leg straight in the long knee brace and unoperated leg bent at 40 of hip flexion and 80 of knee flexion), and the cuff was inflated to 40 mmHg.20 The participants were then asked to perform drawing in manoeuvre and hold it for 10 seconds allowing a rise of > 2 mmHg (up to 10 mmHg). The core stability level was checked thrice with a rest period of 2 minutes in between. The level of core that the participants obtained was followed as the treatment protocol for the 1st week as one set of 10 repetitions of 10 seconds hold, twice daily for 6 days a week. A weekly progression in the level of limb loading was made from 2nd through 4th week. From the 2nd week, treatment protocol was given as three sets of 10 repetitions of 10 seconds hold, twice daily for 6 days. Both the groups received the institutional conventional rehabilitation exercises (Table 3); the experimental group additionally received the lumbar core stability exercise programme (Table 2). The participants in both the groups received standard medication and rehabilitation protocol during the hospital stay. The rehabilitation protocol was thoroughly explained and demonstrated to the participants and to their family members. It was followed by all the participants of both the groups as Home Exercise Programme (HEP) after discharge. Data collection The participants' general evaluation was documented, and demographic data was collected (Table 4). Measurement of pain on VAS was noted before the treatment. Both the groups received treatment from the researcher therapist until the day of discharge. On the day of discharge, ROM was measured. After 4 weeks of intervention, pain and ROM were re-evaluated. Assessment of the function using MLSS and TAL was performed. Data analysis Data was analysed using SPSS version 20, Windows 7 OS. Within group, analysis for pain on VAS for both the groups was done using the Wilcoxon sign ranked test and for ROM for both the groups was done using paired samples t test. Between group analysis for pain on VAS was done using the ManneWhitney U test and for ROM, it was done using Independent samples t test. Between group analysis for MLSS and TAL between both the groups was done using the ManneWhitney U test.
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Table 2 Progressive limb loading Progressive limb loading A. Lift leg to 90 hip flexion Minimum external support Maximum external support
Level Level Level Level Level Level
1: 2: 3: 4: 5: 6:
core activation A, A, A, A,
B, or C B or C B, or C B, or C
B. Slide heel to extend knee
C. Lift straight leg to 45
Draw in and hold 10 s Opposite LE on mat; bent leg fall out Opposite LE is on table Hold opposite LE at 90 of hip flexion with UE Hold opposite LE at 90 of hip flexion (no UE assistance) Bilateral LE movement
Minimum external support LE ¼ lower extremity; UE ¼ upper extremity. Note. (Adapted from Kisner C and Colby L, pg 516)20
Table 3 Institutional conventional rehabilitation protocol 1st week (1 set of 10 repetitions, twice a day) Ankle toe movements Static quadriceps exercise Static hamstrings exercise Patellar mobilisation Knee bending with heel slides Supine hip abduction-adduction with LKB Icing 25% weight bearing walking with walker with LKB 2nd week (3 sets of 10 repetitions, twice a day) Static quadriceps exercise Static hamstrings exercise Patellar mobilisation Knee bending with heel slides Straight leg raising with LKB Side lying hip abduction Standing hamstring curl Icing 25% weight bearing walking with walker with LKB 3rd week (3 sets of 10 repetitions, twice a day) Continue 2nd week exercises Icing 50% weight bearing walking with walker with LKB 4th week (3 sets of 10 repetitions, twice a day) Continue 3rd week exercises Icing 100% weight bearing walking with walker with LKB
10 s hold 10 s hold
20 min, 2e4 times a day
Discussion
1 set of 10 repetition 20 min, 2e4 times a day
With 10 s hold 20 min, 2e4 times a day
With 10 s hold 20 min, 2e4 times a day
LKB ¼ long knee brace. Institute Protocol.
Table 4 Demographic data
Age Sex
At 4 weeks, a statistically significant improvement was noted in VAS and ROM (Table 6) in both the groups. The mean value of improvement in the total ROM of the rehabilitation group was 75.06 [95% confidence interval (CI) ¼ 81.5e68.6) and that of the core stability group was 66.4 (95% CI ¼ 73.4e59.4). There was no statistically significant difference noted in VAS, ROM, and TAL on between group analyses (Table 7). Mean difference in the total ROM between the groups was 8.67 (95% CI ¼ 0.62e18). Statistically significant result was obtained in the MLSS score on between group analyses.
Rehabilitation group mean ± SD)
Core stability group (mean ± SD)
29 ± 5.3 27 Males 3 Females
29 ± 5.5 27 Males 3 Females
Table 6 shows statistically significant improvement in pain (p ¼ 0.001 in rehabilitation group; p ¼ 0.001 in core stability group) and ROM (p ¼ 0.001 in rehabilitation group; p ¼ 0.001 in core stability group) in both the groups, respectively. Postoperatively, immediately inflammatory process starts because of the surgical incision, and there is pain and joint effusion due to the inflammatory mediators. Muscle setting exercises help to improve the local circulation, which pumps nutrition and oxygen through blood. This washes out the inflammatory metabolites and contributes to reduction in pain. Cold therapy is known to decrease postoperative pain and improve ROM after immediate application over the painful operated joint. It also has its beneficial disinhibition effects on the quadriceps muscle, resulting in improved quadriceps contraction and extension ROM post arthroscopic knee surgeries.24,25 Active-assisted heel slides in the early rehabilitation phase with the patellar mobilisation also helps improve the ROM and prevent adhesions.26 Therefore, optimal quadriceps contraction and medial-lateral and superior-inferior patellar mobility results in both improved extension and flexion ROM. Bed side sitting allows the gravity to act on the limb and passively attributes to increase ROM up to 90 . Standing hamstring curls helps in gaining the active flexion ROM. A statistically nonsignificant difference in pain and ROM between the groups (Table 7: p ¼ 0.511 and p ¼ 0.067, respectively) suggests that lumbar core stability exercise has no additional effect
Results There were no statistically significant baseline differences in clinical parameters between the groups under study as seen in Table 5. Seven participants from the rehabilitation group and eight participants from the core stability group did not follow-up. 60 participants were analysed (Figure 1). Baseline characteristics for those who completed the intervention and follow-up were calculated.
Table 5 Baseline Values Baseline Parameter
Rehabilitation Group (mean ± SD)
Core stability Group (mean ± SD)
p
Baseline Pain Baseline available total range of motion
4.67 ± 2.29 35.9 ± 16.2
4.27 ± 2.72 42.8 ± 16.9
0.478 0.108
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134 participants assessed for eligibility
57 participants excluded: 47 did not fulfil the inclusion criteria 9 declined to participate 1 was an overseas participant
Enrolment
75 participants randomized
Allocation 37 allocated to rehabilitation group 37 received allocated intervention
38 allocated to core stability group 38 received allocated intervention
Follow-Up 30 participants reassessed:
30 participants reassessed:
6 had follow-up in a different city
6 had follow-up in a different city
1 discontinued intervention due to medical illness during the study
2 discontinued intervention due to medical illness during the study
Analysis 30 participants reassessed
30 participants reassessed
30 participants analysed
30 participants analysed Figure 1. Study flow chart.
Table 6 Within group analysis of pain and ROM in both the groups Outcome measure
Group
1st reading (mean ± SD)
2nd reading (mean ± SD)
p
Pain (VAS) ROM (Total available)
Rehabilitation group Core stability group Rehabilitation group Core stability group
4.67 ± 2.29 4.27 ± 2.72 35.9 ± 16.2 42.8 ± 16.9
1.99 ± 2.23 0.94 ± 1.20 110.93 ± 17.02 109.23 ± 19.06
0.001 0.001 0.001 0.001
ROM ¼ range of motion; VAS ¼ visual analogue scale.
on the experimental group in improving the pain and ROM. Gain in the ROM in both the groups can be attributed to the conventional exercise protocol. Statistically significant difference in the MLSS score (Table 7; p ¼ 0.038) suggests that lumbar core stability exercises have brought about the change in the MLSS functional scale. MLSS in the rehabilitation group showed a poor result, whereas a fair result in the core stability group was obtained. Core stability is an important component of every gross motor activity, and postural support is a
Table 7 Between the group analysis of pain, ROM, MLSS, and TAL Outcome measures
Rehabilitation group (mean ± SD)
Core stability group (mean ± SD)
p
Improvement in pain score Improvement in the total available ROM MLSS post Rx TAL post Rx
2.68 ± 3.37 75.06 ± 17.21 62 ± 15.7 0.4 ± 0.6
3.33 ± 2.57 66.4 ± 18.68 71.5 ± 7.67 0.4 ± 0.6
0.511 0.067 0.038 0.999
MLSS ¼ modified Lysholm scoring scale; ROM ¼ range of motion; TAL ¼ Tegner activity level.
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prerequisite for initiation of voluntary extremity movements. This was proved by electromyographic studies, demonstrating that trunk muscle activity, specifically the transversus abdominis, occurs before the prime limb mover.27,28 This implies that there is a proper force generation and distribution in the kinetic chain and that core provides proximal stability for distal mobility. Medeni et al29 compared the effects of core stabilisation exercises and conventional rehabilitation exercises in 16 weeks postoperative ACLR. They found a positive outcome in the core stabilisation exercise group in terms of single-limb postural stability compared with the conventional rehabilitation exercise group, and similar results for knee laxity, muscle strength, and functional tests were obtained. The results state that outcomes will be positive if core stability exercises are included in the rehabilitation protocol. In the present study, core stability is introduced in the early intervention and positive outcome has been noted in terms of function. Manske et al30 in a systemic review of the latest evidence regarding ACL rehabilitation, incorporated a phase-wise rehabilitation protocol starting from the immediate rehabilitation to more than 6 months postoperative rehabilitation and home-based rehabilitation as compared to the supervised therapy by physical therapist. The studies in the above systemic review suggested that home-based therapy may produce similar outcomes as clinicalbased programs. At the same time, it was stressed that ACL rehabilitation may not require the need for continuous supervision and it was counted as a safe and effective rehabilitation programme. In the current study too, the immediate postoperative rehabilitation was a supervised physiotherapy session until the patients were discharged from the hospital, post which they followed the HEP. Also, a fortnightly follow-up was maintained to monitor the function, patient education, and progression of the treatment plan. Nonsignificant result in the TAL is suggestive that the core stability exercises did not bring about a change in the activity level of the individual. But it is worth mentioning here that the immediate postoperative phase is the maximum protection phase; therefore, a reduced level of activity was noted in both the groups. Studies have shown that lower extremity injuries may diminish core stability measures and a pre-existing core deficiency may increase the risk of lower extremity injury implying a negative correlation of core stability with the incidence of ACL injury. It is suggested in the literature that identification of these deficits and appropriately addressing these individuals with intervention for diminished core stability measures may reduce the incidences of ACL injury and prepare these individuals for better functional performance.12,27 As noted in this study, lumbar core stability exercise programme showed a favourable result over conventional exercise programme post ACLR in terms of function. Therefore, the clinical implication would be the incorporation of core stability exercise programme in the rehabilitation post ACLR from the early postoperative phase itself. Conclusion In our study, we found that both the institutional rehabilitation protocol with or without additional core stability exercises helped in reduction of pain and improving ROM and the activity levels. Our study provides empirical evidence of use of core stability exercises in the rehabilitation protocol for improvement in the function. However, lumbar core stability exercise programme did not bring about any additional change in terms of pain, ROM, and TAL. The limitation of this study is that patients were given home exercise programme and advised to continue the same; however, a longterm follow-up was not within the scope of the study. This study invites scope for future research and urges the readers and
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researchers to perform similar studies to determine the effect of core stability post ACLR on various other outcome measures for correlating the pretreatment core stability level and the duration of injury, for correlating the pretreatment core stability level and occurrence of re-injury post ACLR with or without core stability training, and to perform studies with a larger sample size. Ethics approval Ethics approval was obtained from the Institutional Review Board of Sancheti Institute for Orthopedics and Rehabilitation, Pune. Reference No. IRB-SIOR/ Agenda 035/ 04. Conflicts of interest The authors have no conflicts of interest to declare. Funding/support None Acknowledgements The authors are thankful to Dr. Rachana Dhabadgav for her help with statistical analysis. References 1. Norris CM. Sports injuries diagnosis and management. 3rd ed. Oxford: Butterworth-Heinemann; 2004. 2. Cooper R, Morris H, Arendt L. Acute knee injuries. In: Buckner P, Khan K, editors. Clinical sports medicine. New Delhi: Tata McGraw-Hill publishing company Ltd; 2008. p. 461. 3. Colby L, Kisner C, Dewitt J. The knee. In: Kisner C, Colby L, editors. Therapeutic exercise foundations and techniques. New Delhi: Jaypee Brothers Medical Publishers Ltd; 2012. p. 802. 4. Biggs A, Jenkins WL, Urch SE, et al. Rehabilitation for patients following ACL reconstruction: a knee symmetry model. N Am J Sports Phys Ther 2009;4:2e12. 5. Glass R, Waddell J, Hoogenboom B. The effects of open versus closed kinetic chain exercises on patients with ACL deficient or reconstructed knees: a systematic review. N Am J Sports Phys Ther 2010;5:74e84. 6. Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 2012;94:1737e48. 7. Beynnon BD, Uh BS, Johnson RJ, et al. Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med 2005;33:347e59. 8. Hartigan EH, Axe MJ, Snyder-Mackler L. Time line for noncopers to pass returnto-sports criteria after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2010;40:141e54. 9. Huxel Bliven KC, Anderson BE. Core stability training for injury prevention. Sports Health 2013;5:514e22. 10. Akuthota V, Ferreiro A, Moore T, et al. Core stability exercise principles. Curr Sports Med Rep 2008;7:39e44. 11. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med 2006;36:189Y198 (Abstract). 12. Shi DL, Li JL, Zhai H, et al. Specialized core stability exercise: a neglected component of anterior cruciate ligament rehabilitation programs. J Back Musculoskelet Rehabil 2012;25:291e7. 13. Cochran WG. Sampling techniques. 2nd ed. New York: John Wiley and Sons, Inc; 1963. 14. Boonstra AM, Schiphorst Preuper HR, Reneman MF, et al. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res 2008;31:165e9. 15. Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983;16:87e101. 16. Bedekar N, Suryawanshi M, Rairikar S, et al. Inter and intra-rater reliability of mobile device goniometer in measuring lumbar flexion range of motion. J Back Musculoskelet Rehabil 2014;27:161e6. 17. Available from: http://www.iorg.co.in/2013/05/goniometer-records-mobileapp/ [Last cited on 19th April 2016]. 18. Rodkey W, Briggs K, Lysholm J, et al. 25 years later: reliability, validity and responsiveness of patient-administered Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee. J Bone Joint Surg Br 2010;92:505e6.
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26. Mariani PP, Cerullo G, Iannella G, et al. Anterior cruciate ligament lesions; Chap 16. Football traumatology. Springer. 2015. p. 151. Available from: https://books. google.co.in/books?id¼FvNUCgAAQBAJ&pg¼PA151&dq¼exerciseþdecreasesþ painþfollowingþACLþreconstruction&hl¼en&sa¼X&redir_esc¼y#v¼ onepage&q¼exercise%20decreases%20pain%20following%20ACL% 20reconstruction&f¼false [Last cited: 22 Nov 2015]. 27. Willson JD, Dougherty CP, Ireland ML, et al. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg 2005;13: 316e25. 28. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther 1997;77:132e42. € 29. Medeni OÇ, Bayramlar K, Baltacı G, et al. Core stabilization training After anterior cruciate ligament reconstruction. Orthop J Sports Med 2014;2. 2325967114S00150. 30. Manske RC, Prohaska D, Lucas B. Recent advances following anterior cruciate ligament reconstruction: rehabilitation perspectives: critical reviews in rehabilitation medicine. Curr Rev Musculoskelet Med 2012;5:59e71.