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How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)
Open accessAbstract
Objectives: To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction. Design: Systematic review of CPGs (PROSPERO number: CRD42017020407). Data sources: Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018. Eligibility criteria: English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations. Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction. Results: Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was ‘applicability’ (can clinicians implement this in practice?) (29%) and the highest ‘scope and purpose’ (78%) and ‘clarity of presentation’ (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing. Conclusion: The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.
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“Patellofemoral joint stress steadily increases from partial to medium depth squatting (0° to 90°).42”
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Ardern, C. L., Büttner, F., Andrade, R., Weir, A., Ashe, M. C., Holden, S., Impellizzeri, F. M., Delahunt, E., Dijkstra, H. P., Mathieson, S., et al. (2022) · British Journal of Sports Medicine · doi:10.1136/bjsports-2021-103987 · Cited by 458
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“19 However, previous clinical practice guidelines 14 and the recent systematic review 19 fail to provide clinically relevant information required for daily practice, including advice for exercise initiation, eccentric training, plyometrics training, cross-education.”
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“12 However, a systematic review focusing on ACL rehabilitation in clinical practice guidelines found conflicting recommendations and poor applicability—indicating barriers for clinicians to implement recommendations into practice.”
Influential
Metadata
- Authors
- Andrade, R., Pereira, R., van Cingel, R., Staal, J. B., & Espregueira-Mendes, J.
- Affiliations
- Universidade do Porto (PT)
- Fernando Pessoa University (PT)
- HAN University of Applied Sciences (NL)
- Corresponding author
- Andrade, Renato
- Venue
- British Journal of Sports Medicine
- Publisher
- BMJ
- Published
- 2019-06-07
- Volume
- 54
- Issue
- 9
- Pages
- 512-519
- ISSN
- 0306-3674 (ISSN-L)
- 1473-0480
- OpenAlex
- W2948803383
- Cited by
- 264
- References
- 59
- Citations by year
- 2026: 32 · 2025: 64 · 2024: 43 · 2023: 45 · 2022: 36 · 2021: 30 · 2020: 12 · 2019: 2
- FWCI
- 4.12
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- British Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
- Keywords
- anterior cruciate ligament reconstruction, postoperative rehabilitation, guideline quality assessment, AGREE II, resistance training, neuromuscular training, closed kinetic chain exercises, open kinetic chain exercises, cryotherapy, neuromuscular electrical stimulation, continuous passive motion, functional bracing, weight-bearing exercise
- MeSH terms
- Anterior Cruciate Ligament Injuries, Early Ambulation, Electric Stimulation Therapy, Exercise Therapy, Humans, Range of Motion, Articular, Practice Guidelines as Topic, Cryotherapy, Resistance Training, Anterior Cruciate Ligament Reconstruction
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