15438620590956197

This article was downloaded by: [200.19.190.219]On: 24 July 2014, At: 10:46Publisher: Taylor & FrancisInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

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A Systematic Review of theEffect Of Proprioceptiveand Balance Exercises onPeople With an Injured OrReconstructed AnteriorCruciate LigamentR. L. Cooper a , N. F. Taylor a & J. A. Feller aa Musculoskeletal Research Centre , La TrobeUniversity , Victoria, AustraliaPublished online: 01 Feb 2007.

To cite this article: R. L. Cooper , N. F. Taylor & J. A. Feller (2005) A SystematicReview of the Effect Of Proprioceptive and Balance Exercises on People With anInjured Or Reconstructed Anterior Cruciate Ligament, Research in Sports Medicine: AnInternational Journal, 13:2, 163-178

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Research in Sports Medicine, 13: 163–178, 2005Copyright © Taylor & Francis Inc.ISSN 1543-8627 print / 1543-8635 onlineDOI: 10.1080/15438620590956197

GSPM1543-86271543-8635Research in Sports Medicine, Vol. 13, No. 02, April 2005, pp. 0–00Research in Sports Medicine

A SYSTEMATIC REVIEW OF THE EFFECT OF PROPRIOCEPTIVE AND BALANCE EXERCISES ON PEOPLE WITH AN INJURED OR RECONSTRUCTED ANTERIOR CRUCIATE LIGAMENT

Balance Training after ACL InjuryR. L. Cooper et al. R. L. CooperN. F. TaylorJ. A. Feller

Musculoskeletal Research Centre, La Trobe University, Victoria, Australia

This systematic review investigated the effect of proprioceptive andbalance exercise on outcomes following injury and surgical reconstruc-tion of the anterior cruciate ligament (ACL). Five studies of high qualitythat offered empirical evidence by comparing one rehabilitationprogram to another were included in this review. There is some evidencethat proprioceptive and balance exercise improves outcomes in individ-uals with ACL-deficient knees. Improvements in joint position sense,muscle strength, perceived knee joint function, and hop testing werereported following proprioceptive and balance exercise. Only oneincluded study investigated proprioceptive exercise following ACLreconstruction. Benefits were noted in the proprioceptive group formeasures of strength and proprioception; however, no benefits werenoted for any measures of activity. No detrimental effects—such asincreased passive joint laxity or decrease in strength—were noted whencompared with standard rehabilitation programs for both ACL-deficientand ACL-reconstructed individuals. Further research is required todetermine if proprioceptive and balance exercise improves long-termoutcomes such as return to sport.

Keywords: rehabilitation, ACL injury, neuromuscular control, systematic review

Received 13 November 2004; accepted 8 February 2005.Address correspondence to Nicholas Taylor, Musculoskeletal Research Centre, School of

Physiotherapy, La Trobe University, Victoria 3086, Australia. E-mail: [email protected].

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164 R. L. Cooper et al.

INTRODUCTION

There is evidence that injury to the anterior cruciate ligament (ACL) maylead to proprioceptive deficits, with several studies showing decreasedknee joint proprioception in people with ACL-deficient knees (Barrack,Skinner, and Buckley 1989; Corrigan, Cashman, and Brady 1992) as wellas after ACL surgical reconstruction (Barrett 1991).

Enhancement of the neuromuscular control of the knee followingACL injury or reconstruction may lead to better outcomes in terms ofreturn to functional activities and a reduced rate of reinjury. Johansson,Sjolander, and Sojka (1991) suggested that stimulation of mechanore-ceptors in joint structures may stimulate the sensitivity of muscle spin-dles around the joint, in turn creating a state of readiness of muscles torespond to destabilizing forces applied to the joint and therebyimprove active joint stability. Although injury to the ACL will disruptlocal mechanoreceptors, compensatory activation of other knee jointmechanoreceptors may produce compensatory muscle activation,aiding joint stabilization. These compensatory neuromuscular patternsmay be developed and enhanced by utilizing treatments that incorpo-rate destabilizing activities and exercises. For these reasons, balanceand proprioceptive exercises, defined as exercises that challengestability and neuromuscular control, have been advocated in the clinicalsetting (Brukner and Khan 2001; Swanik, Lephart, Giannantonio,et al. 1997).

The primary aim of this systematic review was to investigate the effec-tiveness of proprioceptive and balance exercises on outcomes followinginjury and surgical reconstruction of the ACL compared to rehabilitationnot involving proprioceptive and balance exercises.

METHOD

Search Strategy

Electronic searches were performed in October 2003 on MEDLINE,EMBASE, CINAHL, AMED, SPORTS DISCUS, and THECOCHRANE CONTROLLED TRIALS REGISTER from the earliestavailable time using the keywords and synonyms for the terms reha-bilitation/exercise, anterior cruciate ligament, and proprioception/neuromuscular/balance. In addition, citation tracking of reference listswas completed. A supplementary electronic search was conducted onall the above databases in September 2004 to update the originalsearch.

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Balance Training after ACL Injury 165

Inclusion and Exclusion Criteria

Only studies that offered empirical evidence by comparing one rehabil-itation program to another were included. Programs that were based onopinion or a theoretical rationale only were not considered to offerhigh-level evidence of program benefit. Thus, the study types that wereincluded in the search were randomized controlled trials, quasi-randomized trials, observational comparisons, cohort studies, andhistorical comparisons. In addition, papers that were not in Englishwere excluded.

Participants included people with ACL deficiency and people followingsurgical reconstruction of the ACL over 15 years of age, as the surgicaland postoperative management of patients less than 15 years differssignificantly than that of older people. Rehabilitation programs musthave made reference to exercises or therapies given with the intention ofaiding the restoration of neuromuscular performance, balance, andproprioception.

A variety of outcome measures were included. Outcome measureswere classified using the World Health Organization’s International Clas-sification of Functioning, Disability, and Health (ICF) outcome measureframework (International Classification of Functioning, Disability andHealth 2001). The three components of the ICF are impairments of bodyfunctions and structures, activity limitation, and participation restriction.Personal and environmental contextual factors, as well as the healthcondition of pathology to the ACL, can affect a person’s functioning in aspecific component (Figure 1).

Data Extraction

A standardized data extraction form was used including details on(a) publication details, (b) the research question, (c) the study design,(d) participant details (including inclusion and exclusion criteria, recruit-ment and experimental procedures, and randomization and blinding),(e) description of interventions, (f) outcome measures, and (g) results.

Assessment of Methodological Quality

The PEDro scale (Physiotherapy Evidence Database 2003) was used toassess methodological quality, with 3 of the 11 criteria being used as ahurdle requirement for the paper to be included in the review. Thesehurdle criteria were selected as a minimal requirement to enable statisticalanalysis of treatment efficacy. The three hurdle criteria were:

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Item 8: Measures of at least one key outcome were obtained frommore than 85% of the subjects initially allocated to groups

Item 10: The results of between-group statistical comparisonswere reported for at least one key outcome

Item 11: The study provided both point measures and measures ofvariability for at least one key outcome

Harbour and Miller’s (2001) scale also was applied, with the level ofevidence graded from level 1++, indicating a randomized controlled trialwith a very low risk of bias, to level 4, indicating a finding based onexpert opinion.

Data Synthesis

A descriptive synthesis of the data was performed. Effect sizes with 95%confidence were calculated to enable comparison between the selectedstudies. Confidence intervals were calculated on Web-based software

Figure 1. Outcomes to be used described within ICF framework(adapted from ICF 2001).

IMPAIRMENT Proprioception Muscle strength Range of motion

ACTIVITY Hop tests Self-reported function

PARTICIPATION Return to sport

Personal factors Age/sex Management o ACL injury o ACL reconstruction

Environmental factors Group versus individual Exercises Program length

ACL INJURY or RECONSTRUCTION

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(Schwarzer 1989), according to the method described by Hedges andOlkin (1985). To calculate effect sizes, the paper had to report postinter-vention means and standard deviations for both groups. Effect sizes wereunable to be calculated for papers/outcome measures that did not reportthese statistics. Effect sizes were interpreted descriptively using the termsdescribed by Cohen (1988) of small (d = 0.2), medium (d = 0.5), or large(d = 0.8). A meta-analysis was not performed due to clinical and method-ological heterogeneity between the included studies.

RESULTS

The initial yield from the primary search was 1,532 papers. There were352 duplicate references, which were subsequently discarded. Another1,126 references were excluded on the basis of the title, and 48 furtherreferences were excluded on the basis of the abstract. Hard copies wereobtained for 6 references, with 1 further hard-copy reference beingobtained via citation tracking (Ihara and Nakayama 1986). In the supple-mentary search, no paper met the inclusion criteria and subsequently nofurther studies were included in the review.

Of the seven studies that met the inclusion criteria, five were random-ized clinical trials (Ageberg, Zatterstrom, Moritz, et al. 2001; Beard,Dodd, Trundle, et al. 1994; Fitzgerald, Axe, and Snyder Mackler 2000;Liu-Ambrose, Taunton, MacIntyre, et al. 2003; Zatterstrom, Friden,Lindstrand, et al. 2000), one was a retrospective analysis (Shelbourneand Davis 1999), and one a comparative trial (Ihara and Nakayama1986). Table 1 summarizes the PEDro scores and the Harbour and Miller(2001) levels of evidence of the seven studies.

Table 1. Methodological Quality of the Included Studies

Study PEDroHarbour and Miller (2001)

Ageberg et al. (2001) 3 1+Beard et al. (1994) 6 1+Fitzgerald et al. (2000) 5 1+Shelbourne and Davis (1999) 2 3Zatterstrom et al. (2000) 5 1+Ihara and Nakayama (1986) 2 2−Liu-Ambrose et al. (2003) 5 1+

Notes. Harbour and Miller’s (2001) level of evidence: 1+ RCTwith a low risk of bias; 2- case control or cohort study with a high riskof confounding bias; 3 Nonanalytic study such as case report or caseseries.

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Two studies were excluded due to low methodological quality (Iharaand Nakayama 1986; Shelbourne and Davis 1999), as hurdle requirementson the PEDro scale were not met.

Following exclusion of papers on title and abstract, citation tracking,data extraction, and assessment of methodological quality, five paperswere included in this systematic review (Ageberg et al. 2001; Beard et al.1994; Fitzgerald et al. 2000; Liu-Ambrose et al. 2003; Zatterstrom et al.2000). Table 2 summarizes the findings of the five papers. Four studiesinvestigated rehabilitation methods in people with ACL deficiency andone study investigated rehabilitation following ACL reconstruction.PEDro scores for these studies ranged from 3 to 6, with a mean of 4.8. Allfive studies fulfilled items 8, 10, and 11 on the PEDro scale, indicatingthat most subjects completed the designated rehabilitation, and that out-come measures were reported with statistical comparisons of both pointmeasures and measures of variability. All five studies were rated as level1+ evidence (Harbour and Miller 2001), indicating well-conductedrandomized clinical trials with a low risk of bias.

Environmental Factors

There was variety in the interventions, settings, and program length.Three of the included studies used group training as their mode oftreatment delivery (Ageberg et al. 2001; Beard et al. 1994; Zatterstromet al. 2000), whereas two of the included studies had the interventionadministered individually by clinicians (Fitzgerald et al. 2000; Liu-Ambroseet al. 2004). There was some variety in the intervention applied to thecomparison group. Zatterstrom et al. (2000) and Ageberg et al. (2001)compared a neuromuscular supervised training group with a self-monitored training group, whereas the other three studies compared thebalance and proprioceptive training group with supervised “traditional,”“standard,” or “strengthening” regimes (Beard et al. 1994; Fitzgeraldet al. 2000; Liu-Ambrose et al. 2004).

The specific exercises prescribed for balance and proprioceptive trainingvaried, although generally these exercises would be expected to challengebalance control. For example, Beard and associates (1994) progressedparticipants through a series of exercises such as wobble board drills,proprioceptive neuromuscular facilitation, dynamic single leg balance,ballistic hamstring catches, mini-trampoline exercise, lateral ski machinetraining, skipping, and bridging with an inflatable ball. Progression of theprogram was achieved by decreasing stability of the base and removingvisual feedback. Other included studies prescribed exercises on slopingboards with progression of angles (Ageberg et al. 2001; Zatterstrom et al.2000); multidirectional perturbation training using a motorized platform,

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169

Tab

le 2

.Su

mm

ary

of t

he I

nclu

ded

Stud

ies

Stud

ySa

mpl

e si

zeA

geA

CL

R

or A

CL

DE

xper

imen

tal

prog

ram

Com

pari

son

prog

ram

/ con

trol

Fre

quen

cy a

nd

dura

tion

Out

com

es m

easu

res

Stud

y’s

mai

n fi

ndin

g

Age

berg

et

al.

(200

1)63

EX

P

60 C

ontr

ol19

–33

AC

LD

Neu

rom

uscu

lar

supe

rvis

ed

trai

ning

Self

mon

itor

ed

trai

ning

(t

radi

tion

al

exer

cise

s)

2 P

W, 5

0-60

min

s.

Dai

ly h

ome

prog

ram

. D

urat

ion:

5-

8 m

onth

s.

1. S

tabi

lom

etry

2. O

ne le

g ho

p te

st3.

Teg

ner

acti

vity

sc

ale

One

leg

hop

test

im

prov

edw

ith

ane

urom

uscu

lar

trai

ning

pro

gram

Bea

rd e

t al.

(199

4)23

PR

OP

RIO

20

Tra

diti

onal

16–4

9A

CL

DP

ropr

ioce

ptiv

e pr

ogra

mT

radi

tion

al

exer

cise

prog

ram

2 P

W, 6

0 m

ins.

D

urat

ion:

12

wee

ks

1. H

amst

ring

la

tenc

y2.

KT

100

03.

Lys

holm

and

G

illqu

ist

scal

e

PR

OP

RIO

mor

e ef

fect

ive

in

impr

ovin

gfu

ncti

on a

nd

RH

CL

Fit

zger

ald

et a

l.(2

000)

12 P

ER

T

14 S

tand

ard

15–5

7A

CL

DP

ertu

rbat

ion

prog

ram

St

anda

rd p

rogr

am2-

3 P

W.D

urat

ion:

10

ses

sion

s1.

Kin

-Com

2.

KT

-200

0 3.

4 h

op t

ests

4.

AD

LS

5. S

AS

6. G

loba

l rat

ing

for

knee

func

tion

7.

Giv

ing

way

Per

turb

atio

n tr

aini

ng r

educ

es

the

risk

of

furt

her

givi

ng w

ayep

isod

es d

urin

g sp

ort

in A

CL

D

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170

Tab

le 2

.C

onti

nued

Stud

ySa

mpl

e si

zeA

geA

CL

R

or A

CL

DE

xper

imen

tal

prog

ram

Com

pari

son

prog

ram

/ con

trol

Fre

quen

cy a

nd

dura

tion

Out

com

es m

easu

res

Stud

y’s

mai

n fi

ndin

g

Liu

-Am

bros

e et

al.

(200

3)*

5 P

ropr

io5

Stre

ngth

18–3

8A

CL

RP

ropr

ioce

ptiv

e pr

ogra

mSt

reng

th p

rogr

am3

sess

ions

per

wee

k.

Dur

atio

n:

12 w

eeks

1. I

soki

neti

c to

rque

, 2.

Pea

k to

rque

tim

e 3.

Lys

holm

and

G

illqu

ist

Scal

e 4.

Teg

ner

and

Lys

holm

Sca

le, 5

. H

op t

ests

Bot

h gr

oups

de

mon

stra

ted

sign

ific

ant

impr

ovem

ent

over

the

12

wee

ks.T

he

prop

rioc

epti

ve

grou

p de

mon

-st

rate

d gr

eate

r pe

rcen

t cha

nge

in

isok

inet

ic

torq

ues.

Zat

ters

trom

et

al.

(200

0)53

Sup

ervi

sed

47 S

elf-

mon

itor

15–4

2A

CL

DSu

perv

ised

tr

aini

ng

(pos

tura

l ex

erci

ses

in

CK

C)

Self-

mon

itor

ed

(tra

diti

onal

ex

erci

ses)

2 P

W, 5

0-60

min

s.

Dai

ly h

ome

prog

ram

. D

urat

ion:

5-8

mon

ths.

1. J

oint

mob

ility

2.

Cyb

ex I

I 3.

Sin

gle

leg

hop

test

4.

Teg

ner

acti

vity

le

vel s

cale

5. L

ysho

lm's

kne

e sc

ore

Supe

rvis

ed

reha

bilit

atio

n in

clud

ing

post

ural

tr

aini

ng p

rodu

ces

bett

er r

esul

ts in

a

vari

ety

of

outc

omes

in

mal

e pa

tien

ts

follo

win

g A

CL

in

jury

.

Not

e. A

CL

R =

Ant

erio

r C

ruci

ate

Lig

amen

t re

cons

truc

ted;

AC

LD

= A

nter

ior

Cru

ciat

e L

igam

ent

defi

cien

cy; E

XP

= e

xper

imen

tal;

PR

OP

RIO

=pr

opri

ocep

tive

tra

inin

g pr

ogra

m; P

ER

T =

per

turb

atio

n tr

aini

ng p

rogr

am; P

W =

per

wee

k; C

KC

= c

lose

d ki

neti

c ch

ain;

RH

CL

= r

efle

x ha

mst

ring

cont

ract

ion

late

ncy;

AD

LS

= A

ctiv

ity

of D

aily

Liv

ing

Scal

e; S

AS

= S

port

s A

ctiv

ity

Scal

e. *

AC

L r

econ

stru

cted

stu

dy.

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progressing to physiotherapist-assisted tilt board and roller board pertur-bations (Fitzgerald et al. 2001); and balance, agility, and perturbationexercises (Liu-Ambrose et al. 2003).

There also was variety in program length, with the intervention rangingfrom approximately 5 weeks (Fitzgerald et al. 2000) to 10–12 weeks(Beard et al. 1994; Liu-Ambrose et al. 2004) and up to 5–8 months (Ageberget al. 2001; Zatterstrom et al. 2000).

Personal Factors

Four of the five included studies investigated people with deficiency ofthe ACL (Ageberg et al. 2001; Beard et al. 1994; Fitzgerald et al. 2000;Zatterstrom et al. 2000), and only one study investigated people afterACL reconstructive surgery with hamstring grafts (Liu-Ambrose et al.2003). All five studies included young adults in their samples, and threealso included participants aged more than 40 years (Beard et al. 1994;Fitzgerald et al. 2000; Zatterstrom et al. 2000).

Impairment of Body Functions and Structure

ProprioceptionJoint position sense was assessed by Ageberg and associates (2001),Beard and associates (1994), and Liu-Ambrose and associates (2003).Ageberg and colleagues (2001) used stabilometry to measure posturalcontrol of the knee at 6 weeks and at 3, 12, and 36 months followinginjury. One leg standing balance was assessed for 25 sec on a strain gaugeforce plate using amplitude and average speed of center of pressuremeasurements. Both the neuromuscular and standard training groupsdemonstrated improvement of postural control at the 3-year followup,with no significant difference between groups.

Beard and colleagues (1994) assessed reflex hamstring contractionlatency (RHCL) using the Vicon Interfaced Knee Displacement Equipment(VIKDE). Participants were measured for the time required for the ham-strings to react to the displacement of the VIKDE. Surface electromyo-graphy (EMG) was used to identify hamstrings activity. The differencebetween the RHCL of the uninvolved and involved limbs was then calculatedand referred to as between-limb RHCL. Both treatment groups’ RHCLwere similar at baseline. Following treatment, the proprioceptive traininggroup demonstrated a significantly greater reduction in RHCL comparedwith the traditional training group, with a large effect size of d = 0.8 (95%CI = 0.18 to 1.42).

Liu-Ambrose and colleagues (2003) used peak torque time of the ham-strings muscles as a measure of joint position sense. Peak torque time of

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the hamstrings muscles is the time lapse between the initial movement ofa KIN-COM dynamometer arm and the maximum torque by the hamstringsin a response to the movement. The proprioceptive group improved inpeak torque time (hamstring latency) more in the first 6 weeks than thestrengthening group; however, this change was not evident at 12 weeks(Figure 2).

Joint Laxity and Range of MotionPassive sagittal laxity was assessed by both Beard and associates (1994)and Fitzgerald and associates (2000) using the KT 1000 and KT 2000arthrometer, respectively. Both studies reported no additional increase inpassive sagittal laxity following rehabilitation in both the experimentaland control/traditional programs. Zatterstrom and associates (2000)assessed knee range of motion, including passive hyperextension, using astandard goniometer at 3 and 12 months following ACL injury. No differ-ence in range of motion of the involved knee was detected between thesupervised/neuromuscular group and the self-monitored group at bothevaluations.

Muscle StrengthIn the studies that investigated ACL-deficient subjects, muscle strengthwas assessed with dynamometry by Fitzgerald and colleagues (2000) andZatterstrom and colleagues (2000) using a KIN-COM and Cybex II,

Figure 2. Impairment effect size (95% CI). a = Beard reflex hamstring contraction latency; b = Liu-Ambrose proprioception at 6

weeks; c = Liu Ambrose proprioception at 12 weeks;d = Zatterstrom isometric extension 12months;e = Zatterstrom isometric extension 3 months;f = Zatterstrom isokinetic flexion 12months;g = Zatterstrom isokinetic flexion 3 months;h = Fitzgerald isometric force

-0.5 0 0.5 1 1.5 Proprioception

Beard (1994) a d = 0.8 (0.18 to 1.42)

Liu-Ambrose (2003) b d = 2.23 (0.65 to 3.81)

Liu-Ambrose (2003) c d = 0.46 (-0.80 to 1.72)

Muscle Strength

Zatterstrom (2000) d d = 0.45 (0.03 to 0.87)

Zatterstrom (2000) e d = 0.37 (-0.04 to 0.78)

Zatterstrom (2000) f d = 0.34 (-0.07 to 0.75)

Zatterstrom (2000) g d = 0.23 (-0.17 to 0.63)

Fitzgerald (2000) h d = 0.30 (-0.56 to 1.16)

Favours control Favours treatment

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respectively. Fitzgerald’s group (2000) measured maximum isometricquadriceps force output, whereas Zatterstrom’s group (2000) measuredboth isokinetic knee flexor and extensor muscle work and isometric kneeextensor and flexor muscle strength. Fitzgerald and colleagues (2000)detected no differences between groups for maximum quadriceps forceoutput. Zatterstrom and colleagues (2000) reported a significantly highervalue in isometric flexion at 3 months and a significantly higher value inisometric extension at 12 months in the neuromuscular/supervised group.Isokinetic mechanical work of repeated contractions of the knee extensorsand flexors also was significantly higher in the neuromuscular/supervisedgroup at 3 and 12 months. Liu-Ambrose and associates (2003) used aver-age isokinetic torque as a measure of strength. Both concentric and eccen-tric strengths of the quadriceps and hamstrings were assessed using aKinetic Communicator (KIN-COM) dynamometer. The proprioceptivetraining group had significantly greater percentage of increase over the12-week intervention for concentric quadriceps and eccentric hamstringwhen compared to the strength-training group. Treatment effects in favorof proprioceptive and balance training were noted for studies that investi-gated muscle strength, with small to medium effect sizes (Figure 2).Effect sizes for strength for the Zatterstrom group’s (2000) study rangedfrom d = 0.23 (95% CI = –0.17 to 0.63) for isokinetic flexion at 3 monthsto d = 0.45 (95% CI = 0.03 to 0.87) for isometric extension at 12 months.For the Fitzgerald group’s (2000) study, the effect size for isometric forcewas d = 0.30 (95% CI = –0.56 to 1.16).

Activity Limitation

All studies in this systematic review used self-reported measures ofactivity as outcome measures. Ageberg and colleagues (2001), Liu-Ambrose and colleagues (2003), and Zatterstrom and colleagues (2000)assessed perceived knee function with the Tegner Activity Scale, withall three studies finding no significant differences between groups withthis test. Liu-Ambrose and associates (2003) assessed perceived kneefunction with the Lysholm and Gillquist scale, which demonstrated nodifferences between groups. However, Zatterstrom and associates(2000) also assessed subjective knee function with the Lysholm kneescore. There was a significant difference in favor of the neuromuscular/supervised group at 3 months, but not at 12 months. Beard and associ-ates (1994) also reported a significant improvement with a propriocep-tive regimen when assessed using the Lysholm and Gillquist Scale (foreffect size, see Figure 2). Fitzgerald’s group (2000) used three separatescales: the Activity of Daily Living Scale (ADLS), the Sports ActivityScale, and the Global Knee Rating. A positive interaction in favor of the

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proprioceptive/balance training group was noted for the ADLS andglobal knee rating.

Three studies that investigated ACL-deficient subjects used the singleleg hop test as an activity outcome measure (Ageberg et al. 2001; Fitzgeraldet al. 2000; Zatterstrom et al. 2000). A significantly longer single leg hopwas demonstrated after neuromuscular training compared with standardtraining in each of the studies. Ageberg and associates (2001) reportedthat the single leg hop “normalized” in the neuromuscular group at12 months, but remained shorter in the self-monitored group for the entire3-year follow-up. Zatterstrom and colleagues (2000) reported signifi-cantly better values at the 12-month follow-up in the neuromuscular/supervised group with a grade I injury (isolated ACL injury or ACL com-bined with one associated lesion); however, no difference was notedbetween groups with grade II injuries (more than one associated lesion).Fitzgerald and associates (2000) also reported a favorable result for theperturbation group for the single leg hop, triple hop, and the cross-overhop tests, but no differences were seen for the timed hop test.

Effect sizes (Figure 3) for functional activity tests demonstrated a favorfor proprioceptive training in all studies that reported postinterventionmeans and standard deviations.

Liu-Ambrose and associates (2003) also used hop tests as a functionaltest when comparing people following ACL reconstruction. The single leg

Figure 3. Activity limitation effect size. a = Beard Lysholm score;b = Zatterstrom single leg hop test 3 months grade I injury;

c = Zatterstrom single leg hop test 3 months grade II injury;d = Zatterstrom single leg hop test12 months grade I injury;e = Zatterstrom single leg hop test 12 months grade II injury;f = Fitzgerald single hop test; g = Fitzgerald triple hop test.

-0.5 0 0.5 1 1.5 Self reported measures

Beard (1994) a d = 1.21 (0.56 to 1.86)

Functional tests

Zatterstrom (2000) b d = 0.11 (-0.5 to 0.72)

Zatterstrom (2000) c d = 0.22 (-0.34 to 0.78)

Zatterstrom (2000) d d = 0.44 (-0.15 to 1.03)

Zatterstrom (2000) e d = 0.55 (-0.04 to 1.14)

Fitzgerald (2000) f d = 0.92 (0.02 to 1.82)

Fitzgerald (2000) g d = 1.06 (0.15 to 1.97)

Favours control Favours treatment

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hop test and timed hop test were used, with no statistical difference betweengroups being evident for either test following the intervention period.

Participation Restriction

No study included in this review used participation restriction measuressuch as return to sporting activity as an outcome measure.

DISCUSSION

A theoretical rationale exists that proprioceptive and balance training mayimprove the nervous system’s ability to synchronize muscular activityaround a joint improving dynamic knee joint stability, thereby improvingoutcomes in people following injury or surgery to the ACL. The results ofthis systematic review suggest that proprioceptive and balance exercisemay improve outcomes in people with ACL deficiency, and that somemodest benefits are apparent for people who have undergone ACL recon-struction. However, it should be noted that these findings are based on alimited amount of research, with only four papers that investigated reha-bilitation for people with ACL deficiency and one paper investigatingrehabilitation following ACL reconstruction. The results are consistentwith the systematic review of evidence for ACL rehabilitation conductedby Risberg, Lewek, and Snyder-Mackler (2004), which included a briefevaluation of neuromuscular training for ACL rehabilitation based onthree of the studies included in this review (Liu-Ambrose et al. 2003;Beard et al. 1994; Fitzgerald et al. 2000).

Proprioceptive and balance exercises appear to be a safe form of reha-bilitation, with no study reporting increased passive joint laxity ordecrease in strength when compared with standard rehabilitationprograms. Two studies (Beard et al. 1994; Fitzgerald et al. 2000) reportedno additional increase in passive sagittal laxity following rehabilitation inboth the experimental and control/traditional programs. These findingssuggest that neuromuscular or strength training might place no additionalor deleterious stress on the passive restraints of the knee joint.

The results of the review also provide evidence that additionalimprovement in quadriceps and hamstring muscle strength can beobtained using proprioceptive and balance training for both ACL-deficient (Zattestrom et al. 2000) and ACL-reconstructed (Liu-Ambroseet al. 2003) individuals when compared with a standard rehabilitationprogram. That proprioceptive and balance training might improve lowerlimb strength more than a strength-based training program is an interest-ing notion and requires further investigation. This is a contrary findingsince, according to the guidelines of the American College of Sports

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Medicine (2002), proprioceptive and balance training would not beexpected to provide sufficient stimulus to increase muscle strength. Itcould be speculated that proprioceptive and balance training mightenhance neuromotor recruitment, thus enhancing muscle strength.

Following a neuromuscular training program, one might expect animprovement of joint position sense. However, the relevant results ofAgeberg and associates (2001), Liu-Ambrose and associates (2003), andBeard and associates (1994) are not convincing, with a lack of consis-tency in findings and a suggestion that any improvements may not havebeen sustained. Measurement of proprioception and joint position senseremains a controversial area, with no consensus on optimum testing. Thevariety of tests used to measure proprioception in this review mightaccount for the lack of consistency in findings.

Proprioceptive and balance training might be more relevant for peoplewith ACL deficiency rather than for people with surgically reconstructedligaments. This systematic review included studies that investigated bothpeople with ACL deficiency and people after ACL reconstruction. Theremay be differences in the rehabilitation for both populations, andalthough the outcomes and goals for both groups of patients are notdissimilar, the process of rehabilitation may differ substantially. Peoplewith ACL deficiency may rely more heavily on synchronized andcompensatory muscular activity around the knee joint to aid dynamicjoint stability compared with people following ACL reconstruction.These compensatory neuromuscular patterns, which may be developed byway of proprioceptive and balance training, may therefore be best suitedto people with ACL deficiency, whereas the people who have undergoneACL reconstruction may not need such developed neuromuscular patternsfor a dynamically stable knee.

Limited improvements in joint position sense, muscle strength,subjective rating, and hop testing have been reported following propri-oceptive and balance exercise when compared with traditionalstrengthening exercises in ACL-deficient populations (Ageberg et al.2001; Beard et al. 1994; Fitzgerald et al. 2000; Zatterstrom et al. 2000).Although the results of Liu-Ambrose and associates (2003) do notcontradict these findings when investigating people after ACL recon-struction, caution should be exercised when comparing ACL-deficiencystudies with ACL-reconstructed studies, due to the differences in theirmanagement. Future research into rehabilitation following ACL recon-struction will help answer whether ACL deficiency and ACL reconstructedrehabilitation can be compared. Further research in proprioceptivetraining following ACL reconstruction is required. Also, because theLiu-Ambrose group’s study included only participants who had beenreconstructed with a hamstring graft, further research is required

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following patellar-tendon grafts, as there may be differences in rehabilitationapproaches and outcomes.

No study included in this review used participation restriction as anoutcome measure. Many people who suffer ACL injury sustain the injuryparticipating in sports or athletic activity. Anecdotally, these people onmost occasions aim to return to sports or athletic activity following reha-bilitation. In the longer term, it is desirable that outcome measures thatassess whether people have returned to participate in their desired societalroles are incorporated into future studies. In doing so, such future studieswill be able to determine whether their management ultimately has beensuccessful.

CONCLUSION

The results of this systematic review provide some evidence that propriocep-tive and balance exercise improves outcomes in people with ACL-deficientknees. Improvements in joint position sense, muscle strength, perceivedknee joint function, and hop testing were reported following proprioceptiveand balance exercise. No detrimental effects—such as increased passivejoint laxity or decrease in strength—were noted when compared withstandard rehabilitation programs. A variety of proprioceptive and balanceexercises also were used across the ACL-deficiency studies, with no singleexercise or group of exercises being common. No study in this review usedany outcome measure addressing participation restriction.

Only one study included in this review investigated proprioceptiveexercise following ACL reconstruction. Benefits were noted in the propri-oceptive group for measures of strength and proprioception, although nobenefits were noted for any measures of activity. Further research on theeffect of proprioceptive and balance exercise, particularly followingsurgical reconstruction of the ACL, is required.

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