How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)

Abstract

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.

Keywords: ACL; anterior cruciate ligament; clinical practice guidelines; evidence-based; physiotherapy; postoperative; rehabilitation.