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Abstract
Objective To systematically review and summarise the evidence for the effects of neuromuscular training compared with any other therapy (conventional training/sham) on knee proprioception following anterior cruciate ligament (ACL) injury.
Design Systematic Review.
Data sources PubMed, CINAHL, SPORTDiscus, AMED, Scopus and Physical Education Index were searched from inception to February 2020.
Eligibility criteria Randomised controlled trials (RCTs) and controlled clinical trials investigating the effects of neuromuscular training on knee-specific proprioception tests following a unilateral ACL injury were included.
Data extraction and synthesis Two reviewers independently screened and extracted data and assessed risk of bias of the eligible studies using the Cochrane risk of bias 2 tool. Overall certainty in evidence was determined using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool.
Results Of 2706 articles retrieved, only 9 RCTs, comprising 327 individuals with an ACL reconstruction (ACLR), met the inclusion criteria. Neuromuscular training interventions varied across studies: whole body vibration therapy, Nintendo-Wii-Fit training, balance training, sport-specific exercises, backward walking, etc. Outcome measures included joint position sense (JPS; n=7), thresholds to detect passive motion (TTDPM; n=3) or quadriceps force control (QFC; n=1). Overall, between-group mean differences indicated inconsistent findings with an increase or decrease of errors associated with JPS by ≤2°, TTDPM by ≤1.5° and QFC by ≤6 Nm in the ACLR knee following neuromuscular training. Owing to serious concerns with three or more GRADE domains (risk of bias, inconsistency, indirectness or imprecision associated with the findings) for each outcome of interest across studies, the certainty of evidence was very low.
Conclusions The heterogeneity of interventions, methodological limitations, inconsistency of effects (on JPS/TTDPM/QFC) preclude recommendation of one optimal neuromuscular training intervention for improving proprioception following ACL injury in clinical practice. There is a need for methodologically robust RCTs with homogenous populations with ACL injury (managed conservatively or with reconstruction), novel/well-designed neuromuscular training and valid proprioception assessments, which also seem to be lacking.
PROSPERO registration number CRD42018107349.
- knee
- orthopaedic sports trauma
- rehabilitation medicine
- sports medicine
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Supplementary materials
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Footnotes
Contributors AA and CKH conceived the idea of the project. AA, MB, SM and CKH were responsible for designing the review and conceptualising the initial review protocol. AA led the writing of the manuscript. MB, SM and CKH contributed to writing the manuscript. AA, MB and CKH have reviewed and revised the manuscript for intellectual content. All authors approved the final version of the manuscript. AA is the guarantor of this work.
Funding The work was supported by the Swedish Research Council (2017–00892); Region Västerbotten (ALF 7003575; Strategic funding VLL-358901; Project. No. 7002795); the Swedish Research Council for Sports Science (CIF P2019 0068) and King Gustaf V and Queen Victoria’s Foundation of Freemasons 2019 (Häger).
Disclaimer The funders were not involved in the conception, design, execution and writing of the review.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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