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Comparison 1 Conservative: supplementary proprioceptive training versus traditional regime, Outcome 1 Lysholm score (0 to 100; 100 being greatest function) at 12 weeks after treatment.
Figuras y tablas -
Analysis 1.1

Comparison 1 Conservative: supplementary proprioceptive training versus traditional regime, Outcome 1 Lysholm score (0 to 100; 100 being greatest function) at 12 weeks after treatment.

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 1 Knee Outcome Scores.
Figuras y tablas -
Analysis 2.1

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 1 Knee Outcome Scores.

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 2 Return to full activity at 6 month follow up.
Figuras y tablas -
Analysis 2.2

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 2 Return to full activity at 6 month follow up.

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 3 Isometric MVIC quadriceps (% group mean).
Figuras y tablas -
Analysis 2.3

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 3 Isometric MVIC quadriceps (% group mean).

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 4 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months.
Figuras y tablas -
Analysis 2.4

Comparison 2 Conservative: supplementary perturbation training versus standard regime, Outcome 4 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months.

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 1 Lysholm scores (0 to 100; 100 being greatest function).
Figuras y tablas -
Analysis 3.1

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 1 Lysholm scores (0 to 100; 100 being greatest function).

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 2 Tegner score (% change from pre‐injury level of activity) at 6 months after surgery.
Figuras y tablas -
Analysis 3.2

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 2 Tegner score (% change from pre‐injury level of activity) at 6 months after surgery.

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 3 Sickness Impact Profile at 1 year after surgery.
Figuras y tablas -
Analysis 3.3

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 3 Sickness Impact Profile at 1 year after surgery.

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 4 Muscle strength: torque ratio (% of control limb).
Figuras y tablas -
Analysis 3.4

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 4 Muscle strength: torque ratio (% of control limb).

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 5 Knee range of movement (degrees).
Figuras y tablas -
Analysis 3.5

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 5 Knee range of movement (degrees).

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 6 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months after surgery.
Figuras y tablas -
Analysis 3.6

Comparison 3 Reconstruction: home based versus supervised rehabilitation, Outcome 6 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months after surgery.

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 1 Lysholm score (0 to 100; 100 being greatest function) at 1+ year follow up.
Figuras y tablas -
Analysis 4.1

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 1 Lysholm score (0 to 100; 100 being greatest function) at 1+ year follow up.

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 2 Tegner score (0 to 10; 10 being greatest level of activity) at 1+ year follow up.
Figuras y tablas -
Analysis 4.2

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 2 Tegner score (0 to 10; 10 being greatest level of activity) at 1+ year follow up.

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 3 Hughston Clinic Functional Score (0 to 100; 100 being no disability) at 6 weeks after surgery.
Figuras y tablas -
Analysis 4.3

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 3 Hughston Clinic Functional Score (0 to 100; 100 being no disability) at 6 weeks after surgery.

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 4 Patellofemoral pain severe enough to restrict activity at 1 year.
Figuras y tablas -
Analysis 4.4

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 4 Patellofemoral pain severe enough to restrict activity at 1 year.

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 5 Knee laxity: anterior sagittal translation (mm). Between limb difference at 1+ year follow up.
Figuras y tablas -
Analysis 4.5

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 5 Knee laxity: anterior sagittal translation (mm). Between limb difference at 1+ year follow up.

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 6 Lachman test: negative at 1 year.
Figuras y tablas -
Analysis 4.6

Comparison 4 Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation, Outcome 6 Lachman test: negative at 1 year.

Comparison 5 Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation, Outcome 1 Return to pre‐injury level of sport at 31 months after sugery.
Figuras y tablas -
Analysis 5.1

Comparison 5 Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation, Outcome 1 Return to pre‐injury level of sport at 31 months after sugery.

Comparison 5 Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation, Outcome 2 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months after surgery.
Figuras y tablas -
Analysis 5.2

Comparison 5 Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation, Outcome 2 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months after surgery.

Comparison 5 Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation, Outcome 3 Isokinetic quadriceps strength (Nm) testing at 6 months after surgery.
Figuras y tablas -
Analysis 5.3

Comparison 5 Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation, Outcome 3 Isokinetic quadriceps strength (Nm) testing at 6 months after surgery.

Comparison 6 Reconstruction: land based versus water based rehabilitation, Outcome 1 Lysholm score (0 to 100; 100 being greatest function) at 8 weeks after surgery.
Figuras y tablas -
Analysis 6.1

Comparison 6 Reconstruction: land based versus water based rehabilitation, Outcome 1 Lysholm score (0 to 100; 100 being greatest function) at 8 weeks after surgery.

Comparison 6 Reconstruction: land based versus water based rehabilitation, Outcome 2 Muscle strength at 8 weeks post surgery (% of contralateral limb).
Figuras y tablas -
Analysis 6.2

Comparison 6 Reconstruction: land based versus water based rehabilitation, Outcome 2 Muscle strength at 8 weeks post surgery (% of contralateral limb).

Table 1. Details of pre‐injury sports participation and reconstruction technique

Study ID

Injury

Reconstruction

Other repair

Sports

Beard 1994

ACL rupture ‐ confirmed by arthroscopy. Acute and Chronic deficients

No

No

No details

Beard 1998

ACL ‐ chronic deficients

Arthroscopically assisted Bone‐Patella‐Bone middle 1/3 autograft

No

86% Sports injuries

Bynum 1995

ACL ‐ acute and chronic

Arthroscopically assisted Bone‐Patella‐Bone middle 1/3 autograft

No

Recreational sports participation indicated. Nature of injury not stated

Fischer 1998

ACL ‐ acute and chronic

Arthroscopically assisted Bone‐Patella‐Bone autograft (4 patients underwent allograft)

No

No collegiate/elite/professional athletes. No other details

Fitzgerald 2000

ACL ‐ within 6 months of injury

No

No

>50 hours of sports per year minimum

Hooper 2001

ACL ‐ chronic

1. Arthroscopically assisted Bone‐Patella‐Bone middle 1/3 autograft
2. Ligamentous augmentation device technique

Partial meniscectomy (n = 10)

No details

Mikkelsen 2000

ACL

Arthroscopically assisted Bone‐Patella‐Bone middle 1/3 autograft

No

All participants (with exception of 1) were athletes, but it is not stated whether the injury was as a result of the sport

Schenk 1997

ACL

Arthroscopically assisted Bone‐Patella‐Bone middle 1/3 autograft

No

No details

Tovin 1994

ACL

Arthroscopically assisted Bone‐Patella‐Bone autograft

No

No details

Figuras y tablas -
Table 1. Details of pre‐injury sports participation and reconstruction technique
Table 2. Quality assessment items and possible scores

Items & Scores

M‐A (D1b). Was the assigned treatment adequately concealed prior to allocation?
2 = method did not allow disclosure of assignment.
1 = small but possible chance of disclosure of assignment or unclear.
0 = quasi‐randomised or open list/tables.
Cochrane code: Clearly Yes = A; Not sure = B; Clearly No = C

M‐B (D8). Were the outcomes of patients/participants who withdrew described and included in the analysis (intention to treat)?
2 = withdrawals well described and accounted for in analysis.
1 = withdrawals described and analysis not possible.
0 = no mention, inadequate mention, or obvious differences and no adjustment.

M‐C (D4). Were the outcome assessors blinded to treatment status?
2 = effective action taken to blind assessors.
1 = small or moderate chance of unblinding of assessors.
0 = not mentioned or not possible.

M‐D (D2). Were the treatment and control group comparable at entry?
2 = good comparability of groups, or confounding adjusted for in analysis.
1 = confounding small; mentioned but not adjusted for.
0 = large potential for confounding, or not discussed.

M‐E (D6). Were the participants blind to assignment status after allocation?
2 = effective action taken to blind participants.
1 = small or moderate chance of unblinding of participants.
0 = not possible, or not mentioned (unless double‐blind), or possible but not done.

M‐F (D5). Were the treatment providers blind to assignment status?
2 = effective action taken to blind treatment providers.
1 = small or moderate chance of unblinding of treatment providers.
0 = not possible, or not mentioned (unless double‐blind), or possible but not done.

M‐G. Were care programmes, other than the trial options, identical? For example, training programmes, pain relief, advice on activity/mobilisation, follow‐up procedures.
2 = care programmes clearly identical.
1 = clear but trivial differences.
0 = not mentioned or clear and important differences in care programmes.

M‐H (D3). Were the inclusion and exclusion criteria clearly defined?
2 = clearly defined.
1 = inadequately defined.
0 = not defined.

M‐I. Were the interventions clearly defined?
2 = clearly defined interventions are applied with a standardised protocol.
1 = clearly defined interventions are applied but the application protocol is not standardised.
0 = intervention and/or application protocol are poorly or not defined.

M‐J. Were the outcome measures used clearly defined?
2 = clearly defined.
1 = inadequately defined.
0 = not defined.

M‐K. Were tests used in outcome assessment clinically useful?
2 = optimal.
1 = adequate.
0 = not defined, not adequate.

M‐L. Was the surveillance active, and of clinically appropriate duration (i.e. at least 12 months)?
2 = active surveillance and appropriate duration (12 months follow up or more).
1 = active surveillance, but inadequate duration (6‐12 months follow up).
0 = surveillance not active or not defined (0‐6 months).

D7. Were point estimates and measures of variability presented for the primary outcome measures?
2 = yes.
1 = point estimates, but no measures of variability presented.
0 = vague descriptions.

MAC‐1. Was the compliance rate in each group likely to cause bias?
2 = compliance well described and accounted for in analysis.
1 = compliance well described but differences between groups not accounted for in analysis.
0 = compliance unclear.

MAC‐2. Was there a description of adverse effects of the intervention(s)?
2 = well described.
1 = poorly described.
0 = not described.

Figuras y tablas -
Table 2. Quality assessment items and possible scores
Table 3. Methodological quality: conservative management

Item Code

Beard 1994

Fitzgerald 2000

M‐A

2

1

M‐B

2

1

M‐C

2

0

M‐D

2

2

M‐E

2

0

M‐F

1

0

M‐G

2

2

M‐H

2

2

M‐I

2

2

M‐J

2

2

M‐K

2

2

M‐L

0

0

D‐7

2

1

MAC‐1

1

0

MAC‐2

0

0

Figuras y tablas -
Table 3. Methodological quality: conservative management
Table 4. Methodological quality: post reconstruction management

Item code

Beard 1998

Bynum 1995

Fischer 1998

Hooper 2001

Mikkelsen 2000

Schenk 1997

Tovin 1994

M‐A

2

1

1

1

1

1

1

M‐B

2

0

0

0

0

0

0

M‐C

2

2

0

0

1

1

1

M‐D

2

2

0

2

2

0

2

M‐E

2

0

0

0

0

0

0

M‐F

0

0

0

0

0

0

0

M‐G

2

2

2

0

2

2

2

M‐H

1

1

2

2

2

1

1

M‐I

2

2

2

2

2

1

2

M‐J

2

2

2

2

2

1

2

M‐K

2

2

1

1

1

1

1

M‐L

1

2

1

0

2

1

0

D‐7

2

1

0

2

1

0

2

MAC‐1

1

0

0

0

0

0

0

MAC‐2

0

0

0

0

0

0

0

Figuras y tablas -
Table 4. Methodological quality: post reconstruction management
Comparison 1. Conservative: supplementary proprioceptive training versus traditional regime

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Lysholm score (0 to 100; 100 being greatest function) at 12 weeks after treatment Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 1. Conservative: supplementary proprioceptive training versus traditional regime
Comparison 2. Conservative: supplementary perturbation training versus standard regime

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Knee Outcome Scores Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.1 Activities of Daily Living scores (0 to 100%; 100% representing greater function): post treatment

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Activities of Daily Living scores (0 to 100%; 100% representing greater function): 6 month follow up

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 Sports Activity scores (0 to 100%; 100% representing greater level of activity): post treatment

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.4 Sports Activity scores (0 to 100%; 100% representing greater level of activity): 6 month follow up

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.5 Global Rating of Knee Function (0 to 100%; 100% representing pre‐injury function): post treatment

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.6 Global Rating of Knee Function (0 to 100%; 100% representing pre‐injury function): 6 month follow up

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Return to full activity at 6 month follow up Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Isometric MVIC quadriceps (% group mean) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.1 Post‐treatment

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Follow‐up at 6 months

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 2. Conservative: supplementary perturbation training versus standard regime
Comparison 3. Reconstruction: home based versus supervised rehabilitation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Lysholm scores (0 to 100; 100 being greatest function) Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 12 weeks post surgery

1

54

Mean Difference (IV, Fixed, 95% CI)

‐1.0 [‐5.61, 3.61]

1.2 6 months post surgery

2

80

Mean Difference (IV, Fixed, 95% CI)

1.46 [‐3.19, 6.10]

1.3 1 year post surgery

1

37

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Tegner score (% change from pre‐injury level of activity) at 6 months after surgery Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Sickness Impact Profile at 1 year after surgery Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4 Muscle strength: torque ratio (% of control limb) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.1 Quadriceps at 3 months after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.2 Quadriceps at 6 months after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.3 Hamstrings at 3 months after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.4 Hamstrings at 6 months after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5 Knee range of movement (degrees) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5.1 at 6 weeks after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.2 at 12 weeks after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.3 at 18 weeks after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.4 at 24 weeks after surgery

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

6 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months after surgery Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 3. Reconstruction: home based versus supervised rehabilitation
Comparison 4. Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Lysholm score (0 to 100; 100 being greatest function) at 1+ year follow up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Tegner score (0 to 10; 10 being greatest level of activity) at 1+ year follow up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Hughston Clinic Functional Score (0 to 100; 100 being no disability) at 6 weeks after surgery Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4 Patellofemoral pain severe enough to restrict activity at 1 year Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5 Knee laxity: anterior sagittal translation (mm). Between limb difference at 1+ year follow up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5.1 Arthrometry with 20 lbs torque

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.2 Arthrometry with max torque

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

6 Lachman test: negative at 1 year Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 4. Reconstruction: closed kinetic chain versus open kinetic chain rehabilitation
Comparison 5. Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Return to pre‐injury level of sport at 31 months after sugery Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2 Knee laxity: anterior sagittal translation (mm). Between limb difference at 6 months after surgery Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Isokinetic quadriceps strength (Nm) testing at 6 months after surgery Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.1 30º/second concentric

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 30º/second eccentric

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.3 120º/second concentric

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.4 120º/second eccentric

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.5 240º/second concentric

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.6 240º/second eccentric

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figuras y tablas -
Comparison 5. Reconstruction: closed kinetic chain versus closed and open kinetic chain rehabilitation
Comparison 6. Reconstruction: land based versus water based rehabilitation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Lysholm score (0 to 100; 100 being greatest function) at 8 weeks after surgery Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Muscle strength at 8 weeks post surgery (% of contralateral limb) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.1 Peak isokinetic torque at 90º/s: flexion

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 Peak isokinetic torque at 90º/s: extension

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.3 Peak isometric torque: flexion (knee flexed 60º)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.4 Peak isometric torque: extension (knee flexed 85º)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figuras y tablas -
Comparison 6. Reconstruction: land based versus water based rehabilitation