Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial
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Limited evidence suggests that cross-education affords clinical benefits in the initial 8 weeks after anterior cruciate ligament (ACL) reconstruction, but it is unknown if such cross-education effects are reproducible and still present in later phases of rehabilitation. We examined whether cross-education, as an adjuvant to standard therapy, would accelerate the rehabilitation up to 26 weeks after ACL reconstruction by attenuating quadriceps weakness.
ACL-reconstructed patients were randomized into experimental (n = 22) and control groups (n = 21). Both groups received standard care after ACL reconstruction. In addition, the experimental group strength trained the quadriceps of the non-operated leg during weeks 1–12 after surgery (i.e., cross-education). Self-reported knee function was assessed with the Hughston Clinic Knee score as the primary outcome. Secondary outcomes were maximal quadriceps and hamstring strength and single leg hop distance. All outcomes were measured 29 ± 23 days prior to surgery, as a reference, and at 5-week, 12-week, and 26-week post-surgery.
Both groups scored 12% worse on self-reported knee function 5-week post-surgery (95% CI 7–17) and showed 15% improvement 26-week post-surgery (95% CI − 20 to − 10). No cross-education effect was found. Interestingly, males scored 8–10% worse than females at each time point post-surgery. None of 33 secondary outcomes showed a cross-education effect. At 26-week post-surgery, both legs improved maximal quadriceps (5–14%) and hamstring strength (7–18%), and the non-injured leg improved 2% in hop distance. The ACL recovery was not affected by limb dominance and age.
26 weeks of standard care improved self-reported knee function and maximal leg strength relative to pre-surgery and adding cross-education did not further accelerate ACL recovery.
Level of evidence
Clinical Trial Registry name and registration
This randomized controlled clinical trial is registered at the Dutch trial register (http://www.trialregister.nl) under NTR4395.
KeywordsAnterior cruciate ligament reconstruction Hughston Clinic Knee score Limb symmetry index Maximal voluntary force Resistance training
The authors thank BSc. A. Doornbos, BSc. A. Elsinghorst, BSc. K. Koorenhof, and BSc. L. Winkelhorst for their assistance with the data collection, MSc. E. Nieman and MSc. I. Brookman for performing the pilot study, Dr. R. Stewart for his assistance with the statistical analysis, and Medisch Centrum Zuid-Flytta for providing the research facilities.
This work was supported by start-up fund 653013 from the University Medical Center Groningen, Groningen, The Netherlands.
Compliance with ethical standards
Conflict of interest
The authors report that no conflicts of interest have occurred that are associated with the current study.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- 21.Mohtadi NG, Chan DS, Dainty KN, Whelan DB (2011) Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev 9:CD005960Google Scholar
- 27.Papandreou MG, Billis EV, Antonogiannakis EM, Papaioannou NA (2009) Effect of cross exercise on quadriceps acceleration reaction time and subjective scores (Lysholm questionnaire) following anterior cruciate ligament reconstruction. J Orthop Surg Res 4:2 (799X-4-2) CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Rabash J, Steele F, Brown W, Goldstein H (2009) A user’s guide to MLwiN, v. 2.10, 3rd edn. Center for Multilevel Modelling, University of Bristol, BristolGoogle Scholar
- 34.Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49Google Scholar
- 37.Undheim MB, Cosgrave C, King E, Strike S, Marshall B, Falvey E, Franklyn-Miller A (2015) Isokinetic muscle strength and readiness to return to sport following anterior cruciate ligament reconstruction: is there an association? A systematic review and a protocol recommendation. Br J Sports Med 49:1305–1310CrossRefPubMedGoogle Scholar
- 38.van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W, Nijhuis-van der Sanden MW (2016) Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med 50:1506–1515CrossRefPubMedGoogle Scholar
- 41.Welling W, Benjaminse A, Seil R, Lemmink K, Zaffagnini S, Gokeler A (2018) Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-4916-4 Google Scholar
- 42.Zult T, Gokeler A, van Raay JJ, Brouwer RW, Zijdewind I, Hortobagyi T (2017) An anterior cruciate ligament injury does not affect the neuromuscular function of the non-injured leg except for dynamic balance and voluntary quadriceps activation. Knee Surg Sports Traumatol Arthrosc 25:172–183CrossRefPubMedGoogle Scholar