Report of the Primary Outcomes for Gait
Mechanics in Men of the
ACL-SPORTS Trial:
Secondary Prevention With and Without Perturbation Training Does Not Restore Gait
Symmetry in Men 1 or
2 Years After ACL Reconstruction.
Mechanics in Men of the
ACL-SPORTS Trial:
Secondary Prevention With and Without Perturbation Training Does Not Restore Gait
Symmetry in Men 1 or
2 Years After ACL Reconstruction.
Capin JJ, Zarzycki R, Arundale A, Cummer
K, and Snyder-Mackler L. Clin Orthop
Relat Res. 2017. [Epub Ahead of
Print].
K, and Snyder-Mackler L. Clin Orthop
Relat Res. 2017. [Epub Ahead of
Print].
Report of the Clinical and Functional Primary Outcomes in
Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary
Prevention With and Without Perturbation Training 1 and 2 Years After ACL
Reconstruction.
Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary
Prevention With and Without Perturbation Training 1 and 2 Years After ACL
Reconstruction.
Arundale A,
Cummer K,
Capin JJ, Zarzycki R, and Snyder-Mackler L. Clin Orthop Relat Res. 2017. [Epub Ahead of Print].
Cummer K,
Capin JJ, Zarzycki R, and Snyder-Mackler L. Clin Orthop Relat Res. 2017. [Epub Ahead of Print].
Take Home Message: There is no benefit of adding perturbation training to the ACL-SPORTS training program between 3 to 9 months following an ACL reconstruction.
Knee function often
improves over 2 years after an anterior cruciate ligament (ACL) injury;
however, athletes are usually discharged from rehabilitation and returned to
play before then. Clinicians need rehabilitation protocols that help athletes
improve after completing a traditional rehabilitation protocol, when they
return to play. Therefore, Capin and Arundale present 2 articles describing a
randomized trial intended to identify the effectiveness of adding perturbation training
to the Anterior Cruciate Ligament Post-Operative Return-to-Sport (ACL-SPORTS) training program.
The authors conducted a single-blind randomized clinical trial that included 40
male athletes with isolated, unilateral ACL tears (15-54 years old, 27
autographs, 13 allografts). All participants completed a post-operative ACL
rehabilitation protocol and were 3 to 9 months post-ACL reconstruction. During
the study, participants attended treatment sessions 2 times per week for a
total of 10 sessions. Following treatment, Arundale and colleagues assessed lower
limb symmetry during several hop tests and quadriceps strength testing at 1-
and 2-years post-surgery. A total of 36 participants (19 with perturbation, 17
non-perturbation) completed the 1- and 2-year follow up visits. Overall, participants
who completed the perturbation training failed to experience better
self-reported or functional outcomes than those who only completed the ACL-SPORTS
protocol. Capin and colleagues assessed gait mechanics and found gait
asymmetries (involved vs. uninvolved limb) in both treatment groups. They found
no differences between treatment groups. Overall, both studies indicate that adding
perturbation training to the ACL-SPORTS program fails to improve either
clinical outcomes or gait patterns compared to ACL-SPORTS training alone.
improves over 2 years after an anterior cruciate ligament (ACL) injury;
however, athletes are usually discharged from rehabilitation and returned to
play before then. Clinicians need rehabilitation protocols that help athletes
improve after completing a traditional rehabilitation protocol, when they
return to play. Therefore, Capin and Arundale present 2 articles describing a
randomized trial intended to identify the effectiveness of adding perturbation training
to the Anterior Cruciate Ligament Post-Operative Return-to-Sport (ACL-SPORTS) training program.
The authors conducted a single-blind randomized clinical trial that included 40
male athletes with isolated, unilateral ACL tears (15-54 years old, 27
autographs, 13 allografts). All participants completed a post-operative ACL
rehabilitation protocol and were 3 to 9 months post-ACL reconstruction. During
the study, participants attended treatment sessions 2 times per week for a
total of 10 sessions. Following treatment, Arundale and colleagues assessed lower
limb symmetry during several hop tests and quadriceps strength testing at 1-
and 2-years post-surgery. A total of 36 participants (19 with perturbation, 17
non-perturbation) completed the 1- and 2-year follow up visits. Overall, participants
who completed the perturbation training failed to experience better
self-reported or functional outcomes than those who only completed the ACL-SPORTS
protocol. Capin and colleagues assessed gait mechanics and found gait
asymmetries (involved vs. uninvolved limb) in both treatment groups. They found
no differences between treatment groups. Overall, both studies indicate that adding
perturbation training to the ACL-SPORTS program fails to improve either
clinical outcomes or gait patterns compared to ACL-SPORTS training alone.
Overall, both studies suggest
clinicians do not need to add perturbation training to the ACL-SPORTS protocol
3 to 9 months following an ACL reconstruction. However, some caution should be
taken when interpreting these results. Most significant is the lack of
demographic information given regarding participants of the study, especially regarding
previous activity level. Furthermore, these studies only included males even
though the study is also recruiting women. Adding these extra details and
reporting on the women and men would allow clinicians to generalize these
results to a broader patient population. Also of interest is the lack of any baseline
data. While not feasible in the current study, baseline data is something that
future research should strive for as it would help clinicians understand the
impact of the gait analysis data much better. Ideally, this baseline data would
be collected pre-injury so the results can be compared to the participant’s
natural gait. This does, however bring with it methodological restrictions. Still
it would be informative to at least know more about the gait and limb symmetry
before the start of the intervention. Until
more research can be completed to address these limitations, clinicians should
continue the use of ACL-SPORTS training program without perturbation training.
clinicians do not need to add perturbation training to the ACL-SPORTS protocol
3 to 9 months following an ACL reconstruction. However, some caution should be
taken when interpreting these results. Most significant is the lack of
demographic information given regarding participants of the study, especially regarding
previous activity level. Furthermore, these studies only included males even
though the study is also recruiting women. Adding these extra details and
reporting on the women and men would allow clinicians to generalize these
results to a broader patient population. Also of interest is the lack of any baseline
data. While not feasible in the current study, baseline data is something that
future research should strive for as it would help clinicians understand the
impact of the gait analysis data much better. Ideally, this baseline data would
be collected pre-injury so the results can be compared to the participant’s
natural gait. This does, however bring with it methodological restrictions. Still
it would be informative to at least know more about the gait and limb symmetry
before the start of the intervention. Until
more research can be completed to address these limitations, clinicians should
continue the use of ACL-SPORTS training program without perturbation training.
Questions
for Discussion: Do you agree with the overall finding that perturbation training does
not significantly improve outcomes? If not, what tell us what clinical
experience you have with perturbation training.
for Discussion: Do you agree with the overall finding that perturbation training does
not significantly improve outcomes? If not, what tell us what clinical
experience you have with perturbation training.
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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This article was successful in exploring an additional tool to use in ACLR subjects, and raised good clinical questions in how we should intervene to improve outcomes. The limitations mentioned in this summary are very important to consider, but it is also important to consider how perturbation training may affect mechanics in other tasks, such as jump landing as this is the position in which many non-contact ACL ruptures occur. Although the perturbation training did not directly translate to improved symmetry in gait, that does not mean there would not be improvements in other areas that may be clinically meaningful for ACLR patients. Additionally, it would be important to see how patient's subjective scores may have changed in terms of kinesiophobia or perceived improvements following perturbation training.
Alexandra,
Excellent point! I would keep an eye out for more publications from this group who are using the same participants and standardization with different variables. I also agree with your point that 1 method of training should never been stopped or avoided because it does not help fix 1 problem. The body of literature may suggest another very beneficial improvement that perturbation training elicits and as clinicians we should do our best to identify the need and employ the best possible treatments. What variables have you found perturbation training to be especially helpful with treating? Thanks for the comment!
Kyle