ࡱ> suhijklmnopqrxhqbjbjt+t+ѩ AA@a]&&&&rrr> $|j"<<R#no#$#*,,,,,,$)P]r#y###PW&&<R' jWWW#$(&<rR*&&&&#*WW[^r*RdݝK8  Lene Ims Linda Mari Borch Ann-Kristin iaas Vibeke Bergsvik Stavang General supervisor: Jan Rumpt/ Bernadette Smetsers Methodological Supervisor: David deLouw Research report Fontys University of Professional Education Department of Physiotherapy 30. May 2002 FORWORD A systematic review was made for the graduation project in the fourth academic year of the physiotherapy training program at Fontys Hogescholen in Eindhoven, June 2002. The project group consisted of Ann-Kristin iaas, Vibeke Bergsvik Stavang, Linda Mari Borch and Lene Ims. The members of the project group commissioned the project. During the ANSA-Fagseminar held in Eindhoven, 10-11th of February 2001, the commissioners first became aware of the concept of Neuromuscular Training (NMT). The lecture was held by May Arna Risberg, research leader at the centre for clinical research, Ullevl Hospital in Oslo, Norway, where the effect of neuromuscular training among post-operative ACL patients are under investigation. The commissioners found the topic interesting and decided to propose for a study to be done to gain an update on the subject. The initial plan was to make a systematic review of neuromuscular training of the ankle, but as it turned out to be little research done on NMT of the ankle, the project group changed the initial topic to concern neuromuscular training of the knee. The word neuromuscular training was new to the project group, although the training principles were familiar. With the intention to make the effects of physiotherapy treatment evidence based, it is important to make studies and research in the field of physiotherapy in order to produce clinical evidence. The project group wanted a study to be done on the results and effects of neuromuscular training and assess the articles for validity and quality. The result of this systematic review on neuromuscular training will be presented in this report. The project group would like to thank our general supervisors Jan Rumpt and Bernadette Smetsers for advice regarding the project and David de Louw, our methodological supervisor, for support during the realisation process of our report. SUMMARY The study group performed a systematic review on the effect of neuromuscular training. The investigation focused on patients suffering from ACL injury of the knee, as this is a frequent injury in the field of physiotherapy. In recent years there has been conducted research on neuromuscular training effect of the knee. The study group wanted to make an overview of existing research results on this topic. In order to retrieve the necessary information on the subject, an article search was performed. Articles dealing with the topic were found through search engines on the Internet, by contacting authors and using the reference list of found articles. The retrieved articles were either included or excluded by using criteria established by the study group. The included articles were analysed for internal validity using the Pedro scale, and used to answer the questions of this thesis project. Neuromuscular training is used in the rehabilitation of the lower extremities and includes component such as balance, dynamic joint stability, perturbation and plyometric training. The aim of this type of training is to improve the nervous systems ability to generate fast and optimal muscle firing patterns, to decrease joint force, and relearn movement patterns and skills. Research reports decreased proprioceptive sense, longer muscle response time and declined balance of the leg after an ACL injury. This can in turn result in recurrent joint subluxation and deterioration. From the article analysis one can state that neuromuscular training has a beneficial effect on conservative ACL management, and should be integrated in the rehabilitation program. However, more research is needed to establish the effect of neuromuscular training on ACL reconstructed patients. In addition further investigation on the effect of exercises in a neuromuscular training program is needed. Table of Content Chapter 1. Introduction 1. Neuromuscular Training in the Rehabilitation of Anterior Cruciate Ligament Injury 1.1 Anatomy of the Knee 1.1.1 Static Stabilisers 1.1.2 Dynamic Stabilisers 1.1.3 The Function of the Anterior Cruciate Ligament 1.1.4 Risk factors and Incident of Anterior Cruciate Ligament Injuries 1.1.5 Effect of an Anterior Cruciate Ligament Injury on neuromuscular function 1.2 Neuromuscular Control System 1.2.1 Sensory Receptors 1.2.2 Nervous System 1.3 Neuromuscular Training 1.3.1 Primary Neuromuscular Training Variables 1.4 Summary of Chapter 1.  4 6 6 7 8 9 9 10 11 12 13 14 15 162. Method 2.1 Method of Literature Search 2.2 Method of the Analysis17 17 193. Description of the Included Articles214. Results 4.1 Result of the Literature Search 4.2 Result of the Pedro Scale 4.3 Measurement tools used in the literature 4.3.1 Measurement tools on Impairment Level 4.3.2 Measurement tools on Disability Level 4.4 The Effect of NMT after Conservative ACL Treatment 4.5 The Effect of NMT after ACL- Reconstruction23 23 23 25 26 28 29 315. Discussion, Conclusion and Recommendations 5.1 Discussion 5.1.1 Discussion of Method 5.1.2 Discussion of the Pedro Analysis 5.1.3 The Effect of NMT 5.1.4 The Benefits of NMT for Athletes with ACL-Injury 5.2 Conclusion and Recommendations32 32 32 32 34 36 37References39Appendix 1. FLP 2. Pedro Scale 3. Activities of Daily Living Scale of the Knee Outcome Survey 4. Sports Activity Scale of the Knee Outcome Survey 5. ICKD 6.Data Extraction Form 7. Lysholm and Gillquist INTRODUCTION Neuromuscular training (NMT) is a type of training focusing on sensory motor integration. Although the term NMT is relatively new, the principles used are recognised at an early stage in the profession of physical therapy. The term functional instability was introduced as early as in 1965, and a reported reduced symptoms of giving way in ligamentous injuries of the foot and ankle by treatment using an unstable board10. The bony architecture of the knee provides little stability to the joint due to incongruity of the tibia and femoral condyles. The knee is dependent on the strength of muscles, ligaments and capsule for its stability. Not only mechanical aspects, but also sensory motor integration (neuromuscular control) is important for the stability. The knee joint is subject to high forces and movements during sports activities, and ligament injuries are common among athletes. Of the four major ligaments of the knee, the ACL is the most frequently injured. Research has shown a decrease in the proprioceptive sense after an ACL rupture. Due to the disturbed sensory feedback from the joint after a ligament injury, motor programs have to be relearned. Neuromuscular control is the efferent (motor) response to sensory information, which is the result of a complex interaction between the nervous system and the musculoskeletal system. Two control mechanisms are involved with interpreting afferent information and co-ordinating efferent response. Feed-forward neuromuscular control involves planning movements based on sensory information from past experiences and makes use of already learned motor programs. The feedback process, on the other hand, continuously regulate motor control according to afferent stimuli through reflex pathways. This control system is required in order to make an adequate motor response to sensory stimuli and maintain balance and dynamic joint stability. The importance of neuromuscular function required during daily living and sport activities should not be neglected. Neuromuscular control is thought to be important for the functional outcome and to be considered in the design of neuromuscular rehabilitation programs after an ACL rupture. The term Neuromuscular Training (NMT) is increasingly used to describe a particular type of training which includes balance training, dynamic joint stability training, perturbation training and plyometric training. NMT describes training programs that include some or all of these components. The basic concept behind these training methods is that repetitively challenging an individuals ability to maintain static or dynamic control of his or her knee joint results in improved neuromuscular control and subsequently, improved joint stability. In the resent years there has been performed research on the effect on neuromuscular training to investigate the outcome of such training in joint injuries. Ongoing research on this topic is among others being performed in Australia, North America, Scandinavia and southern Europe. This illustrates the international interest and development on the topic neuromuscular control and dynamic joint stability of the knee. The aim of this systematic review is to study the results and effects of neuromuscular training in order to give a review on the topic and answer the main question: What does the present literature state on the effect of Neuromuscular Training on patients suffering from ACL injury of the knee concerning the aspects of balance, dynamic joint stability, co-ordination, sports, ADL, recurrent ACL-injury and quality of life? In order to answer the main question a number of sub-questions were formulated. What does the literature state on the concept of NMT? What does literature say on the effect of NMT after a conservative ACL treatment? What does literature say on the effect of NMT after an ACL reconstruction? Can neuromuscular control compensate for mechanical instability in a patient with an ACL rupture? What does literature say about the beneficial effect of NMT on athletes with an ACL injury? Is there any literature claiming that NMT has a secondary preventative effect on recurrent ACL injury? Is there any literature claiming that NMT improves quality of life of an ACL patient? What measurement tools are used in the literature indicating neuromuscular control? The project group has made some changes in the main question and the sub questions. In the FLP format the expression ACL rupture is used. In the report this is changed to ACL injury as this is the term used in the analysed literature. The project group is of the opinion that this is a more appropriate term, as it is also covers incomplete ruptures of the ACL. The sub question regarding preventative effect is also changed. To limit the extent of the project, this sub-question had to be changed to deal with secondary prevention. This arrangement was made to avoid the need for information gathering on healthy individuals, as prevention can also include reducing the risk of ACL injury in this group. Evidence based physiotherapy is becoming increasingly important for the profession. The objectives of evidence based medicine are to ensure the quality of the treatment for the patients, providing enhancement, development, effectiveness and cost reduction. This is illustrated in the pronounce of Sackett et al (1997): Because the randomised trial, and especially the systematic review of several randomised trials is so much less likely to mislead us, it has become the golden standard for judging whether a treatment does more good than harm 11. The research on neuromuscular training on ACL-deficient knee seeks to identify clinical evidence to document for the importance of neuromuscular training in the rehabilitation for the lower extremities. The project group intends to analyse included articles in order to make a systematic review on the effect of this type of training program after an ACL injury. 1. Neuromuscular Training in the Rehabilitation of Anterior Cruciate Ligament Injuries In this section there will be given information about the knee, the ACL and the nervous system in order to better understand the importance and effect of neuromuscular training in the rehabilitation program for lower extremity following an ACL-injury. An introduction of the concept of neuromuscular training will also be provided.  1.1 Anatomy of the Knee Figure 1. Anatomy of the knee. The knee joint is the junction of three bones the femur, the tibia and the patella. The tibiofemoral is a hinge joint with two degrees of freedom; flexion, extension and axial rotation. The condyles of the femur are convex and the tibial surface is mutually concave. However, this does not make the articular surface completely congruent, which enables the two bones to move to different amounts guided by ligaments and muscles. The two bones have full congruency in full extension and is therefore most stable in this position. The patellofemoral joint is a modified plane joint. During flexion and extension different parts of the patella articulate with the femoral condyles. One of functions of the patella is to increase the efficiency of extension by holding the quadriceps away from the axis of movement12. The ends of the three bones are covered with articular cartilage. This is a tough, elastic material that helps absorb shock and allows the knee joint to move smoothly. The menisci are separating the bones of the knee. These are pads of connective tissue, which are divided into two crescent- shaped discs positioned between the tibia and the femur. The menisci serves several functions in the knee. This structure aids in lubrication and nutrition of the joint12. It also acts as a shock absorber makes the joint surfaces more congruent, reduce friction during movement and aid the ligaments and capsule in preventing hyperextension. The structures of the knee are shown fig. 1. The bony architecture of the knee does not provide a lot of stability. The knee joint is for this reason dependent on the strength and function of muscles, ligaments and capsule. The stability of the knee is of dual nature, and is influenced of both static and dynamic structures. In this project the focus lies on the aspects of dynamic stability of the knee, as it is possible to influence this mechanism by neuromuscular training. However the importance of the static support system should also be considered. 1.1.1 Static Stabilisers  Figure.2. Anatomical figure of the right knee, anterior view; Figure.3. Anatomical figure of right knee, sagittal view Showing the four major ligament of the knee joint. Showing the cruciate ligament of the knee joint. Static stabilisation of the knee is mainly provided by the ligamentous structures and to a lesser extent the joint capsule, the bony architecture and the meniscus. The essential ligaments of the knee are; Medial Collateral Ligament (MCL), Lateral Collateral Ligament (LCL), Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL). Fig. 2 and 3. The medial and lateral collateral ligaments are positioned on the sides of the knee joint. These ligaments prevent valgus and varus movements of the joint and are taut in extension. The ACL is situated in the anterior part of the joint, and prevents the tibia from sliding anteriorly on the femur. In opposition, the PCL prevents posterior translation of the tibia on the femur. Additionally both the ACL and PCL serve to reduce rotation of the femur on the tibia. The cruciate ligaments are tense in all positions, but increase their tension in the extremes of flexion and extension13. The cruciate ligaments are so intimately related to the capsule that they can be considered as actual thickenings of the capsule. The articular capsule is a fibrous sleeve, which invests the distal end of the femur and the proximal end of the tibia, keeping the two bones in contact and forms a non-bony wall of articular space14. The dorsal side of the knee capsule is reinforced by the oblique popliteal ligament and the arcuate popliteal ligament15. The oblique popliteal ligament runs from the intercondylar fossa of the femur to the head of the tibia. While the arcuate popliteal ligament rises from the lateral condyle of the femur to attach to the styloid process of the head of the tibia. These ligaments prevent hyperextension of the knee, and co-operate with the ACL to prevent the tibia of sliding forwards. 1.1.2 Dynamic Stability Dynamic support of the knee is achieved through preparatory and reflexive neuromuscular control. The primary active stabilisers of the knee are the quadriceps, hamstrings and the gastrocnemious. These periarticular muscles contribute to the defence of the knee joint by contracting in a perfectly synchronised manner. Particular movements are preconditioned by the cerebal cortex and prevent mechanical distortions of the joint. Due to this preconditioning they are indispensable for the ligaments, which can only react passively14. When the knee is not locked in extension, it has to rely more on the activity of the muscles for its stability. The quadriceps is an important muscle for the dynamic stability of the knee. The quadriceps activity prevents the flexed knee joint from giving way and is essential for maintenance of the erect posture. By its strength and precise co-ordination it is partly able to compensate for ligamentous failure. The flexor muscles however, play an active part in limiting extension. This is mostly done by the hamstrings and the gastrocnemius. The hamstring muscles are the dynamic agonists of the ACL and prevent the joint from subluxating, as it translates the tibia posteriorly. They have an important role for dynamic joint stability of the knee, as they prevent excessive strain of the ACL to occur. This quadriceps-hamstrings tension balance is necessary for knee joint stability16. They are preventing excessive movements in the joint by counteracting each other. If the change in position is threatening to the joint and likely to exceed the limits of normal movement, the muscle groups activated by this reflex system will be those capable for counteracting the applied external force. When the tibia subluxes anteriorly, the hamstrings contract. It is desirable that the limb exhibits not only sufficient force in the hamstrings (muscle power) to prevent joint subluxation but also to deploy this protective action rapidly1. The neuromuscular regulation system that modulates quadriceps-hamstrings activity is dynamic and there has been investigated whether the mechanoreceptors in the ligamentous structures influence this system. Figure 4. Sagittal view of muscles of the knee This reflexive neuromuscular link between ligaments and muscle has been demonstrated by loading passive structures of the knee as they elicit reflexive electomyographic (EMG) activity in periarticular muscle. In case of the anterior tibial translation, loading the ACL excites the hamstrings and the gastrocnemious musculature 17,18,19,20. It also appears to be an inhibitory pathway that represses quadriceps activity21,22,23. These reflex pathways contribute to dynamic stability of the joint by using the feedback process, and avoid injury to the ligament. 1.1.3 The Function of the Anterior Cruciate Ligament The ACL is one of the four ligaments that are critical to the stability of the knee joint, and has been found to influence both static and dynamic stability. The ligament is made of tough fibrous material and arises from the anterior part of the intercondylar area of the tibia, just posterior to the attachment of the medial meniscus. It extends superiorly, posteriorly and laterally to attach to the posterior part of the medial side of the lateral condyle of the femur, and thus prevents displacement of the femur on the tibia. Research indicates that the ACL also has an impact on the dynamic support system. Anatomical studies demonstrate the existence of mechanoreceptors in the human ACL. Arthroscopic procedures provide direct evidence of the presence of active proprioceptive receptors within the intact ACL of the human knee24. The presence of these receptors and calculated that the neural elements consisted 1 2,5% of the tissue in ACL25,26. Compared to other receptors found in and around the knee joint, this is a relative small amount, but nevertheless the mechanoreceptors in the ACL are thought to play an significant role in the knee stability19,27,28,29,30. The basis for these theories come from studies that have reported that reflex pathways exist between the receptors of the knee joint and the musculature of the thigh. Reflex pathways have been established through electromyography recordings of the quadriceps and hamstrings in response to electrical stimulation or mechanical load to the knee ligaments. The existence of such a reflex pathway between ACL and the hamstring provides evidence for a protective mechanism of the knee, however the degree to which this mechanism contribute to dynamic knee stability remains unclear31. There also appears to be an inhibitory pathway that represses the quadriceps activity21,22,23. Joint receptors are most active in the end range of motion, especially in extension. For this reason it is believed that the primary roles of the mechanoreceptors are to protect the joint from subluxation by facilitating protective muscle reflexes32. An increased reflex hamstring contraction latency has been found in patients with ACL deficient knees and a positive correlation between improvement in reflex hamstring contraction latency and functional gain1. There has been reported that the joint receptors in the knee influence the -motor system based on studies performed on cats. It is suggested that joint receptors contribute to joint stability by modulating the stiffness of the muscles31. The exact mechanism how the relationship is working is not yet found. A stiff muscle resists stretching episodes more effectively, have greater tone and provides a more effective dynamic restraint system to joint displacement33,34. Muscle stiffness is therefore thought to increase the knee joint stability and decrease the strain in its ligaments. 1.1.4 Risk Factors and Incidence of Anterior Cruciate Ligament Injuries The knee is the most commonly injured joint among athletes, and the ACL is frequently jeopardised during sports activity. ACL injury might result in serious damage to the knee stability. Sports presenting the greatest risk for ACL injury are cutting sports. These are sports including fast running and quick lateral movements. Examples are football, handball, skiing, basketball and soccer. The reason for this is the high frequency of jumping, running and pivoting movements with rapid deceleration of the body in a fixed foot-position occurring in these sports. Other causes can be a direct blow to the leg from the front, such as a low tackle, or a twisting injury. The major symptom of an ACL injury is a sudden loss of control of the injured joint in a weight bearing position9. When an ACL rupture is confirmed after a thorough assessment, it can either be treated conservatively or surgically. The decision whether a surgical intervention is recommended should be based on the age and activity level of the subject20. An adolescent patient is for example not considered for surgical intervention because of the skeletal immaturity. Elderly subjects are usually treated conservatively because of a lower activity level. Patients who have an active social sportive lifestyle, a physically demanding job, or who are at elite athletic level are in most cases eligible for reconstruction. Each year there are approximately 2000 ACL-injuries in Norway, which half are operated on. In Norway an ACL-injury cost the society approximately 500.000 NOK / 66.000 Euro. This includes the costs for sick leave (including absence from elite sport), operations, hospitalisation and rehabilitation. The total cost of ACL-injuries are estimated to be over one million NOK / 132 000 Euro annually35. The quality and efficiency of the rehabilitation after an ACL-injury is therefore of extended interest. The young population group in which this injury most commonly occur, has an increased risk of developing genu-arthrose35. Because of this factor, the discontinuation of sports activity and the costs for the society, there has been done research on ACL-insufficient knees. This has provided precious knowledge on knee stability and neuromuscular function. Due to the development within the field of exercise therapy, the content of exercise therapy protocols is subjected to constant evolution. Studies have evaluated the results from different rehabilitation programs in ACL-deficient patients. When comparing traditional strengthening program to neuromuscular training programs, the traditional exercise program show less improvement in knee function and stability compared to the program including proprioception and dynamic joint stability training35. This implies that neuromuscular training should become integrated into clinical practice for lower extremity. 1.1.5 Effect of an Anterior Cruciate Ligament Injury on Neuromuscular Function Disruption of the ACL does not only result in mechanical disturbance, but also in a loss of joint sensation36. This is due to the deafferentiation of peripheral sensory receptors (mechanoreceptors). The partial deafferentiation alters reflex pathways to skeletal muscle, muscle spindles and higher motor centers. Evidence indicates that changes in the muscle activity after an ACL injury is the result of disrupted reflex pathways. Therefore, ACL injury not only reduces the joints mechanical stability but it also often diminishes the capability of the dynamic restraint system, resulting in a functionally unstable knee. Wojtys and Huston (1994) claims that the mechanical stability in the knee joint is not found to correlate with the patients experience of the knee function. There are athletes with excessive anterior laxity who are functioning on a very high level of activity without evidence of instability, while there are those whose laxities are within normal parameters yet in whom symptoms of instability persist. This shows the dual nature of the knee stability: the passive restraint system, which is composed primarily of ligaments and capsule, and the dynamic system, which is composed of the neuromuscular elements. After a physical examination of the knee it is often difficult to predict which patients will be functionally impaired by the loss of the ACL and which patients will have fewer symptoms. In 1983, Noyes et al popularised the rule of thirds theory on the prognosis following an ACL injury: one-third of the patients with ACL tears can continue to participate in their desired sports at pre-injured level, one-third will be satisfied continuing at a less vigorous level after physical therapy and functional bracing, and one-third will experience instability with conservative treatment and opt for surgical intervention37. Research and clinicians aims to identify the neuromuscular control characteristics that compensate for mechanical insufficiencies in the ACL-deficient knees, so that similar adaptations can be encouraged to restore functional stability30. Several studies explain the importance of hamstring activation in the injured knee. While some studies focus on the response time of the muscle activation, others seem to care more about the protective function of muscular stiffness. According to Beard et al (1994), patients with ACL-injuries who have a fast hamstrings muscle reaction time have better knee function and experience fewer incidence of instability of the knee, when compared to patients who show a decrease in the hamstrings reflex latency. This ability to rapidly contract the hamstrings prevents anterior subluxation and deterioration of the knee joint. Research has also shown that stiffness in the musculature of the lower extremity protects the limb against injuries. This is due to the unloading of the knee structures. There has been found a positive correlation between hamstring stiffness and functional ability34. To re-establish neuromuscular control and functional stability, clinicians seek to produce adaptations in the sensitivity of peripheral receptors and facilitate afferent pathways agonist / antagonist co-activation, muscle stiffness, the onset rate and magnitude of muscle activity, reflex muscle activation and discriminatory muscle activation36. 1.2 The Neuromuscular Control System Neuromuscular control is the efferent (motor) response to sensory information, also referred to as the ability to produce controlled movement through co-ordinated muscle activity31. Neuromuscular control results from complex interaction between the nervous system and the musculoskeletal system. In a very basic model, the neuromuscular system can be divided into three components; receptors, nervous system and muscle respons31:   Figure 5. Model of the neural pathway, describing feed-forward and feedback control system The receptors transmit afferent (sensory) information to the central nervous system (CNS), which provide a motor response. A control system is required when processing afferent signals into efferent responses for dynamic joint stabilisation. This complex control strategy incorporates feed-forward and feedback mechanisms, as illustrated in figure 4. Feed-forward neuromuscular control involves planning movements based on sensory information from past experience. This requires building a program depicting the expected conditions with all of the known task parameters. This mechanism pre-activates the muscle tension in anticipation of movements and joint loads. Pre-programming of movements can occur several hundred milliseconds before the movements are initiated, while cognitive appreciation of an event may take up to 120-150 ms36. Without adequate preparatory activity, the static structures may be exposed to injury unless reactive muscle activity is initiated to contribute to dynamic restraint. Feedback is a process that uses information from joint and muscle receptors to continuously regulate ongoing muscle activity. The feed-forward mechanism is responsible for preparatory muscle activity, while feedback processes are associated with reactive muscle activity36. The level of muscle activity, whether it is preparatory or reactive, determines muscular stiffness properties. Muscular stiffness resist stretching episodes, have greater tone and provide the joint an effective dynamic restraint system to joint displacement. Feed forward and feed back neuromuscular control is based on reliable kinaesthetic and proprioceptive information. Altered peripheral afferent information may disrupt preparatory and reactive muscle activity, affecting motor control and functional stability36. 1.2.1 Sensory Receptors Sensory receptors are specialised to respond to energetic stimuli like sound, mechanical stimuli, light etc36. There are different types of receptors. Important for the neuromuscular function is the mechanoreceptors, found in the skin, muscle and joints as well as ligaments and tendons. The mechanoreceptors provide the CNS with sensory information, referred to as proprioception, the conscious and the unconscious appreciation of joint position, and kinaesthesia, the sensation of joint motion or acceleration. Mechanoreceptors in the joint are triggered by the deformation and loading of the soft tissue that compose the joint. These receptors are sensitive to pressure changes resulting from as little as 2( of change in joint position38. Four types of joint receptors have been identified in the soft tissue of the knee; Ruffini endings, Pacinian corpuscles, Golgi tendon organ-like receptors and free nerve endings31 (see table 1). The joint mechanoreceptors can be divided into two major groups; quick adapting and slow adapting mechanoreceptors. Quick adapting mechanoreceptors cease discharging shortly after the onset of the stimulus and provide conscious and unconscious kinaesthetic sensation in response joint movements. Slow adapting mechanoreceptors provide continuos feedback and proprioceptive information relative to joint position. The Pacinian corpuscles are quick adapting mechanoreceptors found in capsule, ligaments, meniscus and fat pad. They are easily activated as their activation threshold is low, and are only active when the joint is moving. Ruffini endings, Golgi tendon organ-like and free nerve endings are all slow adapting mechanoreceptors. They are found in the soft tissue of the knee. Ruffini endings are sensitive to intra articular pressure and velocity of movement. They are easily stimulated and are found in capsule and ligaments. Golgi tendon organ-like mechanoreceptors are found in ligaments and meniscus. They react to tension in the ligaments especially in the end range. Free nerve endings have a high threshold and react to noxious stimuli. They are widely distributed in meniscus, fat pad and ligaments. The activation of these mechanoreceptors provides the CNS with information regarding proprioception and kinaesthesia of the joint, provoking an adequate motor response in order to prevent injury and maintain joint stability31. Receptor typeLocationSensitive to Active when the joint isActivation thresholdResponse to persistent stimuliRuffini endingsCapsule and ligamentJoint position: Intra- articular pressure amplitude of movement velocity of movementStatic and dynamicLowSlowing adaptingPacinian corpusclesCapsule, ligament, menisci and fat padsAcceleration or decelerationDynamic onlyHighRapidly AdaptingGolgi tendon organ- likeLigament and menisciTension in ligament, especially in end range of motionDynamic onlyHighSlowly adaptingFree nerve endingsWidely distributed in capsule, ligaments and fat pads, few in menisciPain from mechanical or chemical originInactive, except in the presence of noxious stimuli; static or dynamicHighSlowly adaptingTable 1. Joint receptors in the tissue of the knee Mechanoreceptors in the muscle and tendinous structures are also important for the proprioception of the knee joint and contribute to the dynamic restraint system. Two types of mechanoreceptors have been identified. Muscle spindles are found in the skeletal muscle and detect stretch in the muscle. When muscle spindles are stimulated by length changes they elicit a reflex contraction in the agonist muscle. The Golgi tendon organ is located near the musculotendinous junction and monitor muscle tension. When stimulated by high muscle tension, the Golgi tendon organ cause reflex inhibition (relaxation) in the muscle being loaded36 and contraction of the antagonist. Muscular stiffness increases the sensitivity of these receptors, lowering the activation threshold and increasing the readiness of the muscle. 1.2.3 Nervous System The sensory signals provided by the mechanoreceptors are mediated in the nervous system. Time for the motor response to occur depends on which level of the CNS the sensory information is being delivered. The CNS can be divided into three levels according to type of motor response. The spinal level produce spinal reflexes and is characterised by gross, quick movements that require no cortical input or sensory feedback. The output is generally stereotypical and modified by the intensity of the afferent signals. Simple reflexes processed on the spinal level is the quickest neuromuscular responses. The most basic spinal reflexes occurs with latency of 30-50 ms. This generating of fast reflex responses are important for joint stabilisation and can be trained by using perturbation training/ local stimuli. The brain stem level produce semiautomatic movements (rhythmic behaviour) usually requiring supraspinal initiation and termination, but proceeds automatically in terms of neural control (e.g. walking, chewing). These motions are intermediated between reflex and voluntary activity. Motor responses mediated in the brain stem are typically referred to as long-loop reflexes and the latency of their responses are 50-80ms longer than those of segmental spinal reflexes. Because these reflexes are processed at a higher level they are more flexible than the spinal reflexes. Improving function at this level can be achieved by performing balance and postural activities. The cortical level consists of motor cortex, basal ganglia and cerebellum. Voluntary activity is affected by attention and motivation. They are learned and require practice for perfection. Once learned, complicated voluntary movements can be used to form a motor-program by which complex tasks are accomplished without thinking about each step. The latency of these responses is usually greater than 120 ms. These motor responses are highly flexible due to the complex processing occurring at this level. The highest level provides with cognitive awareness of body position and movement that are repeated and stored as central commands to be performed without continuos reference to consciousness31,36. 1.3 Neuromuscular Training The term Neuromuscular Training (NMT) is increasingly used to describe a particular type of training which includes; balance training, dynamic joint stability training, perturbation training and plyometric training. NMT describes training programs that include some or all of these components39. The objectives of NMT are to improve the nervous systems ability to generate fast and optimal muscle firing patterns, to decrease joint force, and relearn movement patterns and skills35. The exercises intend to induce compensatory changes in muscle activation patterns and facilitate dynamic joint stability. The definition of the four neuromuscular components according to Risberg and Myklebust (2001): Balance: state of body equilibrium or the ability to maintain the centre of body mass over the base of support without falling Dynamic joint stabilisation: balance exercise where the patient is to maintain body position while moving an extremity in space Perturbation training; an unexpected physical event that changes the movement or movement goal Plyometric training: a quick, powerful movement involving pre-stretching the muscle and activating the strengthening-shortening cycle to produce a subsequently stronger concentric contraction. In the past, rehabilitation programmes focused primarily on strengthening and paid little attention to the neuromuscular-proprioceptive training of the knee joint40. Risberg, Myklebust (2001) claims that although muscle atrophy of the thigh is found among chronic ACL-deficient patients, muscle strength is not reported to correlate with knee function. Several studies have evaluated the results from different types of rehabilitation programs after an ACL-injury. The results and knowledge gained from this research is important for development and improvement of rehabilitation programs, which can also be of value for rehabilitation of other injuries to the lower extremities. The basic concept behind these training methods is that repetitively challenging an individuals ability to maintain static or dynamic control of his or her knee joint results in improved neuromuscular control and subsequently, improved joint stability31. Neuromuscular training is not only thought to be important in conservative management, but also in the rehabilitation after a reconstruction. As Lephard (1996) stated: Simply restoring mechanical restraints is not enough for a functional recovery of the knee. That would neglect the importance of co-ordinated neuromuscular controlling mechanism that is required for dynamic joint stability. A lag time in the neuromuscular reaction time can result in recurrent joint subluxation and deterioration The first clinical report of the use of an unstable board in neuromuscular co-ordination exercises for the lower extremities was in 1965. They found that symptoms of giving way could be reduced in ligamentous injuries of the foot and ankle by treatment using an unstable board10. Rehabilitation programs for the lower extremities are under constant development and several studies have evaluated the effect of neuromuscular training on the outcomes of patients with ACL-deficient or ACL-reconstructed knees31. According to Snyder-Mackler (2001) there are ongoing studies on the effect on neuromuscular training to investigate the outcome of such training in joint injuries. Research is going on in Italy, Western Australia, North America and Scandinavia. These studies illustrate the international interest and development on the topic neuromuscular control and dynamic joint stability of the knee. 1.3.1 Primary Neuromuscular Training Variables  Figure 6. Single limb stands on balance board There are several different training variables that comprise the essence of neuromuscular training of the knee. The exercises used in knee rehabilitation are based on the neuromuscular principles; balance training, dynamic joint stability, perturbation training and plyometric training. According to Risberg and Myklebust (2001), the build up of a treatment program should contain exercises advancing from bilateral to unilateral, from static to dynamic joint stability exercise, and from flat, even surface to unstable surface. These exercises can also be done with closed eyes to make it more challenging for the patient. Plyometric training should start with single jumps on a soft surface, advancing the level of performance to jumps on the trampoline, a series of jumps (scissors jump, cross-jumping etc). Other training variables can also be added to the rehabilitation. After the injury, the patient should gradually increase weight-bearing, advance from open chain exercises to closed chain exercises and maintain balance on a progressively smaller support base. Plyometric training can include jumping down from a higher support base or jumping up from a lower support base. The patient can also be given different kinds of external stimuli while trying to maintain equilibrium. Stimuli should at first be announced in advance and progress to come unexpectedly and with increased forces and speed. All of these exercises can be combined with single tasks and eventually progress to performing the exercise with double tasks. 1.4 Summary of Chapter 1 The ACL is an important stabiliser of the femur on the tibia as it prevents the tibia from rotating and sliding anteriorly and it is the most commonly injured structure of the knee joint. When damage occurs it is often of serious nature, and it results in severely impaired stability of the knee. Disruption of the ACL does not only result in mechanical disturbance, but also a loss of joint sensation due to deafferentation of peripheral sensory receptors (mechanoreceptors). The mechanoreceptors are an important part of the neuromuscular control, and contributes to the dynamic restraint system. Neuromuscular control is the efferent response to sensory information, also referred to as the ability to produce controlled movements through co-ordinated muscle activity. This control is a result of interaction between the neurological and the musculoskeletal system. The feed-forward and feedback mechanisms are essential when discussing neuromuscular control, as they are responsible for preparatory and reactive muscle activity. The feed-forward mechanism involves planning movements based on sensory information from past experience, while the feedback system is a process using continuos information from joint and muscle receptors to regulate ongoing muscle activity. These processes are associated with muscular stiffness, unloading the passive structures of the knee and reducing the risk of injuries. The basic intention behind the neuromuscular training concept is repetitively challenging an individuals ability to maintain static control of his or her knee joint to improve neuromuscular control and joint stability. The exercises used are aimed at inducing compensatory changes in muscle activation patterns and facilitate dynamic joint stability. Studies suggest that neuromuscular training can have a significant impact on the functional level of individuals with an ACL-injury. When comparing traditional strengthening programs to neuromuscular training programs, the traditional exercise programs show less improvement in knee function and stability compared to programs including proprioception and dynamic joint stability training. 2. Method 2.1 Method of the Literature Search The literature search was done by using the search engines on the Internet, the reference lists in the articles found on the topic, and recommendations from professionals involved within the field of knee rehabilitation. The Internet search was initiated by terms related to the main question and condition of interest. Search words that were used: Anterior cruciate ligament ruptures/injury, neuromuscular training, knee, dynamic joint stability, balance, neuromuscular control, co-ordination and proprioception, plyometric training and perturbation. Initially the intention was to compare the key words to the index words listed in the different search engines, but the key words already agreed upon gave a satisfying result. In the Internet search, these search engines were used; PubMed:  HYPERLINK http://www.ncbi.nlm.nih.gov/entrez/query.fcgi http://www.ncbi.nlm.nih.gov/entrez/query.fcgi Medline plus:  HYPERLINK http://www.nlm.nih.gov/medlineplus/advancedsearch.html http://www.nlm.nih.gov/medlineplus/advancedsearch.html Cochrane:  HYPERLINK http://www.update-software.com/search/default.html http://www.update-software.com/search/default.html Pedro The first approach was to combine the main key words, neuromuscular training and anterior cruciate ligament. Neuromuscular training and/or anterior cruciate was combined with these key words; dynamic joint stability, balance, co-ordination, proprioception, perturbation, plyometric, knee, neuromuscular control as listed in figure 4. The search on PubMed was done with the search limitations; age 19+, human subjects and articles from 1960 with abstracts. These criteria were used in all the search engines. In the Medline plus an advanced search was used where all the key words had to match. Main key wordsCombination key wordsNeuromuscular trainingKnee Anterior cruciate ligament Anterior cruciate ligament injury/rupture Dynamic joint stability Balance Co-ordination Proprioception Perturbation Plyometric Neuromuscular controlAnterior cruciate ligamentKnee injury/rupture Dynamic joint stability Balance Co-ordination Proprioception Perturbation Plyometric Neuromuscular controlAnterior cruciate ligament and neuromuscular trainingDynamic joint stability Balance Co-ordination Proprioception Perturbation Table 2 Overview of the Internet search Abstracts found using the search engines on the Internet were assessed according to the exclusion/inclusion criteria already established by the project group. Inclusion criteria: Articles dealing with the concept of neuromuscular training (balance, dynamic joint stability, perturbation training and plyometric training, one or all of these components) with the goal to improve neuromuscular control The patient group should suffer from ACL injury of the knee, both with or without ACL reconstruction The subjects in the articles could be female, male or both The articles should be randomised or quasi randomised The articles must be written in English, Norwegian, Swedish, Danish, German or Dutch Exclusion criteria: Articles using subjects with bilateral knee injury Articles using subjects with co-morbidity Subjects in the articles should not be older than 60 years or younger than 15 years Articles concerning primary prevention of ACL injury The PubMed search was conducted first. The Pedro, MedLine and Cochrane search did not result in any additional information, and the search was ended. Two group members assessed the abstracts independent of each other before comparing the results. After reading the abstracts the two group members discussed and decided which articles should be looked up and copied. Authors of the acquired articles were contacted by e-mail for recommendations of other relevant research articles and information regarding the main- and sub- questions. NIMI (Norges idrettsmedisinsk institutt) was contacted to retrieve more information and training protocols from the ongoing research at Ullevl University Hospital in Oslo. May Arna Risberg, physiotherapist and Dr. Philos, research leader at the Centre for clinical research, Ullevl Hospital, recommended a special edition of JOSPT concerning neuromuscular control and dynamic stability of the knee. This was of special interest for the project group, and contained articles related on the topic on the knee. The reference lists of found articles were also searched for titles of other articles of interest. This search was conducted by using the same key words as in the Internet search. Interesting research mentioned in the article was looked up in the reference list. Copies of the articles believed to fulfil the inclusion criteria were retrieved from the library at Fontys Hogescholen and the NIWI (Netherlands Institute for Scientific Information Services). When all articles of interest were retrieved, two group members read the articles independent of each other, as it was difficult to know the relevance by just reading the abstracts and titles. When both the readers had made their decision whether to include the articles or not, they discussed their opinion and came to a final decision. If consensus was not reached, a third group member was consulted. 2.2 Method of the Analysis Included articles were analysed for methodological quality according to the Pedro assessment list. Initially the Delphi list for quality assessment of randomised clinical trials was considered, but the Pedro list was chosen because it is more extended and has a thorough description of the questions to justify the validation that increases the intra-reliability. The Pedro score for the included articles was calculated by counting the number of checklist criteria that were satisfied in the research article. All was rated on the basis of what they report if a trial does not mention that a particular criterion was met, the score is counted as if the criterion was not met41. The Pedro scale is a measurement tool for measuring the internal validity and whether the study contains sufficient statistical information to make it interpretable. It does not measure the applicability or the meaningfulness of a study, and it does not measure the size of the treatment effect. The Pedro scale contains 11 items, 10 of which is measuring the internal validity. Item number 1 is not included into the count, because it assesses the external validity of a study. The items of the Pedro score are listed in table 2. The Pedro scale is also added to the appendix. 2 1. eligibility criteria were specifiedyes/no2. subjects were randomly allocated to groups ( in a crossover study, subjects were randomly allocated an order in which treatments were received) Yes/no3. allocation was concealedYes/no4. the groups were similar at baseline regarding the most important prognostic indicators Yes/no5. there was blinding of all subjectsYes/no6. there was blinding of all therapists who administered the studyYes/no7. there was blinding of all assessors who measured at least one key outcomeYes/no8. measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups Yes/no9. all subjects for who outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by intention to treat Yes/no10. the results of between-group statistical comparison are reported for at least one key outcome Yes/no11. the study provides both point measures and measures of variability for at least one key outcomeYes/no Table 3 Items of Pedro scale Which article was assessed by which person was decided at random. The process of randomisation was conducted by drawing lots and combining the names of the members of the project group with the included articles. For each included article, two names were drawn. This was repeated if the same name appeared twice for one included article. The analysis was done independently before the results were discussed and the final Pedro score was agreed on. When assessing an article, a data extraction form was used. The data extraction form was made by the project group, with the intention to summarise the content of the articles and to make them more accessible. The form included article information such as title, authors, research design, patient group, objectives, duration of study, intervention, measurement tools and outcome on the level of impairment, disability and handicap, results, conclusions and weaknesses identified. The form can be found as an appendix no 2. 3. Description of Articles The information retrieved from the data extraction form after analysing the nine included articles is summarised in table 3. This table contains information concerning design, patient group type of training and measurement tools used. This was done to get an overview of the information, making it structured and comparable. ArticleDesignPatient groupTraining methodAssessment toolsResult PedroProprioception enhancement for ACL deficiency, a prospective randomised trial of two physiotherapy regimes Beard, Dodd, Trundle, Hamish and Simpson1Randomised studyTraining group: 23 patients mean age 25 (both groups) with ACL injury. Traditional group: 20 patients, median age 25 (both groups) with ACL injury.Both groups received treatment 2*wk for 12 weeks. The training group: exercises to improve dynamic stability through proprioceptive enhancement techniques, most exercises were closed chain and functional. Traditional group: strengthening exercises mostly in open kinetic chain.KT 1000 Lysholm Vicon interfaced knee displacement equipment There was no significant change in passive sagittal laxity of the knee. There was found significant improvement of reflex hamstring contraction latency in the training group compared to the traditional group. There was also significant increase of functional score by Lysholm in both groups from pre-to post treatment. 9/10Home or supervised rehabilitation following anterior cruciate ligament reconstruction Beard and Dodd2Randomised controlled trial studyTraining group:13 male/female with the mean age 28 with an ACL reconstruction. Home rehabilitation: 13 male/female with the mean age 27 with an ACL reconstruction. Training group: 2*wk +home exercises. Training is based mainly on proprioception and functional exercises. Home rehabilitation : only received home exercises which are not described in the article.KinCom, KT1000, Lysholm, IKDC knee assessment form, Tegner, VASNo clinical evidence that the supervised training group improved more than the home exercise group. IKDC and Lysholm shown both improvement, but no difference between the groups8/10The efficiency of perturbation in non- operative ACL ligament rehabilitation for physically active individuals Fitzgerald, Axe, Snyder3Randomised, Two group- pre-test-post test control groupTraining group: 12 subjects mean age 29,2 with ACL injury. Standard group: 14 subjects mean age 27,6 with ACL injury.All subjects were treated for 10 sessions 2- 3 times a week. Training group: Received perturbation training in different positions and directions and at the end sport specific tasks. Standard program: strengthening for lower extremity, cardiovascular training, agility skill training and sport specific exercises. The group was tested pre-post treatment and follow up treatment.KinCom, KT 2000, Hop test (cross over, single hop and triple hop for distance) and The knee outcome surveys of ADL and sport activity scale. No significant difference in self report surveys. No difference was found in the pre- to post training assessment. The perturbation group maintains their hop score while standard group decreases the score. There were found no difference in the knee laxity. A meaningful analysis could not be done in testing muscle strength due absence patients.6/10Rehabilitation following acute ACL injury- a 12month follow up of a randomised clinical trial Ztterstrm, Friden, Lindstrand and Moritz4Randomisation through number generator and block randomisationThe median age of the subjects were 22,75 Training group: 53 patients mean age 27 with ACL injury. Self monitored group 47 patient with ACL injury Compare with the other legTraining group: 2*wk 5-8 months Postural function in closed kinetic chain Self-monitored group: joint mobilisation and knee muscle training to regain mobility and muscle strength.Goniometer Cybex One leg hop Tegner activity LysholmNo significant difference of the passive joint mobility through the training period, There were significant higher values in nearly all measurement of isometric and isokinetic flexion and extension. Supervised group had increased distance of one leg hop test in grade 2 injury. Lysholm showed significant difference in favour of supervised group. Tegner did not prove any significant difference between the groups. 5/10Postural Control after ACL reconstruction and functional rehabilitation Henriksson, Ledin, Good5Non randomised Post Test designTraining group: 25 patients male/female from an earlier prospective study, mean age 27 all undergone a unilateral bone-patellar tendon bone ACL reconstruction. Control group: 20 healthy volunteers with mean age 28. Compares with uninjured leg.Training subjects were recruited from an earlier study, in this study the subjects receive a functional agility program design to promote the return of proprioception. They then compare the result of injured leg with uninjured leg and training group with control group. There were no pre-post assessment so improvement of training can no be stated.Posturography, KT 1000 Tegner, Lysholm The differences in laxity did not correlate with any of the variables in posturography. Stabilometry: Significant body sway was found in the patient group on stable surface with eyes closed. Significant longer reaction time to backward an forward perturbation and latency in both direction was found in the patient group on perturbation in the sagittal plane. No significant difference was found between the groups in perturbation in frontal plane. 4/10Influence of supervised and non-supervised training on postural control after an acute ACL rupture, A three year longitudinal prospective study Ageberg, Ztterstrm, Moritz, Friden6Quasi randomised of pre/ post-test control group designTraining group: 36 male/ female with ACL injury, median age of both groups. Self monitored group: 27 male/ female with ACL injury. Control group: 60 non-impaired volunteers, with median age of 26 years. Training group: 2*wk+ home exercises. Training: mobility of all joint of injured extremity, training model with progression according to neuromuscular function; strength, co-ordination, balance and proprioception. Self-monitored group: home exercises including: joint mobility and strengthStabilometry One-leg hop test Tegner activity levelNo significant difference was found between the training groups in the stabilometric variables and on the Tegner score. The patients in the training group hopped a shorter distance with the injured and uninjured leg at 3 months and normal values at 12 and 3 years compared to control group. The patient in the self-monitored group hopped shorter with both legs compared to control group at 3, 6 and 12 months.4/10Dynamic joint control training for knee ligament injuries Ihara and Nakayama7Non- randomised, non-equivalent pre-/post- testing control group design Training group: 4 female athletes mean age 23,25 with ACL-rupture. Control group: 5 healthy female, mean age 20 that did not receive any treatment.Training group: 4 * wk for 3 months with perturbation by the therapist in different positions; on balance board, grasping object with toes and quick weight transfer.Kin COM Isokinetic Dynamometer which tests the isometric strength and reaction time.Significant differences were found in peak torque time (PTT), rising torque time (RTT) and rising torque value (RTV) and peak torque value (PTV) from initial evaluation to final evaluation. Significant improvement of PTT, RTV and PTV compared to control group.3/10Anterior cruciate insufficient knees treated with physiotherapy- a three year follow up study of patients with late diagnosis Ztterstrm, Lindstrand, Mortiz8Quasi randomised within subject designIn this study they only had 26 subjects with ACL injury with mean age 24,8, They were comparing with uninjured legThe group were treated individually with strengthening exercises incl. co-ordination and stabilisation of the whole limb. The training lasted for 3 months.Cybex (testing knee flexors and extensors, hip abductors and adductors) One hop test Lysholm TegnerThere was found significant difference in quadriceps muscle compared to uninjured side, there was no significant different in hamstrings and hip adductors and abductors. The one-leg hop test had significantly improvement of functional improvement. There was found significant improvement in the Lysholm score test and the Tegner from pre-treatment to post- treatment testing. 3/10The effect of physiotherapy on standing balance in chronic anterior cruciate ligament insufficiency Ztterstrm, Friden, Lindstrand, Moritz9Quasi randomised Non equivalent pre-test (post test) control group designTraining group: 26 subjects, median age 24,8 with ACL injury. Control group: 55 healthy volunteer with median age 26. Compares with the uninjured legThe training group received strengthening to the trunk and closed leg muscles to improve functional stabilisation of the limb by training co-ordination, postural reactions and endurance. Stabilometry testing speed of sway and number of sway exceeding 5mm and 10mmIt was significant improvement in sway speed in the injured leg and after 36 months there was no difference with the healthy reference group. Both legs deviated significantly from the reference group and had significantly improvement. At 3 months the uninjured side is the same as reference group and at 12 months the injured leg is the same.2/10Table 4: Summary of included articles. 4. Results 4.1 Result of the Literature Search The literature search resulted in 37 articles. 9 of these matched the present inclusion criteria. The remaining 27 articles were excluded because; 4 were review articles, 2 were case studies (no randomisation), 4 concerned primary prevention of ACL injuries, 8 articles concerned measures of ACL deficient knees without any therapy, 4 had no neuromuscular focus, 3 did not contain any research, one was a screening article and one was not ACL related. 4 of the included articles were found by using the reference list of other articles on the topic. 3 were found from the PubMed search and researchers on the topic of NMT recommended 2 articles. Six authors were contacted, of which three replied. Replying authors were May Arna Risberg, research leader at Ullevl University Hospital, G Kelley Fitzgerald, author of the article Rehabilitation programs for physically active individuals, and Eva Ageberg, co-author of the article Influence of supervised and non-supervised training on postural control after an acute anterior cruciate ligament rupture: A three year longitudinal prospective study. In the included articles a total number of 271 patients were treated conservatively. 125 subjects served as control subjects, receiving no training. 56 patients underwent ACL reconstruction. 117 patients received standard training, and 163 received training based on neuromuscular principles. The measurement tools used in the included articles were: Cybex 2 device, one-leg hop test, Lysholm and Gillquist, Tegner, Vicon Interfaced knee displacement equipment in combination with EMG, KT 1000 Arthrometer, The international knee documentation committee knee assessment form (IKDC), VAS, KinCom isokinetic dynamometer, Stabilometry, The knee outcome surveys sports activity scale, The knee outcome surveys activities of daily living scale, KinCom 2, Single limb hop test by Noyes, Goniometer and Single stance with perturbation. 4.2 Result of the Pedro Analysis The mean Pedro score for the included articles was 4.88 (range 2-9). The most positive score were acquired for item 11, where all articles had positive results. For item 10 only one negative score was obtained. Item 10 and 11 concerns the statistical comparison and the reports of both point measurements and measures of variability. All articles scored negative on question 6, which is concerning the blinding of the therapist administering the therapy. Items, which received a score under the mean, were the items 5, 6, 7 and 9. Item 5, 6 and 7 are concerning the blinding of subjects, therapist and assessors. Item 9 concerns the intention to treat analysis of drop out subjects. The items of the Pedro score are listed in table 3 on page 20.  Table 5 Overview of score per item The article that scored the highest according to the items in the Pedro scale was the article: Proprioception enhancement for ACL deficiency. A prospective randomised trial of two physiotherapy regimes written by Beard et al, which only had one negative score. The lowest score acquired was for the article by Ztterstrm et al, The effect of physical therapy on standing balance in chronic ACL insufficiency which only scored positive on the items concerning the statistical comparison and the reports of both point measurements and measures of variability. Four of the articles were over the mean score. The score per item of each article is listed in table 6. Article1234567891011SumProprioception enhancement for ACL deficiency. A prospective randomised trial of two physiotherapy regimes. Beard et al, 1993.111110111119/10Home or supervised rehabilitation following ACL reconstruction: A randomized controlled trial. Beard, Dodd, 1998.011110101118/10The efficiency of perturbation training in non-operative ACL rehabilitation programs for physically active individuals. Fitzgerald, Axe, Snyder-Mackler, 2000.111100010116/10Rehabilitation following acute ACL-injuries a 12 month follow-up of a randomised clinical trial. 111100000115/10Postural Control after ACL reconstruction and functional rehabilitation. Henriksson, Ledin, Good, 2001.000000011114/10Influence of supervised and non-supervised training on postural control after an acute ACL-rupture: a three-year longitudinal prospective study. Ageberg et al, 2001.111000000114/10Dynamic joint control training for knee ligament injuries. Ihara, Nakayama, 1986.000000010113/10ACL insufficient knees treated with physical therapy. A three year follow up study of patients with a late diagnosis. Friden et al, 1989100000011013/10The effect of physical therapy on standing balance in chronic ACL insufficiency. Ztterstrm et al, 1994.100000000112/10Sum65542025489 Table 6 The score of the included articles according to the Pedro list 4.3 Measurement Tools used in the Literature The included articles used 14 different measurement tools to measure outcome of the treatment effect. In the following section a short description of how they are used will be given. These tests can be divided according to the ICIDH classification (International Classification of Impairment, Disability and Handicap) to clarify on what level outcome was measured. Of these 14 different measurement tools 8 are on impairment level and 6 on disability level. These divisions can be somewhat indistinct, and some tests can be on two or more levels. Subjective survey scores often measure aspects on all three levels. The surveys used in the included articles are The international knee documentation committee knee assessment form (IKDC), Tegner, VAS, Lysholm and the knee outcome surveys activities of daily living scale and The knee outcome surveys sport activity scale. No tools used were found to measures on the handicap level alone. The most used measurement tools were the Tegner and Lysholm, used in five of the nine included articles, the One-leg hop test used in four articles, and the KT 1000 also used in four articles. 4.3.1 Measurement Tools on Impairment Level The Cybex II test was used in two of the included articles4,8. Friden et al (1991) tested isometric muscle strength of the knee flexors and extensors, hip abductors and adductors, where the ratio between the injured and uninjured legs was calculated for each of the different measurements. Ztterstrm et al (2000) measured isometric muscle strength of knee extensors and flexors. The patient was sitting with 90 flexion in the hip and 60 flexion of the knee with 5 second duration of maximal contraction. The isokinetic muscular work of the knee extensors and flexors were measured by 40 consecutive contractions in the range of 75-15flexion. The mechanical work of the repeated contractions was calculated as the product of power and time within the interval 75-15 of flexion. The ratio between the injured and the uninjured leg was calculated. A Goniometer was used by Ztterstrm et al (2000). This tool measures the angle of a joint to detect decreased or increased range of motion. INCLUDEPICTURE "C:\\Documents and Settings\\Linda Borch\\Application Data\\Microsoft\\Word\\Temporary Internet Files\\Content.IE5\\Temporary Internet Files\\Content.IE5\\images\\mvp.gif" \* MERGEFORMATINET \d"The KT-1000 measurement is used in four of the included articles1,2,3,5,. This device provides a computerised measurement of knee laxity. It was developed to provide objective measurements of the sagittal plane motions of the tibia relative to the femur. The test was performed in 30( flexion of the knee with an anterior-posterior tibial displacement force of 89 N1,2, 135 N5 or force required to obtain maximum manual displacement1. Vicon knee displacement equipment was used by Beard et al (1994) as a proprioceptive measuring tool that measures the time required for the hamstring muscle to react to displacement. Posturography was used by Henriksson, Ledin, Good (2001). It is a tool to quantify balance and postural sway. It is most applicable in situations where balance needs to be followed quantitatively like in response to treatment or progression of a balance disorder. The measurements can be taken when the subject is standing on a fixed plate with both legs, single leg with open or closed eyes. The force plate could also expose the subject to backward, forward, medial or lateral translation perturbations. The posturography measures; (1) the reaction time from the onset of force plate motion to the moment when the centre of force begins to move on Figure 7 Posturography the force plate, (2) the time from the beginning of the centre of force movement to the point when maximum sway was reached and (3) the amplitude from the baseline of this maximum excursion. Stabilometry was used in two included articles6,9. One leg balancing was tested on a strain gauge force plate where the results were analysed with a computer program. The subjects were standing barefoot on one leg with the other leg flexed to 90 in the hip and knee joint. The arms were hanging relaxed and the subject was looking at a point on the wall in front of him/her. The computer gave following variables; the average speed of frontal sway movements reflecting both amplitude and frequency and the number of sway movements exceeding defined amplitude values. The international knee documentation committee knee assessment form (IKDC) is by Beard et al (1994). It contains items that fall into one of seven different measurement domains. However, only the first three of these domains are graded. The seven domains of the assessment form are: effusion, passive motion deficit, ligament examination, compartment findings, Harvest site pathology, X-ray findings and functional test42. See Appendix 5 Figure 8 KinCom Isokinetic dynamometer The KinCom was used in three included articles2,3,7. The KinCom isokinetic dynamometer is used to test muscle strength, increase strength of muscle groups, test muscle performance and increase joint range. The KinCom Isokinetic dynamometer can be programmed for passive movement in addition to active movement. The subject sits on the table of the Kin-Com with hip flexion at 90(. The apparatus is used to measure force, torque and reaction of the muscles. In the articles the KinCom can be used in different manners. Ihara, Nakayama (1986) placed the input arm on the posterior side just below the knee and gave an unexpected 20( anterior force at a speed of 210 (/sec to the lower extremity. This force is just below the maximal angular velocity of knee flexion during normal gait. Subjects were instructed to draw the leg backwards against the forward force as quickly as possible when they felt the anterior force of the input arm. This sudden anterior force made only the knee flexors react; therefore, the curves for the knee extensors were not recorded. Fitzgerald, Axe, Snyder-Mackler (2000) and Beard, Dodd (1998) recorded the knee in 90( of flexion and the dynamometer force arm was placed anterior to the lower extremity. Fitzgerald, Axe, Snyder-Mackler (2000) used self-adhesive electrodes that were applied to the quadriceps femoris muscles so that an electrical stimulus could be applied during muscle contraction. The subjects were asked to exert as much force as possible while extending the knee against the force arm of the dynamometer. An electrical stimulus was applied during the contraction to ensure that the muscle was maximally activated during the test. Beard, Dodd (1998) applied an angular velocity set at 60(/sec for all measures. Range of movement was limited from 20( to 90( of flexion. Full extension was not chosen as dynamic maximally resisted extension into low flexion angles may threaten the graft postoperatively. 4.3.2 Measurement on Disability Level Lysholm scoring scale was used in five of the included articles 1,2,4,5,8,. Lysholm and Gillquist (see Appendix 7) developed a scale to score clinical instability of the knee12. This scale measures limp, support, catching/ locking, instability, pain, swelling, stair climbing and squatting with the maximum score of 100. A score of greater than 83 was rated as good or excellent, 65 to 83 as fair and less than 65 as poor. The one-leg hop test was used in four included articles3,4,6,8. Strobel and Stedtfeld originally developed a single-leg hop for distance test where the patients stand and do a long jump on one leg to land on the same leg. Several modifications have been made since then. Fitzgerald, Axe, Snyder-Mackler (2000) used the original single hop for distance test and three modifications; a triple crossover over a 15.2 cm wide tape, a straight triple hop for distance and a timed hop over a 6 meter distance. Subjects performed two practise trials followed by the measurements. The hop test score for each limb was reported as a percentage of the two measurement trials. The single hop, crossover hop and triple hop scores were expressed as a percentage of the injured extremity score divided by the uninjured extremity score and multiplied by 100. Ageberg et al (2001) and Ztterstrm et al (2000) both used a modified version of the one-leg hop test. Here the arms were free to aim at a more functional execution of the hop, thus making it easier to balance the body. The subjects wore sneakers and were told to hop as far as possible, taking off and landing on the same foot. The test was performed three times on each leg, alternating the right and left leg, the hop distance being measured from toe to toe. The patient first did a trial one leg hop before measurements were taken. The best result of the three jumps where used in the analysis. The knee outcome surveys activities of Daily Living Scale and The knee outcome surveys sports activity scale (See Appendix 4 and 5) were only used by Fitzgerald, Axe, Snyder-Mackler (2000). The activities of Daily Living Scale of the Knee outcome survey assess how a persons knee condition affects daily activities such as ambulating, stair climbing, kneeling, sitting and squatting. The sports Activity Scale of the knee outcome survey assess how a persons knee condition affects participation in sports activities and sports-related tasks such as running, jumping, cutting and quick starting and stopping. Scores for both the scales are reported as percentage scores. It was determined by dividing the subjects score by the total possible score and multiplying it by 100 for each scale. VAS (visual analogue scores) for sports participation and activities of daily living was developed and tested by Beard, Dodd (1998) as a quick method of assessing activity levels. The VAS scores required the patient to represent sports frequency, sports level and level of daily living activities relative to the pre-injury state by placing a mark on a 10-cm long line. INCLUDEPICTURE \d "http://physio.otago.ac.nz/clinic/dn/kincom.jpg" Tegner activity scale was used in five of the included articles2,4,5,6,8. This scale is based on steps of activities, where work and sports are graded on a scale from 1-10 with various physical activities ranked according to the level of difficulty. (Level 10 being competitive sports, level 1 being sedentary activity). Beard, Dodd (1998) chose a modified version of the test, due to the fact that not all of their patients had a high pre-injury level of activity. A non-sporting ACL-reconstructed patient will thus score low on the Tegner activity scale even though they meet pre-injury level. The score was therefore modified and the activity level at assessment was recorded relative to the pre-injury activity level and expressed as percentage 4.4 The Effect of NMT After Conservative ACL Treatment Seven of the nine included articles used ACL injured subjects without reconstruction. The authors used different treatment programs and measurement tools in their studies. The outcome of these measurements will be described below. Cybex 2 device Ztterstrm et al (2000) found that isometric flexion after 3 months rehabilitation demonstrated a significantly higher value in the supervised group who exercised according to a functional program (P=0.006) compared to the self-monitored group training mainly muscle strength and mobility. The positive treatment effect of the supervised group was calculated to 16.6% in comparison to the self monitored group. At 3 months a significantly higher value (P=0.07) was found in isometric extension in the supervised group. The positive treatment effect was calculated to 19.8% for the supervised group. All values of isokinetic mechanical work of the supervised group were significantly higher at 12 months (extension P=0,006, flexion P=0.01) compared to the self-monitored group. The positive treatment effect of the supervised group was calculated to 21.9% for extension and 22.2% for flexion. Friden et al (1991) found that the quadriceps was initially reduced (P<0.001), after three months there was no difference noted between the injured and non-injured leg, but the authors did not discuss if the improvement was significant. The hamstring and hip adductors and abductors had no significant improvement. A treatment effect could not be calculated since a between group comparison was not available. KinCom Isokinetic Dynamometer Ihara, Nakayama (1986) found significant differences in peak torque time (PTT) (P<0.01), rising torque time (RTT) (P<0.05) and rising torque value (RTV) (P<0.01) and peak torque value (PTV) (P<0.05) from initial evaluation to final evaluation in the training group. Between the training group and the control group there was found significant difference of PTT (P<0.01) treatment effect of 11.3%, RTV (P<0.01) treatment effect 150% and PTV (P<0.05) treatment effect 16.8%, in favour in the training group. Fitzgerald, Axe, Snyder-Mackler (2000) found no significant difference in the isometric force of the quadriceps between the groups at pre-and post treatment and the follow-up test. Goniometer Ztterstrm et al (2000) found no significant difference in knee laxity after treatment. KT 1000 Arthrometer Fitzgerald, Axe, Snyder-Mackler (2000) and Beard et al (1994) tested for knee laxity changes before and after treatment. Since the neuromuscular training was found not influence the passive stability no statistical changes was found. Stabilometry Ztterstrm et al (1994) measured the speed of sway and the number of sway exceeding 5 mm and 10mm, by comparing the injured leg to the healthy leg and to a healthy reference group. The pre-training measurements of speed of body sway and number of sway exceeding 5 mm and 10 mm stated that there was a significant difference in both legs between the injured group and the reference group, the injured side (P<0.01) and the non-injured side (P<0.05). No difference was found between the injured leg and the non-injured leg. At three months the non-injured leg did not differentiate significantly from the reference group, whereas the injured side still demonstrated abnormal sway (P<0.05) and number of sway exceeding given values. At 12 months significant improvement (P<0,001) was found between the initial values and the injured and non-injured leg. In the number of sways exceeding 5 and 10 mm the results were the same as for the reference group. The test at 36 months showed no deterioration of number of sways exceeding 10 mm. The speed of sways continued to improve to reach the level of the reference at 36 months. No treatment effect available because of lack of information. Ageberg et al (2001) found no significant difference between the training groups in the stabilometric variables. One-leg hop test Ageberg et al (2001) used a modified version of the one leg-hop test. In the neuromuscular training group the distance was significantly shorter at three months, (P<0.001) for injured leg, (P=0.04) for uninjured leg, compared to the healthy control group, at 12 and 36 months the neuromuscular training group was equal to the healthy control group. The self-monitored group had significantly shorter distance in 3 months, injured leg (P<0,001) uninjured leg (P=0,001), 12 months (P<0,001) and (P=0,001) respectively, and 36 months (P=0,001) compared to the healthy control group. Mean values were unavailable, therefore no treatment effect could be calculated. Fitzgerald, Axe, Snyder-Mackler (2000) used three different hop tests which were tested pre-and post treatment and follow-up. There was found no significant difference between the two groups from pre- to post treatment. In the follow-up test of the hop test the perturbation group maintained their level while the result in the standard group decreased. There was found significant interaction (P<0.05) between the standard and perturbation group. No mean values were available, thus no treatment effect could be calculated. Ztterstrm et al (2000) found a significant (P=0.03) difference between the supervised and non-supervised group for grade II injuries at 12 months. The supervised group, which received neuromuscular training had a 10% positive treatment effect. No significant difference was found in grade I injuries. Friden et al (1991) did not calculate a statistical outcome for the one leg-hop test. Tegner activity scale Friden et al (1991) was the only finding a significant difference with this test. In this research there was a significant improvement (P<0.01) compared to pre-training level. Values are only available from treatment group, therefore no treatment effect could be calculated. Ageberg et al (2001) and Ztterstrm et al (2000) found no difference in activity level after 12 months. Lysholm and Gillquist A significant improvement was found in all studies1,4,8 including this measurement tool. Beard et al 1994 found significant improvement of the functional knee score (P<0.05) in both the perturbation group and the traditional group after 12 weeks of training. The positive treatment effect was calculated to 9% for the perturbation group. Ztterstrm et al (2000) noted a significant difference (P=0.03) at three months in favour of the supervised group, but not in the 12 months measure. Friden et al (1991) found a significant improvement (P<0.001) from pre-treatment measures to post-treatment measures in both training groups. Vision interfaced knee displacement equipment in combination with EMG Beard et al (1994) measures the reflex hamstring contraction latency. There was found a significant difference between the groups (P<0.05). The treatment effect was calculated to 68.5%. This means that the perturbation group had more improvement group receiving traditional training. The knee outcome surveys activities of daily living scale and of sport activity. Fitzgerald, Axe, Snyder-Mackler (2000) found no significant difference on the knee outcome surveys.Among the included articles, only the study of Fitzgerald, Axe, Snyder-Mackler (2000) has calculated the treatment effect. In this study the positive likelihood ratio was 4.88 (11/18)/1-(7/8). This indicates that subjects receiving the perturbation training were 4.88 times more likely to succeed and have a successful outcome with non-operative treatment compared to the standard group not receiving perturbation training. The other studies did not calculate the treatment effect themselves, however it was possible to estimate the progression by studying the mean outcomes of the different groups measured at different intervals in the study. The project group calculated all the other treatment effects. 4.5 The effect of NMT after ACL Reconstruction Henriksson, Ledin, Good (2001) and Beard, Dodd (1994) have done research of NMT on ACL reconstructed patients. They measure the balance (Posturography), knee laxity (KT 1000), concentric muscle strength (KinCom), clinical instability of the knee (Lysholm and The international knee documentation committee knee assessment form), physical activity of sports and ADL (Tegner and VAS). Henriksson, Ledin, Good (2001) measured patients after an ACL reconstruction with a posturography. The patient group had received rehabilitation with proprioceptive and agility training (mean time of 36 months) and were compared against a control group of healthy subjects. The patients were standing on both legs with open and closed eyes, with no perturbation, reacting to perturbation in sagittal and frontal plane. The outcome result was reported in results of reaction time, latency and amplitude. There was no significant difference in the sensory organisation test on stable support surface. When measuring postural reactions to perturbation in the sagittal plane, the reaction time was significantly longer (P<0,001) in the patient group in both backward (34.6 ms longer reaction time in the injured leg compared to healthy subjects), and forward perturbation (34.7 longer reaction time for the patient group). No difference was found between the healthy and the ACL reconstructed leg. The control group had a significant longer latency in both directions than the ACL reconstructed patient group (P<0,001). The treatment effect for backward perturbations was calculated to 45.2%, and 18% for forward perturbations when compared to healthy subjects. Concerning the postural reactions to perturbation in the frontal plane, there was no significant difference between the patient and the control group. Both articles tested for knee laxity. Henriksson, Ledin, Good (2001) found a significant difference (P=0,001) between the patients injured knee and the uninjured knee. No mean value was available, thus no treatment effect calculation could be made. The mean difference was measured to 2,3mm (range 2 to 5) between the knees. Beard, Dodd (1998) were more concerned with the laxity progression over time with training and found no difference to occur between limbs over the time of the study period. There was however a significant difference between the supervised and home exercise group at an  level of 0.1 in anterior tibia translation difference at 6 months. There was not found any significant difference in the concentric muscle strength2, Lysholm score2,5, Tegner score2,5 or of the International knee documentation committee knee assessment form2. The trend for the VAS scores of sports level duplicated that for sports frequency; a gradual increase over time and therefore no result were discussed2. 5.1 Discussion 5.1.1 Discussion of Method To find relevant articles on the topic the group used search engines on the Internet, reference list from found articles, and recommendations from authors/professionals working on knee rehabilitation. The first Internet search engine used was PubMed, which gave good results. The Cochrane and Pedro search did not result in any additional articles. The key words used had a large spectre, and were all combined with each other to ensure a proper result. To reduce the risk of missing topic related articles, two group members conducted the search independently of each other according to the project plan. The results were compared and found similar. Even though a pre-set and structured plan was followed, it can not be guaranteed that all articles on the topic were found, time limit and pre-agreed project plan made it necessary to end the Internet search. At an early stage the project group contacted May Arna Risberg research leader at Ullevl Hospital in Oslo, who gave the lecture on the topic at the ANSA-Fagseminar. She referred to her own study and articles publicised in JOSPT. After gaining some knowledge about NMT, names of other authors became familiar to the group. Where email addresses were available, researchers were contacted. The project group might have received more information if a follow-up email or phone call had been made. When copies of articles were retrieved, the reference list was checked for new articles fitting the inclusion criteria. While reading through the found articles on the topic of neuromuscular training, interesting references were looked up. The project group found this an easy way of finding relevant articles, and made it possible to use the original source of information. The number of articles found matching the inclusion criteria was relatively small. A reason for this might be the lack of earlier research. In recent years evidence based knowledge has become increasingly important for the profession of physical therapy. More research is being performed in order to provide clinical evidence on treatment effects. There are still ongoing studies on this subject and previous clinical information is limited. NMT is a vague term therefore it can be difficult to find specific literature the topic. Due to the small amount of articles found on NMT, border-line articles were also included and analysed. 5.1.2 Discussion of the Pedro Analysis The internal validity evaluation according to the Pedro scale resulted in a wide range of scores for the included articles. The score ranged from 2 to 9 out of 10 possible. This variety of quality made it difficult to compare the results of the articles. The result from the Pedro gave guidelines to which articles one could trust more. The items of the Pedro score are listed in table 3 page 20. All articles scored positive on item 10 and 11, except one study8 scoring negative on item 10. These items are concerning the statistical comparison and the reported mean values. The study scoring negative on item 10, compares the injured with the uninjured leg. Three of the other included studies 4,5,9 use the uninjured leg for comparison, but also use the results of a control group. Experimental studies on cats have shown altered activity of the  muscle spindle system of the ipsilateral as well as the contralateral limb22,43. An impaired standing balance is reported during one leg stance in patients with chronic ACL insufficiency in both lower extremities when compared to healthy individuals44. It is therefore important to compare the outcome with a control group, since using the uninjured leg as a reference is insufficient and is considered to be an unreliable measure6. Five of the included studies1,2,3,4 were randomised. Randomisation ensures that treatment and control groups are comparable. Three of the studies have less than 15 subjects in each group2,3,7, which makes the results less valid for generalisation. Deviation from the mean will in a smaller group have more influence on the result than in a study with more subjects. Some articles5,6,7,9 use a reference group with healthy individuals to compare outcome measurements, which makes the groups unequal and impossible to randomise. To ensure the effect gained during training is not due to placebo, a non-treatment group with ACL injury should be included. For ethical reasons none of the articles have a non treatment group instead the results of the different training programs are compared. It is not only the placebo that can enhance the effect of treatment, since natural healing effect will also occur after an injury. By not controlling the treatment group to a non-treatment group, this effect can not be measured. In acute situation factors such as pain, swelling and inflammation might influence the measurement outcomes. Improvement over time might be due to the natural healing as well as increased confidence in the limb and activity level. This is not discussed in the articles and should be considered as having an influence on results. In four studies allocation was concealed1,2,3,4. Studies that do not conceal the allocation risk a systematic bias. The knowledge of which treatment the patient receives, might influence the outcome. Blinding of subjects and assessor were reported only in two of the studies1,2. It can not be ruled out that the other included articles have performed this, but they are assessed upon what they report, and are considered guilty until proven innocent. Blinding of the therapist has not been reported in any of the included articles. When the therapist has not been blinded, one can not rule out that the effect or lack of effect was due to the therapists level of enthusiasm and knowledge. The low score on the items considered blinding of subjects and therapist can be explained by the fact that several of the,6,7,9 included studies has one patient group compared to a healthy control group. The measurements in a study should include more than 85% of the subjects initially allocated to the groups to avoid potential bias. In five of the studies1,3,5,7,8 the number of dropouts do not exceed this level. The reason for a high number in the other articles is the wish for reconstruction in order to be able to return to previous level of activity4, the need for supervised training4, or not accepting treatment allocation9. This has made it difficult to rely on the results from these studies. When available, an intention to treat analysis, must be included in a study for subjects with a low level of participation, who does not complete treatment or is not able to attend measurements to avoid bias. Item 9 in the Pedro list concerns this analysis, and four included studies1,2,5,8 scored positive regarding this item. The article of Ztterstrm et al 1994 is an example where subjects did not receive treatment as planned. The subjects were intended to receive two different treatment programs, but the patients did not accept this, and all patients trained according to the functional treatment program. In presenting the results the patients had been treated and measured as one group, which might produce a bias. 5.1.3 The Effect of NMT Neuromuscular training (NMT) is an umbrella term and it can be difficult to state a clear definition of the NMT concept, as all balance and stability exercises can some how be defined as NMT. There is no existing standard protocol for knee rehabilitation regarding enhancement on neuromuscular function. All included articles use different training programs and only three of the included studies1,3,7 describe the training protocol used. This makes it difficult to compare the effect, as studies have different approaches and measure various outcomes. Different measurement tools are used, which is due to the fact that neuromuscular function is a multidimensional performance/skill, and there is no existing golden standard on how to measure it. In this systematic review the task of assessing applicability of the measurement tools was too extensive considering the time limit and the outlines of the project. The measurement tools were classified according to the ICIDH. All outcome measurements are done on the level of impairment and disability. Although many of the measurement tools can be classified into several levels, for example the knee outcome survey measured some aspects on the level of handicap, they mainly concern activities such as gait, stair climbing and squatting. In sport rehabilitation setting the patient is mostly interested in the effect occurring on the level of handicap. It is important for the patient to return to pre-injury level of daily life, work and sports activities, and outcomes on this level is therefor of interest. In a clinical setting it could be assumed that improved function correlate with quality of life, but in research this should be measured. None of the included studies report any effect on the quality of life. Neither of the included articles state whether the measurement was taken before or after physical activity. Studies have shown an increased muscle firing latency and less efficient neuromuscular processes in fatigued muscles when compared to non-fatigue muscles44,45. Epidemiological studies have demonstrated increased injury risk at a later stage of a game46,47,48,49,50. Measurements regarding neuromuscular control should be taken both before and after physical activity as fatigue seems to have an influence on the performance and might affect the outcomes. It is important to know when the measurement is performed (before or after training) as this might produce bias if not measured at the same time over the study period. It is also of interest to know the training effect both before and after training, due to the influence of fatigue. There are no results available on secondary prevention of ACL injury. Beard, Dodd (1998) and Henriksson, Ledin, Good (2001) were the only of the included studies that measured patients after an ACL reconstruction. These studies are relatively new and show no result on the reoccurrence of ACL injuries. The other included studies are performed on non operative patients, and it is therefore not possible to examine reoccurrence. The lack of research on the effect of NMT rehabilitation program after ACL reconstruction makes it impossible to state any long-term effect on this approach. An on going study is at the time of writing being performed on post operative ACL patients at Ullevl Hospital University in Oslo, Norway. The results of this study will be of clinical interest. Patients with a reconstructed ACL were used in two of the nine included articles2,5. The study of Henriksson, Ledin, Good (2001) found that the laxity was significantly higher in the patients ACL-reconstructed knee compared to the uninjured knee or the control group. Almost half of the patients had a difference in total anterior-posterior knee laxity in the injured knee versus the uninjured knee of 3mm or more. There was found no difference in postural sway when perturbations were applied between the reconstructed and the uninjured leg or between the control subjects. This means that ACL reconstructed patients normalised their postural control 36 month after ACL reconstruction. Success after an ACL-reconstruction may therefore depend not only on the tightness and strength of the reconstruction (mechanical stability of the ACL), but emphasise the rehabilitation, with proprioceptive and agility training, as an important component in restoring the functional stability in the ACL-reconstructed knee. On the other hand Beard, Dodd (1998) found no significant difference between the two training groups in their study, where one group received additional supervised training based on proprioceptive and/or functional exercises. Most of the included articles deal with rehabilitation of patients with non-ACL reconstructed knees. Beard et al (1994) reported an improvement in the proprioception group in the reflex hamstring contraction latency and the functional knee score in a group of chronic ACL-deficient patients. There was no significant change in joint laxity after treatment in either group. This demonstrates the lack of a correlation between a passive sagittal laxity and functional abilities also confirmed in the ACL reconstructed by Henriksson et al (2001). The Hamstring is the agonist of the ACL and it is desirable for the ACL-deficient limb to deploy a rapid hamstring contraction, as this prevents subluxation of the tibia on the femur. Exercises designed to facilitate rapid recruitment of the hamstring, proprioception and balance reported the greatest improvement in the reflex hamstring contraction latency and the greatest gain in knee function. This shows a positive correlation between improvement of reflex hamstring contraction latency and functional gain. Fitzgerald, Axe, Snyder-Mackler (2000) performed a study on acute ACL patient after performing a screening examination. Most subjects in the standard group had an unsuccessful rehabilitation, where they experienced episode(s) of giving way of the knee or failure to maintain the functional status of a rehabilitation candidate on re-testing. The perturbation training program appears to reduce the risk of continued episodes of giving way of the knee during athletic participation, and it allows subjects to maintain their functional status for longer periods. There were no differences between the groups in laxity from pre-treatment test to the follow-up test session. This supports the conclusion from Beard et al (1994) that the mechanical stability can not be influenced, but perturbation and proprioceptive training programs can improve the functional stability, by enhancing neuromuscular function. Ageberg et al (2001) results showed that postural control was affected in both injured and non-injured legs after an ACL-injury compared to a control group of uninjured subjects. In spite of extensive training, postural control was not restored throughout the 3-year period. However neuromuscular supervised training restored functional performance as measured in one-leg hop test, but not in the self-monitored group. This indicates that although functional performance can be restored, the sensory system for maintenance of finely-tuned postural control might be persistently disturbed, which may increase the risk for of further injuries. Ztterstrm et al (1994) found a significant difference of balance of both legs in patients with chronic ACL-insufficiency when compared with a reference group of healthy subjects. This study only used stabilometry for measuring postural control and body sway. Ihara, Nakayama, (1986) did also find a significant improvement in the reaction time of the hamstrings over a 3 month training period with perturbation training in ACL-deficient patients. The study supports the findings of Beard, as perturbation training was considered possible to shorten the time lag between neural proprioception and muscle response and reduce the sensation of giving way. Simple muscle training was not found to improve the time lag of muscular reaction. Since Ztterstrm et al (1994) and Ihara, Nakayama (1986) only use one measurement tool, the stabilometry and the KinCom Isokinetic Dynamometer, one can not draw any conclusion regarding the relation to the mechanical stability of the knee joint. Friden et al (1991) found improvement in quadriceps and hamstrings strength from initial measurements to follow up measures and significant improvements were found for the Tegner and Lysholm functional scores as well. Comparison of measurement was done only with the uninjured leg. It is therefore difficult to draw any clinical conclusions from the outcome. 5.1.4 The Benefits of NMT for Athletes with ACL Injury Fitzgerald, Axe, Snyder-Mackler (2000) studied the likelihood of successful return to high-level activity among ACL-deficient athletes. The subjects had passed a screening examination designed to identify patients who had the potential to return to sports activity with conservative treatment. The study reported that subjects who received perturbation training demonstrated greater long-term success than subjects who did not receive this training. They found that the patient would be almost 5 times more likely to successfully return high-level physical activity if they receive the perturbation training, than if they only receive the standard training program. The greater proportion of successful return to activity in both treatment groups compared with previously reported success rates, indicates the screening examination enhanced the treatment outcome by identifying patients with a good potential to succeed with non-operative management. Screening examination in front of the research can therefore be of benefit for the outcome of an NMT program and provide optimal treatment results. Screening selects the patients most likely to benefit from conservative treatment with a focus on neuromuscular control. The less suitable subjects should be evaluated for possible surgery. This helps to ensure the best suitable treatment for the individual reducing cost expenses and time delay. No athletes competing in a high level are studied in the included articles. These subjects are more likely to have surgery, as they require a high functional standard and minimum time delay for return to sport activities. In the light of this, it would be of interest to measure the effect and return to high level/elite sport after NMT program. Friden et al (1991) also performed a study on athletes involved in recreational sports or competed on a low to moderate level. They reported a median activity level of 7, assessed by Tegner activity score pre-injury. After injury their activity level was reduced to a median level of 3. After the training period, most patients resumed recreational sports with a significant improvement compared to the pre-training level. No drop in the activity level was noticed at the follow-up examination, and the median level was 6. Twelve of 26 patients regained their pre-injury level. Only non-ACL reconstructed patients are discussed in relation to the return to sport activities. There is a higher chance of returning to sport with perturbation training or neuromuscular training program. Since there are only two studies discussing return to sports, no real conclusion can be drawn. It is important both in research and clinical situations to be able to differentiate subjects who are suitable for conservative management and those who require an ACL reconstruction. Whether or not a patient is able to cope with an ACL insufficiency, depends among other on age, magnitude of laxity, associated lesions, time since injury, compliance to treatment and the patients activity level. Fitzgerald, Axe and Snyder-Mackler (2000) were the only included study screening patients previous to randomisation. They reported a greater success rate in return to activity in both treatment groups compared to previous studies. This indicates the importance of a screening process to identify patients with a good potential to succeed with non-operative management. All included studies show a general positive effect for neuromuscular training after ACL injury, except Beard, Dodd (1998), who found no difference between the two training groups. The effects are reported on the level of impairment and disability, and the levels are found to influence each other. Patients with ACL deficient knees have gained knee stability by improving the neuromuscular control. None of the studies however, show any difference in knee laxity pre- and post-treatment, although the patients improved knee function. From this one can interpret that neuromuscular control is able to compensate for mechanical knee instability. Since most included studies are concerning ACL deficient patients, it is not reliable to state the effect of NMT on ACL reconstructed knees, as only two studies2,5 are included, and no consensus reached. 5.2 Conclusion and Recommendations An ACL injury affects the stability of the knee joint and has an impact on both mechanical and static functions. Mechanoreceptors are found in the ACL and injury to this ligament causes disturbances of the reflex pathways influencing knee instability. Research states that there are no changes in passive knee laxity after rehabilitation, though functional improvement has been reported. This indicates that neuromuscular function appears to compensate for mechanical instability. There is a correlation between hamstring reflex latency and functional ability, but no correlation is found between muscle strength and functional stability. This implies that traditional strengthening exercises are insufficient in knee rehabilitation. Neuromuscular training is found to decrease the hamstring reaction time, which is essential in maintaining dynamic joint stability. NMT has shown a positive effect for improving knee function after an ACL injury concerning the aspects of balance, dynamic joint stability, co-ordination and return to sports activity. It can be difficult to state a clear definition of the neuromuscular training concept as all balance and stability exercises can somehow be defined as NMT. There is no current consensus on how to define NMT as different researchers use their own terms, which are often broad and unspecific. Researchers are currently working on making NMT evidence based, more structured and integrated into clinical practice. However it can be argued whether the NMT term is only a new expression for already applied knowledge, as the benefit of stability exercises was clinically reported four decades ago. The published research literature on the subject is of various qualities, and this makes some of the conclusions less trustworthy. Recommendations for clinical practice Current literature suggests that a training program focusing on neuromuscular control should be applied for conservatively treated patients in the rehabilitation after an ACL injury. The aim of the rehabilitation program should be to reach pre-injury level. The physiotherapist should take advantage of the possibility to include the training principles for NMT, so the rehabilitation results reach an optimal level. Recommendations for clinical research Further research is necessary to confirm the effect of a NMT program after an ACL reconstruction, as only two studies were found and no agreement was made. An evaluation of which exercises give the best outcome on dynamic knee stability in both reconstructed and non-reconstructed ACL patients should be performed. This information would be useful when designing a treatment program for optimal treatment effect. It would also be of interest to investigate the effect of a neuromuscular rehabilitation program on secondary prevention of knee injury. As far as the study group is concerned, no such research has been performed. It should be noted that all of the included articles are using measurement tools mainly on the level of impairment and disability. Considering all the measurement tools used none of them are focusing the level of handicap. Such measurements should be included since this is often the main concern of the patient. No research has been found to measure the effect of treatment on quality of life. Even though this is subjective it is a good indication of improvement, as it is essential for the patients well being. References Included Articles Beard DJ, Dodd CAF, Trundle HR, Simpson AHRW. Proprioception enhancement for anterior cruciate ligament deficiency. J. Bone Joint Surg. 1994, 76B: 654-659. Beard DJ, Dodd CAF. Home or supervised rehabilitation following anterior cruciate ligament reconstruction: A randomized controlled trial. J. Orthop Sport Phys. Ther. 1998, 27(2):134-143. Fitzgerald GK, Axe MJ. The efficiency of perturbation training in non-operative anterior cruciate ligament rehabilitation programs for physically active individuals. Physical therapy. 2000, 80(2): 128-140. Zatterstroem R, Friden T, Lindstrand A, Moritz U. Rehabilitation following acute anterior cruciate ligament injuries a 12-month follow-up of a randomized clinical trial. Scan. J. Med. Sci. Sports. 2000, 10:156-163. Henriksson M, Ledin T, Good L. Postural control after anterior cruciate ligament reconstruction and functional rehabilitation. Am. Orthop. Soc. Sports Med. 2001, 29(3):359-366. Ageberg E, Zatterstroem R, Moritz U, Friden T. Influence of supervised and nonsupervised training on postural control after an acute anterionr cruciate ligament rupture: A three-year longitudinal prospective study. J. Orthop. Sport Phys. Ther. 2001, 31(11):632-644. Ihara, H., Nakayma, A. Dynamic joint control training of knee ligament injuries. Am. J. Sports Med. 1986, 14:309-315. Friden T, Zatterstroem R, Lindstand A, Moritz U. Anterior cruciate insufficient knees treated with physiotherapy. A three year follow-up study of patients with late diagnosis. Clin. Orthop. and Rel. Research, 1991,263:190-199. Zatterstroem R, Friden T, Lindstrand A. The effect of physiotherapy on standing balance in chronic anterior cruciate ligament insufficiency. Am. J. Orthop. Sports Med. 1994, 22(4):531-536. Additional Information Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J. Bone Joint Surg. 1965, 47B:678-685. Sackett DL, Richardson WS, Rosenberg WMC, Haynes RB. Evidenced based medicine: How to practice and teach EBM. Edinburgh, Churchill Livingstone, 1997. Magee DJ. Orthopedic Physical Assessment, third edition. Montreal:1987-1997. Jenkins DB, Hollinshead's Functional Anatomy of the limbs and Back. Harcourt Brace & Company. Philadelphia: 1991 Kapandji IA. The physiology of the joints. Volum two, lower limb. Fifth edition. Churchill Livingtone. 1987. Tortora GJ. Principles of Human Anatomy. HarperCollins Inc: New York. 1992. Cohen LA, Cohen ML. Arthrokinetic reflex of the knee. Am. J Physiol. 1954, 184:433-437. Branch T, Hunter R, Donath M. Dynamic EMG analysis of the anterior cruciate ligament legs with and without brace during cutting. Am. J. Sports Med. 1989, 17(1):35-41. Klund S, Sinkjr T, Arendt-Nielsen A, Simonsen D. Altered timing of hamstrings muscle action in anterior cruciate ligament deficient patients. Am. J. Sports Med. 1990, 18(3):245-248. Solomonow M, Baratta R, Zhou BH, Sholi H, Bose W, Beck C, Ambrosia R.D. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joints stability. Am. J. Sports Med. 1987, 15(3):207-213. Wojtys E, Huston L. Neuromuscular performance in normal and anterior cruciate ligament-deficient lower extremities. Am. J. Sports Med. 1994, 22:89-104. Ciccotti M, Kerlain R, Perry J, Pink M. An electromyographic analysis of the knee during functional activities II. The anterior cruciate ligament-deficient knee and reconstruction profiles. Am. J. Sports Med. 1994, 22(5):651-658. Johansson H, Sjolander P, Sojka P. A sensory role for the cruciate ligaments. Clin. Orthop. 1991, 268:161-178. Wolpaw JR. Acquisition and maintenance of the simples motor skill: Investigation of CNS mechanisms. Med. Sci. Sports Exerc. 1994, 26(2):1475-1479. Pitman MI, Nainzandeh N, Menche D, Gasalberti R, Song EK. The intraopevative evaluation of the neurosensory function of the anterior cruisiate ligament in humans using somatosensory evoked potentials. Artroscopy, 1992, 8: 442-447. Zimny ML, Schutte M, Dabezies E. Mecanoreseptors in the human anterior cruciate ligament. Anat. Rec. 1986, 214: 204-209. Schutte MJ, Dabzies EJ, Zimny ML, Happel. Neural anatomy of the human anterior crusciate ligament. J. Bone Surg. Am. 1987, 69: 243-247. Fabio RP, Graf B, Badke MB, Breunig A, Jensen K. Effect of knee joint laxity on long-loop postural reflexes: evidence for human capsular-hamstring reflex. Exp. Brain Re. 1992, 90:189-200. Johansson H, Sjolander P, Sojka P. Reseptors in the knee joint ligaments and theri role in biomechanics of the joint. Crit. Rev. Biomed. Eng. 1991, 18:341-368. Johansson, H., Sjolander, P., Sojka, P. A sensory role for the cruciate ligaments. Clin. Orthop. 1991, 268:161-178. Kennedy JC, Alexander IJ, Haynes KC. Nerve supply of the human knee and its functional importance. Am. J. Sports Med. 1982, 10: 329-335. Williams GN, Chmielewski t, Rudolph KS, Buchanen TS, Snyder-Mackler L. Dynamic knee stability: Current theory and implications for clinicians and scientists. J. Orthop. Sport Phys. Ther. 2001, 31:546-566. Burke D, Gandevia SC, Macefield G. Responses to passive movement of receptors in joint , skin and muscles of the human hand. J. Physiol. 1988, 402: 347-361. Bach TM, Chapman AE, Calvert TW. Mechanical resonance of the human body during voluntary oscillations about the ankle. J. Biomechanics 1983, 16: 85-90. McNair PJ, Wood GA, Marshall RN. Stiffness of the hamstrings muscles and its relationship to function in anterior cruciate deficient individuals. Clin. Biomech. 1992, 7:131-173. Risberg MA, Myklebust G. Neuromusulr trening som rehabilitering of forebygging relatert til kneskader. Fysioterapeuten, 2002, 2:12-21. Swanik CB, Lephart SM, Giannantonio FP, Fu FH. Reestablishing proprioception and neuromuscular control in the ACL-injured athlete. J.Sports Rehab. 1997, 6(3):182-206. Huston MS, Wojtys E. Neuromuscular performance in the ACL-deficient knee. Chapter 16 Kreighbaum E, Barthels KM. Biomechanics: A qualitative approach for studying human movement. Boston: Allyn and Bacon. 1996. Hewett TE, Linderfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am. J. Sports Med. 1999, 27: 699-706. Lutz GE, Stuart MJ, Sim FH. Rehabilitative techniques for athletes after reconstruction of the anterior cruciate ligament. Mayo Clin. Proc. 1990, 65:1322-1329. Pedro turorial. (Online)1999.  HYPERLINK http://www.cchs.usyd.edu.au/pedro/scaleitems.htm www.cchs.usyd.edu.au/pedro/scaleitems.htm, visited 26.05.02. IKDC Knee examination form (Online) 1999,  HYPERLINK http://www.aclstudygroup.com www.aclstudygroup.com, visited 26.05.02. Tropp H, Odenrick P. Postural control in single limb stance. J. Orthop. Res. 1988, 6:833-839. Hagbarth KE, Bongiovanni LG, Nordin M. Reduced servo-control of fatigued human finger extensors and flexor muscles. J. Physol. 1995, 485:865-872. Nyland JA, Shapiro R, Stine RL, Horn TS, Ireland ML. Relationship of fatigued run and rapid stop to ground reaction forces, lower extremity kinematrics, and muscles activation. J. Orthop. Sports Phys. Ther. 1994, 20:132-137. Gabbett TJ. Incidence, site, and nature of injuries in amateur rugby league over three consecutive seasons. Br. J. Sports Med. 2000, 34:98-103. Molsa J, Airaksinen O, Nasman O, Torstila I. Ice hockey injuries in Findland. A prospective epidemiologic study. Am. J. Sports Med. 1997, 25:495-499. Pettrone FA, Ricciardelli E. Gymnastic injuries: the Virginia experience 1982-1983. Am. J. Sports Med. 1987, 15:59-62. Pinto M, Kuhn JE, Greenfield ML, Hawkins RJ. Prospective analysis of ice hockey injuries at the Junior A level over the course of one season. Clin. J. Sport Med. 1999, 9:70-74. Stuart MJ, Smith A. Injuries in junior A ice hockey. A three-year prospective study. Am. J. Sports Med. 1995, 23:458-461. Appendix 1 FLP-FORMAT 0. Project 0.1 Project Title Neuromuscular training of the knee after an ACL rupture 0.2 Participating students Linda Borch Ann-Kristin iaas Vibeke Stavang Lene Ims E-mail account;  HYPERLINK "mailto:neuromuscular_training@hotmail.com" neuromuscular_training@hotmail.com 0.3 Date 11.04.02 1. Project leader/ Commissioner Commissioner Linda Borch, Lene Ims, Vibeke Stavang and Ann-Kristin iaas  HYPERLINK "mailto:neuromuscular_training@hotmail.com" neuromuscular_training@hotmail.com Supervision General Supervisor: Jan Rumpt E-mail address:  HYPERLINK "mailto:J.Rumpt@fontys.nl" J.Rumpt@fontys.nl Phone nr: +31 877 878 928 Methodological supervisor; David de Louw E-mail address;  HYPERLINK "mailto:D.delouw@fontys.nl" D.delouw@fontys.nl Phone nr; +31 877 878 870 Project co-ordinator; Annelies Simons E-mail address;  HYPERLINK "mailto:A.Simons-ad@fontys.nl" A.Simons-ad@fontys.nl Phone nr; +31 877 878928 2. Definition of the problem 2.1 Previous history Many studies have evaluated the result from different treatment programs after an ACL injury. In a MedLine search in the period of 1966 to 2000, there are only three effect studies, randomized studies or studies found with a control group, concerning rehabilitation of patients with ACL injury where the neuromuscular training (NMT) concept has been used. (Risberg, Myklebust, 2001). Ihara and co workers (1986) were the first to evaluate a NMT-program which contained perturbation training. Beard and co-workers (1994) used the word proprioceptive training on their NMT-program, and Fitzgerald and co-workers (2000) published a study on the effect of perturbation training after an acute ACL injury. In the recent years there has been done research on the effect on neuromuscular training to investigate the outcome of such training in joint injuries. Among ongoing research within this topic one can mention: Biomechanica in Perugia, Italy and the University of Western Australia who are working together on development and description of programs to prevent knee injuries in athletes. The University of Western Ontario investigating fatigue and neuromuscular control, the University of Pittsburgh on hop testing, The University Hospital in Lund Sweden on ACL- deficient knee, and a case study from the Nicolas Institute of Sports Medicine in New York. Postural control is investigated on the University of Lund, Sweden and post- operative ACL at Ullevaal Hospital University in Oslo, Norway. (Lynn Snyder-Mackler 2001) These studies illustrate the international interest and development on the topic neuromuscular control and dynamic joint stability of the knee. There has been done several independent research on NMT related topics. It can be difficult to obtain a complete picture of the research results. The articles are also published in different research journals and this makes it hard to gather all the relevant information. At this moment there is no knowledge of any existing summary on NMT. This is why it would be beneficial to make an overview of the research done in the field in order to evaluate the effect of NMT on patients with ACL rupture. Neuromuscular training programs are increasingly integrated into clinical practice for lower extremity rehabilitation. (Risberg, Mrk, Jenssen, Holm 2001) The term NMT is increasingly used to describe a particular type of training which include balance training, dynamic joint stability training, perturbation training and jump training/plyometric. The objectives of NMT are to improve the nervous systems ability to generate fast and optimal muscle firing patterns, to decrease joint force, and relearn movement patterns and skills (Risberg and Myklebust, 2001.) During all movements, muscles use different sensory (afferent) stimuli to perform an adequate motor response (efferent), neuromuscular response, which describes the impulses from the CNS to the peripheral muscle. Motor response can be described as a transformation of neural information into physical energy. It can be claimed that the term NMT is to general, because all balance/stability exercises can in one way or another be defined as NMT. But with the term, one means a training form which intends to influence both afferent, and CNS mechanisms to stimulate and train a functional muscle activation pattern. The knee joint is subject to extreme high forces and moments during sports activities. The bony architecture of the knee provides little stability to the joint due to incongruity of the tibia and femoral condyles. For this reason the knee is dependent on the strength of muscles, ligaments and capsule for stability. Not only the mechanical aspects, but also sensory motor integration is believed to be important for stability. Research has shown a decrease in the proprioceptive sense after an ACL rupture (Barrack et al, 1989). Because of the disturbed sensory feedback from the joint after a ligament injury, motor programs have to be relearned. The importance of neuromuscular control required during daily living and sport activities should not be neglected. Rehabilitation programmes can not alter the mechanical knee joint stability, but literature suggests it may affect the neuromuscular control and dynamic joint stability. A lag in the neuromuscular reaction time can result in dynamic joint instability with recurrent episodes of joint subluxation and deterioration. Neuromuscular control is thought to be important for the functional outcome and to be considered in the design of neuromuscular rehabilitation programs after ACL rupture (Ageberg, Ztterstrm, Moritz, Friden, 2001). ACL injuries are common among athletes. In Norway there are approximately 2000 ACL injuries annually, half of which are operated on. In recent years there has been an increase of ACL reconstructions, (Risberg and Myklebust, 2001) and the rehabilitation of these are of special interest for physical therapists. 2.2 Social and/or scientific relevancy During the ANSA-Fagseminar held in Eindhoven, 10-11th of February 2001, the commissioners became aware of the concept of Neuromuscular Training (NMT). The lecture was held by May Arna Risberg, research leader at the centre for clinical research, Ullevaal Hospital in Oslo, Norway. There is an ongoing research on postoperative ACL and the commissioners found the topic interesting and would like to explore the aspect of NMT. As there is current research and development within this field it might be of interest for the English stream physical therapy students at Fontys Hogescholen to gain an update on the topic. 2.3 Main question: What does the present literature state on the effect of Neuromuscular Training (NMT) on patients suffering from ACL rupture of the knee concerning the aspect of balance, dynamic joint stability, coordination, sports, ADL, recurrent ACL injury and quality of life? Sub questions: What does the literature state on the concept of NMT? What does literature say on the effect of NMT after a conservative ACL treatment? What does literature say on the effect of NMT after an ACL reconstruction? Can neuromuscular control compensate for mechanical instability with a patient with an ACL rupture? What does literature say about the beneficial effect of NMT on athletes with an ACL injury? Is there any literature claiming that NMT has a preventative effect on recurrent ACL injury? Is there any literature claiming that NMT improves quality of life of an ACL patient? What measurement tools are used in the literature indicating neuromuscular control? 2.4 Working definitions Neuromuscular training: A training form, which focuses on co-ordination and functional movements/activities with attention on the quality of movements and skills. NMT is used to describe a type of training that includes balance training (1) dynamic joint stabilisation (2), perturbation training (3) and plyometric training (4). The term NMT is used to describe training programmes that include all or some of these components (Hewett et al., 1996). Training enhancing unconscious motor responses by stimulating both afferent signals and central mechanisms responsible for dynamic joint control. ( Risberg MA, Moerk M, Jensen HK, Holm I, 2001). With the term NMT one means a training form which intends to influence both afferent and CNS mechanisms to stimulate and train a functional muscle activation pattern. ( Risberg MA, Myklebust G, 2001) It can be difficult to state a clear definition of the NMT concept as all balance and stability exercises can somehow be defined as NMT. In this research project one chose to define NMT as a type of training using one or more of the training forms following the principles of NMT. The goal of the treatment is improved neuromuscular function related to the aspects of dynamic joint stability, balance, co-ordination, ADL, return to previous sports activities and quality of Life. Balance; state of body equilibrium or the ability to maintain the centre of body mass over the base of support without falling (Risberg MA, Myklebust G, 2001) Dynamic joint stabilization; Balance exercise where the patient is to maintain body position while moving an extremity. (Extracted from the article by Risberg MA, Myklebust G, 2001) Perturbation: an unexpected physical event that changes the movement or movement goal. (Risberg MA, Myklebust G, 2001) Plyometric training; a quick, powerful movement involving pre-stretching the muscle and activating the strengthening-shortening cycle to produce a subsequently stronger concentric contraction. (Risberg MA, Myklebust G, 2001) ACL: Anterior cruciate ligament arises from the anterior part of the intercondylar area of the tibia, just posterior to the attachment of the medial meniscus. It extend superiorly, posteriorly and laterally to attach to the posterior part of the medial side of the lateral condyle of the femur. The ACL, which is slack when the knee is flexed and taut when it is fully extended, prevent posterior displacement of the femur on the tibia and hyperextension of the knee joint. When the joint is fixed at the right angle, the tibia cannot be pulled anteriorly because it is held by the ACL. ( Moore KL, 1992) Ruptured ligament: the ligament is completely torn and the joint is unstable (Apley AG and Solomon L, 1999) Recurrent ACL rupture: ACL rupture occurring after first time ACL replacement Sports: Return to previous sport activities on the same level as pre-injury or at a lower level. ADL: Activities of daily living. Functional movements required in coping with daily life. Example: Dressing, walking. Housekeeping. ( Bickley 1999) Quality of life: a persons sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him/her. (Ferrans, 1985) 3. Objective The objective is to perform a literature research of the neuromuscular training on patients suffering from an ACL rupture of the knee, concerning the aspects of balance, dynamic joint stability and proprioception. The literature will be used to investigate if the neuromuscular training will benefit rehabilitation and prevention of an ACL injury. The acquired articles will be analysed for validity and applicability. 4. Method Literature search: Information gathering will be done: Internet: Search engines like Google, Medline plus, PubMed, Cochrane Library and Pedro. Softcopies of articles found in medical journals. Using the reference lists of articles found. Contacting professionals with knowledge within this field. Searching and/or ordering related articles from the libraries. Search strategy: By initiating the Internet search with multiple terms that describe the condition of interest and join these together. Search words that will be used are; ACL ruptures/injury, knee, neuromuscular training, dynamic joint stability, balance, neuromuscular control, co-ordination and proprioception, plyometric training, perturbation. The index words listed in the different search engines will be also be used to compare already mentioned key words to find the most effective key words. The first approach will be to combine the key words neuromuscular training and knee. The results will be narrowed down by combining the NMT or ACL injury/rupture with the interventions (dynamic joint stability, balance, perturbation, plyometric, knee, neuromuscular control, coordination, proprioception) with the Boolean OR. Search wordCombined withNeuromuscular trainingAnterior cruciate ligament injury/rupture Dynamic joint stability Balance Co-ordination Proprioception Perturbation Plyometric Knee Neuromuscular controlAnterior cruciate ligamentDynamic joint stability Balance Co-ordination Proprioception Perturbation Plyometric Knee Neuromuscular control The search will also be limited by language (English, Norwegian, Swedish, Danish and Dutch, German) by using the Boolean IN, and primary prevention will be excluded from the studies by using the Boolean WITHOUT. Through this search relevant abstracts, authors, journal and year of publication will be found. This search will be done by two group members independently of each other before comparing the search results. The reference list from the included articles can also be searched through for titles of related articles that might also be relevant. The research group will contact professionals that work with the field of NMT or ACL rehabilitation, among others May Arna Risberg, research leader at Ullevaal University Hospital, Research department at Ullevaal Hospital, Grethe Myklebust specialist within sports rehabilitation at NIMI (Norges idrettsmedisinsk institutt) and St. Anna Zorggroup in Geldrop. These professional will be able to give information regarding topics like ACL rupture, ACL incidents, recovery time, treatment protocols and NMT concept. They may also be able to recommend articles. The information from the Internet, reference list and by recommendation from professionals will again be used while searching for the articles at the library at Fontys Hogescholen or other libraries in the Netherlands. The articles can either be located or ordered from the library. Only articles believed to meet the inclusion criterias will be located or ordered. After the gathering of articles, a number of inclusion and exclusion criteria will be used in order to select the relevant articles for this literature study. Inclusion criteria: The articles must deal with the concept of neuromuscular training (balance, dynamic joint stabilization, perturbation training and plyometric training, one or all of these components) with the goal to improve the neuromuscular control. The patient group should suffer from ACL rupture of the knee, both with and without ACL reconstruction. The subject in the article could be female, male or both. The articles should be randomised or quasi randomised. The articles must be written in English, Norwegian, Swedish, Danish, German or Dutch. Exclusion criteria: Articles using subjects with bilateral knee injury. Articles using subjects with co-morbidity. Subjects in the article should not be older than 60 years or younger than 15. Articles concerning primary prevention of ACL injury. After including the relevant articles, they need to be assessed for quality. Analysis of the methodological quality of the included articles: In order to evaluate the methodological quality of the included research articles, either A. Verhagen or Sacketts method of evidence based medicine will be used. This will evaluate the internal validity and applicability of the articles to ensure a proper selection. This will be done by two group members independent of each other, before comparing the results. In order to get an overview; relevant data needs to be extracted from the articles. This will also make the information more accessible. Data extraction: What the project group is searching for in the included articles is; Design Year of publication Measurement tools Post-operative or conservative treatment Duration and intensity of the rehabilitation program. Patient group (athletes or non athletes, age, sex) Intervention (which elements of the NMT concept) Results In order to structure the content of the selected articles, a data extraction form will be developed. Two group members will be involved in this task. The outcome of information gathering will be research report. 5. Project Products The research report will meet the minimal requirements as mentioned in the Graduation project Study Guide, as listed under 6.4.1. The research report will give an outline of the recent research and findings done in the field of NMT. This outline will focus on ACL related issues. The topics in the research report will be related to the main and sub-questions. Lay-out description: Introduction: Description Neuromusculaire training. Applied anatomy and biomechanics of the knee. Neurology in relation to neuromuscular control. Movement continuum in relation to neuromuscular function. Chapter 1: Description, analysis and synthesis of the included articles. Chapter 2: Describing the method of the research. Chapter 3: Results related to the main- and sub-questions. Chapter 4: Discussion and conclusion. Evaluating the findings in relation to the main- and sub-questions. Weakness and limitations of the project. Recommendations for future studies. 6. Time Schedule DateActivityBy whom10.01.02Concept-FLP to General SupervisorGroup31.01.02Pre-Definitive FLP to Annelies SimmonsDesign phase22.02.02Contact methodological supervisorGroup15.03.02Revisions FLP-format, ongoing task until the FLP is approved.Preparation phase26.03.02First group meeting at school Class26.03.02Meeting with methodological supervisor to discuss FLP progressVibeke/Anki01.04.02Work distribution02.04.02Meeting with general supervisor02.04.02Work distribution Search for EBM assessment forms Search reference guidelines Search for articles on the search engines on the internet. Library search Vibeke/Anki Vibeke/Anki Linda/Vibeke Lene/Anki08.04.02Meeting with daily supervisor, David de Louw, concerning the FLP formatGroup09.04.02Meeting with supervisors concerning FLP format.Group10.04.02Order articles from the library in NijmegenGroup11.04.02FLP approved?????Group15.04.02Make extraction formLene/Anki19.04.02Contact NIMI and Ullevaal hospital for informationLinda/Vibeke 19.04.02Finish collection of informationGroup22.04.02Include/exclude found articlesTwo group members independent of each other.22.04.02Realization phaseGroup22.04.02Begin the analysis of the methodological quality of the included articles.Two group members independent of each other 30.04.02 Extract date from all the concluded articles Two group members independent of each other 02.05.02 Start the design of the research report Group in pairs of two21.05.02Finish the research reportGroup in pairs of two22.05.02Print and copy the research reportGroup in pairs of two23.05.02Deliver project for independent viewing Group 23.05.02Deliver title and short description Deadline! Before 1200 a.m.Group27.05.02Revision based on comments from independent viewer.Group30.05.02Deliver end product Deadline! Before 12.00 a.m.Group 02.06.02Suggestion to power point presentationGroup03.06.02 07.06.02Presentation rehearsal: Make appointment with general supervisor.Group03.06.02Work on individual reportIndividually06.06.02Deliver individual report Deadline! Before 12.00 a.m.Individual12.06.02Assessment of the end productSupervisors07.06.02 12.06.02Make appointment with general supervisor to discuss individual report Individual13.06.02Presentation graduation productGroup Estimated Costs Cost in Euro100Prints and copies30Phone calls50Articles50Travel cost20Mail cost30Binding of the report 8. Quality requirements Functional Demands: During the physical therapy seminar arranged by the students at Fontys in spring 2001, the commissioners became aware of the research within NMT after ACL ruptures. The commissioners became interested in making a literature research within the development of the concept NMT of an ACL rupture. The literature research should be valid, reliable and applicable. The literature found should answer the main- and sub-questions. Operational Demands: The research report will be written in English. The reader should have some previous knowledge within the field of anatomy, medical terms and training principles. Boundary Conditions: Following the guidelines in the Graduation Project Study guide, as listed under 6.4.1. Design Limitations: Difficulties with finding available computers in the studylandscape. Problems with printing and coping Technical difficulties because of lack of knowledge within the available software (e.g. PowerPoint, Word and explorer) Limited selection of medical journals in the library Problems arising secondary to limited knowledge with such extensive research. Time limitation Financial budget. Two weeks vacation of the supervisors School closed during public holidays Problem with allergy within the group, which is most prominent in the spring The risk of illness within the group 9. Provisional Literature Schillings M, Simons A, Graduation project study guide ES4 Period 12-16 Lundy-Ekman L, Neuroscience Fundamentals for rehabilitation, 1998. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR: The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am. J Sports Med 1999, 27, 699-706. Hewett TE, Stroupe AL, Nance TA, Noyes FR: Plyometric training in female athletes. Decreased impact forces and increased hamstring torque. Am J Sports Med 1996, 24, 765-73. Moore KL, Clincal oriented anatomy, 1992 Risberg MA, Myklebust G, neuromuskulr trening som rehabilitering og forebygging- relatert til kneskader, Fysioterapeuten nr 2 2001, 12-21. Kreighbaum E, Barthels KM, Biomechanincs- a qualitative approach for studying human movement, 1996. Concise system of orthodaedics and fractures; Apley G, Solomon L, 1999 Ageberg E, Ztterstrm R, Moritz U, Friden T; Influenced of supervised and non supervised training on postural control after an acute anterior cruciate ligament rupture: a three year longitudinal prospective study, JOSP 2001; 31(11): 632-644 Lubkin IM, Chronic illness impact and interventions ,1998 Bickley LS, Hoekelman RA, Physical examination and history taking, 1999 Cochranes Reviewers Handbook Appendix 2 PRIVATEPEDro the PEDro scale HYPERLINK "faqs.htm" \l "rated"Back to Frequently Asked QuestionsPEDro Scale (last modified March, 1999) PRIVATE1. eligibility criteria were specified. HYPERLINK \l "c1"[details]no / yes2. subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received). HYPERLINK \l "c2"[details]no / yes3. allocation was concealed. HYPERLINK \l "c3"[details]no / yes4. the groups were similar at baseline regarding the most important prognostic indicators. HYPERLINK \l "c4"[details]no / yes5. there was blinding of all subjects. HYPERLINK \l "c5"[details]no / yes6. there was blinding of all therapists who administered the therapy. HYPERLINK \l "c8"[details]HYPERLINK \l "c6"c6no / yes7. there was blinding of all assessors who measured at least one key outcome. HYPERLINK \l "c5"[details] no / yes8. measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups. HYPERLINK \l "c8"[details]no / yes9. all subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by "intention to treat". HYPERLINK \l "c9"[details]no / yes10. the results of between-group statistical comparisons are reported for at least one key outcome. HYPERLINK \l "c10"[details]no / yes11. the study provides both point measures and measures of variability for at least one key outcome. HYPERLINK \l "c11"[details]no / yesA copy of the PEDro scale in Microsoft Word format can be obtained by clicking HYPERLINK "http://www.cchs.usyd.edu.au/Academic/PT/RH_EBP/"here and then clicking on "PEDro_scale.doc". The following table briefly explains why each item has been included in the PEDro scale. Slightly more detail on some of these items is provided in the HYPERLINK "appraisal.htm"PEDro tutorial. An excellent text for those who want to know more about clinical trial design is Pocock SJ (1983). Clinical Trials. A Practical Approach. Chichester: John Wiley (the emphasis in this text is with drug trials, although most principals apply equally well to trials in physiotherapy).PRIVATEPEDro scale itemExplanation1. eligibility criteria were specifiedThis criterion influences external validity, but not the internal or statistical validity of the trial. It has been included in the PEDro scale so that all items of the Delphi scale are represented on the PEDro scale. This item will not be used to calculate the PEDro score.2. subjects were randomly allocated to groups (or, in a crossover study, subjects were randomly allocated an order in which treatments were received)Random allocation ensures that (within the constraints provided by chance) treatment and control groups are comparable.3. allocation was concealed"Concealment" refers to whether the person who determined if subjects were eligible for inclusion in the trial was aware, at the time he or she made this decision, which group the next subject would be allocated to. Potentially, if allocation is not concealed, the decision about whether or not to include a person to a trial could be influenced by knowledge of whether the subject was to receive treatment or not. This could produce systematic biases in otherwise random allocation. There is empirical evidence that concealment predicts effect size (concealment is associated with a finding of more modest treatment effects; see Schulz et al., JAMA 273(5): 408-412)4. the groups were similar at baseline regarding the most important prognostic indicatorsThis criterion may provide an indication of potential bias arising by chance with random allocation. Gross discrepancies between groups may be indicative of inadequate randomisation procedures.5. there was blinding of all subjectsBlinding of subjects involves ensuring that subjects were unable to discriminate whether they had or had not received the treatment. When subjects have been blinded, the reader can be satisfied that the apparent effect (or lack of effect) of treatment was not due to placebo effects or Hawthorne effects (an experimental artifact in which subjects responses are distorted by how they expect the experimenters want them to respond).6. there was blinding of all therapists who administered the therapyBlinding of therapists involves ensuring that therapists were unable to discriminate whether individual subjects had or had not received the treatment. When therapists have been blinded, the reader can be satisfied that the apparent effect (or lack of effect) of treatment was not due to the therapists' enthusiasm or lack of enthusiasm for the treatment or control conditions.7. there was blinding of all assessors who measured at least one key outcomeBlinding of assessors involves ensuring that assessors were unable to discriminate whether individual subjects had or had not received the treatment. When assessors have been blinded, the reader can be satisfied that the apparent effect (or lack of effect) of treatment was not due to the assessors' biases impinging on their measures of outcomes.8. measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groupsIt is important that measurement of outcome are made on all subjects who are randomised to groups. Subjects who are not followed up may differ systematically from those who are, and this potentially introduces bias. The magnitude of the potential bias increases with the proportion of subjects not followed up.9. all subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data were analysed by "intention to treatAlmost inevitably there are protocol violations in clinical trials. Protocol violations may involve subjects not receiving treatment as planned, or receiving treatment when they should not have. Analysis of data according to how subjects were treated (instead of according to how subjects should have been treated) may produce biases. It is probably important that, when the data are analysed, analysis is done as if subject received treatment and control conditions as planned. This is usually referred to as "analysis by intention to treat". For a recent discussion of analysis by intention to treat see HYPERLINK "http://www.bmj.com/cgi/content/short/319/7211/670"Hollis S, Campbell F (1999) BMJ 319: 670-4.10. the results of between-group statistical comparisons are reported for at least one key outcomeIn clinical trials, statistical tests are performed to determine if the difference between groups is greater than can plausibly be attributed to chance.11. the study provides both point measures and measures of variability for at least one key outcomeClinical trials potentially provide relatively unbiased estimates of the size of treatment effects. The best estimate (point estimate) of the treatment effect is the difference between (or ratio of) the outcomes of treatment and control groups. A measure of the degree of uncertainty associated with this estimate can only be calculated if the study provides measures of variability.Notes on administration of the PEDro scale:PRIVATEAll criteriaPoints are only awarded when a criterion is clearly satisfied. If on a literal reading of the trial report it is possible that a criterion was not satisfied, a point should not be awarded for that criterion.Criterion 1This criterion is satisfied if the report describes the source of subjects and a list of criteria used to determine who was eligible to participate in the study. HYPERLINK \l "p1"[back to PEDro scale]Criterion 2A study is considered to have used random allocation if the report states that allocation was random. The precise method of randomisation need not be specified. Procedures such as coin-tossing and dice-rolling should be considered random. Quasi-randomisation allocation procedures such as allocation by hospital record number or birth date, or alternation, do not satisfy this criterion. HYPERLINK \l "p2"[back to PEDro scale]Criterion 3Concealed allocation means that the person who determined if a subject was eligible for inclusion in the trial was unaware, when this decision was made, of which group the subject would be allocated to. A point is awarded for this criteria, even if it is not stated that allocation was concealed, when the report states that allocation was by sealed opaque envelopes or that allocation involved contacting the holder of the allocation schedule who was "off-site". HYPERLINK \l "p3"[back to PEDro scale]Criterion 4At a minimum, in studies of therapeutic interventions, the report must describe at least one measure of the severity of the condition being treated and at least one (different) key outcome measure at baseline. The rater must be satisfied that the groups outcomes would not be expected to differ, on the basis of baseline differences in prognostic variables alone, by a clinically significant amount. This criterion is satisfied even if only baseline data of study completers are presented. HYPERLINK \l "p4"[back to PEDro scale]Criteria 4, 7-11Key outcomes are those outcomes which provide the primary measure of the effectiveness (or lack of effectiveness) of the therapy. In most studies, more than one variable is used as an outcome measure. HYPERLINK \l "p4"[back to PEDro scale]Criterion 5-7Blinding means the person in question (subject, therapist or assessor) did not know which group the subject had been allocated to. In addition, subjects and therapists are only considered to be "blind" if it could be expected that they would have been unable to distinguish between the treatments applied to different groups. In trials in which key outcomes are self-reported (eg, visual analogue scale, pain diary), the assessor is considered to be blind if the subject was blind. HYPERLINK \l "p5"[back to PEDro scale]Criterion 8This criterion is only satisfied if the report explicitly states both the number of subjects initially allocated to groups and the number of subjects from whom key outcome measures were obtained. In trials in which outcomes are measured at several points in time, a key outcome must have been measured in more than 85% of subjects at one of those points in time. HYPERLINK \l "p8"[back to PEDro scale]Criterion 9An intention to treat analysis means that, where subjects did not receive treatment (or the control condition) as allocated, and where measures of outcomes were available, the analysis was performed as if subjects received the treatment (or control condition) they were allocated to. This criterion is satisfied, even if there is no mention of analysis by intention to treat, if the report explicitly states that all subjects received treatment or control conditions as allocated. HYPERLINK \l "p9"[back to PEDro scale]Criterion 10A between-group statistical comparison involves statistical comparison of one group with another. Depending on the design of the study, this may involve comparison of two or more treatments, or comparison of treatment with a control condition. The analysis may be a simple comparison of outcomes measured after the treatment was administered, or a comparison of the change in one group with the change in another (when a factorial analysis of variance has been used to analyse the data, the latter is often reported as a group time interaction). The comparison may be in the form hypothesis testing (which provides a "p" value, describing the probability that the groups differed only by chance) or in the form of an estimate (for example, the mean or median difference, or a difference in proportions, or number needed to treat, or a relative risk or hazard ratio) and its confidence interval. HYPERLINK \l "p11"[back to PEDro scale]Criterion 11A point measure is a measure of the size of the treatment effect. The treatment effect may be described as a difference in group outcomes, or as the outcome in (each of) all groups. Measures of variability include standard deviations, standard errors, confidence intervals, interquartile ranges (or other quantile ranges), and ranges. Point measures and/or measures of variability may be provided graphically (for example, SDs may be given as error bars in a Figure) as long as it is clear what is being graphed (for example, as long as it is clear whether error bars represent SDs or SEs). Where outcomes are categorical, this criterion is considered to have been met if the number of subjects in each category is given for each group. HYPERLINK \l "p10"[back to PEDro scale] Appendix 3 Activities of Daily Living Scale of the knee Outcome Survey Instructions: The following questionnaire is designed to determine the symptoms and limitations that you experience because of your knee while perform your usual daily activities. Please answer each question by checking the statement that best describes you over the last 1 to 2 days. For a given question, more than one of the statements may describe you but please mark ONLY the statement which best describes you during your usual daily activities Symptoms To what degree does pain in your knee affect your daily activity level? I never have pain in my knee I have pain in my knee but it does not affect my daily activity Pain affects my activity slightly Pain affects my activity moderately To what degree does grinding or grating of your knee effect your daily activity level? I never have grinding or grating in my knee I have grinding or grating in my knee, but it does not affect my daily activity Grinding or grating affects my activity slightly Grinding or grating affects my activity moderately Grinding or grating affects my activity severely Grinding or grating in my knee prevents me from performing all daily activities To what degree does stiffness in you knee affect you daily activity level? I have never stiffness in my knee I have stiffness in my knee, but it does not affect my daily activity Stiffness affect my activity slightly Stiffness affect my activity moderately Stiffness affect my activity severely Stiffness in my knee prevents me form performing all daily activities To what degree does swelling in your knee affect your daily activity level I never have swelling of my knee I have swelling of my, but it does not affect my daily life Swelling of my knee affect my activity slightly Swelling of my knee affect my activity moderately Swelling of my knee affect my activity severely Swelling in my knee prevents me from performing all daily activities To what degree does slipping of your knee affect your daily activity level? I never have slipping of my knee I have slipping of my knee, but it does not affect my daily activity Slipping of my knee affects my activity slightly Slipping of my knee affects my activity moderately Slipping of my knee affects my activity severely Slipping of my knee prevents me from performing all daily activities To what degree does buckling of your knee affect your daily activity level? I have never have buckling of my knee I have buckling of my knee, but it does not affect my daily activity level Buckling of my knee affect my activity slightly Buckling of my knee affect my activity moderately Buckling of my knee affect my activity severely Buckling of my knee prevent me from performing all daily activities To what degree does weakness or lack of strength of your leg affect your daily life? My leg never feels weak My leg feels weak, but it does not affect my daily activity Weakness affects my activity slightly Weakness affects my activity moderately Weakness affects my activity severely Weakness of my leg prevents me from performing all daily activities Functional Disability with Activities of Daily Living How does your knee affect your ability to walk? My knee does not affect my ability to walk I have pain in my knee when walking, but it does not limit my ability to walk My knee prevents me from walking more than 1 mile My knee prevents me from walking more than mile My knee prevents me from walking more than1 block My knee prevents me from walking Because of your knee, do you walk with crutches or a cane? I can walk without crutches or a cane My knee causes me to walk with one crutch or a cane My knee causes me to walk with two crutches Because of my knee, I cannot walk, even with crutches Does your knee cause you to limp when you walk? I can walk without a limp Sometimes my knee causes me to walk with a limp Because of my knee, I cannot walk without a limp How does your knee affect your ability to go up stairs? My knee does not affect my ability to go up stairs I have pain in my knee when going up stairs, but it does not limit my ability to go up stairs I am able to go up stairs one step at a time with the use of a railing I have to use crutches or a cane to go up stairs I cannot go up stairs How does your knee affect your ability to go down stairs? My knee does not affect my ability to go down stairs I have pain in my knee when going down stairs, but it does not limit my ability to go down stairs I am able to go down stairs normally, but I need to rely on use of a railing I am able to go down stairs one step at the time with the use of a railing I have to use crutches or a cane to go down I cannot go down stairs How does your knee affect your ability to stand? My knee does not affect my ability to stand. I can stand for unlimited amounts of time I have pain in my knee when standing, but it does not limit my ability to stand Because of my knee, I cannot stand for more than 1 hour Because of my knee, I cannot stand for more than hour Because of my knee, I cannot stand for more than 10 min I cannot stand because of my knee How does your knee affect your ability to kneel on the front of your knee? My knee does not affect my ability to kneel on the front of my knee. I can kneel for unlimited amounts of time. I have pain when kneeling on the front of my knee, but it does not limit my ability to kneel I cannot kneel on the front of my knee for more than 1 hour I cannot kneel on the front of my knee for more than 10 minutes I cannot kneel on the front of my knee How does your knee affect your ability to squat? My knee does not affect my ability to squat. I can squat all the way down I have pain when squatting, but I can still squat all the way down I cannot squat more than of the way down I cannot squat more than halfway down I cannot squat more than of the way down I cannot squat at all How does your knee affect your ability to sit with your knee bent? My knee does not affect my ability to sit with my knee bent. I can sit for unlimited amounts of time. I have pain when sitting with my knee bent, but it does not limit my ability to sit I cannot sit with my knee bent for more than 1 hour I cannot sit with my knee bent for more than hours I cannot sit with my knee bent for more than 10 minutes I cannot sit with my knee bent How does your knee affect your ability to rise from a chair? My knee does not affect my ability to rise from a chair. I have pain when rising from the seated position, but it does not affect my ability to rise from a seated position Because of my knee, I can only rise from a chair if I use my hands and arms to assist. Because of my knee, I cannot rise from a chair How would your rate your current level of knee function during your usual daily activities on a scale from 0 to 100, with 100 being your level of knee function prior to your injury? 19. How would you rate the overall function of your knee during your usual daily activities? Normal Nearly normal Abnormal Severely abnormal As a result of your knee injury, how would your rate your current level of daily activity? Normal Nearly normal Abnormal Severely abnormal Since initiation of treatment of your knee, how would you describe your progress? Greatly improved Somewhat improved Neither improved/ worsened Somewhat worse Greatly worse Changes in Daily Activity Level Please use the following scale to answer question a-c below 1= I was able to perform unlimited physical work, which included lifting and climbing. 2= I was able to perform limited physical work, which included lifting and climbing. 3= I was able to perform unlimited light activities, which included walking on level surfaces and stairs. 4= I was able to perform limited physical work, which included walking on level surfaces and stairs. 5= I was unable to perform light activities, which included walking on level surfaces and stairs. Prior to your knee injury would you describe your usual daily activity? Please indicate only the HIGHEST level of activity that described you before your knee injury Prior to surgery or treatment of your knee, how would you describe your usual daily activity? Please indicate the HIGHEST level of activity that described you prior to surgery or treatment to your knee. How would you describe your current level of daily activity? Please indicate only the HIGHEST level of activity that describes you over the last 1 to 2 days. Appendix 4 Sports Activity of the Knee Outcome Survey Instructions: the following questionnaire is designed to determine the symptoms and limitations that you experience because of your knee while you participate in sport activities. Please answer each question by checking the statement that best describes you over the last 1 to 2 days. For a given question, more than one of the statements may describe you, but please mark ONLY the statement which best describes you when your participate in sports activities. Symptoms To what degree does pain in your knee affect your sports activity level? I never have pain in my knee Knee pain does not affect my activity Slightly Moderately Severely Prevents me from performing all sports activities To what degree does grinding or grating of your knee affect your sports activity level? I never have grinding or grating in my knee Grinding/ grating does not affect my activity Slightly Moderately Severely Prevents me from performing all sports activities To what degree does stiffness in your knee affect your sport activity level? I never have stiffness in my knee Stiffness does not affect my activity Slightly Moderately Severely Prevents me from performing all sports activities To what degree does swelling in your knee affect your sport activity level? I never have swelling in my knee Swelling does not affect my activity Slightly Moderately Severely Prevents me from performing all sports activities To what degree does partial giving way or slipping of your knee affect your sport activity level? I never have partial giving way or slipping in my knee Partial giving way or slipping does not affect my activity Slightly Moderately Severely Prevents me from performing all sports activities To what degree does complete giving way or buckling of your knee affect your sport activity level? I never complete giving way or buckling in my knee Knee buckling does not affect my activity Slightly Moderately Severely Prevents me from performing all sports activities Functional Disability with Sport Activities How does your knee affect your ability to run straight ahead? I am able to run straight ahead full speed without limitations I have pain in my knee but it does not affect my ability Slightly Moderately Severely Prevents me from running How does your knee affect your ability to jump and land on your involved leg? I am able to jump and land on my involved leg withous limitations I have pain in my knee but it does not affect my ability Slightly Moderately Severely Prevents me from jumping and landing How does your knee affect your ability to stop and start quickly? I am able to start and stop quickly without limitations I have pain in my knee but it does not affect my ability Slightly Moderately Severely Prevents me from stopping a starting quickly How does your knee affect your ability to cut and pivot on your involved leg? I am able to cut and pivot on my involved leg without limitations. I have pain in my knee but it does not affect my ability Slightly Moderately Severely Prevents me from jumping and landing Sports activity of the Knee Outcome Survey (From Irrgang J.J.. MR Safran, and F. H fu: The knee: Ligamentous and meniscal injuries. In Zachazewski J. E D. J Magee and W.S Quillen Jeds j: Athletic Injuries and Rehabilitation. Philadelphia, W.B Saunders Co 1996 p 685) Appendix 5 The IKDC Knee Examination Form Patient Name: Date of Birth Gender f m Age: _____________ Date of examination Generalized Laxity: tight normal lax Alignment: obvious varus normal obvious valgus Patella Position: baja infera normal alta Patella Subluxation/Dislocation: centered subluxable subluxed dislocated Range of motion (Ext/Flex): index passive active opposite passive active THE IKDC KNEE EXAMINATION FORM 1999 Seven Groups four gradesA = NormalB = Nearly normalC = AbnormalD = Severely Abnormal1. EffusionNoneMildModerateSevere2. Passive motion deficit Lack of extension Lack of flexion <3* 0-5* 3-5* 6-15* 6-10* 16-25* >10* >25*3. Ligament examination (manual, instrumented, x-ray) Lachman (25 flex) (135N) Lachman (25*flex) manual max Anterior endpoint: firm soft Total AP translation (25Flex) Total AP translation (70 flex) Posterior Drawer test (70 flex) Med joint opening (20 flex/valgus rot) Lat joint opening (20 flex/varus rot) External Rotation Test (30 flex prone) Pivot shift Reverse pivot equal  1-2 mm 1-2 mm 0-2 mm 0-2 mm 0-2mm 0-2mm 0-2mm <5* equal shift 3-5mm 3-5mm 3-5mm 3-5mm 3-5mm 3-5mm 3-5mm 6-10* glide glide 6-10mm 6-10 mm 6-10 mm 6-10 mm 6-10mm 6-10mm 6-10mm 11-19* gross gross >10mm >10mm > 10 mm >10 mm >10mm >10mm >10mm >20* marked marked4. Compartement Findings Crepitus ant. Compartment Crepitus med. Compartment Crepitus lat, compartement None None None Moderate Moderate Moderate Mild pain Mild pain Mild pain >mild pain >mild pain >mild pain5. Harvest Site Pathology NoneModerateMild pain> Mild pain6. X-ray Findings Med.joint space Post. Joint space Patellofemoral Ant. Joint space (sagittal) Post. Joint space (sagittal)  None None None None Mild Mild Mild Mild Moderate Moderate Moderate Moderate Severe Severe Severe7. Functional Test One leg hop (% of opposite side) > 90% 89-76% 75-50% <50%  *Final Evaluation Appendix 6 DATA EXTRACTION FORM Article controlled by: Date: Title: Author(s): Magazine found in: Year of publishing: Design: Randomised:Quasi randomised: Training group NMT focus Standard training groupControl groupNo of subjectsNo of subjectsNo of subjectsDrop outs: Total no of subjects. Patient Group: Age: Activity level ACL reconstructionConservative  Objective(s): Method. Duration of study: Training session training groupTraining session controlgroupFrequency:Frequency:Intesity:Intensity:Duration:Duration: Intervention: Perturbation trainingBalance trainingDynamic joint stabilityPlyometric training  Additional intervention: Intervention controlgroup: Measurement tool: Impairment level Disability levelHandicap level  Measurement intervals: Outcome: Impairment levelDisability levelHandicap level  Results: Conclusions: Weakness: Notes: Appendix 7. Lysholm and Gillquist scoring scale Limp (5 points) None Slight or periodic Severe an constant 5 3 0Support (5 points) Full support Stick or crutch Weight bearing impossible 5 3 0Stair climbing (10 points) No problems Slightly impaired One step at a time Unable 10 6 2 0Squatting (5 points) No problems Slightly impaired Not past 90( Unable 5 4 2 0Walking, running and jumping (70 points) Instability: Never giving way Rarely during athletic or other exertion Frequently during athletic or other severe exertion (or unable to participate) Occasionally in daily activity Often in daily activities Every step 30 25 20 10 5 0Pain None Inconstant and slight during athletic or other severe exertion Marked on giving away Marked during severe exertion Marked on or after walking more than 2 km Marked on or after walking less than 2 km Constant and severe 30 25 20 15 10 5 0Swelling None With giving away On severe exertion On ordinary exertion Constant 10 7 5 2 0Atrophy of thigh (5 points) None 1-2 cm More than 2 cm 5 3 0Total score100Modified from Lysholm and Gillquist: Evaluation of knee ligament surgery result with special emphasis on use of a scoring scale. 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