The Long-term Effect of 2 Postoperative

Rehabilitation Programs After Anterior

Cruciate Ligament Reconstruction
A Randomized Controlled Clinical Trial
With 2 Years of Follow-Up
May Arna Risberg,*† PT, PhD, and Inger Holm,‡ PT, PhD
†
From the NAR, Orthopedic Center, Oslo University Hospital, Ullevaal, Oslo, Norway,
‡
and the Division of Rehabilitation, Oslo University Hospital, Rikshospitalet, Oslo, Norway

Background: There is no consensus regarding the optimal postoperative rehabilitation program after anterior cruciate ligament
(ACL) reconstruction.
Purpose: The purpose of this study was to examine the long-term outcome of a 6-month neuromuscular exercise (NE) training
program versus a traditional strength exercise (SE) training program after ACL reconstruction.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: Seventy-four patients were randomly assigned to either a NE program or a SE program and tested preoperatively and
at 6 months, 1 year, and 2 years after ACL reconstruction. Outcome measurements were as follows: Cincinnati knee score, visual
analogue scale for pain and global function, Short Form 36, functional knee tests, and isokinetic muscle strength tests.
Results: There were no significant differences between the NE and SE programs 1 and 2 years after ACL reconstruction for the
primary outcome measurement (Cincinnati knee score). There were significantly improved knee function (global function) and
reduced pain during activity for the NE group, compared with the SE group, and significantly improved hamstring muscle
strength for the SE group, compared with the NE group, 2 years after ACL reconstruction.
Conclusion: There were significantly improved knee function and reduced pain during activities in the NE group, compared with
the SE group, 1 year after ACL reconstruction and significantly improved hamstring muscle strength in the SE group, compared
with the NE group, 2 years after ACL reconstruction.
Clinical relevance: On the basis of these results, a postoperative program combining both NE and SE should be included after
ACL reconstruction to improve knee function.
Keywords: anterior cruciate ligament rehabilitation; neuromuscular exercises; long-term outcome; strength exercises

Quadriceps weakness and impaired neuromuscular con-
trol of the lower extremity are the main functional impair-
ments in those who have undergone anterior cruciate
ligament (ACL) reconstruction.24,47,56 For decades, quadri-
ceps muscle strength has been reported to be significant
in improving functional outcome after ACL injury in
*Address correspondence to May Arna Risberg, Kirkeveien 166, Oslo,
Norway 0407 (e-mail: mayarna.risberg@hjelp24.no).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. X, No. X
DOI: 10.1177/0363546509335196
© 2009 The Author(s)
general and ACL surgery in particular.35,46 Furthermore,
substantial research has recently shown that not only is
quadriceps muscle strength significant for functional out-
come, but so is neuromuscular control.13 Lack of neuro-
muscular control, described as dynamic instability during
functional activities, has been shown to significantly
affect knee function.12 Neuromuscular training programs
for patients with ACL injury have shown significant
effects on knee function, as compared with standard reha-
bilitation programs.4,16 However, randomized control trials
on the effect of exercise programs are still needed before
consensus is reached regarding the best and most effective
rehabilitation program for patients with ACL injury—
specifically, postoperative rehabilitation programs after

1
2   Risberg, Holm The American Journal of Sports Medicine
ACL reconstruction. To our knowledge, only 4 randomized
controlled trials have investigated the effect of a neuro-
muscular training program versus a standard or strength
training program for ACL-deficient4,16 or ACL-reconstructed
patients.4,14,16,43 These studies mostly concluded that neu-
romuscular exercise (NE) seems to improve functional
outcome after ACL injury or reconstruction. However, the
studies have no more than 6 months follow-up time, and
long-term follow-up studies are lacking.
Therefore, the aim of this study was to examine the long-
term effect of a 6-month NE program versus a 6-month
standard muscle strengthening exercise (SE) program for
patients who have undergone ACL reconstruction. We
hypothesized that the 6-month NE program, as compared
with a standard training program, would significantly
improve long-term knee function in patients who under-
went ACL reconstruction.
MATERIAL AND METHODS
This study was a single-blinded randomized clinical trial of
2 postoperative rehabilitation programs, 6 months each,
with long-term follow-up of 1 and 2 years. The study was
approved by the Regional Committee for Medical Research
Ethics, and the patients signed an informed consent before
participating.
Patients
In sum, 27 women and 47 men with a mean age of 28.4
years (range, 16.7-40.3) were included in the study.
Inclusion criteria were (1) individuals scheduled for
arthroscopic ACL bone-patellar tendon-bone graft who
were (2) between the ages of 15 and 40 years. Exclusion
criteria were (1) ACL tear more than 3 years before sur-
gery, (2) tears of the menisci that required repair, (3) previ-
ous injury or surgery to either knee, (4) articular cartilage
fissures extending to subchondral bone, or (5) exposed bone
seen intraoperatively (International Cartilage Repair
Society grade 4).
The participants were randomized into 1 of 2 rehabilita-
tion programs (NE or SE) by simple randomization before
discharge from the hospital. Specifically, our statistician
used a computer-generated table of random numbers to
assign the participants; a research coordinator then kept
the assignment scheme and provided the assignment to
the treating physical therapists in a series of consecutively
numbered opaque envelopes. Allocation was concealed
from the 2 senior testers (I.H. and M.A.R.) and research
assistant at all times. The physical therapists treating the
patients were unaware of any results, until the short-term
results were published.43 After the end of the 6-month
rehabilitation program for all participants, the randomiza-
tion key was identified to analyze and publish the short-
term outcome.43 All participants were preoperatively tested
for baseline measurements, and they returned for follow-up
evaluations at 6 months and 1 and 2 years. At the 1- and
2-year follow-ups, all participants first went through all
tests and then stated which group they were allocated to;
afterward, they were informed of the short-term results.
Nine patients were given such information at the 1-year
follow-up (ie, the testers were not blinded to group alloca-
tion for these 9 participants at the 2-year follow-up).
Rehabilitation Programs
The patients were hospitalized for 1 to 3 days, and the
rehabilitation programs started the second week after sur-
gery at the outpatient clinics, occurring 2 to 3 times a
week. Both rehabilitation programs lasted for 6 months,
which in Norway is the customary length of time for a
rehabilitation program after ACL reconstruction and the
length of time that is reimbursed for patients after surgery.
No knee braces were used after the operation, during the
rehabilitation program, or during the knee performance
tests at the follow-ups. Patients who developed pain, swell-
ing, or range of motion deficits during the rehabilitation
programs underwent treatments using cryotherapy, patel-
lofemoral taping, and range of motion exercises until the
impairments were resolved.
NE Program. The whole NE program has been published
by our group.48 It consists of balance exercises, dynamic
joint stability exercises, plyometric exercises, agility drills,
and sport-specific exercises, and it is divided into 6 phases
of 3 to 5 weeks each. Balance exercises include the double-
and single-leg stance on even, flat surfaces, with progres-
sion to balance on a mat, a wobble board, and a trampoline.
The dynamic joint stability exercises are those described
by Gray20 using vectors on the floor (Star excursion exer-
cises) to reference the start and direction of the exercises
using lower and upper extremities. Plyometric exercises
include jumping exercises to improve jumping performance
and technical skills and to improve shock absorption dur-
ing landing. Finally, agility drills and sport-specific exer-
cises are included to allow the patient to adapt to quick
changes in directions, as well as acceleration and decelera-
tion during sport-specific exercises.
SE Program. The SE program is divided into 4 phases of
2 to 8 weeks, and it consists of strength training exercises
of the lower extremity muscles (quadriceps, hamstrings,
gluteus medii, and gastrocnemii). The goal of the first
phase is to reduce swelling and normalize range of motion
using range of motion exercises in prone and supine posi-
tions, in addition to stationary bicycle exercises using
pendulum movements. Phase 2 does not commence until
swelling and range of motion are controlled. This rehabili-
tation program has been described.43 In phase 3, a full
strength training program is introduced. All exercises are
based on the American College of Sports Medicine’s reco-
mendations2 for intensity and frequency and on current
recommendations for strength training after ACL sur-
gery.15 Moderate- to high-intensity strength training is
based on each patient’s ability to tolerate increased load-
ing (weights). Recommended frequency and exercise regi-
men are as follows: 3 sets of 8 to 12 repetitions, 2 to 3 days
a week, at 50% to 80% of 1 repetition max,2 starting with
12 to 15 repetitions and ­progressing to fewer repetitions
Vol. X, No. X, XXXX Long-Term Effect of 2 Postoperative Rehabilitation Programs   3
(ie, 8 to 12). Phase 4 involves decreased repetitions and
increased weights (3 sets, 6 to 8 repetitions), individually
adjusted. For patients who wish to return to sports, sport-
specific exercises based on their previous sporting activi-
ties are introduced.
Compliance. A training diary was completed by the
patients after each training session at the outpatient clinic
to document their compliance with the rehabilitation pro-
gram, in addition to other exercises they performed or to
training that they did elsewhere (leisure time activities).
The training diary included the number of visits and hours
spent at the outpatient clinic performing exercises, as well
as the number of other exercise sessions and hours spent
doing exercise activities outside the outpatient clinic.
Assessments
The primary outcome measurement was a self-adminis-
tered questionnaire, the Cincinnati knee score,37,44,46 which
consists of the following variables: pain (20 points), swell-
ing (10 points), giving way (20 points), general activity level
(20 points), walking (10 points), stair climbing (10 points),
running (5 points), and jumping or twisting activities
(5 points). The maximum score is 100 points, indicating a
normal knee. The Cincinnati knee score has been shown to
have good reliability, with an intraclass correlation coeffi-
cient of .88 for test-retest reliability.33 Patients evaluated
their pain with a visual analogue scale (VAS) that asked
how they considered their knee pain during activities and
right after activities. Specifically, they drew a line on a VAS
where 0 represented no pain and 100 represented extreme
pain.11,39 Furthermore, they used a VAS to self-evaluate
knee function—that is, a global rating of knee function, as
used in several other studies.17,44 In it, 0 represented worst
possible knee function, and 100, same knee function as
before the injury. Before testing, all participants performed
a 6- to 8-minute warm-up on an ergometer bicycle. Knee
extension and flexion muscle strength were isokinetically
tested using a Cybex 6000 (Cybex, Division of Lumex Inc,
Ronkonkoma, New York).23,29 The test protocol consisted of
5 repetitions at an angular velocity of 60° per second
(extension and flexion total work), followed by a 1-minute
rest period, and 30 repetitions at 240° per second (exten-
sion and flexion total work). The muscle strength tests
were performed for the involved leg and the uninvolved leg
(the parameter used was total work23). In addition, the
percentage differences between the 2 legs were calculated:
(injured leg / noninjured leg) × 100. Isokinetic muscle
strength tests have shown high reliability,8 with intraclass
correlation coefficients ranging from .81 to .97.
Three single-legged hop tests were included as knee
performance tests: the 1-legged hop test, the triple hop
test, and the stair hop test.36,41 These functional knee tests
have shown good reliability,7,42 with intraclass correlation
coefficients ranging from .81 to .99. Two trials were per-
formed on each leg, and all patients started jumping on
the noninjured leg. For the 1-legged and triple hop tests,
the distances were measured in centimeters for each leg,
and the side-to-side differences in performance between
injured and noninjured legs were calculated as an index:
(injured leg / noninjured leg) × 100. The stair hop test was
performed as follows: Patients hopped up and down a stair-
case (22 steps) with a step height of 17.5 cm. Time was
recorded, and side-to-side differences in performance
between noninjured and injured leg were given as an
index: (noninjured leg / injured leg) × 100.
The commonly used Short Form 36 (SF-36) was used as
a health-related measurement of quality of life.31,50 The
instrument is divided into 8 subscales: physical function-
ing, role limitations–physical, bodily pain, general health,
vitality, social function, role limitations–emotional, and
mental health. The instrument has a scale of 0 to 100 for
each subscale: the higher the score, the better the health
status. The Norwegian version of the SF-36 has shown
high reliability, with Cronbach alpha for all the 8 subscales
exceeding the .70 standard for group comparison and with
Cronbach alpha exceeding the .90 standard for the Physical
Functioning subscale for individual comparisons.32
Expert raters recorded knee joint laxity using the maxi-
mum manual KT-1000 knee arthrometer test.3 The KT-1000
arthrometer has been shown to be a reliable instrument,
with reported intraclass correlation coefficients between
.91 and .97 for the involved knee8 and with better inter-
rater reliability for expert raters than for novices.5
Statistical Analysis
A priori statistical power analysis was performed. Sample
size calculations estimated that 36 patients would be
needed in each group to detect the following: a 10-point dif-
ference in the Cincinnati knee score between the 2 groups,
a standard deviation of 13 points, an alpha level of .05, and
a beta level of .10. The 10-point difference and the 13-point
standard deviation were based on the results of previous
studies done by our group45,46 and other comparative stud-
ies.25 Intention-to-treat analysis was included using the
last observation carried forward from postintervention
data to the 1- and 2-year follow-up (Figure 1). Data were
analyzed using analysis of covariance for outcome mea-
surements at the 1- and 2-year follow-up (as dependent
variables), with rehabilitation group as the between-factor
variable and with preoperative data as covariates. Studies
have repeatedly demonstrated that analysis of covariance
incorporating baseline data has greater statistical power
to detect a treatment effect than do the other methods of
change in score and follow-up score alone.18,52,53 Independent
t test was used to determine group differences (NE and SE)
at baseline, and Mann-Whitney test was used when para-
metric assumptions were not fulfilled. Normal distribution
was tested using skewness normality test. A probability
level of P < .05 was used to show statistical significance.
RESULTS
Seventy-four patients were included and randomized
to the NE group (n = 39) and the SE group (n = 35)
(Figure 1). Eighty-one patients were eligible for the study
4   Risberg, Holm The American Journal of Sports Medicine

Assessed for eligibility

(n=81)

Excluded
(n=7)
Reason:
Enrollment Not meeting inclusion criteria
(n=6)
Randomization Other reasons
(n=74) (n=1)

Allocated to Allocated to
Neuromuscular exercises (NE) Strength Exercises (SE)
Allocation
(n=39) (n=35)
Received allocated intervention
Received allocated intervention

Lost to follow-up (FU) Post-intervention Lost to follow-up (FU)

6 months (n=5) 6 months 6 months (n=4)
1 year (n=5) 1 year (n=4)
2 years (n=7) 1 year 2 years (n=7)
Reason for lost to FU: Follow-Up Reason for lost to FU:
Did not show up for tests or did 2 years Did not show up for tests or did
not return calls or letters Follow-Up not return calls or letters

ITT analysis
Analysis ITT analysis
1 and 2 years FU (n=36)
1 and 2 years FU (n=33)
Reason:
Reason:
No baseline tests (n=1)
Only baseline tests (n=2)
Only baseline tests (n=2)

Figure 1. CONSORT (Consolidated Standards of Reporting Trials) flow chart of the study, including intention-to-treat (ITT)
analysis.

­ reoperatively, but 7 were not included (1) because of an

p (46%); 29 with cartilage injuries grade 1, 2, or 3 (45%); and
intraoperative evaluation of cartilage injuries, (2) because
of a partial ACL rupture, (3) because they did not show
up at the time of surgery, (4) because they had a menis-
cal repair, or (5) because the surgeon used a hamstring
graft for ACL reconstruction. One patient was included in
the study (randomized) but left the city and was excluded
owing to an inability to attend any of the visits at the out-
patient clinic. Preoperatively, there were no significant dif-
ferences between the 2 rehabilitation groups with respect
to sex, age, time from injury to operation, knee joint laxity,
activity level, or any other variable recorded (Table 1).
Follow-up at 6 Months, 1 Year, and 2 Years
The mean time from injury to surgery was 46.4 weeks
(range, 7.4-152.9). There were 34 with meniscal injuries
19 with both meniscal injury and cartilage injury (30%).
All the meniscal injuries were debrided, and no additional
treatment was required for those with cartilage injury.
Sixty-five patients returned for follow-up examination at
6 months (89%), 65 at 1 year (89%), and 60 at 2 years
(81%). The 14 who did not return for the 2-year follow-up
(7 from the NE group and 7 from the SE group) were not
significantly different from those who returned for the
2-year follow-up, except for preoperative activity level.
Those who returned for follow-up had a significantly higher
preoperative Tegner score (median, 4) than did those who
did not return at the 2-year follow-up (median, 1; P = .003).
At the 2-year follow-up, 7 patients had been through addi-
tional surgery: 3, meniscal surgery (1 from the NE group
and 2 from the SE group); 1, ACL revision surgery owing
to rerupture when he traced a burglar (NE group); 2,
Vol. X, No. X, XXXX Long-Term Effect of 2 Postoperative Rehabilitation Programs   5

TABLE 1
Primary and Secondary Outcome Measurements: Strength Exercise (SE) and Neuromuscular Exercise (NE) Groupsa

Preoperative 6 Months 1 Year 2 Years

SE NE SE NE SE NE SE NE

Variable n = 35 n = 39 n = 31 n = 34 n = 33 n = 36 n = 33 n = 36

KT-1000, mm difference 7.9 ± 3.6 7.2 ± 4.3 3.0 ± 2.9 3.4 ± 2.6 3.1 ± 2.8 3.6 ± 2.6 3.0 ± 2.7 4.0 ± 2.9
Cincinnati knee score 65.3 ± 13.0 65.2 ± 17.0 73.4 ± 9.6 80.5 ± 12.3b 80.6 ± 12.5 85.8 ± 11.5c 85.2 ± 10.8 88.7 ± 10.6
b
Pain during activity 35.4 ± 23.3 35.2 ± 26.5 24.6 ± 20.3 20.7 ± 21.0 26.8 ± 24.4 15.9 ± 16.6 21.1 ± 23.3 14.0 ± 19.3
   (VAS), mm
b
Global function (VAS), mm 33.9 ± 25.3 39.1 ± 25.5 59.3 ± 23.1 72.4 ± 22.1 65.2 ± 28.8 81.8 ± 19.6b 71.8 ± 25.3 82.0 ± 23.4
Triple hop test, % 94.6 ± 10.2 91.8 ± 12.3 83.1 ± 15.4 88.5 ± 10.4 92. 2 ± 11.4 92.9 ± 7.9 96.0 ± 9.7 96.2 ± 8.6
One-legged hop test, % 93.7 ± 11.3 90.1 ± 15.5 81.0 ± 18.2 84.9 ± 10.9 89.5 ± 13.7 91.4 ± 9.9 93.9 ± 12.5 94.0 ± 10.1
Stairs hop test, % 84.8 ± 18.1 78.4 ± 21.0 79.8 ± 16.4 79.8 ± 25.7 86.1 ± 16.9 87.7 ± 12.9 92.3 ± 15.0 91.2 ± 10.4
Flexion total work, 80.6 ± 19.5 82.9 ± 20.4 88.3 ± 14.4 86.3 ± 14.3 94.7 ± 14.6 93.2 ± 18.1 92.0 ± 13.9 95.6 ± 17.7
   60° per second, %
b
Flexion total work 87.6 ± 18.4 86.8 ± 24.2 94.7 ± 16.1 90.8 ± 21.1 100.1 ± 15.7 91.9 ± 16.0 103.9 ± 13.4 91.5 ± 18.9b
  
240° per second, %
Extension total work 79.0 ± 18.0 79.4 ± 20.6 67.3 ± 16.1 70.1 ± 17.1 82.5 ± 14.7 83.8 ± 13.6 88.5 ± 14.1 90.1 ± 13.9
   60° per second, %
Extension total work 84.7 ± 12.8 83.7 ± 17.9 78.0 ± 16.0 79.0 ± 16.8 85.8 ± 13.4 87.3 ± 11.0 90.5 ± 12.5 88.1 ± 17.2
   240° per second, %

a
After anterior cruciate ligament reconstruction based on intention to treat analysis. VAS, visual analogue scale.
b
P < .05 between SE and NE group.
c
P = .058 between SE and NE group.

arthroscopic surgery (1 due to knee-locking problems and 1

due to release of adhesions); and 1, lengthening of the
patellar tendon owing to reduced knee flexion range of
motion (NE group).
After terminating the rehabilitation program 6 months
after surgery, the NE group had significantly improved
knee function, determined by the Cincinnati knee score (P
= .01) and the global function rating (P = .02), when com-
pared with the SE group, as previously published by our
group43 (Table 1 and Figures 2 and 3). At 1-year follow-up,
the Cincinnati knee score was still higher for the NE group
than for the SE group (but only borderline significant; P = Figure 2. Cincinnati knee score tested preoperatively and at
.058), and the NE group showed a significantly improved 6 months, 1 year, and 2 years after anterior cruciate ligament
knee function, as measured by the global function, when reconstruction. aP = .01.
compared with the SE group (P = .009) (Figure 3). The
reduction in pain during activity was larger for the NE
group from 6 months to 1 year, which also disclosed sig-
nificant lower pain during activities at 1 year, as compared
with the SE group (P = .02) (Table 1 and Figure 4). The
muscle strength tests did not show any significant differ-
ences between the 2 groups after termination of the reha-
bilitation program at 6 months,43 nor did the isokinetic
muscle strength tests at 60° per second at the 1- or 2-year
follow-up (Table 1 and Figures 5 and 6). But the knee flex-
ion muscle strength test at 240° per second showed sig-
nificantly improved flexion muscle strength for the SE
Figure 3. The global function rating (visual analogue scale)
group, as compared with the NE group, at the 2-year
tested preoperatively and at 6 months, 1 year, and 2 years
follow-up (P = .005) (Table 1 and Figure 5).
after anterior cruciate ligament reconstruction. aP < .02.
The SF-36 subscale scores showed no significant differ-
ences between the 2 groups at 6 months, 1 year, or 2 years
after ACL reconstruction, except for the Bodily Pain sub- the SE group (72.9 ± 18.6) than the NE group (83.3 ± 18.0)
scale, which showed significantly more pain reported by (P = .03) at the 1-year follow-up.

   5
6   Risberg, Holm The American Journal of Sports Medicine

Compliance

Thirty-four patients in the NE group (87%) and 24 in the

SE group (69%) filled in and returned their training dia-
ries. There were no significant differences between the
number of weeks that the individuals participated in the
rehabilitation program (NE group, 18.8 weeks; SE group,
20.4 weeks; P = .30). The number of physical therapy vis-
its was, however, significantly lower for the NE group
(42.2 visits) than for the SE group (57.6 visits; P = .001),
and the mean number of hours spent at the physical
therapy outpatient clinic was lower for the NE group (43.8 Figure 4. Pain during activities (visual analogue scale) tested
hours) than for the SE group (62.9 hours; P = .002). There preoperatively and at 6 months, 1 year, and 2 years after
were no significant differences between the 2 groups anterior cruciate ligament reconstruction. aP = .02.
regarding the mean number of additional exercise ses-
sions (NE, 12.9; SE, 22.0; P = .09) and the mean hours
spent doing other exercises (NE, 11.0; SE, 16.2; P = .38).
Regarding compliance with the rehabilitation program,
71% of the NE group and 91% of the SE group were cate-
gorized as being compliant.

DISCUSSION

The results show that the NE program was superior to the

SE program on self-reported function and pain up to 1 year
after ACL reconstruction (Cincinnati knee score, global
function, and pain during activities). However, the improve- Figure 5. Knee flexion muscle strength, as measured using
ment in knee flexion muscle strength seemed to be superior isokinetic muscle strength test at 60° per second, tested
for the SE group than for the NE group for the long-term preoperatively and at 6 months, 1 year, and 2 years after
follow-up (both 1 and 2 years). Both training programs pro- anterior cruciate ligament reconstruction. Given as percent-
vided similar long-term improvements for knee extension age differences between injured and uninjured legs.
muscle strength, knee performance (single-legged hop
tests), and health-related quality of life. Our hypothesis
was therefore only partly confirmed.
To our knowledge, this is the first study to report long-
term follow-up results from a randomized controlled trial
of the effect of a postoperative NE program versus a
strength training program after ACL reconstruction.
However, a few randomized controlled trials have examined
the short-term effect of NE,4,14,16,26,30,43 closed versus open
kinetic chain exercises,10,22,34,51 supervised versus home-
based rehabilitation programs, and other types of rehabili-
tation programs after ACL injury4,16,26,34,51 and ACL
reconstruction.14,22,30,34,43 Previous studies on the short-
term effect of NE for ACL-deficient patients have found
significantly improved knee function, compared with stan-
dard rehabilitation programs16 and strength training pro- Figure 6. Knee extension muscle strength measured
grams only.4 Only 2 studies examined the effect of NE after using isokinetic muscle stength test at 60° per second, test-
ACL reconstruction: Liu-Ambrose et al30 included 10 ed properatively and at 6 months, 1 year, and 2 years after
patients (5 in each rehabilitation group) and started the anterior cruciate ligament reconstruction. Given as percent-
program 6 months after surgery; they found no significant age differences between injured and uninjured legs.
differences between the neuromuscular training group and
the strength training group, probably because of a lack of with the neuromuscular training group; however, they did not
statistical power. Cooper et al14 included 30 patients (15 in measure muscle strength.
each group), and the neuromuscular training program and Rehabilitation has been considered one of the key fac-
the strength training program started 4 to 14 weeks after tors for regaining quadriceps muscle strength and neuro-
ACL reconstruction and lasted for 6 weeks. The research- muscular control to return to activities of daily living and
ers found less swelling and significantly improved gait and sporting activities after ACL injury and ACL surgery.47
squatting ability in the strength training group, compared When we started this study in 1999, traditional strength
Vol. X, No. X, XXXX Long-Term Effect of 2 Postoperative Rehabilitation Programs   7
training programs after ACL reconstruction had been the
focus for many years, but the recent focus has been on
neuromuscular training programs. Today current practice
for rehabilitation programs after ACL injury and recon-
struction suggests including both SE and NE.43,47,48
However, strength training is today considered signifi-
cant in all sports rehabilitation programs and in reha-
bilitation after ACL injury.38,55 As such, this study
highlights the importance of including NE in the postop-
erative rehabilitation.
The 2 rehabilitation programs in this study did not target
neuromuscular control only or muscle strengthening only.
NE also includes plyometric exercise, which has shown to
increase muscle strength.1,54 The stretch-shortening cycle
activated during plyometric exercise involves eccentric con-
traction followed by a stronger concentric contraction, which
has been shown to develop forces higher than those of con-
centric contractions only.1,54 Furthermore, the NE group
performed the exercises in more weightbearing positions
(closed kinetic chain exercises) than did the SE group, which
performed more open kinetic chain exercises. The SE pro-
gram included open kinetic chain exercises for quadriceps
and hamstrings.43 Previous studies have shown that open
kinetic chain exercises seem to be superior in improving
muscle strength; however, these studies examined the effect
of open kinetic chain exercises for improving quadriceps
muscle strength34,51 but not hamstrings muscle strength.
Better improvement in hamstring muscle strength was
found for the high speed (240° per second) in the SE group
at the 1-year (P = .052) and 2-year follow-up (P = .005), com-
pared with the NE group; this result could be due to the
open kinetic chain exercises included in the SE program.
However, there were no significant differences at the
6-month follow-up (postintervention), nor were there any
significant differences in any of the other muscle strength
variables between the 2 programs at any time. This signifi-
cant improvement in high-speed isokinetic flexion muscle
strength for the SE group, compared with the NE group, did
not seem to have any clinical relevance based on the other
clinical data at the 2-year follow-up. All other clinical data
showed either no significant difference between the 2
groups or significant better functional outcome for the NE
group (global function and pain during activities). Isokinetic
muscle strength test is the most commonly used strength
test for examining knee flexion and knee extension muscle
strength,23 but most studies included low-speed tests only.
The aim of ACL reconstruction followed by rehabilita-
tion is to get the patients back to normal knee function as
fast as possible. As such, longer follow-up studies are
needed to examine the effect of postoperative rehabilita-
tion. This study showed small differences between the 2
rehabilitation programs after the 1-year follow-up;
however, it is of great clinical relevance to know which
postoperative rehabilitation program resolves knee impair-
ments and dysfunctions early after surgery. The Cincinnati
knee scores from this study are comparable with those
from other studies that evaluated ACL-reconstructed
patients with similar characteristics. Nevertheless, the
knee function score for the ACL-reconstructed patients
indicated that not everyone had returned to normal func-
tion. At the 1-year follow-up, 29% had a Cincinnati score
less than 80 (7 in the NE group and 12 in the SE group).
And at the 2-year follow-up, 18% had a Cincinnati knee
score less than 80, but there were no differences between
the NE and SE groups (6 in NE group and 5 in the SE
group).
Patient-based outcome measures have significantly
increased during the last 10 years; they are now commonly
used as primary outcome measures of a treatment’s effect;
and they have proven to be a significant contribution to
evaluating function after surgical intervention.9,19 Studies
have shown that the evaluation of functional problems,
health-related quality of life, performance limitations, and
activity restrictions appears to be more important to
patients than just the evaluation of clinical symptoms.21 The
individual’s perception of function and adaptation to change
in health status has been reported to change over time after
treatment (response shift in outcome assessment).40 The
Cincinnati knee score was used as the main outcome mea-
surement in this study, and it has been used in several
studies.6,43,46 Previous studies have shown that the
Cincinnati knee score is a sensitive and valid outcome
measurement for evaluating knee function after ACL
reconstruction.44 However, in recent years, other valid
knee outcome questionnaires have been developed,27,49 but
their outcome measurements were not developed when we
planned and started this randomized controlled trial (in
1999). The VAS for global function and the VAS for record-
ing pain have been commonly used in outcome studies for
patients with ACL injury and ACL reconstruction.28,39
Health-related quality of life, using the well-documented
SF-36 form, showed no significant differences between the
2 groups, except for the significantly more pain reported by
SE group on the Bodily Pain subscale (P = .03) at the
1-year follow-up, which supports the significantly lower
pain during activities reported for the NE group as evalu-
ated by the VAS (P = .02). Statistical power was not calcu-
lated on the basis of the SF-36 score; thus, more patients
might have been needed to detect a significant difference
between the 2 groups for the Bodily Pain subscale score.
During the rehabilitation program, we recorded compli-
ance regarding the number of physical therapy visits and
time spent at the rehabilitation facilities, in addition to the
physical activities performed outside the outpatient clinic.
The number of physical therapy visits was significantly
lower for the NE group than for the SE group (P = .001), as
was the mean number of hours spent at the outpatient
clinic (P = .002), but there were no differences in activities
performed outside the outpatient clinic. To ensure that the
participants complied with the specific exercises, we used
2 outpatient clinics (1 for each group); namely, we wanted
to eliminate the possibility of cross-communication between
the NE group and the SE group. The SE program was car-
ried out in a larger facility with more training equipment
and more modern fitness apparatuses.
Some limitations need to be addressed. The most signifi-
cant challenges to prospective long-term follow-up studies
are the dropouts and lost follow-up. In this study, we lost 9
patients (4 in the NE group and 5 in the SE group) at the
1-year follow-up (11%) and 14 (7 in each group) at the 2-year
8   Risberg, Holm The American Journal of Sports Medicine
follow-up (19%). We included intention-to-treat analysis as
recommended in such trials; however, there were only small
differences in outcome using intention-to-treat analysis or
per-protocol analysis. A reduction in statistical power because
of dropouts could be significant; however, there were no other
outcome variables that showed borderline-significant differ-
ences between the 2 groups, except for those already men-
tioned: At the 1-year follow-up, there was a tendency toward
improved knee function for the NE group, compared with the
SE group (P = .058), and a lower Bodily Pain score (SF-36) for
the NE group, compared with the SE group (P = .059). The
statistical power calculations were based on only the main
outcome measurement (Cincinnati knee score); therefore, we
do not know if there was enough statistical power to detect
significant differences between the 2 rehabilitation programs
for the secondary outcome measurements. Those patients
who returned for the 2-year follow-up had a significantly
higher activity level than that of those who did not return for
follow-up (P = .003). It is hard to explain these differences in
activity level other than to say that those who did return
were possibly more motivated to participate because of their
interest in their physical health status (Tegner level: median,
4 vs median, 1). However, this finding was accounted for
through the intention-to-treat analysis. Another limitation of
the study is that we did not have information on the activities
that the participants returned to (and when) after the
6-month rehabilitation program and at the 1- and 2-year fol-
low-up after ACL reconstruction.
The clinical recommendation from the present study is
(1) that NE—including balance exercises, dynamic joint
stability exercises, and plyometric exercises—should be
included in rehabilitation programs after ACL reconstruc-
tion using bone-patellar tendon-bone graft, to achieve
improved self-reported knee function and (2) SE is a sig-
nificant addition to plyometric exercise to increase muscle
strength. However, what remains to be studied is whether
both types of exercise (NE and SE) significantly improve
quadriceps and hamstring muscle strength to a higher
degree than that of one of the programs alone.
CONCLUSION
The patients’ perception of knee function, as reported by
global function and pain during activities, was significantly
improved in the NE group, compared with the SE group, at
the 1-year follow-up. The knee flexion muscle strength (240°
per second) was significantly improved in the SE group, com-
pared with the NE group, 2 years after ACL reconstruction.
For the other outcome measurements, there were no signifi-
cant differences between the 2 postoperative rehabilitation
programs at the 1- and 2-year follow-up. On the basis of the
current available research, we suggest the inclusion of both
types of exercise, NE and SE, in postoperative rehabilitation
programs for patients undergoing ACL reconstruction.
ACKNOWLEDGMENT
We gratefully acknowledge physical therapists Hanne
Krogstad Jenssen and Marianne Mork, Department of
Physical Medicine and Rehabilitation, Ullevaal University
Hospital, Oslo, Norway, and Grethe Myklebust, Turid
Høysveen, and Gitte Madsen at Norwegian, Sports
Medicine Clinic, Oslo, Norway, for performing the rehabili-
tation programs, as well as physical therapists Camilla
Ramsland and Siri Elliassen, Orthopedic Center, Ullevaal
University Hospital, for coordinating patients and tests
throughout this rehabilitation study. This study received
research grants from the Norwegian Research Council,
Oslo, Norway, and the Eastern Health Regional Authority.
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