2025, Vol. 29 ›› Issue (8): 1714-1726

Efficacy of exercise therapy in the treatment of anterior cruciate ligament reconstruction patients: a network meta-analysis

Wang Juan, Wang Guanglan, Zuo Huiwu   

Abstract: OBJECTIVE: Exercise intervention is considered the cornerstone of rehabilitation after anterior cruciate ligament reconstruction. However, no clear conclusion has been reached regarding which exercise therapy is more effective in improving knee muscle strength and function in patients after anterior cruciate ligament reconstruction. To this end, this study used a network meta-analysis method to compare the efficacy of exercise therapy after anterior cruciate ligament reconstruction, providing evidence-based medical basis for selecting the best exercise therapy.
METHODS: A computer search was conducted in PubMed, Web of Science, Embase, The Cochrane Library, and EBSCO to collect randomized controlled trials addressing exercise therapy following anterior cruciate ligament reconstruction. The search time limit was from the establishment of the database to 2023-11-20. Outcome indicators included three continuous variables: quadriceps muscle strength, hamstring muscle strength, and knee joint function score. EndNote X9.1 was used for literature screening. The Cochrane risk of bias assessment tool was used to evaluate the quality of the included literature. The GRADE score was used to rate the strength of evidence for the results of the article. Network meta-analysis was performed using Stata 16.0.
RESULTS: A total of 36 randomized controlled trials were included, involving 1 179 patients undergoing anterior cruciate ligament reconstruction. The overall quality of the included literature was moderate. Nine types of exercise therapies were involved: isokinetic training, cross training, eccentric training, aquatic rehabilitation, blood flow restriction training, motor control training, plyometric training, whole-body vibration training, and multimodal training; the control measure was conventional rehabilitation training. The results of the network meta-analysis showed that compared with conventional rehabilitation training, eccentric training [standardized mean difference (SMD)=2.08, 95% confidence interval (CI): 0.56 to 3.60, P=0.007) had the best improvement effect on quadriceps muscle strength in patients undergoing anterior cruciate ligament reconstruction, followed by multimodal training (SMD=1.69, 95% CI: 0.11 to 3.27, P=0.249) and whole body vibration training (SMD=0.81, 95% CI: 0.11 to 1.51, P=0.042). In terms of improving patients’ hamstring muscle strength, multimodal training (SMD=2.08, 95% CI: 0.30 to 3.86, P=0.022) had the best effect, followed by plyometric training (SMD=1.51, 95% CI: 0.18 to 2.84, P=0.026) and isokinetic training (SMD=1.37, 95% CI: 0.06 to 2.67, P=0.039). Multimodal training (SMD=4.60, 95% CI: 2.40 to 6.80, P < 0.001) was the most effective in improving knee joint function scores, followed by eccentric training (SMD=1.75, 95% CI: 0.24 to 3.25, P=0.023) and aquatic rehabilitation (SMD=1.65, 95% CI: 0.07 to 3.24, P=0.041).
CONCLUSION: Evidence of low to moderate strength suggests that multimodal training may be the most effective exercise therapy in improving knee muscle strength and function in patients after anterior cruciate ligament reconstruction, followed by eccentric training, plyometric training, isokinetic training, whole body vibration training, and aquatic rehabilitation. More high-quality clinical randomized controlled trials are still needed in the future to verify the reliability of the conclusions.
Key words: exercise therapy, anterior cruciate ligament, anterior cruciate ligament reconstruction, muscle strength, quadriceps strength, hamstring strength, knee joint function, randomized controlled trial, network meta-analysis