Hydrotherapy in ACL Rehabilitation: Difference between revisions

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== '''Introduction:''' ==
==Introduction==
[[Aquatherapy]] and [[Hydrotherapy-Balneotherapy]] are terms used interchangeably to indicate a modality of treatment performed in an aquatic environment. This page will attempt to assimilate the current literature for incorporating hydrotherapy into conventional rehabilitation of [[Anterior Cruciate Ligament (ACL) Injury]], conservatively or alongside [[Anterior Cruciate Ligament (ACL) Reconstruction]] (ACLR).
[[Anterior Cruciate Ligament (ACL)]] injuries are a common orthopedic condition, especially among [[Athletes with Disabilities|athletes]] and young people, which can have long term physical and lifestyle impacts<ref>Krause M, Freudenthaler F, Frosch KH, Achtnich A, Petersen W, Akoto R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381773/ Operative Versus Conservative Treatment of Anterior Cruciate Ligament Rupture]. Dtsch Arztebl Int. 2018 Dec 24;115(51-52):855-862.</ref>. This may include post traumatic [[arthritis]], [[Meniscal Lesions|meniscus]] or [[cartilage]] injuries, [[knee]] instability, as well as impaired [[Quality of Life|quality of life]] and not returning to [[Sport Injury Classification|sport]]<ref name=":6">Filbay SR, Grindem H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723618/#bib1 Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture]. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):33-47.</ref><ref>Kohn L, Rembeck E, Rauch A. Verletzung des vorderen Kreuzbandes beim Erwachsenen : [https://pubmed.ncbi.nlm.nih.gov/33084915/ <nowiki>Diagnostik und Therapie [Anterior cruciate ligament injury in adults : Diagnostics and treatment]</nowiki>]. Orthopade. 2020 Nov;49(11):1013-1028. </ref>.  At present, recommended treatment options are surgical [[Anterior Cruciate Ligament (ACL) Reconstruction|reconstruction]], or conservative management, with both these approaches requiring [[Rehabilitation Frameworks|rehabilitation]]<ref name=":6" /> .  Research continues to investigate how to optimize ACL rehabilitation, including utilizing hydrotherapy. [[Aquatherapy|Hydrotherapy]] is the delivery of physiotherapy treatment in an aquatic environment, utilizing the properties of water (density, buoyancy, hydrostatic pressure and viscosity)<ref>Aquatic Therapy Association of Chartered Physiotherapists (ATACP). About ATACP. Available from: https://atacp.csp.org.uk/content/about-atacp (Accessed 19/12/2022)</ref>. [[File:ACL rupture.png|thumb|350x350px|alt=|center]]
 
==Outcome Measures of ACL Rehabilitation==
== '''Outcome measures of ACL rehabilitation:''' ==
* Instability episodes <ref name=":0">Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM. [https://www.ncbi.nlm.nih.gov/pubmed/15716249 Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee]. The American journal of sports medicine. 2005 Mar;33(3):335-46.</ref>
* Instability episodes <ref name=":0">Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM. [https://www.ncbi.nlm.nih.gov/pubmed/15716249 Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee]. The American journal of sports medicine. 2005 Mar;33(3):335-46.</ref>
* Pain <ref name=":0" />
* [[Pain Assessment|Pain]] <ref name=":0" />
* [[Oedema Assessment|Swelling]]
* [[Passive Range of Motion: Shoulder flexion|Passive]] range of motion (knee [[Flexion Deformity of the Knee|flexion]] & [[Knee Extension Resistance Test|extension]])<ref name=":7">Tovin BJ, Wolf SL, Greenfield BH, Crouse J, Woodfin BA. [https://www.ncbi.nlm.nih.gov/pubmed/8047560 Comparison of the effects of exercise in water and on land on the rehabilitation of patients with intra-articular anterior cruciate ligament reconstructions]. Physical Therapy. 1994 Aug 1;74(8):710-9.</ref>
* Muscle strength<ref name=":7" />
* Thigh circumference (thigh girth, thigh muscle mass, knee joint swelling) <ref name=":3">Zamarioli A, Pezolato A, Mieli E, Shimano A. [https://www.researchgate.net/publication/246277800_The_significance_of_water_rehabilitation_in_patients_with_anterior_cruciate_ligament_reconstruction The significance of water rehabilitation in patients with anterior cruciate ligament reconstruction.] Physiotherapy. 2008 Apr 1;16(2):3-6.</ref><ref name=":7" />
* Active range of motion (knee flexion & extension) <ref name=":5" />
* Issues with:
* Issues with:
** Swelling, walking, climbing, stairs, kneeling, squatting, running, lateral motion, cutting, jumping <ref name=":0" />
**[[Gait|Walking]], climbing, stairs, kneeling, squatting, running, lateral motion, cutting, jumping <ref name=":0" />
* Measures of knee function:
* Measures of knee function:
** Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) <ref name=":0" /><ref name=":1">Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. [https://www.nejm.org/doi/full/10.1056/NEJMoa0907797 A randomized trial of treatment for acute anterior cruciate ligament tears]. New England Journal of Medicine. 2010 Jul 22;363(4):331-42.</ref>
** Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) <ref name=":0" /><ref name=":1">Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. [https://www.nejm.org/doi/full/10.1056/NEJMoa0907797 A randomized trial of treatment for acute anterior cruciate ligament tears]. New England Journal of Medicine. 2010 Jul 22;363(4):331-42.</ref>
** International Knee Documentation Committee (IKDC) form, Lysholm and Tegner scores<ref name=":0" />
** International Knee Documentation Committee (IKDC) form, Lysholm and Tegner scores<ref name=":0" />
** Knee Injury and Osteoarthritis Outcome Score (KOOS<sub>4</sub>) <ref name=":1" />
** [[Knee Injury and Osteoarthritis Outcome Score|Knee Injury and Osteoarthritis Outcome Score (KOOS<sub>4</sub>)]] <ref name=":1" />
* Graft rupture (post-ACLR only) <ref name=":2">Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. [https://www.ncbi.nlm.nih.gov/pubmed/16084292 Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction]. Arthroscopy. 2005 Aug 1;21(8):948-57.</ref>
* Graft rupture post-ACL reconstruction <ref name=":2">Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. [https://www.ncbi.nlm.nih.gov/pubmed/16084292 Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction]. Arthroscopy. 2005 Aug 1;21(8):948-57.</ref>
* Contralateral ACL injury <ref name=":2" />
* Contralateral ACL injury <ref name=":2" />
* Lachman and pivot-shift <ref>Kostogiannis I, Ageberg E, Neuman P, Dahlberg LE, Fridén T, Roos H. [https://www.ncbi.nlm.nih.gov/pubmed/18544668 Clinically assessed knee joint laxity as a predictor for reconstruction after an anterior cruciate ligament injury: a prospective study of 100 patients treated with activity modification and rehabilitation]. The American journal of sports medicine. 2008 Aug;36(8):1528-33.</ref>
* [[Lachman Test|Lachman]] and [[Pivot Shift|pivot-shift tests]] <ref>Kostogiannis I, Ageberg E, Neuman P, Dahlberg LE, Fridén T, Roos H. [https://www.ncbi.nlm.nih.gov/pubmed/18544668 Clinically assessed knee joint laxity as a predictor for reconstruction after an anterior cruciate ligament injury: a prospective study of 100 patients treated with activity modification and rehabilitation]. The American journal of sports medicine. 2008 Aug;36(8):1528-33.</ref>
* Passive range of motion (knee flexion & extension), muscle strength, thigh circumference (thigh girth, thigh muscle mass, knee joint swelling) <ref name=":3">Zamarioli A, Pezolato A, Mieli E, Shimano A. [https://content.sciendo.com/view/journals/physio/16/2/article-p3.xml The significance of water rehabilitation in patients with anterior cruciate ligament reconstruction]. Physiotherapy. 2008 Apr 1;16(2):3-6.</ref><ref>Tovin BJ, Wolf SL, Greenfield BH, Crouse J, Woodfin BA. [https://www.ncbi.nlm.nih.gov/pubmed/8047560 Comparison of the effects of exercise in water and on land on the rehabilitation of patients with intra-articular anterior cruciate ligament reconstructions]. Physical Therapy. 1994 Aug 1;74(8):710-9.</ref>
* [[Six Minute Walk Test / 6 Minute Walk Test|6 minute walk test (6MWT)]] <ref name=":5" />
* Active range of motion (knee flexion & extension) <ref name=":5" />
* 6 minute walk test (6MWT) <ref name=":5" />


== '''Advantages of Hydrotherapy in ACL/R Rehabilitation''' ==
==Advantages of Hydrotherapy in ACL and ACL Reconstruction Rehabilitation==
'''In principle:'''
* Early weightbearing <ref name=":5">Momberg BL, Louw Q, Crous L. [https://www.ajol.info/index.php/sasma/article/view/31936 Accelerated hydrotherapy and land-based rehabilitation in soccer players after anterior cruciate ligament reconstruction: a series of three single subject case studies]. South African Journal of Sports Medicine. 2008 Dec 1;20(4):109-14.</ref>
* Postural and gait exercises in a supported environment <ref name=":4">Torres-Ronda L, i del Alcázar XS. [https://content.sciendo.com/view/journals/hukin/44/1/article-p237.xml The properties of water and their applications for training]. Journal of human kinetics. 2014 Dec 1;44(1):237-48.</ref>
* Water resistance induced muscular conditioning <ref name=":4" />


'''Outcomes of Hydrotherapy + Conventional Rehabilitation vs. Conventional Rehabilitation Only:'''
* Reduce pain and swelling<ref name=":8">Buckthorpe M, Pirotti E, Villa FD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878863/ BENEFITS AND USE OF AQUATIC THERAPY DURING REHABILITATION AFTER ACL RECONSTRUCTION -A CLINICAL COMMENTARY]. Int J Sports Phys Ther. 2019 Dec;14(6):978-993.</ref>


After 2 weeks post-ACLR, patients who underwent 3 weeks of combined hydrotherapy with conventional rehabilitation, had superior outcomes in proprioception, walking, muscle strength in the short and medium term, compared to participants exclusively in conventional rehabilitation programme <ref>Peultier-Celli L, Mainard D, Wein F, Paris N, Boisseau P, Ferry A, Gueguen R, Chary-Valckenaere I, Paysant J, Perrin P. [https://www.frontiersin.org/articles/10.3389/fsurg.2017.00061/full Comparison of an innovative rehabilitation, combining reduced conventional rehabilitation with balneotherapy, and a conventional rehabilitation after anterior cruciate ligament reconstruction in athletes]. Frontiers in surgery. 2017;4:61.</ref>. Another trial found that ACLR patients placed through 9 weeks of aquatic rehabilitation immediately post-surgery had better clinical parameters in muscle strength and mass circumference, pain, swelling, and range of motion compared to those on land rehabilitation <ref name=":3" />.
* Early [[Weight bearing|weightbearing]] <ref name=":5">Momberg BL, Louw Q, Crous L. [https://www.ajol.info/index.php/sasma/article/view/31936 Accelerated hydrotherapy and land-based rehabilitation in soccer players after anterior cruciate ligament reconstruction: a series of three single subject case studies]. South African Journal of Sports Medicine. 2008 Dec 1;20(4):109-14.</ref>
*[[Postural Control|Posture]], gait and motor pattern retraining in a supported environment <ref name=":4">Torres-Ronda L, i del Alcázar XS. [https://content.sciendo.com/view/journals/hukin/44/1/article-p237.xml The properties of water and their applications for training]. Journal of human kinetics. 2014 Dec 1;44(1):237-48.</ref>
* Water resistance induced muscular conditioning <ref name=":4" />
* [[Cardiovascular System|Cardiovascular]] exercise<ref name=":8" />
* Early [[plyometrics]]<ref name=":8" />
* In later stages of rehabilitation can support the between session recovery and optimal load management<ref name=":8" />
[[File:Hydrotherapy Pool Exercises.jpg|center|thumb|400x400px]]


A smaller case study of 3 subjects demonstrated no risk of harm in utilizing hydrotherapy to accelerate rehabilitation of ACLR <ref name=":5" />.
== Evidence ==
A study of 67 amateur or professional [[Athletes with difficult or longstanding neuromusculoskeletal symptoms|athletes]] post-ACL reconstruction, found patients who underwent 3 weeks of combined hydrotherapy with conventional rehabilitation, had superior outcomes in [[proprioception]], walking and muscle strength in the short and medium term, compared to participants exclusively in conventional rehabilitation program <ref>Peultier-Celli L, Mainard D, Wein F, Paris N, Boisseau P, Ferry A, Gueguen R, Chary-Valckenaere I, Paysant J, Perrin P. [https://www.frontiersin.org/articles/10.3389/fsurg.2017.00061/full Comparison of an innovative rehabilitation, combining reduced conventional rehabilitation with balneotherapy, and a conventional rehabilitation after anterior cruciate ligament reconstruction in athletes]. Frontiers in surgery. 2017;4:61.</ref>. In addition, another study found patients who received innovative aquatic proprioceptive training alongside conventional rehabilitation had improved proprioception efficiency compared with those receiving only conventional treatment<ref>Hajouj E, Hadian MR, Mir SM, Talebian S, Ghazi S. [https://pubmed.ncbi.nlm.nih.gov/34692934/ Effects of Innovative Aquatic Proprioceptive Training on Knee Proprioception in Athletes with Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial]. Arch Bone Jt Surg. 2021 Sep;9(5):519-526.</ref>.


'''Considerations for ACL hydrotherapy rehabilitation design:'''
Another trial found that ACL reconstruction patients placed through 9 weeks of aquatic rehabilitation immediately post-surgery had better clinical parameters in muscle strength and mass circumference, pain, swelling, and range of motion compared to those on land rehabilitation <ref name=":3" />.
{| class="wikitable"
! colspan="2" |Accelerated Hydrotherapy Programme <ref name=":5" />
|-
|Goal:
|Treatment:
|-
|Gait Retraining
|Gait training
|-
|Quadriceps and hamstring strengthening
|Closed kinetic chain exercises, Open kinematic chain exercises
|-
|Strengthening & endurance training
|Running, Cycling, Deep-water running techniques
|-
|Hip and calf maintenance and strengthening
|Hip exercises and calf raises, kicking and vertical kicking
|-
|Balance and proprioception (perturbation protocol)
|Balance and proprioception exercises
|-
|Plyometric training
|Jumping, running, shuttle runs, side steps with increased speed
|-
|Sports-specific rehabilitation
|Agility exercises making use of a ball
|}


== Video Examples of Hydrotherapy Protocols & Case Studies: ==
A smaller case study of 3 subjects demonstrated no risk of harm in utilizing hydrotherapy to accelerate rehabilitation of ACL reconstruction <ref name=":5" />.
[https://www.hydroworx.com/learning-center/video-library/acl-rehabilitation/ ACL Hydrotherapy Rehabilitation Progression Timeline, Principles, & Advantages] - ''Hydroworx''


[https://www.hydroworx.com/learning-center/video-library/partial-acl-and-pcl-tear-using-aquatic-therapy-in-place-of-surgery/#case-history Acute Partial ACL & PCL Injury in Male Recreational Basketball Player (conservative management)] - ''Hydroworx''
One study compared water-based treadmill walking training with land-based treadmill walking training  via a randomized, single blind trial with 60 patients post anterior ACL reconstruction. They found the ratio of peak torque to body weight ratio for the knee extensor muscles, passive position sense and [[Tegner Lysholm Knee Scoring Scale|Lysholm]] scores showed significantly greater improvement in the water-based group than in the land based group<ref>Li D, Zhang Q, Liu X, Chen C, Lu J, Ye D, Li Y, Wang W, Shen M. [https://pubmed.ncbi.nlm.nih.gov/35101723/ Effect of water-based walking exercise on rehabilitation of patients following ACL reconstruction: a prospective, randomised, single-blind clinical trial.] Physiotherapy. 2022 Jun;115:18-26</ref>.


[https://www.hydroworx.com/learning-center/video-library/acl-autograft/ ACL-R Patellar Autograft (5.5 weeks post-op with regression)] - ''Hydroworx''
Further research is needed, including among non-athlete populations<ref>Singh SP, Borthwick KG, Qureshi FM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8260827/ Commentary: Comparison of an Innovative Rehabilitation, Combining Reduced Conventional Rehabilitation With Balneotherapy, and a Conventional Rehabilitation After Anterior Cruciate Ligament Reconstruction in Athletes]. Front Surg. 2021 Jun 23;8:665748. </ref>. For example, a 2022 systematic review for the OPTIKNEE consensus did not include hydrotherapy due to its inclusion in only 1 of the 142 randomized control trials reviewed<ref>Culvenor AG, Girdwood MA, Juhl CB, Patterson BE, Haberfield MJ, Holm PM, Bricca A, Whittaker JL, Roos EM, Crossley KM. [https://bjsm.bmj.com/content/56/24/1445.long Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus.] Br J Sports Med. 2022 Dec;56(24):1445-1453.</ref>.


[https://www.hydroworx.com/learning-center/video-library/anterior-cruciate-ligament-tear/ ACL-R in Female Soccer Goalie (4 weeks post-op with delayed rehabilitation)] - ''Hydroworx''
== '''Considerations for ACL hydrotherapy rehabilitation design''' ==
For ACL injury or reconstruction rehabilitation, the hydrotherapy program can include<ref name=":5" />:


[https://www.hydroworx.com/learning-center/video-library/acl-mcl-and-medial-meniscus-tear-case-history/ Unhappy Triad in Female Volleyball Player (8 weeks post-op)] - ''Hydroworx''
* Gait training
* [[Quadriceps Muscle|Quadriceps]] and [[Hamstrings|hamstring]] strengthening ([[Closed Chain Exercise|closed]] and [[Open Chain Exercise|open]] kinetic chain exercises)
* Strength and endurance training ([[Running Gait Retraining|running]] and [[Cycling Biomechanics|cycling]])
* [[Hip]] and [[Calf Strain|calf]] maintenance and strengthening
* [[Balance]] and [[proprioception]] exercises
* Plyometric training
* Sport-specific rehabilitation


[https://www.youtube.com/watch?v=OIh8GLZ5nFs Gait Retraining and Lower Limb Mobility Exercises] - ''Sports Med Mumbai''
== Resources ==
[https://www.hydroworx.com/research-education/video-library/ Hydroworx Video Examples of Hydrotherapy Protocols & Case Studies]


== References: ==
== References: ==
<references />
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]

Latest revision as of 13:27, 22 December 2022

Original Editor - Falcone Tseng

Top Contributors - Falcone Tseng, Chloe Waller, Kim Jackson and Wanda van Niekerk

Introduction[edit | edit source]

Anterior Cruciate Ligament (ACL) injuries are a common orthopedic condition, especially among athletes and young people, which can have long term physical and lifestyle impacts[1]. This may include post traumatic arthritis, meniscus or cartilage injuries, knee instability, as well as impaired quality of life and not returning to sport[2][3]. At present, recommended treatment options are surgical reconstruction, or conservative management, with both these approaches requiring rehabilitation[2] . Research continues to investigate how to optimize ACL rehabilitation, including utilizing hydrotherapy. Hydrotherapy is the delivery of physiotherapy treatment in an aquatic environment, utilizing the properties of water (density, buoyancy, hydrostatic pressure and viscosity)[4].

Outcome Measures of ACL Rehabilitation[edit | edit source]

Advantages of Hydrotherapy in ACL and ACL Reconstruction Rehabilitation[edit | edit source]

  • Reduce pain and swelling[12]
Hydrotherapy Pool Exercises.jpg

Evidence[edit | edit source]

A study of 67 amateur or professional athletes post-ACL reconstruction, found patients who underwent 3 weeks of combined hydrotherapy with conventional rehabilitation, had superior outcomes in proprioception, walking and muscle strength in the short and medium term, compared to participants exclusively in conventional rehabilitation program [14]. In addition, another study found patients who received innovative aquatic proprioceptive training alongside conventional rehabilitation had improved proprioception efficiency compared with those receiving only conventional treatment[15].

Another trial found that ACL reconstruction patients placed through 9 weeks of aquatic rehabilitation immediately post-surgery had better clinical parameters in muscle strength and mass circumference, pain, swelling, and range of motion compared to those on land rehabilitation [7].

A smaller case study of 3 subjects demonstrated no risk of harm in utilizing hydrotherapy to accelerate rehabilitation of ACL reconstruction [8].

One study compared water-based treadmill walking training with land-based treadmill walking training via a randomized, single blind trial with 60 patients post anterior ACL reconstruction. They found the ratio of peak torque to body weight ratio for the knee extensor muscles, passive position sense and Lysholm scores showed significantly greater improvement in the water-based group than in the land based group[16].

Further research is needed, including among non-athlete populations[17]. For example, a 2022 systematic review for the OPTIKNEE consensus did not include hydrotherapy due to its inclusion in only 1 of the 142 randomized control trials reviewed[18].

Considerations for ACL hydrotherapy rehabilitation design[edit | edit source]

For ACL injury or reconstruction rehabilitation, the hydrotherapy program can include[8]:

Resources[edit | edit source]

Hydroworx Video Examples of Hydrotherapy Protocols & Case Studies

References:[edit | edit source]

  1. ↑ Krause M, Freudenthaler F, Frosch KH, Achtnich A, Petersen W, Akoto R. Operative Versus Conservative Treatment of Anterior Cruciate Ligament Rupture. Dtsch Arztebl Int. 2018 Dec 24;115(51-52):855-862.
  2. ↑ 2.0 2.1 Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):33-47.
  3. ↑ Kohn L, Rembeck E, Rauch A. Verletzung des vorderen Kreuzbandes beim Erwachsenen : Diagnostik und Therapie [Anterior cruciate ligament injury in adults : Diagnostics and treatment]. Orthopade. 2020 Nov;49(11):1013-1028.
  4. ↑ Aquatic Therapy Association of Chartered Physiotherapists (ATACP). About ATACP. Available from: https://atacp.csp.org.uk/content/about-atacp (Accessed 19/12/2022)
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. The American journal of sports medicine. 2005 Mar;33(3):335-46.
  6. ↑ 6.0 6.1 6.2 Tovin BJ, Wolf SL, Greenfield BH, Crouse J, Woodfin BA. Comparison of the effects of exercise in water and on land on the rehabilitation of patients with intra-articular anterior cruciate ligament reconstructions. Physical Therapy. 1994 Aug 1;74(8):710-9.
  7. ↑ 7.0 7.1 Zamarioli A, Pezolato A, Mieli E, Shimano A. The significance of water rehabilitation in patients with anterior cruciate ligament reconstruction. Physiotherapy. 2008 Apr 1;16(2):3-6.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Momberg BL, Louw Q, Crous L. Accelerated hydrotherapy and land-based rehabilitation in soccer players after anterior cruciate ligament reconstruction: a series of three single subject case studies. South African Journal of Sports Medicine. 2008 Dec 1;20(4):109-14.
  9. ↑ 9.0 9.1 Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. New England Journal of Medicine. 2010 Jul 22;363(4):331-42.
  10. ↑ 10.0 10.1 Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy. 2005 Aug 1;21(8):948-57.
  11. ↑ Kostogiannis I, Ageberg E, Neuman P, Dahlberg LE, Fridén T, Roos H. Clinically assessed knee joint laxity as a predictor for reconstruction after an anterior cruciate ligament injury: a prospective study of 100 patients treated with activity modification and rehabilitation. The American journal of sports medicine. 2008 Aug;36(8):1528-33.
  12. ↑ 12.0 12.1 12.2 12.3 Buckthorpe M, Pirotti E, Villa FD. BENEFITS AND USE OF AQUATIC THERAPY DURING REHABILITATION AFTER ACL RECONSTRUCTION -A CLINICAL COMMENTARY. Int J Sports Phys Ther. 2019 Dec;14(6):978-993.
  13. ↑ 13.0 13.1 Torres-Ronda L, i del Alcázar XS. The properties of water and their applications for training. Journal of human kinetics. 2014 Dec 1;44(1):237-48.
  14. ↑ Peultier-Celli L, Mainard D, Wein F, Paris N, Boisseau P, Ferry A, Gueguen R, Chary-Valckenaere I, Paysant J, Perrin P. Comparison of an innovative rehabilitation, combining reduced conventional rehabilitation with balneotherapy, and a conventional rehabilitation after anterior cruciate ligament reconstruction in athletes. Frontiers in surgery. 2017;4:61.
  15. ↑ Hajouj E, Hadian MR, Mir SM, Talebian S, Ghazi S. Effects of Innovative Aquatic Proprioceptive Training on Knee Proprioception in Athletes with Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial. Arch Bone Jt Surg. 2021 Sep;9(5):519-526.
  16. ↑ Li D, Zhang Q, Liu X, Chen C, Lu J, Ye D, Li Y, Wang W, Shen M. Effect of water-based walking exercise on rehabilitation of patients following ACL reconstruction: a prospective, randomised, single-blind clinical trial. Physiotherapy. 2022 Jun;115:18-26
  17. ↑ Singh SP, Borthwick KG, Qureshi FM. Commentary: Comparison of an Innovative Rehabilitation, Combining Reduced Conventional Rehabilitation With Balneotherapy, and a Conventional Rehabilitation After Anterior Cruciate Ligament Reconstruction in Athletes. Front Surg. 2021 Jun 23;8:665748.
  18. ↑ Culvenor AG, Girdwood MA, Juhl CB, Patterson BE, Haberfield MJ, Holm PM, Bricca A, Whittaker JL, Roos EM, Crossley KM. Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus. Br J Sports Med. 2022 Dec;56(24):1445-1453.
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