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Assessment of Quadriceps Corticomotor and Spinal-Reflexive Excitability in Individuals with a History of Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

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Abstract

Background

Differences in the excitability of motor generating neural pathways are reported following anterior cruciate ligament reconstruction (ACLR) that is associated with quadriceps dysfunction and theorized to prevent the full recovery of muscle function.

Objective

The aims of this systematic review and meta-analysis were to compare quadriceps neural excitability between the involved ACLR limb, the uninvolved limb, and uninjured controls, and to determine at what time intervals these differences are present after surgery.

Methods

We conducted a search of PubMed, SPORTDiscus, Embase, and Web of Science, and extracted measures assessing difference of quadriceps spinal-reflexive, corticospinal, and intracortical excitability from studies that compared (1) involved limb to the uninvolved limb, (2) involved limb to a control limb, or (3) uninvolved limb to a control limb. We stratified time at 24 months, since this represents a period of heightened risk for reinjury. A modified Downs and Black checklist and Egger’s test were used to determine the methodological quality of individual studies and risk of bias between studies.

Results

Fourteen studies comprising 611 participants (371 individuals with a history of ACLR; median time from surgery: 31.5 months; range 0.5–221.1 months) were included in the review. Overall, the involved (g = 0.60, 95% CI [0.24, 0.96]) and uninvolved (g = 0.49, 95% CI [0.00, 0.98]) limbs exhibited greater motor threshold (MT) in comparison to uninjured controls. Motor-evoked potential (MEP) amplitudes were greater in the uninvolved limb in comparison to uninjured controls (g = 0.31, 95% CI [0.03, 0.59]). Lesser intracortical inhibition was exhibited in the uninvolved limb compared to uninjured controls (g = 0.54, 95% CI [0.14, 0.93]). When stratified by time from surgery, MEP amplitudes were greater in the uninvolved limb compared to uninjured controls (g = 0.33, 95% CI [0.03, 0.63]) within the first 24 months after surgery. When evaluated more than 24 months after surgery, the involved limb exhibited greater Hoffmann reflex (H-reflex) compared to uninjured controls (g = 0.38, 95% CI [0.00, 0.77]). MT were greater in the involved limb (g = 0.93, 95% CI [− 0.01, 1.88]) and uninvolved limb (g = 0.57, 95% CI [0.13, 1.02]) compared to uninjured controls. MEP amplitudes in the involved limb were lesser compared to uninjured controls when evaluated more than 24 months after ACLR (g = -1.11, 95% CI [− 2.03, − 0.20]).

Conclusions

The available evidence supports that there are neural excitability differences within the corticospinal tract in individuals with ACLR when compared to uninjured controls. Future research should focus further on longitudinal assessments of neural excitability prior to and following ACLR. Identifying interventions aimed to facilitate corticospinal excitability after ACLR appears to be warranted to improve quadriceps function.

Trial Registration

Registered through PROSPERO CRD42020158714.

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Acknowledgements

The authors would like to acknowledge all of the investigators and participants that completed the original research included in this review.

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Authors and Affiliations

  1. Exercise Science Program, School of Exercise and Rehabilitation Sciences, University of Toledo, 2801 W. Bancroft St., Toledo, OH, USA

    Justin L. Rush & Grant E. Norte

  2. Department of Kinesiology, College of Agriculture, Health and Natural Resources, University of Connecticut, Storrs, CT, USA

    Neal R. Glaviano

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Justin L. Rush, Neal R. Glaviano, and Grant E. Norte declare that they have no conflicts of interest relevant to the content of this review.

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The data from the current study are available from the corresponding author upon request.

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All authors (JLR, NRG, and GEN) have contributed equally and demonstrated significant involvement in the planning. Conceptualization: JLR and GEN. Literature search: JLR. Data analysis: JLR and GEN. Drafting and critical review: JLR, NRG, and GEN.

Supplementary Information

Below is the link to the electronic supplementary material.

40279_2020_1403_MOESM1_ESM.pdf

Electronic Supplementary Material Fig S6 Risk of bias assessment of studies comparing early (< 24 months after surgery) and late (> 24 months after surgery) MEP amplitudes between the involved limb and uninvolved limb (left), involved and healthy controls (middle), and uninvolved and healthy controls (right)

40279_2020_1403_MOESM2_ESM.pdf

Electronic Supplementary Material Fig S1 Risk of bias assessment of studies comparing H-reflex amplitudes between the involved limb and uninvolved limb (left), involved and healthy controls (middle), and uninvolved and healthy controls (right)

40279_2020_1403_MOESM3_ESM.pdf

Electronic Supplementary Material Fig S2 Risk of bias assessment of studies comparing motor threshold between the involved limb and uninvolved limb (left), involved and healthy controls (middle), and uninvolved and healthy controls (right)

40279_2020_1403_MOESM4_ESM.pdf

Electronic Supplementary Material Fig S3 Risk of bias assessment of studies comparing MEP amplitudes between the involved limb and uninvolved limb (left), involved and healthy controls (middle), and uninvolved and healthy controls (right)

40279_2020_1403_MOESM5_ESM.pdf

Electronic Supplementary Material Fig S4 Risk of bias assessment of studies comparing early (< 24 months after surgery) and late (> 24 months after surgery) H-reflex amplitudes between the involved limb and uninvolved limb (left), involved and healthy controls (middle), and uninvolved and healthy controls (right)

40279_2020_1403_MOESM6_ESM.pdf

Electronic Supplementary Material Fig S5 Risk of bias assessment of studies comparing early (< 24 months after surgery) and late (> 24 months after surgery) motor thresholds between the involved limb and uninvolved limb (left), involved and healthy controls (middle), and uninvolved and healthy controls (right)

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Rush, J.L., Glaviano, N.R. & Norte, G.E. Assessment of Quadriceps Corticomotor and Spinal-Reflexive Excitability in Individuals with a History of Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Sports Med 51, 961–990 (2021). https://doi.org/10.1007/s40279-020-01403-8

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