***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: STUDY DESIGN R and omized clinical trial , single-masked . OBJECTIVES To determine the effectiveness of using a modified neuromuscular electrical stimulation ( NMES ) training program as an adjunct treatment for improving quadriceps strength and physical function in rehabilitation following anterior cruciate ligament reconstruction ( ACLR ) . BACKGROUND NMES training for quadriceps strengthening has previously been shown to be an effective adjunct treatment following ACLR when performed against isometric resistance using a dynamometer with the knee positioned in flexion . We developed a modified version of published NMES protocol because some patients have difficulty tolerating the existing protocol and many clinics may not have instrumented dynamometers . There is a need to determine the effectiveness of this modified protocol . METHODS AND MEASURES Forty-three subjects who had undergone ACLR were r and omly assigned to either a group that received ( NMES group ) or did not receive ( comparison group ) the NMES treatment in conjunction with their rehabilitation . Group means for quadriceps strength and self-reported measures of knee function were compared after 12 and 16 weeks of rehabilitation . The proportion of subjects in each group achieving clinical criteria to initiate ambulation without crutches , treadmill running , and agility training at selected times during rehabilitation were also compared . RESULTS The NMES group demonstrated moderately greater quadriceps strength at 12 weeks ( effect size , 0.48 ) , and moderately higher levels of self-reported knee function at both 12 ( effect size , 0.72 ) and 16 ( effect size , 0.65 ) weeks of rehabilitation compared to the comparison group . A greater proportion of subjects in the NMES group achieved clinical criteria for advancing to agility training at 16 weeks . CONCLUSIONS The modified NMES quadriceps training protocol can be a useful adjunct to ACLR rehabilitation programs , but the treatment effect is smaller than what has been reported in previous studies The objective of this study was to eluci date how cryotherapy after anterior cruciate ligament reconstruction affects intraarticular temperature and clinical results . A prospect i ve and r and omized study was performed on 21 knees of 21 patients . The ligament reconstruction was performed by single-incision arthroscopy using autogenous ham-string tendon . On completion of the surgery , thermosensors were implanted in the suprapatellar pouch and the intracondylar notch , and the intraarticular temperature was monitored while the joint was cooled . Cooling was performed in one group at 5 ° C ( N 7 ) and in another at 10 ° C ( N 7 ) , for 48 hours . A control group ( N 7 ) did not undergo cryotherapy . The cooled groups showed three temperature phases : a low-temperature phase immediately after the ligament reconstruction , followed by a temperature-rising phase and a thermostatic phase . The control group had no low-temperature phase and immediately entered a thermostatic phase . During the low-temperature phase in the treated groups , the temperature of the suprapatellar pouch and of the intercondylar notch were significantly lower than the body temperature . The pain score and the number of times an analgesic had to be administered were both significantly lower in the 10 ° C group than in the control group . Blood loss was significantly less in the 5 ° C group than in the control group Immediately after reconstruction of the anterior cruciate ligament , 110 patients were r and omly assigned to treatment with high-intensity neuromuscular electrical stimulation ( thirty-one patients ) , high-level volitional exercise ( thirty-four patients ) , low-intensity neuromuscular electrical stimulation ( twenty-five patients ) , or combined high and low-intensity neuromuscular electrical stimulation ( twenty patients ) . All treatment was performed isometrically with the knee in 65 degrees of flexion . All of the patients participated in an intensive program of closed-kinetic-chain exercise . After four weeks of treatment , the strength of the quadriceps femoris muscle and the kinematics of the knee during stance phase were measured . Quadriceps strength averaged 70 per cent or more of the strength on the uninvolved side in the two groups that were treated with high-intensity electrical stimulation ( either alone or combined with low-intensity electrical stimulation ) , 57 per cent in the group that was treated with high-level volitional exercise , and 51 per cent in the group that was treated with low-intensity electrical stimulation . The kinematics of the knee joint were directly and significantly ( p < 0.05 ) correlated with the strength of the quadriceps . There was a clinical ly and statistically significant ( p < 0.05 ) difference in the recovery of the quadriceps and the gait parameters according to the type of operation that had been performed : the patients who had had reconstruction of the anterior cruciate ligament with use of an autologous patellar-ligament graft did poorly compared with the other patients Sixty patients undergoing total knee replacement were r and omized to receive either a cold compression dressing ( Cryo/Cuff , Aircast , UK ) or a modified Robert Jones b and age immediately after surgery . The cold compression dressing was used for a minimum of 6 h per day throughout the hospital stay , and the modified Robert Jones b and age remained in place for 48 h from the time of operation . The 2 groups of patients were compared during their hospital stay for blood loss , range of movement , pain scores and need for analgesia . No difference was found between the 2 groups except for less blood loss in the surgical drains in the cold compression group ( P<0.05 ) . Postoperative complications were seen in both groups , but no complication was associated with either the cold compression dressing or the modified Robert Jones b and age . RésuméEtude r and omisée de 60 patients qui , immédiatement après une arthroplastie totale du genou ont eu soit un pansement compressif froid de type “ Cryocuff ” soit un pansement compressif de type Robert Jones . Le pansement froid a été utilisé 6 heures par jour pendant la durée de l'hospitalisation t and is que le pansement compressif de type Robert Jones a été laisse en place pendant 48 heures après l'opération . Aucune différence statistiquement significative n'a pu être mise en évidence entre les deux groupes , à l'exception des pertes sanguines dans le drainage , moins importantes dans le premier groupe de patients . Nous avons eu des complications post opératoires dans les deux groupes mais aucune corrélation n'a pu être établie entre ces complications et le type de b and age appliqué While cryotherapy has been shown to decrease postoperative pain after anterior cruciate ligament ( ACL ) reconstruction , less is known of the effects of combined cryotherapy and compression . The goal of this study was to compare subjective and objective patient outcomes following ACL reconstruction with combined compression and cryotherapy compared with traditional ice therapy alone .  Patients undergoing ACL reconstruction were r and omized to  cryotherapy/compression device ( group 1 ) or a st and ardized ice pack ( group 2 ) . Both groups were instructed to use the ice or cryotherapy/compression device three times per day and return to the clinic at 1 , 2 , and 6 weeks postoperatively . Patient-derived outcome measurements used in this study consisted of the visual analog scale ( VAS ) , the Lysholm knee score , Short Form-36 ( SF-36 ) , and single assessment numerical evaluation ( SANE ) . Circumferential measurements of the knee at three locations ( 1 cm proximal to patella , mid-patella , and 1 cm distal to patella ) were also obtained as a measure of postoperative edema . Narcotic medication use was recorded by question naire . The primary outcome measure ( VAS ) was significantly different among groups in the preoperative measurement , despite similarities in group demographics . Baseline VAS for group 1 was 54.9 compared with group 2 at 35.6 ( p = 0.01 ) . By 6 weeks , this had lowered to 28.1 and 40.3 , respectively , result ing in a significant 27-point decrease in mean VAS for group 1 ( p < 0.0001 ) . However , the small increase in VAS for group 2 was not significant ( p = 0.34 ) . No significant differences were noted for the Lysholm , SF-36 , or SANE scores either between groups or time points . Furthermore , no significant differences were noted for any of the circumferential measurements either between groups or time points . Of all patients , 83 % of group 1 discontinued narcotic use by 6 weeks , compared with only 28 % of group 2 ( p = 0.0008 ) . The use of combined cryotherapy and compression in the postoperative period after ACL reconstruction results in improved , short-term pain relief and a greater likelihood of independence from narcotic use compared with cryotherapy alone Abstract Introduction Anterior cruciate ligament ( ACL ) reconstruction requires an intensive rehabilitation program to be completely successful . Cryotherapy has been described to be helpful in reducing post-operative pain and edema . Aim of this prospect i ve r and omized study is to compare two homogeneous groups of patients , one receiving traditional icing regimen and the other a temperature-controlled continuous cold flow device , in post-operative setting after ACL reconstruction . Material s and methods Forty-seven patients treated for ACL reconstruction using “ over the top ” technique were enrolled for this study . All patients received the same elastocompressive b and age . Regarding the coolant device , 23 patients were r and omized to temperature-controlled continuous cold flow device ( Hilotherm ® group ) and 24 patients were r and omized to receive ice bag ( control group ) . The two groups were homogenous for pre-operative ( age , sex , and time “ lesion to surgery ” ) and intra-operative parameters ( duration of the procedure , meniscectomy , and chondral damage ) . NRS ( numeric rating scale ) , blood loss , knee volume increase at three established sites , ROM , and pain killers consumption were assessed . The subjective evaluation of the device including practicality and usefulness of the device was investigated . Results Hilotherm group result ed in lower pain perception ( NRS ) , blood loss , knee volume increase at the patellar apex and 10 cm proximal to the superior patellar pole , and higher range of motion ( p < 0.05 ) in the first post-operative day . No difference in pain killers consumption was noted . Hilotherm device was considered “ comfortable ” and “ useful ” by the majority of patients . Conclusions Hilotherm group showed significant better results in first post-operative day . Further studies with higher number of patients and longer follow-up are required to assess the beneficial effects on rehabilitation and the cost-effectiveness of the routinely use of this device . Level of evidence : II OBJECTIVE To determine the effects of electromyographic biofeedback treatment in patients with patellofemoral pain syndrome . DESIGN R and omized controlled trial . SETTING A physical medicine and rehabilitation department in a research hospital of a university referral center . PATIENTS Sixty patients with patellofemoral pain syndrome . Patients were r and omly placed into 2 groups : biofeedback group ( n = 30 ) and a control group ( n = 30 ) . INTERVENTION The biofeedback group received electromyographic biofeedback training and a conventional exercise program , whereas the control group received a conventional exercise program only . MAIN OUTCOME MEASURES Maximum and mean contraction values of the vastus medialis and the vastus lateralis muscles were assessed with the biofeedback device . Pain and functional status of the patients were measured by a visual analog scale ( VAS ) and the Functional Index Question naire ( FIQ ) , respectively . RESULTS Contraction values improved significantly at the end of the first month , compared with the pretreatment values in both groups . Mean contraction values in the biofeedback group of the vastus medialis muscles in all 3 monthly measurements , and the vastus lateralis muscles at the end of the first month , were significantly higher than those of the control group . Significant improvements were shown for both the VAS and the FIQ in both groups . Monthly follow-ups showed no VAS and FIQ differences between the groups . CONCLUSION Electromyographic biofeedback treatment did not result in further clinical improvement when compared with a conventional exercise program in patients with patellofemoral pain syndrome Evidence -based medicine uses the best available evidence to make decisions with patients . The highest- quality evidence is well- design ed r and omized trials . The most compelling example of the power of trials comes from pediatric oncology . The improvement in the survival rate of children with cancer from 10 % to 90 % has been attributed almost exclusively to multiple r and omized trials1 . Since January 2003 , every clinical article published in The Journal of Bone and Joint Surgery has been assigned a level-of- evidence rating2 . Levels of evidence provide a concise and simple appraisal of study quality . The essence of levels of evidence is that , in general , controlled studies are better than uncontrolled studies , prospect i ve studies are better than retrospective studies , and r and omized studies are better than nonr and omized studies . Levels of evidence have multiple purpose s. First , levels of evidence provide the readers of The Journal with a rapid appraisal of study quality . Although a complete critical appraisal is required to determine study quality 3 , readers generally find higher levels of evidence more compelling . Second , levels of evidence for multiple studies evaluating a clinical question can be summarized as a “ grade of recommendation . ” Grade s of recommendations , such as A , B , C , or I , provide an overall appraisal of the quality of literature for or against a treatment recommendation 4 . Third , levels of evidence can be used to develop practice guidelines and performance measures . In an era of pay-for-performance , whereby evidence -based interventions receive higher reimbursement5,6 , underst and ing levels of evidence is important for surgeons . In considering levels of evidence , surgeons need to know that the evaluation is reliable and valid . Several studies have shown that the assignment of levels of evidence is reliable7,8 . The first table explaining the level-of- evidence ratings , published in the January 2003 issue of The Seventy-five patients undergoing arthroscopically-as sisted anterior cruciate ligament reconstruction by the 
    Output:
    
For alleviating pain and decreasing narcotic consumption following arthroscopic knee surgery , cryocompression devices are more effective than traditional icing alone , though not more than compression alone .
CPM  does not affect post-operative outcomes .
sEMG biofeedback and NMES  improve quadriceps strength and overall knee functional outcomes following knee surgery .
There is limited evidence regarding the effects of ESWT .
Conclusion Cryotherapy , NMES and sEMG are recommended for inclusion into rehabilitation protocol s following arthroscopic knee surgery to assist with pain relief , recovery of muscle strength and knee function , which are all essential to accelerate recovery .