***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 
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    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 Pre- clinical studies have shown that treatment by pulsed electromagnetic fields ( PEMFs ) can limit the catabolic effects of pro-inflammatory cytokines on articular cartilage and favour the anabolic activity of the chondrocytes . Anterior cruciate ligament ( ACL ) reconstruction is usually performed by arthroscopic procedure that , even if minimally invasive , may elicit an inflammatory joint reaction detrimental to articular cartilage . In this study the effect of I-ONE PEMFs treatment in patients undergoing ACL reconstruction was investigated . The study end-points were ( 1 ) evaluation of patients ’ functional recovery by International Knee Documentation Committee ( IKDC ) Form ; ( 2 ) use of non-steroidal anti-inflammatory drugs ( NSAIDs ) , necessary to control joint pain and inflammation . The study design was prospect i ve , r and omized and double blind . Sixty-nine patients were included in the study at baseline . Follow-up visits were scheduled at 30 , 60 and 180 days , followed by 2-year follow-up interview . Patients were evaluated by IKDC Form and were asked to report on the use of NSAIDs .  Patients were r and omized to active or placebo treatments ; active device generated a magnetic field of 1.5 mT at 75 Hz . Patients were instructed to use the stimulator ( I-ONE ) for 4 h per day for 60 days . All patients underwent ACL reconstruction with use of quadruple hamstrings semitendinosus and gracilis technique . At baseline there were no differences in the IKDC scores between the two groups . At follow-up visits the SF-36 Health Survey score showed a statistically significant faster recovery in the group of patients treated with I-ONE stimulator ( P < 0.05 ) . NSAIDs use was less frequent among active patients than controls ( P < 0.05 ) . Joint swelling resolution and return to normal range of motion occurred faster in the active treated group ( P < 0.05 ) too . The 2-year follow-up did not shown statistically significant difference between the two groups . Furthermore for longitudinal analysis the generalized linear mixed effects model was applied to calculate the group × time interaction coefficient ; this interaction showed a significant difference ( P < 0.0001 ) between the active and placebo groups for all investigated variables : SF-36 Health Survey , IKDC Subjective Knee Evaluation and VAS .  Twenty-nine patients ( 15 in the active group ; 14 in the placebo group ) underwent both ACL reconstruction and meniscectomy ; when they were analysed separately the differences in SF-36 Health Survey scores between the two groups were larger then what observed in the whole study group ( P < 0.05 ) . The results of this study show that patient ’s functional recovery occurs earlier in the active group . No side effects were observed and the treatment was well tolerated . The use of I-ONE should always be considered after ACL reconstruction , particularly in professional athletes , to shorten the recovery time , to limit joint inflammatory reaction and its catabolic effects on articular cartilage and ultimately for joint preservation 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 Background This study will attempt to evaluate the efficacy of knee immobilization on patient pain levels after an anterior cruciate ligament reconstruction . Hypothesis There is no difference in visual analog scale pain scores 2 days after anterior cruciate ligament reconstruction between patients who wear a knee immobilizer  and those who do not wear a knee immobilizer . Study Design R and omized clinical trial ; Level of evidence , 1 . Methods Patients aged 18 to 40 years who met study inclusion criteria were eligible . Patients meeting intraoperative inclusion critiera were r and omized  ( immobilizer or no immobilizer ) after wound closure . The immobilizer used was a soft , unhinged brace with Velcro ® straps . Preoperative , intraoperative , and postoperative protocol s were st and ardized . The primary outcome was patient self-assessed pain using a 0-to-100-mm visual analog scale at day 2 after surgery . Secondary outcomes included pain and analgesic use in the first 14 days after surgery , complications , and range of motion ( approximately 3 weeks postoperatively ) . A sample size estimate was calculated and result ed in the need for 44 patients per group . Results A total of 102 patients were enrolled ; 88 patients were r and omized , and 14 were excluded intraoperatively . There was no difference in mean visual analog scale pain scores at 2 days after surgery between immobilized and nonimmobilized patients ( 32.6 and 35.2 , respectively ; P = .59 ; difference , —2.6 ; 95 % confidence interval , —12.2 to 6.9 ) . There were no differences between groups in medication consumed , range of motion , or complications . Pain and analgesic use were the same for both groups at 7 and 14 days postoperatively . Conclusion No differences in pain or any of the secondary outcomes were detected between immobilized and nonimmobilized patients at any point during the first 14 days after anterior cruciate ligament reconstruction A prospect i ve , blinded , r and omised controlled trial investigated the effectiveness of quadriceps exercises  following anterior cruciate ligament reconstruction . A treatment group ( Quadriceps exercise group ) performed straight leg raises and isometric quadriceps contractions throughout the first two postoperative weeks , and a second group ( No quadriceps exercise group ) did not . A battery of outcome measures assessed subjects postoperatively at day one , two weeks , and one , three and six months . A total of 103 patients ( Quadriceps exercise n = 48 , No quadriceps exercise n = 55 ) commenced the study with 91 subjects available at final follow up ( Quadriceps exercise n = 47 , No quadriceps exercise n = 44 ) . Performance of quadriceps exercises significantly improved a number of knee flexion and extension range of motion measurements ( p = 0.01 to 0.04 ) . No significant differences were found between the two groups at any postoperative period for quadriceps lag ( p = 0.36 ) , functional hop testing ( p = 0.49 to 0.51 ) , isokinetic quadriceps strength ( p = 0.70 to 0.72 ) , the majority of numerical analogue scores ( p = 0.1 to 0.94 ) and Cincinnati scores ( p = 0.10 to 0.84 ) . Subjects performing quadriceps exercises reported significantly higher pain scores with exercise on the first postoperative day ( p = 0.02 ) . At six months postoperatively , the Quadriceps exercise subjects reported significantly more favourable Cincinnati scores for symptoms ( p = 0.005 ) and problems with sport ( p = 0.05 ) . While average knee laxity was not significantly different between treatment groups over time ( p = 0.27 to 0.94 ) , quadriceps exercise performance was associated with a significantly lower incidence of abnormal knee laxity .  Isometric quadriceps exercises and straight leg raises can be safely prescribed during the first two postoperative weeks and confer advantages for faster recovery of knee range of motion and stability . It remains to be proven whether the magnitude of differences between groups is clinical ly significant The aim of the present study is to compare the effect of electrical muscle stimulation combined with voluntary muscle contractions with a program only with voluntary muscle contractions during immobilization in casts after anterior cruciate ligament surgery . Twenty-three patients , 7 women and 16 men with a mean age of 28 yr , were r and omized into two groups : an experimental group ( 13 patients ) and a control group ( 10 patients ) . Post-operatively , the patients were immobilized for 3 wk in a full leg cast with the knee flexed at an angle of 20 degrees to 30 degrees and then in a knee cast for another 3 wk . All patients had a st and ard program with quadriceps muscle contractions . In addition , the experimental group received electrical stimulation of the quadriceps muscle 4 X 10 min , 3 times.wk-1 , at a frequency of 30 Hz . During each stimulation , the patients were requested to contract the quadriceps muscle voluntarily as well . When pre-operative measurements were compared with those at the end of the immobilization period ( 6 wk after the operation ) , a significantly larger reduction in the knee extension isometric muscle strength was found for the control group than for the experimental group . In comparisons of the data of the male subjects only , this difference was still seen to be significant . The cross-sectional area of the quadriceps muscle measured with computed tomography was significantly less reduced during the immobilization period in the experimental group than in the control group . ( ABSTRACT TRUNCATED AT 250 WORDS To evaluate the effects of a rehabilitation brace locked in extension for the first week on the recovery of full extension after ACL reconstruction we compared two groups of subjects who underwent ACL bone-patellar tendon-bone reconstruction .  The brace was unlocked twice a day for assisted physiotherapy . In Group A , 18 male subjects wore a post-operative brace locked from 0 ° to 90 ° .  In Group B , 18 male subjects wore the same post-op brace locked in full extension for the first week . In both groups the brace was unlocked ( 0 ° -120 ° ) at the beginning of the second postoperative week , and then removed at the beginning of the third week . All the subjects followed the same rigorous , accelerated rehabilitation protocol . Each subject was evaluated pre and post-operatively ( at second , fourth and eighth week ) with bubble-level heel height difference ( HHD ) measurements and KT 1000 arthrometric assessment at the fourth postoperative month . Preoperative bubble-level HHD measurements of the two groups were statistically similar ( Group A 0.6 cm , Group B 1 cm ; not significant , n.s . ) . At the fourth week ( Group A 2.2 cm , Group B 0.6 cm ) and eighth week ( Group A 1.6 cm , Group B 0.1 cm ) follow-ups , bubble-level HHD measurements showed that the extension of the operated knees of Group B was significantly greater than in Group A. KT 1000 arthrometric scores showed no difference between the two groups ( Group A 1.8 mm , Group B 1.5 ; n.s . ) If permission of full active and passive extension immediately after an anterior cruciate ligament ( ACL ) reconstruction will increase the post-operative laxity of the knee has been a subject of discussion . We investigated whether a post-operative rehabilitation protocol including active and passive extension without any restrictions in 
    Output:
    
Continuous passive motion did not improve ultimate motion .
Early weightbearing decreases patellofemoral pain .
Postoperative rehabilitative bracing did not improve swelling , pain range of motion , or safety .
Open chain quadriceps activity can begin at 6 weeks .