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The Effect of Early Whole-Body Vibration Therapy on Neuromuscular Control After Anterior Cruciate
Ligament Reconstruction: A Randomized Controlled Trial
Chak Lun Allan Fu, Shu Hang Patrick Yung, Kan Yip Billy Law, King Ho Holly Leung, Po Yee Pauline Lui, Hon Kit Siu
and Kai Ming Chan
Am J Sports Med 2013 41: 804 originally published online March 4, 2013
DOI: 10.1177/0363546513476473

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The Effect of Early Whole-Body Vibration
Therapy on Neuromuscular Control After
Anterior Cruciate Ligament Reconstruction
A Randomized Controlled Trial
Chak Lun Allan Fu,*y MSc, Shu Hang Patrick Yung,z MD, Kan Yip Billy Law,z MD,
King Ho Holly Leung,y MSc, Po Yee Pauline Lui,z PhD, Hon Kit Siu,y MSc,
and Kai Ming Chan,z MD
Investigation performed at the Physiotherapy Department, Prince of Wales Hospital, Hong Kong

Background: Despite rehabilitation training, deficiency in knee joint position sense, muscular performance, postural control, and
functional ability is common after anterior cruciate ligament reconstruction (ACLR). Whole-body vibration therapy (WBVT), which
is initiated from 3 months postoperatively, has proven benefits. However, the effect of earlier WBVT is unknown.
Purpose: To investigate the effect of early WBVT on neuromuscular control after ACLR.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 48 patients with unilateral complete isolated ACL tears were recruited. Single-bundle hamstring ACLR was
performed in all patients. After surgery, they were randomly assigned to either the reference or treatment group. Reference group
patients received conventional ACL rehabilitation, while treatment group patients received 8 weeks of WBVT in addition to con-
ventional rehabilitation, starting from 1 month postoperatively. Joint position sense, postural control, and knee isokinetic perfor-
mance were assessed before surgery and at 1, 3, and 6 months postoperatively using the Biodex dynamometer, Biodex Stability
System, and Cybex NORM, respectively. Knee range of motion (ROM), stability (manual testing and KT-1000 arthrometer), and
functional ability (single-legged hop test, triple hop test, shuttle run test, and carioca test) were also examined. Two-way
repeated-measures analysis of variance and the Mann-Whitney U test were used for statistical analysis.
Results: There was no complication throughout the rehabilitation. All patients achieved full knee ROM and stable knee joints at 6
months after surgery. The WBVT group demonstrated significantly better postural control, muscle performance, single-legged
hop, and shuttle run (P \ .05) than the reference group, but there was no significant difference in knee joint position sense,
triple hop, carioca, ROM, and stability (P . .05).
Conclusion: Early WBVT started from 1 month postoperatively was an effective training method without compromising knee
ROM and stability. It improved postural control, isokinetic performance, single-legged hop, and shuttle run but not knee joint posi-
tion sense, triple hop, and carioca.
Keywords: whole-body vibration therapy; ACL rehabilitation; ACL reconstruction; neuromuscular control; function; physical therapy

Anterior cruciate ligament injury is one of the most common
knee injuries.34 Anterior cruciate ligament reconstruction
(ACLR) is one of the orthopaedic surgical interventions that
improve the mechanical stability of the knee joint.6 However,
*Address correspondence to Chak Lun Allan Fu, MSc, Physiother-
apy Department, Prince of Wales Hospital, Hong Kong (e-mail:
allanfu@gmail.com).
y stability and functional movement patterns.10,44
Physiotherapy Department, Prince of Wales Hospital, Hong Kong.
z
Department of Orthopaedics and Traumatology, The Chinese Uni-
versity of Hong Kong, Hong Kong.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 41, No. 4
DOI: 10.1177/0363546513476473
Ó 2013 The Author(s)
it has been clinically observed and reported that patients with
ACLR still have deficits in postural control,19,21 knee proprio-
ception,17,41,48 and knee strength23,25,39,52 after a period of
rehabilitation. The decrease in proprioception may last up
to 6 months60 or even 4 years after reconstruction.17 Muscle
weakness may also result in an altered gait pattern.29,39
These functional deficits are basically a neuromuscular con-
trol problem that affects the ability to restore dynamic joint
At the early phase of ACLR rehabilitation, the exercise
intensity is insufficient to increase neural drive and to stim-
ulate muscular hypertrophy because of graft protection.4 It
has been shown that muscle strength, proprioception, and
balance start to resume progressively from 3 months after
surgery.44 Therefore, rehabilitation during the first 3 months
is crucial for later function. A recent randomized controlled

804
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Vol. 41, No. 4, 2013
trial (RCT) with 2 years’ follow-up recommended that both
neuromuscular and strengthening exercises should be
included into ACLR rehabilitation programs.42
According to the American College of Sports Medicine
(ACSM), loads of 45% to 50% of maximum intensity improve
dynamic muscular strength in untrained patients.40 Exercise
during the early stage of rehabilitation (such as quadriceps
femoris muscle setting, manual lateralization of patella,
rhythmic stabilization) achieves \35% of maximum inten-
sity. Closed chain resistance exercises achieve a margin of
55% to 60% of maximum intensity.4 Despite the fact that
open chain resistance exercise can produce 67% to 79% of
maximum intensity,4 it is prohibited during the early stage
of rehabilitation because of the considerable anterior shear
forces exerted on the tibia during knee extension. Other
dynamic or plyometric exercises like running, jumping, or
hopping are thus not recommended for the same reason.
A safe and efficient method for stimulating neuromuscu-
lar control in the early rehabilitative phase is thus needed to
incorporate into current neuromuscular rehabilitation pro-
grams to speed up a healthy return. This training should
aim at improving joint proprioception, postural control,
muscle strength, and functional ability. Hurd et al22 sug-
gested that rehabilitation focused on neuromuscular stimu-
lation might improve proprioception and muscle strength.
Liu-Ambrose et al30 showed that proprioception training
alone after ACLR induced an increase of isokinetic strength.
In turn, Bouët and Gahéry8 demonstrated that strengthen-
ing exercise alone could improve proprioception.
Whole-body vibration therapy (WBVT) could be a potential
candidate for ACLR rehabilitation.35 The possible mechanism
for improving neuromuscular activation is the ‘‘tonic vibration
reflex’’ and adaptation of the higher cortex.13,45 There is
emerging evidence that WBVT can improve balance, postural
control, muscle strength, and functional performance.45 To
date, positive effects were reported in a number of studies
on healthy patients12,33,49,54,56 as well as the elderly, postmen-
opausal, stroke victims, and those with Parkinson disease,
multiple sclerosis, and spasms.32,50,55,56 It is reasonable to
postulate that there could be positive effects for patients
who have undergone ACLR as well.
To the best of the authors’ knowledge, there are no stud-
ies investigating the effect of WBVT during early rehabilita-
tion. The earliest that WBVT has been initiated is 3 months
after surgery.35 Better knee proprioception and postural
control were demonstrated. As it is beneficial to start neuro-
muscular training as early as possible, the objective of this
study was to compare the effect of early WBVT (starting
at 1 month after surgery) on neuromuscular control after
ACLR by evaluating knee proprioception, postural control,
peak torque, and functional ability with a reference group.
Joint stability was also assessed for its safety.
MATERIALS AND METHODS
Sample Size Calculation
The software package PASS2008 (NCSS, Kaysville, Utah)
was used to calculate sample size. Joint position sense
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Early Whole-Body Vibration Therapy After ACLR 805
was used as the primary outcome measure. In a related
study35 (N = 20), the angular error when testing joint posi-
tion sense at 60° of knee flexion improved around 50% in the
WBVT group, which was similar to our pilot study. Group
sample sizes of 17 and 17 achieved 81% power and 5% a
(level of significance) to detect a difference of 3.0° (corre-
sponding to 50% improvement) between the null hypothesis
that the WBVT group mean was 6.0° and the reference
group mean was 3.0°. With an estimated group standard
deviation of 3.0° for both groups using a 2-sided, 2-sample
t test and assuming a 40% attrition rate, it was demon-
strated that each group should recruit 24 participants.
Participants
A total of 48 patients who had undergone ACLR at Prince
of Wales Hospital, Hong Kong, were invited to participate
in this study. Participants were patients who had ACLR
with a single-bundle approach. They must have been able
to walk with a pair of elbow crutches independently by 1
month after surgery and were excluded if they had the fol-
lowing histories: (1) concomitant posterior cruciate liga-
ment, lateral collateral ligament, or medial collateral
ligament injury in the same knee; (2) previous operation
on either lower limbs; (3) medical problems that were con-
tradictory to WBVT such as pregnancy, acute thrombosis,
serious cardiovascular disease, pacemaker, acute hernia,
discopathy, spondylolysis, severe diabetes, epilepsy, recent
infections, severe migraine, tumors or kidney stones or so
forth,3 and neurological conditions such as Guillain-Barré
syndrome, myasthenia gravis, and postpolio syndrome;
and (4) prior experience of WBVT to avoid any training
or memory effect. Cases with concomitant meniscal repair
or partial meniscectomy were not excluded. This study was
approved by the joint Chinese University of Hong Kong–
New Territories East Cluster Clinical Research Ethics
Committee. Explanations were given, and consent was
obtained from each patient before participating in this
study.
A physical therapist assistant randomly allocated partici-
pants to either the WBVT or reference group by using a block
randomization program (http://www.randomization.com;
seed number 2327) with a block size of 6.11
Interventions
Both the WBVT and the reference group underwent the
same conventional rehabilitation protocol that was used
by the outpatient Physiotherapy Department, Prince of
Wales Hospital, Hong Kong. The flow of participants in rela-
tion to time and assessments is summarized in Figure 1.
Current research and clinical experiences were consid-
ered in the design of the conventional rehabilitation ther-
apy. It was composed of cryotherapy, magnetotherapy,
neuromuscular electrical stimulation, mobilization exer-
cise, stretching exercise, strengthening exercise, proprio-
ceptive training, balance exercise, functional training,
gait re-education, and home exercise. Criteria for exercise
progression were based on clinical conditions and the pro-
gression models recommended by the ACSM. Patients
806 Fu et al
Figure 1. Flow of participants.
were requested to use elbow crutches for partial weight-
bearing walking for the first 4 weeks after ACLR and to
wear a protective brace for 6 weeks. Details of the protocol
are listed in Appendix 1 (available in the online version of
this article at http://ajs.sagepub.com/supplemental/).
The WBVT group started WBVT training at 1 month
after surgery in addition to the conventional rehabilitation
program (Figure 1). There were 2 sessions per week for
a total of 16 sessions (Appendix 1). Patients were requested
to notify their physical therapist of any unattended train-
ing sessions in advance. Extra training sessions were allo-
cated before or after the missed session within 1 week so
that all training was finished within 2 months. If patients
developed pain, swelling, or decreased knee range of
motion (ROM), they underwent other treatments
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The American Journal of Sports Medicine
(electrotherapy, cryotherapy, taping, ROM exercise) until
the impairments were resolved.
The WBVT was carried out on Fitvibe Excel Pro (model
332015, GymnaUniphy NV, Bilzen, Belgium). The vibra-
tion plates operated in a vertical direction. The frequency
of that vibration was adjusted with a step of 5 Hz, and
vibration frequency ranges were from 20 to 60 Hz. The
amplitude was set as high (4 mm) or low (2 mm). To avoid
attention effects, the vibration therapy was performed in
another room so that the patients in the reference group
were not exposed.
Three designated registered physical therapists who are
experienced in ACLR rehabilitation were responsible for all
the treatments. Before this study, these physical therapists
were instructed with the standard ACLR neuromuscular
Vol. 41, No. 4, 2013
rehabilitation protocol again to ensure the consistency of the
whole rehabilitation program. A physical therapist assis-
tant supervised all WBVT sessions, and an exercise booklet
including exercise positions, training durations, and param-
eters of each session in detail was given to patients to facil-
itate their training and to improve the accuracy of the
exercises (Appendix 1, available online).
Program Adherence
Attendance record sheets were completed by the physical
therapist in charge to document adherence to the program
for the first 3 months of the WBVT group. The patients
were requested to attend 2 sessions per week for the first
3 months. Whenever the patient could not make up 2 ses-
sions per week, they were asked to make an additional
training session 1 week before or after that missed session.
Otherwise, it was counted as a missed session. Program
adherence of 80% was defined as being adherent to the
rehabilitation program.
Outcome Measures
All assessments of the outcome measures were conducted
by another physical therapist assistant who was blinded
to the treatments provided to the participants. To avoid
potential corruption of the results because of fatigue, tests
that required more muscle strength were performed later.
The sequence of the tests is listed below. Each patient had
10 minutes to warm up before the isokinetic test using
a static bicycle.
Joint Position Sense Test
The Biodex dynamometer (Biodex Medical Systems, Shir-
ley, New York) was validated to examine knee joint posi-
tion sense in a nonweightbearing position.14 The patients
were seated upright on the dynamometer with the seat
adjusted approximately 5 cm from the popliteal fossa.
The knee joint of the tested leg was aligned with the axis
of the dynamometer, and patients wore shorts up to mid-
thigh. To eliminate visual input during testing, patients
were blindfolded, and an air splint was positioned around
the ankle to reduce cutaneous sensory input. The tibial
pad was secured to the posterior part of the ankle splint.
The dynamometer extended the knee passively from the
starting position (90° of knee flexion) to the target angle (ie,
30° and 60° of knee flexion) at 2 deg/s. This slow angular
velocity was thought to selectively stimulate Ruffini- or
Golgi-type mechanoreceptors in the joint and to minimize
the contribution of muscle spindles.28 When the target angle
was reached, the dynamometer would hold the position for 5
seconds, and the participants were asked to remember that
target angle. The dynamometer then returned to the start-
ing position and re-extended the knee joint passively. The
patients were asked to press a button when the ‘‘perceived’’
target angle was reached. This ‘‘perceived’’ target angle was
recorded as the matching angle.
Both knees were tested 3 times for each target angle.
The mean of the 3 measured absolute angular errors
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Early Whole-Body Vibration Therapy After ACLR 807
(absolute value of the difference of the target angle and
matching angle) was recorded.
Postural Control Test
The Biodex Stability System (with software version 3.1,
Biodex Medical Systems) was used to evaluate postural
control. Schmitz and Arnold53 showed that the Biodex sys-
tem was a reliable tool to assess postural control. It meas-
ures the deviation from the center of gravity of the body by
providing 3 numerical stability indexes: overall stability
index (OSI), anterior-posterior stability index (API), and
medial-lateral stability index (MLI). The API and MLI
denoted the sagittal and frontal plane, respectively, while
the OSI signified the overall score in all directions. The
lower the score, the better the stability.
Participants were positioned with both feet on the plat-
form and in a comfortable position with knee flexion
around 15°. The foot positions recorded in the first session
were used at all subsequent assessments. Each patient had
to maintain the static position with the platform progres-
sively decreased in stability from level 8 to level 4 within
25 seconds. There were a total of 3 trials, with a 10-second
resting time between. The mean 6 standard deviation of
the OSI, API, and MLI were recorded. Identical testing
procedures were performed with the eyes closed.35
Isokinetic Testing
Peak torque (N
m) measurements were taken with Cybex
NORM (CSMI, Stoughton, Massachusetts) for both quadri-
ceps and hamstrings at speeds of 60, 180, and 300 deg/s.
The dynamometer was calibrated as part of the regular
schedule for testing as suggested by the manufacturer.
The patients were tested in a seated position with the
hips snugly against the back of the chair and flexed at
70° to 90° in an anatomic angle. Stabilization straps were
applied to the trunk, waist, and thigh so as to stabilize
other body parts and maximize the knee torque. The resis-
tance pad was placed at a level 1 inch proximal to the
medial malleolus58 and the lateral femoral condyle as an
anatomic reference for the axis of rotation.16
Before the commencement of each testing speed, partic-
ipants were allowed to familiarize themselves with 3 trials.
The reconstructed limb was tested first. Verbal encourage-
ment at a conversational level was given during testing.
Tests were performed before surgery, 3 months after sur-
gery, and 6 months after surgery. The limb symmetry
index (LSI) was recorded using side-to-side comparison:
reconstructed limb/normal limb 3 100.
Functional Tests
Single-Legged and Triple Hop Tests. Both tests have
good reliability; the single-legged hop test has intraclass
correlation coefficients ranging from 0.97 to 0.99,7 whereas
the triple hop test has reliability coefficients ranging from
0.81 to 0.97.43
Both tests were performed 3 times with each leg. Partic-
ipants were asked to hop with their arms on their hips as
808 Fu et al The American Journal of Sports Medicine

far as possible (maximal effort) from a predetermined line TABLE 1

and to land on the same leg. The best distance (in cm) Baseline Characteristicsa
among the 3 trials was recorded. The normal limb was
tested first, followed by the reconstructed limb.44 The LSI Reference Group WBVT Group P
was calculated for the hop tests. Sex, n .358b
Shuttle Run and Carioca Tests. The reliability coeffi- Male 14 18
cient of these tests ranges from 0.92 to 0.96.27 Both tests Female 10 6
measured the time taken to move across a 6.3-m flat testing Dominant limb, n .492b
area 4 times. In the shuttle run test, patients were asked to Right 20 17
run as fast as was safe and to turn on the reconstructed limb Left 4 7
toward the uninjured side at each end. For the carioca test, Meniscectomy, n .759b
participants were asked to use an alternating crossover step Yes 7 9
No 17 15
to move laterally as quickly as possible to one end and
Meniscal repair, n .371b
reverse direction to the starting position.23 Yes 11 7
No 13 17
Clinical Assessment Age, y 25.2 6 7.3 23.3 6 5.2 .363
(21.7-28.6) (20.9-25.7)
Weight, kg 66.7 6 10.5 66.5 6 12.8 .961
The KT-1000 arthrometer (MEDmetric Corp, San Diego,
(61.8-71.6) (60.6-72.5)
California) was used to assess anterior laxity of the knee.
Height, m 1.70 6 0.07 1.71 6 0.08 .683
A 30-lb load was applied to displace the tibia anteriorly. (1.67-1.73) (1.67-1.74)
The side-to-side difference was calculated by subtracting Body mass index 23.11 6 2.84 22.75 6 3.44 .717
the value of the normal knee from the reconstructed (21.79-24.44) (21.13-24.35)
knee.26 Anterior drawer, Lachman, and pivot-shift tests Days from injury 166.0 6 82.3 182.4 6 95.9 .565
were used to evaluate ligament stability by the same ortho- to surgery (127.4-204.5) (137.5-227.2)
paedic surgeon (K.Y.B.L.). Results of the clinical tests were
a
recorded as grade 0 for negative (no instability) and grades Data are expressed as mean 6 standard deviation (95% confi-
I, II, and III for mildly, moderately, and severely positive, dence interval) unless otherwise indicated. WBVT, whole-body
vibration therapy.
respectively. Knee ROM of all participants was measured b 2
x test.
using a goniometer at 6 months after surgery.

Statistical Analysis RESULTS

Statistical analysis was performed with the Statistical
Package for the Social Sciences (SPSS, Version 19, SPSS
Inc, Chicago, Illinois). Baseline characteristics were tested
using independent t tests for parametric parameters and
the x2 test for nonparametric parameters. The time of base-
line assessments of joint position sense and postural control
was at 1 month postoperatively, while the isokinetic and
functional tests were conducted around 2 weeks before sur-
gery because the ACL graft was unstable for testing at 1
month after surgery. Repeated-measures analysis of vari-
ance (ANOVA) with time as the repeated-measures factor
for the outcomes measure was used to analyze the difference
between the 2 groups. Tests of within-patient effect were
utilized to find any difference between different time inter-
vals in each group. Contrast with F statistics was used to
test for the difference at different time points in the post
hoc analysis. The Mann-Whitney U test was employed to
compare for any difference between the 2 groups in the
anterior drawer, Lachman, and posterior drawer tests. A
P value of \.05 was considered statistically significant.
Participants who missed follow-up assessments were
contacted by telephone within 1 week for reassessment.
Those who missed assessments at 1 and 3 months postop-
eratively were excluded from analysis. Otherwise, the last
observation carried forward method was used to replace
the missing value at 6 months postoperatively. The degree
of program adherence was expressed as a percentage.
Dropout Rate and Program Adherence
The dropout rate ranged from 4.1% to 16.7% at different
time intervals (Figure 1). The main reason for dropping
out was personal time limitations rather than any adverse
effects. One patient discontinued physical therapy treat-
ment because of geographical reasons. Program adherence
within the first 3 months was 83.2% in the WBVT group
and 84.4% in the reference group.
Baseline Demographics and Pretest Measurements
There was no significant difference in any patient charac-
teristics and pretest measurements (Table 1) between the
reference group and the WBVT group. The P values ranged
from .107 to .961.
Posttreatment Group Measurements
Joint Position Sense Test. There was no significant dif-
ference between the 2 groups with the test performed for
the reconstructed limb at 60° of knee flexion (overall P =
.08) and 30° of knee flexion (overall P = .057) and the nor-
mal limb at 60° of knee flexion (overall P = .638) and 30° of
knee flexion (overall P = .510) throughout 6 months of
rehabilitation (Table 2 and Appendix 2).

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Vol. 41, No. 4, 2013 Early Whole-Body Vibration Therapy After ACLR 809

TABLE 2
Results of Posttreatment Measurementsa

Baseline 3 Months Postoperatively 6 Months Postoperatively

Reference WBVT P Baseline Reference WBVT Reference WBVT P Overall

Joint position sense, deg

60° of flexion
RL 4.12 6 1.83 5.42 6 3.02 .111 4.48 6 3.20 4.45 6 2.00 4.77 6 2.93 4.07 6 2.17 .080
(2.99-5.26) (4.29-6.55) (3.27-5.69) (3.24-5.65) (3.60-5.93) (2.90-5.24)
NL 5.64 6 3.21 4.34 6 2.95 .189 4.58 6 3.48 3.77 6 2.65 4.96 6 2.57 4.54 6 2.79 .638
(4.24-7.04) (2.94-5.73) (3.17-5.98) (2.37-5.17) (3.75-6.17) (3.33-5.75)
30° of flexion
RL 5.13 6 2.41 6.63 6 3.28 .107 4.76 6 2.27 4.68 6 2.30 5.25 6 2.84 4.43 6 3.09 .057
(3.83-6.43) (5.33-7.93) (3.73-5.79) (3.64-5.71) (3.91-6.59) (3.08-5.77)
NL 5.52 6 3.40 6.06 6 2.56 .578 5.50 6 2.34 5.14 6 2.10 5.08 6 2.06 4.60 6 2.18 .510
(4.16-6.88) (4.69-7.42) (4.49-6.50) (4.14-6.15) (4.12-6.04) (3.64-5.56)
Postural control (index)
With eyes open
OSI 2.59 6 1.68 2.24 6 1.41 .473 2.18 6 1.44 1.86 6 0.98 2.09 6 0.90 1.62 6 1.00 .921
(1.89-3.30) (1.54-2.94) (1.62-2.74) (1.30-2.41) (1.66-2.51) (1.19-2.05)
API 2.06 6 1.72 1.64 6 1.20 .375 1.56 6 1.33 1.37 6 0.96 1.54 6 0.97 1.46 6 1.80 .780
(1.39-2.73) (0.97-2.31) (1.03-2.08) (0.84-1.90) (0.89-2.19) (0.80-2.11)
MLI 1.22 6 0.62 1.29 6 0.77 .753 1.35 6 0.84 0.98 6 0.49 1.37 6 0.90 1.01 6 0.62 .108
(0.90-1.54) (0.97-1.61) (1.04-1.66) (0.66-1.29) (1.02-1.71) (0.66-1.35)
With eyes closed
OSI 6.06 6 1.37 6.37 6 2.46 .626 6.03 6 2.23 4.69 6 2.01c 5.57 6 1.53 5.20 6 2.30 .013b
(5.16-6.96) (5.47-7.27) (5.07-6.99) (3.73-5.65c) (4.69-6.45) (4.31-6.08)
API 3.90 6 1.13 4.15 6 1.71 .588 4.70 6 2.20c 3.09 6 1.37c 4.20 6 1.58 3.37 6 1.62 \.001b
(3.25-4.56) (3.50-4.81) (3.87-5.53c) (2.26-3.92c) (3.48-4.92) (2.65-4.09)
MLI 3.89 6 0.97 4.09 6 1.48 .616 3.88 6 1.28 2.91 6 1.30c 3.64 6 1.03 3.05 6 1.42 .002b
(3.32-4.46) (3.52-4.66) (3.30-4.46) (2.33-3.50c) (3.07-4.20) (2.48-3.61)
Knee peak torque, N
m
Quadriceps
60 deg/s
RL 84.1 6 30.1 79.4 6 30.4 .628 — — 120.0 6 34.9 139.7 6 32.4 .012b
(70.3-97.8) (65.7-93.1) (104.8-135.2) (124.4-154.9)
NL 140.6 6 40.1 142.8 6 30.1 .848 — — 147.3 6 34.9 153.5 6 26.6 .521
(124.6-156.6) (126.7-158.8) (133.2-161.3) (139.4-167.5)
180 deg/s
RL 62.9 6 22.0 55.8 6 27.9 .379 — — 90.0 6 22.2 98.9 6 22.4 .013b
(51.5-74.3) (44.5-67.2) (80.0-100.1) (88.8-109.0)
NL 94.5 6 20.2 93.0 6 25.3 .842 — — 108.8 6 20.4 116.1 6 24.9 .061
(84.1-104.8) (82.6-103.4) (98.5-119.1) (105.8-126.4)
300 deg/s
RL 46.5 6 22.8 39.2 6 17.3 .259 43.4 6 18.8 49.8 6 18.4c 56.8 6 22.9c 65.5 6 15.7c .005b
(37.3-55.7) (30.0-48.3) (34.9-51.8) (41.4-58.2c) (47.9-65.6c) (56.6-74.4c)
NL 65.9 6 17.1 59.5 6 16.3 .23 63.6 6 16.0 69.0 6 21.1 73.3 6 19.5 75.7 6 20.2 .053
(58.3-73.5) (51.9-67.0) (55.1-72.1) (60.5-77.4) (64.3-82.3) (66.7-84.7)
Hamstrings
60 deg/s
RL 71.9 6 17.6 67.2 6 25.9 .511 — — 87.2 6 19.4 92.4 6 23.1 .045b
(61.8-81.9) (57.2-77.2) (77.6-96.9) (82.7-102.0)
NL 90.0 6 23.3 87.2 6 19.1 .687 — — 99.4 6 22.6 103.6 6 20.5 .151
(80.3-99.6) (77.6-96.9) (89.6-109.1) (93.9-113.4)
180 deg/s
RL 56.6 6 23.0 53.7 6 18.9 .66 — — 66.5 6 21.9 71.6 6 16.2 .070
(47.1-66.1) (44.1-63.2) (57.8-75.2) (62.9-80.4)
NL 68.8 6 20.8 71.3 6 16.8 .681 — — 76.1 6 20.2 81.3 6 14.5 .494
(60.3-77.4) (62.7-79.9) (68.1-84.1) (73.4-89.3)
300 deg/s
RL 42.1 6 16.9 35.0 6 18.6 .218 41.5 6 16.3 48.5 6 18.8c 51.5 6 13.9c 58.6 6 18.0c .014b
(34.0-50.1) (26.9-43.1) (33.5-49.4) (40.5-56.4c) (44.2-58.8c) (51.3-65.9c)
NL 57.8 6 18.4 52.6 6 14.5 .334 59.5 6 17.6 63.7 6 16.5 65.5 6 16.8 68.2 6 14.7 .082
(50.3-65.2) (45.1-60.1) (51.8-67.2) (56.0-71.5) (58.3-72.6) (61.0-75.3)

(continued)

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810 Fu et al The American Journal of Sports Medicine

TABLE 2
(Continued)

Baseline 3 Months Postoperatively 6 Months Postoperatively

Reference WBVT P Baseline Reference WBVT Reference WBVT P Overall

Functional tests
1-legged hop, cm
RL 105.1 6 37.2 100.1 6 33.2 .661 — — 129.5 6 38.4 140.8 6 27.1 .022b
(89.1-121.0) (84.2-116.1) (114.5-144.6) (125.8-155.9)
NL 138.4 6 43.3 136.0 6 31.7 .841 — — 148.7 6 37.0 154.5 6 28.4 .331
(121.2-155.6) (118.8-153.1) (133.7-163.6) (139.5-169.4)
Triple hop, cm
RL 281.1 6 79.5 273.3 6 68.5 .741 — — 365.2 6 49.4 381.2 6 59.5 .345
(247.5-314.7) (239.7-306.9) (340.5-390.0) (356.4-405.9)
NL 401.7 6 90.2 408.5 6 78.2 .8 — — 416.8 6 80.7 423.1 6 69.56 .967
(363.5-439.9) (370.3-446.7) (382.7-450.9) (389.0-457.2)
Shuttle run, s 10.1 6 1.2 10.5 6 1.4 .36 — — 9.5 6 1.7 9.1 6 0.8 .036b
(9.5-10.7) (9.9-11.1) (8.9-10.1) (8.5-9.7)
Carioca, s 16.5 6 4.9 15.9 6 4.0 .658 — — 14.0 6 3.0 13.7 6 2.7 .758
(14.5-18.5) (13.9-17.9) (12.8-15.3) (12.4-14.9)
KT-1000 4.6 6 1.9 4.4 6 2.4 .74 1.5 6 1.1 1.4 6 1.2 1.4 6 1.2 1.4 6 1.3 .848
arthrometer (3.7-5.6) (3.5-5.4) (1.0-2.1) (0.9-1.9) (0.8-1.9) (0.8-1.9)
side-to-side
difference, mm

a
Data are expressed as mean 6 standard deviation (95% confidence interval). WBVT, whole-body vibration therapy; RL, reconstructed
limb; NL, normal limb; OSI, overall stability index; API, anterior-posterior stability index; MLI, medial-lateral stability index. Dashes indi-
cate that there is no assessment at that time interval.
b
P \ .05.
c
P \ .05, post hoc test.

Postural Control Test. Postural control was better in all
directions with tests performed with eyes opened than with
eyes closed, and the WBVT group had better postural con-
trol in both testing conditions after surgery (Table 2 and
Appendix 2). There was no significant difference in the
OSI (overall P = .921), API (overall P = .780), and MLI
(overall P = .108) for tests performed with eyes opened,
but the WBVT group performed significantly better than
the reference group in the OSI (overall P = .013), API (over-
all P \ .001), and MLI (overall P = .002) for tests performed
with eyes closed between baseline and 6 months postoper-
atively. It was noted that postural control significantly
improved in the WBVT group for the OSI (post hoc P \
.001), API (post hoc P = .001), and MLI (post hoc P \
.001) 3 months after rehabilitation but significantly
decreased in the API (post hoc P = .03) for the reference
group.
Isokinetic Testing. The quadriceps of the reconstructed
limbs in the WBVT group had higher peak torques at
60 deg/s (overall P = .012), 180 deg/s (overall P = .013),
and 300 deg/s (overall P = .005) than the reference group
at 6 months postoperatively. Also, the hamstrings of the
WBVT group had higher peak torques at 60 deg/s (overall
P = .045) and 300 deg/s (overall P = .014) but not at
180 deg/s (overall P = .070) nor in the normal limb (overall
P range, .053-.521). Three months after rehabilitation, only
the WBVT group had significant improvement in the quad-
riceps (post hoc P = .002) and hamstrings (post hoc P =
.007) at 300 deg/s (Table 2 and Appendix 2). Patients in
the WBVT group also had better limb symmetry through-
out 6 months of rehabilitation (Table 3).
Functional Assessments. The WBVT group performed
significantly better in the shuttle run test (overall P =
.036; post hoc P \ .001). In the single-legged hop test,
both the reconstructed limb (overall P = .022; post hoc
P \ .001) of the WBVT group and the reconstructed limb
(overall P = .022; post hoc P \ .001) of the reference group
were significantly better. There was no significant differ-
ence in the triple hop and carioca between the 2 groups
(Table 2 and Appendix 2). Patients in the WBVT group
also had better limb symmetry throughout 6 months of
rehabilitation (Table 3).
Clinical Assessments. No complication was noted, and
all patients achieved full knee ROM. There was no side-
to-side difference between the 2 groups for the KT-1000
arthrometer with P = .848 (Table 2). For the clinical assess-
ments, around 80% of the patients were grade 0, and 20%
were grade I in both groups. There was no significant dif-
ference in anterior drawer (Z \ 0.001; P = 1.000), Lachman
(Z = –0.374; P = .708), and pivot-shift (Z = –1.561; P = .118)
test results between the 2 groups.
DISCUSSION
There were no complications throughout the rehabilita-
tion. All patients achieved full knee ROM and stable
knee joints at 6 months after surgery. The WBVT group

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Vol. 41, No. 4, 2013 Early Whole-Body Vibration Therapy After ACLR 811

TABLE 3 proportional to the force generated by the machine and

Limb Symmetry Indexa thus absorbed by the resonator.
The proportion of training and resting time was
3 Months 6 Months increased gradually to provide more stimuli to muscle
Parameter Postoperatively Postoperatively
and higher training intensity for exercise progression.
Knee strength, N/m The training sessions lasted for 8 weeks because neural
Extensors adaptation and skeletal muscle hypertrophy take about 4
60 deg/s Ref — 81.5 to 8 weeks of time,24 and training periods of at least 6
WBVT — 90.8 weeks were shown to be more effective for remarkable
180 deg/s Ref — 82.8 physiological adaptations responsible for recurrent injury
WBVT — 85.2 prevention.59
300 deg/s Ref 68.2 77.4
Training Position. The protocol was composed of both
WBVT 72.2 86.5
static and dynamic exercises (exercises A-H), as it was
Flexors
60 deg/s Ref — 87.8 demonstrated that electromyogram (EMG) activity of
WBVT — 89.1 knee extensors improved from 2.9% to 6.7% in static condi-
180 deg/s Ref — 87.4 tions and 3.7% to 8.7% in dynamic conditions18 and signif-
WBVT — 88.1 icantly improved in knee proprioception and postural
300 deg/s Ref 69.66 78.7 balance.35 Three general positions were used in this study
WBVT 76.0 85.9 (ie, high squat, low squat, and single-legged squat) because
Functional tests Roelants et al51 showed that the WBVT group significantly
1-legged hop, cm Ref — 87.1 increased EMG activity for all muscles during exercise in
WBVT — 91.2
these positions, ranging from a 49% to 365% greater
Triple hop, cm Ref — 87.6
response when compared with the reference group. Exer-
WBVT — 90.1
cises J to K were cool-down and muscle relaxation exer-
a
Limb symmetry index = reconstructed limb/normal limb 3 100. cises, and the target muscles were hamstring, calves, and
Ref, reference; WBVT, whole-body vibration therapy. hip adductor, respectively (Appendix 1).
Safety Issues. There is no safety guideline for WBVT.45
On the basis of previous studies, participants were
demonstrated significantly better postural control, muscle excluded as in the exclusion criteria to avoid possible dele-
performance, single-legged hop, and shuttle run (P \ .05) terious effects. The training frequency was higher than
than the reference group, but there was no significant dif- 20 Hz45 and lower than 50 Hz.46 All of the training posi-
ference in knee joint position sense, triple hop, carioca, tions in our study adopted a certain degree of flexion in
ROM, and stability (P . .05). the ankle, knee, and hip joints to avoid high transmission
factors to their heads.2 Also, to date, no major adverse
Rationale of the Parameters in WBVT effect was reported in the literature. The most common
side effects appeared to be erythema, itching, and edema
Mode and Training Intensity. The training frequency in in the lower limbs,13 but none of our patients had any of
this study increased gradually from 35 to 50 Hz with an these complications. The training positions in WBVT
amplitude of 4 mm. This was based on Hazell et al18 that were safe for patients who had undergone ACLR who
higher frequencies (ie, 35, 40, 45 Hz) resulted in the great- were limited to certain ROMs and types of exercise (plyo-
est knee extensor activities when combined with a 4-mm metric, open chain, and functional exercises) at the early
amplitude on a vertically oscillating platform. Indeed, stage of rehabilitation. All of our patients achieved full
Abercromby et al1 showed that the responses of knee knee ROM as well as good knee stability. We thus believe
extensors were significantly greater in side-alternating that WBVT was safe for ACLR patients using hamstring
vibration than vertical vibration, so it was also possible grafts within the range of our parameters.
that side-alternating oscillation can improve muscle
strength and postural balance with this protocol. Joint Position Sense
In addition, Rittweger et al46 demonstrated that a fre-
quency between 26 and 44 Hz was used for improving mus- Histological studies revealed that mechanoreceptors were
cle power and strength and that a frequency lower than located in the subsynovial layers and at the insertions of
20 Hz was for muscle relaxation. This was why the lower the ACL.15 Mechanoreceptors such as Ruffini endings,
limit was set at 35 Hz. The upper limit was set at 50 Hz Pacinian corpuscles, and Golgi tendon organs that were
because frequencies .50 Hz were reported to cause severe present in the ACL were responsible for the sensation of
muscle damage.46 joint motion and position.15,47 Removal of the torn ACL
The amplitude was fixed at 4 mm because it was the and thus the mechanoreceptors within it could decrease
highest amplitude that the machine could achieve. The joint position sense. However, this study showed that there
larger the amplitude, the more force is needed to maintain was no difference in joint position sense in any conditions
a posture. According to simple harmonic motion and New- as opposed to other studies, which demonstrated that the
ton’s second law, acceleration increases with increasing time needed for the re-establishment of ACL grafts was
amplitude at the same frequency and is directly around 6 months.5,35

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812 Fu et al
One possible reason is that the function for detecting
joint position may be substituted by other mechanorecep-
tors within the knee joints. Another reason is that the
recovery period for the re-establishment of mechanorecep-
tors and neural incorporation into the ACL graft is longer
than 6 months. Ochi et al38 denoted that 18 months was
needed for neural incorporation into the ACL hamstring
graft.
Postural Control
Moezy et al35 showed that there were significant differen-
ces for tests performed with eyes opened and eyes closed
(P \ .05). In contrast, our study showed differences for
tests performed with eyes closed only. These results were
reasonable, as balance was influenced by visual, vestibu-
lar, and somatosensation systems. Blocking input from
any of these systems can result in decreasing postural bal-
ance.31 All indexes in our tests performed with eyes open
had better postural control when compared with eyes
closed in both groups (P \ .05).
Better postural control in the WBVT group could be
caused by the improvement in muscle performance and
neural adaptation. After ACLR, the mechanoreceptors
could lose feedback25 or diminish in neuromuscular excit-
ability.52 Signal loss from mechanoreceptors may induce
changes for the remaining receptor inputs. The altered
feedback mechanism may prolong muscle reaction time
and limit postural control.59 Patients who have undergone
WBVT were shown to recruit a larger proportion of the a
motoneuron pool and decrease the sensory threshold,36
thereby reducing the muscle reaction time. In addition,
motor unit excitability was enhanced with increased motor
unit activity through descending pathways.36
Isokinetic Testing
The improvement of peak torque in the quadriceps and
hamstrings at different testing speeds supported the
hypothesis that early neuromuscular stimulation through
WBVT can improve muscle strength at an earlier stage of
ACLR rehabilitation than conventional neuromuscular
training programs. There were many studies investigating
the effect of WBVT on other specific populations.32,55,56 To
the best of the authors’ knowledge, this was the first RCT
to evaluate the effect of muscle performance using WBVT
and compared with neuromuscular training on ACLR
patients but not ACL-deficient patients.
The LSI was higher in the WBVT group (Table 3). The
WBVT group had minimal deficits, while the reference
group had moderate deficits58 at 3 months postoperatively,
and these improvements were continued up to 6 months
postoperatively. Indeed, WBVT was demonstrated to be
an effective and time-saving method to strengthen knee
muscle groups in the lower limb compared with traditional
methods that usually aim at 1 muscle group.
This could be accounted for in the lower limb muscles,
which work concentrically and eccentrically against the
damping effect at each oscillation cycle of vibration. This
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The American Journal of Sports Medicine
kind of stretch-shortening cycle (plyometric properties)
was shown to increase muscle strength.57 This can be
a solution to decreased knee strength in the normal knee
after ACLR reported by some authors.20
One similar study used localized vibration instead of
WBVT9; the treatments were initiated at 1 month postop-
eratively and assessed at 3 months postoperatively. Both
vibration therapies showed superior effects over conven-
tional rehabilitation programs (strength, balance, and pro-
prioception training). A shorter neural adaptation period
through vibration is possibly the mechanism for increasing
muscle strength, as muscle hypertrophy cannot result from
3 days of training. With the enhancement of motor unit
recruitment, the continuum of WBVT in our study should
be the reason for a further percentage increase in muscle
strength, as muscle hypertrophy takes around 6 weeks to
develop.40 However, the rate of neural adaptation between
the 2 methods of vibration cannot be determined in this
study.
The main differences between our study and Brunetti
et al’s9 were the training intensity (the present study
has a much lower frequency and higher amplitude) and
training duration (a total of 319 minutes in the present
study vs 30 minutes in the Brunetti et al study9). In Bru-
netti et al’s study,9 they directly applied localized
mechanical vibration to the area close to the tendon inser-
tion of the intermedius femoris, rectus femoris, vastus
medialis, and vastus lateralis. The vibration was per-
formed for 3 consecutive days for 10 minutes at 1 month
postoperatively, with a frequency of 100 Hz and ampli-
tude of oscillation of \20 mm. Three months after surgery,
the peak torque of knee extensors muscles in Brunetti
et al’s9 patients recovered to presurgical levels (6% less
than the nonoperated side), while those under conserva-
tive training showed a decline of 14%. Our study demon-
strated that both knee extensors and knee flexors were
around 30% better in the WBVT group and 10% weaker
in the reference group.
Functional Ability
The hop tests were used to assess muscle strength,
dynamic muscle coactivation, and confidence, while the
shuttle run test and carioca test examined agility.23 All
patients demonstrated better functional ability after 6
months of rehabilitation, with the WBVT group signifi-
cantly performing better in the single-legged hop test and
shuttle run test (Table 2 and Appendix 2). The LSI of the
hop tests were .85% for all patients and were considered
within the normal range.37 The LSI of the WBVT group
even achieved .90%.
WBVT Versus Conventional Neuromuscular Training
This study, and other RCTs that focus on conventional
neuromuscular training and balance training,42,44 showed
positive results in postural control and proprioception at
3 months postoperatively. In addition, WBVT demon-
strated significant superior knee strength compared with
Vol. 41, No. 4, 2013
the reference group at 3 months after surgery and up to 6
months postoperatively. It is therefore advisable to start
WBVT at 1 month postoperatively.
Limitations and Further Studies
This study did not document patient satisfaction, confi-
dence to return to sports, or effect of WBVT on the graft
itself. It will be more comprehensive to quantify these in
further studies. Also, to date, there has been no study
that investigated the effect of WBVT on healing of the graft
within the bone. Another limitation is that we did not
record a patient-oriented outcome score such as the Inter-
national Knee Documentation Committee (IKDC),
Lysholm, or Knee injury and Osteoarthritis Outcome Score
(KOOS), so we cannot state whether the observed changes
corresponded to subjective functional improvement as
would have been measured by such scales. Also, owing to
the nature of the treatment, the patients could not be
blinded to the treatment they were receiving.
There was no statistically significant difference between
the 2 groups for patients with meniscal repair; however,
we still believe that there may have been some influence
on the rehabilitation program. Further studies may try to
investigate the difference between the two.
It is suggested to increase the number of training ses-
sions for more than 2 months and investigate for any addi-
tional effect. Based on the patient’s clinical performance,
a more dynamic training protocol is preferred for each
patient instead of a fixed protocol for exercise progression.
Neuromuscular performance improved with WBVT.
Further studies may investigate the difference of using
WBVT and local vibration during early rehabilitation after
ACLR.
CONCLUSION
This is the first RCT to demonstrate that early WBVT
started from 1 month postoperatively is an effective train-
ing method without compromising knee stability. The
WBVT group had better postural control, muscle strength,
single-legged hop, and shuttle run than the reference
group, but not for knee joint position sense, triple hop,
and carioca. We suggest incorporating WBVT into current
neuromuscular rehabilitation programs to facilitate recov-
ery starting from 1 month postoperatively.
ACKNOWLEDGMENT
The authors acknowledge the generous assistance provided
by the physical therapists at the Prince of Wales Hospital in
Hong Kong and the staff of the Department of Orthopaedics
and Traumatology at The Chinese University of Hong Kong.
They are particularly grateful for the help provided by
Ms S.Y. Lau, the senior physical therapist at Prince of
Wales Hospital, for editorial assistance; Professor T.P.
Fong of the Sport Performance and Biomechanics Labora-
tory at The Chinese University of Hong Kong for technical
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Early Whole-Body Vibration Therapy After ACLR 813
advice; and Ms S.F. Leung for technical assistance. Special
appreciation is offered to Ms M.Y. Ng and Mr T.C. Fu for
their continuous support throughout the research process.
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