Effectiveness of the Addition of a Cross-Education, Mirror Therapy, and Virtual Reality Exercises in Patients with Anterior Cruciate Ligament Reconstruction: The CROSSMIRV Trial Protocol

Background: Based on the available evidence, there are no published clinical trials that have analyzed the effectiveness of adding cross-education, mirror therapy, and virtual reality exercises (combined) to standard treatment to improve clinical outcomes in patients after anterior cruciate ligament (ACL) reconstruction. Methods: A total of 58 patients with ACL reconstruction, aged 18-50 years, will be randomized (1:1) to two treatment arms. The control group (n = 29) will receive a standard physiotherapy program based on a consensus developed by the Sport and Health Rehabilitation Guidelines. The experimental group (n = 29) will receive a novel physiotherapy program that includes cross-education exercise with visual biofeedback, mirror therapy, and virtual reality in addition to the standard exercise program. Five evaluations will be performed: at the beginning of physiotherapy treatment (baseline), at 6 weeks, 12 weeks, 24 weeks and 52 weeks after surgery. The primary outcome will be passive knee extension range of motion at 6 weeks (for sample size), assessed by goniometry; the remaining outcomes are secondary and exploratory. The secondary outcomes measures will be pain intensity, fear of movement, the level of anxiety, knee function, and isometric quadriceps strength. Discussion: We hypothesize that patients who receive a novel physiotherapy program that includes cross-education with visual biofeedback, mirror therapy, and virtual reality will show greater benefits in knee extension and other clinical outcomes than those who receive a standard physiotherapy program. Conclusions: The trial proposed in this protocol will provide new data on the effectiveness of the combination of cross-education, motor imagery, and virtual reality therapy added to a standard physiotherapy program compared with the standard physiotherapy program alone in patients who undergo ACL reconstruction. The findings will generate new insights into the effects of the interventions and expand the multimodal rehabilitation strategies available to patients who undergo this surgery.