How Much Time Is Needed Between Serial "Return to Play" Assessments to Achieve Clinically Important Strength Gains in Patients Recovering From Anterior Cruciate Ligament Reconstruction?

BACKGROUND: Pass rates for return-to-play evaluations are alarmingly low for patients after anterior cruciate ligament reconstruction (ACLR). Since timing of return to play is a complicated decision, it is important that patients be given optimal time to realize meaningful improvements in strength that warrant additional testing. PURPOSE: To (1) compare outcomes among patients assessed at different time points after ACLR, (2) determine strength gains indicative of improvements in subjective function, and (3) determine the amount of time necessary to achieve meaningful strength gains. STUDY DESIGN: Cross-sectional/case-control study; Level of evidence, 3. METHODS: A total of 293 patients participated in the study after ACLR (mean ± SD, 23.2 ± 10.1 years old; n = 142 female participants; 6.4 ± 0.9 months after ACLR). Participants were stratified on the month of their evaluation after ACLR: 5 to 6 months (n = 122), 6 to 7 months (n = 102), 7 to 8 months (n = 43), and 8 to 9 months (n = 26). The International Knee Documentation Committee (IKDC) subjective form and knee extensor and flexor torque and symmetry, as assessed through an isokinetic dynamometer, were compared among groups. Forty patients (20 female participants, 20.4 ± 7.1 years old) were referred for subsequent testing (2.14 ± 0.78 months after initial visit). Subjective improvement between visits was defined as a ≥9-point change of the IKDC score. Thresholds of knee extensor torque and symmetry indicative of subjective improvement and the time between assessments needed to achieve these strength improvements were determined. RESULTS: Patients between 5 and 6 months (IKDC, 79.7; interquartile range [IQR], 70.1-88.5) had lower subjective function compared to patients between 6 and 7 months (IKDC, 83.9; IQR, 74.5-92.0; P = .019) and 8 and 9 months after ACLR (IKDC, 89.1; IQR 75.8-92.3; P = .026). Patients between 5 and 6 months (1.41 N·m/kg; IQR, 1.16-1.73 N·m/kg]) had lower knee extensor torque compared to patients 6 and 7 months (1.59 N·m/kg; IQR, 1.23-1.95 N·m/kg; P = .013) and 7 and 8 months after ACLR (1.62 N·m/kg; IQR, 1.30-1.86 N·m/kg; P = .046). Patients between 5 and 6 months (66.4%; IQR, 54.2-78.6) had lower symmetry compared to patients between 6 and 7 months (71.8%; IQR,61.1-82.9; P = .019) and 8 and 9 months afterACLR (75.2%; IQR, 66.6-87.7; P = .014). Of the 40 patients that completed follow-up assessments, an increase in knee extensor torque of 0.22 N·m/kg and symmetry of 5.75% discriminated patients that achieved subjective improvement. A period of 1.97 months between assessments discriminated those that achieved the established symmetry threshold. CONCLUSION: Patients demonstrate increasing subjective and quadriceps function when tested at later time points from surgery; however, the observed values are low, suggesting that at 9 months patients are demonstrating deficits that may be improving. Approximately 2 months is needed to observe clinically meaningful improvements.

Demographic and surgical factors affect quadriceps strength after ACL reconstruction.

PURPOSE: To investigate the effects of graft source, time since surgery, age, and sex on unilateral and symmetry-based measures of knee extension strength among individuals with ACL reconstruction (ACLR). METHODS: Three hundred and eight individuals aged 13-40 years old with primary, unilateral ACLR in the last 60 months were enrolled in this multi-site clinical measurement study. Participants completed bilateral knee extension maximal voluntary isometric contraction (MVIC) torque assessments which were normalized to body mass (Nm/kg) and limb symmetry indices (LSI) were calculated. The effects of graft source (patellar tendon autograft; hamstring tendon autograft), time since surgery (≤ 12 months; >12 mo.), age (≤ 18 years; >18 years), and sex were evaluated using separate ANCOVAs. RESULTS: A significant interaction was present between time since surgery and graft source for LSI (P = 0.01) as participants with patellar tendon autografts ≤ 12 months post-ACLR experienced the greatest asymmetry (LSI = 69.2 ± 24.5%). Significant interactions were present between time since surgery and sex for involved limb (P = 0.01) and uninvolved limb MVIC torque (P = 0.05) with females ≤ 12 months post-ACLR being weakest (involved MVIC = 1.81 ± 0.70 N m/kg; uninvolved MVIC = 2.40 ± 0.68 N m/kg). Participants ≤ 18-year-old displayed weaker involved limb (P < 0.001) and contralateral limb (P < 0.001) MVIC torque as compared to participants > 18-year-old during the first year after ACLR. CONCLUSIONS: Graft source, sex, age, and time since surgery effect quadriceps strength and symmetry after ACLR. Surgical and demographic factors should be considered when developing treatment approaches to optimize quadriceps function prior to re-integration into pre-injury levels of physical activity. LEVEL OF EVIDENCE: IV.

Black Americans' Perspectives of Barriers and Facilitators of Community Screening for Kidney Disease.

BACKGROUND AND OBJECTIVES: Incidence of ESKD is three times higher in black Americans than in whites, and CKD prevalence continues to rise among black Americans. Community-based kidney disease screening may increase early identification and awareness of black Americans at risk, but it is challenging to implement. This study aimed to identify participants' perspectives of community kidney disease screening. The Health Belief Model provides a theoretic framework for conceptualization of these perspectives and optimization of community kidney disease screening activities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Researchers in collaboration with the Tennessee Kidney Foundation conducted three focus groups of adults in black American churches in Nashville, Tennessee. Questions examined views on CKD information, access to care, and priorities of kidney disease health. Content analysis was used. Guided by the Health Belief Model, a priori themes were generated, and additional themes were derived from the data using an inductive approach. RESULTS: Thirty-two black Americans completed the study in 2014. Participants were mostly women (79%) with a mean age of 56 years old (range, 24-78). Two major categories of barriers to kidney disease screening were identified: (1) participant factors, including limited kidney disease knowledge, spiritual/religious beliefs, emotions, and culture of the individual; and (2) logistic factors, including lack of convenience and incentives and poor advertisement. Potential facilitators of CKD screening included provision of CKD education, convenience of screening activities, and use of culturally sensitive and enhanced communication strategies. Program recommendations included partnering with trusted community members, selecting convenient locations, tailored advertising, and provision of compensation. CONCLUSIONS: Findings of this study suggest that provider-delivered culturally sensitive education and stakeholder engagement are critical to increase trust, decrease fear, and maximize participation and early identification of kidney disease among black Americans considering community screening.