Persistent Early Knee Osteoarthritis Symptoms From 6 to 12 Months After Anterior Cruciate Ligament Reconstruction.

CONTEXT: Early identification of knee osteoarthritis (OA) symptoms after anterior cruciate ligament reconstruction (ACLR) could enable timely interventions to improve long-term outcomes. However, little is known about the change in early OA symptoms from 6 to 12 months post-ACLR. OBJECTIVE: To evaluate the change over time in meeting classification criteria for early knee OA symptoms from 6 to 12 months after ACLR. DESIGN: Prospective cohort study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Eighty-two participants aged 13 to 35 years who underwent unilateral primary ACLR. On average, participants' first and second visits were 6.2 and 12.1 months post-ACLR. MAIN OUTCOME MEASURE(S): Early OA symptoms were classified using generic (Luyten Original) and patient population-specific (Luyten Patient Acceptable Symptom State [PASS]) thresholds on Knee injury and Osteoarthritis Outcome Score (KOOS) subscales. Changes in meeting early OA criteria were compared between an initial and follow-up visit at an average of 6 and 12 months post-ACLR, respectively. RESULTS: Twenty-two percent of participants exhibited persistent early OA symptoms across both visits using both the Luyten Original and PASS criteria. From initial to follow-up visit, 18% to 27% had resolution of early OA symptoms, while 4% to 9% developed incident symptoms. In total, 48% to 51% had no early OA symptoms at either visit. No differences were found for change in early OA status between adults and adolescents. CONCLUSIONS: Nearly one-quarter of participants exhibited persistent early knee OA symptoms based on KOOS thresholds from 6 to 12 months post-ACLR. Determining if this symptom persistence predicts worse long-term outcomes could inform the need for timely interventions after ACLR. Future researchers should examine if resolving persistent symptoms in this critical window improves later outcomes. Tracking early OA symptoms over time may identify high-risk patients who could benefit from early treatment.

Effectiveness of interventions for the improvement of mental health and well-being post-concussion: a systematic review.

OBJECTIVE: To identify and assess the effectiveness and quality of interventions targeted at improving mental health, well-being, and psychosocial impairments post-concussion. DATA SOURCES: EBSCOHost, SPORTSDiscus, PsychINFO, Medline (Web of Science), PubMed, and Embase databases. REVIEW METHODS: This systematic review is reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement in exercise, rehabilitation, sport medicine and sports science (PERSiST). Articles were included if they: (1) were randomized controlled trials or repeated measures pre-posttest study designs, (2) reported mild traumatic brain injury (mTBI) or concussion injury, and (3) evaluated interventions targeting mental health, well-being, and psychosocial impairments post-injury. RESULTS: Twenty-three studies were included which evaluated interventions targeting mental health, well-being, and psychosocial impairments post-concussion. Interventions included cognitive rehabilitation (n = 7), psychotherapy (n = 7), psychoeducational (n = 3), neurocognitive training (n = 4), neurocognitive training combined with cognitive rehabilitation (n = 1), and psychotherapy combined with cognitive rehabilitation (n = 1). The seven (100%) cognitive rehabilitation intervention studies and four of the five (80%) neurocognitive training intervention studies observed significant improvements in mental health and well-being outcomes. CONCLUSIONS: Cognitive rehabilitation and neurocognitive training may be the most effective interventions for mental health and well-being impairments post-concussion. Researchers and clinicians should continue to explore the effectiveness of these interventions, specifically in populations most impacted by concussion (i.e. athletes).

Age-, Sex-, and Graft-Specific Reference Values From 783 Adolescent Patients at 5 to 7 Months After ACL Reconstruction: IKDC, Pedi-IKDC, KOOS, ACL-RSI, Single-Leg Hop, and Thigh Strength.

OBJECTIVE: To describe age-, sex-, and graft source-specific reference values for patient-reported, physical function, and strength outcome measures in adolescents at 5 to 7 months after anterior cruciate ligament reconstruction. DESIGN: Cross-sectional study. METHODS: Data were collected at 3 universities and 2 children's hospitals. The participants completed at least one of the International Knee Documentation Committee (IKDC) Subjective Evaluation Form, Pediatric IKDC (Pedi-IKDC), Knee Injury and Osteoarthritis Outcomes Score (KOOS), and Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Participants also completed single-leg hop tests and/or isokinetic quadriceps and hamstrings strength assessments (at 60°/s). Reference values were summarized using descriptive statistics and stratified for age, sex, and graft source. RESULTS: Reference values were reported for common patient-reported outcomes and measures of physical function and strength from 783 participants (56% females, age = 16. 4 ± 2.0 years) who were in early adolescence (12-14 years, N = 183, 52% females), middle adolescence (15-17 years, N = 456, 58% females), or late adolescence (18-20 years, N = 144, 55% females). Three hundred seventy-nine participants (48.4%) received a bone-patellar tendon-bone autograft, 292 participants (37.3%) received hamstring tendon autograft, and 112 participants (14.3%) received autograft or allograft from an alternative source. CONCLUSION: Reference values for common patient-reported outcomes and measures of physical function and strength differed depending on a patient's age, sex, and graft source. Using patient-specific reference values, in addition to previously described age-appropriate cutoff values, may help clinicians monitor and progress patients through rehabilitation and return to physical activity after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2023;53(4):1-8. Epub: 23 January 2023. doi:10.2519/jospt.2023.11389.

Exploratory Examination of Knee Self-Efficacy in Individuals With a History of ACL Reconstruction and Sport-Related Concussion.

CONTEXT: Knee self-efficacy and injury-related fear are associated with poor self-reported knee function and decreased physical activity (PA) after ACL reconstruction (ACLR). Limited research has explored contextual factors that may influence psychological responses in this population, such as history of sport-related concussion (SRC). After SRC, individuals may experience increased negative emotions, such as sadness and nervousness. However, it is unknown how SRC history may influence knee-self efficacy and injury-related fear in individuals with ACLR. The purpose of this study was to compare knee self-efficacy and injury-related fear in individuals after ACLR who present with and without history of SRC. DESIGN: Cross-sectional study. METHODS: Forty participants ≥1 year postunilateral ACLR were separated by history of SRC (no SRC = 29, SRC = 11). The Knee Self-Efficacy Scale (KSES) and subscales measured certainty regarding performance of daily activities (KSES-ADL), sports/leisure activities (KSES-Sport), physical activities (KSES-PA), and future knee function (KSES-Future). The Tampa Scale of Kinesiophobia-11 measured injury-related fear. Mann-Whitney U tests were used to examine between-group differences. Hedges g effect sizes and 95% confidence interval were used to examine clinically meaningful group differences. RESULTS: Individuals with a history of ACLR and SRC demonstrated worse KSES-PA (7.5 [5.3]) compared with those without a history of SRC (8.1 [6.1], P = .03). No other statistically significant differences were observed. A medium effect size was present for the KSES-PA (0.62), KSES-ADL (0.42), KSES-Present (ADL + PA + Sport) (0.48), KSES-Total (0.53), and Tampa Scale of Kinesiophobia-11 (0.61) but must be interpreted with caution as 95% confidence interval crossed 0. CONCLUSIONS: This exploratory study indicated that individuals with a history of ACLR and SRC had worse knee self-efficacy for PA compared with those without history of SRC. Rehabilitation specialists should monitor knee self-efficacy deficits in the post-ACLR population and recognize the potential influence of cumulative injury history on rehabilitative outcomes.

Perceived Instability, Pain, and Psychological Factors for Prediction of Function and Disability in Individuals With Chronic Ankle Instability.

CONTEXT: Chronic ankle instability (CAI) is associated with residual instability, pain, decreased function, and increased disablement. Injury-related fear has been associated with CAI, although its relationship to other impairments is unclear. The fear-avoidance model is a theoretical framework hypothesizing a relationship among pain catastrophizing, injury-related fear, chronic pain, and disability. It has been useful in understanding fear's influence in other musculoskeletal conditions but has yet to be studied in those with CAI. OBJECTIVE: To explore relationships among instability, pain catastrophizing, injury-related fear, pain, ankle function, and global disability in individuals with CAI. DESIGN: Cross-sectional study. SETTING: Anonymous online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 259 people, recruited via email and social media, with a history of ankle sprain completed the survey; of those, 126 participants (age = 32.69 ± 4.38 years, females = 84.92%, highly active = 73.81%) were identified as having CAI and were included in the analysis. MAIN OUTCOME MEASURE(S): Demographics of gender identity, age, and physical activity level were recorded. Assessments used were the Identification of Functional Ankle Instability questionnaire (instability), the Pain Catastrophizing Scale (pain catastrophizing), the Tampa Scale of Kinesiophobia-11 (injury-related fear), a numeric pain rating scale and activity-based question (pain presence), the Quick Foot and Ankle Ability Measure (ankle function), and the modified Disablement in the Physically Active Scale (disability). Relationships among variables were explored through correlation and regression analyses. RESULTS: After we controlled for instability and pain, pain catastrophizing and injury-related fear were significantly related to function and disability ratings in individuals with CAI. Together, the variables predicted 48.7% (P < .001) of the variance in function and 44.2% (P < .001) of the variance in disability. CONCLUSIONS: Greater instability, pain catastrophizing, injury-related fear, and pain predicted decreased function and greater disability in those with CAI. These findings are consistent with the hypothesized relationships in the fear-avoidance model, although further investigation is needed to determine causality of these factors in the development of CAI.

The relationship between injury-related fear and physical activity in people with a history of anterior cruciate ligament reconstruction.

OBJECTIVE: The objective of this study was to examine the relationship between fear-avoidance beliefs and physical activity (PA) in people with a history of anterior cruciate ligament reconstruction (ACLR). DESIGN: Modified cross-sectional. SETTING: Research laboratory Participants: A total of 19 participants with a history of unilateral ACLR. MAIN OUTCOME MEASURES: Participants completed the Fear-Avoidance Beliefs Questionnaire (FABQ), a valid and reliable measure of FAB measured across two subscales (FABQ-Sport and FABQ-Physical Activity (PA)). Higher scores indicated greater FAB. The participants were provided a wearable accelerometer to wear on the wrist for one-week to capture PA outcomes (vertical counts per minute and average steps/day). RESULTS: Weak, non-statistically significant positive correlations were identified between average daily steps per day (11,237.7 ± 5667.7), FABQ-PA (6 ± 8; r = 0.12, p = .63) and FABQ-S (8 ± 15; r = 0.26, p = .35). Weak, non-statistically significant negative correlations were identified between vertical counts per minute (131.4 ± 141.4) and FABQ-PA (r = -0.13, p = .59) and no relationship was observed with FABQ-Sports (r = 0.00, p = .98). CONCLUSIONS: There were no significant relationships between FABs and PA. The ability for individuals to remain physically active, with measurable levels of FABs (greater than 0), may be due to other psychological variables that should be further examined.

The Reliability of an Upper- and Lower-Extremity Visuomotor Reaction Time Task.

CONTEXT: Fast visuomotor reaction time (VMRT), the time required to recognize and respond to sequentially appearing visual stimuli, allows an athlete to successfully respond to stimuli during sports participation, while slower VMRT has been associated with increased injury risk. Light-based systems are capable of measuring both upper- and lower-extremity VMRT; however, the reliability of these assessments are not known. OBJECTIVE: To determine the reliability of an upper- and lower-extremity VMRT task using a light-based trainer system. DESIGN: Reliability study. SETTING: Laboratory. Patients (or Other Participants): Twenty participants with no history of injury in the last 12 months. METHODS: Participants reported to the laboratory on 2 separate testing sessions separated by 1 week. For both tasks, participants were instructed to extinguish a random sequence of illuminated light-emitting diode disks, which appeared one at a time as quickly as possible. Participants were provided a series of practice trials before completing the test trials. VMRT was calculated as the time in seconds between target hits, where higher VMRT represented slower reaction time. MAIN OUTCOME MEASURES: Separate intraclass correlation coefficients (ICCs) with corresponding 95% confidence intervals (CIs) were calculated to determine test-retest reliability for each task. The SEM and minimal detectable change values were determined to examine clinical applicability. RESULTS: The right limb lower-extremity reliability was excellent (ICC2,1 = .92; 95% CI, .81-.97). Both the left limb (ICC2,1 = .80; 95% CI, .56-.92) and upper-extremity task (ICC2,1 = .86; 95% CI, .65-.95) had good reliability. CONCLUSIONS: Both VMRT tasks had clinically acceptable reliability in a healthy, active population. Future research should explore further applications of these tests as an outcome measure following rehabilitation for health conditions with known VMRT deficits.

The Relationship Between Injury-Related Fear and Visuomotor Reaction Time in Individuals With a History of Anterior Cruciate Ligament Reconstruction.

CONTEXT: Deficits in reaction time, decreased self-reported knee function, and elevated levels of injury-related fear have been observed in individuals who sustain anterior cruciate ligament injury. Understanding the relationship between these variables may provide the impetus to further investigate effective intervention strategies to address these deficits in individuals after anterior cruciate ligament reconstruction (ACLR). OBJECTIVE: To examine the relationship between injury-related fear and lower-extremity visuomotor reaction time (VMRT) in individuals with a history of ACLR. A secondary purpose was to determine the relationship between self-reported knee function and lower-extremity VMRT in individuals with a history of ACLR. DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: Twenty participants between the ages of 18-35 years, with history of unilateral ACLR within the last 10 years, who injured their knee playing or training for organized or recreational sports. MAIN OUTCOME MEASURES: Scores on the athlete fear avoidance questionnaire, the fear-avoidance beliefs questionnaire (FABQ), the knee injury and osteoarthritis outcome score, and reaction time (in seconds) on the lower-extremity VMRT task using the FitLight Trainer™, bilaterally. Spearman Rho correlations examined the relationship between the dependent variables. RESULTS: There was a moderate positive correlation between VMRT and FABQ-total (r = .62, P < .01), FABQ-sport (r = .56, P = .01), and FABQ-physical activity (r = .64, P < .01) for the injured limb. Correlations between FABQ scores and VMRT for the uninjured limb were weak positive correlations (r = .36-.41, P > .05). Weak correlations between the osteoarthritis outcome score subscales, athlete fear avoidance questionnaire, and VMRT were observed for the injured limb (P > .05). CONCLUSIONS: Individuals with a history of ACLR who exhibited elevated levels of injury-related fear demonstrated slower VMRT. There were no relationships between self-reported knee function and VMRT. Future research should explore interventions to address injury-related fear and VMRT in individuals after ACLR.

Psychological factors are associated with return to pre-injury levels of sport and physical activity after ACL reconstruction.

PURPOSE: The impetus of anterior cruciate ligament reconstruction (ACLR) is to allow patients to return to sport and to remain engaged in physical activity. Many patients exhibit deficits in psychological domains of health-related quality of life which may impede return to sport and physical activity participation. Therefore, the purpose of this study was to examine the association of patient-based, specifically psychological, and functional outcomes with return to sport and physical activity. METHODS: Forty participants, a minimum of 1-year post-ACLR, reported to the laboratory for one-testing session. Participants completed a series of patient-based and functional outcome assessments. Participants were also instructed to wear a pedometer for 1 week to monitor their daily steps. RESULTS: Twenty-five participants (62%) did not return to sport and 29 participants (72%) did not average 10,000 steps per day. Individuals with elevated levels of self-reported kinesiophobia were 17% less likely to return to sport. Self-reported knee self-efficacy and knee-related quality of life accounted for 27.1% of the variance of average daily step counts. CONCLUSIONS: Psychological factors, specifically injury-related fear and self-efficacy, were associated more significantly than functional outcomes with return to sport and physical activity levels. Clinicians should examine psychological factors throughout rehabilitation in patients after ACLR. Future research should explore the effectiveness of psychoeducation techniques to decrease injury-related fear and enhance self-efficacy in this population. LEVEL OF EVIDENCE: III.

Fear-Avoidance Beliefs and Health-Related Quality of Life in Post-ACL Reconstruction and Healthy Athletes: A Case-Control Study.

CONTEXT: Many athletes return to sport after anterior cruciate ligament reconstruction (ACLR) with lingering physical or mental health impairments. Examining health-related quality of life (HRQL) and fear-avoidance beliefs across the spectrum of noninjured athletes and athletes with a history of ACLR may provide further insight into targeted therapies warranted for this population. OBJECTIVE: The purpose of this study was to examine differences in fear-avoidance beliefs and HRQL in college athletes with a history of ACLR not participating in sport (ACLR-NPS), participating in sport (ACLR-PS), and healthy controls (Control) with no history of injury participating in sport. DESIGN: Cross-sectional. SETTING: Laboratory. Patients (or Other Participants): A total of 10 college athletes per group (ACLR-NPS, ACLR-PS, and Control) were included. Participants were included if on a roster of a Division I or III athletic team during data collection. INTERVENTIONS: Participants completed a demographic survey, the modified Disablement in the Physically Active Scale (mDPA) to assess HRQL, and Fear-Avoidance Beliefs Questionnaire (FABQ) to assess fear-avoidance beliefs. MAIN OUTCOME MEASURES: Scores on the mDPA (Physical and Mental) and FABQ subscales (Sport and Physical Activity) were calculated, a 1-way Kruskal-Wallis test and separate Mann-Whitney U post hoc tests were performed (P < .05). RESULTS: ACLR-NPS (30.00 [26.00]) had higher FABQ-Sport scores than ACLR-PS (18.00 [26.00]; P < .001) and Controls (0.00 [2.50]; P < .001). ACLR-NPS (21.50 [6.25]) had higher FABQ-Physical Activity scores than ACLR-PS (12.50 [13.00]; P = .001) and Controls (0.00 [1.00]; P < .001). Interestingly, ACLR-PS scores for FABQ-Sport (P = .01) and FABQ-Physical Activity (P = .04) were elevated compared with Controls. ACLR-NPS had higher scores on the mDPA-Physical compared with the ACLR-PS (P < .001) and Controls (P < .001), and mDPA-Mental compared with ACLR-PS (P = .01), indicating decreased HRQL. CONCLUSIONS: The ACLR-NPS had greater fear-avoidance beliefs and lower HRQL compared with ACLR-PS and Controls. However, the ACLR-PS had higher scores for both FABQ subscales compared with Controls. These findings support the need for additional psychosocial therapies to address fear-avoidance beliefs in the returned to sport population.

The Relationship Between Musculoskeletal Injury and Objectively Measured Physical Activity Levels: A Critically Appraised Topic.

Clinical Scenario: Physical activity is vital for human health. Musculoskeletal injury may inhibit adults from participating in physical activity, and this amount may be less than adults without a history of musculoskeletal injury. Clinical Question: Do individuals with a history of ankle or knee musculoskeletal injury participate in less objectively measured physical activity compared with healthy controls? Summary of Key Findings: Four studies were included. Two studies concluded patients who have undergone an anterior cruciate ligament reconstruction (ACLR) spent less time in moderate to vigorous physical activity levels when compared with healthy controls, but still achieved the daily recommended amount of physical activity. One study determined that participants with CAI took fewer steps per day compared with the control group. The fourth study determined patients with patellofemoral pain were less physically active than healthy controls as they took fewer steps per day and spent less time participating in mild and high activity. Clinical Bottom Line: There is consistent, high quality evidence that demonstrates individuals with a history of ankle or knee musculoskeletal injury participate in less objectively measured physical activity compared with healthy individuals. Strength of Recommendation: Due to nature of study designs of the included articles in this critically appraised topic, we recommend a grade of 3B.

Use of Goal Setting to Enhance Self-Efficacy After Sports-Related Injury: A Critically Appraised Topic.

Clinical Scenario: Patients after sports-related injury experience deficits in self-efficacy. Goal setting may be an appropriate psychoeducation technique to enhance self-efficacy after sports-related injury. Clinical Question: Does goal setting-enhanced rehabilitation improve self-efficacy compared with traditional rehabilitation alone in individuals with sports-related injury? Summary of Key Findings: Two randomized controlled trials were included. The two studies selected assessed changes in self-efficacy before and after a goal-setting intervention following sports-related injury in an athletic population. Both studies used the Sports Injury Rehabilitation Beliefs Survey to evaluate self-efficacy. Clinical Bottom Line: There is currently consistent, good-quality, patient-oriented evidence that supports the use of goal setting to improve self-efficacy in patients undergoing rehabilitation for sports-related injury compared with the standard of care group. Future research should examine optimal timing for the implementation of goal setting in order to enhance self-efficacy following sports-related injury. Strength of Recommendation: The grade of A is recommended by the Strength of Recommendation Taxonomy for consistent, good-quality, patient-oriented evidence.

Examination of ankle function in individuals with a history of ACL reconstruction.

OBJECTIVE: To determine the relationship between self-reported ankle and knee function, and to examine differences in ankle function between healthy and injured limbs in individuals with a history of ACL reconstruction (ACLR). DESIGN: Cross-sectional. SETTING: Laboratory. PARTICIPANTS: A total of 18 adults with a history of ACLR. MAIN OUTCOME MEASURES: Participants completed four patient-reported outcomes: the Knee Injury and Osteoarthritis Outcome (KOOS), the Fear-Avoidance Belief Questionnaire, the modified Disablement in the Physically Active Scale, and the Quick-Foot and Ankle Ability Measure (Quick-FAAM). Additional ankle function measures collected bilaterally included plantar cutaneous sensation, dorsiflexion range of motion and dorsiflexion and plantarflexion strength. RESULTS: Three KOOS-subscales were significantly, moderately correlated to the Quick-FAAM for the injured limb. There were differences in the uninjured and injured Quick-FAAM scores. No other differences were observed in ankle function measures. CONCLUSIONS: Self-reported ankle and knee function are correlated in participants with a history of ACLR. Clinicians should be made aware of the influence of this health condition on the distal joint, and treatment strategies to address these perceived impairments should be considered.

Differences in the Modified Disablement in the Physically Active Scale in Those With and Without Chronic Ankle Instability.

Context: The modified Disablement in the Physically Active scale (mDPA) has become a commonly utilized patient-reported outcome instrument for physically active patients. However, the factor structure of this instrument has not been verified in individuals with chronic ankle instability (CAI). Furthermore, additional evidence examining the mDPA in individuals with CAI is warranted. Objective: The purpose of this study was to verify the factor structure of the mDPA and compare the physical summary component (PSC) and mental summary component (MSC) in those with and without CAI. Design: Cross-sectional. Setting: Laboratory. Participants: A total of 118 CAI and 81 healthy controls from a convenience sample participated. Intervention: Not applicable. Main Outcome Measures: All subjects completed the 16-item mDPA that included the PSC and MSC; higher scores represent greater disablement. To examine the model fit of the mDPA, a single-factor and 2-factor (PSC and MSC) structures were tested. Group differences were examined with independent t tests (P ≤ .05) and Hedges' g effect sizes (ESs). Results: Model fit indices showed the 2-factor structure to possess adequate fit to the data, χ2(101) = 275.58, P < .001, comparative-fit index = .91, root mean square error of approximation = .09 (95% confidence interval [CI], .08-.11), and standardized root mean square residual = .06. All items loaded significantly and in expected directions on respective subscales (λ range = .59-.87, all Ps < .001). The CAI group reported greater disablement as indicated from PSC (CAI: 11.45 [8.30] and healthy: 0.62 [1.80], P < .001, ES = 1.67; 95% CI, 1.33-1.99) and MSC (CAI: 1.75 [2.58] and healthy: 0.58 [1.46], P < .001, ES = 0.53; 95% CI, 0.24-0.82) scores. Conclusions: The 2-factor structure of the mDPA was verified. Individuals with CAI reported greater disablement on the PSC compared with healthy controls. The moderate ES on the MSC between groups warrants further investigation. Overall, these results indicate the mDPA is a generic patient-reported outcome instrument that can be utilized with individuals who have CAI.