Comparison of Patients Based on Their Self-Selected Discharge Pathway after Total Knee Arthroplasty at an Ambulatory Surgical Center.

Outpatient total knee arthroplasty (TKA) is being performed more frequently in ambulatory surgical centers (ASCs) to decrease the cost of care. Discharge pathways include 23-hour observation (OBSERVATION) or same-day discharge home (HOME), which differ in postoperative medical supervision. Few studies allow patients to self-select their discharge pathway. This study compared patient variables between self-selected OBSERVATION or HOME discharge after TKA at an ASC. We hypothesized that age, sex, and distance lived from the ASC would differ between discharge pathways. Clinical and patient-reported outcomes were explored.A chart review identified 130 patients with TKA at an ASC between November 2017 and December 2019. Patients self-selected OBSERVATION or HOME during a preoperative physician visit. Patient variables obtained from the electronic medical record were age, sex, race/ethnicity, marital status, body mass index, diabetic status, American Society of Anesthesiologists (ASA) class, distance lived from the ASC, anesthesia type, procedure time, and time in the postanesthesia recovery unit. Clinical outcomes (knee range of motion, infection rate, and reoperation rate) and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS, JR]; Oxford Knee Score [OKS]) were collected at either 6 or 12 weeks postsurgery. Variables were compared between groups.Pathway selection was n = 70 OBSERVATION and n = 60 HOME, and all patients completed their self-selected discharge pathway. Age and proportion of females were significantly higher in OBSERVATION than in HOME (61.3 ± 3.5 vs. 58.5 ± 5.4 years, 85.7 vs. 65.0%, respectively; p < 0.05). Distance lived from the ASC tended to be greater in OBSERVATION than HOME (22.1 ± 24.6 vs. 15.3 ± 10.1 miles, p = 0.056). Across groups, clinical outcomes were favorable (i.e., >88% met the 6-week knee flexion milestone, 1.9% infection rate, and 3.1% manipulation under anesthesia), and the preoperative to 12-week postoperative change in KOOS, JR and OKS scores met the minimal clinically important difference.Older age, female sex, and farther distance lived from the ASC may influence patients to select OBSERVATION over HOME discharge following TKA at an ASC. No robust differences were found in early outcomes.

How Does Physical and Psychological Recovery Vary Among Competitive and Recreational Athletes After Anterior Cruciate Ligament Reconstruction?

BACKGROUND: The recovery and rehabilitation journey after anterior cruciate ligament reconstruction (ACLR) surgery can be different for competitive and recreational athletes as their motivation and goals toward sports are different. HYPOTHESIS: Competitive athletes would present with better patient-reported outcomes and higher muscle strength compared with recreational athletes postsurgery. Second, competitive athletes would recover better (patient-reported outcome [PRO] measures and muscle strength) compared with recreational athletes at later stages. STUDY DESIGN: Cross-sectional laboratory-based study. LEVEL OF EVIDENCE: Level 2. METHODS: A total of 245 patients with unilateral ACLR were categorized as competitive or recreational athletes and grouped into early (4-6.9 months) or late (7-10 months) stages of recovery. PRO were collected for psychological response (Tampa Scale Kinesiophobia; Anterior Cruciate Ligament-Return to Sport after Injury), perceived knee function (International Knee Documentation Committee subjective form [IKDC]), and quality of life (Knee injury and Osteoarthritis Outcome Score; Veteran Rand-12). Isokinetic, concentric knee extension strength was measured bilaterally with a multimodal dynamometer (System 4, Biodex Medical Systems) at a speed of 90° and 180°/s. RESULTS: Competitive athletes had significantly higher scores for IKDC (P = 0.03), and quadriceps peak torque at 90°/s (P = 0.01) and 180°/s (P < 0.01) compared with recreational athletes. Competitive athletes had higher quadriceps strength at 90°/s (P < 0.01) and 180°/s (P = 0.02) in the late group. Recreational athletes displayed higher sports participation in the late group. CONCLUSION: Outcomes of ACLR may differ based on preinjury athletic level. Whereas competitive athletes had higher knee and muscle function than recreational athletes, psychological measures were not different among groups. CLINICAL RELEVANCE: There is a need for more individualized care for patients with ACLR since there is variability among patient goals postsurgery. This information might help set realistic expectations for competitive and recreational athletes after surgery.

Athletic Fear Avoidance in Athletes Receiving Rehabilitation for Sport-Related Concussion: A Preliminary Study.

BACKGROUND: Fear avoidance after musculoskeletal injury is avoiding activity due to fear of pain and contributes to persistent symptoms, depression, and disability. Little is known about fear avoidance for sport (athletic fear avoidance) in athletes with sport-related concussion (SRC). HYPOTHESIS: Athletic fear avoidance after SRC would be elevated at the start of rehabilitation, improve over time, and be associated with postconcussion recovery outcomes. STUDY DESIGN: Observational study. LEVEL OF EVIDENCE: Level 4. METHODS: Athletes in rehabilitation after SRC participated. Testing at initial and discharge visits and 6-month follow-up included Athletic Fear Avoidance Questionnaire (AFAQ), Postconcussion Symptom Scale (PCSS), Profile of Mood States (POMS), and Dizziness Handicap Inventory (DHI). Differences were explored in AFAQ score at initial testing based on sex or age (<18 or ≥18 years). Change in questionnaire scores over time was examined. Association of AFAQ score with other questionnaire scores was determined at each timepoint. RESULTS: A total of 48 athletes participated: 28 completed initial testing only (INITIAL ONLY), and 20 completed all testing (LONGITUDINAL). Across cohorts, the mean (SD) AFAQ score at initial testing was 24.3 (7.6) points, with no significant difference by sex or age. AFAQ, PCSS, POMS, and DHI scores improved in LONGITUDINAL; the effect size was large from initial to discharge testing (1.0, 1.0, 1.0, and 1.2, respectively) and variable from discharge to follow-up testing (0.52, -0.34, -0.08, and 0.02, respectively). AFAQ scores increased from discharge to follow-up in 3 athletes and were consistently above the mean value in 2 athletes. AFAQ score was significantly correlated to the other questionnaire scores at each timepoint (range, r = 0.36-0.75). CONCLUSION: Athletic fear avoidance was elevated at the start of SRC rehabilitation, improved over time in most patients, and was associated with postconcussion symptoms, mood, and disability. CLINICAL RELEVANCE: Athletic fear avoidance may impact recovery after SRC.

Mild Quadriceps and Hamstring Strength Deficits Do Not Persist After Sport-Related Concussion.

BACKGROUND: Risk for lower extremity musculoskeletal injury increases after sport-related concussion (SRC) and may result from unresolved motor control deficits. Muscle weakness is a deficit that could contribute to musculoskeletal injury risk. HYPOTHESIS: Athletes with SRC will demonstrate quadriceps and hamstring muscle weakness at the time of return to sport and 30 days later compared with controls. STUDY DESIGN: Prospective matched cohort. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 31 athletes with SRC (CONCUSSION) were matched by sex, age, and activity level to controls (CONTROL). Testing was conducted at initial assessment and 30 days later; initial assessment in CONCUSSION occurred when cleared for return to play. Isokinetic testing assessed quadriceps and hamstring strength of the dominant and nondominant legs at 60 and 180 deg/s. Peak torque values were normalized to body mass (N-m/kg). Data were analyzed with repeated measures general linear models (group × time), and effect sizes were calculated. RESULTS: Analysis at 60 deg/s included 26 matched pairs (15 male per group) and at 180 deg/s included 30 matched pairs (17 males per group). Time from concussion to initial assessment was 21.3 (7.8) mean (standard deviation) days. No significant interactions or main effects were detected (P > 0.05). Across muscle groups, legs, and testing speeds, effect sizes at initial assessment were small (d = 0.117 to 0.353), equating to a strength deficit in CONCUSSION of 0.04 to 0.18 N-m/kg, and effect sizes were further reduced at 30-day follow-up (d = -0.191 to 0.252). CONCLUSION: In athletes with SRC, quadriceps and hamstring strength were decreased only minimally at return to play compared with controls and the difference lessened over 30 days. CLINICAL RELEVANCE: Strength deficits may not be a major contributor to increased lower extremity musculoskeletal injury risk after SRC. Strength training could be implemented before return to play after SRC to mitigate any strength deficits.

Injury-related psychological distress and the association with perceived running ability in injured runners.

OBJECTIVE: Examine injury-related psychological distress and association with perceived running ability in injured runners. DESIGN: Prospective longitudinal study. PARTICIPANTS: Forty-three patients with a running-related injury. MAIN OUTCOME MEASURES: Data collection at initial physical therapy visit and 12-16 weeks later included Optimal Screening for Prediction of Referral and Outcome - Yellow Flag (OSPRO-YF) and Athlete Fear Avoidance Questionnaire (AFAQ) for injury-related psychological distress, and University of Wisconsin Running and Recovery Index (UWRI) for perceived running ability. OSPRO-YF composite score, total yellow flags, and yellow flags in each domain (negative mood, fear-avoidance, positive affect/coping) were calculated. RESULTS: UWRI score and OSPRO-YF composite score and yellow flags significantly improved over time, while AFAQ score and yellow flags in OSPRO-YF negative mood domain did not. AFAQ scores were significantly correlated with UWRI score at baseline, follow-up and change over time, while OSPRO-YF composite score and yellow flags were not. Baseline OSPRO-YF composite score and AFAQ score were not correlated with follow-up UWRI score. CONCLUSIONS: Injury-related psychological distress is elevated when injured runners start rehabilitation, and generally improves; however, negative mood and athletic fear-avoidance may persist. Higher athletic fear-avoidance is associated with lower perceived running ability at the same time point or interval.

Advanced training enhances readiness to return to sport after anterior cruciate ligament reconstruction.

Patients with anterior cruciate ligament reconstruction (ACLR) are often psychologically and physically under-prepared for sports participation. This study compared readiness to return to sport based on completion of advanced training after ACLR. Patients with ACLR who self-selected participation in a 6-week group-format advanced training program (TRAINING) were compared to age- and sex-matched patients who did not participate (NoTRAINING). Each group had 23 participants (14 females). Advanced training consisted of plyometric, strengthening, and agility exercises. Baseline and follow-up testing included psychological measures (Anterior Cruciate Ligament Return to Sport after Injury [ACL-RSI]; Tampa Scale for Kinesiophobia [TSK-11]; Knee Activity Self-Efficacy [KASE]; and fear intensity for the primary fear-evoking task or situation) and a hop test battery. Return to sport criteria were ACL-RSI score ≥70 points and limb symmetry index ≥90% on all hop tests. At follow-up, KASE score was higher in TRAINING than NoTRAINING (92.7 vs. 89.1 points; respectively), but ACL-RSI, TSK-11 and fear intensity scores were not significantly different between groups. Return to sport criteria passing rate was not significantly different between groups at baseline (TRAINING: 13%, NoTRAINING: 30%) or follow-up (TRAINING: 52%, NoTRAINING: 43%); however, the distribution of criteria met at follow-up differed with more patients in TRAINING than NoTRAINING meeting hop test criteria (30% vs. 4%, respectively) and more patients in NoTRAINING than TRAINING failing to meet any criteria (25% vs. 0%, respectively). Advanced training after ACLR facilitated readiness for sport participation by improving confidence and hop performance, but may not have a preferential effect on fear.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group.

OBJECTIVES: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making. METHODS: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS: Key points include that RTS is characterised by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries. CONCLUSION: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biological assessment of healing and recovery.

Impaired motor control after sport-related concussion could increase risk for musculoskeletal injury: Implications for clinical management and rehabilitation.

This review presents a conceptual framework and supporting evidence that links impaired motor control after sport-related concussion (SRC) to increased risk for musculoskeletal injury. Multiple studies have found that athletes who are post-SRC have higher risk for musculoskeletal injury compared to their counterparts. A small body of research suggests that impairments in motor control are associated with musculoskeletal injury risk. Motor control involves the perception and processing of sensory information and subsequent coordination of motor output within the central nervous system to perform a motor task. Motor control is inclusive of motor planning and motor learning. If sensory information is not accurately perceived or there is interference with sensory information processing and cognition, motor function will be altered, and an athlete may become vulnerable to injury during sport participation. Athletes with SRC show neuroanatomic and neurophysiological changes relevant to motor control even after meeting return to sport criteria, including a normal neurological examination, resolution of symptoms, and return to baseline function on traditional concussion testing. In conjunction, altered motor function is demonstrated after SRC in muscle activation and force production, movement patterns, balance/postural stability, and motor task performance, especially performance of a motor task paired with a cognitive task (i.e., dual-task condition). The clinical implications of this conceptual framework include a need to intentionally address motor control impairments after SRC to mitigate musculoskeletal injury risk and to monitor motor control as the athlete progresses through the return to sport continuum.

FEAR-AVOIDANCE AND SELF-EFFICACY PSYCHOSOCIAL FACTORS ARE ALTERED AFTER PARTIAL MENISCECTOMY AND ASSOCIATED WITH REHABILITATION OUTCOMES.

BACKGROUND: Little research has examined how psychosocial factors change over time and influence rehabilitation outcomes following meniscectomy. This information can inform the need to assess and address psychosocial factors in meniscectomy rehabilitation. HYPOTHESIS/PURPOSE: The purpose of this study was to examine changes in fear-avoidance and self-efficacy psychosocial factors from pre-surgery to one year after meniscectomy and their associations with rehabilitation outcomes. The hypothesis was that psychosocial factors would improve following meniscectomy, and less improvement in psychosocial factors would be associated with less improvement in rehabilitation outcomes. STUDY DESIGN: Prospective cohort. METHODS: Twenty-five patients with partial meniscectomy participated. Testing time points were pre-surgery, after post-surgical rehabilitation, and one-year post-surgery. Fear avoidance (pain catastrophizing and kinesiophobia) and self-efficacy (knee-related activity) psychosocial factors were assessed with the Pain Catastrophizing Scale (PCS), the Tampa Scale for Kinesiophobia (TSK-11), and Knee Activity Self-efficacy (KASE) questionnaires; respectively. Rehabilitation outcomes were quadriceps strength, evaluated with isokinetic testing at 60 °/sec; knee pain, measured with the Numeric Pain Rating Scale (NPRS); and self-reported knee function, measured with the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). RESULTS: PCS scores improved from pre-surgery to after post-surgical rehabilitation, while TSK-11 and KASE scores improved from pre-surgery to after post-surgical rehabilitation and from after post-surgical rehabilitation to 1-year post-surgery. Pre-surgery PCS and KASE scores were associated with 1-year post-surgery NPRS score (r = 0.50) and quadriceps peak torque (r = 0.48), respectively. From pre-surgery to 1-year post-surgery, change in TSK-11 score was associated with change in NPRS score (r = 0.65), and change in KASE score was associated with change in IKDC-SKF score (r = 0.44). From pre-surgery to after post-surgical rehabilitation, changes in TSK-11 and KASE scores were associated with changes in NPRS (TSK-11, r = 0.47; KASE, r = -0.50) and IKDC-SKF scores (TSK-11, r = -0.39; KASE, r = 0.71). From after post-surgical rehabilitation to 1-year post-surgery, changes in KASE score was associated with changes in IKDC-SKF score (r = 0.59). CONCLUSIONS: Assessment of pain catastrophizing and knee activity self-efficacy pre-surgery might help to identify patients at risk for sustained knee pain and quadriceps muscle weakness. Decreasing kinesiophobia and increasing knee activity self-efficacy were associated with improved knee pain and function. LEVEL OF EVIDENCE: 2b.

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group.

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.

Return to Sport After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Return to Sport Consensus Group.

BACKGROUND: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. PURPOSE: The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. STUDY DESIGN: Consensus statement. METHODS: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS: Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. CONCLUSION: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group.

PURPOSE: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making. METHODS: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS: Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries. CONCLUSION: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery. LEVEL OF EVIDENCE: IV.

Injury-Related Fears During the Return-to-Sport Phase of ACL Reconstruction Rehabilitation.

BACKGROUND: Fear of reinjury is common after anterior cruciate ligament reconstruction (ACLR) and often deters a return to preinjury sport participation. A better understanding of injury-related fear is needed to inform rehabilitation strategies. PURPOSE/HYPOTHESIS: The purpose of this study was to (1) identify individual fear-evoking tasks or situations, (2) compare the intensity and amount of change relative to other injury-related fears (reinjury, knee giving way, and knee pain) after completion of a return-to-sport training program, and (3) determine whether standardized questionnaires can identify the intensity of fear for the individual fear-evoking task or situation and for fear of reinjury. The hypothesis was that the task or situation that evokes fear would vary across patients and the intensity of that fear would be higher and show less change after return-to-sport training compared with other injury-related fears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Participants included 33 patients (15 males; mean age, 18 years) with ACLR who enrolled in a group-format return-to-sport training program. Questionnaires completed before and after return-to-sport training included items to specify fear-evoking tasks or situations, items to rate the intensity of various injury-related fears, the Anterior Cruciate Ligament Return to Sport after Injury scale (ACL-RSI), and the Tampa Scale for Kinesiophobia (TSK-11). RESULTS: The most common fear-evoking task or situation was cutting, followed by contact, jumping, and other. Intensity of fear-evoking task or situation was higher than other injury-related fears, but all fears decreased in intensity after training. The ACL-RSI score better identified the intensity of fear for the individual fear-evoking task or situation and for fear of reinjury than did the TSK-11 score. CONCLUSION: Activities that evoke fear vary across patients, but fear of cutting is common. The intensity of common fears after ACLR decreased after advanced group training, and large effect sizes were seen for nearly all examined fears. Fear of reinjury and intensity of individually feared tasks may be better reflected in the ACL-RSI score than the TSK-11 score.

Fear avoidance and self-efficacy at 4 weeks after ACL reconstruction are associated with early impairment resolution and readiness for advanced rehabilitation.

PURPOSE: To examine the association of fear avoidance and self-efficacy psychological factors within 4 weeks after anterior cruciate ligament (ACL) reconstruction with knee impairment resolution and readiness for advanced rehabilitation at 12 weeks post-surgery. METHODS: Seventy-five patients participated. Data collection included demographics; questionnaires on fear avoidance (Pain Catastrophizing Scale, PCS; shortened Tampa Scale for Kinesiophobia, TSK-11) and self-efficacy (modified Self-Efficacy for Rehabilitation Outcome Scale, SER; Knee Activity Self-Efficacy, KASE) at 1, 4, and 12 weeks post-surgery; and knee impairment measures (pain intensity, range of motion, and quadriceps symmetry index) at 12 weeks post-surgery. Readiness for advanced rehabilitation (READY or NOT READY) was determined by knee impairment resolution criteria; demographics and questionnaire scores were compared between groups. Questionnaire scores at 1 and 4 weeks post-surgery and the change between time points were examined for association with knee impairment measures and group assignment. RESULTS: READY included 32 patients; NOT READY included 43 patients. Questionnaire scores improved in both groups over time. Significant correlations across groups were: PCS scores at 1 and 4 weeks post-surgery with pain intensity at 12 weeks post-surgery (r = 0.24 and 0.29, respectively) and KASE score 4 weeks post-surgery with range of motion deficit at 12 weeks post-surgery (r = - 0.26). Contact injury was more prevalent in READY. After accounting for mechanism of injury, higher TSK-11 and fear of re-injury subscale scores at 4 weeks post-surgery increased the odds of NOT READY assignment at 12 weeks post-surgery (odds ratios 1.10 and 1.31, respectively). CONCLUSIONS: Lower pain catastrophizing and higher knee activity self-efficacy levels 4 weeks after ACL reconstruction were associated with better knee impairment resolution at 12 weeks post-surgery, whereas lower kinesiophobia at 4 weeks post-surgery increased the odds of meeting advanced rehabilitation criteria at 12 weeks post-surgery. The clinical implication of these findings is that measuring pain catastrophizing, knee activity self-efficacy and kinesiophobia at 4 weeks post-surgery may improve prediction of patients at risk for delayed rehabilitation progression 12 weeks post-surgery. LEVEL OF EVIDENCE: III.

Examination of Early Functional Recovery After ACL Reconstruction: Functional Milestone Achievement and Self-Reported Function.

BACKGROUND: Few studies have documented early functional recovery after anterior cruciate ligament (ACL) reconstruction. PURPOSE: To quantify the time to early functional milestone achievement and change in function over 12 weeks after ACL reconstruction and to identify demographic characteristic predictors of the outcomes. STUDY DESIGN: Prospective, longitudinal, observational study. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 182 patients (95 females, 87 males; mean ± SD age, 28 ± 12 years; mean ± SD body mass index [BMI], 25 ± 4 kg/m2) who received primary, unilateral, ACL reconstruction were included. Testing occurred before surgery as well as 1, 2, 4, 8, and 12 weeks postsurgery. Outcomes included demographic characteristics, self-reported functional milestone achievements and responses on the Short Musculoskeletal Function Assessment (SMFA) questionnaire. Time to functional milestone achievement was calculated, and patients were categorized into "faster" or "prolonged" recovery groups based on the median value. Longitudinal change in SMFA subscale scores (daily activities and mobility) as well as demographic predictors of functional recovery group assignment and postsurgical change in SMFA subscale scores were examined. RESULTS: Median time for discontinuing narcotic pain medication was 9 days, while that for discontinuing crutches was 15 days. Time to return to work occurred at a median of 11 days, return to school at 7 days, and return to driving at 11 days. Both SMFA subscale scores significantly decreased (improved) over time, with the greatest change occurring between 1 and 4 weeks postsurgery. The demographic predictor of faster functional recovery for discontinuation of narcotic pain medication was surgery with allograft; those for return to work were higher age, male sex, decreasing BMI, and sedentary/light occupational demand; and those for return to driving were higher age, male sex, and surgery on the left side of the body. CONCLUSION: Functional recovery occurs rapidly over the first month after ACL reconstruction for most patients. Nonmodifiable demographic characteristics may influence recovery time for specific functional milestones. CLINICAL RELEVANCE: Results can be used to counsel patients on early functional recovery after ACL reconstruction.

Psychological and Functional Readiness for Sport Following Advanced Group Training in Patients With Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Decreased psychological readiness for sport may contribute to poor return-to-sport rates after anterior cruciate ligament reconstruction (ACLR). Though advanced rehabilitation is used to improve functional readiness for sport after ACLR, the effect of advanced rehabilitation on psychological readiness is unknown. OBJECTIVE: To examine changes in psychological and functional measures and readiness for sport based on these measures in patients with ACLR following advanced group training. METHODS: In this retrospective cohort study, patients with primary ACLR enrolled in a 5-week group training program after completing traditional physical therapy. Data collection pretraining and posttraining included demographic information, the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, and single-leg hop testing (single, triple, crossover triple, and timed hops). Readiness for sport was based on criteria for the ACL-RSI scale score (low threshold, 56 points or greater; high threshold, 75 points or greater) and hop tests (90% or greater limb symmetry). RESULTS: Fifty-eight patients (21 male) participated. Mean ACL-RSI scale scores, mean hop test limb symmetry, and the proportion of patients meeting ACL-RSI and hop test readiness-for-sport criteria significantly improved from pretraining to posttraining. Posttraining ACL-RSI scale scores were correlated with single hop (r = 0.269) and triple hop (r = 0.275) limb symmetry, yet changes in the measures were not significantly correlated. After training, only 53.4% (lower ACL-RSI threshold) or 37.9% (higher ACL-RSI threshold) of the sample met both psychological and functional readiness criteria. CONCLUSION: Advanced group training following ACLR improved psychological and functional outcomes; however, further, individualized intervention may be needed to address residual deficiencies in some patients. LEVEL OF EVIDENCE: Therapy, level 2b. J Orthop Sports Phys Ther 2018;48(11):864-872. Epub 12 Jun 2018. doi:10.2519/jospt.2018.8041.

Kinesiophobia and Its Association With Health-Related Quality of Life Across Injury Locations.

OBJECTIVE: To compare baseline kinesiophobia levels and their association with health-related quality of life across injury locations. DESIGN: Retrospective cross-sectional study. SETTING: Single, large outpatient physical therapy clinic within an academic medical center. PARTICIPANTS: Patients (N=1233) who underwent an initial evaluation for a diagnosis related to musculoskeletal pain and completed the 11-item version of the Tampa Scale for Kinesiophobia (TSK-11) and the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) questionnaires within 7 days of their first visit were eligible for inclusion. Three hundred eighty patients were excluded because of missing data or because they were younger than 18 years. A total of 853 patients (mean age, 43.55y; range, 18-94y) were included. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparison of baseline kinesiophobia levels and their association with health-related quality of life across injury locations in an outpatient physical therapy setting. RESULTS: Separate analysis of variance models compared TSK-11 scores based on involved body region, and Pearson correlation coefficients were used to examine the association between TSK-11 scores and the SF-8 subscales at each body region. TSK-11 scores did not differ by body region (range, 23.9-26.1). Weak to moderate negative correlations existed between kinesiophobia and the SF-8 subscales. CONCLUSIONS: Kinesiophobia levels appear elevated and negatively associated with health-related quality of life at initial physical therapy evaluation regardless of injury location. These findings suggest that physical therapists in outpatient orthopedic settings should implement routine kinesiophobia assessment and provide stratified care based on kinesiophobia levels across musculoskeletal conditions.

Lower Extremity Stiffness Changes after Concussion in Collegiate Football Players.

PURPOSE: Recent research indicates that a concussion increases the risk of musculoskeletal injury. Neuromuscular changes after concussion might contribute to the increased risk of injury. Many studies have examined gait postconcussion, but few studies have examined more demanding tasks. This study compared changes in stiffness across the lower extremity, a measure of neuromuscular function, during a jump-landing task in athletes with a concussion (CONC) to uninjured athletes (UNINJ). METHODS: Division I football players (13 CONC and 26 UNINJ) were tested pre- and postseason. A motion capture system recorded subjects jumping on one limb from a 25.4-cm step onto a force plate. Hip, knee, and ankle joint stiffness were calculated from initial contact to peak joint flexion using the regression line slopes of the joint moment versus the joint angle plots. Leg stiffness was (peak vertical ground reaction force [PVGRF]/lower extremity vertical displacement) from initial contact to peak vertical ground reaction force. All stiffness values were normalized to body weight. Values from both limbs were averaged. General linear models compared group (CONC, UNINJ) differences in the changes of pre- and postseason stiffness values. RESULTS: Average time from concussion to postseason testing was 49.9 d. The CONC group showed an increase in hip stiffness (P = 0.03), a decrease in knee (P = 0.03) and leg stiffness (P = 0.03), but no change in ankle stiffness (P = 0.65) from pre- to postseason. CONCLUSION: Lower extremity stiffness is altered after concussion, which could contribute to an increased risk of lower extremity injury. These data provide further evidence of altered neuromuscular function after concussion.

Patient-reported outcomes after open carpal tunnel release using a standard protocol with 1 hand therapy visit.

STUDY DESIGN: Retrospective case series. INTRODUCTION: Open carpal tunnel release (OCTR) is a common treatment for carpal tunnel syndrome, but there is no consensus on the number of hand therapy visits needed to achieve optimal patient outcomes. PURPOSE OF THE STUDY: The purpose is to examine changes in patient-reported symptoms and function over a 12-week period after OCTR with 1 postoperative hand therapy visit. METHODS: Eligible subjects were consecutive patients treated with a standard OCTR protocol by a fellowship trained hand surgeon that included 1 hand therapy visit at 10-14 days postoperatively. Patients were excluded from participation if they had additional surgery at the time of OCTR, had another upper extremity diagnosis that required therapeutic intervention, or received more or less than 1 visit of hand therapy. Responses on the Boston Carpal Tunnel Questionnaire (BCTQ) were collected at preoperative and 3 postoperative time points: at the hand therapy visit, 6 weeks, and 12 weeks. Change over time in the BCTQ Symptom Severity Scale and Functional Status Scale was assessed. RESULTS: A total of 134 patients who were treated with the standard protocol had a complete BCTQ data set. Both BCTQ scales showed significant improvement over time. The Symptom Severity Scale showed significant improvement by the hand therapy visit at 10-14 days postoperatively, whereas significant improvement on the Functional Status Scale did not occur until 6 weeks postoperatively. The magnitude of change from preoperative to 12 weeks postoperative was 1.51 points on the Symptom Severity Scale and 0.91 points on the Functional Status Scale. Complication rates were low with an incidence of 13% for pillar pain and palm pain combined. CONCLUSIONS: Patient-reported symptoms and function improved significantly up to 12 weeks after OCTR. Moreover, there was a low incidence of pillar and palm pain. In a retrospective review of patients with a favorable prognosis based on having no need for extra surgical procedures or additional therapy visits, one therapy visit associated with improvements in symptoms and function, a low incidence of pillar/palm pain and favorable 12-weeks outcomes. There appears to be a subset of less complicated patients for whom one visit can allow for favorable outcomes. LEVEL OF EVIDENCE: 2B.