Late-stage rehabilitation after anterior cruciate ligament reconstruction: A multicentre randomised controlled trial (PReP).

BACKGROUND: At the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation. OBJECTIVE: To compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction. METHODS: This prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated. RESULTS: In total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4-104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7-114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0-129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4-135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10-0.57; 0.31, 0.08-0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level. CONCLUSIONS: The Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

Investigating effects of FFP2 wearing during physical activity on gas exchange, metabolism and affective state using a randomized controlled trial.

Concerns are repeatedly raised about possible adverse respiratory effects of wearing filtering face pieces (FFP) during physical activity. This study compared the impact of FFP type 2 (NF95) on pulmonary function, blood gas values, metabolism and discomfort during light, moderate and vigorous physical activity. Healthy adults (n = 13; 6 females, 7 males; mean 31.3, SD 5.5 years) participated in this randomized two-armed (Ergometer cycling with a FFP type 2 vs. no mask) crossover trial. Baseline cardiopulmonary exercise testing and two interventions (masked and unmasked ergometer cycling 40%, 50% and 70% VO2max, 10 min each) were separated by 48 h washout periods. Spiroergometric data (End tidal carbon dioxide partial pressure PetCO2; breathing frequency; inspiration time), blood gas analysis outcomes (capillary carbon dioxide partial pressure, pCO2) and subjective response (Breathing effort and perceived exertion) were contrasted between conditions using ANOVAs. All participants completed the crossover trial, seven started with the FFP2 condition (No adverse events or side effects). FFP2 decreased breathing frequency, prolonged inspiration time, increased perceived breathing effort and PetCO2 (p < .05). Blood pCO2 in millimetres mercury increased during exercise with 50%VO2max (mean 36.67, SD 3.19 vs. mean 38.46, SD 2.57; p < .05) and 70%VO2max (35.04, 2.84 vs. 38.17, 3.43; p < .05) but not during exercise with 40%VO2max (36.55, 2.73 vs. 38.70). Perceived exertion was not affected (p > 0.05) by mask wearing. Conclusion: Mask-induced breathing resistance decreased respiratory performance and limited pulmonary gas exchange. While FFP2 affected subjective breathing effort per se, invasive diagnostics showed that statistically significant metabolic effects are induced from moderate intensity upwards. Trial registration: DRKS-ID: DRKS00030181, Date of registration: 05/09/2022 (German Register for Clinical Trials).

Effects on temporomandibular disorder in the treatment of tension-type headache with acupuncture and therapeutic exercises. A secondary analysis from a randomized controlled trial.

OBJECTIVES: To examine the effects of acupuncture and therapeutic exercise alone and in combination on temporomandibular joint symptoms in tension-type headache and to evaluate the potential interaction of existing temporomandibular dysfunction on the success of headache treatment. DESIGN: Pre-planned secondary analysis of a randomized controlled, non-blinded trial. SETTING: Outpatient clinic of a German university hospital. SUBJECTS: Ninety-six Participants with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups. INTERVENTIONS: Six weeks of acupuncture or therapeutic exercise either as monotherapies or in combination, or usual care. Follow-up at 3 and 6 months. MAIN MEASURES: Subjective temporomandibular dysfunction symptoms were measured using the Functional Questionnaire Masticatory Organ, and the influence of this sum score and objective initial dental examination on the efficacy of headache treatment interventions was analyzed. RESULTS: Temporomandibular dysfunction score improved in all intervention groups at 3-month follow-up (usual care: 0.05 [SD 1.435]; acupuncture: -5 [SD 1.436]; therapeutic exercise: -4 [SD 1.798]; combination: -3 [SD 1.504]; P = 0.03). After 6 months, only acupuncture (-6 [SD 1.736]) showed a significant improvement compared to the usual care group (P < 0.01). Subjective temporomandibular dysfunction symptoms had no overall influence on headache treatment. CONCLUSIONS: Only acupuncture had long-lasting positive effects on the symptoms of temporomandibular dysfunction. Significant dental findings seem to inhibit the efficacy of acupuncture for tension-type headache.

The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. METHODS: In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. RESULTS: At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers." CONCLUSIONS: The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment.

PURPOSE: The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS: For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE: Level V.

Effects of exercise prehabilitation before anterior cruciate ligament reconstruction on functional outcomes during pre- and postoperative rehabilitation - protocol for a single-blinded randomised controlled trial.

BACKGROUND: Although a benefit of preoperative training prior to anterior cruciate ligament (ACL) reconstruction is likely, there is no consensus on the optimal content (criteria-based programme), supervision (one-on-one guidance or self-administered training) and general setting of preoperative training after ACL injuries. The purpose of this trial is to investigate the efficacy of an individually adaptive, guided, structured and criteria-based preoperative rehabilitation programme in comparison to a non-guided and self-administered home training programme. METHODS: The planned single-blinded randomised controlled trial study was approved by the ethics committee of the German Sport University on June 14, 2022 (ethics application no. 093/2022) and prospectively registered (DRKS-ID: DRKS00030312; date of registration: 26.09.2022). N = 114 participants between 16 and 60 years of age with a unilateral ACL rupture and scheduled ACL reconstruction with a hamstring or quadriceps tendon autograft will be randomly (block-randomisation, 1:1 allocation) and blinded assigned to one of two groups: intervention group (structured, criteria-based, guided prehabilitation training) and comparator group (non-guided, self-administered home training). After surgical reconstruction, patients of both groups participate in the same standard, functional measurement-guided, postoperative rehabilitation programme. Stepwise increasing the functional requirements of the assessments, all participants participate in testing at the day of anamnesis (t1), 1-7 days before surgical reconstruction (t2), day of surgical reconstruction (t3) and 30 (t4), 60 (t5), 90 (t6) and 180 (t7) days post-reconstruction. The primary outcome is the overall self-reported knee condition, assessed by the sum score of all sub-scales of the Knee injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include functional outcomes (range of motion, knee flexors and extensors and plantar flexors strength/torque, functional postural control, jumping ability), workability and return to sport (RTS) (psychological readiness, RTS success). DISCUSSION: The planned study targets to fill a gap in the evidence regarding effective designs of prehabilitation training before surgical ACL reconstruction. Potential difficulties that could affect the conduct of the study are lack of treatment adherence of the patients and high dropout. TRIAL REGISTRATION: German Register of Clinical Trials DRKS-ID: DRKS00030312 . Registered on 26 September 2022.

Feasibility, Reliability, and Validity of the Modified Forward Hop Test After Anterior Cruciate Ligament Reconstruction: Double- Instead of Single-legged Landing is Reliable and Results in Greater Hopping Distance.

OBJECTIVE: To investigate the feasibility, reliability, and validity of the Modified forward hop (MFH) test in participants after ACL reconstruction (ACLR). DESIGN: Reliability study. SETTING: Assessments were administered at different clinical locations in Germany and Switzerland by the same 2 investigators. PARTICIPANTS: Forty-eight active individuals participated in this study (N=48). MAIN OUTCOME MEASURES: The participants performed MFHs and Forward hops for distance in a predetermined order. The feasibility of the MFH was quantified with proportions of successfully executed attempts and Pearson's χ2 test. Its reliability was estimated using intraclass correlation coefficient (ICC) and standard error of measurement (SEM). Test validity was explored using Pearson's product moment correlation analyses. RESULTS: Fewer failed attempts were recorded among the participants (age: 30 [Standard deviation 11] years; 22 women, 26 (13) months post-surgery) when compared with the Forward hop for distance test (25/288 trials; 9% vs 72/288 trials; 25%). Within-session ICC values were excellent (>0.95) for both types of Forward hop tests, independent of the side examined. The SEM values were comparable between the Modified (injured: 5.6 cm, uninjured: 5.9 cm) and the classic Forward hop (injured: 4.3 cm, uninjured: 7.2 cm). CONCLUSION: The MFH is a feasible, reliable, and valid tool for judging neuromuscular performance after ACLR. If the aim of a hop for distance incorporates enhanced perceived or real landing safety, landing on both feet should be used.

Machine learning-based identification of determinants for rehabilitation success and future healthcare use prevention in patients with high-grade, chronic, nonspecific low back pain: an individual data 7-year follow-up analysis on 154,167 individuals.

ABSTRACT: To individually prescribe rehabilitation contents, it is of importance to know and quantify factors for rehabilitation success and the risk for a future healthcare use. The objective of our multivariable prediction model was to determine factors of rehabilitation success and the risk for a future healthcare use in patients with high-grade, chronic low back pain. We included members of the German pension fund who participated from 2012 to 2019 in multimodal medical rehabilitation with physical and psychological treatment strategies because of low back pain (ICD10:M54.5). Candidate prognostic factors for rehabilitation success and for a future healthcare use were identified using Gradient Boosting Machines and Random Forest algorithms in the R-package caret on a 70% training and a 30% test set. We analysed data from 154,167 patients; 8015 with a second medical rehabilitation measure and 5161 who retired because of low back pain within the study period. The root-mean-square errors ranged between 494 (recurrent rehabilitation) and 523 (retirement) days (R2 = 0.183-0.229), whereas the prediction accuracy ranged between 81.9% for the prediction of the rehabilitation outcome, and 94.8% for the future healthcare use prediction model. Many modifiable prognostic factors (such as duration of the rehabilitation [inverted u-shaped], type of the rehabilitation, and aftercare measure), nonmodifiable prognostic factors (such as sex and age), and disease-specific factors (such as sick leave days before the rehabilitation [linear positive] together with the pain grades) for rehabilitation success were identified. Inpatient medical rehabilitation programmes (3 weeks) may be more effective in preventing a second rehabilitation measure and/or early retirement because of low back pain compared with outpatient rehabilitation programs. Subsequent implementation of additional exercise programmes, cognitive behavioural aftercare treatment, and following scheduled aftercare are likely to be beneficial.

Metabolic power in the men's European handball championship 2020.

PURPOSE: To ascertain the typical metabolic power characteristics of elite handball players of different positions, and whether changes occur within matches. METHODS: 414 elite male handball players were included. During all 65 matches of the EURO 2020, local positioning system data were collected, yielding 1853 datasets. Field players were categorised into six positional groups: centre backs (CB), left/right wings (LW/RW), left/right backs (LB/RB) and pivots (P). Metabolic power, total energy expenditure, high-power energy, and the equivalent distance index were calculated. We used linear mixed models with players as random and positions as fixed effects models. Intensity models adjusted for time-dependency by incorporating the duration of play. RESULTS: LW/RW spent most time on the court, expanded most total energy, and most relative energy per kg body weight in the high-intensity categories. CB played at the highest mean metabolic power (7.85 W/kg; CI95% [7.67, 8.03]). Playing intensity decreased by 2.5% (0.2 kJ/kg/s; CI95% [0.17, 0.23]) per 10 min played. CONCLUSION: Positional differences in metabolic power parameters exist. In general, wing players had the highest volume and CB the highest intensity of match-play. Analysis of metabolic intensity in handball should take position and players' time on the court into account.

Resistance, Motor Control, and Mindfulness-Based Exercises Are Effective for Treating Chronic Nonspecific Neck Pain: A Systematic Review With Meta-Analysis and Dose-Response Meta-Regression.

OBJECTIVE: We aimed to analyze the effects and dose-response relationship of the most effective exercises for improving pain and disability in people with chronic nonspecific neck pain. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched the PubMed, PEDro, and CENTRAL databases from their inception to September 30, 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials that involved people with chronic neck pain adopting a longitudinal exercise intervention and assessed one pain and/or disability outcome. DATA SYNTHESIS: Restricted maximum-likelihood random-effects meta-analyses were modeled separately for resistance, mindfulness-based, and motor control exercises; standardized mean differences (Hedge's g, standardized mean difference [SMD]) were effect estimators. Meta-regressions (dependent variable: effect sizes of the interventions; independent variables: training dose and control group effects) were conducted to explore the dose-response relationship for therapy success of any exercise type. RESULTS: We included 68 trials. Compared to true control, effects on pain and disability were significantly larger for resistance exercise (pain: SMD, -1.27; 95% confidence interval [CI]: -2.26, -0.28; |2 = 96%; disability: SMD, -1.76; 95% CI: -3.16, -0.37; |2 = 98%), motor control exercise (pain: SMD, -2.29; 95% CI: -3.82, -0.75; |2 = 98%; disability: SMD, -2.42; 95% CI: -3.38, -1.47; |2 = 94%), and Yoga/Pilates/Tai Chi/Qui Gong exercise (pain: SMD, 1.91; 95% CI:-3.28, -0.55; |2 = 96%; disability: SMD, -0.62; 95% CI: -0.85, -0.38; |2 = 0%). Yoga/Pilates/Tai Chi/Qui Gong exercise was more effective than other exercises (SMD, -0.84; 95% CI: -1.553, -0.13; |2 = 86%) for reducing pain. For disability, motor control exercise was superior to other exercises (SMD, -0.70; 95% CI: -1.23, -0.17; |2 = 98%). There was no dose-response relationship for resistance exercise (R2 = 0.32). Higher frequencies (estimate = -0.10) and longer durations (estimate = -0.11) of motor control exercise had larger effects on pain (R2 = 0.72). Longer sessions (estimate = -0.13) of motor control exercise had larger effects on disability (R2 = 0.61). CONCLUSION: Resistance, mindfulness-based, and motor control exercises were effective for reducing neck pain (very low- to moderate-certainty evidence). Higher frequencies and longer duration of sessions had a significant effect on pain for motor control exercise. J Orthop Sports Phys Ther 2023;53(8):1-41. Epub: 20 June 2023. doi:10.2519/jospt.2023.11820.

Comparative Effectiveness of Upper Limb Exercise Interventions in Individuals With Stroke: A Network Meta-Analysis.

BACKGROUND: Although numerous effective exercise interventions can treat upper limb motor impairments after stroke, it remains unknown as to which are the most effective. The objective of the present study was to investigate the comparative effectiveness of various exercise interventions of the upper limb for individuals with an acute or subacute stroke. METHODS: For this systematic review with network meta-analysis, we searched PubMed/MEDLINE, Cochrane Library CENTRAL and Web of Science from database inception to September 2021 for randomized controlled trials examining individuals within 6 months of stroke onset, active upper limb exercise interventions, and any kind of control intervention. The primary outcome was upper limb motor function, secondary outcomes were activities of daily living and social participation, both assessed at post-intervention and follow-up. Nonspecific/multimodal active upper limb therapy was the standard comparator. Standardized mean differences, that is, Hedge's g, were the effect size estimators. We calculated Frequentist-based network meta-analysis for the comparative effectiveness calculations using the R package netmeta. Main analyses were network plotting to display the geometry of the network and P-scores to summarize the intervention hierarchy. Results were derived from direct within-study and indirect between-study evidence comparisons. The Cochrane risk-of-bias tool II assessed all risk of bias domains. RESULTS: This review involved 145 randomized controlled trial on 6432 participants and 45 different treatment categories. The network meta-analysis analyzed 119 randomized controlled trials on 5553 participants and 41 different treatment categories. Electrical stimulation combined with task-specific training (standardized mean difference, 1.03 [95% CI, 0.51-1.55]; P<0.0001, P-score=0.11), high-volume constraint-induced movement therapy (0.86 [0.4-1.32]; P=0.0003, P-score=0.18), and strength training (0.65 [0.17-1.13]; P=0.01, P-score=0.28) were the most effective interventions (each k=107). CONCLUSIONS: Electrical stimulation combined with task-specific training (low evidence), high-volume constraint-induced movement therapy (moderate evidence), and strength training (low evidence) were the most effective interventions in improving upper limb motor function in individuals with a stroke. As the results were sensitive against a high risk of bias, likewise, these interventions should receive more attention in research and practice. Due to the heterogeneous use, electrical stimulation in combination with task-specific training should be further investigated in well-designed studies alongside other successful interventions (eg, constraint-induced movement therapy). REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021284064.

Quadriceps and hamstring anterior cruciate ligament reconstruction differ only marginally in function after the rehabilitation: a propensity score-matched case-control study.

PURPOSE: To determine potential quadriceps versus hamstring tendon autograft differences in neuromuscular function and return to sport (RTS)-success in participants after an anterior cruciate ligament (ACL) reconstruction. METHODS: Case-control study on 25 participants operated on with an arthroscopically assisted, anatomic ipsilateral quadriceps femoris tendon graft and two control groups of 25 participants each, operated on with a semitendinosus tendon or semitendinosus-gracilis (hamstring) tendon graft ACL reconstruction. Participants of the two control groups were propensity score matched to the case group based on sex, age, Tegner activity scale and either the total volume of rehabilitation since reconstruction (n = 25) or the time since reconstruction (n = 25). At the end of the rehabilitation (averagely 8 months post-reconstruction), self-reported knee function (KOOS sum scores), fear of loading the reconstructed knee during a sporting activity (RSI-ACL questionnaire), and fear of movement (Tampa scale of kinesiophobia) were followed by hop and jump tests. Front hops for distance (jumping distance as the outcome) were followed by Drop jumps (normalised knee joint separation distance), and concluded by qualitative ratings of the Balanced front and side hops. Between-group comparisons were undertaken using 95% confidence intervals comparisons, effect sizes were calculated. RESULTS: The quadriceps case group (always compared with the rehabilitation-matched hamstring graft controls first and versus time-matched hamstring graft controls second) had non-significant and only marginal higher self-reported issues during sporting activities: Cohen's d = 0.42, d = 0.44, lower confidence for RTS (d = - 0.30, d = - 0.16), and less kinesiophobia (d = - 0.25, d = 0.32). Small and once more non-significant effect sizes point towards lower values in the quadriceps graft groups in the Front hop for distance limb symmetry values in comparison to the two hamstring control groups (d = - 0.24, d = - 0.35). The normalised knee joint separation distance were non-significantly and small effect sized higher in the quadriceps than in the hamstring groups (d = 0.31, d = 0.28). CONCLUSION: Only non-significant and marginal between-graft differences in the functional outcomes at the end of the rehabilitation occurred. The selection of either a hamstring or a quadriceps graft type cannot be recommended based on the results. The decision must be undertaken individually. LEVEL OF EVIDENCE: III.

Functional outcomes after anterior cruciate ligament reconstruction: unravelling the role of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries.

BACKGROUND: Numerous individual, temporal, injury- and surgery-specific factors impact the functional capacity during rehabilitation, return to sports (RTS), and re-injury prevention after an anterior cruciate ligament (ACL) reconstruction. PURPOSE: This multicentre cohort study evaluated the isolated and interactive contributions of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries as to inertial sensor-assessed motor function after ACL reconstructions in multiple linear mixed model regressions. METHODS: Anonymized data were retrieved from a nationwide German registry. In this cohort study, patients with an acute unilateral ACL rupture, with or without concomitant ipsilateral knee injuries, and having passed an arthroscopically assisted anatomic reconstruction were included. Potential predictors were age [years], gender/sex, time since reconstruction [days], time between injury and reconstruction [days], concomitant intra-articular injuries (isolated ACL tear, meniscal tear, lateral ligament, unhappy triad), graft type (hamstrings, patellar, or quadriceps tendon autograft), and pain during each measurement (visual analogue scale 0-10 cm). Repeated inertial motion unit-assessments of a comprehensive battery of classic functional RTS test were performed in the course of the rehabilitation and return to sports: Joint position sense/kinesthesia (Angle reproduction error [degrees]), Dynamic Balance Composite score [cm] of the Y-Balance test), drop jumps (Knee displacement [cm]), Vertical hop (Hopping height [mm]), Speedy jumps (Duration [seconds]), Side hops (Number of hops [n]), single leg hop for distance (hopping distance [cm]). Repeated measures multiple linear mixed models investigated the impact and nesting interaction of the potential predictors on the functional outcomes. RESULTS: Data from 1441 persons (mean age 29.4, SD 11.8 years; 592 female, 849 male) were included. Most had an isolated ACL rupture: n = 938 (65.1%). Minor shares showed lateral ligament involvement: n = 70 (4.9%), meniscal tear: n = 414 (28.7%), or even unhappy triad: n = 15 (1%). Several predictors such as time between injury and reconstruction, time since reconstruction (estimates for ndays ranged from + .05 (i.e., an increase of the hopping distance of 0.05 cm per day since reconstruction occurs) for single leg hop for distance to + 0.17 for vertical hopping height; p < 0.001), age, gender, pain, graft type (patellar tendon graft: estimates between + 0.21 for Y-balance and + 0.48 for vertical hop performance; p < 0.001), and concomitant injuries contribute to the individual courses of functional abilities of the reconstructed side after ACL reconstruction. The unimpaired side was mostly influenced by sex, age, the time between injury and reconstruction (estimates between - 0.0033 (side hops) and + 0.10 (vertical hopping height), p < 0.001)), and time since reconstruction. CONCLUSIONS: Time since reconstruction, time between injury and reconstruction, age, gender, pain, graft type, and concomitant injuries are not independent but nested interrelating predictors of functional outcomes after anterior cruciate ligament reconstruction. It might not be enough to assess them isolated; the knowledge on their interactive contribution to motor function is helpful for the management of the reconstruction (earlier reconstructions should be preferred) deficit-oriented function-based rehabilitation (time- and function based rehabilitation instead of solely a time- or function based approach) and individualized return to sports strategies.

Contributors to self-report motor function after anterior cruciate ligament reconstruction.

Numerous functional factors may interactively contribute to the course of self-report functional abilities after anterior cruciate ligament  (ACL)-reconstruction. This study purposes to identify these predictors using exploratory moderation-mediation models in a cohort study design. Adults with post unilateral ACL reconstruction (hamstring graft) status and who were aiming to return to their pre-injury type and level of sport were included. Our dependent variables were self-reported function, as assessed by the the KOOS subscales sport (SPORT), and activities of daily living (ADL). The independent variables assessed were the KOOS subscale pain and the time since reconstruction [days]. All other variables (sociodemographic, injury-, surgery-, rehabilitation-specific, kinesiophobia (Tampa Scale of Kinesiophobia), and the presence or absence of COVID-19-associated restrictions) were further considered as moderators, mediators, or co-variates. Data from 203 participants (mean 26 years, SD 5 years) were finally modelled. Total variance explanation was 59% (KOOS-SPORT) and 47% (KOOS-ADL). In the initial rehabilitation phase (< 2 weeks after reconstruction), pain was the strongest contributor to self-report function (KOOS-SPORT: coefficient: 0.89; 95%-confidence-interval: 0.51 to 1.2 / KOOS-ADL: 1.1; 0.95 to 1.3). In the early phase (2-6 weeks after reconstruction), time since reconstruction [days] was the major contributor (KOOS-SPORT: 1.1; 0.14 to 2.1 / KOOS-ADL: 1.2; 0.43 to 2.0). Starting with the mid-phases of the rehabilitation, self-report function was no longer explicitly impacted by one or more contributors. The amount of rehabilitation [minutes] is affected by COVID-19-associated restrictions (pre-versus-post: - 672; - 1264 to - 80 for SPORT / - 633; - 1222 to - 45 for ADL) and by the pre-injury activity scale (280; 103 to 455 / 264; 90 to 438). Other hypothesised contributors such as sex/gender or age were not found to mediate the time or pain, rehabilitation dose and self-report function triangle. When self-report function is rated after an ACL reconstruction, the rehabilitation phases (early, mid, late), the potentially COVID-19-associated rehabilitation limitations, and pain intensity should also be considered. As, for example, pain is the strongest contributor to function in the early rehabilitation phase, focussing on the value of the self-report function only may, consequently, not be sufficient to rate bias-free function.

Sensor-based telerehabilitation system increases patient adherence after knee surgery.

OBJECTIVES: Implementing evidence-based recommendations with the option of patient-individualised and situation-specific adaptations in telerehabilitation may increase adherence with improved clinical outcome. METHODS: As part of a registry-embedded hybrid design (part 1), digital medical device (DMD)-usage in a home-based setting was analysed in a multinational registry. The DMD combines an inertial motion-sensor system with instructions for exercises and functional tests on smartphones. A prospective, single-blinded, patient-controlled, multicentre intervention study (DRKS00023857) compared implementation capacity of the DMD to standard physiotherapy (part 2). Usage patterns by health care providers (HCP) were assessed (part 3). RESULTS AND CONCLUSION: Registry raw data (10,311 measurements) were analysed from 604 DMD-users, demonstrating clinically expected rehabilitation progression post knee injuries. DMD-users performed tests for range-of-motion, coordination and strength/speed enabling insight to stage-specific rehabilitation (χ2 = 44.9, p<0.001). Intention-to-treat-analysis (part 2) revealed DMD-users to have significantly higher adherence to the rehabilitation intervention compared to the matched patient-control-group (86% [77-91] vs. 74% [68-82], p<0.05). DMD-users performed recommended exercises at home with higher intensity (p<0.05). HCP used DMD for clinical decision making. No adverse events related to the DMD were reported. Adherence to standard therapy recommendations can be increased using novel high quality DMD with high potential to improve clinical rehabilitation outcome, enabling evidence-based telerehabilitation.

Effects of acupuncture and medical training therapy on depression, anxiety, and quality of life in patients with frequent tension-type headache: A randomized controlled study.

OBJECTIVES: To compare the effects of acupuncture and medical training therapy in combination or individually with usual care on quality of life, depression, and anxiety in patients with tension-type headache. METHODS: In this single-center, prospective, randomized, controlled, unblinded trial, 96 adults (38.7(+/-13.3) years of age; 75 females/20 males/one dropout) with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups (n = 24). The treatment groups received six weeks of either acupuncture or medical training therapy as monotherapies or in combination (12 interventions each), or usual care. We assessed depressiveness (PHQ-9), anxiety (GAD-7), and health-related quality of life (SF-12) as secondary outcome parameters at baseline, six weeks, three months, and six months after initiation of treatment. Linear mixed models were calculated. RESULTS: Both, acupuncture (baseline to six-weeks change scores: mean: -2(standard deviation: 2.5 points), three months: -2.4(2.4), six-months -2.7(3.6)) and the combination of acupuncture and medical training therapy (-2.7(4.9), -2.2(4.0), -2.2(4.2)) (each within-group p < .05) significantly reduced depressiveness-scores (PHQ-9) to a greater extent than medical training therapy (-0.3(2.0), -0.5(1.6), -0.9(2.6)) or usual care alone (-0.8(2.9), 0.1(2.8), 0.2(3.6)). We found similar results with anxiety scores and the physical sum scores of the SF-12. No severe adverse events occurred. CONCLUSIONS: Acupuncture and the combination of acupuncture and medical training therapy elicit positive effects on depression, anxiety, quality of life, and symptom intensity in patients with episodic and chronic tension-type headache. Acupuncture appears to play a central role in mediating the therapeutic effects, underscoring the clinical relevance of this treatment. An additive benefit of the combination of both therapies does not appear to be relevant.Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

The course of knee extensor strength after total knee arthroplasty: a systematic review with meta-analysis and -regression.

PURPOSE: Muscular strength loss and atrophy are postoperative complications. This systematic review with meta-analysis investigated the course of on knee extensor mass and strength from pre-surgery over total knee arthroplasty to rehabilitation and recovery. METHODS: A systematic literature search was conducted in PubMed (Medline), Cochrane Library (CINAHL, Embase) and Web of Science (until 29th of June 2022). Main inclusion criteria were ≥ 1 preoperative and ≥ 1 measurement ≥ 3-months post-operation and ≥ 1 objective assessment of quadriceps strength, muscle mass or neuromuscular activity, measured at both legs. Studies were excluded if they met the following criteria: further impairment of treated extremity or of the contralateral extremity; further muscle affecting disease, or muscle- or rehabilitation-specific intervention. The Robins-I tool for non-randomized studies, and the Cochrane Rob 2 tool for randomized controlled studies were used for risk of bias rating. Pre-surgery, 3 months, 6 months and 1 year after surgery data were pooled using random effects meta-analyses (standardized mean differences, SMD, Hedge's g) in contrast to the pre-injury values. RESULTS: 1417 studies were screened, 21 studies on 647 participants were included. Thereof, 13 were non-randomized controlled trails (moderate overall risk of bias in most studies) and 7 were randomized controlled trials (high risk of bias in at least one domain in most studies). Three (k = 12 studies; SMD = - 0.21 [95% confidence interval = - 0.36 to - 0.05], I2 = 4.75%) and six (k = 9; SMD = - 0.10 [- 0.28 to - 0.08]; I2 = 0%) months after total knee arthroplasty, a deterioration in the strength of the operated leg compared with the strength of the non-operated leg was observed. One year after surgery, the operated leg was stronger in all studies compared to the preoperative values. However, this increase in strength was not significant compared to the non-operated leg (k = 6, SMD = 0.18 [- 0.18 to 0.54], I2 = 77.56%). CONCLUSION: We found moderate certainty evidence that deficits in muscle strength of the knee extensors persist and progress until 3 months post-total knee arthroplasty in patients with end-stage knee osteoarthritis. Very low certainty evidence exists that preoperatively existing imbalance of muscle strength and mass in favor of the leg not undergoing surgery is not recovered within 1 year after surgery.

Changes in miRNA expression in patients with peripheral arterial vascular disease during moderate- and vigorous-intensity physical activity.

BACKGROUND: Walking is the preferred therapy for peripheral arterial disease in early stage. An effect of walking exercise is the increase of blood flow and fluid shear stress, leading, triggered by arteriogenesis, to the formation of collateral blood vessels. Circulating micro-RNA may act as an important information transmitter in this process. We investigated the acute effects of a single bout of 1) aerobic walking with moderate intensity; and 2) anaerobic walking with vigorous intensity on miRNA parameters related to vascular collateral formation. METHODS: Ten (10) patients with peripheral arterial disease with claudication (age 72 ± 7 years) participated in this two-armed, randomized-balanced cross-over study. The intervention arms were single bouts of supervised walking training at (1) vigorous intensity on a treadmill up to volitional exhaustion and (2) moderate intensity with individual selected speed for a duration of 20 min. One week of washout was maintained between the arms. During each intervention, heart rate was continuously monitored. Acute effects on circulating miRNAs and lactate concentration were determined using pre- and post-intervention measurement comparisons. RESULTS: Vigorous-intensity walking resulted in a higher heart rate (125 ± 21 bpm) than the moderate-intensity intervention (88 ± 9 bpm) (p < 0.05). Lactate concentration was increased after vigorous-intensity walking (p = 0.005; 3.3 ± 1.2 mmol/l), but not after moderate exercising (p > 0.05; 1.7 ± 0.6 mmol/l). The circulating levels of miR-142-5p and miR-424-5p were up-regulated after moderate-intensity (p < 0.05), but not after vigorous-intensity training (p > 0.05). CONCLUSION: Moderate-intensity walking seems to be more feasible than vigorous exercises to induce changes of blood flow and endurance training-related miRNAs in patients with peripheral arterial disease. Our data thus indicates that effect mechanisms might follow an optimal rather than a maximal dose response relation. Steady state walking without the necessity to reach exhaustion seems to be better suited as stimulus.

Dose-response relationship and effect modifier of stabilisation exercises in nonspecific low back pain: a project-wide individual patient data re-analysis on 1483 intervention participants.

ABSTRACT: This planned MiSpEx-Network reanalysis was designed to derive a dose-response relationship under consideration of further effect modifiers in exercises on low back pain. One thousand four hundred eighty three intervention participants with low back pain (mean age, 40.9 years [SD 14 years]) performed stabilisation exercises (3 weeks supervised, 9 weeks self-administered). Patients reported pain intensity, disability, and disability days at baseline, 3 weeks, 12 weeks, and 6 months post randomisation. Exercise characteristics and effect modifiers were prospectively monitored. Beyond the comparison to the results of the control group, linear mixed models were calculated to determine a dose-response relationship. The interventions led to small but significantly larger symptom reductions than in the control group at each measurement. Longer durations of the intervention led to larger symptom reductions. Higher exercise frequencies were associated with a decrease in pain intensity: to train once more per week led to a mean decrease of 0.93 points in pain intensity [95% CI = -1.54 to -0.32]. Disability days were also impacted (estimate = -0.07 [-0.14 to 0.00]), but disability was not (-0.09 [-0.67 to 0.48]). Adding perturbation was superior to adding stretching or a behavioural module. The relationships were robust when additional effect modifiers were considered and against the control group' effects. The odds ratio for a clinically important effect with higher exercise frequencies decreased at 3 weeks (OR = 0.71 [0.618-0.813] for >2.5*week -1 ) and increased at 12 weeks (1.13 [1.006-1.270], >1.5*week -1 ). Using longer intervention durations, adding a perturbation component to the stabilisation trainings and using higher frequencies (up to a certain point) may lead to an even more beneficial response on exercise in patients with low back pain. Developing strategies to maintain a training frequency of at least 2 times per week may be relevant in stabilisation exercises to treat low back pain.