Exploring the biopsychosocial impact of hypermobility spectrum disorders and Ehlers-Danlos syndrome in an adult population: a protocol for a scoping review.

BACKGROUND: Conditions such as hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndrome (EDS) are most often diagnosed when an individual has joint flexibility beyond the normal physiological limits. Additional characteristics and symptoms include pain and fatigue with individuals also being more likely to report feelings of anxiety and depression. Due to the varied presentation of these conditions, there is a lack of understanding amongst the various healthcare professionals (HCPs) individuals present to, leading to delayed diagnoses and negative experiences for the individuals themselves. This scoping review therefore aims to map the known biopsychosocial impact of adults with HSD and EDS. METHODS: The scoping review will follow the six-step framework as outlined by Arskey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) checklist. The search will be conducted using the following databases: AMED, CINAHL, Cochrane Library, Embase, MEDLINE, PsycINFO, PubMed PEDro. Full-text published articles in the English language (excluding literature and systematic reviews) with adult samples (over the age of 18 years) and a diagnosis of a HSD or EDS, published between 2012 and 2022, will be included in the review. DISCUSSION: This review will aim to explore the existing literature for the reported biopsychosocial impact of adults with a HSD or EDS. It will also aim to further acknowledge the gaps in understanding of the condition, how the condition and the impact of the condition is being measured and what HCPs are involved in supporting such individuals. These gaps will be used to inform a future systematic review. It is the overall goal to increase the knowledge of HCPs and the quality of life of adults living with a joint hypermobility condition.

Patient experience of chronic illness care and complementary integrative health use: a cross-sectional study of patients with hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndromes (EDS).

PURPOSE: Hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndromes (EDS) are frequently underdiagnosed, contributing to patient dissatisfaction in the healthcare system. This study evaluated the health service utilization, care, and subjective experiences of living with chronic illness among adults with HSD and EDS in the United States and Canada. METHODS: This was an anonymous, web-based, cross-sectional healthcare survey. The survey obtained basic demographic information, the Patient Assessment of Chronic Illness Care (PACIC+), as well as responses to questions on the use of healthcare and integrative medicine. RESULTS: A total of 353 surveys were received. The most common complementary therapies used were physical therapy (82%), massage (68%), yoga (58%), chiropractic (48%), and meditation (43%). Mean (SD) summary PACIC and PACIC 5 As scores were 2.16 (0.77) and 2.25 (0.83), respectively. Across all PACIC domains, mean scores of individuals whose typical doctor visit was 30 min or at least an hour were significantly higher than those of individuals who indicated typical visits of 15 min (all p < 0.0001 by one-way ANOVA). There was widespread agreement on the importance of patient-provider relationship and trust, physicians' understanding of the individual's complete medical history, and prioritization of physical and emotional safety (>95% agree or strongly agree to each). CONCLUSION: Individuals with HSD or EDS report low satisfaction with chronic illness care and commonly seek out complementary and self-administered therapies, likely in an attempt to manage symptoms. Respondents reported a desire for greater time and attention from physicians. Results from this study could educate the healthcare community to improve support mechanisms for HSD and EDS populations.IMPLICATIONS FOR REHABILITATIONPatients with hypermobility spectrum disorders (HSD) or Ehlers-Danlos syndromes (EDS) express a desire for patient-centered care and peer support from other individuals with HSD or EDS.Individuals with HSD or EDS have typically seen multiple doctors for their condition and their satisfaction with chronic care, as measured by the Patient Assessment of Chronic Illness Care (PACIC+), is low.The use of various complementary and integrative health treatments, as well as specialized diets, is common in this population, and might be beneficial for symptom management.Healthcare delivery for HSD and EDS may require a multidisciplinary healthcare team, as complementary and self-care modalities are typically used in addition to physical therapy, pain medication, and other conventional care.

Copers adopt an altered movement pattern compared to individuals with chronic ankle instability and control groups in unexpected single-leg landing and cutting task.

Individuals with chronic ankle instability (CAI) demonstrate altered ankle kinematics during landing compared to uninjured individuals. However, if copers may have adopted unique movement strategy to prevent repeated ankle sprains is unclear. The purpose of this study compares the lower-extremity joint kinematics and muscle activities of CAI (N = 8), coper (COP) (N = 8), and control (CON) (N = 8) groups in unexpected single-leg landing and cutting. Performance time (from initial contact to toe-off), number of mistakes in the jumping direction, low-extremity joint angle are assessed. Muscle activities were recorded from the tibialis anterior, medial gastrocnemius, and peroneus longus (PL), and mean muscle activity, co-contraction index (CI), and PL latency were analyzed. Results of performance time and CI are not significant. Significantly less number of mistakes in the jumping direction and a shorter PL latency were discovered in the COP and CON compared with the CAI group (P < 0.05). The peak hip joint flexion angle is significantly smaller in the COP than in the CON (P = 0.04). In dynamic tasks requiring quick judgments of ankle inclination, the COP may be able to accurately sense the inclination of the foot. Additionally, movement strategies differed between the COP and CON groups in an unexpected single-leg landing and cutting.

The Relationship Between Fear Avoidance Beliefs, Muscle Strength, and Short-Term Disability After Surgical Repair of Shoulder Instability.

CONTEXT: Arthroscopic surgical repair of the shoulder is recommended when conservative treatment for shoulder instability (SI) fails. However, many patients undergoing this procedure do not return to same level of activity. Psychological factors and muscle strength have been shown to be associated with postoperative outcomes in other musculoskeletal conditions. OBJECTIVE: To investigate the association between fear avoidance, muscle strength, and short-term function in patients after surgical SI repair. METHODS: Twenty-five male patients who underwent shoulder surgery following at least one event of SI were included in this study. Evaluations of fear avoidance related to physical activity and disability were performed at baseline (during the first encounter with the physical therapist) and 7 to 8 weeks postsurgery. Fear avoidance beliefs were assessed using the Fear Avoidance Beliefs Questionnaire. Disability was assessed using the Disabilities of Arm, Shoulder, and Hand questionnaire and the Western Ontario SI index. The follow-up evaluation (weeks 7-8) included measurement of maximal isometric strength of the internal and external rotators. Nonparametric Kendall tau was used to determine the correlations between baseline fear avoidance, muscle strength, and disability at follow-up. RESULTS: Disabilities of Arm, Shoulder, and Hand questionnaire at follow-up was significantly correlated with baseline Disabilities of Arm, Shoulder, and Hand questionnaire (τ = .520, P < .001), baseline fear avoidance (τ = .399, P = .008), and both internal rotator (τ = -.400, P = .005) and external rotator strength (τ = -.353, P = .014). Western Ontario SI index at follow-up was moderately correlated with baseline Western Ontario SI index (τ = .387, P = .007), internal rotator (τ = -.427, P = .003), and external rotator (τ = -.307, P = .032), but not with baseline Fear Avoidance Beliefs Questionnaire (τ = .22, P = .145). CONCLUSIONS: The results indicate a possible association between fear avoidance beliefs and short-term disability. Further studies are warranted to better explore and understand these relationships.

Males with chronic ankle instability demonstrate deficits in neurocognitive function compared to control and copers.

The purpose of this study was to determine if there were neurocognitive deficits among controls, copers and those with chronic ankle instability (CAI). Participants included those without history of ankle injury (n = 14), ankle sprain copers (n = 13) and patients with self-reported CAI (n = 14). They completed a battery of valid and reliable computer-based neurocognitive tests. The differences between neurocognitive domain scores were compared across the Control, Coper and CAI groups. Patients with CAI had lower composite memory, visual memory and simple attention compared to controls. In males with CAI, large differences in memory and attention were found relative to control participants. These differences may contribute to uncontrolled episodes of giving way through deficits in spatial awareness and/or an inability to identify environmental obstacles. Clinicians should explore ways to provide additional stimuli through innovative rehabilitation protocols aimed at maximizing neurocognitive abilities in patients with CAI.

Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability.

PURPOSE: The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors. METHODS: Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores. RESULTS: Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p < 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p < 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship. CONCLUSION: This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research. Level of evidence IV.

Quality of life, function and disability in individuals with chronic ankle symptoms: a cross-sectional online survey.

BACKGROUND: Chronic ankle conditions affect approximately 20% of Australian adults. Although there is a plethora of research on chronic hip and knee conditions, there is limited understanding of the impact of ankle problems. Thus, the significance of chronic ankle conditions is not clear. The aim of this study was to compare self-reported function, disability, instability, physical activity and quality of life (QoL) between adults with and without ankle symptoms. A secondary aim was to explore factors associated with QoL. METHOD: Individuals with symptoms of ankle pain and stiffness (symptomatic individuals) and controls with no ankle pain or stiffness (asymptomatic individuals) completed a cross-sectional online survey. The survey included the Ankle Osteoarthritis Scale (AOS), Foot and Ankle Ability Measure (FAAM), Cumberland Ankle Instability Tool (CAIT), International Physical Activity Questionnaire (IPAQ), Assessment of QoL (AQoL-6D), and questions about ankle injury history. RESULTS: A total of 394 individuals (270 symptomatic and 124 asymptomatic) with mean age of 48.8 (standard deviation (SD): 12.1) years and body mass index of 28.7 (7.7) kgm- 2 completed the survey. Standardized mean differences (SMD) were large to very large (1.45 to 3.20) for greater disability (AOS) and instability (CAIT), and poorer function (FAAM) in symptomatic compared to asymptomatic individuals. Individuals with ankle symptoms had higher body mass index and lower QoL (medium effect: SMD > 1). There were no differences in self-report physical activity between groups. Lower activities of daily living (ADL) function (FAAM-ADL) best explained QoL in a multiple regression model (R2 = 0.66, p = 0.001). CONCLUSION: Individuals with ankle symptoms reported ankle instability, greater disability, compromised function and worse QoL compared to asymptomatic individuals. There was a strong relationship between ankle function and QoL. Ankle-specific ability during ADL best explained the reduced QoL in individuals with ankle symptoms. Clinicians and researchers should consider ankle function as an antecedent to poorer QoL in patients who have ankle symptoms.

Knee arthrodesis for a congenital luxation with Larsen syndrome.

A 31-year-old woman with known Larsen syndrome presented with congenital chronic luxation of her right knee with increasing instability symptoms, which limited her daily activities. We refrained from a constrained knee arthroplasty due to her relatively young age and decided to perform a knee arthrodesis. Knee arthrodesis is a viable lifelong-lasting operative treatment alternative for specific instability-related knee disease. The knee arthrodesis was performed by double plating with an additional fixation of the patella. At 1-yearfollow-up, she was able to walk without limitations and did not experience any pain with complete consolidation of the arthrodesis. At 2-year follow-up, she performed all her daily activities without limitations. Both the Knee injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee subjective knee form (IKDC) improved at 2-year follow-up (KOOS: 61.3; IKDC: 56.3) compared with 1-year follow-up (KOOS: 52; IKDC: 40.2).

Health-Related Quality of Life Among Middle-Aged Adults With Chronic Ankle Instability, Copers, and Uninjured Controls.

CONTEXT: People with chronic ankle instability (CAI) display a lower regional and global health-related quality of life (HRQoL). Examinations of HRQoL outcomes associated with CAI have addressed younger adults, restricting our understanding of the long-term consequences of CAI. OBJECTIVE: To compare ankle regional and global HRQoL in middle-aged participants with and those without CAI. DESIGN: Cross-sectional study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 59 middle-aged volunteers, consisting of 18 with CAI (age = 50.2 ± 9.3 years), 17 who were ankle-sprain copers (age = 54.5 ± 8.7 years), and 24 uninjured controls (age = 56.7 ± 10.0 years). MAIN OUTCOME MEASURE(S): Participants completed the Foot and Ankle Disability Index (FADI) and the Patient-Reported Outcomes Measurement Information System Adult Profile. Regional HRQoL was assessed using the FADI Activities of Daily Living and Sport subscales. Global HRQoL was measured using the 43-item Patient-Reported Outcomes Measurement Information System Adult Profile, which contains 7 short forms-Physical Function, Pain Interference, Fatigue, Depression, Sleep Disturbance, Anxiety, and Ability to Participate in Social Roles and Activities. Separate Kruskal-Wallis tests were used to determine between-groups differences. RESULTS: Middle-aged participants with CAI had lower scores on both subscales of the FADI than the coper and control groups (all P values <.001). Participants with CAI scored lower on the Physical Function (U = 116.0, z = -2.78, P = .005) and Ability to Participate in Social Roles and Activities (U = 96.0, z = -3.09, P = .002) subscales but higher on the Pain Interference (U = 144.0, z = -2.36, P = .02), Fatigue (U = 110.0, z = -2.72, P = .006), and Depression (U = 110.5, z = -2.91, P = .004) subscales than the control group. Participants with CAI also scored lower on the Physical Function (U = 74.5, z = -2.79, P = .005) and Ability to Participate in Social Roles and Activities (U = 55.0, z = -3.29, P = .001) subscales but higher on the Fatigue (U = 90.0, z = -2.09, P = .04) and Depression (U = 96.5, z = -1.97, P = .048) subscales than the coper group. CONCLUSIONS: Middle-aged participants with CAI displayed worse ankle regional and global HRQoL than their age-matched healthy counterparts and copers. These results demonstrated that CAI can affect HRQoL outcomes in middle-aged adults.

Decreased ankle and hip isometric peak torque in young and middle-aged adults with chronic ankle instability.

OBJECTIVES: To compare ankle, knee and hip isometric peak torque between young and middle-aged adults with CAI, copers and un-injured controls. DESIGN: Cross-sectional. SETTING: Research Laboratory. PARTICIPANTS: One hundred fifty-six young and middle-aged adults with or without CAI volunteered. MAIN OUTCOME MEASURES: A handheld dynamometer measured isometric dorsiflexion, plantarflexion, knee extension, hip extension and hip abduction peak force during a 5 s trial. Average peak torque was calculated and normalized to body mass. RESULTS: A significant Age by Injury interaction for dorsiflexion suggest middle-aged un-injured controls (p < 0.001) and copers (p < 0.001) had lower isometric peak torque compared to their young adult counterparts, but there were no differences between young and middle-aged adults with CAI (p > 0.05). Significant Injury main effects suggest the CAI group had decreased plantarflexion (p = 0.004) and hip extension (p = 0.010) strength compared to un-injured controls, but not copers (p > 0.05). Significant Age main effects for all primary outcome measures were observed, indicating peak torque decreased with age (p < 0.05). CONCLUSIONS: Regardless of age, isometric ankle and hip peak torque was lower in participants with CAI compared to un-injured controls, but not copers. These findings provide further evidence towards the impact of CAI in both young and middle-aged adults.

Ability of the Bristol Impact of Hypermobility questionnaire to discriminate between people with and without Joint Hypermobility Syndrome: a known-group validity study.

INTRODUCTION: A number of psychometric properties of the Bristol Impact of Hypermobility (BIoH) questionnaire have previously been demonstrated, including strong concurrent validity and test-retest reliability. This study aimed to identify whether it can discriminate between those with and without Joint Hypermobility Syndrome (JHS). METHODS: The wording of a small number of BIoH questionnaire items was adapted to create a generic version that asked about 'general health' rather than 'hypermobility'. The generic questionnaire was distributed online to university students and staff. A sampling frame was used to create age and sex-matched samples from the non-JHS respondents in the current study and a pre-existing JHS cohort. Questionnaire scores were then compared between samples. RESULTS: 790 responses were received. 414 were excluded, mainly due to self-reported generalized joint hypermobility or a JHS diagnosis. The sampling frame was applied to the remaining non-JHS responders (n = 376) and the pre-existing JHS cohort (n = 448), resulting in 206 age and sex-matched participants in each sample. The median (IQR) BIoH scores (out of a maximum 360) were 81 (57.25) and 231.5 (74.25) in the non-JHS and JHS samples respectively (p < 0.001). There was a very strong correlation between BIoH score and the number of painful areas (r = 0.867, p < 0.001). CONCLUSIONS: The BIoH questionnaire discriminates between those with and without JHS. The median difference (151.5 points) far exceeds the smallest detectable change of 42 points previously identified. The results provide further evidence of the psychometric properties of the BIoH questionnaire and its potential to support research and clinical practice.

The relationship between pain and associated characteristics of chronic ankle instability: A retrospective study.

Background: Up to 74% of people with a history of ankle sprain develop chronic ankle instability (CAI). One commonly reported residual impairment is ankle pain; however, it has not been included in models or inclusion criteria for CAI. We investigated the prevalence of pain in people with CAI and the association between presence of pain and other CAI characteristics. Methods: Retrospective data from 1147 participants with CAI (age 26.6 ± 10.7 years, 59% female) were collated from previous studies that used the Cumberland Ankle Instability Tool as an assessment tool. Pain was assessed from Item 1 of the Cumberland Ankle Instability Tool, which asks participants about ankle pain. Responses were divided into 3 categories: pain during daily activities, pain during moderate/vigorous physical activities, and no pain. The presence of pain was analyzed with descriptive statistics, the correlation between pain category and CAI characteristics was analyzed by χ2 tests and factors associated with each pain category were analyzed by logistic regression. Results: Among the participants, 60.1% (n = 689) reported ankle pain. Of all participants, 12.4% (n = 142) reported pain during daily activities, 47.7% (n = 547) reported pain during moderate/vigorous physical activities, and 39.9% (n = 458) reported no pain. There was a strong association between ankle instability and ankle pain (χ2 = 122.2, p < 0.001, OR = 5.38, 95% confidence interval (CI): 3.84-7.53). Perceived ankle instability, age and unilateral ankle sprains were independently associated with pain (ankle instability: χ2 = 43.29, p < 0.001; age: χ2 = 30.37, p < 0.001; unilateral ankle sprains: χ2 = 6.25, p < 0.05). There was no significant difference in the presence of pain between genders. Conclusion: The prevalence of pain in people with CAI was high and was related to perceived ankle instability. Number of sprains, age, gender and unilateral or bilateral sprain did not modify this result except for the first pain category (pain during daily activities). There is large gap in current knowledge about the impact of pain in people with CAI, and this topic needs further investigation.

Fear Avoidance Beliefs in College Athletes with a History of Ankle Sprain.

Ankle sprains are the most prevalent injuries, and elevated fear avoidance beliefs after ankle sprain episodes could inhibit athletic performance and contribute to residual symptoms, such as functional and/or mechanical instability. However, it remains unclear how fear avoidance beliefs differ according to conditions of posttraumatic sequelae. The purpose of this study was to determine whether fear of movement/reinjury differed between individuals with and without functional ankle instability (FI, NFI) and healthy controls (CON) and to examine the relationship between fear and ankle joint laxity by sex. Participants (115 male athletes, 105 female athletes) completed the Identification of Functional Ankle Instability, Athlete Fear Avoidance Questionnaire (AFAQ), Tampa Scale for Kinesiophobia (TSK), and ankle joint laxity test. Total 168 athletes (79 males, 89 females) data were eligible for analysis. The results demonstrated that fear of movement/reinjury was lower in individuals in the absence of functional ankle instability although they experienced ankle sprain (FI; TSK=38.6±4.5, AFAQ=27.4±6.2, NFI; TSK=35.7±5.6, AFAQ=24.5±6.6). The fear of movement/reinjury had correlation with ankle joint laxity only in female athletes (TSK; r=0.285, p=0.013, AFAQ; r 0=0.322, p=0.045).

A systematic review of patient-reported outcome measures used in shoulder instability research.

BACKGROUND: Shoulder instability is extremely common, with various outcome scores used to assess its progression after treatment. This review was performed to identify the scores most commonly used and to evaluate them according to the 4 core domains of shoulder trials (according to the Core Outcome Measures in Effectiveness Trials [COMET] initiative) and their respective psychometric qualities. METHODS: A systematic review of the literature of 3 databases (MEDLINE, Embase, PubMed) was undertaken. Studies were identified using eligibility criteria and critically appraised by 2 authors. Data were extracted using an a priori template. Outcome scores were identified and assessed regarding COMET domain inclusion and their psychometric properties. RESULTS: The most frequently used scores were the Rowe (58%), Constant (33%), Western Ontario Shoulder Instability Index (WOSI; 24%), and American Shoulder and Elbow Surgeons (23%) scores. The majority of outcome scores assessed pain and all assessed physical functioning. Quality of life and a global assessment of treatment success were rarely incorporated. No single outcome score considered all core COMET domains. The WOSI was the most acceptable measure of those assessed with respect to its validity, reliability, and responsiveness. CONCLUSIONS: The WOSI incorporated 3 of the 4 core domains for shoulder trials (pain, physical functioning, and health-related quality of life). It had the most psychometric testing of the identified scores, confirming its reliability, validity, and responsiveness in the setting of shoulder instability. We recommend its use in this setting; however, it should be supplemented with additional outcome scores, such as the University of California-Los Angeles score, to cover all of the core COMET domains.

Decreased perceived ankle and knee joint health in individuals with perceived chronic ankle instability.

PURPOSE: Abnormal movement patterns and neuromuscular impairments at the ankle are thought to contribute to ankle joint degeneration in those with chronic ankle instability. However, these impairments are not confided to the ankle; rather, proximal neuromuscular deficiencies at the knee and aberrant movement patterns, thought to be responsible for reductions in knee joint health, have also been identified. While neuromuscular impairments and self-reported functional limitations have been examined in those with chronic ankle instability, patient-generated symptoms associated with joint health of the ankle and knee have not been investigated. Therefore, the purpose was to compare perceived ankle and knee joint health in individuals with and without chronic ankle instability. METHODS: The Ankle Osteoarthritis Scale and the Knee Injury and Osteoarthritis Outcome Score assessed region-specific ankle and knee joint health. RESULTS: Participants with chronic ankle instability reported more ankle pain (P < 0.001) and disability (P < 0.001) than the control group. Chronic ankle instability individuals also reported worse knee joint health (P < 0.05). CONCLUSIONS: The increased symptomology associated with decreased ankle joint health further supports information demonstrating joint degeneration in young adults with chronic ankle instability. The decreased perceived knee joint health provides preliminary evidence of the negative impact proximal neuromuscular impairments associated with chronic ankle instability that may have on joints other than the ankle. Assessing subjective ankle and knee joint function can guide clinicians in developing individualized rehabilitation by providing them with an understanding if a patient presenting with chronic ankle instability suffers from symptoms arising from more than just the ankle. LEVEL OF EVIDENCE: Case-control, Level III.

Psychometric properties of the Norwich Patellar Instability Score in people with recurrent patellar dislocation.

BACKGROUND: Patellar dislocations account for two percent of all knee injuries with a 17% chance of re-dislocation. There are few validated scores specific to instability. One of these is the Norwich Patellar Instability Score. There has been limited assessment of the validity, floor-ceiling effect and responsiveness of the Norwich Patellar Instability (NPI) Score from an independent centre. The purpose of this paper is to address this limitation. METHODS: Data from 90 patients referred to a tertiary referral patellofemoral clinic were analysed. All routinely completed data including NPI Score, Kujala Patellofemoral Disorder Score, and demographic outcomes during appointments, up to 36 months following initial clinical assessment was analysed. Convergent validity was assessed by correlating outcomes of the Kujala Patellofemoral Disorder Score to the NPI Score. Effect size (ES) was determined between baseline to 12-month and 12 to 36-month assessments to determine responsiveness. Floor-ceiling effect was evaluated at baseline, 12-month and 12 to 36-month follow-up. RESULTS: NPI Score demonstrated good convergent validity to the Kujala Patellofemoral Disorder Score (p < .001; 95% confidence interval (CI): -0.71 to -0.52). NPI Score demonstrated good responsiveness to change both between baseline to 12 months (ES: 0.43; 95% CI: 0.42 to 0.10) and 12 to 36 months (ES: 0.67; 95% CI: 0.60 to 0.15). Whilst the NPI Score did not demonstrate a ceiling effect, there was moderate risk of a floor-effect where 13% of the cohort reported the lowest levels of NPI scores. CONCLUSIONS: The NPI Score is a valid and responsive outcome for people with recurrent patellar dislocation.

Prevalence of Clinical Depression Among Patients After Shoulder Stabilization: A Prospective Study.

BACKGROUND: Depression is a potential risk factor for poor postoperative outcomes. This study aimed to identify the prevalence of clinical depression symptoms before and after shoulder stabilization, as well as the relationship between depression and functional outcomes. METHODS: Patients undergoing arthroscopic primary glenohumeral stabilization for recurrent instability were eligible for enrollment. Participants completed the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) and the Western Ontario Shoulder Instability Index (WOSI) questionnaire preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patients with a preoperative QIDS-SR score of ≥6 were assigned to the clinical depression group. RESULTS: Seventy-six patients were enrolled and were prospectively followed during this study. Thirty-nine patients were stratified into the clinical depression group. Preoperatively, the clinical depression cohort had worse WOSI scores than the cohort without clinical depression (mean difference, 8.3% [95% confidence interval (CI), 0.5% to 16.1%]; p = 0.04). Both the clinical depression cohort and the cohort without clinical depression displayed an improvement in WOSI scores at 1 year postoperatively (p < 0.01 for both cohorts). Both the clinical depression cohort and the cohort without clinical depression displayed an improvement in QIDS-SR scores at 1 year postoperatively (p < 0.01 for both cohorts). At 1 year postoperatively, the clinical depression cohort continued to have worse WOSI scores than the cohort without clinical depression (mean difference, 12.2% [95% CI, 5.9% to 18.5%]; p < 0.01) and worse QIDS-SR scores; the median QIDS-SR score was 5.0 points (interquartile range [IQR], 2.0 to 8.0 points) for the clinical depression group and 0.0 points (IQR, 0.0 to 3.0 points) for the group without clinical depression (p < 0.01). The postoperative prevalence of clinical depression (24%) was lower than the preoperative prevalence (51%) (p < 0.01). Increasing patient age was associated with preoperative depression symptoms (odds ratio, 3.1; p = 0.03). CONCLUSIONS: Fifty-one percent of patients with shoulder instability reported depression symptoms before the surgical procedure. Surgical intervention improved shoulder function and depression symptoms over time; however, the clinical depression cohort had worse postoperative shoulder and depression outcomes. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Generic and psychological patient-reported deficits in those with chronic ankle instability: A cross sectional study.

OBJECTIVES: To quantify differences in generic and psychological patient-reported outcomes (PROs) between those with CAI and uninjured controls. To determine associations between generic and psychological PROs, in those with CAI, to regional PROs and injury history characteristics. DESIGN: Cross-sectional, descriptive. SETTING: Sport Medicine Research Laboratory. PARTICIPANTS: Included 45 individuals with CAI and 45 uninjured controls. CAI was defined based on the recommendations of the International Ankle Consortium. MAIN OUTCOME MEASURES: Two regional PROs (e.g. Foot and Ankle Ability Measure), and several generic and psychological PROs (e.g. SF-36, select PROMIS short forms, Fear Avoidance Beliefs Questionnaire). RESULTS: Those with CAI had worse scores, relative to controls, in PROs related to regional function, generic physical function, pain, ability to participate in social roles and activities, and injury related fear. The number of giving way episodes, CAI severity, and regional PROs associated with generic physical function scales as well as a pain scale. CONCLUSIONS: Select generic physical function and psychological scales can detect differences between those with and without CAI. Specific injury history characteristics and regional PROs associate with generic and psychological PROs.

Translation and validation of a Hebrew version of the Western Ontario Shoulder Instability index.

BACKGROUND: The Western Ontario Shoulder Instability index (WOSI) is a questionnaire designed to measure health-related quality of life in patients with shoulder instability. The aim of the current study was to translate the WOSI into Hebrew and assess its psychometric properties. METHODS: The WOSI was translated into Hebrew according to World Health Organization guidelines. Twenty-five patients completed the WOSI and the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire 2 weeks and 2 months after surgical shoulder stabilization. Internal consistency (Cronbach's α), criterion validity (Pearson's correlation coefficient with DASH), responsiveness, and floor and ceiling effects were assessed. RESULTS: Cronbach's α was 0.88-0.95 for total WOSI (range 0.68-0.95 for different sections). Strong correlation with DASH score (r = 0.76-0.84) indicated good criterion validity. Changes between baseline and follow-up for WOSI and DASH scores were moderately correlated (r = 0.68), suggesting moderate responsiveness. Some items demonstrated floor and ceiling effects, especially at baseline, but no floor or ceiling effects were observed for total WOSI or for the WOSI sections. CONCLUSIONS: The results of the current study demonstrate that the Hebrew version of the WOSI is a valid instrument that can be used to assess disability in patients with shoulder instability. Additional studies are warranted to assess its psychometric properties among various subpopulations. TRIAL REGISTRATION: The study was pre-registered at the ClinicalTrials.gov website, registration number NCT02978365 .

A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift.

Lateral ankle sprains are the most common injuries sustained during physical activity. The epidemiologic trends associated with chronic ankle instability (CAI) suggest that current rehabilitation approaches may be inadequate. We sought to synthesize best-practices evidence for the rehabilitation of patients with acute ankle sprains and CAI through the integration of emerging paradigms in perception, the dynamics of skill acquisition, and the biopsychosocial model of function, disability, and health. From the best available evidence, 4 key factors emerged for effective treatment and rehabilitation strategies: pain reduction, external ankle support for up to 1 year, progressive return to motion, and coordination training. We combined these factors into a meta-theoretical framework that centers on the perceptual interdependence of the cellular, local, and global functioning levels by linking insights from the body-self neuromatrix, the dynamics of skill acquisition, and the biopsychosocial model. Based on the best-practice recommendations from systematic reviews, ankle-sprain rehabilitation represents a multidimensional phenomenon governed by perception. The impairments, activity limitations, and participation restrictions associated with CAI may be linked to perceptual-interdependence alterations. Pain and edema reduction, the use of external ankle support for up to 1 year, progressive return to motion, and coordination training foster enhanced perceptual interdependence from cells to society. Using the perceptual-interdependence framework for ankle-sprain rehabilitation, we offer new insights for charting the course of effective strategies for enhancing function, reducing disability, and preventing the long-term sequelae associated with CAI.