Prospective telehealth analysis of functional performance, frailty, quality of life, and mental health after COVID-19 hospitalization.

BACKGROUND: COVID-19 is a global pandemic with poorly understood long-term consequences. Determining the trajectory of recovery following COVID-19 hospitalization is critical for prioritizing care, allocating resources, facilitating prognosis, and informing rehabilitation. The purpose of this study was to prospectively evaluate recovery following COVID-19 hospitalization. METHODS: Participants age 18 years or older who were hospitalized for ≥24 h due to COVID-19 completed phone/video call virtual assessments (including the 10-time chair rise test) and survey forms at three time points (2-6, 12, and 18 weeks) after hospital discharge. Univariate logistic and linear regression models assessed the associations of the outcomes with primary predictors (categorical age, sex, race/ethnicity group, and categorical pre-hospitalization frailty) at baseline; the same were used to assess differences in change from week 2-6 (continuous outcomes) or outcome persistence/worsening (categorical) at last contact. RESULTS: One hundred nine adults (age 53.0 [standard deviation 13.1]; 53% female) participated including 43 (39%) age 60 or greater; 59% identified as an ethnic and/or racial minority. Over 18 weeks, the mean time to complete the 10-time chair rise test decreased (i.e., improved) by 6.0 s (95% CI: 4.1, 7.9 s; p < 0.001); this change did not differ by pre-hospital frailty, race/ethnicity group, or sex, but those age ≥ 60 had greater improvement. At weeks 2-6, 67% of participants reported a worse Clinical Frailty Scale category compared to their pre-hospitalization level, whereas 42% reported a worse frailty score at 18 weeks. Participants who did not return to pre-hospitalization levels were more likely to be female, younger, and report a pre-hospitalization category of 'very fit' or 'well'. CONCLUSIONS: We found that functional performance improved from weeks 2-6 to 18 weeks of follow-up; that incident clinical frailty developed in some individuals following COVID-19; and that age, sex, race/ethnicity, and pre-hospitalization frailty status may impact recovery from COVID-19. Notably, individuals age 60 and older were more likely than those under age 45 years to return to their pre-hospitalization status and to make greater improvements in functional performance. The results of the present study provide insight into the trajectory of recovery among a representative cohort of individuals hospitalized due to COVID-19.

Report of the Primary Outcomes for Gait Mechanics in Men of the ACL-SPORTS Trial: Secondary Prevention With and Without Perturbation Training Does Not Restore Gait Symmetry in Men 1 or 2 Years After ACL Reconstruction.

BACKGROUND: Movement asymmetries during walking are common after anterior cruciate ligament (ACL) injury and reconstruction and may influence the early development of posttraumatic osteoarthritis. Preoperative neuromuscular training (like perturbation training, which is neuromuscular training requiring selective muscle activation in response to surface perturbations) improves gait asymmetries and functional outcomes among people who are ACL-deficient, but the effect of postoperative perturbation training on gait mechanics after ACL reconstruction is unknown. QUESTIONS/PURPOSES: Among men undergoing ACL reconstruction, we sought to compare strength, agility, and secondary prevention (SAP) treatment with SAP plus perturbation training (SAP+PERT) with respect to (1) gait mechanics; and (2) elimination of gait asymmetries 1 and 2 years after ACL reconstruction. METHODS: Forty men were randomized into a SAP group or a SAP+PERT group after ACL reconstruction and before returning to preinjury activities. Participants were required to achieve ≥ 80% quadriceps muscle strength symmetry, minimal knee effusion, full ROM, no reports of pain, and completion of a running progression (all between 3 and 9 months postoperatively) before enrollment. Of 94 potentially eligible athletic male patients evaluated < 9 months after ACL reconstruction, 54 were excluded for prespecified reasons. Participants underwent motion analysis during overground walking at 1 and 2 years postoperatively. Variables of interest included (1) sagittal and frontal plane hip and knee angles and moments at peak knee flexion angle; (2) sagittal plane hip and knee angles and moments at peak knee extension angle; (3) sagittal plane hip and knee excursion during weight acceptance; and (4) sagittal plane hip and knee excursion during midstance. We also calculated the proportion of athletes in each group who walked with clinically meaningful interlimb asymmetry in sagittal plane hip and knee variables and compared these proportions using odds ratios. There was no differential loss to followup between groups. RESULTS: There were no differences between the SAP or SAP+PERT groups for the biomechanical gait variables. The involved limb's knee excursion during midstance for the SAP (mean ± SD: 1 year: 15° ± 5°; 2 years: 16° ± 5°) and SAP+PERT (1 year: 16° ± 5°; 2 years: 15° ± 4°) athletes was not different between groups at 1 year (mean difference: -1°; 95% confidence interval [CI], -5° to 2°; p = 0.49) or 2 years (mean difference: 1°; 95% CI, -2° to 4°; p = 0.54). There were no differences between SAP and SAP+PERT athletes regarding the elimination of gait asymmetries, and gait asymmetries persisted to a large degree in both groups 1 and 2 years postoperatively. At 1 year, 11 of 18 SAP and 11 of 20 SAP+PERT athletes walked with truncated knee excursions during weight acceptance (odds ratio: 0.8, p = 0.70) and midstance (SAP 12 of 18, SAP+PERT 12 of 20; odds ratio: 0.8, p = 0.67), whereas at 2 years postoperatively, truncated knee excursions during weight acceptance (SAP seven of 17, SAP+PERT eight of 19; odds ratio: 1.0, p = 0.96) and midstance (SAP five of 17, SAP+PERT 11 of 19; odds ratio: 3.3, p = 0.09) remained prevalent. CONCLUSIONS: We found that a comprehensive, progressive return-to-sport training program with or without perturbation was not effective at restoring interlimb symmetry among men 1 or 2 years after ACL reconstruction. Although gait asymmetries improved from 1 to 2 years postoperatively, meaningful asymmetries persisted in both groups. To restore gait symmetry after ACL reconstruction, additional interventions likely are necessary. LEVEL OF EVIDENCE: Level II, therapeutic study.

Report of the Clinical and Functional Primary Outcomes in Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary Prevention With and Without Perturbation Training 1 and 2 Years After ACL Reconstruction.

BACKGROUND: Athletes often are cleared to return to activities 6 months after anterior cruciate ligament (ACL) reconstruction; however, knee function measures continue to improve up to 2 years after surgery. Interventions beyond standard care may facilitate successful return to preinjury activities and improve functional outcomes. Perturbation training has been used in nonoperative ACL injury and preoperative ACL reconstruction rehabilitation, but has not been examined in postoperative ACL reconstruction rehabilitation, specifically return to sport rehabilitation. QUESTIONS/PURPOSES: The purpose of this study was to determine whether there were differences at 1 and 2 years after ACL reconstruction between the male SAP (strengthening, agility, and secondary prevention) and SAP+PERT (SAP protocol with the addition of perturbation training) groups with respect to (1) quadriceps strength and single-legged hop limb symmetry; (2) patient-reported knee outcome scores; (3) the proportion who achieve self-reported normal knee function; and (4) the time from surgery to passing return to sport criteria. METHODS: Forty men who had completed ACL reconstruction rehabilitation and met enrollment criteria (3-9 months after ACL reconstruction, > 80% quadriceps strength limb symmetry, no pain, full ROM, minimal effusion) were randomized into the SAP or SAP+PERT groups of the Anterior Cruciate Ligament-Specialised Post-Operative Return to Sports trial (ACL-SPORTS), a single-blind randomized clinical study of secondary prevention and return to sport. Quadriceps strength, single-legged hopping, the International Knee Documentation Committee (IKDC) 2000 subjective knee form, Knee Injury and Osteoarthritis Outcome Score (KOOS)-sports and recreation, and KOOS-quality-of-life subscales were collected 1 and 2 years after surgery by investigators blind to group. Athletes were categorized as having normal or abnormal knee function at each time point based on IKDC score, and the time until athletes passed strict return-to-sport criteria was also recorded. T-tests, chi square tests, and analyses of variance were used to identify differences between the treatment groups over time. RESULTS: There were no differences between groups for quadriceps symmetry (1 year: SAP = 101% ± 14%, SAP+PERT = 101% ± 14%; 2 years: SAP = 103% ± 11%, SAP+PERT = 98% ± 14%; mean differences between groups at 1 year: 0.4 [-9.0 to 9.8], 2 years = 4.5 [-4.3 to 13.1]; mean difference between 1 and 2 years: SAP = -1.0 [-8.6 to 6.6], SAP+PERT = 3.0 [-4.3 to 10.3], p = 0.45) or single-legged hop test limb symmetry. There were no clinically meaningful differences for any patient-reported outcome measures. There was no difference in the proportion of athletes in each group who achieved normal knee function at 1 year (SAP 14 of 19, SAP+PERT 18 of 20, odds ratio 0.31 [0.5-19.0]; p = 0.18); however, the SAP+PERT group had fewer athletes with normal knee function at 2 years (SAP 17 of 17, SAP+PERT 14 of 19, p = 0.03). There were no differences between groups in the time to pass return to sport criteria (SAP = 325 ± 199 days, SAP+PERT = 233 ± 77 days; mean difference 92 [-9 to 192], p = 0.09). CONCLUSIONS: This randomized trial found few differences between an ACL rehabilitation program consisting of strengthening, agility, and secondary prevention and one consisting of those elements as well as perturbation training. In the absence of clinically meaningful differences between groups in knee function and self-reported outcomes measures, the results indicate that perturbation training may not contribute additional benefit to the strengthening, agility, and secondary prevention base of the ACL-SPORTS training program. LEVEL OF EVIDENCE: Level II, therapeutic study.

Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction.

BACKGROUND: Approximately 1 in 4 athletes returning to sports will sustain a second anterior cruciate ligament (ACL) injury. Psychological factors related to kinesiophobia, confidence, and psychological readiness are associated with second ACL injury; however, the evidence is conflicting. HYPOTHESIS: Athletes who sustain a second ACL injury (ie, graft rupture or contralateral ACL rupture) within 2 years of ACL reconstruction (ACLR) would have greater kinesiophobia, less confidence, and lower psychological readiness prior to return to sport (RTS) compared with athletes who do not sustain a second ACL injury. STUDY DESIGN: Secondary analysis of a prospective randomized trial. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 39 female Level I/II athletes completed the following measures after postoperative rehabilitation and a 10-session RTS and second ACL injury prevention program: ACL Return to Sport after Injury (ACL-RSI) scale, the 11-item Tampa Scale of Kinesiophobia (TSK-11), and question 3 on the Knee injury and Osteoarthritis Outcome Score (KOOS) quality of life (QoL) subscale. Athletes were dichotomized based on whether they sustained a second ACL injury within 2 years of ACLR or not. Independent t tests determined group differences in TSK-11, KOOS-QoL, ACL-RSI, and the 3 individual components of the ACL-RSI (ie, emotions, confidence, risk appraisal). RESULTS: Nine athletes sustained a second ACL injury (4 graft ruptures and 5 contralateral ACL ruptures). The group that sustained a second ACL injury had higher scores on the ACL-RSI (P = 0.03), higher on the risk appraisal questions of the ACL-RSI (P < 0.01), and met RTS criteria sooner than athletes who did not (P = 0.04). All second ACL injuries occurred in athletes who underwent primary ACLR with hamstring tendon autografts. CONCLUSION: Athletes who sustained a second ACL within 2 years of ACLR had a more positive psychological outlook, higher scores on the specific questions related to the risk appraisal construct of the ACL-RSI, and met RTS criteria sooner than athletes who did not sustain a second ACL injury. CLINICAL RELEVANCE: Counseling athletes about delaying RTS to reduce the risk of second ACL injury may be especially important in athletes who display high psychological readiness and meet RTS criteria sooner.

Activity levels across the intensity spectrum in athletes: a systematic review protocol.

Physical activity (PA) promotes better cardiometabolic health, physical function, brain health and longevity. In contrast, prolonged sedentary behaviour (SB) is a risk factor for many chronic diseases and poor health. Limited research has evaluated or synthesised how competitive sports participation influences PA across the lifespan. Some evidence suggests, ironically, that former competitive athletes may be insufficiently active and current athletes may be highly sedentary away from sport. This study describes the protocol for a systematic review and meta-analysis on activity levels across the intensity spectrum in athletes, addressing the primary research question: is sports participation significantly associated with PA and/or SB among current and former competitive athletes? PubMed, Embase, Cochrane Database of Systematic Reviews, Web of Science and SPORTDiscus databases will be searched. Two reviewers will independently screen titles/abstracts and full texts of selected abstracts. Data will be extracted regarding the study population, sport played, PA measures and protocols, outcomes of interest and findings. Primary outcomes will include step counts, daily activity across the intensity spectrum (ie, sedentary, light, moderate and vigorous PA), metabolic equivalent of task and whole-day energy expenditure. Secondary outcomes will include additional accelerometry measures of PA, activity patterns and self-reported PA. The risk of bias will be assessed using the National Institutes of Health Study Quality Assessment Tools. Extracted data will be presented using narrative synthesis and tabular presentation. Meta-analyses will be conducted to determine outcomes with sufficient data.PROSPERO registration number: CRD42024469267.https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=469267.

Midlife health crisis of former competitive athletes: dissecting their experiences via qualitative study.

Sports participation confers many health benefits yet greatly increases injury risk. Long-term health outcomes in former athletes and transition to life after competitive sports are understudied. Ending a sport may pose physical and psychosocial challenges. The purpose was to determine the lived experiences of former competitive athletes and how their sports participation impacted their long-term health and well-being. Former college varsity athletes participated in semistructured interviews focusing on their experiences, including past and current health, the impact of injuries, activity, exercise, diet and transition to life after competitive sport. Thematic analysis was completed using a collaborative, iterative process. Thirty-one (16 female, 15 male) former college athletes aged 51.3±7.4 years were interviewed. Six themes emerged: (1) lifelong athlete identity; (2) structure, support and challenges of the college athlete experience; (3) a big transition to life beyond competitive sport; (4) impact of competitive sport on long-term health; (5) facilitators and barriers to long-term health after sport and (6) transferable life skills. Continuing sports eased the transition for many but often delayed their postathlete void. Challenges included managing pain and prior injury (eg, If I didn't have my knee injury, I would definitely be more active), reducing energy needs and intake (eg, When I was an athlete, I could eat anything; and unfortunately, that's carried into my regular life), lack of accountability, changed identity and lost resources and social support. Participants suggested a programme, toolkit, mentoring or exit course to facilitate the transition. While former athletes benefit from transferrable life skills and often continue sports and exercise, they face unique challenges such as managing pain and prior injury, staying active, reducing energy intake and changing identity. Future research should develop and evaluate a toolkit, programme and other resources to facilitate life after ending competitive sports under 'normal' conditions (eg, retirement) and after a career-ending injury.

Prolonged quadriceps latency during gait early after anterior cruciate ligament injury predicts radiographic knee osteoarthritis 6-years after anterior cruciate ligament reconstruction.

BACKGROUND: The purpose was to explore quadriceps electromechanical function (quadriceps latency) during gait after anterior cruciate ligament injury as a predictor for radiographic knee osteoarthritis 6-years after anterior cruciate ligament reconstruction. Change in latency after preoperative physical therapy was also examined. METHODS: Quadriceps latency (time between peak knee moment and quadriceps electromyography) was calculated before preoperative physical therapy (2.4 [0.5-7.5] months after anterior cruciate ligament injury) and after preoperative physical therapy in 24 athletes. Participants were dichotomized into osteoarthritis (Kellgren and Lawrence grade ≥ 2) and non-osteoarthritis groups at 6-years. Forward selection logistic regression was performed using z-score normalized quadriceps latency and demographics. A 2 × 2 repeated measure ANOVA was performed for quadriceps latency between groups before and after preoperative physical therapy. FINDINGS: Quadriceps latency before preoperative physical therapy was the only predictor of 6-year radiographic osteoarthritis (p = 0.014, odds ratio [95% confidence interval] = 5.859 [1.435-23.924]). Time by group interaction was observed for quadriceps latency (p = 0.039, η2p = 0.179). In the osteoarthritis group, latency may reduce after training (before preoperative physical therapy = 115.7 ± 20.6 ms, after preoperative physical therapy = 99.5 ± 24.0 ms, p = 0.082). INTERPRETATION: Prolonged latency after anterior cruciate ligament injury may predict post-traumatic knee osteoarthritis 6-years after anterior cruciate ligament reconstruction. Latency may shorten with preoperative physical therapy, yet athletes still moved on to develop osteoarthritis. Quadriceps function may need intervention immediately following anterior cruciate ligament injury for prevention of post-traumatic knee osteoarthritis.

Improved Outcomes Following a Care Guideline Implementation: Part 1 of an Analysis of 12 355 Patients After Total Knee Arthroplasty.

OBJECTIVE: To describe the application and examine the influence of a continuous quality improvement intervention, which had a goal of standardizing care to reduce the proportion of patients who do not have a meaningful improvement in patient-reported outcomes following total knee arthroplasty (TKA). DESIGN: Continuous quality improvement. METHODS: A physical therapy (PT) care guideline was initiated in 2013 for patients following TKA. The Knee Outcome Survey - Activities of Daily Living (KOS-ADL) was measured at every visit, and scores were extracted from a clinical outcomes database to calculate the proportion of patients who did not achieve a minimal clinically important difference. Based on logistic regression analysis, we compared the proportion of patients who did not progress on the KOS-ADL in a non-care guideline group (2008-2012) to a care guideline (CG) group (2014-2019). RESULTS: This study included 12 355 patients (aged 18-92 years) following TKA incurring at least 3 PT visits from 2008 to 2019. The percentage of patients who did not progress in the non-care guideline group was 25.8% and in the care guideline group 14.3% (P<0.001). The relationship between care guideline adherence and lack of progression on the KOS-ADL was statistically significant, X2 (df = 1) = 148.7, P<.001. CONCLUSION: The percentage of patients who did not achieve meaningful progress on the KOS-ADL declined significantly in the 6 years after implementing a TKA care guideline without an increase in the number of clinical visits. The standardized care guideline was associated with meaningful improvements for patients following TKA when applied in conjunction with PT access to outcome data, feedback through audits, performance goals, and financial incentives. J Orthop Sports Phys Ther 2023;53(3):143-150. Epub: 12 December 2022. doi:10.2519/jospt.2022.11369.

Variation in Outcomes and Number of Visits Following Care Guideline Implementation: Part 2 of an Analysis of 12 355 Patients After Total Knee Arthroplasty.

OBJECTIVE: To describe the variation in outcomes and number of visits before and after implementing a care guideline for total knee arthroplasty (TKA) rehabilitation. DESIGN: Nonrandomized intervention study. METHODS: We compared 2558 patients with TKA who received care that was not standardized (non-care guideline [NCG] group) to 9797 patients with TKA who received care according to the care guideline (CG). We fit 2 Bayesian hierarchical linear regression models using the Knee Outcome Survey - Activities of Daily Living (KOS-ADL) change score and number of physical therapy (PT) visits as the response variables, controlling for relevant predictor variables. We also compared the ratio of the standard deviations of the KOS-ADL change scores and the number of PT visits within and between clinics. RESULTS: The overall estimated mean improvement in KOS-ADL change score was 23.0 points (95% confidence interval [CI]: 20.3, 25.7) in the NCG group and 28.7 points (95% CI: 27.5, 29.7) in the CG group; the mean difference was 5.6 (2.7-8.6). Mean KOS-ADL change scores were higher in the CG group than the NCG group in every clinic, although only 8 clinics improved significantly. The number of PT visits did not change meaningfully (NCG: mean, 10.7 [95% CI: 9.9, 11.5]; CG: mean, 10.5 [95% CI: 9.9, 10.9]). Variation in KOS-ADL change score decreased by 4% within clinics (CG-NCG ratio: 0.96 [95% CI: 0.93, 0.99]) and 63% between clinics (CG-NCG ratio: 0.37 [95% CI: 0.21, 0.62]). Variation in number of visits decreased by 7% within clinics (CG-NCG ratio: 0.93 [95% CI: 0.90, 0.96]) and 19% between clinics (CG-NCG ratio: 0.81 [95% CI: 0.39, 1.49]). CONCLUSION: Implementing a care guideline for TKA rehabilitation may improve outcomes and reduce unwarranted variation in practice within clinics and especially between clinics within a large health care system. J Orthop Sports Phys Ther 2023;53(3):151-158. Epub: 12 December 2022. doi:10.2519/jospt.2022.11370.

Using Wearable Technology to Quantify Physical Activity Recovery: Secondary Report From the AFTER (App-Facilitated Tele-Rehabilitation) Program for COVID-19 Survivors Randomized Study.

BACKGROUND: Knowledge on physical activity recovery after COVID-19 survival is limited. The AFTER (App-Facilitated Tele-Rehabilitation) program for COVID-19 survivors randomized participants, following hospital discharge, to either education and unstructured physical activity or a telerehabilitation program. Step count data were collected as a secondary outcome, and we found no significant differences in total step count trajectories between groups at 6 weeks. Further step count data were not analyzed. OBJECTIVE: The purpose of this analysis was to examine step count trajectories and correlates among all participants (combined into a single group) across the 12-week study period. METHODS: Linear mixed models with random effects were used to model daily steps over the number of study days. Models with 0, 1, and 2 inflection points were considered, and the final model was selected based on the highest log-likelihood value. RESULTS: Participants included 44 adults (41 with available Fitbit [Fitbit LLC] data). Initially, step counts increased by an average of 930 (95% CI 547-1312; P<.001) steps per week, culminating in an average daily step count of 7658 (95% CI 6257-9059; P<.001) at the end of week 3. During the remaining 9 weeks of the study, weekly step counts increased by an average of 67 (95% CI -30 to 163; P<.001) steps per week, resulting in a final estimate of 8258 (95% CI 6933-9584; P<.001) steps. CONCLUSIONS: Participants showed a marked improvement in daily step counts during the first 3 weeks of the study, followed by more gradual improvement in the remaining 9 weeks. Physical activity data and step count recovery trajectories may be considered surrogates for physiological recovery, although further research is needed to examine this relationship. TRIAL REGISTRATION: ClinicalTrials.gov NCT04663945; https://tinyurl.com/2p969ced.

Long-term function, body composition and cardiometabolic health in midlife former athletes: a scoping review.

While sports medicine has traditionally focused on recovering from injury and returning athletes to sport safely after injury, there is a growing interest in the long-term health of athletes. The purpose of this scoping review was to (1) summarise the literature (methodologies and findings) on physical function, body composition and cardiometabolic health in midlife (age 40-65 years) former competitive athletes compared with non-athlete controls, (2) identify areas for future study in long-term health in athletes and (3) determine outcomes that could be evaluated in a future systematic review(s). We searched PubMed, CINAHL, Web of Science and SPORTDiscus for studies published between 2000 and 2022 evaluating former athletes and controls on physical function, body composition and/or cardiometabolic measures using MeSH terms. We identified 20 articles that met our criteria. Outcomes varied considerably across studies, most of which were cross-sectional and evaluated only males. Limited data suggest that former endurance athletes have leaner body compositions, higher aerobic capacity and better cardiometabolic indicators than controls; former athletes who maintain higher physical activity (ie, self-reported exercise) are healthier than those who do not; and former team sport athletes, who have higher injury prevalence, may have poorer functional performance than controls who were recreationally active in college. Studies rarely evaluated functional performance, did not control for prior injury or diet and seldom assessed current physical activity levels. Future research should include females and evaluate sex differences, control for prior sports-related injury(ies), quantify physical activity, use standardised outcome measures including performance-based functional assessments and incorporate longitudinal designs.

Bone-Patellar Tendon-Bone Autograft Harvest Prolongs Extensor Latency during Gait 2 yr after ACLR.

PURPOSE: Bone-patellar tendon-bone (BPTB) graft harvest for anterior cruciate ligament reconstruction alters patellar tendon properties, which inflict poor quadriceps neuromuscular function. BPTB autografts are associated with higher rates of posttraumatic osteoarthritis, which in turn is associated with pathological gait. The purpose of this study was to investigate the latency between the time of peak quadriceps activity and the peak knee flexion moment during gait, between those with BPTB grafts ( n = 23) and other graft types (hamstring autograft or allografts, n = 54), 5 ± 2 months and 2 yr (25 ± 3 months) after anterior cruciate ligament reconstruction. We hypothesized that longer latencies would be observed in the BPTB graft group in the involved limb. We expected latencies to shorten over time. METHODS: Knee moments and quadriceps EMG were collected during gait, and vastus medialis, vastus lateralis, rectus femoris (RF), and quadriceps latencies were calculated. Linear mixed-effects models were used to compare latencies between graft types and over the two time points. RESULTS: The main effects of graft type were observed for vastus medialis ( P = 0.005) and quadriceps ( P = 0.033) latencies with the BPTB graft group demonstrating longer latencies. No main effects of graft type were observed for vastus lateralis ( P = 0.051) and RF ( P = 0.080) latencies. Main effects of time were observed for RF latency ( P = 0.022). CONCLUSIONS: Our hypothesis that the BPTB graft group would demonstrate longer extensor latency was supported. Contrary to our second hypothesis, however, latency only improved in RF and regardless of graft type, indicating that neuromuscular deficits associated with BPTB grafts may persist 2 yr after surgery. Persistent deficits may be mediated by changes in the patellar tendon's mechanical properties. Graft-specific rehabilitation may be warranted to address the long-term neuromechanical deficits that are present after BPTB graft harvest.

Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures.

Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy.

Identifying Gait Pathology after ACL Reconstruction Using Temporal Characteristics of Kinetics and Electromyography.

PURPOSE: Asymmetrical gait mechanics after anterior cruciate ligament reconstruction (ACLR) are associated with the development of posttraumatic knee osteoarthritis. Current measures of gait mechanics have focused heavily on peak magnitudes of knee kinematics, kinetics, and joint contact forces but have seldom considered the rate of knee loading, cumulative knee load, or the timing of motor input surrounding peaks. The purpose of this study was to introduce and describe novel metrics of gait using temporal characteristics of kinetics and EMG to identify neuromuscular deficits of the quadriceps in patients after ACLR. METHODS: Gait mechanics were assessed 6 months (n = 145) and 24 months (n = 116) after ACLR. External knee flexion rate of moment development (RMD) and knee flexion moment impulse (KFMI) leading up to the time of peak knee flexion moment (pKFM), peak RMD between initial contact to pKFM, and cumulative KFMI were calculated. Extensor latencies from the quadriceps, vastus medialis, vastus lateralis, and rectus femoris (time of pKFM - time of peak EMG activity) during the weight acceptance phase of gait were also calculated. Paired-sample t-tests (α = 0.05) were performed between limbs at both time points. RESULTS: Slower RMD, smaller KFMI, and longer extensor latencies in the involved compared with uninvolved limb were observed across all measures at 6 months (P < 0.005). At 24 months, RMDpeak was slower, and KFMI50ms, KFMI100ms, and KFMItotal were lower in the involved limb (P < 0.003), but no other asymmetries were found. CONCLUSIONS: Slower RMD, smaller KFMI, and prolonged extensor latencies may characterize neuromuscular deficits underlying aberrant gait mechanics early after ACLR. RMD, KFMI, and extensor latencies during gait should be considered in the future to quantify asymmetrical movement patterns observed after ACLR and as markers of recovery.

Knee joint biomechanics during gait improve from 3 to 6 months after anterior cruciate ligament reconstruction.

Gait alterations after anterior cruciate ligament reconstruction (ACLR) are commonly reported and have been linked to posttraumatic osteoarthritis development. While knee gait alterations have been studied at several time points after ACLR, little is known about how these biomechanical variables change earlier than 6 months after surgery, nor is much known about how they differ over the entire stance phase of gait. The purpose of this study was to examine knee gait biomechanical variables over their entire movement pattern through stance at both 3 and 6 months after ACLR and to study the progression of interlimb asymmetry between the two postoperative time points. Thirty-five individuals underwent motion analysis during overground walking 3 (3.2 ± 0.5) and 6 (6.4 ± 0.7) months after ACLR. Knee biomechanical variables were compared between limbs and across time points through 100% of stance using statistical parametric mapping; this included a 2 × 2 (Limb × Time) repeated measures analysis of variance and two-tailed t-tests. Smaller knee joint angles, moments, extensor forces, and medial compartment forces were present in the involved versus uninvolved limb. Interlimb asymmetries were present at both time points but were less prevalent at 6 months. The uninvolved limb's biomechanical variables stayed relatively consistent over time, while the involved limb's trended toward that of the uninvolved limb. Statement of Clinical Significance: Interventions to correct asymmetrical gait patterns after ACLR may need to occur early after surgery and may need to focus on multiple parts of stance phase.

Disparities in the allocation of inpatient physical and occupational therapy services for patients with COVID-19.

BACKGROUND: Survivors of the novel coronavirus (COVID-19) experience significant morbidity with reduced physical function and impairments in activities of daily living. The use of in-hospital rehabilitation therapy may reduce long-term impairments. OBJECTIVE: To determine the frequency of therapy referral and treatment amongst hospitalized COVID-19 patients, assess for disparities in referral and receipt of therapy, and identify potentially modifiable factors contributing to disparities in therapy allocation. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study using data collected from the University of Colorado Health Data Compass data warehouse assessing therapy referral rates and estimated delivery based on available administrative billing. MEASUREMENTS: Multivariable logistic regression was used to determine the association between sex and/or underrepresented minority race with therapy referral or delivery. RESULTS: Amongst 6239 COVID-19-related hospitalization, a therapy referral was present in 3952 patients (51.9%). Hispanic ethnicity was independently associated with lower odds of receipt of therapy referral (adjusted OR [aOR]: 0.78, 95% confidence interval [CI]: 0.67-0.93, p = .001). Advanced age (aOR: 1.53, 95% CI: 1.46-1.62, p < .001), greater COVID illness severity (aOR for intensive care unit admission: 1.63, 95% CI: 1.37-1.94, p < .01) and hospital stay (aOR: 1.14, 95% CI: 1.12-1.15, p < .01) were positively associated with referral. CONCLUSIONS AND RELEVANCE: In a cohort of patients hospitalized for COVID-19 across a multicenter healthcare system, we found that referral rates and delivery of physical therapy and/or occupational therapy sessions were significantly reduced for patients of Hispanic identity compared with patients of non-Hispanic, Caucasian identity after adjustment for potential confounding by available demographic and illness severity variables.

Safety, feasibility and initial efficacy of an app-facilitated telerehabilitation (AFTER) programme for COVID-19 survivors: a pilot randomised study.

OBJECTIVES: Determine the safety, feasibility and initial efficacy of a multicomponent telerehabilitation programme for COVID-19 survivors. DESIGN: Pilot randomised feasibility study. SETTING: In-home telerehabilitation. PARTICIPANTS: 44 participants (21 female, mean age 52 years) discharged home following hospitalisation with COVID-19 (with and without intensive care unit (ICU) stay). INTERVENTIONS: Participants were block randomised 2:1 to receive 12 individual biobehaviourally informed, app-facilitated, multicomponent telerehabilitation sessions with a licenced physical therapist (n=29) or to a control group (n=15) consisting of education on exercise and COVID-19 recovery trajectory, physical activity and vitals monitoring, and weekly check-ins with study staff. Interventions were 100% remote and occurred over 12 weeks. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was feasibility, including safety and session adherence. Secondary outcomes included preliminary efficacy outcomes including tests of function and balance; patient-reported outcome measures; a cognitive assessment; and average daily step count. The 30 s chair stand test was the main secondary (efficacy) outcome. RESULTS: No adverse events (AEs) occurred during testing or in telerehabilitation sessions; 38% (11/29) of the intervention group compared with 60% (9/15) of the control group experienced an AE (p=0.21), most of which were minor, over the course of the 12-week study. 27 of 29 participants (93%; 95% CI 77% to 99%) receiving the intervention attended ≥75% of sessions. Both groups demonstrated clinically meaningful improvement in secondary outcomes with no statistically significant differences between groups. CONCLUSION: Fully remote telerehabilitation was safe, feasible, had high adherence for COVID-19 recovery, and may apply to other medically complex patients including those with barriers to access care. This pilot study was designed to evaluate feasibility; further efficacy evaluation is needed. TRIAL REGISTRATION NUMBER: NCT04663945.

Knee cartilage T2 relaxation times 3 months after ACL reconstruction are associated with knee gait variables linked to knee osteoarthritis.

Osteoarthritis development after ACL reconstruction (ACLR) is not well understood. Investigators have examined associations between knee biomechanical alterations and quantitative MRI (qMRI) variables, reflective of cartilage health, 12-60 months following ACLR; however, none have done so early after surgery. As part of an exploratory study, 45 individuals (age, 23 ± 7 years) underwent motion analysis during walking and qMRI 3 months after ACLR. For each limb, peak knee adduction moment (pKAM) and peak knee flexion moment (pKFM) were determined using inverse dynamics and peak medial compartment force was calculated using a neuromusculoskeletal model. T2 relaxation times in the medial compartment and linear regressions were used to determine the associations between gait variables and deep and superficial cartilage T2 relaxation times in six regions. pKAM was positively associated with deep layer T2 relaxation times within the femoral central and posterior regions when examined in the involved limb and from an interlimb difference perspective (involved limb - uninvolved limb). After adjusting for age, the association between interlimb difference of pKAM and interlimb difference of deep layer T2 relaxation times in the tibial central region became significant (p = .043). Interlimb difference of pKFM was negatively associated with interlimb difference of deep layer T2 relaxation times within the femoral central and posterior regions. These associations suggest that degenerative pathways leading to osteoarthritis may be detectable as early as 3 months after reconstruction. Preventative therapeutic techniques may need to be employed early in the rehabilitation process to prevent cartilage degradation.

Association of the Psychological Response to the ACL-SPORTS Training Program and Self-reported Function at 2 Years After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Psychological readiness to return to sport has emerged as an important factor associated with outcomes after anterior cruciate ligament reconstruction (ACLR). Psychological factors are potentially modifiable during the course of rehabilitation, and improving them may lead to better outcomes. PURPOSE: To determine whether athletes with a positive psychological response after participation in a neuromuscular training and second injury prevention program had better self-reported function and activity outcomes compared with athletes who did not have a meaningful change. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: After ACLR and the completion of formal rehabilitation, 66 level I/II athletes completed the following self-reported measures at enrollment (pretraining): the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, the International Knee Documentation Committee (IKDC) subjective knee form, and the 5 subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS). Participants completed these measures after 10 sessions of agility, plyometric, and progressive strength training and at 1 and 2 years after ACLR. Participants who displayed an increase in the ACL-RSI score from pretraining to posttraining that exceeded the minimal clinically important difference (≥10 points) were defined as having a positive psychological response (responders) to training, and those who did not were defined as nonresponders. A mixed-model analysis of variance was used to determine if group differences in IKDC and KOOS scores existed over the 4 time points (pretraining, posttraining, and the 1- and 2-year follow-ups). RESULTS: The responders reported better self-reported function compared with the nonresponders, regardless of time, on the IKDC form (P = .001), KOOS-Sport and Recreation (P = .014), KOOS-Pain (P = .007), and KOOS-Symptoms (P = .002) but not on the KOOS-Quality of Life (P = .078). Overall, 77% of responders and 67% of nonresponders returned to their previous level of sport by 1 year after ACLR (P = .358), and 82% of responders and 78% of nonresponders returned to their previous level of sport by 2 years after ACLR (P = .668). CONCLUSION: Ultimately, 59% of the athletes in this study displayed a meaningful improvement in their psychological outlook over the course of the training program. Responders demonstrated persistently better self-reported function at posttraining and at 1 and 2 years after ACLR, but there were no between-group differences in return-to-sport rates.