Reliability and validity of videotaped functional performance tests in ACL-injured subjects

Effectiveness of Virtual Reality-Based Rehabilitation Interventions in Improving Postoperative Outcomes for Orthopedic Surgery Patients

PURPOSE OF REVIEW

The surge in orthopedic surgeries strains the US healthcare system, necessitating innovative rehabilitation solutions. This review examines the potential of virtual reality (VR)-based interventions for orthopedic rehabilitation.

RECENT FINDINGS

The effectiveness of VR-based interventions in orthopedic surgery patients is scrutinized. While some studies suggest better patient-reported outcomes and satisfaction, mixed results emerge from others, demonstrating comparable or varied results compared to traditional rehabilitation. The underlying mechanisms of VR-based rehabilitation are elucidated, showing its positive impact on proprioception, pain management, agency, and balance. Challenges of unfamiliarity, patient engagement, and drop-out rates are identified, emphasizing the need for tailored approaches. VR technology's immersive environments and multisensory experiences offer a novel approach to addressing functional deficits and pain post-surgery. The conclusion drawn is that VR-based rehabilitation complements rather than replaces conventional methods, potentially aiding in pain reduction and functional improvement. VR-based rehabilitation holds promise for enhancing orthopedic surgery outcomes, presenting a dynamic approach to recovery. Its potential to reshape healthcare delivery and reimbursement structures underscores its significance in modern healthcare. Overall, VR-based rehabilitation offers a promising avenue for optimizing postoperative recovery in orthopedic surgery patients.

Content validity, interpretability, and internal consistency of the "Quality First" assessment to evaluate movement quality in hop tests following ACL rehabilitation. A cross-sectional study

Introduction

Current approaches fail to adequately identify sport readiness after anterior cruciate ligament (ACL) rehabilitation. Altered landing biomechanics after ACL reconstruction are associated with increased risk of a noncontact ACL reinjury. There is a lack of objective factors to screen for deficient movement patterns. Therefore, the aim of this study was to investigate content validity, interpretability, and internal consistency for the newly developed "Quality First" assessment to evaluate movement quality during hop tests in patients after ACL rehabilitation.

Method

Participants in this cross-sectional study were recruited in collaboration with the Altius Swiss Sportmed Center in Rheinfelden, Switzerland. After a successful ACL reconstruction, the movement quality of 50 hop test batteries was evaluated between 6 and 24 months postoperatively with the "Quality First" assessment. Content validity was assessed from the perspective of professionals. To check the interpretability, classical test theory was employed. Cronbach's α was calculated to evaluate internal consistency.

Results

Content validity resulted in the inclusion of three different hop tests (single-leg hop for distance, vertical hop, and side hop). The "Quality First" assessment is enabled to evaluate movement quality in the sagittal, vertical, and the transversal plane. After the exclusion process, the "Quality First" assessment was free from floor and ceiling effects and obtained a sufficient Cronbach's α. The final version consists of 15 items, rated on a 4-point scale.

Discussion

By means of further validations, the "Quality First" assessment could offer a possibility to evaluate movement quality after ACL rehabilitation during hop tests.

A standardised template for reporting lower limb kinematic waveform movement compensations from a sensor-based portable clinical movement analysis toolkit

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Standardised terminology for the interpretation of movement analysis waveforms is provided, to describe the amount, nature and timing of a compensation strategy.

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A stand-alone application have been created for users to generate a movement analysis report for lower limb joint kinematics.

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A digital, interactive version of the movement analysis report is now being created in the next iteration of the sensor based portable movement analysis toolkit.

Objectives

To develop a standardised template to support physiotherapist reporting of lower limb kinematic waveform data

Design

Within and between user agreement identification of movement compensation strategies.

Setting

University Health Board Physiotherapy Department

Participants

Fourteen individuals with anterior cruciate ligament reconstruction performed overground gait, double-leg squat, and stair ascent wearing body-worn sensors. Six users viewed 252 kinematic waveforms of hip, knee and ankle joint angles in the sagittal and frontal planes.

Main outcome measures

Between and within-user observed agreement and themes from movement analysis reports

Results

Between-user observed agreement for presence of a movement compensation was 0.6–0.9 for the sagittal plane and 0.75–1.0 for the frontal place. Within-user observed agreement was 0.57–1.00 for the sagittal plane and 0.71–1.00 for the frontal plane. Three themes and seven categories were identified from the waveform interpretations: Amount (qualitative and quantitative description), timing (phase, discrete time point, cycle), and nature (peak, range of motion, timing) of the compensation.

Conclusion

There was good agreement between users at identifying the presence of movement compensation from the kinematic waveforms, but there was variation in how movement compensations were described. An interactive report, a standardised template for interpretation of kinematic waveforms, and training to support the clinical application of a movement analysis toolkit are proposed.

Electronically augmented gait abnormality assessment following lower extremity trauma

Background:

Objective evaluation of patient outcomes has become an essential component of patient management. Along with patient-reported outcomes, performance-based measures (PBMs) such as gait analysis are an important part of this evaluation. The purpose of this study was to evaluate the validity of utilizing a wearable inertial measurement unit (IMU) in an outpatient clinic setting to assess its ability to provide clinically relevant data in patients with altered gait resulting from lower extremity trauma.

Methods:

Five orthopaedic trauma patients with varying degrees of gait pathologies were compared to 5 healthy control subjects. Kinematic data were simultaneously recorded by the IMU and a gold standard Vicon video motion analysis system (Vicon Motion Systems Ltd, Oxford, UK) during a modified 10-m walk test. Raw data captured by the IMU were directly compared to Vicon data. Additionally, 5 objective gait parameters were compared for controls and the 5 trauma patients.

Results:

The IMU data streams strongly correlated with Vicon data for measured variables used in the subsequent gait analysis: vertical acceleration, vertical displacement, pitch angular velocity, and roll angular velocity (Pearson r-value > 0.9 for all correlations). Quantitative kinematic data in post-trauma patients significantly differed from control data and correlated with observed gait pathology.

Conclusions:

When compared to the gold standard motion capture reference system (Vicon), an IMU can reliably and accurately measure clinically relevant gait parameters and differentiate between normal and pathologic gait patterns. This technology is easily integrated into clinical settings, requires minimal time, and represents a performance-based method for quantifiably assessing gait outcomes.

Level of Evidence:

Diagnostic Level 1.

Measurement Properties of a Test Battery to Assess Postural Orientation During Functional Tasks in Patients Undergoing Anterior Cruciate Ligament Injury Rehabilitation

Study Design Cross-sectional study. Background Visual rating of postural orientation during functional tasks may be a valuable tool to track rehabilitation progress following anterior cruciate ligament (ACL) injury. A valid test battery assessing postural orientation as a separate construct is lacking. Objectives To evaluate measurement properties of a test battery to assess postural orientation in patients with ACL injury. Methods The content validity of functional tasks was assessed by expert focus group discussions. Fifty-one patients (45% women) with ACL injury performed 9 functional tasks of varying difficulty. Interpretability, internal consistency, interrater reliability, and measurement error were assessed for segment-specific postural orientation errors (POEs), within-task POEs, and total POE score. Postural orientation errors were scored on video on an ordinal scale from 0 (no POEs) to 3 (major POEs). Results Stair ascent, deep squat, and crossover hop for distance were excluded in focus group discussions. Postural orientation errors in some tasks were excluded due to floor effects. The mini-squat and drop jump were excluded due to poor internal consistency (α≤.184). Interrater reliability values for segment-specific POEs and within-task POEs yielded fair to almost perfect agreement (κ = 0.429-0.875) and almost perfect agreement for total POE score (intraclass correlation coefficient = 0.842), without systematic differences between raters. The smallest detectable changes were 0.7 and 5 points for groups and individuals, respectively. Conclusion The final test battery (single-leg mini-squat, stair descent, forward lunge, single-leg hop for distance) of 4 POEs (foot pronation, medial knee-to-foot position, hip joint POEs, and trunk segment POEs) demonstrated good measurement properties in people with ACL injury. J Orthop Sports Phys Ther 2017;47(11):863-873. doi:10.2519/jospt.2017.7270.

Functional performance 2-9 years after ACL reconstruction: cross-sectional comparison between athletes with bone-patellar tendon-bone, semitendinosus/gracilis and healthy controls

PURPOSE

The purpose of this cross-sectional study was to provide descriptive data on functional performance in men and women with ACLR, to compare bone-patellar tendon-bone (BPTB) with semitendinosus/gracilis (STG) within the same sex and to compare the ACLR subjects with healthy controls.

METHODS

Eligible participants comprised 100 men (43 % BPTB) and 84 women (41 % BPTB) after ACLR, of whom 30 men (STG n = 19; BPTB n = 11) and 18 women (STG n = 12; BPTB n = 6) were untraceable/not willing and 15 men (STG n = 9; BPTB n = 6) and 18 women (STG n = 12; BPTB n = 3) were not able to take part in the measurements because of injury. Besides men BPTB (n = 24), men STG (n = 27), women BPTB (n = 23) and women STG (n = 23), healthy men (n = 22) and women (n = 22) participated. Measurements consisted of questionnaires, isokinetic peak torque and endurance tests, a hop test battery and drop jump including video analysis.

RESULTS

Only the occurrence of dynamic knee valgus differed between ACLR and healthy subjects.

CONCLUSION

Two to nine years after ACLR, 16 % of athletes could not participate because of a lower extremity injury. In the remaining group, this study showed similar results for males and females with BPTB compared with STG. Also, similar results are found for quantity of movement comparing operated and healthy subjects. For quality of movement, only the occurrence of dynamic knee valgus in landing from a jump is higher in operated subjects compared with healthy controls. This supports the relevance of a focus on quality of movement as part of ACLR rehabilitation programmes and return to sports criteria.

LEVEL OF EVIDENCE

III.

Measurement properties of visual rating of postural orientation errors of the lower extremity - A systematic review and meta-analysis

OBJECTIVES

To systematically review measurement properties of visual assessment and rating of Postural Orientation Errors (POEs) in participants with or without lower extremity musculoskeletal disorders.

METHODS

A systematic review according to the PRISMA guidelines was conducted. The search was performed in Medline (Pubmed), CINAHL and EMBASE (OVID) databases until August 2016. Studies reporting measurement properties for visual rating of postural orientation during the performance of weight-bearing functional tasks were included. No limits were placed on participant age, sex or whether they had a musculoskeletal disorder affecting the lower extremity.

RESULTS

Twenty-eight articles were included, 5 of which included populations with a musculoskeletal disorder. Visual rating of the knee-medial-to-foot position (KMFP) was reliable within and between raters, and meta-analyses showed that this POE was valid against 2D and 3D kinematics in asymptomatic populations. Other segment-specific POEs showed either poor to moderate reliability or there were too few studies to permit synthesis. Intra-rater reliability was at least moderate for POEs within a task whereas inter-rater reliability was at most moderate.

CONCLUSIONS

Visual rating of KMFP appears to be valid and reliable in asymptomatic adult populations. Measurement properties remain to be determined for POEs other than KMPF.

Functional Performance Testing and Patient Reported Outcomes following ACL Reconstruction: A Systematic Scoping Review

Objective. A systematic scoping review of the literature to identify functional performance tests and patient reported outcomes for patients who undergo anterior cruciate ligament (ACL) reconstruction and rehabilitation that are used in clinical practice and research during the last decade. Methods. A literature search was conducted. Electronic databases used included Medline, PubMed, Cochrane Library, EMBASE, CINAHL, SPORTDiscus, PEDro, and AMED. The inclusion criteria were English language, publication between April 2004 and April 2014, and primary ACL reconstruction with objective and/or subjective outcomes used. Two authors screened the selected papers for title, abstract, and full-text in accordance with predefined inclusion and exclusion criteria. The methodological quality of all papers was assessed by a checklist of the Critical Appraisal Skills Programme (CASP). Results. A total of 16 papers were included with full-text. Different authors used different study designs for functional performance testing which led to different outcomes that could not be compared. All papers used a measurement for quantity of functional performance except one study which used both quantity and quality outcomes. Several functional performance tests and patient reported outcomes were identified in this review. Conclusion. No extensive research has been carried out over the past 10 years to measure the quality of functional performance testing and control stability of patients following ACL reconstruction. However this study found that the measurement of functional performance following ACL reconstruction consisting of a one-leg hop for a set distance or a combination of different hops using limb symmetry index (LSI) was a main outcome parameter of several studies. A more extensive series of tests is suggested to measure both the quantitative and qualitative aspects of functional performance after the ACL reconstruction. The KOOS and the IKDC questionnaires are both measures that are increasingly being used for ACL reconstruction throughout the last decade.

Hop performance and leg muscle power in athletes: Reliability of a test battery

OBJECTIVES

To measure the absolute and relative reliability and the smallest real difference (SRD) in three commonly used hop tests, two leg-power tests and the single-leg squat jump.

DESIGN

Methodological study.

SETTING

Clinical setting.

PARTICIPANTS

Fourteen healthy athletes (seven women and seven men) were evaluated in a standardized test-retest design.

MAIN OUTCOME MEASURES

The Intra-class correlation coefficient (ICC2.1), Standard Error of Measurement (SEM) and SRD were calculated for the vertical jump, one-leg hop for distance, side-hop, single-leg squat jump and knee-flexion and knee-extension power tests.

RESULTS

All tests showed good to excellent ICC (0.84-0.98). The SEM (%) ranged between 3.4 and 11.1 for the four hop tests and between 8.1 and 12.4 for the leg-power tests. The SRD (%) for the hop tests ranged between 9.3 and 30.7 and for the three power tests between 22.4 and 34.3.

CONCLUSIONS

The absolute reliability of this test protocol showed good to excellent ICC values and measurement errors of approximately 10%. This instrument can be recommended for determining function in terms of power in healthy athletes or late in the rehabilitation process. The tests' methodological errors must be considered and caution should be taken regarding the standardization procedure during testing.

Assessment of functional performance after anterior cruciate ligament reconstruction: a systematic review of measurement procedures

PURPOSE

The purpose of this systematic review was to identify the measurements that are used in clinical practice to assess the quantity and quality of functional performance in men and women more than 2 years after ACL reconstruction with bone patellar-tendon bone (BPTB) or semitendinosus/gracilis (STG) graft.

METHODS

A systematic literature search was performed in Medline (Pubmed), EMBASE (OVID), the Cochrane Library and PEDro to identify relevant articles from 1990 up to 2010. Articles were included if they described functional performance after BPTB or STG reconstruction and had a follow-up of more than 2 years. Two authors screened the selected articles for title, abstract and full-text in accordance with predefined inclusion and exclusion criteria. The methodological quality of all articles was assessed by checklists of the Cochrane Library by two authors. Only the articles with good methodological quality were considered for further analysis.

RESULTS

A total of 27 studies were included by full-text. According to their methodological quality six were rated as good. Different authors used different study designs for muscle testing which led to different outcomes that could not be compared. Besides strength, a single-leg hop for distance was used as a measurement for quantity of functional performance. No measurements for quality of functional performance were reported.

CONCLUSIONS

Measurement of functional performance more than 2 years after ACL reconstruction consists of concentric or isometric strength, the single-leg hop for distance or a combination. The Limb Symmetry Index is used as the main outcome parameter to compare the involved leg with the uninvolved. In all studies the results of men and woman are combined. Based on our findings and previous studies that discussed additional important parameters a more extensive test battery to assess functional performance is suggested.

Hop tests correlate with IKDC and KOOS at minimum of 2 years after primary ACL reconstruction

PURPOSE

The hypothesis of this study was that single-legged horizontal hop test ratios would correlate with IKDC, KOOS, and Marx activity level scores in patients 2 years after primary ACL reconstruction.

METHODS

Individual patient-reported outcome tools and hop test ratios on 69 ACL reconstructed patients were compared using correlations and multivariable modeling. Correlations between specific questions on the IKDC and KOOS concerning the ability to jump and hop ratios were also performed.

RESULTS

The triple-hop ratio was moderately but significantly correlated with the IKDC, KOOS Sports and Recreation subscale, and the KOOS Knee Related Quality of Life subscale, as well as with the specific questions related to jumping. Similar but weaker relationship patterns were found for the single-hop ratio and timed hop. No significant correlations were found for the Marx activity level or crossover-hop ratio. Multivariable modeling showed almost no significant additional contribution to predictability of the IKDC or KOOS subscores by gender, BMI, or the number of faults on either leg.

CONCLUSIONS

The triple-hop test is most significantly correlated with patient-reported outcome scores. Multivariable modeling indicates that less than a quarter of the variability in outcome scores can be explained by hop test results. This indicates that neither test can serve as a direct proxy for the other; however, assessment of patient physical function by either direct report using validated outcome tools or by the hop test will provide relatively comparable data.

Physiotherapist agreement when visually rating movement quality during lower extremity functional screening tests

OBJECTIVES

To investigate physiotherapist agreement in rating movement quality during lower extremity functional tests using two visual rating methods and physiotherapists with differing clinical experience.

DESIGN

Clinical measurement.

PARTICIPANTS

Six healthy individuals were rated by 44 physiotherapists. These raters were in three groups (inexperienced, novice, experienced).

MAIN MEASURES

Video recordings of all six individuals performing four lower extremity functional tests were visually rated (dichotomous or ordinal scale) using two rating methods (overall or segment) on two occasions separated by 3-4 weeks. Intra and inter-rater agreement for physiotherapists was determined using overall percentage agreement (OPA) and the first order agreement coefficient (AC1).

RESULTS

Intra-rater agreement for overall and segment methods ranged from slight to almost perfect (OPA: 29-96%, AC1: 0.01 to 0.96). AC1 agreement was better in the experienced group (84-99% likelihood) and for dichotomous rating (97-100% likelihood). Inter-rater agreement ranged from fair to good (OPA: 45-79%; AC1: 0.22-0.71). AC1 agreement was not influenced by clinical experience but was again better using dichotomous rating.

CONCLUSIONS

Physiotherapists' visual rating of movement quality during lower extremity functional tests resulted in slight to almost perfect intra-rater agreement and fair to good inter-rater agreement. Agreement improved with increased level of clinical experience and use of dichotomous rating.

Correlation of single leg vertical jump, single leg hop for distance, and single leg hop for time

OBJECTIVES

To determine the correlation among three functional tests: single leg vertical jump (SLVJ), single leg hop for distance (SLHD), and single leg hop for time (SLHT).

DESIGN

Prospective correlational investigation.

SETTING

University research laboratory.

PARTICIPANTS

Forty healthy men (n = 19) and women (n = 21) between the ages of 18 and 30 (23.9 ± 2.0 years).

MAIN OUTCOME MEASURES

SLVJ was measured using the Vertec. SLHD was measured using a standard tape measure. SLHT was measured over a 10-m course using a standard stopwatch.

RESULTS

The strongest correlation was between SLHT and SLHD, -0.89 and -0.89 for dominant and non-dominant lower extremities (LE), respectively. The weakest pairwise correlation was between SLVJ and SLHT, -0.71 and -0.63 for dominant and non-dominant LE, respectively. The correlation between SLVJ and SLHD was 0.74 and 0.71 for dominant and non-dominant LE, respectively.

CONCLUSION

There is a strong correlation between SLHT and SLHD, suggesting that each test measures similar constructs of function, while the modest correlation between SLVJ and SLHT suggest these two tests do not measure the same functional components, and could be paired as outcome measures for the clinical assessment of lower extremity function.