Translation, cross-adaptation and measurement properties of the Brazilian version of the ACL-RSI Scale and ACL-QoL Questionnaire in patients with anterior cruciate ligament reconstruction

Responsiveness of a Persian version of the international knee documentation committee and the anterior cruciate ligament-quality of life questionnaires in athletes with anterior cruciate ligament reconstruction following physiotherapy intervention

INTRODUCTION

The International Knee Documentation Committee (IKDC) and Anterior Cruciate Ligament - Quality of Life Questionnaire (ACL-QOL) are frequently used patient-reported instruments designed for individuals with anterior cruciate ligament reconstruction (ACL-R).

PURPOSE

To evaluate responsiveness and determine minimal important change (MIC) for the Persian-version of IKDC and ACL-QOL in athletes with ACL-R following physiotherapy intervention.

METHOD

One hundred athletes with ACL-R, undergoing 16-week physiotherapy completed IKDC and ACL-QOL at weeks 4 and 20 post ACL-R. Participants also rated their overall changes on a 7-point global rating of change at follow-up. Responsiveness was evaluated using the receiver operating characteristics (ROC) curve and correlation analysis. In addition, the minimal important change (MIC) was determined on the ROC curve.

RESULTS

Acceptable responsiveness was reached by the IKDC and most of the subscales of ACL-QOL (area under the ROC curve (AUC) of 0.72-0.79). Also, the subscale of Lifestyle issues of ACL-QOL (AUC of 0.81 (95% CI = 0.72-0.89) and the overall of ACL-QOL (AUC of 0.87 (95% CI = 0.80-0.93) showed the good level of responsiveness. The MIC scores of IKDC and the Overall ACL-QOL were determined 25 and 26 points, respectively.

CONCLUSION

The IKDC and ACL-QOL questionnaires have adequate responsiveness and are able to measure the change in athletes with ACL-R following a 16-week physiotherapy intervention.

Anterior cruciate ligament-Return to sport after injury scale brief version after ACL reconstruction: Persian translation, cross-cultural adaptation and validation

Purpose

The purpose of this study is to analyze the short anterior cruciate ligament return to sport after injury (ACL-RSI) (Persian) version's cultural adaption and validity.

Methods

To assess test-retest reliability, 102 participants were filled out the short ACL-RSI(Per) scale 6 months or more after ACLR surgery. Internal consistency (Cronbach's alpha), test-retest reliability (intraclass correlation coefficients), construct validity (Pearson's r) and sensitivity (floor/ceiling effect) were determined. In addition, patient completed other relevant measures such as Lysholm scores, the hospital for special surgery ACL satisfaction survey (HSS ACL-SS), the visual analogue scale (VAS) of pain and patient's satisfaction, the Tegner activity score (TAS), the single assessment numeric evaluation (SANE) and the Cincinnati Knee Rating System (CKRS).

Results

The short ACL-RSI(Per) scale showed high internal consistency (Cronbach's alpha = 0.91) and test-retest reliability (ICC = 0.923). Significant correlations between short ACL-RSI(Per) and other scales supported validity. There was a statistically significant connection between the short ACL-RSI(Per) and the following outcomes: HSS ACL-SS (r = 0.698, p < 0.001), VAS pain (r = 0.356, p < 0.001), CKRS (r = 0.644, p < 0.001), TAS (r = 0414, p < 0.001), Lysholm score (r = 0.467, p < 0.001) and SANE score (r = 0.536; p < 0.001). In addition to a satisfactory ceiling impact (15%), a sizeable floor effect (16.7%) was also seen.

Conclusion

The short ACL-RSI(Per) scale is a reliable and valid tool for assessing psychological readiness for return to sport after ACL reconstruction in Persian.

Level of Evidence

III.

Cross-cultural adaptation and measurement properties of the Persian version of the modified Cincinnati knee rating system

Purpose

To validate and assess the cross-sectional adaptation of the modified Cincinnati knee rating system (MCRKS) Persian translation.

Methods

To assess test-pretest reliability, 102 participants were asked to fill out the MCRKS (Per) scale after anterior cruciate ligament (ACL) reconstruction surgery. Internal consistency (Cronbach's α), reliability (intraclass correlation coefficients), construct validity (Pearson's r) and sensitivity (floor/ceiling effect) were determined. In addition, patients completed other relevant measures as the ACL return to sports after injury (ACL-RSI) survey, hospital for special surgery ACL satisfaction survey (HSS ACL-SS), visual analogue scale (VAS) of pain and patient's satisfaction, Tegner activity score (TAS), single assessment numeric evaluation, and Lysholm score.

Results

Using MCRKS (Per), the internal consistency (Cronbach's α) was 0.9 (if item deleted: 0.81-0.86); the construct validity (Pearson's r) varied between -0.50 (for VAS pain scale) and 0.79 (for Lysholm score); the reliability (ICC value) varied between 0.82 and 0.97; furthermore, no ceiling or floor effect was present.

Conclusion

The MCRKS (Per) has adequate measurement properties and is considered a valid, reliable and sensitive instrument which can identify clinical outcomes after ACLR surgery.

Level of Evidence

Level IV.

Brazilian Version of the Vestibular Activities and Participation Measure: Cross-Cultural Adaptation, Validity, and Reliability

BACKGROUND

Vestibular Activities and Participation Measure (VAP) subscales assess the effect of vestibular disorders on activity and participation. This study aimed to perform the cross-cultural adaptation and assess the validity, internal consistency, reliability, and measurement error of the Brazilian version of VAP subscales.

METHODS

The cross-cultural adaptation followed the translation, synthesis, back-translation, review by a committee of experts, and pretesting phases. Structural validity was assessed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), while Spearman's correlation between VAP subscales and the Dizziness Handicap Inventory (DHI) was used to assess construct validity. Cronbach's alpha measured internal consistency. Intraclass correlation coefficient (ICC) assessed intra- and inter-rater reliability, and measurement error was calculated by using the standard error of measurement (SEM) and minimal detectable change (MDC).

RESULTS

Additional information was included in the Brazilian version of the Vestibular Activities and Participation measure (VAP-BR) after approval by one of the developers of the instrument to improve the understanding among individuals. One factor was found in the EFA for each subscale with 50% explained variance. Regarding CFA, the subscales 1 (S1) and 2 (S2) presented, respectively, adequate model fit indices (ie, comparative fit index of 0.99 and 0.97, and standardized root mean square residual of 0.04 for both subscales), but a very low factor load in item 6 of S1 (0.08). Chronbach's alpha was 0.80 (S1) and 0.82 (S2). For intra-rater assessment, the S1 and S2 presented an ICC of 0.87 and 0.90, SEM of 0.01 and 1.16, and MDC of 0.39 and 0.46, respectively. When assessed by 2 different raters, SEM values were 1.03 and 1.53, and MDC values were 2.85 and 4.23 for S1 and S2, respectively; both subscales showed an ICC of 0.92. Correlations between DHI and VAP subscales presented coefficients above 0.57.

CONCLUSION

The Brazilian version of VAP subscales presents good measurement properties and may assist health professionals in identifying activity limitations and participation restrictions in individuals with vestibular disorders.

Comparison of Impairments, Activity Limitations, Balance, and Quality of Life between Patients with and without Meniscus Repair or Partial Meniscectomy Post-ACL Reconstruction

(1) Background: The anterior cruciate ligament (ACL) is a crucial ligament in the knee joint. This study compares the differences in knee range of motion (ROM), knee proprioception error, balance, function, and quality of life (QOL) among participants with and without meniscus repair or partial meniscectomy nine months post ACL reconstruction. (2) Methods: In this cross-sectional study, 57 male participants were selected through convenience sampling from a tertiary care hospital. Knee flexion and extension ROM were assessed using a digital goniometer; a digital inclinometer was used to assess knee proprioception error; the Y balance test was used to evaluate balance; the lower extremity functional scale (LEFS) was used to assess activity; and QOL was assessed using the ACLQOL questionnaire. (3) Results: There were no significant differences in outcomes except balance. The YB composite score had a moderate negative correlation with knee proprioception error with an R-value of -0.372 **. (4) Conclusions: Nine to 12 months post ACL reconstruction, the isolated ACL reconstruction participants had better lower-quarter single-leg balance than those who underwent ACL reconstruction and meniscal repair or partial meniscectomy. The remaining parameters, like knee ROM, knee proprioception error, LEFS score, and ACLQOL scores, were similar between these two groups.

_Combining return to sport, psychological readiness, body mass, hamstring strength symmetry, and hamstring/quadriceps ratio increases the risk of a second anterior cruciate ligament injury

PURPOSE

To investigate the combinations of variables that comprise the biopsychosocial model domains to identify clinical profiles of risk and protection of second anterior cruciate ligament injury.

METHODS

One hundred and forty-five patients for return-to-sport testing after anterior cruciate ligament (ACL) reconstruction (ACLR) were contacted, and 97 were deemed eligible. All were evaluated between 6 and 24 months and followed up for 2 years. Participants answered the International Knee Documentation Committee (IKDC) and Anterior Cruciate Ligament-Return to Sport after Injury Scale (ACL-RSI), performed the postural stability assessment using the Biodex Balance System, and assessed muscle strength at 60° and 300°/s on the isokinetic dynamometer. Personal factors (age, gender, body mass index), body structures (graft type and concomitant injuries), and environmental factors (time between surgery and evaluation) were also collected. The participants were asked about the occurrence of a second ACL injury and return to sport after 2 years of follow-up. Classification and regression tree (CART) analysis was used to determine predictors of a second ACL injury. The receiver operating characteristic (ROC) curve was performed to verify the accuracy of the CART analysis, in addition to the sensitivity, specificity, and relative risk (RR) of the model.

RESULTS

Of the initial 97 participants, 88 (89.8%) responded to follow-up and 14 (15.9%) had a second ACL injury (11 graft ruptures and three contralateral ACL). CART analysis identified the following variables as predictors of second ACL injury: return to sport, hamstring strength symmetry at 300°/s, ACL-RSI score, hamstrings/quadriceps ratio at 60°/s, and body mass index (BMI). CART correctly identified 9 (64.3%) of the 14 participants who were reinjured and 71 (95.9%) of the 74 participants who were not. The total correct classification was 90.9%. The area under the ROC curve was 0.88 (95% CI 0.72-0.99; p < 0.001), and the model showed a sensitivity of 75% (95% CI 42.8-94.5), specificity of 93.4% (95% CI 85.3-97.8), and RR of 15.9 (95% CI 4.9-51.4; p < 0.0001).

CONCLUSION

The combination of hamstring strength symmetry, hamstring/quadriceps ratio (body functions); return to sport (activity and participation); psychological readiness; and BMI (personal factors) could identify three clinical risk profiles for a second ACL injury with good accuracy.

LEVEL OF EVIDENCE

IV.

Validation of the ACL-RSI Scale in Pediatric and Adolescent Patients

BACKGROUND

The Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them.

PURPOSE

To validate the ACL-RSI scale for use with pediatric and adolescent patients.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach's alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort.

RESULTS

A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores (R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores (R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach's alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions.

CONCLUSION

The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.

It is time to target psychological readiness (or lack of readiness) in return to sports after Anterior Cruciate Ligament tears

Functional recovery has for long been the focus of rehabilitation after an Anterior Cruciate Ligament (ACL) injury. It is now increasingly recognized that more attention should be given to patients` mental recovery, their psychological readiness for returning to sport, after such an injury. Within this relatively new field of science, clinicians need clarity on when and how psychological factors should be monitored and how inexpedient psychological responses may be addressed during rehabilitation. In this Expert Opinion suggestions on how targeting psychological readiness may improve rehabilitation and return-to-sport evaluations are made based on current evidence-and issues in need of further clarification are addressed.

Spanish Version of the Anterior Cruciate Ligament-Quality of Life Questionnaire: Translation, Cross-cultural Adaptation, and Validation

Background

The Anterior Cruciate Ligament-Quality of Life (ACL-QOL) questionnaire is a patient-reported outcome measure used to assess the effect of an anterior cruciate ligament (ACL) injury on the lives of patients. It was originally written in English, which may affect its use when completed by nonnative English speakers.

Purpose

To translate and adapt the ACL-QOL to Spanish and provide evidence of its psychometric properties.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

A total of 183 patients with an ACL injury from 4 Catalan hospitals were included: 99 patients who had undergone ACL reconstruction (ACLR) completed the Spanish version of the ACL-QOL (ACL-QOL-Sp) twice (mean interval, 15.2 days) in 2 weeks for test-retest reliability, and 84 patients completed the ACL-QOL-Sp, the Lysholm knee scoring scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale, and the 12-item Short Form Health Survey (SF-12) before and at 4 and 9 months after ACLR to assess responsiveness. The association between the ACL-QOL-Sp and the other outcome measures was evaluated with the Spearman correlation coefficient.

Results

The ACL-QOL-Sp showed good internal consistency (Cronbach alpha = 0.96) and test-retest reliability (intraclass correlation coefficient = 0.97). The standard error of measurement was 3.6, also suggesting the precision of measurements. The smallest detectable change was 9.98 in 94% of patients. No association was found between the ACL-QOL-Sp score and the Tegner score or SF-12 mental component summary score; however, a moderate correlation was found with the overall KOOS score (r = -0.545), Lysholm score (r = 0.509), and SF-12 physical component summary score (r = 0.607). The correlation ranged from weak for the KOOS-Symptoms subscore (r = -0.290) to moderate for the KOOS-Quality of Life subscore (r = -0.698). No ceiling or floor effects were observed. The ACL-QOL-Sp showed a moderate effect size (0.73) at 4 months but a large effect size (1.70) at 9 months.

Conclusion

The ACL-QOL-Sp showed adequate internal consistency, test-retest reliability, and responsiveness in evaluating quality of life after ACLR in Spanish-speaking patients.

Validation of the Polish Version of Knee Outcome Survey Activities of the Daily Living Scale in a Group of Patients after Arthroscopic Anterior Cruciate Ligament Reconstruction

BACKGROUND

The study aimed to assess the reliability, validity, and responsiveness of the Polish version of Knee Outcome Survey Activities of the Daily Living Scale (KOS-ADLS) in a group of patients after arthroscopic reconstruction of the anterior cruciate ligament (ACL).

METHODS

The study was a longitudinal study with repeated measures. One hundred and twelve subjects who qualified for arthroscopic ACL reconstruction (mean age = 31.8 years) were initially enrolled in this study. The Polish version of KOS-ADLS and Short Form-36 v. 2.0 (SF-36) were used.

RESULTS

The Polish version of KOS-ADLS in subjects after ACL rupture demonstrated excellent internal consistency (Cronbach's alpha for KOS-ADLS- total = 0.91), and test-retest reliability using the intraclass correlation coefficient (ICC-total = 0.98). The standard error of measurement (SEM) value was 0.81 and the minimal detectable change (MDC) was 2.23 for KOS-ADLS-total. The validity analysis showed a moderate and low correlation between KOS-ADLS and different domains of SF-36 from r = 0.354 between KOS-ADLS activity and the physical component scale (PCS) of SF-36: to r = 0.206 between KOS-ADLS activity and the mental component scale (MCS) of SF-36.

CONCLUSIONS

The Polish version of KOS-ADLS turned out to be a reliable, valid and responsive self-reported outcome measure, allowing for the self-assessment of symptoms and function related to the knee joint impairment after ACL reconstruction. Therefore, the scale can be applied in clinical practice and research.

Cross-Culturally Adapted Versions of Patient Reported Outcome Measures for the Lower Extremity

Background

A large number of patient reported outcome measures (PROMs) have been developed in the English language for various lower extremity orthopaedic pathologies. Twenty different PROMs were recommended for 15 specific musculoskeletal lower extremity pathologies or surgeries. However, the availability of cross-culturally adapted versions of these recommended PROMs is unknown.

Purpose

The purpose of this study was to identify the cross-culturally adapted versions of recommended PROMs for individuals experiencing orthopedic lower extremity pathologies or undergoing surgeries, and to identify the psychometric evidence that supports their utilization.

Study design

Literature Review.

Methods

PubMed, Embase, Medline, Cochrane, CINAHL, SPORTDisucs and Scopus were searched for cross-culturally adapted translated studies through May 2022. The search strategy included the names of the 20 recommended PROMs from previous umbrella review along with the following terms: reliability, validity, responsiveness, psychometric properties and cross-cultural adaptation. Studies that presented a non-English language version of the PROM with evidence in at least one psychometric property to support its use were included. Two authors independently evaluated the studies for inclusion and independently extracted data.

Results

Nineteen PROMS had cross-culturally adapted and translated language versions. The KOOS, WOMAC, ACL-RSL, FAAM, ATRS, HOOS, OHS, MOXFQ and OKS were available in over 10 different language versions. Turkish, Dutch, German, Chinese and French were the most common languages, with each language having more than 10 PROMs with psychometric properties supporting their use. The WOMAC and KOOS were both available in 10 languages and had all three psychometric properties of reliability, validity, and responsiveness supporting their use.

Conclusion

Nineteen of the 20 recommended instruments were available in multiple languages. The PROM most frequently cross-culturally adapted and translated were the KOOS and WOMAC. PROMs were most frequently cross-culturally adapted and translated into Turkish. International researchers and clinicians may use this information to more consistently implement PROMs with the most appropriate psychometric evidence available to support their use.

Level of evidence

3a.

Translation and Validation of a Simplified Chinese Version of the Anterior Cruciate Ligament-Quality of Life Questionnaire

Background

The Anterior Cruciate Ligament-Quality of Life (ACL-QOL) questionnaire is a widely used and effective scale for quality of life in patients with chronic anterior cruciate ligament (ACL) injury.

Purpose

To translate and adapt the ACL-QOL questionnaire for Chinese patients and evaluate its reliability, validity, and responsiveness in this population.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

Translation and adaptation were conducted in accordance with the guidelines of the A merican Academy of Orthopaedic Surgeons Outcome Committee. Included were 121 patients who were diagnosed with a chronic ACL injury and underwent ACL reconstruction between January 2020 and June 2021. Preoperatively, patients completed the simplified Chinese version of the ACL-QOL (ACL-QOL-C), the Knee injury and Osteoarthritis Outcome Score, and the 12-Item Short Form Health Survey. The ACL-QOL-C was also completed at 12- and 24-week follow-ups. Psychometric evaluations were then performed and included score distribution, internal consistency, test-retest reliability, construct validity, and responsiveness.

Results

The Cronbach alpha ranged from .905 to .975, indicating excellent internal consistency, and the intraclass correlation coefficient ranged from 0.864 to 0.985, indicating excellent test-retest reliability. The consistency between the above results and our a priori hypotheses was more than 70% (35/42), indicating good construct validity. The standard error of measurement and effect size of the total score and each item of the ACL-QOL-C were >0.8 at the final follow-up, indicating good responsiveness.

Conclusion

The English version of the ACL-QOL has been successfully translated into Chinese, and it has been shown to be applicable for the assessment of the quality of life in Chinese patients with chronic ACL injury.

Performance in field-tests and dynamic knee valgus in soccer players psychologically ready and not ready to return to sports after ACL reconstruction

BACKGROUND

The objective was to compare the performance in field tests, dynamic knee valgus, knee function, and kinesiophobia of soccer players who were psychologically ready and not ready to return to unrestricted training or competitions after ACL reconstruction.

METHODS

Thirty-five male soccer players who had undergone primary ACL reconstruction at least 6 months were divided based on the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) questionnaire score into ready (≥60) and not-ready (<60) groups. The modified Illinois change of direction test (MICODT) and reactive agility test (RAT) were used to impose the demand for directional change and reactive decision-making. We assessed the frontal plane knee projection angle (FPKPA) during a single-leg squat and distance in crossover hop test (CHD). In addition, we assessed kinesiophobia through the shortened version of the Tampa Scale of Kinesiophobia (TSK-11) and knee function using the International Knee Documentation Committee Subjective Knee Form (IKDC). Independent t-tests were used to compare the groups.

RESULTS

The not-ready group had lower performance on the MICODT (effect size (ES) = -1.2; p < 0.001) and RAT (ES = -1.1; p = 0.004) tests and higher FPKPA (ES = 1.5; p < 0.001). In addition, they presented lower IKDC (ES = 3.1; p < 0.001) and higher TSK-11 (ES = -3.3; p < 0.001) scores.

CONCLUSIONS

Physical and psychological deficits may persist in some individuals after rehabilitation. On-field tests and dynamic knee alignment evaluation should be included in the athlete evaluation before the decision-making about clearance to sports participation, especially in athletes who perceive themselves as psychologically not ready.

The Relationship of Knee-related Quality of Life With Function, Psychological Factors, Strength, Performance, and Postural Stability After ACL Reconstruction: A Cross-Sectional Study

BACKGROUND

Patients after anterior cruciate ligament reconstruction (ACLR) have decreased health-related quality of life (QoL) compared with healthy control participants. Few studies have verified the predictors of QoL using Quality of Life Outcome Measure Questionnaire for Chronic Anterior Cruciate Ligament Deficiency (ACL-QoL), and no study has verified the relationship of psychological factors and knee function with ACL-QoL in patients after ACLR.

HYPOTHESIS

Knee functional status, muscle strength, performance in hop tests, postural stability, and psychological factors would be the predictors of QoL after ACLR.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 131 participants who had undergone ACLR at least 6 months previously were evaluated. QoL was assessed using ACL-QoL; knee functional status, using International Knee Documentation Committee Subjective Knee (IKDC) and global rating scale (GRS); psychological readiness, using Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI); kinesiophobia, using Tampa Scale for Kinesiophobia (TSK-17); knee strength, using isokinetic dynamometer; performance, using single-leg hop tests; and postural stability, using Biodex Balance System. Pearson's linear correlation and stepwise hierarchical multiple linear regression analyses were performed to verify the predictors of QoL.

RESULTS

ACL-QoL showed a moderate correlation with IKDC (r = 0.69), GRS (r = 0.55), ACL-RSI (r = 0.50), and TSK-17 (r = -0.49). ACL-QoL presented none to low correlations with the variables of muscle strength, postural stability, and performance in hop tests. The variables related to the knee functional status and psychological factors (IKDC, GRS, ACL-RSI, and TSK-17) were found to be the predictors of QoL (R2 = 0.56; P = 0.01).

CONCLUSION

Knee functional status, psychological readiness, and kinesiophobia were the predictors of knee-related QoL in patients after ACLR.

CLINICAL RELEVANCE

These results can assist clinicians in the therapeutic monitoring of the factors that may interfere with QoL in patients after ACLR.

Anterior Cruciate Ligament-Return to Sport After Injury Scale: Reliability and Validity of the Persian Version

BACKGROUND

The Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) is used to measure athletes' psychological readiness in terms of their emotions, confidence in performance, and risk appraisal with respect to return to sport after ACL reconstruction.

OBJECTIVE

To translate and cross-culturally adapt the ACL-RSI to the Persian version and evaluate the reliability and validity of this scale in patients with ACL reconstruction.

STUDY DESIGN

Clinical measurement study (psychometric analysis).

METHODS

To assess test-retest reliability, 100 participants were asked to complete the Persian version of the ACL-RSI 2 times with a 7- to 10-day interval. In the first assessment, the patients also filled the Injury-Psychological Readiness to Return to Sport Questionnaire, Tampa Scale of Kinesiophobia, International Knee Documentation Committee Subjective Knee Form, and Knee Injury and Osteoarthritis Outcome Score. Internal consistency (Cronbach alpha, α), test-retest reliability (intraclass correlation coefficients), measurement error (standard error of measurement and minimum detectable change), and construct validity (Pearson r) were determined.

RESULTS

Our results showed good internal consistency (Cronbach alpha = .94) and excellent test-retest reliability (intraclass correlation coefficients = .90 (.85-.93)]. Standard error of measurement and minimum detectable change were 4.64 and 12.85, respectively. No significant bias was observed between test and retest. In addition, based on the results of correlation analysis, all hypotheses of this study were confirmed. The Persian version of the ACL-RSI had a strong correlation with Injury-Psychological Readiness to Return to Sport (I-PPR) (P < .001, r = .76) and Tampa scale of Kinesiophobia (TKS) (P < .001, r = -.68). Furthermore, a moderate correlation was observed between the Persian version of the ACL-RSI and the International Knee Documentation Committee Subjective Knee Form (P < .001, r = .44) and between this version of the ACL-RSI and the subscales of Knee Injury and Osteoarthritis Outcome Score (P < .001, r = .30-.55).

CONCLUSION

Given its acceptable reliability and validity, the Persian version of the ACL-RSI seems to be a suitable tool for evaluating psychological readiness to return to sport after ACL reconstruction.

Translation, cross-cultural adaptation, and validation of the Athlete Fear Avoidance Questionnaire (AFAQ) into Brazilian Portuguese

Background

Psychological factors play an important role in the adequate return of an athlete to sport. Our aim was to perform the translation, cross-cultural adaptation, and validation of the Athlete Fear Avoidance Questionnaire (AFAQ) into Brazilian Portuguese.

Methods

We performed the translation and cross-cultural adaptation and evaluated the structural validity, construct validity, and test–retest reliability. In addition to the AFAQ, we used the Numerical Pain Scale (NPS), Pain-Related Catastrophizing Thoughts Scale (PCTS), Self-Estimated Functional Inability because of Pain Questionnaire for athletes (SEFIP-sport), and Hospital Anxiety and Depression Scale (HADS). We used the exploratory factor analysis (EFA) to analyze the internal structure of the AFAQ. We used the Spearman’s correlation coefficient (rho) to determine the magnitude of correlation between the AFAQ and the other instruments. We evaluated the test–retest reliability and internal consistency by means of intraclass correlation coefficient (ICC) and Cronbach’s alpha, respectively.

Results

No adaptation was necessary to produce the AFAQ version in Brazilian Portuguese. We included 160 participants in the study. We identified the one-dimensionality of the AFAQ through the EFA with the implementation of parallel analysis (KMO = 0.83, p < 0.001 in Bartlett's Sphericity test). In construct validity, the magnitudes of correlation between the AFAQ and the other instruments ranged from 0.257 to 0.548. We identified adequate reliability (ICC = 0.85) and internal consistency (Cronbach’s alpha = 0.90).

Conclusion

The Brazilian version of the AFAQ with one domain and 10 items has adequate measurement properties in injured professional and recreational athletes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05951-0.

Translation, Validity, and Reliability of the Dutch Anterior Cruciate Ligament-Quality of Life Questionnaire

Background

The Anterior Cruciate Ligament-Quality of Life (ACL-QoL) questionnaire is a valid and reliable injury-specific instrument to assess the impact of an ACL rupture on the daily life of a patient.

Purpose

To translate the ACL-QoL into Dutch (ACL-QoL-NL) and to study its psychometric properties in patients with an ACL rupture.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

The original ACL-QoL questionnaire was translated from English to Dutch according to international guidelines. The study population consisted of 122 patients with a confirmed ACL rupture who completed the ACL-QoL-NL as well as 4 questionnaires: the International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, 36-item Short Form Health Survey, and Lysholm Knee Score. We determined the internal consistency, construct validity, and prevalence of floor and ceiling effects of the ACL-QoL-NL total score as well as its 5 subscales. To determine test-retest reliability, we analyzed the data of 68 patients who had a stable knee condition and who completed the ACL-QoL-NL a second time after a 2-week interval.

Results

The confirmatory factor analysis showed that the original structure of the ACL-QoL-NL was confirmed, except for 4 of 31 items. Internal consistency of the total scale and all 5 subscales was good. More than 75% of the predefined hypotheses on the correlations between the ACL-QoL-NL and the 4 questionnaires were met, indicating good construct validity. No significant floor or ceiling effects were observed. Test-retest reliability was good, and no systematic bias between test and retest was found. Standard error of measurement for the total score was 4.8 points out of 100, and the smallest detectable changes at the group and individual levels were 1.6 and 13.2 points, respectively.

Conclusion

The ACL-QoL-NL questionnaire was successfully translated from English to Dutch and demonstrated good internal consistency, validity, and reliability, with no presence of floor or ceiling effects.

Kinesiophobia, Knee Self-Efficacy, and Fear Avoidance Beliefs in People with ACL Injury: A Systematic Review and Meta-Analysis

BACKGROUND

To improve the understanding of the psychological impacts of anterior cruciate ligament (ACL) injury, a systematic review synthesizing the evidence on knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury is needed.

OBJECTIVE

The aim of this systematic review was to investigate knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury, and compare these outcomes following management with rehabilitation alone, early and delayed ACL reconstruction (ACLR).

METHODS

Seven databases were searched from inception to April 14, 2022. Articles were included if they assessed Tampa Scale of Kinesiophobia (TSK), Knee Self-Efficacy Scale (KSES), or Fear Avoidance Beliefs Questionnaire (FABQ). Risk of bias (RoB) was assessed using domain-based RoB tools (ROBINS-1, RoB 2, RoBANS), and GRADE-assessed certainty of evidence. Random-effects meta-analyses pooled outcomes, stratified by time post-injury (pre-operative, 3-6 months, 7-12 months, > 1-2 years, > 2-5 years, > 5 years).

RESULTS

Seventy-three studies (70% high RoB) were included (study outcomes: TSK: 55; KSES: 22; FABQ: 5). Meta-analysis demonstrated worse kinesiophobia and self-efficacy pre-operatively (pooled mean [95% CI], TSK-11: 23.8 [22.2-25.3]; KSES: 5.0 [4.4-5.5]) compared with 3-6 months following ACLR (TSK-11: 19.6 [18.7-20.6]; KSES: 19.6 [18.6-20.6]). Meta-analysis suggests similar kinesiophobia > 3-6 months following early ACLR (19.8 [4.9]) versus delayed ACLR (17.2 [5.0]). Only one study assessed outcomes comparing ACLR with rehabilitation only.

CONCLUSIONS

Knee self-efficacy and kinesiophobia improved from pre-ACLR to 3-6 months following ACLR, with similar outcomes after 6 months. Since the overall evidence was weak, there is a need for high-quality observational and intervention studies focusing on psychological outcomes following ACL injury.

Fear of Return to Sport Scale (FRESS): a new instrument for use in injured professional or recreational athletes in rehabilitation

Objective

To create, develop, and validate the Fear of Return to Sport Scale (FRESS) for injured professional or recreational athletes in rehabilitation.

Methods

This is a questionnaire validation study. To determine the structural and construct validity, 192 injured professional or recreational athletes of different sports modalities were included. We used a subsample with 32 participants to analyze test-retest reliability and internal consistency. Main outcome measures were the FRESS, Numerical Pain Scale (NPS), Pain-Related Catastrophizing Thoughts Scale (PCTS), Self-Estimated Functional Inability because of Pain Questionnaire for athletes (SEFIP-sport), and Hospital Anxiety and Depression Scale (HADS).

Results

Initially, 25 questions were proposed by the specialists. Of these, 4 questions were excluded due to similarity with others. After applying the content validity coefficient, 8 questions were excluded for presenting a value lower than 0.80, leaving 13 items. The exploratory factor analysis identified the one-dimensional structure of the FRESS with 13 items. However, five items were excluded for presenting high covariance with the error of several other FRESS items in the confirmatory factor analysis. Thus, the final version of the FRESS was defined with one domain and eight items. Regarding the construct validity, we observed a magnitude of correlation varying between 0.257 and 0.470 between the FRESS and the instruments used here. We observed adequate test-retest reliability (intraclass correlation coefficient = 0.896) and internal consistency (Cronbach's alpha = 0.868). Ceiling and floor effects were not observed.

Conclusion

The FRESS with one domain and eight items has acceptable measurement properties and its use in clinical and sports environments to measure the fear of returning to sport in injured professional or recreational athletes is supported.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11332-022-00975-4.

Arabic Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Translation, Cross-cultural Adaptation, and Validation

Background:

The short version of the Anterior Cruciate Ligament–Return to Sport After Injury (ACL-RSI) scale is a self-reported questionnaire developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR).

Purpose:

To translate, cross-culturally adapt, and validate the short version of the ACL-RSI scale into the Arabic language (ACL-RSI-Ar).

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

The original short version of the ACL-RSI scale was forward and backward translated, cross-culturally adapted, and validated following international standardized guidelines. Sixty patients who participated in sports activities and underwent ACLR completed the ACL-RSI-Ar, the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and Knee injury and Osteoarthritis Outcome Score (KOOS) scales. To assess test-retest reliability, 34 participants completed the ACL-RSI-Ar scale twice. Statistical tests were conducted to test the internal consistency, reliability, and construct and discriminant validity of the ACL-RSI-Ar scale.

Results:

The ACL-RSI-Ar showed adequate internal consistency (Cronbach alpha = 0.734) and excellent test-retest reliability (intraclass correlation coefficient, 0.871). The ACL-RSI-Ar was strongly correlated with the IKDC (Spearman ρ = 0.515, P < .001) and weakly to strongly correlated with all KOOS subscales (Spearman ρ = 0.247-0.590, P < .05). Patients who returned to sports had significantly higher scores on the ACL-RSI-Ar scale when compared with those who did not return to sports (P = .001).

Conclusion:

The short ACL-RSI-Ar scale, as translated, was internally consistent, reliable, and valid for evaluating psychological readiness to return to sports after ACLR in Arabic-speaking patients.

Italian version of the anterior cruciate ligament-return to sport after injury scale (IT ACL-RSI): translation, cross-cultural adaptation, validation and ability to predict the return to sport at medium-term follow-up in a population of sport patients

PURPOSE

The timing of psychological and physical recovery after anterior cruciate ligament reconstruction represents an open issue in current orthopedic practice. Several tools have been developed to evaluate these factors, with the most recent being represented by the anterior cruciate ligament (ACL) return to sport injury scale (ACL-RSI). The aims of this study were to provide a validated Italian translation of the ACL-RSI in a population of sport patients, and to identify a possible correlation of the ACL-RSI score with the return to sport (RTS) time and the level of sport participation in comparison to the pre-injury one.

METHODS

The Italian translation and cultural adaptation of the scale were completed using a using the "translation-back translation" method. A total of 130 patients were enrolled and completed the study questionnaires 6 months after ACL reconstruction. Randomly, 65 of them were re-tested for the ACL-RSI within 2 weeks. The internal consistency, reliability, feasibility, and construct validity of the Italian version of ACL-RSI were assessed and compared to Italian version of the KOOS, the Lysholm Score, the AKPS and the IKDC subjective score. Responsiveness was tested comparing patients returning to sport at 6 and 12 months. The Tegner activity scale was collected at baseline, 6 and 12 months to identify the level of activity after return to sport, in relation to the ACL-RSI score.

RESULTS

The Italian adaptation of the ACL-RSI demonstrated excellent internal consistency (Cronbach's alpha = 0.953), reliability (test-retest ICC = 0.916) and feasibility, with no ceiling or floor effect. Construct validity was confirmed by the moderate to strong correlation with all the other scales (p < 0.0001). Slight and non-significant higher ACL-RSI score was shown by patients returned to sport at 6 or 12 months after surgery. Nevertheless, the ACL-RSI score at 6 months was significantly different between patients who returned and those who did not returned to the same level of sport activity 12 months after the procedure.

CONCLUSIONS

This study demonstrated that the Italian ACL-RSI is a reliable tool for evaluating the psychological readiness for return to sports of athletes who underwent ACL reconstruction, especially when collected at the end of the rehabilitation process. Since the IT ACL-RSI used in this study is a faithful translation of the original English version, this finding can be generalized to other cultural contexts and languages too.

LEVEL OF EVIDENCE

Level II.

Validity, Responsiveness, and Reliability of the ACL-QOL in an Adolescent Population

BACKGROUND

The anterior cruciate ligament quality of life (ACL-QOL) score is a disease-specific patient-reported outcome measure that assesses patients with ACL deficient and reconstructed knees. The ACL-QOL has demonstrated validity, responsiveness, and reliability in adult populations but has yet to be specifically evaluated in adolescent patients. The purpose of this study was to assess the validity, responsiveness, and reliability of the ACL-QOL in an adolescent population.

METHODS

Between 2010 and 2015, questionnaires from 294 consecutive adolescent patients consented for an ACL reconstruction were collected from an orthopaedic sport medicine clinic. The ACL-QOL was administered preoperatively, and at 6, 12, and 24 months following primary ACL reconstruction. To assess content validity, the Cronbach α and floor and ceiling effects were measured. Question reading level was measured with an online tool (https://readable.com/). Responsiveness was assessed with a 1-way analysis of variance to compare the preoperative and postoperative time periods. A test-retest strategy with completion of the ACL-QOL twice within 3 weeks was used to assess reliability using an intraclass correlation coefficient (ICC 2,k) and the SEM.

RESULTS

The ACL-QOL demonstrated high content validity with a Cronbach αbetween 0.93 and 0.97, with no evidence of floor or ceiling effects at any study time point. The mean readability grade level was calculated to be 6.9, along with a readability score of 68. The ACL-QOL scores revealed a statistically significant improvement over time (P<0.001) with a Cohen d of 0.56, indicating a large effect size. Test-retest reliability revealed an ICC (2,k) of 0.997 (95% confidence interval=0.992-0.999).

CONCLUSIONS

The ACL-QOL demonstrated content validity, responsiveness to change, and reliability in an adolescent ACL reconstruction population. The readability of the ACL-QOL is acceptable for adolescents with an ACL injury. The ACL-QOL is a valid, responsive, and reliable patient-reported outcome measure that can be used in an adolescent population with ACL deficiency or following ACL reconstruction.

LEVEL OF EVIDENCE

Level III.

Evaluation of the Responsiveness of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale

Background

The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale is a reliable and valid tool for evaluation of psychological readiness to return to sport after ACL injury, but its responsiveness to change has not been extensively evaluated.

Purpose

To determine the responsiveness of the ACL-RSI scale.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

The ACL-RSI scale and the knee confidence question from the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale was completed at 6 and 12 months after ACL reconstruction surgery. Responsiveness was assessed using distribution and anchor-based methods for the full- and short-form versions of the scale and subgroup analyzed for sex. From distribution statistics, the standardized response mean (SRM) and the smallest detectable change (SDC) were calculated. Using the anchor-based method, the minimally important change (MIC) that was associated with an improvement in knee confidence was determined using receiver operating characteristic analysis.

Results

A total of 441 patients (257 men, 184 women; mean age of 25 years) were included in this study. An SRM of 0.7 was found for both versions, indicating a moderate level of responsiveness. The MIC was 13.4 points for the full-form version and 15.1 points for the short-form version. These values were larger than SDC values at the group level but not at the individual patient level. Responsiveness was similar between male and female patients.

Conclusion

The ACL-RSI scale had sufficient responsiveness to investigate the efficacy of an intervention at a group level, but it may be more limited at an individual patient level.

Clinical Decision Algorithm Associated With Return to Sport After Anterior Cruciate Ligament Reconstruction

CONTEXT

Understanding the factors that predict return to sport (RTS) after anterior cruciate ligament reconstruction facilitates clinical decision making.

OBJECTIVE

To develop a clinical decision algorithm that could predict RTS and non-RTS based on the differences in the variables after anterior cruciate ligament reconstruction.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 150 athletes in any sport involving deceleration, jumping, cutting, or turning enrolled in the study. All participants answered the International Knee Documentation Committee and Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) questionnaires and performed balance and isokinetic tests.

MAIN OUTCOME MEASURE(S)

The classification and regression tree (CART) was used to determine the clinical decision algorithm associated with RTS at any level and RTS at the preinjury level. The diagnostic accuracy of the CART was verified.

RESULTS

Of the 150 participants, 57.3% (n = 86) returned to sport at any level and 12% (n = 18) returned to sport at the preinjury level. The interactions among the peak torque extension at 300°/s >93.55 Nm, ACL-RSI score >27.05 (P = .06), and postoperative time >7.50 months were associated with RTS at any level identified by CART and were factors associated with RTS. An ACL-RSI score >72.85% was the main variable associated with RTS at the preinjury level. The interaction among an ACL-RSI score of 50.40% to 72.85%, agonist : antagonist ratio at 300°/s ≤63.6%, and anteroposterior stability index ≤2.4 in these participants was the second factor associated with RTS at the preinjury level.

CONCLUSIONS

Athletes who had more quadriceps strength tended to RTS at any level more quickly, even with less-than-expected psychological readiness. Regarding a return at the preinjury level, psychological readiness was the most important factor in not returning, followed by a better agonist : antagonist ratio and better balance.

RETURN TO PLAY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

ABSTRACT The anterior cruciate ligament (ACL) tear represents more than half of all knee injuries in sports that involve body rotations and sudden changes of direction. Discharging the athlete for return to play (RTP) post-ACL reconstruction (ACLR) is a difficult task with multidisciplinary responsibility. For many years, a six-month period post-ACLR was adopted as the only criterion for RTP. However, it is now suggested that RTP should not be exclusively time-based, but to clinical data and systematic assessments. Despite the importance of post-ACLR factors for RTP, pre- and peri-ACLR factors must also be considered. Historically, ACLR is performed with the hamstring or autologous patellar tendons, although the choice of graft is still an open and constantly evolving theme. Anterolateral ligament reconstruction and repair of meniscal ramp tear associated with ACLR have recently been suggested as strategies for improving knee joint stability. Subjective questionnaires are easy to apply, and help identify physical or psychological factors that can hamper RTP. Functional tests, such as hop tests and strength assessment by means of isokinetic dynamometers, are fundamental tools for decision making when associated with clinical evaluation and magnetic resonance imaging. Recently, the capacity to generate force explosively has been incorporated into the muscle strength assessment. This is quantified through the rate of torque development (RTD). Due to characteristics inherent to the practice of sport, there is an extremely short time available for produce strength. Thus, RTD seems to better represent athletic demands than the maximum strength assessment alone. This review investigates the pre-, peri- and post-ACLR factors established in the literature, and shares our clinical practice, which we consider to be best practice for RTP. Level of evidence V; Specialist opinion.

Translation and Validation of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for French Paediatric Populations

Purpose: Physical activity level is a prognostic variable for patients with injuries. Self-report questionnaires exist to obtain these measures; however, they are not accessible to all populations because of language barriers. Therefore, the purpose of this study was to translate and validate the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) for francophones. Method: We translated the HSS Pedi-FABS using the forward–reverse translation approach and validated it among bilingual adults and an expert panel before administering it to a paediatric population. A repeated-measures crossover design was used: forty-three middle school students, aged 13.1 (SD 0.75) years, were randomly administered either the English or the French questionnaire. Two days later, all participants completed the other version. The translated questionnaire was assessed for its convergent validity (Spearman’s r correlation coefficients [ rs]), internal consistency (Cronbach’s α), and reliability (standard error of measurement [SEM]). Results: All assessments had a significance level of p < 0.001 with an excellent Spearman’s r correlation coefficient between the participants’ total scores on the translated questionnaires ( rs = 0.911). The overall scores for the questionnaire and the individual items of the questionnaire revealed excellent internal consistency (α = 0.868) and reliability (SEM = 0.334). Conclusions: The validated and reliable translated questionnaire can be used by researchers and clinicians to assess physical activity levels in French paediatric populations.

The Japanese version of the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale has acceptable validity and reliability

PURPOSE

The anterior cruciate ligament-return to sports after injury (ACL-RSI) scale assesses the psychological impact of returning to sports (also referred to as psychological readiness) after ACL reconstruction. The aim of this study was to evaluate important measurement properties of the Japanese version of ACL-RSI scale.

METHODS

Ninety-three participants who underwent ACL reconstruction filled out the Japanese version of ACL-RSI scale, the Tampa scale for kinesiophobia (TSK), the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF), and Knee injury and Osteoarthritis Outcome Score (KOOS). To assess test re-test reliability, 50 of the 93 participants re-answered the Japanese version of ACL-RSI scale within 10 days. Floor and ceiling effects, internal consistency, construct validity, and reliability of the Japanese version of ACL-RSI scale were analysed.

RESULTS

There were no floor and ceiling effects. The Japanese version of ACL-RSI scale showed good internal consistency (Cronbach's alpha = 0.912). It was positively correlated with total points of IKDC-SKF and the Lysholm score, and with the all sub-categories of the KOOS, and it was negatively correlated with the TSK. Reliability of the Japanese version of ACL-RSI scale was satisfactory.

CONCLUSION

The Japanese version of ACL-RSI scale has acceptable measurement properties. It can be a useful for evaluation of psychological readiness for return to sports in Japanese athletes who undergo primary ACL reconstruction. Information provided by the Japanese version of the ACL-RSI scale may also help to identify athletes who find return to sport a challenge, and guide conversations regarding treatment and rehabilitation plans.

LEVEL OF EVIDENCE

II.

Anterior cruciate ligament-return to sport after injury scale: validation of the Norwegian language version

PURPOSE

Evidence is emerging on the importance of psychological readiness to return to sport after anterior cruciate ligament (ACL) reconstruction. The ACL-Return to Sport after Injury scale (ACL-RSI) is developed to assess this. The aim of the current study was to translate ACL-RSI into Norwegian and examine the measurement properties of the Norwegian version (ACL-RSI-No).

METHODS

ACL-RSI was translated according to international guidelines. A cohort of 197 ACL-reconstructed patients completed ACL-RSI-No and related questionnaires nine months post-surgery. One hundred and forty-six patients completed hop tests and 142 patients completed strength tests. Face and structural validity (confirmative factor analysis and explorative analyses), internal consistency [Cronbach's alpha (α)], test-retest reliability [Intraclass Correlation Coefficients (ICC)], measurement error [Standard error of measurement (SEM) and smallest detectable change at individual (SDCind) and group level (SDCgroup)] and construct validity (hypotheses testing; independent t tests, Pearson's r) were examined.

RESULTS

ACL-RSI-No had good face validity. Factor analyses suggested that the use of a sum score is reasonable. Internal consistency and test-retest reliability were good (α 0.95, ICC 0.94 (95% CI 0.84-0.97) and measurement error low (SEM 5.7). SDCind was 15.8 points and SDCgroup was 2.0. Six of seven hypotheses were confirmed.

CONCLUSIONS

ACL-RSI-No displayed good measurement properties. Factor analyses suggested one underlying explanatory factor for "psychological readiness"-supporting the use of a single sum score. ACL-RSI-No can be used in the evaluation of psychological readiness to return to sport after ACL injury.

LEVEL OF EVIDENCE

III.

Current clinical practice and return-to-sport criteria after anterior cruciate ligament reconstruction: a survey of Brazilian physical therapists

BACKGROUND

Adherence to the use of recommended measures/criteria for return to sport clearance after anterior cruciate ligament reconstruction is crucial for successful rehabilitation.

OBJECTIVES

The purpose of this study was to describe the current clinical practice of Brazilian physical therapists that treat patients after anterior cruciate ligament reconstruction, including the measures/criteria used to support the decision-making process regarding return to sport. The secondary aim was to investigate factors associated with the use of the most recommended measures/criteria for return to sport.

METHODS

An electronic survey questionnaire was sent to Brazilian physical therapists. The survey consisted of questions about demographics and professional and clinical practice data related to anterior cruciate ligament reconstruction postoperative rehabilitation and return to sport criteria. Descriptive statistics and chi-square tests were used for analyses.

RESULTS

A sample of 439 professionals participated in the survey. Only 6.4% of the physical therapists use the most recommended measures/criteria for return to sport after anterior cruciate ligament reconstruction. Professional certification in Sports Physical Therapy was the only factor associated with the use of these recommended measures/criteria (p=0.02). The measures most used for return to sport clearance were related to physical factors (65.3% to 75.1%), such as range of motion and muscle strength. A small number of professionals use questionnaires to assess functional (16.6%) and psychological (19.1%) aspects of their patients to support the decision-making process.

CONCLUSION

In their clinical practice, most Brazilian physical therapists do not use the recommended measures/criteria for return to sport after anterior cruciate ligament reconstruction.

Hand-held dynamometer identifies asymmetries in torque of the quadriceps muscle after anterior cruciate ligament reconstruction

PURPOSE

To verify the validity and diagnostic accuracy of the hand-held dynamometer (HHD) with the isokinetic dynamometer for evaluating the quadriceps strength of subjects who have undergone ACL reconstruction (ACLR).

METHODS

This validity and diagnostic accuracy study was conducted prospectively by examining 70 consecutive participants who had undergone ACLR at least 6 months previously. All participants performed strength evaluation of the quadriceps muscle using the HHD and isokinetic dynamometer.

RESULTS

The HHD presented high test-retest reliability [intraclass correlation coefficient (ICC) = 0.98], moderate to good validity with the isokinetic dynamometer when compared for the quadriceps strength (r = 0.62), 100% perfect specificity [LR + infinity, 95% confidence interval (CI) 81.4%-100%] to identify those with LSI > 10%, and a sensitivity of 63.4% (48.9%-76.3%).

CONCLUSION

The HHD is an instrument valid and reliable of low cost and easy handling compared to the isokinetic dynamometer to evaluate the quadriceps torque and the limb symmetry index after the ACLR with high diagnostic accuracy.

LEVEL OF EVIDENCE

I.

Translation and cultural adaptation of Lithuanian version of the anterior cruciate ligament return to sport after injury (ACL-RSI) scale

Purpose

To translate, cross-culturally adapt and validate the scale to Lithuanian.

Methods

The process of translation and cultural adaptation followed the recommendations of international guidelines. All included patients were after unilateral ACL reconstruction. Study participants completed Tegner Activity Scale, IKDC and ACL-RSI-Lt questionnaires. Reliability, construct validity and internal consistency were measured.

Results

Study included sixty-five patients after ACL reconstruction: mean age 25.55 ± 6.77, mean height 180.91 ± 11.78 cm, mean weight 79.12 ± 14.88 kg and mean BMI 24.01 ± 2.90. The ACL-RSI-Lt showed excellent internal consistency (Cronbanch’s alpha 0.94). Scale scores were correlated with IKDC score (r = 0.637, p < 0.001) and IKDC subscales (r = 0.530–0.581, p < 0.001) and Tegner activity score (r = 0.303–0.493, p < 0.001). Tegner activity score before injury was significantly higher than after ACLR (6.95 ± 1.49 vs. 6.1 ± 1.37, p < 0.001).

Conclusions

The ACL-RSI is successfully translated into Lithuanian (ACL-RSI-Lt). It is valid and reliable scale to evaluate the psychological impact of returning to sports in Lithuanian patients after ACLR surgery.

Translation, cross-cultural adaptation, reliability and validity of the Persian version of the ACL-QOL questionnaire in patients with anterior cruciate ligament reconstruction

BACKGROUND

Quality of life (QOL) measures can be used to make sound clinical decisions after reconstruction of the anterior cruciate ligament (ACL). The purpose of the present study was to translate and cross-culturally adapt the Anterior Cruciate Ligament Quality of Life (ACL-QOL) questionnaire into the Persian language and to evaluate its psychometric properties.

METHODS

The process of translation and cross-cultural adaptation followed the World Health Organization method. One hundred and forty-five patients with ACL reconstruction (ACL-R) filled out the Persian versions of ACL-QOL and the SF-36 Questionnaire. The measurement properties of internal consistency, agreement, criterion validity, floor and ceiling effects were measured. 40 out of 145 patients with ACL-R completed the Persian version of the ACL-QOL questionnaire twice for the test-retest reliability.

RESULTS

The questionnaire had high internal consistency (Cronbach's α = 0.96). The intraclass correlation was excellent for reliability and agreement in five domains and overall score (ICC 0.87, 0.74, 0.90, 0.85, 0.81 and 0.89; p < 0.001). The standard error of measurement and the minimum detectable change were found to be 3.28 points and 9.9 points, respectively. There was a strong correlation between each item and the total score of the Persian version of ACL-QOL questionnaire. The questionnaire showed strong and moderate criterion validity (r = 0.61, r = 0.37) with SF-36 physical component score and mental component score, respectively. No ceiling and floor effects were observed.

CONCLUSIONS

Persian version of the ACL-QOL questionnaire has acceptable reliability and validity and can be used in assessing Iranians quality of life after ACL reconstruction.

Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale

Background

The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale was developed to measure an athlete's psychological readiness to return to sport after anterior cruciate ligament (ACL) injury and reconstruction surgery. The scale is being used with increasing frequency in both research and clinical settings.

Purpose

To generate and validate a short version of the ACL-RSI scale.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

The ACL-RSI scale was administered to 535 patients who had undergone ACL reconstruction surgery. Reliability (Cronbach alpha) was determined and factor analysis of the full scale was undertaken along with a process of item selection and elimination. A second group of 250 patients participated in a predictive validation analysis. This group completed the ACL-RSI scale at 6 months and reported return-to-sport outcomes 12 months following ACL reconstruction surgery. The predictive validity of both scales (full and short versions) was assessed by use of receiver operating characteristic (ROC) curve statistics.

Results

The scale was found to have high internal consistency (Cronbach alpha, 0.96), which suggested that item redundancy was present. After an item selection process, the scale was reduced to a 6-item format. Cronbach alpha for the short version was 0.92, and factor analysis confirmed the presence of 1 factor accounting for 71% of the total variance. Scores for the short version were significantly different between patients who had and those who had not returned to sport. Six-month ACL-RSI scores for both the full and short versions had fair to good predictive ability for 12-month return-to-sport outcomes (full version: area under ROC curve, 0.77 [95% CI, 0.7-0.8]; short version: area under ROC curve, 0.75 [95% CI, 0.7-0.8]).

Conclusion

A 6-item short version of the ACL-RSI scale was developed from a large cohort of patients undergoing ACL reconstruction. The short version appears to be as robust as the full version for discriminating between and predicting return-to-sport outcomes. The short version of the ACL-RSI may be of use in busy clinical settings to help identify athletes who may find return to sport challenging.

Cross-cultural adaptation and measurement properties testing of the Iconographical Falls Efficacy Scale (Icon-FES)

BACKGROUND

The Iconographical Falls Efficacy Scale (Icon-FES) is an innovative tool to assess concern of falling that uses pictures as visual cues to provide more complete environmental contexts. Advantages of Icon-FES over previous scales include the addition of more demanding balance-related activities, ability to assess concern about falling in highly functioning older people, and its normal distribution.

OBJECTIVE

To perform a cross-cultural adaptation and to assess the measurement properties of the 30-item and 10-item Icon-FES in a community-dwelling Brazilian older population.

METHODS

The cross-cultural adaptation followed the recommendations of international guidelines. We evaluated the measurement properties (i.e. internal consistency, test-retest reproducibility, standard error of the measurement, minimal detectable change, construct validity, ceiling/floor effect, data distribution and discriminative validity), in 100 community-dwelling people aged ≥60 years.

RESULTS

The 30-item and 10-item Icon-FES-Brazil showed good internal consistency (alpha and omega >0.70) and excellent intra-rater reproducibility (ICC_2,1=0.96 and 0.93, respectively). According to the standard error of the measurement and minimal detectable change, the magnitude of change needed to exceed the measurement error and variability were 7.2 and 3.4 points for the 30-item and 10-item Icon-FES, respectively. We observed an excellent correlation between both versions of the Icon-FES and Falls Efficacy Scale - International (rho=0.83, p<0.001 [30-item version]; 0.76, p<0.001 [10-item version]). Icon-FES versions showed normal distribution, no floor/ceiling effects and were able to discriminate between groups relating to fall risk factors.

CONCLUSION

Icon-FES-Brazil is a semantically and linguistically appropriate tool with acceptable measurement properties to evaluate concern about falling among the community-dwelling older population.