What tests should be used to assess functional performance in youth and young adults following anterior cruciate ligament or meniscal injury? A systematic review of measurement properties for the OPTIKNEE consensus

One leg testing in hip and knee osteoarthritis: A comparison with a two-leg oriented functional outcome measure and self-reported functional measures

OBJECTIVE

To compare the responsiveness of two unilateral lower-limb performance-based tests, the one-leg rise test and the maximal step-up test, with the bilateral 30-second chair-stand test and the self-reported measure of physical function (HOOS/KOOS). Specific aims were to evaluate responsiveness, floor/ceiling effect and association between the instruments.

METHOD

Data was included from 111 participants, mean age 61.3 years (8.3), with clinically verified hip or knee osteoarthritis, who reported less than 150 minutes/week of moderate or vigorous intensity physical activity. Responsiveness, how well the instruments captured improvements, was measured as Cohen's standardised mean difference for effect size, and was assessed from baseline to 12 months following a physical activity intervention. Other assessments were floor and ceiling effects, and correlations between tests.

RESULTS

The maximal step-up test had an effect size of 0.57 (95% CI 0.37, 0.77), the 30-second chair-stand 0.48 (95% CI 0.29, 0.68) and the one-leg rise test 0.12 (95% CI 0.60, 0.31). The one-leg rise test had a floor effect as 72% of the participants scored zero at baseline and 63% at 12 months. The correlation between performance-based tests and questionnaires was considered to be minor (r = 0.188 to 0.226) (p = 0.018 to 0.048).

CONCLUSION

The unilateral maximal step-up test seems more responsive to change in physical function compared to the bilateral 30-second chair-stand test, although the tests did not differ statistically in effect size. The maximal step-up test provides specific information about each leg for the individual and allows for comparison between the legs.

Toward designing human intervention studies to prevent osteoarthritis after knee injury: A report from an interdisciplinary OARSI 2023 workshop

Objective

The global impact of osteoarthritis is growing. Currently no disease modifying osteoarthritis drugs/therapies exist, increasing the need for preventative strategies. Knee injuries have a high prevalence, distinct onset, and strong independent association with post-traumatic osteoarthritis (PTOA). Numerous groups are embarking upon research that will culminate in clinical trials to assess the effect of interventions to prevent knee PTOA despite challenges and lack of consensus about trial design in this population. Our objectives were to improve awareness of knee PTOA prevention trial design and discuss state-of-the art methods to address the unique opportunities and challenges of these studies.

Design

An international interdisciplinary group developed a workshop, hosted at the 2023 Osteoarthritis Research Society International Congress. Here we summarize the workshop content and outputs, with the goal of moving the field of PTOA prevention trial design forward.

Results

Workshop highlights included discussions about target population (considering risk, homogeneity, and possibility of modifying osteoarthritis outcome); target treatment (considering delivery, timing, feasibility and effectiveness); comparators (usual care, placebo), and primary symptomatic outcomes considering surrogates and the importance of knee function and symptoms other than pain to this population.

Conclusions

Opportunities to test multimodal PTOA prevention interventions across preclinical models and clinical trials exist. As improving symptomatic outcomes aligns with patient and regulator priorities, co-primary symptomatic (single or aggregate/multidimensional outcome considering function and symptoms beyond pain) and structural/physiological outcomes may be appropriate for these trials. To ensure PTOA prevention trials are relevant and acceptable to all stakeholders, future research should address critical knowledge gaps and challenges.

Assessing the efficacy of the Stop OsteoARthritis (SOAR) program: A randomized delayed-controlled trial in persons at increased risk of early onset post-traumatic knee osteoarthritis

OBJECTIVE

Assess the efficacy of an 8-week virtual, physiotherapist (PT)-guided knee health program (Stop OsteoARthritis (SOAR)) to improve knee extensor strength in individuals at risk of post-traumatic knee osteoarthritis (PTOA).

METHOD

In this superiority, randomized delayed-control trial, persons aged 16-35 years, 1-4 years after a self-reported knee joint injury were randomly assigned (1:1) to receive the SOAR program immediately (experimental group) or after a 9-week delay (control group). SOAR includes 1) one-time Knee Camp (virtual PT-guided group education, knee assessment, 1:1 exercise and physical activity (PA) goal-setting); 2) Weekly personalized home-based exercise and PA program with tracking; 3) Weekly 1:1 PT counseling (virtual). The primary outcome was a change in isokinetic knee extensor strength (baseline to 9-weeks). Additional outcomes included change in self-reported knee-related quality-of-life (QOL), self-efficacy, self-management and kinesiophobia, and PA (accelerometer) at 9 and 18-weeks. Linear regression models estimated the effect of the 8-week intervention at the primary endpoint (9-week).

RESULTS

49 of 54 randomized participants completed the study (91%). Participants were a mean ± standard deviation age of 27 ± 5.0 years, and 2.4 ± 0.9 years post-injury. No mean between group differences for the primary (0.05; 95% confidence interval (CI): -0.10, 0.19) or other outcomes were seen at 9 weeks except for greater improvements in perceived self-management (Partner in Health Scale; 11.3/96, 95%CI: 5.5, 17.1) and kinesiophobia (Tampa Scale of Kinesiophobia; -4.4/33, 95%CI: -7.0, -1.8).

CONCLUSION

For active persons with elevated risk of PTOA, an 8-week SOAR program did not change knee-related strength, QOL, self-efficacy, or PA, on average, but may benefit the ability to self-manage knee health and kinesiophobia.

Functional testing following isolated meniscus repair may help to identify patients who need additional physical therapy prior to a return to activity

OBJECTIVES

Functional testing (FT), commonly used to evaluate dynamic knee function and provide objective information about how well a patient, has progressed in rehabilitation following an anterior cruciate ligament (ACL) reconstruction. The purpose of the study was to determine whether a functional test could be used as an assessment tool for return to activity following isolated meniscus repair.

METHODS

The results of FT completed between 80 and 150 days post-operation (representing 4-months post-operative) in isolated meniscal repair patients were analysed for the involved limb, uninvolved limb, and limb symmetry index (LSI). Involved limb performance and LSI on FT were also recorded for a matched cohort of patients who underwent an isolated ACL reconstruction between 151 and 220 days post-operation (representing 6-months post-operative). The meniscus cohort was compared to the ACL cohort.

RESULTS

The meniscus cohort (n ​= ​26) performed well (LSI of 88% or better) on all functional test exercises, including all hop tests. There were patients in the meniscus cohort who did not achieve 90% LSI on the FT at 4 months. There was no statistically significant difference in any of the tests between the meniscus and ACL (n ​= ​39) cohorts.

CONCLUSION

A majority of isolated meniscal repair patients perform well on FT by 4 months post-operatively and similar to patients undergoing isolated ACL reconstruction at 6 months post-operatively. Not all patients performed well on FT at 4 months post-operatively; however so, there may be a role for FT in isolated meniscal repair patients, and those patients may need further physical therapy prior to a return to sports.

LEVEL OF EVIDENCE

III; Retrospective cohort study.

LEVEL OF EVIDENCE

IV.

Evaluating Functional Performance Tests in those with Non-arthritic Intra-articular Hip Pain: An International Consensus Statement

Background

Non-arthritic intra-articular hip pain, caused by various pathologies, leads to impairments in range of motion, strength, balance, and neuromuscular control. Although functional performance tests offer valuable insights in evaluating these patients, no clear consensus exists regarding the optimal tests for this patient population.

Purpose

This study aimed to establish expert consensus on the application and selection of functional performance tests in individuals presenting with non-arthritic intra-articular hip pain.

Study Design

A modified Delphi technique was used with fourteen physical therapy experts, all members of the International Society for Hip Arthroscopy (ISHA). The panelists participated in three rounds of questions and related discussions to reach full consensus on the application and selection of functional performance tests.

Results

The panel agreed that functional performance tests should be utilized at initial evaluation, re-evaluations, and discharge, as well as criterion for assessing readiness for returning to sports. Tests should be as part of a multimodal assessment of neuromuscular control, strength, range of motion, and balance, applied in a graded fashion depending on the patient's characteristics. Clinicians should select functional performance tests with objective scoring criteria and prioritize the use of tests with supporting psychometric evidence. A list of recommended functional performance tests with varying intensity levels is provided. Low-intensity functional performance tests encompass controlled speed in a single plane with no impact. Medium-intensity functional performance tests involve controlled speed in multiple planes with low impact. High-intensity functional performance tests include higher speeds in multiple planes with higher impact and agility requirements. Sport-specific movement tests should mimic the patient's particular activity or sport.

Conclusion

This international consensus statement provides recommendations for clinicians regarding selection and utilization of functional performance tests for those with non-arthritic intra-articular hip pain. These recommendations will encourage greater consistency and standardization among clinicians during a physical therapy assessment.

The association between knee muscle performance and clinical outcomes of knee function 1-4 years after a sport-related knee joint injury

OBJECTIVE

Estimate the association between index leg knee muscle strength and rate of torque development (RTD), and self-reported and performance-based (i.e., hop) knee function in persons 1-4 years after a sport-related knee joint injury.

METHODS

Data were collected at baseline of a clinical trial. Assessments included the Knee injury and Osteoarthritis Outcome Score Sport & Recreation subscale (KOOSsport), 6-m timed hop (TH), and peak concentric isokinetic knee extensor and flexor torque and isometric RTD. Associations between peak torque and RTD with KOOSsport and TH were assessed using multivariable regression with nonlinear transformations.

RESULTS

53 participants (64.2% female) were included. Knee extensor peak torque was nonlinearly related to TH time, with a strong inverse relationship at lower torque values that changed as torque increased. Results were inconsistent for flexor peak torque, extensor RTD and flexor RTD, with inconsistencies in relationship shape and estimates of association between primary and sensitivity analyses. There was no association between strength/RTD and KOOSsport.

CONCLUSION

There was a nonlinear relationship between knee extensor strength and hop function, with lower strength being associated with a stronger relationship. As strength values increased, the relationship attenuated. Knee extensor and flexor strength, or RTD, were not associated with self-reported function.

Knee- and Overall Health-Related Quality of Life Following Anterior Cruciate Ligament Injury: A Cross-sectional Analysis of Australian and Canadian Cohorts

OBJECTIVE: To describe the knee- and overall health-related quality of life (QOL) 3 to 12 years after anterior cruciate ligament (ACL) tear, and to assess the association of clinical and structural features with QOL after ACL tear. DESIGN: Cross-sectional analysis of combined data from Australian (n = 76, 5.4 years postinjury) and Canadian (n = 50, 6.6 years postinjury) prospective cohort studies. METHODS: We conducted a secondary analysis of patient-reported outcomes and index knee magnetic resonance imaging (MRI) acquired in 126 patients (median 5.5 [range: 4-12] years postinjury), all treated with ACL reconstruction. Outcomes included knee (ACL Quality of Life questionnaire [ACL-QOL]) and overall health-related QOL (EQ-5D-3L). Explanatory variables were self-reported knee pain (Knee Injury and Osteoarthritis Outcome Score [KOOS-Pain subscale]) and function (KOOS-Sport subscale), and any knee cartilage lesion (MRI Osteoarthritis Knee Score). Generalized linear models were adjusted for clustering between sites. Covariates were age, sex, time since injury, injury type, subsequent knee injuries, and body mass index. RESULTS: The median [range] ACL-QOL score was 82 [24-100] and EQ-5D-3L was 1.0 [-0.2 to 1.0]. For every 10-point higher KOOS-Sport score, the ACL-QOL score increased by 3.7 points (95% confidence interval [CI]: 1.7, 5.7), whereas there was no evidence of an association with the EQ-5D-3L (0.00 points, 95% CI: -0.02, 0.02). There were no significant association between KOOS-Pain and ACL-QOL (4.9 points, 95% CI: -0.1, 9.9) or EQ-5D-3L (0.05 points, 95% CI: -0.01, 0.11), respectively. Cartilage lesions were not associated with ACL-QOL (-1.2, 95% CI: -5.1, 2.7) or EQ-5D-3L (0.01, 95% CI: -0.01, 0.04). CONCLUSION: Self-reported function was more relevant for knee-related QOL than knee pain or cartilage lesions after ACL tear. Self-reported function, pain, and knee structural changes were not associated with overall health-related QOL. J Orthop Sports Phys Ther 2023;53(7):1-12. Epub: 8 June 2023. doi:10.2519/jospt.2023.11838.

OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis

The goal of the OPTIKNEE consensus is to improve knee and overall health, to prevent osteoarthritis (OA) after a traumatic knee injury. The consensus followed a seven-step hybrid process. Expert groups conducted 7 systematic reviews to synthesise the current evidence and inform recommendations on the burden of knee injuries; risk factors for post-traumatic knee OA; rehabilitation to prevent post-traumatic knee OA; and patient-reported outcomes, muscle function and functional performance tests to monitor people at risk of post-traumatic knee OA. Draft consensus definitions, and clinical and research recommendations were generated, iteratively refined, and discussed at 6, tri-weekly, 2-hour videoconferencing meetings. After each meeting, items were finalised before the expert group (n=36) rated the level of appropriateness for each using a 9-point Likert scale, and recorded dissenting viewpoints through an anonymous online survey. Seven definitions, and 8 clinical recommendations (who to target, what to target and when, rehabilitation approach and interventions, what outcomes to monitor and how) and 6 research recommendations (research priorities, study design considerations, what outcomes to monitor and how) were voted on. All definitions and recommendations were rated appropriate (median appropriateness scores of 7–9) except for two subcomponents of one clinical recommendation, which were rated uncertain (median appropriateness score of 4.5–5.5). Varying levels of evidence supported each recommendation. Clinicians, patients, researchers and other stakeholders may use the definitions and recommendations to advocate for, guide, develop, test and implement person-centred evidence-based rehabilitation programmes following traumatic knee injury, and facilitate data synthesis to reduce the burden of knee post-traumatic knee OA.

Four Distinct 5-Year Trajectories of Knee Function Emerge in Patients Who Followed the Delaware-Oslo ACL Cohort Treatment Algorithm

BACKGROUND

Impairments and dysfunction vary considerably after anterior cruciate ligament (ACL) injury, and distinct subgroups may exist.

PURPOSE

(1) To identify subgroups of patients with ACL injury who share common trajectories of patient-reported knee function from initial presentation to 5 years after a treatment algorithm where they chose either ACL reconstruction (ACLR) plus rehabilitation or rehabilitation alone. (2) To assess associations with trajectory affiliation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We included 276 patients with a acute first-time complete unilateral ACL injury. All patients underwent a 5-week neuromuscular and strength training program before a shared decision-making process about treatment. Within their latest attended follow-up, 62% of patients had undergone early ACLR (<6 months after the 5-week program), 11% delayed ACLR (>6 months after the 5-week program), and 27% progressive rehabilitation alone. Patients completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at inclusion, after the 5-week program, and at 6 months, 1 year, 2 years, and 5 years after ACLR or completion of the 5-week program (patients treated with rehabilitation alone). We used group-based trajectory modeling to identify trajectories of IKDC-SKF and multinomial logistic regression to assess associations with trajectory affiliation.

RESULTS

Four distinct trajectories of IKDC-SKF were identified: Low (n = 22; 8.0% of the cohort), Moderate (n = 142; 51.4%), High (n = 105; 38.0%), and High Before Declining (n = 7; 2.5%). The High trajectory had higher scores at inclusion than the Moderate trajectory, but both improved considerably within 1 year and had thereafter stable high scores. The High Before Declining trajectory also started relatively high and improved considerably within 1 year but experienced a large deterioration between 2 and 5 years. The Low trajectory started low and had minimal improvement. New knee injuries were important characteristics of the High Before Declining trajectory, concomitant meniscal injuries were significantly associated with following the Low (vs Moderate) trajectory, and early/preoperative quadriceps strength and hop symmetry (measured at inclusion) were significantly associated with following the High (vs Moderate) trajectory.

CONCLUSION

We identified 4 distinct 5-year trajectories of patient-reported knee function, indicating 4 subgroups of patients with ACL injury. Importantly, 88% of the patients who followed our treatment algorithm followed the Moderate and High trajectories characterized by good improvement and high scores. Due to eligibility criteria and procedures in our cohort, we can only generalize our model to athletes without major concomitant injuries who follow a similar treatment algorithm. Concomitant meniscal injuries and new knee injuries were important factors in the unfavorable Low and High Before Declining trajectories. These associations were exploratory but support the trajectories' validity. Our findings can contribute to patient education about prognosis and underpin the importance of continued secondary injury prevention.

Think outside the box: Incorporating secondary cognitive tasks into return to sport testing after ACL reconstruction

The optimal set of return to sport (RTS) tests after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) remains elusive. Many athletes fail to pass current RTS test batteries, fail to RTS, or sustain secondary ACL injuries if they do RTS. The purpose of this review is to summarize current literature regarding functional RTS testing after ACLR and to encourage clinicians to have patients "think" (add a secondary cognitive task) outside the "box" (in reference to the box used during the drop vertical jump task) when performing functional RTS tests. We review important criteria for functional tests in RTS testing, including task-specificity and measurability. Firstly, tests should replicate the sport-specific demands the athlete will encounter when they RTS. Many ACL injuries occur when the athlete is performing a dual cognitive-motor task (e.g., attending to an opponent while performing a cutting maneuver). However, most functional RTS tests do not incorporate a secondary cognitive load. Secondly, tests should be measurable, both through the athlete's ability to complete the task safely (through biomechanical analyses) and efficiently (through measures of performance). We highlight and critically examine three examples of functional tests that are commonly used for RTS testing: the drop vertical jump, single-leg hop tests, and cutting tasks. We discuss how biomechanics and performance can be measured during these tasks, including the relationship these variables may have with injury. We then discuss how cognitive demands can be added to these tasks, and how these demands influence both biomechanics and performance. Lastly, we provide clinicians with practical recommendations on how to implement secondary cognitive tasks into functional testing and how to assess athletes' biomechanics and performance.