The Role of Athletic Trainers in Preventing and Managing Posttraumatic Osteoarthritis in Physically Active Populations: a Consensus Statement of the Athletic Trainers' Osteoarthritis Consortium

Effect of Purposely Induced Asymmetric Walking Perturbations on Limb Loading After Anterior Cruciate Ligament Reconstruction

Background

Patients often sustain prolonged neuromuscular dysfunction after anterior cruciate ligament reconstruction (ACLR). This dysfunction can present as interlimb loading rate asymmetries linked to reinjury and knee osteoarthritis progression.

Purpose/Hypothesis

To evaluate how asymmetric walking protocols can reduce interlimb loading rate asymmetry in patients after ACLR. It was hypothesized that asymmetric walking perturbations would (1) produce a short-term adaptation of interlimb gait symmetry and (2) induce the temporary storage of these new gait patterns after the perturbations were removed.

Study Design

Descriptive laboratory study.

Methods

Fifteen patients who had undergone ACLR were asked to perform an asymmetric walking protocol during the study period (2022-2023). First, to classify each limb as overloaded or underloaded based on the vertical ground-reaction force loading rate for each limb, participants were asked to perform baseline symmetric walking trials. Participants then performed an asymmetric walking trial for 10 minutes, where one limb was moving 0.5 m/s faster than the other limb (1 vs 1.5 m/s), followed by a 2-minute 1 m/s symmetric deadaptation walking trial. This process was repeated with the limb speeds switched for a second asymmetric trial.

Results

Participants adopted a new, symmetric interlimb loading rate gait pattern over time in response to the asymmetric trial, where the overloaded limb was set at 1 m/s. A linear mixed-effects model detected a significant change in gait dynamics (P < .001). The participants exhibited negative aftereffects after this asymmetric perturbation, indicating the temporary storage of the new gait pattern. No positive short-term gait adaptation or storage was observed when the overloaded limb was set to a faster speed.

Conclusion

Asymmetric walking successfully produced the short-term adaptation of interlimb loading rate symmetry in patients after ACLR and induced the temporary storage of these gait patterns in the initial period when the perturbation was removed.

Clinical Relevance

These findings are promising, as they suggest that asymmetric walking could serve as an effective gait retraining protocol that has the potential to improve long-term outcomes in patients after ACLR.

Evidence Review for Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement

CONTEXT

The Osteoarthritis Action Alliance formed a secondary prevention task group to develop a consensus on secondary prevention recommendations to reduce the risk of osteoarthritis after a knee injury.

OBJECTIVE

Our goal was to provide clinicians with secondary prevention recommendations that are intended to reduce the risk of osteoarthritis after a person has sustained an anterior cruciate ligament injury. Specifically, this manuscript describes our methods, literature reviews, and dissenting opinions to elaborate on the rationale for our recommendations and to identify critical gaps.

DESIGN

Consensus process.

SETTING

Virtual video conference calls and online voting.

PATIENTS OR OTHER PARTICIPANTS

The Secondary Prevention Task Group consisted of 29 members from various clinical backgrounds.

MAIN OUTCOME MEASURE(S)

The group initially convened online in August 2020 to discuss the target population, goals, and key topics. After a second call, the task group divided into 9 subgroups to draft the recommendations and supportive text for crucial content areas. Twenty-one members completed 2 rounds of voting and revising the recommendations and supportive text between February and April 2021. A virtual meeting was held to review the wording of the recommendations and obtain final votes. We defined consensus as >80% of voting members supporting a proposed recommendation.

RESULTS

The group achieved consensus on 15 of 16 recommendations. The recommendations address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models.

CONCLUSIONS

This consensus statement reflects information synthesized from an interdisciplinary group of experts based on the best available evidence from the literature or personal experience. We hope this document raises awareness among clinicians and researchers to take steps to mitigate the risk of osteoarthritis after an anterior cruciate ligament injury.

Post-traumatic osteoarthritis: epidemiology, pathogenesis, clinical picture, approaches to pharmacotherapy

Post-traumatic osteoarthritis (PTOA) is an inflammatory and degenerative disease that occurs as a result of the joint structures injury. It is a common pathology, accounting for approximately 12% of all cases of osteoarthritis (OA). PTOA often occurs in people of young productive age, progresses rapidly, causing chronic pain and increasing dysfunction. Individuals undergoing joint replacement for PTOA are, on average, 10 years younger than those with primary OA. The time interval from the moment of injury to the onset of typical PTOA radiological signs varies widely – from 1 year to 15–20 years.The main injuries that cause PTOA are intra-articular fractures, anterior cruciate ligament injuries, meniscus rupture and dislocation of the patella of the knee joint, joint dislocations with damage to the ligamentous apparatus of the ankle and shoulder joints.The pathogenesis of PTOA is determined by chronic inflammation accompanied by macrophage activation, hyperproduction of cytokines, primarily interleukin (IL) 1â, chemokines and growth factors, progressive destruction of joint tissue and degenerative changes (fibrosis, neoangiogenesis, osteophytosis).Pathogenetic treatment of PTOA, which would stop the progression of the disease, has not been developed. The possibility of using inhibitors of IL1â, IL6, inhibitors of tumor necrosis factor á, glucocorticoids, hyaluronic acid, autologous cell based therapy is under study. The control of pain and inflammation in PTOA requires the prescription of traditional drugs that are widely used in the practice of managing patients with primary OA. In particular, the use of symptomatic delayed-acting agents, such as the injectable form of chondroitin sulfate, seems to be appropriate.

Understanding Athletic Trainers' Knowledge, Intervention, and Barriers Toward Arthrogenic Muscle Inhibition

CONTEXT

Arthrogenic muscle inhibition (AMI) is a common neurophysiological response to joint injury. While athletic trainers (ATs) are constantly treating patients with AMI, it is unclear how clinicians are using the available evidence to treat the condition.

OBJECTIVE

To investigate ATs' general knowledge, clinical practice, and barriers for treating AMI.

METHODS

A cross-sectional web-based survey was utilized. The survey was distributed to a random sample of 3000 ATs from the National Athletic Trainers' Association and through social media. 143 board certified ATs (age: 34.6 [10.3] y; experience: 11.7 [9.8] y) from various clinical settings and educational backgrounds were included in the analysis.

RESULTS

One hundred one respondents were able to correctly identify the definition of AMI. The majority of these respondents correctly reported that joint effusion (n = 95, 94.1%) and abnormal activity from joint receptors (n = 91, 90.1%) resulted in AMI. Of the 101 respondents, only 58 (57.4%) reported using disinhibitory interventions to treat AMI. The most frequently used evidence supported interventions were transcutaneous electrical nerve stimulation (n = 38, 65.5%), neuromuscular electrical stimulation (n = 33, 56.9%), and focal joint cooling (n = 25, 43.1%). The interventions used correctly most often based on current evidence were neuromuscular electrical stimulation (n = 29/33, 87.9%) and transcutaneous electrical nerve stimulation (n = 26/38, 68.4%). Overall, difficulty quantifying AMI (n = 62, 61.24%) and lack of education (n = 71, 76.2%) were most frequently perceived as barriers. Respondents that did not use disinhibitory interventions perceived lack of experience treating AMI, understanding the terminology, and access to therapeutic modalities more often than the respondents that reported using disinhibitory interventions.

CONCLUSION

Further education about concepts and treatment about AMI is warranted for ATs. Continued understanding of ATs' clinical practice in regard to AMI may help identify gaps in athletic training clinical education.

Feasibility of a Wearable-Based Physical Activity Goal-Setting Intervention Among Individuals With Anterior Cruciate Ligament Reconstruction

CONTEXT

Individuals with a history of anterior cruciate ligament reconstruction (ACLR) demonstrate persistent reductions in physical activity (PA) volume that are not being addressed during rehabilitation. Currently, it is challenging for clinicians to prescribe exercise interventions that extend beyond in-person rehabilitative care in a manner that is responsive and acceptable to patients.

OBJECTIVE

To investigate the feasibility of using a novel, technology-driven, personalized goal-setting intervention over a 2-month period among young individuals with a history of primary unilateral ACLR.

DESIGN

Single-blinded feasibility study.

SETTING

University community.

PATIENTS OR OTHER PARTICIPANTS

Ten women and 2 men (age = 22.0 ± 3.0 years, time since surgery = 56.0 ± 36.3 months) with a history of primary unilateral ACLR.

INTERVENTION(S)

All participants completed a 28-day PA observation period immediately followed by a 28-day individualized PA goal-setting intervention period delivered via a commercially available PA monitor.

MAIN OUTCOME MEASURE(S)

Primary feasibility outcomes were days of PA monitor wear compliance and days of goal achievement during the intervention period. Participants also completed the Knee Osteoarthritis Outcome Score (KOOS) at study enrollment and after the intervention period, and the individual change in the KOOS Quality of Life subscale was compared with the minimal detectable change (7.2 points).

RESULTS

Average PA monitor wear compliance was 95.5% ± 7.3% during the observation period and 97.7% ± 2.9% during the intervention period. Median goal achievement was 31.5% ± 6.8% during the intervention period. Five participants demonstrated meaningful improvements in the KOOS Quality of Life subscale during the study period.

CONCLUSIONS

Individualized goal setting via mobile technology appears to be a feasible approach to PA promotion. However, based on the low rate of daily goal attainment during the intervention period, continued refinement of this intervention aproach would be beneficial before broad clinical implementation.

The effectiveness of the functional movement screen in determining injury risk in tactical occupations

Injures are common in workers engaged in tactical occupations. Research suggests that the functional movement screen (FMS) may provide practitioners the ability to identify tactical athletes most at risk for injury. However, there exists controversy as to the effectiveness of the FMS as a tool for classifying injury risk. The purpose of the meta-analysis was to determine the predictive value of the FMS in determining injury risk in workers engaged in tactical occupations. We searched MEDLINE, Military and Government Collection (EBSCO), National Institute for Occupational Safety and Health Technical Information Center and PubMed databases for articles published between January 2000 and October 2017 [corrected]. Ten studies met the inclusion criteria. Multiple random-effects model meta-analyses were conducted, with an odds ratio as the effects metric. FMS cut-off score, occupation, injury type and sex were used as moderators for the analyses. The odds of injury were greatest for tactical athletes with FMS scores ≤14. Personnel scoring ≤14 had almost 2 times the odds of injury as compared to those scoring >14. However, the magnitude of the effects were small; thus the relationship between FMS cut scores and injury prediction does not support its use as a sole predictor of injury.

The Impact of Knee Injury History on Health-Related Quality of Life in Adolescent Athletes

CONTEXT

Current evidence suggests that, despite returning to full participation, physically active adults with a previous knee injury experience lower health-related quality of life (HRQOL) than those with no knee injury history. It is unknown if this relationship is present in adolescent athletes.

OBJECTIVE

To determine the impact of knee injury history on HRQOL in adolescent athletes who were medically cleared for full participation.

DESIGN

Cross-sectional.

SETTING

Athletic training clinics.

PARTICIPANTS

A convenience sample of 183 adolescent athletes, who were medically cleared for full participation, were grouped by self-report of a previous knee injury: positive knee injury history (HIS; n = 36, age = 15.7 [1.4] y, height = 168.0 [11.9] cm, and weight = 71.8 [11.9] kg) and no knee injury history (NO-HIS; n = 147, age = 15.5 [1.4] y, height = 166.0 [10.5] cm, and weight = 67.6 [14.6] kg).

INTERVENTIONS

Participants completed the Pediatric International Knee Documentation Committee form and Pediatric Quality of Life Inventory during their preparticipation examination.

MAIN OUTCOME MEASURES

Generalized linear models were used to compare group differences for the total and subscale scores of the Pediatric International Knee Documentation Committee and Pediatric Quality of Life Inventory.

RESULTS

Main effects of injury group indicated that the HIS group reported significantly lower scores than the NO-HIS group for the Pediatric International Knee Documentation Committee total score (P < .001; HIS = 79.2 [21.7], NO-HIS = 95.8 [8.6]) and for the Pediatric Quality of Life Inventory total (P = .001; HIS = 85.7 [10.9], NO-HIS = 90.9 [7.3]), physical functioning (P = .002; HIS = 86.7 [13.6], NO-HIS = 92.1 [8.2]), school functioning (P = .01; HIS = 80.6 [12.4], NO-HIS = 86.8 [12.2]), and social functioning (P = .01; HIS = 89.3 [12.4], NO-HIS = 94.6 [8.9]) scores. No group differences were reported for the emotional functioning subscale (P = .13; HIS = 85.7 [17.7], NO-HIS = 89.7 [13.1]). No interactions or main effects of sex were reported (P > .05).

CONCLUSIONS

Our findings suggest that, despite returning to full sport participation, adolescent athletes with a previous knee injury generally experience lower HRQOL than their peers with no knee injury history, specifically for knee-specific HRQOL, physical functioning, school functioning, and social functioning. Our results are similar to previous findings reported in college athletes and military cadets.

The Influence of Body Armor on Balance and Movement Quality

Body armor is essential to the protection of military personnel; however, body armor may impede the users balance and movement quality. A better understanding of the influence of body armor on balance and movement quality may help in the development of new guidelines for training standards and procedures to mitigate the risk of injury associated with wearing of body armor in warfighters. The purpose of this study was to identify the effects of body armor (combat boots, tactical vest and combat helmet) on balance and movement quality in male military cadets and personnel. Twelve male participants completed the Functional Movement Screen (FMS) and Star Excursion Balance Test (SEBT) under two separate conditions, body armor and non-body armor. Results indicated a significant difference in FMS composite score between the non-body armor and body armor conditions (p =.012), with the non-body armor condition resulting in significantly higher FMS scores than the body armor condition. Additionally, the FMS item score for shoulder mobility was significantly higher (2.25±0.62) in the non-body armor condition than the body armor condition (p= 0.03). The SEBT composite and the three individual reach distances were not significantly different between conditions. Based on the current findings, body armor within a 4.8 kg - 5.3 kg range does appear to impact movement quality as evaluated using the FMS in male military personnel and cadets. More research is needed to determine a threshold of compensatory movement patterns relative to an increase in body armor weight.