Upper limb functional testing in athletes: A Delphi study

Background

Functional testing has recently become more and more popular to assess athletes, both for injury prevention, as well as in an objective of performance. However, the relationship between the results of these tests and performances (or injuries) or their interpretation remains unclear.

Objective

The aim of this study is to explore the usefulness, the characteristics, and the interpretation of the most frequently used upper-limb functional test.

Methods

Twenty-two experts with an excellent knowledge of upper limb functional tests and an expertise in sports medicine and/or sports training of at least 5 years were recruited. They answered to qualitative and quantitative questions about functional testing trough structured questionnaires (online).

Results

Four rounds were needed to reach a consensus about the usefulness as well as the characteristics of each test. Different sports-specific batteries of tests were also suggested by the experts and reached consensus. However, concerning the interpretation of the test, a consensus was only found for half of the tests considered.

Conclusion

The current study summarizes the characteristics and the usefulness of the most popular upper-limb functional tests. However, the interpretation of some tests will have to be further explored since no consensus was found for them.

Differences in Short-Term Sport-Specific Functional Recovery After Primary ACL Reconstruction in the Adolescent Athlete

BACKGROUND

Although anterior cruciate ligament (ACL) injury rates have been studied extensively, it is unclear whether levels of functional and psychological readiness for return-to-sport after primary ACL reconstruction (ACLR) differ based on an athlete's primary sport.

HYPOTHESIS

Youth athletes in different primary sports will demonstrate differences in short-term functional recovery, as well as patient-reported psychological and functional recovery after primary ACLR.

STUDY DESIGN

Retrospective cohort study of consecutive patients treated for ACL injury in pediatric sports medicine clinics.

LEVEL OF EVIDENCE

Level 3.

METHODS

Patients included underwent primary ACLR between December 1, 2015 and December 31, 2019 and reported sports participation at the time of injury. Demographic data, sports participation, surgical data, functional testing scores (Y-Balance Test [YBT]), functional and psychological patient-reported outcome measures (PROMs), and timing of return-to-play clearance were reviewed. YBT scores were the primary metric for clearance. Four groups were studied: soccer, football, basketball, and other.

RESULTS

A total of 220 male and 223 female athletes were included; 65.28% of soccer players were female and 100% of football players were male (P < 0.01). At initial postoperative YBT testing (6-9 months), soccer players had higher operative (P < 0.01) and nonoperative (P < 0.01) leg composite scores when compared with basketball players. No significant differences were found between sports in functional or psychological PROMs at presurgical baseline or 6 months postoperatively. When compared with football, soccer players completed functional clearance in a shorter time from surgery (P = 0.02). Multivariate analysis showed level of competition as a significant independent variable for clearance in female athletes.

CONCLUSION

After primary ACLR, athletes, especially female athletes, demonstrated short-term sport-specific differences in YBT scores. Soccer players attained clearance sooner than football players. Level of competition influenced YBT composite scores in all athletes and time to clearance in female athletes.

CLINICAL RELEVANCE

Sport-specific differences in reinjury should be investigated to determine whether changes in return-to-play evaluation should be implemented.

Next-Generation Preclinical Functional Testing Models in Cancer Precision Medicine: CTC-Derived Organoids

Basic and clinical cancer research requires tumor models that consistently recapitulate the characteristics of prima tumors. As ex vivo 3D cultures of patient tumor cells, patient-derived tumor organoids possess the biological properties of primary tumors and are therefore excellent preclinical models for cancer research. Patient-derived organoids can be established using primary tumor tissues, peripheral blood, pleural fluid, ascites, and other samples containing tumor cells. Circulating tumor cells acquired by non-invasive sampling feature dynamic circulation and high heterogeneity. Circulating tumor cell-derived organoids are prospective tools for the dynamic monitoring of tumor mutation evolution profiles because they reflect the heterogeneity of the original tumors to a certain extent. This review discusses the advantages and applications of patient-derived organoids. Meanwhile, this work highlights the biological functions of circulating tumor cells, the latest advancement in research of circulating tumor cell-derived organoids, and potential application and challenges of this technology.

Development and Validation of the Ankle-GO Score for Discriminating and Predicting Return-to-Sport Outcomes After Lateral Ankle Sprain

BACKGROUND

Lateral ankle sprain (LAS) is the most common sports-related injury. However, there are currently no published evidence-based criteria to guide the patient's return to sport (RTS) and this decision is generally time-based. The aim of this study was to assess the psychometric properties of a new score (Ankle-GO) and its predictive ability for RTS at the same level of play after LAS.

HYPOTHESIS

The Ankle-GO is robust for discriminating and predicting RTS outcomes.

STUDY DESIGN

Prospective diagnostic study.

LEVEL OF EVIDENCE

Level 2.

METHODS

The Ankle-GO was administered to 30 healthy participants and 64 patients at 2 and 4 months after LAS. The score was calculated as the sum of 6 tests for a maximum of 25 points. Construct validity, internal consistency, discriminant validity, and test-retest reliability were used to validate the score. The predictive value for the RTS was also validated based on the receiver operating characteristic (ROC) curve.

RESULTS

The internal consistency of the score was good (Cronbach's alpha coefficient of 0.79) with no ceiling or floor effect. Test-retest reliability was excellent (intraclass coefficient correlation = 0.99) with a minimum detectable change of 1.2 points. The 2-month scores were significantly lower than 4-month and control group scores (7.7 ± 4, 13.9 ± 4.6, and 19.6 ± 3.4 points, respectively, P < 0.01). Ankle-GO values were also significantly higher in patients who returned to their preinjury level at 4 months compared with those who did not (P < 0.01). The predictive value of the 2-month Ankle-GO score was fair for a RTS at the same or higher than preinjury level at 4 months (area under ROC curve, 0.77; 95% CI, 0.65-0.89; P < 0.01).

CONCLUSION

The Ankle-GO appears to be a valid and robust score for clinicians to predict and discriminate RTS in patients after LAS.

CLINICAL RELEVANCE

Ankle-GO is the first objective score to help in the decision-making of the RTS after LAS. At 2 months, patients with an Ankle-GO score <8 points are unlikely to RTS at the same preinjury level.

Remote Perimetry in a Virtual Reality Metaverse Environment for Out-of-Hospital Functional Eye Screening Compared Against the Gold Standard Humphrey Visual Fields Perimeter: Proof-of-Concept Pilot Study

BACKGROUND

The growing global burden of visual impairment necessitates better population eye screening for early detection of eye diseases. However, accessibility to testing is often limited and centralized at in-hospital settings. Furthermore, many eye screening programs were disrupted by the COVID-19 pandemic, presenting an urgent need for out-of-hospital solutions.

OBJECTIVE

This study investigates the performance of a novel remote perimetry application designed in a virtual reality metaverse environment to enable functional testing in community-based and primary care settings.

METHODS

This was a prospective observational study investigating the performance of a novel remote perimetry solution in comparison with the gold standard Humphrey visual field (HVF) perimeter. Subjects received a comprehensive ophthalmologic assessment, HVF perimetry, and remote perimetry testing. The primary outcome measure was the agreement in the classification of overall perimetry result normality by the HVF (Swedish interactive threshold algorithm-fast) and testing with the novel algorithm. Secondary outcome measures included concordance of individual testing points and perimetry topographic maps.

RESULTS

We recruited 10 subjects with an average age of 59.6 (range 28-81) years. Of these, 7 (70%) were male and 3 (30%) were female. The agreement in the classification of overall perimetry results was high (9/10, 90%). The pointwise concordance in the automated classification of individual test points was 83.3% (8.2%; range 75%-100%). In addition, there was good perimetry topographic concordance with the HVF in all subjects.

CONCLUSIONS

Remote perimetry in a metaverse environment had good concordance with gold standard perimetry using the HVF and could potentially avail functional eye screening in out-of-hospital settings.

Gait analysis in swine, sheep, and goats after neurologic injury: a literature review

Medical research on neurologic ailments requires representative animal models to validate treatments before they are translated to human clinical trials. Rodents are the predominant animal model used in neurological research despite limited anatomic and physiologic similarities to humans. As a result, functional testing designed to assess locomotor recovery after neurologic impairment is well established in rodent models. Comparatively, larger, more clinically relevant models have not been as well studied. To achieve similar locomotor testing standardization in larger animals, the models must be accessible to a wide array of researchers. Non-human primates are the most relevant animal model for translational research, however ethical and financial barriers limit their accessibility. This review focuses on swine, sheep, and goats as large animal alternatives for transitional studies between rodents and non-human primates. The objective of this review is to compare motor testing and data collection methods used in swine, sheep, and goats to encourage testing standardization in these larger animal models. The PubMed database was analyzed by searching combinations of swine, sheep, and goats, neurologic injuries, and functional assessments. Findings were categorized by animal model, data collection method, and assessment design. Swine and sheep were used in the majority of the studies, while only two studies were found using goats. The functional assessments included open pen analysis, treadmill walking, and guided free walking. Data collection methods included subjective behavioral rating scales and objective tools such as pressure-sensitive mats and image-based analysis software. Overall, swine and sheep were well-suited for a variety of assessment designs, with treadmill walking and guided free walking offering the most consistency across multiple trials. Data collection methods varied, but image-based gait analysis software provided the most robust analysis. Future studies should be conducted to standardize functional testing methods after neurologic impairment in large animals.

Patient-Derived Ex Vivo Cultures and Endpoint Assays with Surrogate Biomarkers in Functional Testing for Prediction of Therapeutic Response

Prediction of therapeutic outcomes is important for cancer patients in order to reduce side effects and improve the efficacy of anti-cancer drugs. Currently, the most widely accepted method for predicting the efficacy of anti-cancer drugs is gene panel testing based on next-generation sequencing. However, gene panel testing has several limitations. For example, only 10% of cancer patients are estimated to have druggable mutations, even if whole-exome sequencing is applied. Additionally, even if optimal drugs are selected, a significant proportion of patients derive no benefit from the indicated drug treatment. Furthermore, most of the anti-cancer drugs selected by gene panel testing are molecularly targeted drugs, and the efficacies of cytotoxic drugs remain difficult to predict. Apart from gene panel testing, attempts to predict chemotherapeutic efficacy using ex vivo cultures from cancer patients have been increasing. Several groups have retrospectively demonstrated correlations between ex vivo drug sensitivity and clinical outcome. For ex vivo culture, surgically resected tumor tissue is the most abundant source. However, patients with recurrent or metastatic tumors do not usually undergo surgery, and chemotherapy may be the only option for those with inoperable tumors. Therefore, predictive methods using small amounts of cancer tissue from diagnostic materials such as endoscopic, fine-needle aspirates, needle cores and liquid biopsies are needed. To achieve this, various types of ex vivo culture and endpoint assays using effective surrogate biomarkers of drug sensitivity have recently been developed. Here, we review the variety of ex vivo cultures and endpoint assays currently available.

Cardiovascular Outcomes of Coronary Computed Tomography Angiography Versus Functional Testing in Suspected Coronary Syndromes: Real-World Evidence From the Nationwide Cohort

Background Real-world evidence for the selection of gatekeeping studies in patients with suspected coronary syndromes is limited. Methods and Results We identified 27 036 patients who underwent coronary computed tomography angiography (CCTA), single-photon emission computed tomography, and the treadmill test for suspected coronary syndromes from the Korean National Health Insurance Service-National Sample Cohort between 2006 and 2014. The primary end point was a composite of cardiac death and myocardial infarction, and the secondary end point was a composite of the primary end point and revascularization. During a median follow-up of 5.4 years, the risk of both primary and secondary end points was significantly higher in the single-photon emission computed tomography group (hazard ratio [HR], 1.81 [95% CI, 1.34-2.45]; and HR, 1.42 [95% CI, 1.22-1.66]), but significantly lower in the treadmill test group (HR, 0.53 [95% CI, 0.42-0.67]; and HR, 0.69 [95% CI, 0.62-0.76]) compared with the CCTA group. After balancing baseline risk factors, there was no significant difference in the primary end point in those with single-photon emission computed tomography (HR, 1.11 [95% CI, 0.78-1.57]; P=0.58) or treadmill test (HR, 0.84 [95% CI, 0.65-1.08]; P=0.18) groups, compared with the CCTA group. The event rate of the secondary end point was significantly lower in the treadmill test group than in the CCTA group (HR, 0.87 [95% CI, 0.78-0.96]; P=0.008). Conclusions Compared with functional testing, initial CCTA was not associated with a lower rate of cardiac death or myocardial infarction when used as an initial diagnostic test for patients with suspected coronary syndromes.

Comparison of Patient-Reported Outcomes, Strength, and Functional Performance in Primary Versus Revision Anterior Cruciate Ligament Reconstruction

BACKGROUND

Clinical outcomes after revision anterior cruciate ligament reconstruction (ACLR) are not well understood.

HYPOTHESIS

Patients undergoing revision ACLR would demonstrate worse patient-reported outcomes and worse limb symmetry compared with a cohort undergoing primary ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

672 participants (373 with primary ACLR, 111 with revision ACLR, and 188 uninjured) completed functional testing at a single academic medical center. Descriptive information, operative variables, and patient-reported outcomes (International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Tegner Activity Scale score) were assessed for each patient. Quadriceps and hamstring strength tests were conducted using a Biodex System 3 Dynamometer. Single-leg hop for distance, triple hop test, and the 6-m timed hop test were also assessed. Limb symmetry index (LSI) between the ACLR limb and contralateral limb was calculated for strength and hop testing. Normalized peak torque (N·m/kg) was calculated for strength testing.

RESULTS

No differences were found in group characteristics, excluding body mass (P < .001), or in patient-reported outcomes. There were no interactions between revision status, graft type, and sex. Knee extension LSI was inferior (P < .001) in participants who had undergone primary (73.0% ± 15.0%) and revision (77.2% ± 19.1%) ACLR compared with healthy, uninjured participants (98.8% ± 10.4%). Knee flexion LSI was inferior (P = .04) in the primary group (97.4% ± 18.4%) compared with the revision group (101.9% ± 18.5%). Difference in knee flexion LSI between the uninjured and primary groups, as well as between the uninjured and revision groups, did not reach statistical significance. Hop LSI outcomes were significantly different across all groups (P < .001). Between-group differences in extension in the involved limb (P < .001) were noted, as the uninjured group exhibited stronger knee extension (2.16 ± 0.46 N·m/kg) than the primary group (1.67 ± 0.47 N·m/kg) and the revision group (1.78 ± 0.48 N·m/kg). As well, differences in flexion in the involved limb (P = .01) were found, as the revision group exhibited stronger knee flexion (1.06 ± 0.25 N·m/kg) than the primary group (0.97 ± 0.29 N·m/kg) and the uninjured group (0.98 ± 0.24 N·m/kg).

CONCLUSION

At 7 months postoperatively, patients who had undergone revision ACLR did not demonstrate inferior patient-reported outcomes, limb symmetry, strength, or functional performance compared with patients who had undergone primary ACLR. Patients who had undergone revision ACLR exhibited greater strength and LSI than their counterparts with primary ACLR, but these parameters were still inferior to those of uninjured controls.

"Biofeedback-based return to sport": individualization through objective assessments

Elite athletes are regularly exposed to high and repetitive mechanical stresses and impacts, resulting in high injury rates. The consequences of injury can range from time lost from training and competition to chronic physical and psychological burden, with no guarantee that the athlete will return to preinjury levels of sport activity and performance. Prominent predictors include load management and previous injury, highlighting the importance of the postinjury period for effective return to sport (RTS). Currently, there is conflicting information on how to choose and assess the best reentry strategy. Treating RTS as a continuum, with controlled progression of training load and complexity, seems to provide benefits in this process. Furthermore, objectivity has been identified as a critical factor in improving the effectiveness of RTS. We propose that assessments derived from biomechanical measurements in functional settings can provide the objectivity needed for regular biofeedback cycles. These cycles should aim to identify weaknesses, customize the load, and inform on the status of RTS progress. This approach emphasizes individualization as the primary determinant of RTS and provides a solid foundation for achieving it.

Molecular Features of SLC26A4 Common Variant p.L117F

The SLC26A4 gene, which encodes the anion exchanger pendrin, is involved in determining syndromic (Pendred syndrome) and non-syndromic (DFNB4) autosomal recessive hearing loss. SLC26A4 c.349C>T, p.L117F is a relatively common allele in the Ashkenazi Jewish community, where its minor allele frequency is increased compared to other populations. Although segregation and allelic data support the pathogenicity of this variant, former functional tests showed characteristics that were indistinguishable from those of the wild-type protein. Here, we applied a triad of cell-based assays, i.e., measurement of the ion transport activity by a fluorometric method, determination of the subcellular localization by confocal microscopy, and assessment of protein expression levels, to conclusively assign or exclude the pathogenicity of SLC26A4 p.L117F. This protein variant showed a moderate, but significant, reduction in ion transport function, a partial retention in the endoplasmic reticulum, and a strong reduction in expression levels as a consequence of an accelerated degradation by the Ubiquitin Proteasome System, all supporting pathogenicity. The functional and molecular features of human pendrin p.L117F were recapitulated by the mouse ortholog, thus indicating that a mouse carrying this variant might represent a good model of Pendred syndrome/DFNB4.

Disagreement in Pass Rates Between Strength and Performance Tests in Patients Recovering From Anterior Cruciate Ligament Reconstruction

BACKGROUND

Performance on strength and functional tests is often used to guide postoperative rehabilitation progress and return to activity decisions after anterior cruciate ligament reconstruction (ACLR). Clinicians may have difficulty in determining which criteria to follow if there is disagreement in performance outcomes among the tests.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare pass rates between strength tests and single-leg hop (SLHOP) tests among men and women and between patients with lower and higher preinjury activity levels recovering from ACLR. We hypothesized that pass rates would be nonuniformly distributed among test types, sex, and activity level and that more participants would pass hop tests than strength tests.

DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 299 participants (146 men; 153 women)-at a mean of 6.8 ± 1.4 months after primary, unilateral, and uncomplicated ACLR (mean age, 23 ± 9.7 years; mean height, 172 ± 10.5 cm; mean mass, 75.8 ± 18.4 kg)-completed testing. Quadri.tif strength was evaluated using peak torque during isokinetic knee extension at 90 deg/s and 180 deg/s. Jump distance during the SLHOP and triple hop tests was measured (in cm). Strength and hop test measures were evaluated based on the limb symmetry index ((LSI) = (ACLR / contralateral side) × 100). We operationally defined "pass" as >90% on the LSI.

RESULTS

Pass rates were nonuniformly distributed between isokinetic knee extension at 90 deg/s and the SLHOP test (χ² = 18.64; P < .001). Disagreements between isokinetic testing at 90 deg/s and the SLHOP test occurred in 36.5% (109/299) of the participants. Among those who failed strength testing and passed hop testing, a greater portion reported higher activity levels before their injury (χ² = 6.90; P = .01); however, there was no difference in pass rates between men and women. Similar patterns of disagreement were observed between all strength test and hop test outcomes.

CONCLUSION

ACLR patients with higher activity levels may be more likely to pass hop testing despite failing quadri.tif strength testing. This may be an indicator of movement compensations to achieve jump symmetry in the presence of quadri.tif weakness.

PLATELET FUNCTION IN TRAUMA: IS CURRENT TECHNOLOGY IN FUNCTION TESTING MISSING THE MARK IN INJURED PATIENTS?

ABSTRACT

Platelets are subcellular anucleate components of blood primarily responsible for initiating and maintaining hemostasis. After injury to a blood vessel, platelets can be activated via several pathways, resulting in changed shape, adherence to the injury site, aggregation to form a plug, degranulation to initiate activation in other nearby platelets, and acceleration of thrombin formation to convert fibrinogen to fibrin before contracting to strengthen the clot. Platelet function assays use agonists to induce and measure one or more of these processes to identify alterations in platelet function that increase the likelihood of bleeding or thrombotic events. In severe trauma, these assays have revealed that platelet dysfunction is strongly associated with poor clinical outcomes. However, to date, the mechanism(s) causing clinically significant platelet dysfunction remain poorly understood. We review the pros, cons, and evidence for use of many of the popular assays in trauma, discuss limitations of their use in this patient population, and present approaches that can be taken to develop improved functional assays capable of elucidating mechanisms of trauma-induced platelet dysfunction. Platelet dysfunction in trauma has been associated with need for transfusions and mortality; however, most of the current platelet function assays were not designed for evaluating trauma patients, and there are limited data regarding their use in this population. New or improved functional assays will help define the mechanisms by which platelet dysfunction occurs, as well as help optimize future treatment.

Rapid Quantification of the Binocular Visual Field for Clinical Trials: Performance of a Modified Esterman Supra-Threshold Test Implemented with the Open Perimetry Interface

Purpose

We aimed to assess the performance of the modified-Esterman test (mET) as a rapid suprathreshold binocular quantification tool for the assessment of peripheral visual fields. The mET consists of an even spread of test points across the visual field.

Materials and Methods

The mET was implemented on the Octopus 0900 perimeter using the Open Perimetry Interface (OPI) and consisted of 160 points. Patients with choroideremia, a rod-cone dystrophy, Stargardt disease, a cone-rod dystrophy, and healthy volunteers underwent both the mET and the standard Esterman tests twice. Disease severity (mild/moderate/severe) was graded on both tests independently. Voronoi tessellation was utilised to compare the tests.

Results

The Voronoi visualisation was able to demonstrate that the mET was able to provide more information about the disease state at all stages of diseases. This was confirmed by the agreement statistic, which showed that the mET detected 27% more points of visual field loss compared to the Esterman test, being most useful in patients with rod-cone dystrophies.

Conclusion

The mET provides a speedy quantitative measure of the peripheral visual field loss, which can be used in clinical trials to monitor longitudinal assessment of peripheral visual function. The mET provides a more even coverage across the visual field compared to the Esterman test points, making it more suitable for this purpose. This is a key part of safety monitoring in retinal clinical trials. The mET can easily be implemented on commercially available perimeters that allow Open Perimetry.

The Concept of Acceleration and Deceleration in Isokinetics and Its Relation to 3 Hop Tests

CONTEXT

Both isokinetic testing and functional tests are often used during patient rehabilitation programs. Most researchers have assessed the relationship of isokinetic testing and functional tests in parameters such as peak moment, work, or power. However, little information exists regarding the acceleration and deceleration parameters and their relationship to function.

DESIGN

The purpose of the study was to investigate the concept of acceleration and deceleration of the knee flexor and extensor muscle groups during isokinetic testing and its relationship to function.

METHODS

Twenty-six healthy individuals (14 men and 12 women) participated in the study. Isokinetic bilateral concentric knee flexion and extension muscular performance was assessed isokinetically at the angular velocities of 60°/s, 180°/s, and 300°/s. Functional performance was also assessed using (1) single hop for distance, (2) triple hop for distance, and (3) single timed hop. Functional data were normalized to body weight. A P value <.05 was considered to be significant.

RESULTS

Fair and moderate to good correlations (r = .396, P = .045 to r = .705, P = .001) were discovered between flexors' and extensors' acceleration/deceleration variables and the normalized to body weight functional tests.

CONCLUSIONS

Appropriate understanding of isokinetic parameters as described in this study, including acceleration/deceleration values, may provide useful information about the functional ability of the lower limb muscular system.

Evaluating Spatial Hearing Using a Dual-Task Approach in a Virtual-Acoustics Environment

Spatial hearing is critical for communication in everyday sound-rich environments. It is important to gain an understanding of how well users of bilateral hearing devices function in these conditions. The purpose of this work was to evaluate a Virtual Acoustics (VA) version of the Spatial Speech in Noise (SSiN) test, the SSiN-VA. This implementation uses relatively inexpensive equipment and can be performed outside the clinic, allowing for regular monitoring of spatial-hearing performance. The SSiN-VA simultaneously assesses speech discrimination and relative localization with changing source locations in the presence of noise. The use of simultaneous tasks increases the cognitive load to better represent the difficulties faced by listeners in noisy real-world environments. Current clinical assessments may require costly equipment which has a large footprint. Consequently, spatial-hearing assessments may not be conducted at all. Additionally, as patients take greater control of their healthcare outcomes and a greater number of clinical appointments are conducted remotely, outcome measures that allow patients to carry out assessments at home are becoming more relevant. The SSiN-VA was implemented using the 3D Tune-In Toolkit, simulating seven loudspeaker locations spaced at 30° intervals with azimuths between -90° and +90°, and rendered for headphone playback using the binaural spatialization technique. Twelve normal-hearing participants were assessed to evaluate if SSiN-VA produced patterns of responses for relative localization and speech discrimination as a function of azimuth similar to those previously obtained using loudspeaker arrays. Additionally, the effect of the signal-to-noise ratio (SNR), the direction of the shift from target to reference, and the target phonetic contrast on performance were investigated. SSiN-VA led to similar patterns of performance as a function of spatial location compared to loudspeaker setups for both relative localization and speech discrimination. Performance for relative localization was significantly better at the highest SNR than at the lowest SNR tested, and a target shift to the right was associated with an increased likelihood of a correct response. For word discrimination, there was an interaction between SNR and word group. Overall, these outcomes support the use of virtual audio for speech discrimination and relative localization testing in noise.

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.

Diverging Playing Positions do not Lead to Differences in YBT-UQ Performance in Youth Handball Players

Handball playing positions can be differentiated between first line players who position themselves near the 6-m line and second line players who typically play outside the 9-m space. Handball is characterized by a high number of throwing actions that cause adaptations in the throwing shoulder. The objective of this cross-sectional study was to assess whether the specific physiological positional demands in handball lead to functional performance differences between the playing positions ( N =196; goalkeepers: n =25; backcourt: n =99; pivots: n =21; winger: n =51) in terms of shoulder mobility and stability in any reach direction as assessed through the Upper Quarter Y Balance Test (YBT-UQ). Contrary to our hypothesis, the results did not show significant differences between the playing positions in shoulder mobility and stability in youth handball players, irrespective of reach arm and reach direction. The obtained effect sizes ( η _p ² ) were solely small and ranged between 0.01 and 0.03. The adaptations following the demands of the diverging playing positions do not lead to significant differences in shoulder mobility and stability on the basis of the YBT-UQ. The overall training load of youth handball players may not be sufficient to lead to significant position-specific differences in shoulder mobility and stability.

Validation of the Circular Tandem Walk Test and Optimal Cutoff Score to Determine the Risk of Falls in Active Community-Dwelling Older Adults

This study was to develop and validate the circular tandem walk test (CTWT) by deriving an optimal cutoff score to indicate the fall risk in 89 active community-dwelling older individuals. The participants aged 65 years and older were assessed for their demographic data, fear of fall variables, and history of falls in the past 6 months. Subsequently, participants were randomized for the sequence of tests between the tandem walk test and the CTWT. The outcomes of CTWT showed the highest significant correlation with all the fall variables (ranging from .631 to .827, p < .001). Moreover, the time to perform the CTWT ≥ 14.6 s and ≥ two error scores had excellent and acceptable diagnostic accuracy to determine the risk of falls in the older individuals, respectively. The CTWT can be used as alternative screening tests for assessing the fall risk in active older adults in community settings.

Recovery After ACL Reconstruction in Male Versus Female Adolescents: A Matched, Sex-Based Cohort Analysis of 543 Patients

Background:

Differences in postoperative recovery after anterior cruciate ligament reconstruction (ACLR) between men and women have been demonstrated in the adult population. Sex-based differences have been incompletely investigated in adolescents, which represent the subpopulation most affected by ACL injury.

Purpose/Hypothesis:

The purpose of this study was to compare the 6-month postoperative functional recovery after ACLR between adolescent boys and girls. It was hypothesized that significant differences in postoperative strength, dynamic balance, and functional hop test performance would be seen between the sexes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in this study were athletes aged 12 to 19 years with closed or closing growth plates who underwent ACLR with hamstring autograft between May 2014 and May 2018 at a single institution. All athletes had undergone strength and functional testing between 5 and 8 months postoperatively. Exclusion criteria were previous knee surgery (contralateral or ipsilateral knee), concomitant injury/surgery other than meniscal tear/repair, allograft supplementation, and incomplete medical records. The limb symmetry index (LSI) for strength (measured with handheld dynamometer), as well as dynamic Y-balance and functional hop test performance, was compared between groups. To account for differences in physical characteristics between the sexes, 1-way between-group multivariate analysis of covariance was used to analyze the data.

Results:

Overall, 543 patients (211 boys, 332 girls) were included. There was no significant difference in age, body mass index, incidence of concomitant meniscal pathology, use of regional anesthesia, or time to functional testing between cohorts. Female athletes demonstrated a statistically significantly greater deficit in quadriceps strength LSI compared with male athletes (boys, +3.4%; girls, –2.3%; P = .011). Both male and female athletes demonstrated 33% hamstring strength deficits, with no statistically significant sex-based differences in dynamic balance or functional hop testing.

Conclusion:

Female athletes demonstrated greater quadriceps strength deficits than male athletes at 6 months after ACLR with hamstring autograft. Severe hamstring strength deficits persisted in both male and female patients at this time point. The correlation of such deficits to risk of ACL retear warrants continued study in the adolescent population and may support a delay in return to sports, which has been suggested in the more recent literature.

Comparison of Different Functional Tests for Leg Power and Normative Bilateral Asymmetry Index in Healthy Collegiate Athletes

Background

Bilateral leg power is being increasingly investigated as a proxy for the recovery of muscle performance after injury. Functional tests like the single leg hop for distance (SLHD) and single leg vertical jump (SLVJ) are often used to determine symmetry and return to play (RTP) readiness. As an injury predictor, leg power is accurately measured with the Keiser Air420 seated leg press.

Purpose

To measure and analyze lower leg asymmetry in healthy collegiate athletes across each test battery.

Methods

Eighty-eight healthy student-athletes (44 males, 44 females) across 14 varsity teams at Wake Forest University performed the SLHD, SLVJ, and the Keiser. Horizontal and vertical displacement were measured via the SLHD and SLVJ, respectively. Peak power was recorded via the Keiser Air420 leg press. Pearson correlations and repeated measures ANOVA were used to calculate associations and compare bilateral asymmetry indices (BAI) and raw scores.

Results

There was a significant effect on each test’s raw BAI (P < 0.01). The mean absolute BAI were 5.42 ± 4.9%, 6.64 ± 4.9% and 5.36 ± 4.7% for the SLHD, SLVJ and Keiser, respectively. The SLVJ and Keiser (dominant leg r = 0.832, nondominant leg r = 0.826) were more highly correlated than the SLHD and Keiser (dominant leg r = 0.645, nondominant leg r = 0.687), all of which were statistically significant (P < 0.01).

Conclusion

At the 90th percentile, healthy collegiate athletes attained <15% BAI. We recommend the implementation of a battery of tests to determine normative lower limb asymmetry. A battery of functional tests may present different asymmetry indices as opposed the 10% reference asymmetry.

Safety and Effectiveness of a Perturbation-based Neuromuscular Training Program on Dynamic Balance in Adolescent Females: A Randomized Controlled Trial

BACKGROUND

Adolescent females are at much greater risk for ACL injury than their male counterparts when participating in the same sports. Preventative and pre-operative rehabilitation neuromuscular (NM) exercise programs are often recommended to improve knee function and reduce injury rates. The effectiveness of perturbation-based NM training program has been established in an adult population but has yet to be investigated in the at-risk adolescent female population.

PURPOSE

To determine the effectiveness of a perturbation-based NM exercise program in a group of physically active adolescent females.

STUDY DESIGN

Prospective randomized trial.

METHODS

Twenty-four healthy and an exploratory group of 10 ACL-injured females (ages 12-18) were equally randomized into a perturbation-based NM training or control group and evaluated before and after a five-week intervention period. The primary outcome of dynamic balance was measured using the Y-Balance test (YBT); secondary outcome measures included lower limb strength, proprioception, and flexibility.

RESULTS

The perturbation-based NM training intervention was safely completed by all participants but had no significant effect on YBT scoring, lower limb strength, proprioception or flexibility in either the healthy or ACL-injured groups.

CONCLUSIONS

Perturbation-based NM training is safe, but may offer little preventative benefit for healthy or pre-operative rehabilitation benefit for ACL-injured adolescent females. Future research should examine whether the effectiveness of perturbation-based NM training is influenced by the length of the training intervention, training intensity, or when it is combined with other forms of prophylactic or pre-surgical rehabilitation frequently used with at-risk adolescent females who regularly participate in sport.

LEVEL OF EVIDENCE

Level 3.

Criteria-based return-to-sport testing is associated with lower recurrence rates following arthroscopic Bankart repair

HYPOTHESIS AND BACKGROUND

This study aimed to analyze the impact of a criteria-based return-to-sport (CBRTS) testing protocol on recurrent instability following arthroscopic Bankart repair. We hypothesized that patients who underwent an objective CBRTS testing protocol to guide their clearance to return to sports would have less recurrent instability than those who did not undergo testing.

METHODS

Thirty-six consecutive patients who underwent arthroscopic Bankart repair from 2016 to 2018, had a minimum of 1 year of follow-up, and completed functional and strength testing to evaluate readiness to return to sports were included in this retrospective case-control study. Patients with critical glenoid bone loss > 13.5%, multidirectional instability, and off-track Hill-Sachs lesions necessitating a remplissage or bone augmentation procedure were excluded from the study. Recurrence was defined as dislocation or subluxation symptoms requiring revision surgery. Statistical analysis included analysis of variance and the independent t test.

RESULTS

There was no difference between the study and control groups regarding age (P = .15), sex (P = .11), hand dominance (P = .56), or participation in contact sports (P = .78). Patients who underwent the CBRTS testing protocol had a reduced rate of recurrent shoulder instability (5% vs. 22%; odds ratio, 4.85; P < .001). There was no difference in the time from surgery to recurrence between the groups (12 months vs. 13.6 months, P = .43).

CONCLUSION

Athletes who underwent an objective CBRTS testing protocol to guide their clearance to return to sports had a lower rate of recurrent instability following arthroscopic Bankart repair than those cleared to return based on the time from surgery. Athletes who did not undergo CBRTS testing after arthroscopic shoulder stabilization had a 4.85 times increased likelihood of recurrent instability development after return to sports.

Lower Extremity Kinematics of the Y-Balance Test in Healthy and ACL Injured Adolescent Females

BACKGROUND

Adolescent females are at significant risk for sustaining an ACL injury. The Y-Balance Test (YBT) is frequently used to evaluate neuromuscular control and lower extremity function. However, few studies have quantified 2D lower extremity kinematics during performance of the YBT, and there is an absence of kinematic data specific to at-risk adolescent females.

PURPOSE

To examine lower extremity joint kinematics during execution of the YBT by healthy and ACL-injured adolescent females.

STUDY DESIGN

Prospective cohort.

METHODS

Twenty-five healthy and ten ACL-injured (mean time from injury 143 days) adolescent females were assessed using the YBT. Sagittal and frontal plane knee and ankle motion was video recorded during execution of the YBT anterior reach movement. Ankle dorsi-flexion, knee flexion, and knee valgus angles were quantified via kinematic analysis. ANOVAs with a post hoc Bonferroni correction were used to compare YBT scoring (%LL) and kinematic data between groups. Pearson product-moment correlations determined the relationship between kinematic data and YBT scoring.

RESULTS

Healthy and ACL-injured subjects demonstrated similar YBT scores and lower extremity kinematic data. Healthy subjects demonstrated a weak positive correlation between ankle dorsiflexion and YBT scoring, and a weak negative correlation between knee valgus and YBT scoring. These relationships did not exist for ACL-injured subjects. Kinematic data for both groups also demonstrated a large degree of variability, regardless of YBT score.

CONCLUSIONS

Adolescent females frequently utilize a variety of lower extremity movement strategies when performing a functional movement task, and scoring on the YBT offers limited insight regarding lower extremity joint kinematics and ACL-injury risk in a physically active adolescent female population.

LEVEL OF EVIDENCE

Level 3.

Line Hops and Side Hold Rotation Tests Load Both Anterior and Posterior Shoulder: A Biomechanical Study

BACKGROUND

Clinical tests should replicate the stressful positions encountered during sport participation. Evaluating the kinetic and electromyographical demands of clinical tests enables clinicians to choose appropriate tests for specific sports.

PURPOSE

To describe the shoulder forces and muscle activation levels during closed chain functional tests of Line Hops (LH) and Side Hold Rotation (SHR).

STUDY DESIGN

Descriptive biomechanical study.

METHODS

Ten asymptomatic participants were examined in a university laboratory. Two functional tests were evaluated using three-dimensional video analysis and electromyography to measure shoulder forces, moments, and muscular activity levels.

RESULTS

SHR produced a peak average posterior translation force of 4.84 N/kg (CI95 4.32-5.36N/kg) and a peak average anterior translational force of 1.57 N/kg (CI95 1.10-2.01N/kg). High levels of serratus anterior (98% maximum voluntary isometric contraction (MVIC) and infraspinatus (52 %MVIC) were recorded during SHR. LH produced a posterior translational force of 4.25 N/kg (CI95 3.44-5.06N/kg). High levels of serratus anterior (105 %MVIC) and infraspinatus (87 %MVIC) were recorded during the push off phase of this activity.

CONCLUSIONS

LH and SHR placed large posterior translational forces that approached half of a person's bodyweight on shoulder structures. SHR produced an anterior translation force at extremes of horizontal abduction placing approximately 18% of bodyweight on shoulder structures. The LH test required the serratus anterior to provide power to push the upper torso of the ground while both the serratus and the infraspinatus provides scapular and humeral stability, respectively.

LEVEL OF EVIDENCE

4: Case series.

Full-field electroretinography in age-related macular degeneration: an overall retinal response

PURPOSE

Age-related macular degeneration (AMD) is generally considered a disease of the macula. However, recent studies show peripheral retinal lesions are prevalent in patients with AMD, indicative of a disease process that is more widespread. Full-field electroretinography (ffERG) measures an electrical response, not only from the macula, but from the entire retina. We wanted to study the ffERG response in eyes with AMD.

METHODS

We performed full-field electroretinography (RETI-port/scan 21, Roland, Berlin) in 13 patients with early AMD, 25 patients with late AMD and 24 individuals without vitreoretinal disease as a control group. Dawson-Trick-Litzkow fibre electrodes were used. Statistical analysis was performed and a p-value <0.05 was considered significant.

RESULTS

After adjusting for multiple comparisons, both the light-adapted 3.0 a-wave implicit time (p < 0.001) and 30-Hertz flicker peak time (p = 0.012) showed significant difference between patients with late AMD and individuals without vitreoretinal disease. There was a significant difference in the light-adapted 3.0 a-wave implicit time (p = 0.011) between patients with early AMD and the control group, but the difference in 30 Hz flicker peak time was not significant (p = 0.256).

CONCLUSION

The difference in cone function measured by light-adapted 3.0 a-wave implicit time and 30-Hertz flicker peak time in early and late AMD when compared to healthy controls suggests a more diminished overall response when AMD has reached later stages.

The Influence of Fatigue on Throwing and YBT-UQ Performance in Male Adolescent Handball Players

Purpose: The goal of the present study was to assess the effects of fatigue on throwing and Upper Quarter Y Balance Test (YBT-UQ) performance in male adolescent handball players. We hypothesized that throwing and YBT-UQ performance will be decreased in response to an upper-body fatigue-protocol.

Method: All male participants (N = 24, age: 14.8 ± 0.7 yrs) were handball players of a regional youth selection team. A radar gun was used for the assessment of throwing velocity. The YBT-UQ was executed assessing medial, inferolateral and superolateral reach directions normalized to the upper limb length together with a composite score. Immediately following a fatigue protocol of different sets of push-ups until failure (i.e., not being able to perform 60% of the initial maximal amount of push-ups), throwing and YBT-UQ performance were assessed again.

Results: Fatigue resulted in a significant decrease in throwing velocity (−3%, p = 0.022, d = 0.32). Concerning YBT-UQ, the fatigue protocol produced significant decreases for the superolateral reach direction (throwing arm reach: −5%, p = 0.017, d = 0.39; non-throwing arm reach: −10%, p < 0.001, d = 0.87) and the composite score (throwing arm reach: −2%, p = 0.026, d = 0.31; non-throwing arm reach: −4%, p = 0.001, d = 0.52) but not for the medial and the inferolateral reach directions.

Conclusions: Fatigue was found to be an impairing factor for throwing performance and shoulder mobility and stability. Therefore, a lower level of fatigue and/or a higher tolerance of fatigue is desirable. Strength-endurance and mobility exercises especially for the shoulder girdle may be a valuable addition for the training routine of youth handball players.

USE OF AN UPPER EXTREMITY FUNCTIONAL TESTING ALGORITHM TO DETERMINE RETURN TO PLAY READINESS IN COLLEGIATE FOOTBALL PLAYERS: A CASE SERIES

BACKGROUND/PURPOSE

Return to play decision making for upper extremity injuries is challenging due to a lack of evidence-based protocols and testing. Current guidelines utilize tests and measures with minimal evidence on re-injury risks and prediction. The purpose of this case series is to highlight a functional testing algorithm for upper extremities injuries and the outcomes for the patients that followed it.

STUDY DESIGN

Case series.

CASE DESCRIPTIONS

Six subjects (18 - 21 years old) who underwent shoulder capsulolabral repair secondary to recurrent instability and/or unyielding pain are included. All subjects underwent a criterion-based rehabilitation program before being assessed with the authors' upper extremity functional testing algorithm. The upper extremity functional testing algorithm consists of measures of active range of motion (AROM), passive range of motion (PROM), peak isometric force, a fatigue testing battery, and the closed kinetic chain upper extremity stability test (CKCUEST) to assess readiness for return to sport.

OUTCOMES

All athletes achieved > 90% symmetry on at least two out of three tests during a fatigue testing protocol and at least 25 touches on the CKCUEST. All of the athletes returned to unrestricted football the season following surgical intervention. None of the athletes sustained an additional glenohumeral subluxation, dislocation, or upper extremity injury requiring surgical intervention for the remainder of their athletic careers (six years).

DISCUSSION

The presented cases help to illustrate the effectiveness of the upper extremity functional testing algorithm to assess return to sport readiness for male collegiate football athletes. The algorithm included testing of AROM/PROM and strength that is typically used, but also included the CKCUEST and fatigue testing to further challenge and assess the upper extremity prior to returning to sports.

LEVEL OF EVIDENCE

4.

A multi-dimensional analysis of genotype-phenotype discordance in malignant hyperthermia susceptibility

BACKGROUND

Malignant hyperthermia (MH) susceptibility is an inherited condition, diagnosed either by the presence of a pathogenic genetic variant or by in vitro caffeine-halothane contracture testing. Through a multi-dimensional approach, we describe the implications of discordance between genetic and in vitro test results in a patient with a family history of possible MH.

METHODS

The patient, whose brother had a possible MH reaction, underwent the caffeine-halothane contracture test (CHCT) according to the North American MH Group protocol. Screening of the complete RYR1 and CACNA1S transcripts was done using Sanger sequencing. Additional functional analyses included skinned myofibre calcium-induced calcium release sensitivity, calcium signalling assays in cultured myotubes, and in silico evaluation of the effect of any genetic variants on their chemical environment.

RESULTS

The patient's CHCT result was negative but she carried an RYR1 variant c.1209C>G, p.Ile403Met, that is listed as pathogenic by the European Malignant Hyperthermia Group. Functional tests indicated a gain-of-function effect with a weak impact, and the variant was predicted to affect the folding stability of the 3D structure of the RyR1 protein. Based on American College of Medical Genetics and Genomics/Association of Molecular Pathology guidelines, this variant would be characterised as a variant of uncertain significance.

CONCLUSIONS

Available data do not confirm or exclude an increased risk of MH for this patient. Further research is needed to correlate RyR1 functional assays, including the current gold standard testing for MH susceptibility, with clinical phenotypes. The pathogenicity of genetic variants associated with MH susceptibility should be re-evaluated.

Novel Bionics Assessment of Anorectal Mechanosensory Physiology

Biomechatronics (bionics) is an applied science that creates interdisciplinary bonds between biology and engineering. The lower gastrointestinal (GI) tract is difficult to study but has gained interest in recent decades from a bionics point of view. Ingestible capsules that record physiological variables during GI transit have been developed and used for detailed analysis of colon transit and motility. Recently, a simulated stool named Fecobionics was developed. It has the consistency and shape of normal stool. Fecobionics records a variety of parameters including pressures, bending, and shape changes. It has been used to study defecation patterns in large animals and humans, including patients with symptoms of obstructed defecation and fecal incontinence. Recently, it was applied in a canine colon model where it revealed patterns consistent with shallow waves originating from slow waves generated by the interstitial Cells of Cajal. Novel analysis such as the "rear-front" pressure diagram and quantification of defecation indices has been developed for Fecobionics. GI research has traditionally been based on experimental approaches. Mathematical modeling is a unique way to deal with the complexity. This paper describes the Fecobionics technology, related mechano-physiological modeling analyses, and outlines perspectives for future applications.

Simulated stool for assessment of anorectal physiology

Fecal continence is maintained by several mechanisms including anatomical factors, anorectal sensation, rectal compliance, stool consistency, anal muscle strength, mobility, and psychological factors. The homeostatic balance is easily disturbed, resulting in symptoms including fecal incontinence and constipation. Current technologies for assessment of anorectal function have limitations. Overlap exist between data obtained in different patient groups, and there is lack of correlation between measurements and symptoms. This review describes a novel technology named Fecobionics for assessment of anorectal physiology. Fecobionics is a simulated stool, capable of dynamic measurements of a variety of variables during defecation in a single examination. The data facilitate novel analysis of defecatory function as well as providing the foundation for modeling studies of anorectal behavior. The advanced analysis can enhance our physiological understanding of defecation and future interdisciplinary research for unraveling defecatory function, anorectal sensory-motor disorders, and symptoms. This is a step in the direction of improved diagnosis of anorectal diseases.

Grasping Ability and Motion Synergies in Affordable Tendon-Driven Prosthetic Hands Controlled by Able-Bodied Subjects

Affordable 3D-printed tendon-driven prosthetic hands are a rising trend because of their availability and easy customization. Nevertheless, comparative studies about the functionality of this kind of prostheses are lacking. The tradeoff between the number of actuators and the grasping ability of prosthetic hands is a relevant issue in their design. The analysis of synergies among fingers is a common method used to reduce dimensionality without any significant loss of dexterity. Therefore, the purpose of this study is to assess the functionality and motion synergies of different tendon-driven hands using an able-bodied adaptor. The use of this adaptor to control the hands by means of the fingers of healthy subjects makes it possible to take advantage of the human brain control while obtaining the synergies directly from the artificial hand. Four artificial hands (IMMA, Limbitless, Dextrus v2.0, InMoov) were confronted with the Anthropomorphic Hand Assessment Protocol, quantifying functionality and human-like grasping. Three subjects performed the tests by means of a specially designed able-bodied adaptor that allows each tendon to be controlled by a different human finger. The tendon motions were registered, and correlation and principal component analyses were used to obtain the motion synergies. The grasping ability of the analyzed hands ranged between 48 and 57% with respect to that of the human hand, with the IMMA hand obtaining the highest score. The effect of the subject on the grasping ability score was found to be non-significant. For all the hands, the highest tendon-pair synergies were obtained for pairs of long fingers and were greater for adjacent fingers. The principal component analysis showed that, for all the hands, two principal components explained close to or more than 80% of the variance. Several factors, such as the friction coefficient of the hand contact surfaces, limitations on the underactuation, and impairments for a correct thumb opposition need to be improved in this type of prostheses to increase their grasping stability. The principal components obtained in this study provide useful information for the design of transmission or control systems to underactuate these hands.

Return to sport testing at 6 months after arthroscopic shoulder stabilization reveals residual strength and functional deficits

OBJECTIVES

A good outcome after arthroscopic stabilization for recurrent shoulder instability is often characterized by a successful return to sport while minimizing complications. There is currently no consensus regarding timing or objective criteria for return to sport. The objective of this study is to evaluate the ability of postoperative patients to meet expected goals by using standardized objective evaluations of strength and physical function.

METHODS

Forty-three (10 females, 76.7% male) subjects (mean age, 18.1 ± 3.7 years) who underwent arthroscopic shoulder stabilization surgery (anterior or posterior) from 2016 until 2018 were referred during their postoperative rehabilitation for functional testing at 6 months postoperatively to evaluate their readiness for return to sport. The Closed Kinetic Chain Upper Extremity Stability test and Unilateral Seated Shot Put test were used to assess shoulder function. Posterior rotator cuff activation was evaluated using a repetition to failure technique with 5% body weight at 0° and 90° of abduction with the goal of 90% of nonoperative extremity. Isokinetic strength testing of external rotation (ER) and internal rotation (IR) was evaluated using a Biodex isokinetic dynamometer at angular velocities of 60° and 180° per second, and a passing score was considered achieving 90% of nonoperative shoulder strength at both 60° and 180° per second.

RESULTS

All subjects were competitive athletes (20 collegiate, 23 high school). The dominant extremity was the surgical extremity in 22 subjects. Only 5 subjects were able to successfully pass the battery of tests for strength and function. Strength testing revealed that 7 patients achieved 90% of the strength of the nonoperative extremity in both repetitions to failure (23 of 43) and comparative isokinetic testing (7 of 43). More subjects were able to meet IR strength (20 of 43) than ER strength (12 of 43) goals. Functional test goals were more frequently achieved, with 26 of 43 subjects meeting both functional test goals (33 Closed Kinetic Chain Upper Extremity Stability, 34 Unilateral Seated Shot Put). Only 2 subjects were able to achieve strength goals but did not pass functional tests, whereas 21 subjects passed functional tests without meeting strength goals.

CONCLUSION

A substantial number of athletes in our cohort do not meet the expected goals for their operative shoulder in achieving appropriate function and strength, compared with the contralateral shoulder. Functional goals were more often met than strength. IR strength goals were more frequently achieved than ER strength. Strength and functional testing could provide more reliable criteria than arbitrary passage of time for return to play after shoulder stabilization surgery.

Test-Retest Reliability of the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) in a Modified Test Position in Division I Collegiate Basketball Players

BACKGROUND

The closed kinetic chain upper extremity stability test (CKCUEST) as originally described may not be appropriate for assessing athletes interchangeably considering body size variations. A modified test position may be warranted to normalize the CKCUEST to body size, in order to reflect an accurate representation of upper limb function.

PURPOSE

To determine test-retest reliability of the CKCUEST in a modified test position in Division I collegiate basketball players.

STUDY DESIGN

Test-retest reliability.

METHODS

15 subjects (8 male, 7 female) were recruited from Division I basketball teams. Subjects began in a push-up position with their hands located directly under their shoulders. Subjects performed one 15 second trial of the modified CKCUEST initially and a second trial one week later. Hand-written data was transferred to a spreadsheet for analysis using Minitab Statistical Software for comparison.

RESULTS

Test-retest reliability was 0.88 for men's basketball, 0.79 for women's basketball, and 0.90 when both teams were combined. Test mean for men's basketball were 29.5 ± 4.78, and retest mean were 31.88 ± 4.99. Test mean for women's basketball were 24.86 ± 5.52, and retest mean were 26.71 ± 5.41. Test mean for both teams combined were 27.33 ± 5.5, and retest mean were 29.47 ± 5.67.

CONCLUSIONS

The CKCUEST in a modified test position is a reliable assessment tool. Results support previous findings and may contribute to injury prevention and return to sport decision-making.

LEVEL OF EVIDENCE

3b.

Hop Testing Lacks Strong Association With Key Outcome Variables After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

BACKGROUND

Single-legged hop tests are commonly used assessments in return to sport (RTS) testing after anterior cruciate ligament reconstruction (ACLR). Although these tests are commonly used, their predictive validity has not yet been established.

PURPOSE

To determine the strength of association between hop testing and RTS, knee reinjury, subjective report of knee function, and posttraumatic knee osteoarthritis (PTOA) after primary ACLR. Secondarily, to determine whether hop testing is able to predict a favorable result on the same outcome variables.

STUDY DESIGN

Systematic review.

METHODS

A systematic, computer-assisted literature search was performed in PubMed/MEDLINE, CINAHL, EMBASE, SPORTDiscus, Cochrane Library, and ClinicalTrials.gov. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when conducting and reporting this review. Primary outcome variables for this review were self-report of knee function, return to preinjury level of activity, presence of reinjury, and presence of PTOA. The Oxford Centre for Evidence-Based Medicine Levels of Evidence tool was used to assess the level of evidence for each included study. Quality assessment of each included study was performed through use of a modified Downs and Black scale. Available metrics were tabulated based on outcome variables.

RESULTS

Overall, 21 studies (4476 patients) met inclusion for this review. The majority of evidence (95.2%) was of moderate to high methodologic quality. The most commonly associated outcome measure was the International Knee Documentation Committee (IKDC) score, with Pearson correlation coefficients ranging from 0.20 to 0.60. The strength of association between the Knee injury and Osteoarthritis Outcome Score (KOOS) and hop testing ranged from -0.10 to 0.62 in 4 studies. In all, 10 studies examined the relationship between hop testing and RTS, with variable association statistics reported. No meaningful association was found between hop testing and knee reinjury in 2 studies. Worse preoperative hop testing was associated with PTOA in 1 study.

CONCLUSION

Hop testing appears to possess fair association to subjective report of knee function measured by the KOOS and IKDC and a patient's ability to RTS after ACLR. Insufficient evidence is available to determine the relationship between hop testing and PTOA and knee reinjury. Predictive validity cannot be established based on available literature.

Machine Learning Groups Patients by Early Functional Improvement Likelihood Based on Wearable Sensor Instrumented Preoperative Timed-Up-and-Go Tests

BACKGROUND

Wearable sensors permit efficient data collection and unobtrusive systems can be used for instrumenting knee patients for objective assessment. Machine learning can be leveraged to parse the abundant information these systems provide and segment patients into relevant groups without specifying group membership criteria. The objective of this study is to examine functional parameters influencing favorable recovery outcomes by separating patients into functional groups and tracking them through clinical follow-ups.

METHODS

Patients undergoing primary unilateral total knee arthroplasty (n = 68) completed instrumented timed-up-and-go tests preoperatively and at their 2-, 6-, and 12-week follow-up appointments. A custom wearable system extracted 55 metrics for analysis and a K-means algorithm separated patients into functionally distinguished groups based on the derived features. These groups were analyzed to determine which metrics differentiated most and how each cluster improved during early recovery.

RESULTS

Patients separated into 2 clusters (n = 46 and n = 22) with significantly different test completion times (12.6 s vs 21.6 s, P < .001). Tracking the recovery of both groups to their 12-week follow-ups revealed 64% of one group improved their function while 63% of the other maintained preoperative function. The higher improvement group shortened their test times by 4.94 s, (P = .005) showing faster recovery while the other group did not improve above a minimally important clinical difference (0.87 s, P = .07). Features with the largest effect size between groups were distinguished as important functional parameters.

CONCLUSION

This work supports using wearable sensors to instrument functional tests during clinical visits and using machine learning to parse complex patterns to reveal clinically relevant parameters.

A NOVEL TEST TO ASSESS CHANGE OF DIRECTION: DEVELOPMENT, RELIABILITY, AND REHABILITATION CONSIDERATIONS

BACKGROUND

Several researchers have investigated functional testing with regard to return to sport decision making. Change of direction activities play a role in the advancement of rehabilitation as an athlete progresses towards return to sport. Few studies have assessed tests that measure change of direction tasks.

PURPOSE

The primary purpose of this study was to establish test-retest and intra- and inter-rater reliability of performing the Change of Lateral Direction (COLD) test. The second purpose was to provide normative data for healthy college aged subjects performing the COLD test. The final purpose of this study was to assess the role of fatigue while performing lateral change of direction tasks.

STUDY DESIGN

Cross-sectional, descriptive reliability study.

METHODS

Thirty-three female and 18 male healthy college students (mean age = 25.5) were tested on two occasions, one week apart. Subjects started out standing on a standard 4" step and rapidly altered stepping to tape markers on either side of the step as many times as possible for 30 seconds. The total number of steps achieved in 30 seconds was video recorded and watched later to count steps in order to determine reliability. The effect of fatigue was assessed by subdividing the 30 second trial into three increments: 0-10 seconds (T_0-10), 11-20 seconds (T_11-20), and 21-30 seconds (T_21-30).

RESULTS

Normative data for session 1 and session 2 were 76.0 (±10.9) and 80.1 (±11.2) steps respectively. Inter-rater (ICC: 0.994-0.996) and intra-rater (ICC: 0.930-0.984) reliability was excellent. Test-retest reliability demonstrated a strong correlation (r = 0.88) between session 1 and session 2. A significant decline (p<0.001) in total number of steps was demonstrated between T_0-10 and T_21-30, as well as T_11-20 and T_21-30 during both session 1 and session 2.

CONCLUSIONS

The COLD test demonstrated excellent inter-rater and intra-rater reliability. A possible fatigue effect occurred at T_21-30. Because of the ease of administration, minimal equipment required, and excellent intra and inter-rater reliability, the COLD test provides an excellent functional change of direction test. This test could be used for serial reassessment during pre-season screening, rehabilitation, or return to sport.

LEVEL OF EVIDENCE

2c.

The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review With Meta-analysis

BACKGROUND

There is no consensus on the components of return-to-sport (RTS) testing following anterior cruciate ligament (ACL) reconstruction or whether passing RTS criteria can reduce a patient's risk of reinjury.

OBJECTIVES

To determine whether impartial, criteria-based RTS decisions are associated with less risk of a second ACL injury (either graft failure or contralateral ACL injury).

METHODS

In this systematic review with meta-analysis, the authors conducted an electronic literature search in PubMed/MEDLINE, Embase, CINAHL, SPORTDiscus, and ProQuest Dissertations and Theses Global using database-specific vocabulary related to ACL reconstruction and return to sport. Individual study quality was assessed using the modified Downs and Black checklist, and overall quality of evidence was determined with the Grading of Recommendations Assessment, Development and Evaluation scale. Pooled risk difference (passed versus failed RTS criteria), injury incidence proportion, and the diagnostic accuracy of each RTS criterion were calculated.

RESULTS

Four studies met the selection criteria. Overall, 42.7% (95% confidence interval [CI]: 18%, 69%) of patients passed RTS criteria, and 14.4% (95% CI: 8%, 21%) of those who passed experienced a second ACL injury (graft rupture or contralateral ACL injury). There was a nonsignificant 3% reduced risk of a second ACL injury after passing RTS criteria (risk difference, -3%; 95% CI: -16%, 10%; I² = 74%, P = .610). The evidence rating of the Grading of Recommendations Assessment, Development and Evaluation scale was "very low quality," due to imprecision and heterogeneity of the pooled risk difference estimate.

CONCLUSION

Passing RTS criteria did not show a statistically significant association with risk of a second ACL injury. The quality-of-evidence rating prevents a definitive conclusion on this question and indicates an opportunity for future research.

LEVEL OF EVIDENCE

Prognosis, Level 2a-. J Orthop Sports Phys Ther 2019;49(2):43-54. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8190.

Determinants of survival in lung transplantation patients with idiopathic pulmonary fibrosis: a retrospective cohort study

Survival after lung transplantation (LTx) for idiopathic pulmonary fibrosis (IPF) is worse compared to other indications for LTx. We investigated the effect of several pretransplant variables including the use of pretransplant corticosteroids (CS) on post-transplant graft and chronic lung allograft dysfunction (CLAD)-free survival and functional testing (maximum inspiratory and expiratory pressure, six-minute walk test, quadriceps and hand pinch force) in a small cohort of IPF patients. We retrospectively compared two groups of IPF patients (n = 36 on CS vs. n = 18 not on CS) who underwent LTx between 2000 and 2016. Analysis of 54 IPF-LTx patients showed no significant effect on graft survival or functional tests except for maximum inspiratory pressure (P = 0.033) between these two groups (all LTx patients, CS vs. no CS). Regression analysis showed significant impact of procedure with a hazard ratio of 0.423 (CI 95% 0.194, 0.924) favoring sequential single LTx (SSLTx) compared to single lung transplantation (SLTx). When analyzing only the 40 SSLTx patients, corticosteroid-free patients showed significantly better graft survival compared to patients on CS (P = 0.045) and CLAD-free survival (P = 0.019). The possible detrimental effect of corticosteroid therapy before LTx was demonstrated in this cohort of SSLTx patients, which questions the use of corticosteroids in a pretransplantation setting.

PASSPORT-seq: A Novel High-Throughput Bioassay to Functionally Test Polymorphisms in Micro-RNA Target Sites

Next-generation sequencing (NGS) studies have identified large numbers of genetic variants that are predicted to alter miRNA–mRNA interactions. We developed a novel high-throughput bioassay, PASSPORT-seq, that can functionally test in parallel 100s of these variants in miRNA binding sites (mirSNPs). The results are highly reproducible across both technical and biological replicates. The utility of the bioassay was demonstrated by testing 100 mirSNPs in HEK293, HepG2, and HeLa cells. The results of several of the variants were validated in all three cell lines using traditional individual luciferase assays. Fifty-five mirSNPs were functional in at least one of three cell lines (FDR ≤ 0.05); 11, 36, and 27 of them were functional in HEK293, HepG2, and HeLa cells, respectively. Only four of the variants were functional in all three cell lines, which demonstrates the cell-type specific effects of mirSNPs and the importance of testing the mirSNPs in multiple cell lines. Using PASSPORT-seq, we functionally tested 111 variants in the 3′ UTR of 17 pharmacogenes that are predicted to alter miRNA regulation. Thirty-three of the variants tested were functional in at least one cell line.

Functional Assays Are Essential for Interpretation of Missense Variants Associated with Variable Expressivity

Missense DNA variants have variable effects upon protein function. Consequently, interpreting their pathogenicity is challenging, especially when they are associated with disease variability. To determine the degree to which functional assays inform interpretation, we analyzed 48 CFTR missense variants associated with variable expressivity of cystic fibrosis (CF). We assessed function in a native isogenic context by evaluating CFTR mutants that were stably expressed in the genome of a human airway cell line devoid of endogenous CFTR expression. 21 of 29 variants associated with full expressivity of the CF phenotype generated <10% wild-type CFTR (WT-CFTR) function, a conservative threshold for the development of life-limiting CF lung disease, and five variants had moderately decreased function (10% to ∼25% WT-CFTR). The remaining three variants in this group unexpectedly had >25% WT-CFTR function; two were higher than 75% WT-CFTR. As expected, 14 of 19 variants associated with partial expressivity of CF had >25% WT-CFTR function; however, four had minimal to no effect on CFTR function (>75% WT-CFTR). Thus, 6 of 48 (13%) missense variants believed to be disease causing did not alter CFTR function. Functional studies substantially refined pathogenicity assignment with expert annotation and criteria from the American College of Medical Genetics and Genomics and Association for Molecular Pathology. However, four algorithms (CADD, REVEL, SIFT, and PolyPhen-2) could not differentiate between variants that caused severe, moderate, or minimal reduction in function. In the setting of variable expressivity, these results indicate that functional assays are essential for accurate interpretation of missense variants and that current prediction tools should be used with caution.

Functional hemodynamic testing in pregnancy: recommendations of the International Working Group on Maternal Hemodynamics

In the general population, functional hemodynamic testing, such as that during submaximal aerobic exercise and isometric handgrip, and the cold pressor test, has long been utilized to unmask abnormalities in cardiovascular function. During pregnancy, functional hemodynamic testing places additional demands on an already stressed maternal cardiovascular system. Dysfunctional responses to such tests in early pregnancy may predict the development of hypertensive disorders that develop later in gestation. For each of the above functional hemodynamic tests, these recommendations provide a description of the test, test protocol and equipment required, and an overview of the current understanding of clinical application during pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Facioscapulohumeral muscular dystrophy functional composite outcome measure

INTRODUCTION

We developed an evaluator-administered functional facioscapulohumeral muscular dystrophy composite outcome measure (FSHD-COM) comprising patient-identified areas of functional burden for future clinical trials.

METHODS

We performed a prospective observational study of 41 patients with FSHD at 2 sites. The FSHD-COM includes functional assessment of the legs, shoulders and arms, trunk, hands, and balance/mobility. We determined the test-retest reliability and convergent validity compared to established FSHD disease metrics.

RESULTS

The FSHD-COM demonstrated excellent test-retest reliability (intraclass correlation coefficient [ICC] 0.96; subscale ICC range, 0.90-0.94). Cross-sectional associations between the FSHD-COM and disease duration, clinical severity, and strength were moderate to strong (Pearson correlation coefficient range |0.51-0.92|).

DISCUSSION

The FSHD-COM is a disease-relevant, functional composite outcome measure suitable for future FSHD clinical trials that shows excellent test-retest reliability and cross-sectional associations to disease measures. Future directions include determining multisite reliability, sensitivity to change, and the minimal clinically important change in the FSHD-COM. Muscle Nerve, 2018.

Diagnostic accuracy of instantaneous wave free-ratio in clinical practice

AIMS

To evaluate the correlation between iFR and FFR in real-world clinical practice.

METHODS AND RESULTS

Retrospective, single-centre study of 229 consecutive pressure-wire studies (n_p  = 158). Real-time iFR and FFR measurements were performed for angiographically borderline stenoses. Functionally significant stenoses were defined as iFR <0.86 or FFR ≤0.80. An iFR between 0.86 and 0.93 was considered within the grey zone (Hybrid approach). Median iFR and FFR (IQR) were 0.92 (0.87-0.95) and 0.83 (0.76-0.89), respectively. Pearson's correlation coefficient was 0.75 (P < 0.001). Bland-Altman plot showed a mean difference between iFR and FFR that remained consistent throughout the range of values. The optimal iFR cutoff was 0.91-sensitivity 80%, specificity 82% with ROC area under curve of 89%. Using the Hybrid iFR-FFR strategy, we demonstrated high accuracy of iFR results-sensitivity 95%, specificity 96%, PPV 95%, and NPV 96%. In addition, this method would have avoided adenosine in 56% of patients. Mean follow-up period was 17.2 (±3.4) months. All-cause mortality was 3.2% (n_p  = 5) and repeat intervention was required in six lesions (2.6%).

CONCLUSIONS

This study demonstrates that iFR is a valuable adjunct to FFR using the Hybrid iFR-FFR strategy in a real-world population. The use of adenosine may be avoided in about half the cases.

The Effect of Fatigue on Upper Quarter Y-Balance Test Scores in Recreational Weightlifters: A Randomized Controlled Trial

BACKGROUND

A paucity of research currently exists for upper extremity return to sport testing. The Upper Quarter Y-Balance Test (YBT-UQ) is a clinical test of closed kinetic chain performance with demonstrated reliability. Prior investigations of the YBT-UQ were conducted with individuals in a resting state and no comparison to performance in a fatigued state has been conducted.

PURPOSE

To examine the effect of upper extremity fatigue on the performance of the YBT-UQ in recreational weightlifters.

STUDY DESIGN

Randomized controlled trial.

METHODS

24 participants who participated in recreational weight training three days per week were randomly allocated to a control or experimental group. Individuals in the control group were tested using the YBT-UQ and re-tested after a 20-minute rest period. Participants in the experimental group were tested with the YBT-UQ, performed an upper extremity exercise fatigue protocol, and immediately re-tested. Examiners were blinded to participant allocation.

RESULTS

Differences from pre- to post-fatigue YBT-UQ testing revealed score reductions between 2.04cm - 12.16cm for both composite scores and individual reach directions. The repeated measures ANOVA revealed significant differences when comparing the pre- and post-testing results between the fatigue and non-fatigue groups for all individual directions (p ≤ .006) and composite scores both limbs (p<.035).

CONCLUSION

The performance of an upper body fatigue protocol significantly reduces YBT-UQ scores in recreational weightlifters.

LEVEL OF EVIDENCE

1b.

Objective functional results in patients with knee osteoarthritis submitted to a 2-day educational programme: a prospective randomised clinical trial

BACKGROUND

Although education is recommended for the treatment of knee osteoarthritis (KOA), its effectiveness in osteoarthritis (OA) remains low according to subjective questionnaires. The timed-up-and-go (TUG) and five-times-sit-to-stand tests (FTSST) reflect muscle strength and balance and could be used as objective measures of effectiveness.

AIM

To measure the effect of an educational programme in patients with KOA by TUG and FTSST and correlate these results to those of subjective questionnaires.

METHODS

Prospective randomised controlled trial of patients with KOA. Participants (n=198) were allocated into four groups. Three groups participated in 2 days of lectures with 1 (group 1), 2 (group 2) and 3-month (group 3) intervals between classes. Group 4 had no classes. Participants were asked to exercise at least three times a week. Half of the patients from all groups received bimonthly telephone calls reinforcing diet and exercise instructions. All four groups received the printed and video material presented in the classes. At baseline and at 1 year after initial assessment, patients performed the FTSST and TUG and answered WOMAC, Lequesne, SF-36 and Visual Analogue Scale questionnaires.

RESULTS

The TUG results did not change at 1 year follow-up, whereas FTSST improved (average difference of 4.66, p<0.001) irrespective of the implementation of classes or telephone calls. Both baseline and 1 year TUG and FTSST results correlated weakly (r<0.3) to the subjective functional, pain and quality of life results (p<0.001).

CONCLUSIONS

This educational programme improved function as determined by lower limb muscle strength (FTSST) irrespective of the patients' subjective non-improvement.

TRIAL REGISTRATION NUMBER

Clinical trials registration number: NCT01572051.

LEVEL OF EVIDENCE

Level 1A.

Pharmacogenetic characterization of naturally occurring germline NT5C1A variants to chemotherapeutic nucleoside analogs

BACKGROUND

Mutations or alterations in expression of the 5' nucleotidase gene family can lead to altered responses to treatment with nucleoside analogs. While investigating leukemia susceptibility genes, we discovered a very rare p.L254P NT5C1A missense variant in the substrate recognition motif. Given the paucity of cellular drug response data from the NT5C1A germline variation, we characterized p.L254P and eight rare variants of NT5C1A from genomic databases.

MATERIALS AND METHODS

Through lentiviral infection, we created HEK293 cell lines that stably overexpress wild-type NT5C1A, p.L254P, or eight NT5C1A variants reported in the National Heart Lung and Blood Institute Exome Variant Server (one truncating and seven missense). IC50 values were determined by cytotoxicity assays after exposure to chemotherapeutic nucleoside analogs (cladribine, gemcitabine, 5-fluorouracil). In addition, we used structure-based homology modeling to generate a three-dimensional model for the C-terminal region of NT5C1A.

RESULTS

The p.R180X (truncating), p.A214T, and p.L254P missense changes were the only variants that significantly impaired protein function across all nucleotide analogs tested (>5-fold difference vs. wild-type; P<0.05). Several of the remaining variants individually showed differential effects (both more and less resistant) across the analogs tested. The homology model provided a structural framework to understand the impact of NT5C1A mutants on catalysis and drug processing. The model predicted active site residues within NT5C1A motif III and we experimentally confirmed that p.K314 (not p.K320) is required for NT5C1A activity.

CONCLUSION

We characterized germline variation and predicted protein structures of NT5C1A. Individual missense changes showed considerable variation in response to the different nucleoside analogs tested, which may impact patients' responses to treatment.

Workstation-Based Calculation of CTA-Based FFR for Intermediate Stenosis

OBJECTIVES

This study sought to evaluate the proportion of patients with intermediate coronary stenosis diagnosed on computed tomography angiography (CTA), which may be saved from any further testing due to use of CTA-based fractional flow reserve (FFR).

BACKGROUND

Coronary CTA often results in diagnosis of intermediate stenosis, triggering further physiological testing. CTA-based FFR (CTA-FFR) is a promising diagnostic tool, which may obviate the need for further testing. However, the specific thresholds for CTA-FFR values predicting ischemic versus nonischemic FFR with acceptable confidence are unknown, obscuring clinical utility of the diagnostic strategy using CTA-FFR.

METHODS

We analyzed 96 lesions (mean CTA stenosis: 69.7 ± 11.7%) in 90 patients (63.4 ± 8.2 years, 32% were men) who underwent CTA for suspected CAD and were diagnosed with at least 1 intermediate coronary stenosis (50% to 90%) scheduled for further physiological testing. All patients underwent routine invasive FFR and CTA-FFR evaluation. The objective was to determine the proportion of patients falling between the lower and upper CTA-FFR thresholds that predict ischemic and nonischemic stenosis, respectively (on the basis of an invasive FFR cutpoint of ≤0.80), with ≥90% accuracy.

RESULTS

The invasive FFR ≤0.8 was observed in 41 of 96 lesions (42.7%). According to Bland-Altman analysis, the CTA-FFR underestimated FFR by 0.01 and the 95% limits of agreement were ±0.19. Receiver-operating characteristic area under the curve was significantly higher for CTA-FFR than that for CTA (per lesion 0.835 vs. 0.660, respectively; p = 0.007). The CTA-FFR thresholds for which the positive and negative predictive values were each ≥90% (corresponding to an FFR of ≤0.80) were >0.87 or <0.74, respectively, encompassing 49 lesions (51%) and 45 of 90 patients.

CONCLUSIONS

In around one-half of the patients diagnosed with intermediate stenosis, coronary CTA-based FFR may confidently discriminate between ischemic versus nonischemic stenoses. Our findings require validation in an independent cohort.

Assessment of body-powered upper limb prostheses by able-bodied subjects, using the Box and Blocks Test and the Nine-Hole Peg Test

BACKGROUND

The functional performance of currently available body-powered prostheses is unknown.

OBJECTIVE

The goal of this study was to objectively assess and compare the functional performance of three commonly used body-powered upper limb terminal devices.

STUDY DESIGN

Experimental trial.

METHODS

A total of 21 able-bodied subjects (n = 21, age = 22 ± 2) tested three different terminal devices: TRS voluntary closing Hook Grip 2S, Otto Bock voluntary opening hand and Hosmer Model 5XA hook, using a prosthesis simulator. All subjects used each terminal device nine times in two functional tests: the Nine-Hole Peg Test and the Box and Blocks Test.

RESULTS

Significant differences were found between the different terminal devices and their scores on the Nine-Hole Peg Test and the Box and Blocks Test. The Hosmer hook scored best in both tests. The TRS Hook Grip 2S scored second best. The Otto Bock hand showed the lowest scores.

CONCLUSION

This study is a first step in the comparison of functional performances of body-powered prostheses. The data can be used as a reference value, to assess the performance of a terminal device or an amputee.

CLINICAL RELEVANCE

The measured scores enable the comparison of the performance of a prosthesis user and his or her terminal device relative to standard scores.

Perspectives on Aging Vestibular Function

Much is known about age-related anatomical changes in the vestibular system. Knowledge regarding how vestibular anatomical changes impact behavior for older adults continues to grow, in line with advancements in diagnostic testing. However, despite advancements in clinical diagnostics, much remains unknown about the functional impact that an aging vestibular system has on daily life activities such as standing and walking. Modern diagnostic tests are very good at characterizing neural activity of the isolated vestibular system, but the tests themselves are artificial and do not reflect the multisensory aspects of natural human behavior. Also, the majority of clinical diagnostic tests are passively applied because active behavior can enhance performance. In this perspective paper, we review anatomical and behavioral changes associated with an aging vestibular system and highlight several areas where a more functionally relevant perspective can be taken. For postural control, a multisensory perturbation approach could be used to bring balance rehabilitation into the arena of precision medicine. For walking and complex gaze stability, this may result in less physiologically specific impairments, but the trade-off would be a greater understanding of how the aging vestibular system truly impacts the daily life of older adults.