Examining the diagnostic accuracy of common physical examination and functional tests in the diagnosis of patellofemoral pain syndrome among patients with anterior knee pain

PURPOSE

The aims of this study were to evaluate the diagnostic accuracy of common physical examination and functional evaluation tests, and to determine a set of tests with the highest diagnostic accuracy for diagnosing patellofemoral pain syndrome (PFPS) in patients with anterior knee pain.

METHODS

Based on careful evaluation of clinical findings and imaging methods by orthopedic physicians, 162 patients with anterior knee pain were classified into two groups of PFPS and non-PFPS. The physical examination and functional tests were performed by two physiotherapists. The accuracy of these measures was determined by calculating sensitivity, specificity, area under the receiver operating characteristic (ROC) curve (AUC), likelihood ratio (LR), and predictive value (PV).

RESULTS

Our results showed the most sensitive tests in identifying patients with PFPS were as follows: eccentric step test [0.82 (95%CI: 0.72-0.89)]; palpation test [0.81(95%CI: 0.70-0.88)]; and prolonged sitting [0.73 (95%CI: 0.62-0.82)]. The palpation test, patellar tilt test, eccentric step test, navicular drop test, squatting, and stair descending tests had an acceptable accuracy (AUC ≥ 70). The strongest combination of the physical examination and functional tests included pain severity between 3 and 10 during stair descending test and pain severity between 6 and 10 during prolonged sitting test. This combination showed a positive LR of 19.47 (95% CI: 6.36-59.65) and a posttest probability of 95%.

CONCLUSION

Our findings provide evidence for the good accuracy of the palpation test, patellar tilt test, eccentric step test, navicular drop test, squatting, and stair descending and prolonged sitting tests for diagnosing PFPS. Also, the combination of stair descending test and prolonged sitting test could be very useful for ruling in PFPS patients.

Direction-Specific Changes in Trunk Muscle Synergies in Individuals With Extension-Related Low Back Pain

Background Identifying altered trunk control is critical for treating extension-related low back pain (ERLBP), a common subgroup classified by clinical manifestations. The changed coordination of trunk muscles within this group during particular trunk tasks is still not clearly understood. Objectives The objective of this study is to investigate trunk muscle coordination during 11 trunk movement and stability tasks in individuals with ERLBP compared to non-low back pain (LBP) participants. Methods Thirteen individuals with ERLBP and non-LBP performed 11 trunk movement and stability tasks. We recorded the electromyographic activities of six back and abdominal muscles bilaterally. Trunk muscle coordination was assessed using the non-negative matrix factorization (NMF) method to identify trunk muscle synergies. Results The number of synergies in the ERLBP group during the cross-extension and backward bend tasks was significantly higher than in the non-LBP group (p<0.05). The cluster analysis identified the two trunk synergies for each task with strikingly similar muscle activation patterns between groups. In contrast, the ERLBP group exhibited additional trunk muscle synergies that were not identified in the non-LBP group. The number of synergies in the other tasks did not differ between groups (p>0.05). Conclusion Individuals with ERLBP presented directionally specific alterations in trunk muscle synergies that were considered as increased coactivations of multiple trunk muscles. These altered patterns may contribute to the excessive stabilization of and the high frequency of hyperextension in the spine associated with the development and persistence of ERLBP.

Remote administration of the short physical performance battery, the 1-minute sit to stand, and the Chester step test in post-COVID-19 patients after hospitalization: establishing inter-reliability and agreement with the face-to-face assessment

PURPOSE

To assess the inter-reliability of the Short Physical Performance Battery (SPPB), the 1-min Sit to Stand test (1-MSTS), and the Chester Step Test (CST) via remote assessment in post-COVID-19 patients after hospitalization.

METHODS

Twenty-five post-COVID-19 patients randomly performed the functional tests via remote assessment using a software platform at home and via face-to-face assessment at the rehabilitation center 24-72 h apart. One day before the remote assessment, all participants had a 1-h guidance session regarding the platform use, safety instructions, and home equipment preparation.

RESULTS

Participants completed all tests for both assessment procedures without experience of adverse events. The mean age was 53 (SD = 10) years old, and the median days of hospitalization were 23 (IQR = 10-33). The inter-reliability was moderate for the total score in the SPPB: Cohen's kappa = 0.545 (95% CI: 0.234 to 0.838), excellent for the number of repetitions in the 1-MSTS: ICC = 0.977 (95% CI: 0.948 to 0.990) and good for the total number of steps in the CST: ICC = 0.871 (95% CI: 0.698 to 0.944).

CONCLUSION

Remote functional assessments for SPPB, 1-MSTS, and CST indicated moderate to excellent inter-reliability in post-COVID-19 patients after hospitalization.

Effect of nutritional supports on malnutrition, cognition, function and biomarkers of Alzheimer's disease: a systematic review

AIM

To summarize the nutritional supplementation on biochemical parameters, cognition, function, Alzheimer's Disease (AD) biomarkers and nutritional status.

MATERIALS AND METHODS

PubMed, Web of Science, Korean Journal Database, Russian Science Citation Index, SciELO Citation Index, Cochrane Library and Scopus databases were searched until 16 April 2021. 22.193 records in total were reached according to inclusion and exclusion criteria. Included Studies were evaluated through the Modified Jadad Scale and gathered under four subheadings.

RESULTS

Forty-eight studies with a total of 7009 AD patients were included. Souvenaid, ONS (368 ± 69 kcal), Vegenat-med, 500 mg Resveratrol, ONS (200 mL) were effective nutritional supplements on promoting weight gain and protecting malnutrition status but showed conflicting results in Body mass index, Mid-Upper-Arm Circumference and Triceps Skin Fold Thickness. ONS and a lyophilized whole supplementation Vegenat-med intake made an increase in MNA scores. While all nutritional supplements showed controversial results in biochemical parameters but caused a decrease in Hcy levels which caused reductions in brain Aβ plaque (increase serum Aβ), p-Tau and cognitive improvement. Folic acid and vitamin D decreased serum APP, BACE1, BACE1mRNA. Resveratrol, Hericium erinaceus mycelia, vitamin D and Betaine supplements improved cognitive, functional prognosis and quality of life unlike other nutritional supplements had no effect on cognitive scales.

CONCLUSIONS

Better designed trials with holistic measures are needed to investigate the effect of nutritional support on the AD biomarkers, cognitive status, biochemical parameters and functional states. Also, more beneficial results can be obtained by examining the simultaneous effects of nutritional supplements with larger sample groups.

The Relationship between Magnetic Resonance Imaging and Functional Tests Assessment in Patients with Lumbar Disk Hernia

Although magnetic resonance imaging (MRI) findings are the gold standard for diagnosing herniated discs, there are many limitations to accessing MRI scanning devices in practice. This study aimed to evaluate the relationship between functional tests (the visual analog scale (VAS), the SLUMP test, the Sciatica Bothersomeness Index (SBI), the Oswestry Disability Index (ODI), and the LASEGUE test and MRI findings (LSA, IVDH L4-L5, IVDH L5-S1, DHS L4-L5, and DHS L5-S1) in patients diagnosed with disc herniation. Seventy-eight patients who met the inclusion criteria participated in the study. Radiologists and neurologists evaluated patients with disc herniation. After the disc hernia diagnosis, the patients were referred to a physical therapist for conservative management of the disk hernia. The physical therapists assessed the pain level and performed functional tests on patients. All statistical analyses were performed using R (Core Team) software. The correlation between the measured variables was conducted using the Pearson and Spearman tests. The study results indicated statistically significant correlations between DHS L4-L5 vertebral level and functional tests (VAS: r = 0.49, p = 0.00; SBI: r = 0.44, p = 0.00; ODI: r = 0.49, p = 0.00; LASEGUE: r = -0.48, p = 0.00; SLUMP: r = 0.50, p = 0.00). In conclusion, physiotherapists may prefer functional tests to diagnose the herniated disc, and these functional tests may contribute to performing evidence-based assessments.

Correlation between Power Elbow Flexion and Physical Performance Test: A Potential Predictor for Assessing Physical Performance in Older Adults

BACKGROUND

With the increasing number of older adults and their declining motor and cognitive function, it is crucial to find alternative methods for assessing physical functionality. The Short Physical Performance Battery (SPPB), the Time Up and Go (TUG) test, the 4 Meter Walk Test and the Barthel Index (BI) have been used to evaluate mobility and fragility and predict falls. But some of these functional test tasks could be difficult to perform for frail older adults or bedridden patients that cannot ambulate. This study aimed to evaluate the relationship between these functional tests and the power elbow flexion (PEF test).

MATERIAL AND METHODS

A correlation study was designed with 41 older adults over 65 years of age. The upper limb muscle power was measured using a linear encoder (VITRUBE VBT) with the flexion of the elbow.

RESULTS

Strong correlations were found between the PEF test and the 4mWT (rho = 0.715, p = 0.001) and TUG (rho= -0.768, p = 0.001), indicating that the greater the upper limb muscle power is, the greater physical performance will be. Moderate correlations were also found between the PEF and Barthel Index (rho = 0.495, p = 0.001) and SPPB (rho = 0.650, p < 0.001).

CONCLUSIONS

There is a strong correlation between PEF and the functional tests, proving that older adults that have greater upper limb muscle power have better physical performance. Upper limb muscle power and PEF could be an interesting tool for the assessment of physical performance in bedridden older adults.

Delayed Surgical Treatment in Patients with Chronic Carpal Tunnel Syndrome Is Still Effective in the Improvement of Hand Function

Background and Objectives: Severe carpal tunnel syndrome (CTS) is the most common compression neuropathy in the upper extremities treated conservatively; later, when advanced, CTS is treated mostly surgically. The most prevalent symptoms comprise numbness, as well as sensation loss in the thumb, index, and middle finger, and thenar muscle strength loss, resulting in impaired daily functioning for patients. Data on the results of CTS treatment in patients with delayed surgical intervention are scarce. The aim of this study was to determine the postoperative results of chronic carpal tunnel syndrome treatment in patients with symptoms lasting for at least 5 years. Materials and Methods: A total of 86 patients (69 females, 17 males) with a mean age of 58 years reporting symptoms of CTS for at least 5 years (mean: 8.5 years) were prospectively studied. The average follow-up time was 33 months. All patients underwent the surgical open decompression of the median nerve at the wrist. A preoperative observation was composed of an interview and a clinical examination. The subjects completed the DASH (the Disabilities of the Arm, Shoulder, and Hand), PRWE (Patient-Rated Wrist Evaluation), and self-report questionnaires. Global grip strength, sensory discrimination, characteristic symptoms of CTS, and thenar muscle atrophy were examined. Postoperatively, clinical and functional examinations were repeated, and patients expressed their opinions by completing a BCTQ (Boston Carpal Tunnel Syndrome Questionnaire). Results: We found improvements in daily activities and hand function postoperatively. Overall, 88% of patients were satisfied with the outcome of surgery. DASH scores decreased after surgery from 44.82 to 14.12 at p < 0.001. PRWE questionnaire scores decreased from 53.34 to 15.19 at p < 0.001. The mean score of the BCTQ on the scale regarding the severity of symptoms was 1.48 and 1.62 on the scale regarding function after surgery. No significant differences were found in the scores between the male and female groups or between age groups (p > 0.05). A significant increase in global grip strength from 16.61 kg to 21.91 kg was observed postoperatively at p < 0.001. No significant difference was detected in the measurement of sensory discrimination (6.02 vs. 5.44). In most of the examined patients, night numbness and wrist pain subsided after surgery at p < 0.001. Thenar muscle atrophy diminished after surgery at p < 0.001. Conclusions: Most patients were satisfied with the results of CTS surgery regarding the open decompression of the median nerve even after 5 years of ineffective conservative treatment. Significant improvement of the hand function was confirmed in the functional studies.

Association among inflammaging, body composition, physical activity, and physical function tests in physically active women

Background

Inflammaging is a phenomenon that has been associated with the development and progression of sarcopenia and frailty syndrome. According to the literature, on the one side, the increase in body fat is associated with a systemic pro-inflammatory status, which consequently favors inflammaging, and on the other side, the regular practice of physical exercise can mitigate the development of this scenario. Therefore, here, we aimed to evaluate the association between inflammaging and physical factors, both body and functional, in a group of physically active older women.

Methods

Seventy older women (mean age 72.66 ± 6.17 years) participated in this observational cross-sectional and were separated into the eutrophic, overweight, and obese groups. It was assessed: by bioimpedance-body fat percentage (Fat%) and total (Fat kg), skeletal muscle mass (muscle), and free fat mass both in percentage (FFM%) and total (FFMkg); by the International Physical Activity Questionnaire (IPAQ)-the time of moderate-intensity physical activity per week; by physical tests-handgrip (HG), sit-up-stand-on-the-chair in 5 repetitions (Sit-up) and vertical squat jump test (SJ); in addition to the determination of serum cytokine concentration (IL-6, TNF-α, IL-10, and IL-8), and also body mass index (BMI) and calf circumference (Calf).

Results

Higher FFM% and lower body fat (both kg and %) were found in the eutrophic group than in the other groups. The eutrophic group also performed more weekly physical activity, jumped higher, and presented not only higher serum IL-6 concentration but also an increased ratio of IL-10/IL-6, IL-10/TNF-α, IL-10/IL-8 as compared to the values found in the overweight group. The obese group presented higher body fat (kg and %) and lower FFM% than the other groups and also higher serum IL-6 concentration than the overweight group. Interestingly, several significant negative and positive correlations between body composition, physical tests, and serum cytokine concentrations were found in the eutrophic and obese groups.

Conclusion

While the eutrophic older women group showed a remarkable regulation of the systemic inflammatory status with positive associations in the physical parameters assessed, the overweight and obese groups presented impairment regulations of the inflammaging, which could be related to less weekly physical activity and higher body fat.

Objective assessment of functional capacity in patients with peripheral artery disease: a narrative review

INTRODUCTION

Peripheral artery disease (PAD) patients with claudication symptoms exhibit impaired functional capacity, which has been associated with disease severity, worse quality of life and higher risk of cardiovascular events. Different tests have been used to assess functional capacity in PAD patients. Therefore, understanding the characteristics, strengths and limitations of these tests are important to support the choice of tests to be used in clinical practice.

AREAS COVERED

This review summarizes the main methods to assess functional capacity in PAD patients, discussing their psychometric properties, applications, and limitations.

EXPERT OPINION

Robust evidence supports the use of treadmill and six-minute walk tests in PAD patients, as their results are associated with clinically meaningful outcomes, adequate psychometric properties and are sensitive to effects of interventions. On the other hand, other functional tests (Shuttle-walk test, outdoor walking capacity test, timed-up and go, four-meter walk test, heel-rise test, short physical performance battery and modified physical performance battery) are related to activities of daily living and do not require sophisticated equipment and can be easily used in clinical practice. However, these other tests still need evidence regarding their clinical relevance, reliability, and ability to detect long-term intervention changes, providing further investigation directions.

Effect of 12-Week BMI-Based Vitamin D3 Supplementation in Parkinson's Disease with Deep Brain Stimulation on Physical Performance, Inflammation, and Vitamin D Metabolites

Parkinson's disease (PD) is the second most common neurodegenerative disease. To manage motor symptoms not controlled adequately with medication, deep brain stimulation (DBS) is used. PD patients often manifest vitamin D deficiency, which may be connected with a higher risk of falls. We administered a 12-week vitamin D₃ supplementation based on BMI (with higher doses given to patients with higher BMI) to investigate its effects on physical performance and inflammation status in PD patients with DBS. Patients were randomly divided into two groups: treated with vitamin D₃ (VitD, n = 13), and supplemented with vegetable oil as the placebo group (PL, n = 16). Patients underwent functional tests to assess their physical performance three times during this study. The serum 25(OH)D₃ concentration increased to the recommended level of 30 ng/mL in the VitD group, and a significant elevation in vitamin D metabolites in this group was found. We observed significant improvement in the Up and Go and the 6 MWT in the VitD group. In inflammation status, we noticed a trend toward a decrease in the VitD group. To conclude, achieving the optimal serum 25(OH)D₃ concentration is associated with better functional test performance and consequently may have a positive impact on reducing falling risk in PD.

Physical Performance and Mobility Tests Using Telehealth: A Feasibility Study With Athletes

CONTEXT

Physical performance tests (PPTs) and mobility tests have been widely used in sports rehabilitation. However, the feasibility of PPTs and mobility tests via telehealth is unknown.

OBJECTIVES

To verify the feasibility of PPTs and mobility tests to assess athletes via telehealth.

DESIGN

This is a feasibility study.

PARTICIPANTS

Athletes enrolled in a sports team or club for at least 2 years and with previous enrollment in a competitive league were recruited through advertisements on social media. The athletes included in this study (mean age = 25.9 y, from different sports) performed a battery of PPTs and mobility tests for the lower-extremity or upper-extremity and trunk, according to their sport modality.

MAIN OUTCOME MEASURE

The feasibility was assessed with recruitment, success, and dropout rates. In addition, athletes' perceptions of easiness, satisfaction, and safety during the lower-extremity or upper-extremity and trunk PPTs and mobility tests were assessed.

RESULTS

Seventy-three athletes were included, between January and April 2021: 41 were allocated to the lower-extremity and 32 to the upper-extremity and trunk PPTs and mobility test, according to their sports modality. The overall dropout rate was 20.55%; >89% of the athletes agreed that the PPTs and mobility tests via telehealth were easy to perform, >78% were satisfied, and >75% felt safe during the assessments.

CONCLUSION

This study indicated that these 2 batteries of performance and mobility tests via telehealth are feasible to assess the lower and upper-extremities, and the trunk of athletes, considering the adherence, athletes' perception of easiness, satisfaction, and safety.

Lower Extremity Physical Performance Tests for the Assessment of Athletes via Telehealth are Reliable

CONTEXT

Lower extremity physical performance tests (PPTs) have been widely used in sports rehabilitation and are commonly performed in person. However, some situations may disrupt the in-person health care delivery, such as social distancing due to the pandemic, traveling, and living in remote locations. Those situations may require adjustments in planning and applying measurement tests, and telehealth has become an alternative. Nevertheless, the reliability of lower extremity PPT tests via telehealth is still unknown.

OBJECTIVES

To verify the test-retest reliability, SEM, and the minimum detectable change (MDC95) of PPTs via telehealth.

METHODS

Fifty asymptomatic athletes completed 2 assessment sessions 7 to 14 days apart. The assessment via telehealth consisted of warm-up exercises followed by the single-, triple-, and side-hop tests, and the long jump test, in random order. Intraclass correlation coefficient, SEM, and MDC95 were calculated for each PPT.

RESULTS

Single-hop test showed good to excellent reliability, with SEM and MDC95 ranging from 6.06 to 9.24 cm and 16.79 to 25.61 cm, respectively. The triple-hop test showed excellent reliability, with SEM and MDC95 ranging from 13.17 to 28.17 cm and 30.72 to 78.07 cm, respectively. Side-hop tests showed moderate reliability, with SEM and MDC95 ranging from 0.67 to 1.22 seconds and 2.00 to 3.39 seconds, respectively. The long jump test showed excellent reliability, with SEM and MDC95 ranging from 5.34 to 8.34 cm and 14.80 to 23.11 cm, respectively.

CONCLUSION

The test-retest reliability of those PPTs via telehealth was acceptable. The SEM and MDC were provided to assist clinicians in interpreting those PPTs.

Functional Tests Predicting Return to Work of Workers with Non-Specific Low Back Pain: Are There Any Validated and Usable Functional Tests for Occupational Health Services in Everyday Practice? A Systematic Review

The literature predominantly advocates subjective perception of disability and pain as an outcome measure for the functional evaluation of patients with low back pain (LBP). Physical outcome measurements are almost completely ignored. In this systematic review, we focused on physical functional measurements that can contribute to the prediction of patients' return to work (RTW) readiness after sick leave or rehabilitation. Searches were conducted in July 2022 without any time limit in the Cochrane Library, PEDro, PubMed and Scopus databases for functional and clinical tests reliable and applicable in clinical practice without demanding equipment. Two independent researchers extracted the data from the included articles in a standardised data collection form, and a third researcher validated the data extraction. No date restriction was applied. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in conducting the review. We found seven original articles, including six with an impact on predicting RTW. We found four fair and three poor original studies fulfilling our criteria. We found the Back Performance Scale (BPS) and back endurance test to be the most promising tests for occupational health service and the clinical practitioner. Radiation of back pain, with or without neurological deficiencies, had some predictive value in terms of RTW, too. The working conditions vary a lot, which causes inconsistency in the studies and in their interpretation. Functional tests could complete the widely used working ability evaluations methods such as the Work Ability Index (WAI) and are worth considering for future research. Overall, more research is needed in this field. The question of when LBP patients can resume everyday activities and work is not possible to determine with functional tests alone. Psychosocial aspects and work demands must be considered. PROSPERO: CRD42022353955. The study was funded by the University of Helsinki.

Dynamic Methods for Childhood Hypoglycemia Phenotyping: A Narrative Review

Hypoglycemia results from an imbalance between glucose entering the blood compartment and glucose demand, caused by a defect in the mechanisms regulating postprandial glucose homeostasis. Hypoglycemia represents one of the most common metabolic emergencies in childhood, potentially leading to serious neurologic sequelae, including death. Therefore, appropriate investigation of its specific etiology is paramount to provide adequate diagnosis, specific therapy and prevent its recurrence. In the absence of critical samples for biochemical studies, etiological assessment of children with hypoglycemia may include dynamic methods, such as in vivo functional tests, and continuous glucose monitoring. By providing detailed information on actual glucose fluxes in vivo, proof-of-concept studies have illustrated the potential (clinical) application of dynamic stable isotope techniques to define biochemical and clinical phenotypes of inherited metabolic diseases associated with hypoglycemia. According to the textbooks, individuals with glycogen storage disease type I (GSD I) display the most severe hypoglycemia/fasting intolerance. In this review, three dynamic methods are discussed which may be considered during both diagnostic work-up and monitoring of children with hypoglycemia: 1) functional in vivo tests; 2) in vivo metabolic profiling by continuous glucose monitoring (CGM); 3) stable isotope techniques. Future applications and benefits of dynamic methods in children with hypoglycemia are also discussed.

Detection of Upper Limb Asymmetries in Athletes According to the Stage of the Season-A Longitudinal Study

Sports injuries can affect the performance of athletes. For this reason, functional tests are used for injury assessment and prevention, analyzing physical or physiological imbalances and detecting asymmetries. The main aim of this study was to detect the asymmetries in the upper limbs (right and left arms) in athletes, using the OctoBalance Test (OB), depending on the stage of the season. Two hundred and fifty-two participants (age: 23.33 ± 8.96 years old; height: 178.63 ± 11.12 cm; body mass: 80.28 ± 17.61 kg; body mass index: 24.88 ± 4.58; sports experience: 12.52 ± 6.28 years), practicing different sports (rugby, athletics, football, swimming, handball, triathlon, basketball, hockey, badminton and volleyball), assessed with the OB in medial, superolateral, and inferolateral directions in both arms, in four moments of the season (May 2017, September 2017, February 2018 and May 2018). ANOVA test was used with repeated measures with a p ≤ 0.05, for the analysis of the different studied variances. Significant differences were found (p = 0.021) in the medial direction of the left arm, between the first (May 2017) and fourth stages (May 2018), with values of 71.02 ± 7.15 cm and 65.03 ± 7.66 cm. From the detection of asymmetries, using the OB to measure, in the medial, superolateral and inferolateral directions, mobility and balance can be assessed. In addition, it is possible to observe functional imbalances, as a risk factor for injury, in each of the stages into which the season is divided, which will help in the prevention of injuries and in the individualization of training.

Biomechanical Response of the Lower Extremity to Running-Induced Acute Fatigue: A Systematic Review

Objective: To investigate (i) typical protocols used in research on biomechanical response to running-induced fatigue, (ii) the effect of sport-induced acute fatigue on the biomechanics of running and functional tests, and (iii) the consistency of analyzed parameter trends across different protocols.

Methods: Scopus, Web of Science, Pubmed, and IEEE databases were searched using terms identified with the Population, Interest and Context (PiCo) framework. Studies were screened following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and appraised using the methodological index for non-randomized studies MINORS scale. Only experimental studies with at least 10 participants, which evaluated fatigue during and immediately after the fatiguing run were included. Each study was summarized to record information about the protocol and parameter trends. Summary trends were computed for each parameter based on the results found in individual studies.

Results: Of the 68 included studies, most were based on in-lab (77.9%) protocols, endpoint measurements (75%), stationary measurement systems (76.5%), and treadmill environment (54.4%) for running. From the 42 parameters identified in response to acute fatigue, flight time, contact time, knee flexion angle at initial contact, trunk flexion angle, peak tibial acceleration, CoP velocity during balance test showed an increasing behavior and cadence, vertical stiffness, knee extension force during MVC, maximum vertical ground reaction forces, and CMJ height showed a decreasing trend across different fatigue protocols.

Conclusion: This review presents evidence that running-induced acute fatigue influences almost all the included biomechanical parameters, with crucial influence from the exercise intensity and the testing environment. Results indicate an important gap in literature caused by the lack of field studies with continuous measurement during outdoor running activities. To address this gap, we propose recommendations for the use of wearable inertial sensors.

Substantiation of Methods for Predicting Success in Artistic Swimming

To develop a methodology for predicting success in artistic swimming based on a set of morphofunctional indicators and indices, 30 schoolgirls, average age (12.00 ± 0.22), were divided into two groups. Group 1: 15 athletes, training experience 4–5 years. Group 2: 15 schoolgirls without training experience. For each participant, we determined the length and weight of the body, the circumference of the chest, vital lung capacity, and the circumference of the biceps in a tense and at rest. The Erisman index, biceps index, and the ratio of proper and actual vital lung capacity was calculated. Them, we conducted the Stange and Genchi hypoxic tests, and flexibility tests for “Split”, “Crab position”, and “Forward bend”. Prediction was conducted using the Wald test with the calculation of predictive coefficients and their informativeness. A predictive table containing results of functional tests and indices of artistic swimming athletes is developed. It includes nine criteria, which informativeness varied in the range of 395.70–31.98. The content of the prediction consists of evaluating the results, determining the appropriate predictive coefficient, and summing these coefficients before reaching one of the predictive thresholds. The conducted research allowed us to substantiate and develop a method for predicting the success of female athletes with the use of morphofunctional indicators and indices.

[Modern methods in diagnostics of lacrimal system vertical part obliteration]

A review of the literature is devoted to the description of modern diagnostic methods that are directed at detecting lacrimal pathway obstruction. The presented analysis is based on the study of data from Russian and foreign literary sources on both routine and high-tech lacrimal system examination methods, as well as on authors' experience in studying the diagnostic efficiency of imaging methods such as lacrimal scintigraphy, computed tomography with lacrimal pathway contrasting, and also single photon emission computed tomography. The article gives information about the advantages and disadvantages of the presented methods, highlights the questions of the prospects of their usage in practical dacryology.

Validity, Reliability and Reproducibility of OctoBalance Test as Tool to Measure the Upper Limb Compared to Modified-Upper Quarter Y-Balance Test

The articular evaluation of range of motion (ROM) is currently used to observe imbalance or limitations as possible risk factors or predispositions to suffer future injures. The main aim of this study is to verify the concurrent validity, reliability and reproducibility of the OctoBalance Test (OB) as a valid and reliable tool to measure articular ROM of the upper limb compared to the modified-Upper Quarter Y-Balance Test (mUQYBT). The twenty-five participants were male athletes. All of them were assessed with OB and mUQYBT in medial, superolateral, and inferolateral directions in both right and left arms with a three-minute break during these attempts. The process was repeated a second time with a week gap between measurements. Pearson correlation and linear logarithmic regression were used to examine the relationship between scores obtained with OB and mUQYBT. In order to verify the reliability, the intraclass correlation coefficient (ICC) was used (3.1). Concordance and reproducibility were assessed using Bland–Altman’s graph. A perfect correlation and an almost linear logarithmic regression (R² = 0.97) were observed between both measurement systems, with values of 73.531 ± 21.226 cm in mUQYBT and 69.541 ± 16.330 cm in OB. The differences were minimal between week one and week two. The assessment with Bland’s graph showed the concordance and reproducibility of scores, showing the dispersion and the upper and lower limits. OB is shown as valid in comparison to the other test as a reliable and reproducible tool for the assessment of the articular ROM in the upper limb, and it could be used for the evaluation of injuries.

Designing a screening battery for exercisers with Parkinson's disease

PURPOSE

Develop a screening battery for persons with Parkinson's Disease (PD) that is easily administered in a short amount of time by community exercise professionals and measures changes in function.

METHODS

An integrated, stakeholder-engaged, mixed methods approach included interviews and meetings with community exercise professionals on the development of a screening battery. Persons with PD (n = 57, age = 72.1 ± 8.1 years) who were already enrolled in fitness classes or individualized training at three locations participated in the screening battery twice over 8-16 weeks and provided feedback. Trends from interviews and meeting notes were identified using summative content analysis. Quantitative changes in performance were compared with paired t-tests. Cohen's d effect sizes were calculated for all significant differences.

RESULTS

Current barriers for functional screenings included time and space. Using this feedback, we developed a screening battery that took under 20 min, required little equipment, had been previously validated, could be performed in individual and group settings, and provided objective feedback that was motivating for persons with PD to continue exercising. Persons with PD demonstrated improved functional performance on sit-to-stand (d = -0.71), two-minute walk test (d = -3.83), and arm curls (d = -0.78).

CONCLUSION

Test results can be a motivator for persons with PD and lead to increased exercise adherence. Easily administered tests can show improvements in this population. Community exercise professionals are able to safely screen persons with PD to detect functional deficits and assist with programming.Implications for RehabilitationRegular exercise can slow declines in physical function and quality of life in people with Parkinson's disease.Use of physical assessments in community exercise programs can improve motivation to exercise for this population.Physical assessments such as sit-to-stand and arm curls can be used to demonstrate improvements in people with Parkinson's disease.

Screening tools for hereditary hemolytic anemia: new concepts and strategies

INTRODUCTION

Hereditary hemolytic anemias are a group of rare and heterogeneous disorders due to abnormalities in structure, metabolism, and transport functions of erythrocytes; they may overlap in clinical and hematological features making differential diagnosis difficult, particularly in mild and atypical forms.

AREAS COVERED

In the present review, the main tools currently adopted in routine hematologic investigation for the diagnosis of hereditary hemolytic anemias are described, together with the new diagnostic approaches that are being to be developed in the next future. Available recommendations in this field together with a systematic review through MEDLINE, EMBASE, and PubMED for publications in English from 2000 to 2020 in regards to diagnostic aspects of hereditary hemolytic anemias have been considered.

EXPERT OPINION

The recent development of specific molecules and treatments for hereditary hemolytic anemias and the increased interest in translational research raised the attention on differential diagnosis and the demand for novel diagnostic assays and devices. Automatic blood cell analyzers, omic-approaches including NGS technologies, and development of new automated tools based on artificial neural networks definitely represent the future strategies in this field.

RETURN TO SPORT PARTICIPATION CRITERIA FOLLOWING SHOULDER INJURY: A CLINICAL COMMENTARY

CONTEXT

The shoulder complex is frequently injured during sports. The tremendous mobility of the shoulder makes returning to sport participation following shoulder injury a challenging task for both the clinician and athlete. The purpose of this clinical commentary is to review the current literature on return to sport criteria and provide evidence-informed and clinically useful guidelines and recommendations to aid in clinical decision making for return to sports after shoulder micro- and macro-traumatic injuries.

EVIDENCE ACQUISITION

A search of the PubMed database using the terms functional tests, upper extremity testing, return to play, and shoulder injury was performed. Further evaluation of the bibliographies of the identified articles expanded the evidence. This evidence was used to inform the clinical commentary.

RESULTS

Return to sport decision making is a sequential, criterion-based process. Assessment of patient reported outcomes, range of motion, strength, and functional performance must all be considered. Numerous tests are available for the clinician to determine whether a patient is ready to return to sports following a shoulder injury or surgery. A different set of tests should be utilized for the overhead athlete (microtrauma injury) compared to the patient with a macrotraumatic shoulder injury because of the differing demands and sports requirements.

CONCLUSION

Use of pre-determined criteria, available in the literature, minimizes the reliance on the subjective element alone during takes athlete progression and provides everyone involved in the process with known, pre-established, measurable markers and goals that must be achieved prior to progressing to practice and returning to competition. This type of performance progression assessment testing provides the clinician with a useful set of tools to objectively assist and guide the determination regarding when an athlete can safely progress back to practice and then return to unrestricted athletic activities.

LEVEL OF EVIDENCE

5.

When Would Immunologists Consider a Nanomaterial to be Safe? Recommendations for Planning Studies on Nanosafety

The immune system is professional in recognizing and responding to non-self, including nanomaterials. Immune responses by professional and nonprofessional immune cells are thus nearly inevitable upon exposure of cells and organisms to such materials. The state of research into taking the immune system into account in nanosafety studies is reviewed and three aspects in which further improvements are desirable are identified: 1) Due to technical limitations, more stringent testing for endotoxin contamination should be made. 2) Since under overdose conditions immunity shows unphysiological responses, all doses used should be justified by being equivalent to tissue-delivered doses. 3) When markers of acute inflammation or cell stress are observed, functional assays are necessary to distinguish between homeostatic fluctuation and genuine defensive or tolerogenic responses. Since immune activation can also indicate that the immune system considers a stimulus to be harmless and induces tolerance, activation markers by themselves do not necessarily imply a danger to the body. Guidelines such as these are necessary to approach the point where specific nanomaterials are classified as safe based on reliable testing strategies.

Multifunctional Coatings for Robotic Implanted Device

The objective of this study was the preparation and physico-chemical, mechanical, biological, and functional characterization of a multifunctional coating for an innovative, fully implantable device. The multifunctional coating was designed to have three fundamental properties: adhesion to device, close mechanical resemblance to human soft tissues, and control of the inflammatory response and tissue repair process. This aim was fulfilled by preparing a multilayered coating based on three components: a hydrophilic primer to allow device adhesion, a poly(vinyl alcohol) hydrogel layer to provide good mechanical compliance with the human tissue, and a layer of poly(3-hydroxybutyrate-co-3-hydroxyvalerate) fibers. The use of biopolymer fibers offered the potential for a long-term interface able to modulate the release of an anti-inflammatory drug (dexamethasone), thus contrasting acute and chronic inflammation response following device implantation. Two copolymers, poly(vinyl acetate-acrylic acid) and poly(vinyl alcohol-acrylic acid), were synthetized and characterized using thermal analysis (DSC, TGA), Fourier transform infrared spectroscopy (FT-IR chemical imaging), in vitro cell viability, and an adhesion test. The resulting hydrogels were biocompatible, biostable, mechanically compatible with soft tissues, and able to incorporate and release the drug. Finally, the multifunctional coating showed a good adhesion to titanium substrate, no in vitro cytotoxicity, and a prolonged and controlled drug release.

Multicomponent Exercise on Physical Function, Cognition and Hemodynamic Parameters of Community-Dwelling Older Adults: A Quasi-Experimental Study

This paper reports on a quasi-experimental study that aimed to identify changes in muscle function (i.e., mobility, maximal walking speed, lower limb muscle strength, balance, and transfer capacity), cognition (i.e., executive function) and hemodynamic parameters of community-dwelling Brazilian older adults during a six-month multicomponent exercise program (MCEP). A total of 436 community-dwelling older adults performed functional, cognitive and hemodynamic assessments before and after a six-month MCEP. The program of exercise was performed twice a week over 26 weeks at moderate intensity. Results indicate that balance, mobility (i.e., usual and maximal walking speeds) and transfer capacity (p < 0.05) were significantly improved after the MCEP. Moreover, all hemodynamic parameters (i.e., systolic, diastolic and mean arterial pressures), except for heart rate (p > 0.05), were significantly reduced after the intervention. The current findings indicate that a six-month MCEP may provide physical and hemodynamic benefits in community-dwelling older adults. Nevertheless, our findings need to be confirmed in larger samples and better designed studies.

Effects of ankle dorsiflexion limitation on lower limb kinematic patterns during a forward step-down test: A reliability and comparative study

BACKGROUND

Altered lower limb movement patterns (LLMP) during the forward step down (FSD) test have been studied in people suffering from knee instability. However, ankle dorsiflexion range of motion (ADROM) seems to be related to LLMP but no causal inference has been defined between those variables.

OBJECTIVE

Our goals were to evaluate (1) psychometric quality of the FSD test in healthy people and (2) the influence of experimental restricted ADROM on LLMP.

METHODS

Kinematics were measured by a motion capture system. Angular displacement and speed were calculated as well as center of mass (COM) and knee linear displacement. Forty-two healthy participants; firstly, performed the test three times to assess reliability, and secondly the same test in an experimental condition limiting the ADROM.

RESULTS

Reliability was excellent for all parameters (ICC: 0.75-0.99, SEM%: 2.0-34.0%). ADROM limitation significantly decreased Knee flexion range of motion (ROM) (-3.8∘), increased Hip flexion ROM (6∘), Hip adduction ROM (6.1∘), Pelvis drop ROM (3.5∘), Pelvic rotation ROM (3.1∘). No significant effect was found for Hip rotation ROM.

CONCLUSIONS

LLMP was affected by this experimental ADROM limitation in healthy people. As this limitation is often encountered in post-traumatic ankle sprain patients, clinicians should consider this point during FSD assessment test.

Commonly available outcome measures for use in Indian boys with Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder. It is still an incurable disease and many clinical trials are going on to find the cure for this disease. There is a need for sensitive and reliable measures for detecting the disease progression. This manuscript focuses on reviewing the different outcome measures which can be used in the Indian DMD patients.

The influence of iatrogenic interatrial septum leaks after left atrial appendage closure on cardiac function test results

AIM

Left atrial appendage occlusion (LAAO) is a technique for preventing thromboembolism in patients with atrial fibrillation and a high risk of irreversible bleeding. In some patients, a spontaneous iatrogenic transseptal leak (ITL) remains after LAAO. The aim of this study was to assess the correlation between ITL incidence and the results of cardiac function tests in patients who underwent LAAO.

METHODS AND RESULTS

LAOO was performed in 62 consecutive patients using the Amplatzer Amulet. Before and 3 months after LAA occlusion, the 6-min walking distance (6MWD) test was performed in all patients and oxygen consumption assessment (VO_2max ) was performed in 32. All patients had transesophageal echocardiography before and 3 months after LAAO to assess ITL incidence. The patients were divided according to the presence and absence of ITL and the subgroup of patients with heart failure (HF) were further analyzed. In patients with HF and ITL, an increased VO_2max (12.8 ± 5.2 vs 15.3 ± 4.7; P < 0.05) and 6MWD (350.1 ± 77.4 vs 414.3 ± 70.6; P < 0.05) was observed after the procedure comparing to the results before the procedure. The 6MWD was also significantly higher in the patients with transseptal leaks in comparison to those without (P < 0.0001).

CONCLUSION

The presence of transseptal leaks after LAAO does not influence overall cardiac function test results. However, in patients with HF, there is an increase in oxygen consumption and 6MWD. These results indicate that ITLs in patients with HF decrease left atrial pressure, which is the key contributor to the symptoms of heart failure during physical activity.

Risk Factors for Anterior Cruciate Ligament Injury in Competitive Adolescent Alpine Skiers

Background:

There is a high risk for anterior cruciate ligament (ACL) injuries in alpine skiers. To reduce or try to prevent these injuries, intrinsic and extrinsic risk factors need to be identified.

Purpose:

To identify possible intrinsic and extrinsic ACL injury risk factors among competitive adolescent alpine skiers.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Between 2006 and 2009, a cohort of 339 alpine ski students (176 male, 163 female) from Swedish ski high schools were prospectively observed in terms of ACL injuries. First-time ACL injuries were recorded. In September, prior to each ski season, the skiers were clinically examined according to a specific knee protocol.

Results:

Overall, 11 male and 14 female skiers sustained a total of 25 first-episode ACL injuries. The majority of injuries occurred in the left knee (P < .05). Skiers who had participated in alpine skiing for >13 years (hazard ratio, 0.83; 95% CI, 0.68-1.00; P < .05) had a reduced risk of sustaining an ACL injury. Eighteen ACL injuries occurred during training, 12 in the technical discipline of giant slalom, and 8 in slalom. Fourteen skiers reported not to be fatigued at all at the time of injury, and 8 skiers reported that they were somewhat fatigued.

Conclusion:

ACL injuries occurred more often in the left knee than the right. This should be taken into consideration in the design of ACL injury prevention programs. Those who reported a higher number of active years in alpine skiing showed a reduced risk of sustaining an ACL injury. No other factor among those studied could be identified as an independent risk factor for ACL injury.

The 1-minute sit-to-stand test to detect exercise-induced oxygen desaturation in patients with interstitial lung disease

BACKGROUND

Although the 6-min walk test (6MWT) is the gold standard for assessing exercise-induced impairment of gas exchange, it cannot easily be performed in a clinical office environment. The aim of this study was to compare the 1-min sit-to-stand test (1STST) with the 6MWT for the ability to assess exercise-induced oxygen desaturation in patients with interstitial lung diseases (ILDs).

METHODS

A total of 107 patients were enrolled and classified into three groups: sarcoidosis, fibrotic idiopathic interstitial pneumonia (f-IIP), and other forms of ILD. The 6MWT and 1STST were performed on the same day, and pulmonary function tests, pulse oxygen saturation (SpO2), and dyspnea and fatigue (modified Borg scale) were assessed. SpO2 desaturation was evaluated by intraclass correlation coefficient (ICC), Bland-Altman analysis, and kappa (κ) coefficient in the whole population and the patient subgroups.

RESULTS

The SpO2 nadir during the 1STST and 6MWT showed good consistency [mean ± standard deviation: 92.5% ± 5% and 90% ± 7%, respectively; ICC 0.77, 95% confidence interval (CI) 0.71-0.83] and correlated strongly ( r = 0.9, p < 0.0001). The frequency of patients with oxygen desaturation ⩾4% was also consistent for the two exercise tests ( κ = 0.68, 95% CI 0.54-0.82). The number of repetitions in the 1STST correlated with the 6MWT distance ( r = 0.5, p < 0.0001), but the dyspnea scores were higher during the 1STST than the 6MWT ( p < 0.0001). These findings did not differ for the three patient subgroups.

CONCLUSION

The 1STST can measure exercise-induced desaturation in ILD patients and could be used as an alternative test to the 6MWT in office practice.

[Assessment methods risk of falls in people over age 65]

The aim of study was to investigate the effect of functional tests on the risk factors of falls in the elderly. A prospective cohort study of 537 patients over 65 years using validated functional tests and hand dynamometer. High speed gait (0,8 m / s and more) was observed in only 11,04 % of the elderly. The best results of tests «Stand up from a chair five times» (<16,7 sec) and «Stand up and go» (10 to 12 sec) were observed in 42,86 % and 23.05 % of patients (p<0,01). The worst performance observed over the age of 85 years. The risk of falling is higher in men and women with low muscle strength (dynamometry) and worst test «Get up and go» (p<0,01). Correlation relationship has been detected between dynamometry and functional tests with age, polymorbidity, polypharmacy, the frequency of falls and physical activity which are risk factors for falls in the elderly (p<0,05).

Balance Functional Assessment in People with Visual Impairment

The aims of this study were twofold: to assess the level of balance of people with visual impairment against the BOT-2 standard scores for the able-bodied, and to identify in which trials subjects had the greatest difficulties in maintaining balance with respect to the degree of vision loss and age categories. One hundred twenty-seven subjects with visual impairment aged 6–16 years, participated in the study (68 girls and 59 boys). The division for partially sighted people (61) and the blind (66) was made according to the WHO classification. Functional balance assessment was made using a balance subtest from the Bruininks-Oseretsky test. Significant relationships were noticed between age and the level of balance (χ2 = 8.35 p <0,05), as well as between the degree of vision loss and the level of balance (χ2 = 24.53 p <0,001). The level of balance of almost all blind subjects was below (20%) or well-below (60%) the average for the able-bodied. The subjects’ ability to maintain balance was not dependent on gender and was associated primarily with the degree of visual impairment and age. Partially sighted people had better balance than the blind and the decrease in visual acuity resulted in reduction of balance skills. The lowest level of balance was observed in blind students aged 7–11 years. Elaborating physical fitness improvement programs for children and adolescents with visual impairment, diversity of age, the degree of vision loss and limitations of ablility to maintain balance should be taken into account.

RELATIONSHIP BETWEEN ISOKINETIC KNEE STRENGTH AND JUMP CHARACTERISTICS FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

BACKGROUND

Clinicians are often challenged when making return-to-play decisions following anterior cruciate ligament reconstruction (ACL-R). Isokinetic strength and jump performance testing are common tools used to make this decision. Unfortunately, vertical jump performance standards have not been clearly established and many clinicians do not have access to isokinetic testing equipment.

PURPOSE

To establish normative jump and strength characteristics in ACL-R patients cleared by an orthopedic physician to return-to-play and to determine if relationships exist between knee isokinetic strength measurements and jump characteristics described using an electronic jump map system.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Thirty-three ACL-R patients who had been cleared to return to athletic competition participated in this study. Twenty-six of these ACL-R participants were also matched to 26 asymptomatic athletes based on sex, limb, height, and mass to determine isokinetic strength and jump characteristic differences between groups. Jump tests consisted of single leg vertical, double leg vertical, and a 4-jump single leg vertical jump assessed using an electronic jump mat system. Independent t-tests were used to determine differences between groups and multiple regression analyses were used to identify any relationships between jump performance and knee strength (p<0.05).

RESULTS

The ACL-R group had lower vertical jump capabilities and some bilateral knee strength deficiencies compared to the matched control group. The ACL-R group also showed several moderate-to-strong positive relationships for both knee extension and flexion strength with several jump performance characteristics, such as single and double leg vertical jump height.

CONCLUSION

The current results indicate that ACL-R patients present with several knee strength and vertical jump differences compared to a matched control group at the time of return-to-play. Also, ACL-R patient's performance on an electronic jump mat system is strongly related to isokinetic knee strength measures.

LEVEL OF EVIDENCE

2b.

A randomized trial of isokinetic versus isotonic rehabilitation program after arthroscopic meniscectomy

BACKGROUND

Although both isotonic and isokinetic exercises are commonly used in the rehabilitation of patients after arthroscopic meniscectomy no studies have compared their effect on strength recovery and functional outcomes.

PURPOSE

The purpose of this study was to investigate the effects of two rehabilitation programs (isotonic and isokinetic) on muscle strength and functional performance after partial knee meniscectomy. A secondary purpose was to assess the correlation between isokinetic strength deficits and hop test performance deficits.

METHODS

Twenty male patients who underwent arthroscopic partial meniscectomy volunteered for the study. Both isotonic and isokinetic training were performed with the same equipment thereby blinding subjects to the mode of exercise. Main outcome measures were collected on the 14th and 33rd postoperative days and included isokinetic strength of the knee extensors and flexors, functional performance (single, triple, and vertical hopping) and the Lysholm questionnaire. Multivariate and univariate analyses of variance were used to assess the effects of the independent variables on the isokinetic variables, functional tests, and Lysholm score. Pearson's correlation was used to assess the relationship between isokinetic strength deficits and functional performance deficits.

RESULTS

Isokinetic measures, functional tests, and the Lysholm score all increased between initial and final assessment (p≤0.003). However, there were no group or group*time effects on any of the outcome variables (p≥0.33). Functional tests were better predictors of isokinetic deficits in the 14(th) compared to the 33(rd) postoperative day.

CONCLUSION

No differences were found in the outcomes of patients treated using an isokinetic and an isotonic protocol for rehabilitation after arthroscopic meniscectomy. More than half of patients did not meet the 90% criterion in the hop tests for safe return to sports five weeks after meniscectomy. There were correlations between the hop tests and isokinetic deficits two weeks after meniscectomy but not at the fifth week.

LEVEL OF EVIDENCE

1b.

Functional tests should be accentuated more in the decision for ACL reconstruction

A high pre-injury activity level, the desire of the patient to continue pivoting sports and fear of future give-way episodes are considered the most significant factors affecting the decision to perform anterior cruciate ligament reconstruction. However, since the functional status of the knee at the time of surgery affects the final outcome, assessments of knee function should be considered in the decision making for surgery. Individuals with anterior cruciate ligament injury can be classified as potential copers or non-copers from an existing screening examination. The purpose of this study was to investigate whether the functional tests incorporated in the original screening examination could contribute to explain those who later go through anterior cruciate ligament reconstruction and to examine whether changes to the content or the time of conducting the screening examination (before or after ten sessions of exercise therapy) could improve its explanatory value. One-hundred and forty-five individuals were included and prospectively followed for 15 months, after where 51% had gone through anterior cruciate ligament reconstruction and 49% were managed non-operatively. The only significant baseline differences between those who later went through anterior cruciate ligament reconstruction and those who were non-operatively treated were that those who had surgery were younger and had a higher activity level (P < 0.05). Regression analyses revealed that the explanatory value for those who later went through anterior cruciate ligament reconstruction significantly improved when the original screening examination was considered compared to only age, activity level and give-way episodes. Changes to the content further improved the explanatory value, with quadriceps muscle strength as the single variable with the highest impact. Finally, conducting the screening examination after ten sessions of progressive exercise therapy gave the overall highest explanatory values, suggesting that the screening examination should be conducted subsequent to a short period of rehabilitation to inform decision making for anterior cruciate ligament reconstruction.