Johanna M. Hoch

Patient-Reported Outcome Measures in Individuals With Chronic Ankle Instability: A Systematic Review

CONTEXT A comprehensive systematic literature review of the health-related quality-of-life (HRQOL) differences among individuals with chronic ankle instability (CAI), ankle-sprain copers, and healthy control participants has not been conducted. It could provide a better indication of the self-reported deficits that may be present in individuals with CAI. OBJECTIVE To systematically summarize the extent to which HRQOL deficits are present in individuals with CAI. DATA SOURCES We searched for articles in the electronic databases of EBSCO Host and PubMed Central using key words chronic, functional, mechanical, coper, instability, sprains, and patient-assessed. We also performed a hand search of reference lists, authors, and patient-reported outcomes (PROs) of the articles screened for inclusion. STUDY SELECTION Studies were included if they (1) incorporated a PRO as a participant descriptor or as a study outcome to compare adults with CAI to ankle-sprain copers or healthy controls, (2) were written in English, and (3) were published in peer-reviewed journals. DATA EXTRACTION Two authors independently assessed methodologic quality using the modified Downs and Black Index. Articles were filtered into 3 categories based on between-groups comparisons: CAI and copers, CAI and healthy control participants, copers and healthy participants. We calculated Hedges g effect sizes and 95% confidence intervals to examine PRO group differences. DATA SYNTHESIS Of the 124 studies assessed for eligibility, 27 were included. A total of 24 articles compared PROs in individuals with CAI and healthy controls, 7 compared individuals with CAI and copers, and 4 compared copers and healthy controls. Quality scores on the modified Downs and Black Index ranged from 52.9% to 88.2%, with 8 high-, 16 moderate-, and 3 low-quality studies. Overall, we observed moderate to strong evidence that individuals with CAI displayed deficits on generic and region-specific PROs compared with copers and healthy controls. However, evidence that differences exist between copers and healthy controls was conflicting. In addition, for dimension-specific outcomes, evidence to suggest that fear of reinjury is heightened in individuals with CAI was limited. CONCLUSIONS The evidence suggested that CAI is associated with functional and HRQOL deficits, particularly when examined with region-specific PROs. However, PROs do not appear to differ between copers and healthy controls.

Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review

Ankle dorsiflexion range of motion (DROM) is often a point of emphasis during the rehabilitation of lower extremity pathologies. With the growing popularity of weight-bearing DROM assessments, several versions of the weight-bearing lunge (WBLT) test have been developed and numerous reliability studies have been conducted. The purpose of this systematic review was to critically appraise and synthesize the studies which examined the reliability and responsiveness of the WBLT to assess DROM. A systematic search of PubMed and EBSCO Host databases from inception to September 2014 was conducted to identify studies whose primary aim was assessing the reliability of the WBLT. The Quality Appraisal of Reliability Studies assessment tool was utilized to determine the quality of included studies. Relative reliability was examined through intraclass correlation coefficients (ICC) and responsiveness was evaluated through minimal detectable change (MDC). A total of 12 studies met the eligibility criteria and were included. Nine included studies assessed inter-clinician reliability and 12 included studies assessed intra-clinician reliability. There was strong evidence that inter-clinician reliability (ICC = 0.80-0.99) as well as intra-clinician reliability (ICC = 0.65-0.99) of the WBLT is good. Additionally, average MDC scores of 4.6° or 1.6 cm for inter-clinician and 4.7° or 1.9 cm for intra-clinician were found, indicating the minimal change in DROM needed to be outside the error of the WBLT. This systematic review determined that the WBLT, regardless of method, can be used clinically to assess DROM as it provides consistent results between one or more clinicians and demonstrates reasonable responsiveness.

Clinical and laboratory measures associated with health-related quality of life in individuals with chronic ankle instability

OBJECTIVE To identify clinician and laboratory-oriented measures of function capable of explaining health-related quality of life in individuals with chronic ankle instability. DESIGN Cross-sectional. SETTING Laboratory. PARTICIPANTS Forty physically active individuals with chronic ankle instability attended a single testing session. MAIN OUTCOME MEASURES Participants completed health-related quality of life, postural control, strength, sensory, and mechanical assessments. Health-related quality of life assessments included the Short Form-12 Physical and Mental Summary Components, Disablement in the Physically Active Scale, Fear-Avoidance Beliefs Questionnaire, and the Foot and Ankle Ability Measure. RESULTS A combination of mechanical and functional impairments accounted for 18-35% of the variance associated with health-related quality of life related to physical function and fear. Although physical impairments accounted for 7% of the variance associated with mental health-related quality of life, the overall model was associated with a weak effect size. CONCLUSION Measures of postural control, dorsiflexion range of motion, plantar cutaneous sensation, and ankle arthrometry contributed to a significant proportion of the variance associated with health-related quality of life in those with chronic ankle instability. Other variables should be examined to address mental components of health-related quality of life.

Longitudinal Documentation of Serum Cartilage Oligomeric Matrix Protein and Patient-Reported Outcomes in Collegiate Soccer Athletes Over the Course of an Athletic Season

Background: Serum cartilage oligomeric matrix protein (sCOMP) is a biomarker for cartilage degradation. Patient-reported outcomes (PRO) are used to document postinjury recovery and may be used to prospectively identify changes in the course of a season. It is unknown what effect intense, continuous physical activity has on sCOMP levels and PRO values in athletes over the duration of a soccer season. Hypothesis/Purpose: The purpose of this study was to longitudinally document sCOMP levels and to determine whether changes in PROs occur in collegiate soccer athletes during a season. The hypotheses tested were that sCOMP levels and PRO scores would remain stable over the duration of the spring soccer season. Study Design: Case series; level of evidence, 4. Methods: Twenty-nine National Collegiate Athletic Association Division-I soccer athletes (18 men, 11 women; age, 19.6 ± 1.2 years; height, 177.8 ± 7.4 cm; mass, 73.8 ± 10.2 kg) participated in 3 (pre-[T1], mid-[T2], and postseason [T3]) data collection sessions. Subjects were included if they were participants in the spring soccer season and were free of severe knee injury at the time of data collection. At each session, subjects completed PROs (Lysholm, International Knee Documentation Committee scores) before serum collection. Results: For sCOMP (ng/mL), there was a significant effect for time, with significant increases at T2 (1723.5 ± 257.9, P < .001) and T3 (1624.7 ± 231.6, P = .002) when compared with T1(1482.9 ± 217.9). For each of the PROs, there was a significant effect for time from T1-T3, and at T2-T3 for the IKDC. Conclusion: These data indicate sCOMP levels increased as athletes reported an increased level of function over time. However, the differences in sCOMP levels did not reach the calculated minimal detectable change (MDC) value and the differences in PRO scores did not reach previously calculated MDC values. It is unclear whether these increases in sCOMP levels were caused by an increase in cartilage matrix breakdown or turnover. Even though these elevations may not be clinically meaningful, this biomarker may have the potential to be used for future research studies investigating the effects of exercise on overall joint health in longitudinal studies. In addition, these results indicate fluctuations in sCOMP occur during a competitive season and must be taken into consideration for future biomarker studies.

Interrater and intrarater reliability of the semmes‐weinstein monofilament 4‐2‐1 stepping algorithm

Semmes‐Weinstein Monofilaments (SWM) are used to examine light touch sensation of the skin. Reliability of the 4‐2‐1 stepping algorithm approach for determining light touch detection thresholds has not been examined. The purpose of this study was to determine the interrater and intrarater reliability of the SWM 4‐2‐1 stepping algorithm on the plantar surface of the foot.

Comparing Responsiveness of Six Common Patient-Reported Outcomes to Changes Following Autologous Chondrocyte Implantation: A Systematic Review and Meta-Analysis of Prospective Studies.

Objective: To compare the responsiveness of six common patient-reported outcomes (PROs) following autologous chondrocyte implantation (ACI). Design: A systematic search was conducted to identify reports of PROs following ACI. Study quality was evaluated using the modified Coleman Methodology Score (mCMS). For each outcome score, pre- to postoperative paired Hedge’s g effect sizes were calculated with 95% confidence intervals (CIs). Random effects meta-analyses were performed to provide a summary response for each PRO at time points (TP) I (<1 year), II (1 year to <2 years), III (2 years to <4 years), IV (≥4 years), and overall. Results: The mean mCMS for the 42 articles included was 50.9 ± 9.2. For all evaluated instruments, none of the mean effect size CIs encompassed zero. The International Knee Documentation Committee Subjective Knee Form (IKDC) had increasing responsiveness over time with TP-IV, demonstrating greater mean effect size [confidence interval] (1.78 [1.33, 2.24]) than TP-I (0.88 [0.69, 1.07]). The Knee Injury and Osteoarthritis Outcome Score–Sports and recreation subscale (KOOS-Sports) was more responsive at TP-III (1.76 [0.87, 2.64]) and TP-IV (0.98 [0.81, 1.15]) than TP-I (0.61 [0.44, 0.78]). Overall, the Medical Outcomes Study 36-Item Short Form Health Survey Physical Component Scale (0.60 [0.46, 0.74]) was least responsive. Both the Lysholm Scale (1.42 [1.14, 1.72]) and the IKDC (1.37 [1.13, 1.62]) appear more responsive than the KOOS-Sports (0.90 [0.73, 1.07]). All other KOOS subscales had overall effect sizes ranging from 0.90 (0.74, 1.22) (Symptoms) to 1.15 (0.76, 1.54) (Quality of Life). Conclusions: All instruments were responsive to improvements in function following ACI. The Lysholm and IKDC were the most responsive instruments across time. IKDC and KOOS-Sports may be more responsive to long-term outcomes, especially among active individuals.

Health-Related Quality of Life in Athletes: A Systematic Review With Meta-Analysis.

CONTEXT Assessment of health-related quality of life (HRQOL) after injury is important. Differences in HRQOL between nonathletes and athletes and between injured and uninjured athletes have been demonstrated; however, the evidence has not been synthesized. OBJECTIVE To answer the following questions: (1) Does HRQOL differ among adolescent and collegiate athletes and nonathletes? (2) Does HRQOL differ between injured adolescent and collegiate athletes or between athletes with a history of injury and uninjured athletes or those without a history of injury? DATA SOURCES We systematically searched CINAHL, MEDLINE, SPORTDiscus, and PubMed. A hand search of references was also conducted. STUDY SELECTION Studies were included if they used generic instruments to compare HRQOL outcomes between athletes and nonathletes and between uninjured and injured athletes. Studies were excluded if they did not use a generic instrument, pertained to instrument development, or included retired athletes or athletes with a chronic disease. DATA EXTRACTION We assessed study quality using the modified Downs and Black Index Tool. Bias-corrected Hedges g effect sizes and 95% confidence intervals (CIs) were calculated. The Strength of Recommendation Taxonomy (SORT) was used to determine the overall strength of the recommendation. A random-effects meta-analysis was performed for all studies using the composite or total score. DATA SYNTHESIS Eight studies with modified Downs and Black scores ranging from 70.6% to 88.4% were included. For question 1, the overall random-effects meta-analysis was weak (effect size = 0.27, 95% confidence interval = 0.14, 0.40; P < .001). For question 2, the overall random-effects meta-analysis was moderate (effect size = 0.68, 95% confidence interval = 0.42, 0.95; P < .001). CONCLUSIONS Grade A evidence indicates that athletes reported better HRQOL than nonathletes and that uninjured athletes reported better HRQOL than injured athletes. However, the overall effect for question 1 was weak, suggesting that the differences between athletes and nonathletes may not be clinically meaningful. Clinicians should monitor HRQOL after injury to ensure that all dimensions of health are appropriately treated.

Somatosensory Deficits in Post-ACL Reconstruction Patients: A Case-Control Study.

Introduction: Diminished cutaneous detection thresholds have been identified in patients with multiple orthopedic conditions, and these phenomena may occur in postanterior cruciate ligament reconstructed (ACLR) patients. The purpose of this study was to determine if differences in lower extremity cutaneous detection thresholds exist in post‐ACLR patients when compared with healthy controls. Methods: Fifteen individuals who were post‐ACLR and 15 individuals who had no history of knee injury participated. Light touch cutaneous detection thresholds were assessed at 4 locations on the foot and ankle (first metatarsal, fifth metatarsal, medial malleolus, and lateral malleolus). Nonparametric statistics examined group differences between the sites. Results: ACLR subjects had decreased cutaneous sensation at the first metatarsal and medial malleolus compared with healthy controls. Conclusions: Somatosensory deficits are present in post‐ACLR patients. Future research should investigate these phenomena longitudinally in post‐ACLR individuals along with somatosensory targeted interventions. Muscle Nerve 55: 5–8, 2017

Rehabilitation and Improvement of Health-Related Quality-of-Life Detriments in Individuals With Chronic Ankle Instability: A Meta-Analysis

OBJECTIVE   To conduct a systematic review with meta-analysis assessing the effectiveness of conservative rehabilitation programs for improving health-related quality of life (HRQL) in individuals with chronic ankle instability (CAI). DATA SOURCES   PubMed, MEDLINE, CINAHL, and SPORTDiscus were searched from inception to January 2016. STUDY SELECTION   Studies were included if the researchers examined the effects of a conservative rehabilitation protocol in individuals with CAI, used validated patient-reported outcomes (PROs) to quantify participant-perceived HRQL, and provided adequate data to calculate the effect sizes (ESs) and 95% confidence intervals (CIs). Studies were excluded if the authors evaluated surgical interventions, prophylactic taping, or bracing applications or examined only the immediate effects of 1 treatment session. DATA EXTRACTION   Two investigators independently assessed methodologic quality using the Physiotherapy Evidence Database (PEDro) Scale. Studies were considered low quality if fewer than 60% of the criteria were met. Level of evidence was assessed using the Strength of Recommendation Taxonomy. Preintervention and postintervention sample sizes, means, and standard deviations of PROs were extracted. DATA SYNTHESIS   A total of 15 studies provided 24 participant groups that were included in the analysis. Seven high-quality studies with a median PEDro score of 50% (range = 10%-80%) and a median level of evidence of 2 (range = 1-2) were identified. The magnitudes of preintervention to postintervention PRO differences were examined using bias-corrected Hedges g ESs. Random-effects meta-analysis was performed to synthesize PRO changes across all participant groups. Positive ES values indicated better PRO scores at postintervention than at preintervention. The α level was set at .05. Meta-analysis revealed a strong ES with a nonoverlapping 95% CI (ES = 1.20, CI = 0.80, 1.60; P < .001), indicating HRQL improved after conservative rehabilitation. CONCLUSIONS   Based on the quality of the evidence and the results of the meta-analysis, grade A evidence showed that conservative rehabilitation produces large improvements in HRQL for people with CAI.

Patient-Reported Outcomes in Male and Female Collegiate Soccer Players During an Athletic Season

CONTEXT Clinicians are urged to document patient-based outcomes during rehabilitation to measure health-related quality of life (HRQOL) from the patients perspective. It is unclear how scores on patient-reported outcome instruments (PROs) vary over the course of an athletic season because of normal athletic participation. OBJECTIVE Our primary purpose was to evaluate the effect of administration time point on HRQOL during an athletic season. Secondary purposes were to determine test-retest reliability and minimal detectable change scores of 3 PROs commonly used in clinical practice and if a relationship exists between generic and region-specific outcome instruments. DESIGN Cross-sectional study. SETTING Athletic facility. PATIENTS OR OTHER PARTICIPANTS Twenty-three collegiate soccer athletes (11 men, 12 women). MAIN OUTCOME MEASURE(S) At 5 time points over a spring season, we administered the Disablement in the Physically Active Scale (DPA), Foot and Ankle Ability Measure-Sport, and Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS Time effects were observed for the DPA (P = .011) and KOOS Quality of Life subscale (P = .027). However, the differences between individual time points did not surpass the minimal detectable change for the DPA, and no post hoc analyses were significant for the KOOS-Quality of Life subscale. Test-retest reliability was moderate for the KOOS-Pain subscale (intraclass correlation coefficient = 0.71) and good for the remaining KOOS subscales, DPA, and Foot and Ankle Ability Measure-Sport (intraclass correlation coefficients > 0.79). The DPA and KOOS-Sport subscale demonstrated a significant moderate relationship (P = .018). CONCLUSIONS Athletic participation during a nontraditional, spring soccer season did not affect HRQOL. All 3 PROs were reliable and could be used clinically to monitor changes in health status throughout an athletic season. Our results demonstrate that significant deviations in scores were related to factors other than participation, such as injury. Finally, both generic and region-specific instruments should be used in clinical practice.