Kate E. Webster

Concurrent related validity of the GAITRite® walkway system for quantification of the spatial and temporal parameters of gait

The GAITRite is a portable gait analysis tool for automated measurement of spatiotemporal gait parameters. Although frequently used for clinical and research purposes, the concurrent validity of GAITRite has not been validated against a criterion measure. The aim of this experiment was to investigate the concurrent validity and test retest reliability of the GAITRite carpet walkway system for quantification of spatial and temporal parameters of the footstep pattern. Twenty-five healthy adults aged 21-71 years (mean 40.5 years, S.D. 17.2) performed three walk trials at self-selected pace, three at fast pace and three at slow pace. For each trial, data were simultaneously collected from the GAITRite and a Clinical Stride Analyzer, which has established reliability and validity. At preferred, slow and fast walking pace there were very high correlations between the two measurement systems for gait speed (ICC (2,1)=0.99), stride length (ICC (2,1)=0.99) and cadence (ICC (2,1)=0.99). Correlations between the electronic carpet and the stride analyser were moderate to high for single limb support (SLS) time (ICC (2,1)=0.69-0.91) and weak for the proportion of the gait cycle spent in double limb support (ICC (2,1)=0.44-0.57). The reliability of repeated measures for the GAITRite was good at preferred and fast speed for speed (ICC (3,1)=0.93-0.94), cadence (ICC (3,1)=0.92-0.94), stride length (ICC (3,1)=0.97), single support (ICC (3,1)=0.85-0.93) and the proportion of the gait cycle spent in double limb support (ICC (3,1)=0.89-0.92). The repeatability of the GAITRite measures were more variable at slow speed (ICC (3,1)=0.76-0.91). These results indicate that the GAITRite system has strong concurrent validity and test retest reliability, in addition to being a portable, simple clinical tool for the objective assessment of gait.

Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play

Background An athletes intention to return to sport following anterior cruciate ligament (ACL) injury is a major indication for surgical intervention. Purpose The purpose of this review was to determine postoperative return-to-sport outcomes after ACL reconstruction surgery. Study design Meta-analysis and systematic review Methods Electronic databases including Medline, Embase, SPORTDiscus and CINAHL were searched from the earliest possible entry to April 2010. Studies were included that reported the number of patients returning to sports participation following ACL reconstruction surgery. The results were presented using the World Health Organizations International Classification of Functioning, Disability and Health as a framework and combined using proportion meta-analyses. Results Forty-eight studies evaluating 5770 participants at a mean follow-up of 41.5 months were included for review. Overall, 82% of participants had returned to some kind of sports participation, 63% had returned to their preinjury level of participation, and 44% had returned to competitive sport at final follow-up. Approximately 90% of participants achieved normal or nearly normal knee function when assessed postoperatively using impairment-based outcomes such as laxity and strength, and 85% when using activity-based outcomes such as the International Knee Documentation Committee knee evaluation form. Fear of reinjury was the most common reason cited for a postoperative reduction in or cessation of sports participation. Conclusion The relatively low rate of return to competitive sport despite the high rates of successful outcome in terms of knee impairment-based function suggests that other factors such as psychological factors may be contributing to return-to-sport outcomes.

A Randomized Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction

Background Patellar and hamstring tendon autografts are the most frequently used graft types for anterior cruciate ligament reconstruction, but few direct comparisons of outcomes have been published. Hypothesis There is no difference in outcome between the two types of reconstruction. Study Design Prospective randomized clinical trial. Methods After isolated anterior cruciate ligament rupture, 65 patients were randomized to receive either a patellar tendon or a four-strand hamstring tendon graft reconstruction, and results were reviewed at 4, 8, 12, 24, and 36 months. Results Pain on kneeling was more common and extension deficits were greater in the patellar tendon group. There were greater quadriceps peak torque deficits in the patellar tendon group at 4 and 8 months but not thereafter. In the hamstring tendon group, active flexion deficits were greater from 8 to 24 months, and KT-1000 arthrometer side-to-side differences in anterior knee laxity at 134 N were greater. Cincinnati knee scores, International Knee Documentation Committee ratings, and rates of return to preinjury activity levels were not significantly different between the two groups. Conclusions Both grafts resulted in satisfactory functional outcomes but with increased morbidity in the patellar tendon group and increased knee laxity and radiographic femoral tunnel widening in the hamstring tendon group.

Validity of the Microsoft Kinect for assessment of postural control

Clinically feasible methods of assessing postural control such as timed standing balance and functional reach tests provide important information, however, they cannot accurately quantify specific postural control mechanisms. The Microsoft Kinect™ system provides real-time anatomical landmark position data in three dimensions (3D), and given that it is inexpensive, portable and simple to setup it may bridge this gap. This study assessed the concurrent validity of the Microsoft Kinect™ against a benchmark reference, a multiple-camera 3D motion analysis system, in 20 healthy subjects during three postural control tests: (i) forward reach, (ii) lateral reach, and (iii) single-leg eyes-closed standing balance. For the reach tests, the outcome measures consisted of distance reached and trunk flexion angle in the sagittal (forward reach) and coronal (lateral reach) planes. For the standing balance test the range and deviation of movement in the anatomical landmark positions for the sternum, pelvis, knee and ankle and the lateral and anterior trunk flexion angle were assessed. The Microsoft Kinect™ and 3D motion analysis systems had comparable inter-trial reliability (ICC difference=0.06±0.05; range, 0.00-0.16) and excellent concurrent validity, with Pearsons r-values >0.90 for the majority of measurements (r=0.96±0.04; range, 0.84-0.99). However, ordinary least products analyses demonstrated proportional biases for some outcome measures associated with the pelvis and sternum. These findings suggest that the Microsoft Kinect™ can validly assess kinematic strategies of postural control. Given the potential benefits it could therefore become a useful tool for assessing postural control in the clinical setting.

Return to the Preinjury Level of Competitive Sport After Anterior Cruciate Ligament Reconstruction Surgery Two-thirds of Patients Have Not Returned by 12 Months After Surgery

Background: An athlete’s desire to return to sport after anterior cruciate ligament (ACL) injury is a major indication for ACL reconstruction surgery. Typical clearance to return is 6 to 12 months postoperatively. Purpose: To investigate the return-to-sport rate and participation level of a large cohort at 12 months after ACL reconstruction surgery. Study Design: Case series; Level of evidence, 4. Methods: Data were analyzed for 503 patients who participated in competitive-level Australian football, basketball, netball, or soccer after ACL reconstruction surgery using a quadruple-strand hamstring autograft. Inclusion criteria included participation in competitive sport before the ACL injury and clearance from the orthopaedic surgeon to return to sport postoperatively. Patients completed a self-report questionnaire regarding preoperative and postoperative sports participation and the Cincinnati Sports Activity Scale. The International Knee Documentation Committee (IKDC) knee evaluation form and hop tests were used to evaluate knee function. Results: Sixty-seven percent of patients attempted some form of sports activity by 12 months postoperatively; 33% attempted competitive sport. Of those who did not attempt any sports activity by 12 months, 47% indicated that they were planning to return. Men were significantly more likely than women to return. Patients who played sports with a seasonal competition, versus a year-round competition, were significantly more likely to return by 12 months. Patients with normal postoperative knee function (IKDC category A), versus those with nearly normal function (IKDC category B), were no more likely to return, but patients with good hop test results (≥85% limb symmetry index) were more likely to return than patients with poor results (<85%). Conclusion: People may require a longer postoperative rehabilitation period than that typically advocated to facilitate a successful return to competitive sport after ACL reconstruction surgery. The relationship between postoperative knee function and return-to-sport outcomes at 12 months after surgery was inconclusive.

Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors

Background The aim of this study was to update our original systematic review of return to sport rates following anterior cruciate ligament (ACL) reconstruction surgery. Method Electronic databases were searched from April 2010 to November 2013 for articles reporting the number of patients returning to sport following ACL reconstruction surgery. Return to sport rates, physical functioning and contextual data were extracted and combined using random-effects meta-analyses. Data from the original review (articles published up to April 2010) were combined with data from the updated search. Results Sixty-nine articles, reporting on 7556 participants, were reviewed. On average, 81% of people returned to any sport, 65% returned to their preinjury level of sport and 55% returned to competitive level sport after surgery. Symmetrical hopping performance (d=0.3) and the contextual factors of younger age (d=−0.3), male gender (OR=1.4), playing elite sport (OR=2.5) and having a positive psychological response (d=0.3) favoured returning to the preinjury level sport. Receiving a hamstring tendon autograft favoured returning to competitive level sport (OR=2.4), whereas receiving a patellar tendon autograft favoured returning to the preinjury level sport (OR=1.2). Conclusions Returning to sport varied according to different physical functioning and contextual factors, which could warrant additional emphasis in postoperative rehabilitation programmes to maximise participation.

Return-to-Sport Outcomes at 2 to 7 Years After Anterior Cruciate Ligament Reconstruction Surgery

Background: Most people have not returned to their preinjury level of sports participation at 12 months after anterior cruciate ligament (ACL) reconstruction surgery. Twelve months’ follow-up may be too early to assess return-to-sport outcomes accurately. Purpose: This study was undertaken to evaluate the medium-term return-to-sport outcomes after ACL reconstruction surgery. Study Design: Case series; Level of evidence, 3. Methods: A self-report questionnaire was used to collect data at 2 to 7 years after ACL reconstruction surgery regarding preinjury sports participation, postoperative sports participation, and subjective knee function. The main inclusion criteria were participation in regular sports activity before injury and the attendance at routine surgical follow-up appointments. Results: A total of 314 participants (mean age, 32.5 ± 10.2 years) were included at a mean 39.6 ± 13.8 months after ACL reconstruction surgery. At follow-up, 45% were playing sport at their preinjury level and 29% were playing competitive sport. Ninety-three percent of the study sample had attempted sport at some time after their ACL reconstruction surgery. Those who had not attempted their preinjury level of sport by 12 months after surgery were just as likely to have returned to preinjury level by 39 months after surgery as those who had played sport by 12 months (risk ratio, 1.1; 95% confidence interval, 0.76-1.6). Conclusion: Less than 50% of the study sample had returned to playing sport at their preinjury level or returned to participating in competitive sport when surveyed at 2 to 7 years after ACL reconstruction surgery. Return to the preinjury level of sport at 12 months after surgery was not predictive of participation at the preinjury level in the medium term, which suggests that people who return to sport within 12 months may not maintain their sports participation.

Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery

OBJECTIVES The purpose of this study was to develop a scale to measure the psychological impact of returning to sport after anterior cruciate ligament (ACL) reconstruction surgery. MAIN OUTCOME MEASURE Three types of psychological responses believed to be associated with resumption of sport following athletic injury--emotions, confidence in performance, and risk appraisal--were incorporated into a 12-item ACL-Return to Sport after Injury (ACL-RSI) scale. PARTICIPANTS Two hundred and twenty participants who had undergone ACL reconstruction completed the scale between 8 and 22 months following surgery. RESULTS The scale was shown to have acceptable reliability (Cronbachs alpha=0.92). Participants who had given up sport scored significantly lower on the scale (reflecting a more negative psychological response) than those who had returned or were planning to return to sport (p<0.001). CONCLUSION It was concluded that the decision to return to sport after ACL reconstruction is associated with a significant psychological response. Preliminary reliability and validity was found for the ACL-RSI scale. This scale may help to identify athletes who will find sport resumption difficult.

Psychological Responses Matter in Returning to Preinjury Level of Sport After Anterior Cruciate Ligament Reconstruction Surgery

Background: Up to two-thirds of athletes may not return to their preinjury level of sport by 12 months after anterior cruciate ligament (ACL) reconstruction surgery, despite being physically recovered. This has led to questions about what other factors may influence return to sport. Purpose: To determine whether psychological factors predicted return to preinjury level of sport by 12 months after ACL reconstruction surgery. Study Design: Case control study; Level of evidence, 3. Methods: Recreational and competitive-level athletes seen at a private orthopaedic clinic with an ACL injury were consecutively recruited. The primary outcome was return to the preinjury level of sports participation. The psychological factors evaluated were psychological readiness to return to sport, fear of reinjury, mood, emotions, sport locus of control, and recovery expectations. Participants were followed up preoperatively and at 4 and 12 months postoperatively. Results: In total, 187 athletes participated. At 12 months, 56 athletes (31%) had returned to their preinjury level of sports participation. Significant independent contributions to returning to the preinjury level by 12 months after surgery were made by psychological readiness to return to sport, fear of reinjury, sport locus of control, and the athlete’s estimate of the number of months it would take to return to sport, as measured preoperatively (χ22 = 18.3, P < .001, classification accuracy = 70%) and at 4 months postoperatively (χ24 = 38.7, P < .001, classification accuracy = 86%). Conclusion: Psychological responses before surgery and in early recovery were associated with returning to preinjury level of sport at 12 months, suggesting that attention to psychological recovery in addition to physical recovery after ACL injury and reconstruction surgery may be warranted. Clinical screening for maladaptive psychological responses in athletes before and soon after surgery may help clinicians identify athletes at risk of not returning to their preinjury level of sport by 12 months.

A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery

Objective: To determine whether the psychological characteristics of athletes who have undergone an anterior cruciate ligament (ACL) reconstruction change during rehabilitation are related to returning to competitive sport. Design: Prospective longitudinal study. Method: 87 athletes completed the Emotional Response of Athletes to Injury Questionnaire (ERAIQ) and the ACL Return to Sport after Injury scale (ACL-RSI) at 3, 6 and 12 months following ACL reconstruction surgery. Physical outcome measures were also taken at each time point. Results: At 12 months 44 (51%) participants had returned to competitive sport and 43 (49%) participants had not returned. There were no differences in physical recovery or scores on the ERAIQ between the two groups. Participants who had returned to competitive sport at 12 months, however, scored significantly higher on the ACL-RSI scale (reflecting a more positive psychological response about sport participation) at both 6 and 12 months than participants who had not returned to competitive sport. Conclusions: During rehabilitation there are significant psychological differences regarding sport resumption between athletes who do, and do not, resume competitive sport 12 months following ACL reconstruction. These differences occur as early as 6 months postoperatively and highlight the importance of addressing all aspects of an athlete’s recovery in order to help facilitate the athlete returning to sport.