Nicholas F. Taylor

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.

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.

Psychosocial predictors of failure to return to work in non-chronic non-specific low back pain: a systematic review

Objectives: To identify psychosocial predictors of failure to return to work in non-chronic (lasting less than 3 months) non-specific low back pain (NSLBP). Methods: A systematic review of prognostic studies was carried out. Medline, Embase, PsychINFO, CINAHL and PEDro electronic bibliographic databases up to April 2006 were searched. Included studies took baseline measures in the non-chronic phase of NSLBP (ie, within 3 months of onset), included at least one psychosocial variable and studied a sample in which at least 75% of participants had NSLBP. Baseline measures had to be used to predict at least one work-specific outcome. Results: The search identified 24 studies meeting the inclusion criteria. From these studies there is strong evidence that recovery expectation is predictive of work outcome and that depression, job satisfaction and stress/psychological strain are not predictive of work outcome. There is moderate evidence that fear avoidance beliefs are predictive of work outcome and that anxiety is not predictive of work outcome. There is insufficient evidence to determine whether compensation or locus of control are predictive of work outcome. Conclusions: To predict work outcome in non-chronic NSLBP, psychosocial assessment should focus on recovery expectation and fear avoidance. More research is needed to determine the best method of measuring these constructs and to determine how to intervene when a worker has low recovery expectations.

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.

Correction: additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomised controlled trial [BMC Medicine, 11, (2013), 198]

Authors’ correction note On reviewing our recently published trial in BMC Medicine [1], we realised that there were some minor errors in the demographic data reported in Table 1 and in 2 sentences of the accompanying text. Specifically, our sample comprised 365 men, not 359 as reported, and there were some very minor differences in the numbers of participants reported in each diagnostic category. The main contributing factors for the minor errors were misinterpretation of gender neutral first names, and grouping of the diagnostic codes assigned during data collection for reporting. We believe these changes do not affect the results or conclusions of our study, and are confident in the processes we employed (full double data entry by two independent teams) to ensure the integrity of the rest of our data. Table 1 has been corrected and the first two sentences in the accompanying text in the methods when describing the participants should read: Participants had a mean (SD) age of 74 (13) years and 631 (63%) were women (Table 1). A total of 581 (58%) participants were admitted with an orthopedic diagnosis, 203 (20%) with a neurological diagnosis and 212 (21%) participants were admitted with other disabling impairments. A total of 94% of participants were living independently in the community prior to their acute hospital admission. This is a Correction article on http://www.biomedcentral. com/1741-7015/11/198.

Therapeutic exercise in physiotherapy practice is beneficial : a summary of systematic reviews 2002-2005.

QUESTION Is therapeutic exercise of benefit? DESIGN A summary of systematic reviews on therapeutic exercise published from 2002 to September 2005. PARTICIPANTS People with neurological, musculoskeletal, cardiopulmonary, and other conditions who would be expected to consult a physiotherapist. INTERVENTION Therapeutic exercise was defined as the prescription of a physical activity program that involves the client undertaking voluntary muscle contraction and/or body movement with the aim of relieving symptoms, improving function or improving, retaining or slowing deterioration of health. OUTCOME MEASURES Effect of therapeutic exercise in terms of impairment, activity limitations, or participation restriction. RESULTS The search yielded 38 systematic reviews of reasonable or good quality. The results provided high level evidence that therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice, including people with conditions such as multiple sclerosis, osteoarthritis of the knee, chronic low back pain, coronary heart disease, chronic heart failure, and chronic obstructive pulmonary disease. Therapeutic exercise was more likely to be effective if it was relatively intense and there were indications that more targeted and individualised exercise programs might be more beneficial than standardised programs. There were few adverse events reported. However, in many areas of practice there was no evidence that one type of exercise was more beneficial than another. CONCLUSION Therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice. Further high quality research is required to determine the effectiveness of therapeutic exercise in emerging areas of practice.

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.

Should we be testing and training muscle strength in cerebral palsy

Cerebral palsy (CP) is a collection of disorders characterized by an insult to the developing brain that produces a physical disability as the primary or distinguishing feature. The spastic form of CP is most common and in those patients, additional clinical signs may include muscle shortening, diminished selective control, and weakness. The recognition of weakness as a component of CP has been longstanding as evidenced by the names given to this disorder and its subtypes. ‘Cerebral palsy’ means weakness originating from the brain, and the use of the suffixes ‘plegia’ or ‘paresis’ also indicate that weakness is a prominent feature. More than 50 years ago, Phelps contended that resisted exercise ‘to develop strength or skill in a weakened muscle or an impaired muscle group’ was an integral part of treatment in CP. (p 59) Since that time, physical educators have also advocated strengthening. Yet for years, conventional clinical wisdom in physical therapy argued against the use of strength testing and training in children with CP and, indeed, in all persons with CNS disorders. The rationale for this exclusion appears to be multifaceted. First, therapists were discouraged by the relatively meager functional responses to strength training in patients with spasticity compared with those with polio. Clinicians also feared that strong near maximal effort would exacerbate spasticity and muscle tightness in those who were already ‘stiffer’ than normal. Many also attested that impaired selective control in CP essentially prohibited performance of strengthening activities. Consequently, this approach was discarded in favor of a more direct focus on the brain. Only recently has strength testing and training experienced a resurgence in habilitation and rehabilitation programs for this population and for other spastic motor disorders. However, hesitation and even resistance to their incorporation are still encountered despite the lack of evidence to suggest that strengthening is detrimental in the presence of spasticity and accumulating evidence to support this type of exercise. The purpose of this annotation is to summarize existing research on strength testing and training, primarily focusing on CP and address the following clinical questions: (1) Can strength be measured reliably and in a valid way in cerebral palsy? (2) Is weakness a significant impairment in CP? (3) Is strength training effective in increasing force production and improving motor function and disability in CP? (4) Is strength training safe in the presence of spasticity and for children and adolescents, regardless of health status, who have an immature musculoskeletal system?

Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis

Objective: A systematic review and meta-analysis of randomized controlled trials to determine if motivational interviewing leads to increased physical activity, cardiorespiratory fitness or functional exercise capacity in people with chronic health conditions. Data sources: Seven electronic databases (MEDLINE, PsychINFO, EMBASE, AMED, CINHAL, SPORTDiscus and the Cochrane Central Register of Controlled trials) were searched from inception until January 2014. Trial selection: Two reviewers independently examined publications for inclusion. Trials were included if participants were adults (>18 years), had a chronic health condition, used motivational interviewing as the intervention and examined physical activity, cardiorespiratory fitness or functional exercise capacity. Data extraction: Two reviewers independently extracted data. Risk of bias within trials was assessed using the Physiotherapy Evidence Database Scale. Data synthesis: Meta-analyses were conducted with standardized mean differences and 95% confidence intervals (CIs) were calculated. The Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of the evidence. Results: Eleven publications (of ten trials) were included. There was moderate level evidence that motivational interviewing had a small effect in increasing physical activity levels in people with chronic health conditions relative to comparison groups (standardized mean differences = 0.19, 95% CI 0.06 to 0.32, p = 0.004). Sensitivity analysis based on trials that confirmed treatment fidelity produced a larger effect. No conclusive evidence was observed for cardiorespiratory fitness or functional exercise capacity. Conclusion: The addition of motivational interviewing to usual care may lead to modest improvements in physical activity for people with chronic health conditions.