Motor Control after Anterior Cruciate Ligament ...

Motor Control after Anterior Cruciate Ligament Reconstruction

Alli Gokeler


Alli Gokeler

Alli Gokeler Motor Control after Anterior Cruciate Ligament Reconstruction Dissertation University of Groningen, The Netherlands. With summary in Dutch.

ISBN:

978-94-91487-21-7

Cover by: Layout by: Printed by: Publisher:

Edwin Keijzer (www.edwinkeijzer.nl) Nikki Vermeulen, Ridderprint BV, Ridderkerk, the Netherlands Ridderprint BV, Ridderkerk, the Netherlands Medix Publishers BV, Keizersgracht 317A, 1016 EE Amsterdam, the Netherlands

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The photographs in this dissertation are courtesy of Edwin Keijzer (www.edwinkeijzer.nl) and photograph cover chapter 5 courtesy of Bert Otten (http//:www.photoplaza.nl/lindolfi) All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronical or mechanical, including photocopy,recording or any information storage or retrieval system, without the prior written permission of the copyright owner.


Proefschrift ter verkrijging van de graad van doctor aan de Rijksuniversiteit Groningen op gezag van de rector magnificus prof. dr. E. Sterken en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woensdag 11 maart 2015 om 16:15 uur

door

Alouis Gokeler geboren op 18 september 1967 te Groningen

Promotores

Prof. dr. E.Otten Prof. dr. K. Postema Prof. dr. P.U. Dijkstra

Co-promotor

Dr. M.P. Arnold

Beoordelingscommissie

Prof. dr. R.L. Diercks Prof. dr. L.H.V. van der Woude Prof. dr. J. Duysens

TA B L E O F C O N T E N T S Chapter 1

Introduction

7

Chapter 2

The Relationship between Isokinetic Quadriceps Strength and Laxity on Gait Analysis Parameters in ACL Reconstructed Knees.

13

Chapter 3

Abnormal Landing Strategies after ACL Reconstruction.

27

Chapter 4

Proprioceptive Deficits after ACL Injury. Are they Clinically Relevant? A Systematic Review.

43

Chapter 5

Movement Patterns of Patients Immersed in Virtual Reality after ACL Reconstruction.

71

Chapter 6

Summary

85

Chapter 7

General Discussion

99

Acknowledgment About the Author Financial Support

111 117 127

Chapter Introduction

1

Introduction

INTRODUCTION

Chapter

Of all athletic knee injuries, a rupture of the anterior cruciate ligament (ACL) is most common and most devastating, resulting in the greatest time lost from sport participation.1 The ACL plays a vital role in the normal function and stability of the knee. Specifically, the native ACL consists of an anteromedial (AM) and posterolateral (PL) bundle, which together provide anterior and rotational stability of the knee.2 Due to its inherent contributions to joint stability and function, when injured, it is widely accepted in the orthopedic community that treatment of choice for an active person should be surgical reconstruction.3 However, successful ACL-reconstruction (ACLR) in terms of restoring the mechanical stability of the knee joint does not ensure restoration of normal knee function. Moreover, despite the fact that surgical techniques and rehabilitation have evolved over the last decade, there is an ongoing debate related to the long term outcome of surgical versus a non-surgical approach.4 An ACL injury increases the risk of osteoarthritis (OA) and until now, ACLR has not been able to revert that course. Altered movement patterns after ACLR have been linked to early development of OA. It has been shown that for months and even years after ACLR, deficits in common daily activities as gait as well as athletic activities such as running and jumping and landing exist. The aim of this dissertation is to contribute to the body of knowledge that may help us to understand the causes of altered movement patterns after ACLR.

O U T L I N E O F T H E D I S S E R TAT I O N Chapter 2 In chapter 2, the results of gait analysis conducted six months after ACLR are presented. In this study the relationships between frequent clinical outcome measurements such as strength and anterior laxity of the knee and gait parameters were determined. Previous studies reported on altered gait after ACLR but were more or less descriptive in nature. This study was undertaken to aid in our understanding as to why patients demonstrate altered gait patterns after ACLR. We chose the six months time frame to study these measures as it is common to release patients to sports after this period of rehabilitation.

Chapter 3 In one of our previous studies we determined that gait had returned to normal levels in only about a third of all patients at one year after ACLR.5 Gait can be considered an activity with relative low intensity and as most patients after ACLR desire to return to

9

1

Chapter 1

high demanding activities, we were therefore interested in examining more demanding tasks in chapter 3. In the final stages of rehabilitation, hop test are commonly used to determine if patients after ACLR can return to sports. Thus, if hop tests are used as indicators of the functional performance after ACLR, it is imperative that a comprehensive assessment is carried out that includes a kinematic, kinetic and EMGanalysis. In this study, such a comprehensive examination was conducted in order to better understand the biomechanical and neuromuscular profiles at the time of release to sports.

Chapter 4 The first two experiments presented in this dissertation provided descriptive information related to altered function following ACLR. Additional proposed mechanisms are related to altered proprioception after ACL injury.6 The ACL contains mechanoreceptors which relay proprioceptive information to the central nervous system (CNS), which may activate the muscles around the knee for stabilization. However the precise mechanism is subject of controversy. In this chapter a literature review was conducted with the specific aim to find relationships between proprioception and often used clinical outcome measures as muscle strength, laxity, hop test, balance and patient-reported outcome.

Chapter 5 The two biomechanical studies that are presented in this dissertation, offer only descriptions of the changed movement patterns after ACLR. However they fail to provide an explanation of the phenomena encountered. In chapter 5, a new theoretical framework to fill this gap is presented. The contention is that patients after ACLR may utilize an increased attentional, cognitive focus on movements which inhibits the learning process to regain normal movements. We employed virtual reality as a tool to explore the effect of cognitive motor control during an easy and common daily task.

Chapters 6 and 7 In chapters 6 and 7, the findings of the research projects are summarized and placed in perspective with an outline for future research. More specifically, thought-provoking issues are presented pertaining the potential causes of altered movements as well a paradigm change in terms of rehabilitation.

10

Introduction

REFERENCES

Chapter

1. Dick R, Hootman JM, Agel J, Vela L, Marshall SW, Messina R. Descriptive epidemiology of collegiate women’s field hockey injuries: National Collegiate Athletic Association Injury Surveillance System, 19881989 through 2002-2003. J Athl Train. 2007;42(2):211-220. 2. van Eck CF, Kopf S, Irrgang JJ, et al. Single-bundle versus double-bundle reconstruction for anterior cruciate ligament rupture: a meta-analysis--does anatomy matter? Arthroscopy. 2012;28(3):405-424. 3. Marx RG, Jones EC, Angel M, Wickiewicz TL, Warren RF. Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury. Arthroscopy. 2003;19(7):762-770. 4. Delince P, Ghafil D. Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):48-61. 5. Schmalz T, Blumentritt S, Wagner R, Gokeler A. Gait analysis of patients within one year after anterior cruciate ligament reconstruction. Phys Med Reh Kurortmed. 1998;8:1-8. 6. Friden T, Roberts D, Ageberg E, Walden M, Zatterstrom R. Review of knee proprioception and the relation to extremity function after an anterior cruciate ligament rupture. J Orthop Sports Phys Ther. 2001;31(10):567-576.

11

1

Chapter

2

The Relationship between Isokinetic Quadriceps Strength and Laxity on Gait Analysis Parameters in ACL Reconstructed Knees

A. Gokeler, T. Schmalz, E. Knopf, J. Freiwald, S. Blumentritt Knee Surg Sports Traumatol Arthrosc 2003; 11(6):372–378

Chapter 2

ABSTRACT Gait alterations after anterior cruciate ligament (ACL) reconstruction have been reported in the literature. In the current study, a group of 14 patients who all had an ACL-reconstruction (ACLR) with a patellar tendon autograft were examined. Kinetic and kinematic data were obtained from the knee during walking. The Flexion-ExtensionDeficit (FED) calculated from the angular difference between maximal flexion and maximal extension during the stance phase in the ACLR and the normal knee was measured. We investigated whether these alterations in gait are related to quadriceps strength and residual laxity of the knee. It may be that patients modify their gait patterns to protect the knee from excessive anterior translation of the tibia by reducing the amount of extension during stance. On the other hand, persistent quadriceps weakness may also cause changes in gait patterns as the quadriceps is functioning as an important dynamic stabilizer of the knee during stance. Results showed that patients had a significantly higher FED value of 4.9 ± 4.0 when compared to data obtained from a healthy control group (CTRL) in a previous stud (FED 1.3 ± 0.9). This is mainly caused by an extension deficit during mid stance. External extension moments of the knee were significantly lower in the ACLR group -0.27 ± 0.19 TZMAX Nm/kg when compared to a CTRL group -0.08 ± 0.06 TZMAX Nm/kg. Correlation coefficient analysis did not show any positive relationship between quadriceps strength and gait analysis parameters. Furthermore no correlation was found between the amount of laxity of the knee and gait. The relevance of this study lies in the fact that apparently the measured gait alterations cannot be solely explained by often used biomechanical indicators such as laxity and strength. Possibly, the measured gait alterations are a result of the surgical procedure with subsequent modified motor programming. Key words: ACL, Gait analysis, Isokinetic strength, Neuromuscular, Rehabilitation

14

The Relationship between Isokinetic Quadriceps Strength and Laxity

INTRODUCTION Anterior cruciate ligament-reconstruction (ACLR) has become a routine surgical procedure in the last 15 years. Since the early nineties more aggressive rehabilitation programs have been advocated including immediate full knee extension, weight bearing as tolerated and early initiation of closed chain exercises emphasizing quadriceps strengthening.1 Subsequently coordinative exercises are implemented with the goal of return to sports at four-six months after surgery. Several quantitative tests are described in the literature such as arthrometric knee laxity testing1-3 and isokinetic strength testing4-6 to evaluate the outcome of these surgical procedures. It has been demonstrated that laxity tests may not necessarily provide information about the functional status of the knee.7 Furthermore, it is commonly accepted that return of a strong quadriceps muscle after knee injuries is vital for functional and athletic use of the lower extremity8-11 although others did not observe this correlation.12,13 Reports about isokinetic peak torque measurements taken approximately six months after ACLR and comparing the involved with the non-involved side show quadriceps ratios ranging from 59.5% to more then 90%.5,6,14-17 Despite the differences reported, the consensus seems that quadriceps strength has not returned to normal levels at this time after surgery. This is interesting considering that most athletes are able to resume sports approximately six months after surgery. We know from investigations performed at our gait laboratory18 that a large percentage of patients show significant abnormalities during gait even at 26 weeks after ACLR, equivalent to the time period when most patients return to sports. In fact, the evidence from our study showed that the return of normal gait may even take more than one year. The most striking differences were an extension deficit and reduced external extension moments in the involved knee in the mid-stance phase of gait. The question arises as to the nature of different biomechanical strategies used – consciously or unconsciously - by patients after ACLR. It may be that patients modify their gait patterns to protect the knee from excessive anterior translation of the tibia by reducing the amount of extension during stance. On the other hand persistent quadriceps weakness may also cause changes in gait patterns as the quadriceps is functioning as an important dynamic stabilizer of the knee during stance. The purpose of this study was to determine whether gait alterations were present in patients whose ACL-deficient (ACLD) knees were surgically reconstructed with a patellar tendon autograft, and in that case, whether that had a relationship with residual laxity and quadriceps strength. We chose to take the measurements 26 weeks after surgery as we know from a previous study that kinetic and kinematic characteristics of gait are still significantly different from controls.19

15

Chapter

2

Chapter 2

M AT E R I A L A N D M E T H O D S Subjects Fourteen subjects (7 men and 7 women) with a mean age of 24 years (range 21-40), mean height 183 cm (range 162-192) and a mean weight of 74.4 kg (range 56101) participated in this study. All had a complete rupture of the ACL that was arthroscopically reconstructed using the central third of the patellar tendon. All patients participating in the study were collegiate or recreational athletes. After surgery, they completed an intensive rehabilitation program as outpatients three times a week at the same rehabilitation center. The program included immediate weight bearing, range of motion exercises, pool therapy, stationary bicycle and closed chain strengthening and coordination exercises. Running was permitted after 10 weeks and once dynamic stability was satisfactory, agility and sports specific exercises were started. Return to sports involving pivoting and jumping was allowed after six months. Patients gave their consent to participate in this study.

Experimental Design Clinical examination All patients were examined by the same two physical therapists with respectively ten and eight years experience in orthopedics. The examination consisted of passive range of motion measurements of both knees for knee extension and flexion with a standard goniometer and instrumented laxity testing using the KT-1000 arthrometer (MEDmetric Corp., San Diego, Cal. USA) tests with application of a 89-N force. Side-to-side differences (in mm) were reported for comparison. Isokinetic testing Muscular performance of both knees was evaluated on an isokinetic testing device (Lido Active, Loredon Biomedical Inc., Davis, CA) of both knees at a velocity of 60 deg/sec. All patients had two-three training sessions on the isokinetic device in the weeks prior to testing to familiarize them with the testing procedure. The subjects did a 15 minute warm-up on a stationary bicycle (Kardiomed Bike, Proxomed, Karlstein, Germany) before the test procedure. Testing was done with the subjects in a seated position with the hip in 90° flexion and the thigh fixated with straps. The ROM for the knee was set at 0° to 90° flexion. The noninvolved side was tested first. Prior to testing 10 sub-maximal repetitions were performed. The test procedure consisted of 10 maximal concentric repetitions for flexion and extension at a speed of 60 deg/sec. The patients received standardized verbal commands but visual information from the curves as displaced on the monitor was withheld. The peak torque of quadriceps and hamstring strength was

16


compared with the noninvolved side and was expressed as a ratio (involved torque/ noninvolved torque x 100). Gait analysis Gait analysis was performed for level walking at our gait laboratory using a 4-camera optoelectric system (Primas, Delft Motion Analysis, Delft, the Netherlands) with a 100 Hz frequency for collection of the 2-dimensional data. Reflective markers were placed on the subjects at anatomic landmarks according to the description in a previous paper.18 The markers were placed at the greater trochanter, lateral femoral epicondyle, lateral malleolus and on the outside of the shoe representing the location of the head of the fifth metatarsal. Thus only sagittal plane motions could be calculated. Two force plates (Kistler Instruments, Winterthur, Switzerland) embedded in a 12 meter long walkway measured the ground reaction forces of both legs with a sampling rate of 400 Hz. The 2-dimensional data derived from the four cameras were synchronized with the collection of data from the force plates. All subjects were instructed to walk steadily during the test procedure. For each subject a specific starting point was determined from test trials so that the subject would contact the platform each time with the same limb without having to consciously focus to touch the plate. All subjects walked with sport shoes. The data used in this study were obtained from the mean values of 10-12 consistent cycles of walking over the walkway. Definitions of the quantitative parameters were described in detail in an earlier publication from our institution.18 For the purpose of this study we will summarize the most important kinetic and kinematic parameters. To describe the kinematic changes during the stance phase, we calculated the angular difference between maximal flexion and maximal extension in the ACLR and the normal knee. We defined this as the “Flexion-Extension-Deficit“ (FED) (Figure 1). The differentiation whether a significant FED-value is due to reduced flexion or extension motion during stance can be made with the calculation of joint toques. In 90% of the cases a higher value is associated with an extension deficit in stance.18

180

θ [°]

180

θ [°]

DNOR

DACL 140

140

20

60

t [%]

20

60

t [%]

FED = D ACL - DNOR Figure 1. Sagittal knee angles (θ) during the stance phase (t expressed as percentage of stance phase) for the reconstructed knee (left) and normal knee (right). DACL Difference between maximal knee flexion an extension for the reconstructed knee; DNOR difference between maximal knee flexion an extension for the normal knee; FED DACL–DNOR 17

Chapter

2

Chapter 2

The external, sagittal moment acting on the knee joint was calculated from kinematic data and ground reaction forces. During normal human gait there is an external flexion moment in the first 50% of stance which is followed by an external extension moment in the second half. The difference between the maximal values of the external flexion moments comparing the ACLR knee with the normal knee is defined as TZMIN whereas the difference between maximal external extension moments is defined as TZMAX (Figure 2).

Figure 2. The sagittal knee moments during stance phase (t expressed as percentage of stance phase) normalized to body weight (MZ). The external flexion (MZMIN) and extension (MZMAX) moments are shown for the ACL-reconstructed knee (left) and normal knee (right). The difference between the maximal values of the external flexion moments comparing the ACL-reconstructed knee with the normal knee is defined as TZMIN whereas the difference between maximal external extension moments is defined as TZMAX.

In this study we only calculated for TZMAX as this was shown to be a sensitive indicator of gait abnormalities.18 All measurements were performed 26 weeks after surgery on all subjects.

Statistical analysis Linear correlation coefficients were calculated with SPSS 10.0 for Windows to determine the relationship between isokinetic strength, laxity measurements and gait analysis.

R E S U LT S Gait analysis The mean value of FED in our patients during stance phase of gait was 4.9° ± 4.0 and was significantly different (p < 0.01) when compared to a control group in a previous study. (Figure 3). The mean external extension torque, TZMAX was - 0.27 ± 0.19 Nm/kg and is also significantly different (p < 0.05) when compared to controls (Figure 4).

18


6

*

*

4.5

FED [º]

Chapter

2

3

1.5

0

Patients current study

Patients previous study

Controls

Figure 3. Kinematic flexion extension deficit FED for the current patient group in comparison to the earlier recorded data of a comparable patient group (n=35, mean age 27 years) and a healthy control group (n=30, mean age 28 years)28 indicating significant difference (*) of the patients in comparison to the natural right-leftdifferences of uninjured people (p < 0.01). 0.4

Tzmax [Nm/kg]

0.3

* *

0.2

0.1

0

Patients current study

Patients previous study

Controls

Figure 4. External extension moments TZMAX for the current patient group in comparison to the earlier recorded data of comparable patient group (n=35, mean age 27 years) and a healthy control group (n=30, mean age 28 years)28 indicating significant difference (*) of the patients in comparison to the natural right-left-differences of uninjured people (p < 0.05).

Laxity examination and Isokinetic Strength Laxity measurements with the KT-1000 with a 89N force showed a mean side to side difference of 2 ± 0.9 mm. The mean isokinetic quadriceps peak torque ratio at 60 deg/ sec for the involved side was 74.9 ± 17.8 % of the non-involved side.

19

Chapter 2

Correlation between Laxity, Isokinetic Strength and Gait Analysis The linear correlation coefficients between clinical examination, isokinetic strength and gait analysis were calculated and are summarized in Table 1. A correlation exists between FED and TZMAX (p < 0.05). We did not find a correlation between laxity examination, isokinetic quadriceps torque and gait analysis parameters. Table 1. Correlation coefficients (r) between the Gait Analysis Parameters FED and TZMAX and Isokinetic Quadriceps Peak Torque and Laxity TZMAX

KT-1000

Isokinetic Quadriceps Peak Torque

FED

0.56 (*)

0.005

0.33

TZMAX

X

0.19

0.24

(*: indicates statistically significant relationship p 90% and those with ratios < 80%. They found a significant relationship between strength and knee angles and moments during the early phase of stance. Mittlmeier and colleagues30 found that weakness of the quadriceps

22


measured isokinetically 24 weeks after ACLR was related to gait abnormalities. However they studied gait by assessing plantar pressure distribution which cannot calculate for joint moments as we did in our study. Rudolph et al.26 did not find a correlation between isometric quadriceps strength and the amount of knee flexion during weight acceptance in subjects with ACL-deficient knees. It has to be noted that isokinetic testing usually involves maximal muscle activation whereas kinetic and kinematic parameters obtained during gait do not place maximal demands on the knee joint. This could be a possible explanation for the lack of relationship between isokinetic quadriceps strength and gait analysis parameters. Several investigators22,23,31 have described the dynamic stabilizing function of the hamstrings in ACLD knees. Less is known about the role of the hamstrings in a population with ACLR knees. Cicotti and co-workers25 reported near normal activity of the hamstrings during the swing phase of gait in ACLR knees when compared to controls. Work at our own institution has shown that the activity of the gastrocnemius muscle is significantly reduced during the stance phase.32 Although improvements in surgical techniques and more aggressive rehabilitation programs have been implemented, several authors continue to report persistent deficits in quadriceps strength.33-35 Engelhardt and co-workers showed that afferent signals from the central nervous system inhibit the activation of the quadriceps muscle after injury or surgery of the knee, causing the often observed atrophy of the quadriceps.36 Freiwald and colleagues demonstrated that isokinetic torque of the quadriceps was significantly reduced 12 weeks after ACLR when compared to pre-operative measurements.33,37 At 16 months after surgery the maximal isokinetic quadriceps ratio was 81% in comparison to the normal knee. Interestingly the patients had a Lysholm score > 95 points and had all resumed their pre-operative sports level. Recently, Keays et al. corroborated these findings.6 They showed that an isokinetic peak torque ratio of the quadriceps of 88% before surgery and decreasing to 72% at six months after surgery despite intensive quadriceps training. Interestingly, functional tests improved by in the same time period. One may conclude that isokinetic quadriceps peak torque is not as important a predictor of function as initially thought. It may be that when a - so far undefined - “peak torque deficit” is crossed, subjective and objective limitations may become noticeable. From the perspective of the theories in motor learning it appears that reprogramming of the central nervous system after ACLR allows for improvement of functional tasks despite weakness of the quadriceps.38 The clinical implication may be that primarily focusing on return of full quadriceps strength is no longer warranted and rehabilitation should rather implement goal-oriented exercises that replicate the functional demands as in sports or work.38

23

Chapter

2

Chapter 2

Several limitations have to be addressed about this paper. First, we had a relative small patient population. Second, the data derived can only be applied to patients who underwent the same surgical procedures as in our study population. Third, to the best of our knowledge, the external validity of gait analysis has has not been demonstrated to more athletic functional demands of the knee. The kinematic and kinetic data as measured in this study thus only applies to gait. Studying more strenuous activities such as running, jumping and cutting movements may provide more relevant information about the differences in kinetic and kinematic parameters necessary for sports related function of the knee. They could then be used as indicators of a safe return to sports after ACLR-reconstruction. Our study clearly indicates that gait analysis parameters in ACLR knees are not related to quadriceps strength and laxity. Central reprogramming of the central nervous system38 may be the reason why gait is significantly altered after surgical reconstruction of the ACL39 as these changes cannot be fully explained by quadriceps weakness and laxity of the knee.

Acknowledgments Otto Bock Research Department, Biomechanics Laboratory, Göttingen, Germany

Declaration We followed the principles outlined in the Declaration of Helsinki and the experiment complied with the law in Germany. The subjects were free to withdraw from the study at any time.

24


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Chapter

3. Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am. 1985;67(5):720-726. 4. Witvrouw E, Bellemans J, Verdonk R, Cambier D, Coorevits P, Almqvist F. Patellar tendon vs. doubled semitendinosus and gracilis tendon for anterior cruciate ligament reconstruction. Int.Orthop. 2001;25(5):308-311. 5. Carter TR, Edinger S. Isokinetic evaluation of anterior cruciate ligament reconstruction: hamstring versus patellar tendon. Arthroscopy. 1999;15(2):169-172. 6. Keays SL, Bullock-Saxton J, Keays AC. Strength and function before and after anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2000(373):174-183. 7. Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR, 3rd, Ciccotti MG. The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med. 1997;25(2):191195. 8. Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment of functional limitations in normal and anterior cruciate ligament-deficient knees. Clin Orthop Relat Res. 1990(255):204214. 9. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513-518. 10. Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am. 1995;77(8):1166-1173. 11. Karlsson J, Kalebo P, Goksor LA, Thomee R, Sward L. Partial rupture of the patellar ligament. Am J Sports Med. 1992;20(4):390-395. 12. Anderson MA, Gieck JH, Perrin DH, Weltman A, Rutt RA, Denegar CR. The Relationships among Isometric, Isotonic, and Isokinetic Concentric and Eccentric Quadriceps and Hamstring Force and Three Components of Athletic Performance. J Orthop Sports Phys Ther. 1991;14(3):114-120. 13. Delitto A, Irrgang JJ, Harner CD, Fu FH. Relationship of Isokinetic Quadriceps Peak Torque and Work to One Legged Hop and Vertical Jump in ACL Reconstructed Knees. Phys Ther. 1993;73(6):S85. 14. Shelbourne KD, Foulk DA. Timing of surgery in acute anterior cruciate ligament tears on the return of quadriceps muscle strength after reconstruction using an autogenous patellar tendon graft. Am J Sports Med. 1995;23(6):686-689. 15. Wilk KE, Romaniello WT, Soscia SM, Arrigo CA, Andrews JR. The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J Orthop Sports Phys Ther. 1994;20(2):60-73. 16. Wilk KE, Keirns MA, Andrews JR, Clancy WG, Arrigo CA, Erber DJ. Anterior cruciate ligament reconstruction rehabilitation: a six-month followup of isokinetic testing in recreational athletes. Isokinet Exc Sci. 1991;1(1):36. 17. Wilk KE, Andrews JR. Current concepts in the treatment of anterior cruciate ligament disruption. J Orthop Sports Phys Ther. 1992;15(6):279-293. 18. Schmalz T, Blumentritt S, Wagner R, Gokeler A. Gait analysis of patients within one year after anterior cruciate ligament reconstruction. Phys Med Reh Kurortmed. 1998;8:1-8. 19. Schmalz T, Blumentritt S, Wagner R, Junge R. [Evaluation with biomechanical gait analysis of various treatment methods after rupture of the anterior cruciate ligament]. Sportverletz Sportschaden. 1998;12(4):131-137.

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20. Andriacchi TP, Birac D. Functional testing in the anterior cruciate ligament-deficient knee. Clin Orthop Relat Res. Mar 1993(288):40-47. 21. Berchuck M, Andriacchi TP, Bach BR, Reider B. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg Am. 1990;72(6):871-877. 22. Beard DJ, Soundarapandian RS, O’Connor JJ, Dodd CA. Gait and electromyographic analysis of anterior cruciate ligament deficient subjects. Gait Posture. 1996;4(2):83. 23. Roberts CS, Rash GS, Honaker JT, Wachowiak MP, Shaw JC. A deficient anterior cruciate ligament does not lead to quadriceps avoidance gait. Gait Posture. 1999;10(3):189-199. 24. Timoney JM, Inman WS, Quesada PM, et al. Return of normal gait patterns after anterior cruciate ligament reconstruction. Am J Sports Med. 1993;21(6):887-889. 25. Ciccotti MG, Kerlan RK, Perry J, Pink M. An electromyographic analysis of the knee during functional activities. II. The anterior cruciate ligament-deficient and -reconstructed profiles. Am J Sports Med. 1994;22(5):651-658. 26. Rudolph KS, Eastlack ME, Axe MJ, Snyder-Mackler L. 1998 Basmajian Student Award Paper: Movement patterns after anterior cruciate ligament injury: a comparison of patients who compensate well for the injury and those who require operative stabilization. J Electromyogr Kinesiol. 1998;8(6):349-362. 27. Sekiya I, Muneta T, Ogiuchi T, Yagishita K, Yamamoto H. Significance of the single-legged hop test to the anterior cruciate ligament-reconstructed knee in relation to muscle strength and anterior laxity. Am J Sports Med. 1998;26(3):384-388. 28. Kovaleski JE, Heitman RJ, Andrew DP, Gurchiek LR, Pearsall AW. Relationship between closed-linear-kineticand open-kinetic-chain isokinetic strength and lower extremity functional performance. J Sport Reh. 2001;10(3):196. 29. Lewek M, Rudolph K, Axe M, Snyder-Mackler L. The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction. Clin Biomech. 2002;17(1):56-63. 30. Mittlmeier T, Weiler A, Sohn T, et al. Functional monitoring during rehabilitation following anterior cruciate ligament reconstruction. A novel Award Second Prize Paper. Clin Biomech. 1999;14(8):576-584. 31. Liu W, Maitland ME. The effect of hamstring muscle compensation for anterior laxity in the ACL-deficient knee during gait. J Biomech. 2000;33(7):871-879. 32. Schmalz T, Freiwald J, Greiwing A, Kocker L, Ludwig H, Blumentritt S. Mechanical and electromyographical gait parameters in the course of rehabilitation after anterior cruciate ligament reconstruction. Eur J Sports Traumatol Relat Res 2001;23(4):146-151. 33. Freiwald J, Jager A, Starker M. [EMG-assisted functional analysis within the scope of follow-up of arthroscopically managed injuries of the anterior cruciate ligament]. Sportverletz Sportschaden. 1993;7(3):122-128. 34. Yasuda K, Ohkoshi Y, Tanabe Y, Kaneda K. Quantitative evaluation of knee instability and muscle strength after anterior cruciate ligament reconstruction using patellar and quadriceps tendon. Am J Sports Med. 1992;20(4):471-475. 35. Natri A, Jarvinen M, Latvala K, Kannus P. Isokinetic muscle performance after anterior cruciate ligament surgery. Long-term results and outcome predicting factors after primary surgery and late-phase reconstruction. Int J Sports Med. 1996;17(3):223-228. 36. Engelhardt M, Reuter I, Freiwald J. Alterations of the neuromuscular system after knee injury. Eur J Sports Traumatol Rel Res. 2001;23 75-81. 37. Freiwald J, Reuter I, Engelhardt M. Neuromuscular and motor system alterations after knee trauma and knee surgery. A new paradigm. In: Lehmann L, ed. Overload, Performance Incompetence and Regeneration in Sport. New York: Kluwer Academic Press/Plenum Publishers; 1999:81-100. 38. Freiwald J, Engelhardt M. Status of Motor Learning and Coordination in Orthopedic Rehabilitation. Sportorth Sporttraum 2002;18:5-11. 39. Ferber R, Osternig LR, Woollacott MH, Wasielewski NJ, Lee JH. Gait mechanics in chronic ACL deficiency and subsequent repair. Clin Biomech. 2002;17(4):274-285.

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Abnormal Landing Strategies after ACL Reconstruction

A. Gokeler, A.L. Hof, M.P. Arnold, P.U. Dijkstra, K.Postema, E. Otten Scan J Med Sci Sports 2009; 20: e12–e19

Chapter 3

ABSTRACT The objective was to analyze muscle activity and movement patterns during landing of a single leg hop for distance after anterior cruciate ligament (ACL) reconstruction. Nine (six males, three females) patients six months after ACL-reconstruction (ACLR) and 11 (eight males, three females) healthy control (CTRL) subjects performed the hop task. Electromyographic signals from lower limb muscles were analyzed to determine onset time before landing. Biomechanical data were collected using an Optotrak Motion Analysis System and force plate. Matlab was used to calculate kinetics and joint kinematics. Side-to-side differences in ACLR and CTRL subjects as well as differences between the patients and CTRL group were analyzed. In ACLR limbs, significantly earlier onset times were found for all muscles, except vastus medialis, compared with the uninvolved side. The involved limbs had significantly reduced knee flexion during the take-off and increased plantarflexion at initial contact. The knee extension moment was significantly lower in the involved limb. In the CTRL group, significantly earlier onset times were found for the semitendinosus, vastus lateralis and medial gastrocnemius of the non-dominant side compared with the dominant side. Muscle onset times are earlier and movement patterns are altered in the involved limb six months after ACLR.

28


INTRODUCTION Successful anterior cruciate ligament (ACL) reconstruction in terms of restoring the anterior laxity of the knee joint to near-normal values does not automatically mean restoration of normal knee function.1 For example, only 31% of patients after ACL-reconstruction (ACLR) regain a normal walking pattern one year after surgery.2 Biomechanical analysis of hop tasks revealed persistent altered knee joint moments > one year after ACLR.3 Recent research has shown that the results of hop tests can be used as predictors of short-term dynamic stability in subjects with ACL-deficient (ACLD) knees.4 These tests are appealing as they are easy to perform, simulate in part sportspecific demands and have satisfactory reliability.5 In several papers studying high demand activities of the ACLR knee, substitutions of moments were shown to occur from the knee to the hip or ankle.6,7 The data suggest that the patients used a strategy by transferring the moments from the knee to the hip and/or the ankle in order to reduce the knee moment. The studies cited above, however, lack the incorporation of electromyographic (EMG) data during the hopping tasks.3,6,7 If functional deficits last more than one year after surgery, it is reasonable to assume that deficits are even more pronounced six months after surgery. Thus, if hop tests are used as indicators of the functional performance of patients after ACLR, it is imperative that a comprehensive assessment that includes kinematic, kinetic and EMG-analysis is conducted in order to better understand the biomechanical and neuromuscular profiles. EMG analysis is a method that offers a partial insight into neuromuscular activity. The onset of muscle activity before landing is particularly of interest because it increases the stiffness of the joints.8 This feed-forward mechanism is important as it allows the muscles time to generate force to provide correct lower extremity alignment during landing. Insufficient timing may place the knee in an unfavorable position, increasing the risk of sustaining an ACL (re)injury. So far, research on muscle onset during hop tasks have been performed in ACLD patients or in patients more than one year after reconstructive surgery.9-11 Muscle onset patterns of patients six months after ACLR, at which time return to sports is commonly allowed, are currently unknown. The purpose of this study was, therefore, to assess the bilateral lower limb joint kinematics and kinetics and onset time of EMG activity during the single leg hop test in patients after ACLR during the single leg hop for distance. These data will be compared with a CTRL group.

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Chapter 3

M AT E R I A L A N D M E T H O D S Subjects Nine consecutive patients after ACLR (six males and three females) with a mean age of 28.4 ± 9.7 years were measured 27 ± 1.5 weeks post-operatively. Eleven healthy subjects (eight males and three females) with a mean age of 26.3 ± 5.5 years were used as CTRL. All subjects were level I–II athletes. Level I sports are described as jumping, pivoting and hard cutting sports. Level II sports also involve lateral motion, but with less jumping or hard cutting than level I.12 Inclusion criteria for the patients were: isolated ACL lesion, no major meniscal or cartilage lesion, normal limb alignment as determined on a standardized lower extremity x-ray and defined as an anatomical femoro-tibial axis of between 2° and 7° of valgus and no varus as well as no relevant previous surgery at any other joint of the limbs. Exclusion criteria were joint effusion, varus thrust of the knee, >50% removal of the width of the base of the meniscus, grade 3 rupture of the collateral ligaments, concomitant ligament injuries to the posterolateral or – medial corner, traumatic or degenerative cartilage lesions 110 dB common mode rejection, 500 MΩ input impedance. The pre-amplified EMGs were sampled at 800 Hz and high-pass filtered at 20 Hz with a third-order digital Butterworth filter. The force plate signal was sampled at 750 Hz and used for the kinematic and kinetic analysis. An analogue trigger circuit was connected to the vertical GRF output, using a trigger level of approximately 100 N. This trigger signal was recorded, together with the EMGs, on the EMG recording device. The latter had a sampling frequency of 800 Hz, but was asynchronous with the kinematic data acquisition. For the detection of the onset times τ, the “approximated generalized likelihood ratio” (AGLR) was used.20 In this test, the ratio (variance after t=τ)/(variance before t=τ) is determined for all possible values of τ over a sensible interval. The value of τ at which the logarithm of this ratio is maximal is selected as the most probable onset time. Identification of this point allowed to differentiate between activity shortly after take-off and the preparatory activity before landing. The latter was of interest in this study and was defined as onset time. In our experiments, we first calculated the smoothed (10 Hz zero-lag Butterworth filter) rectified EMG. The square of two × its minimum value over the interval (0.5–0 s) before landing was taken as the “variance before.” The start of the “sensible interval” was the interval before landing over which the smoothed rectified EMG remained below three × the minimum value. The duration of this interval was 1 s. The onset time is the continuous rise in EMG activity as defined by the algorithm, indicating the build-up of muscle activity preparing for landing.

32


Statistical analysis The mean onset times of the EMG signals for each muscle were calculated. Differences between uninvolved and involved limbs in the ACLR and differences between dominant and non-dominant limbs in the CTRL group were analyzed using the Wilcoxon signed ranks test. The Mann–Whitney test for independent samples was used to analyze leg differences in onset times between ACLR and CTRL groups, α-levels were set at < 0.05 for statistical significance. For each kinematic and kinetic variable, mean values from five jumps were compared between the involved and the uninvolved limbs of all patients. The mean difference was used for statistical analysis with a non-parametric Wilcoxon signed ranks test.

R E S U LT S IKDC The mean subjective IKDC score for the ACLR was 81 ± 7.1. The objective IKDC score revealed that one patient had an A, seven had a B and one patient scored a C (donor site pain on palpation). Mean laxity showed 85% as one of the criteria to return to sports as proposed in the literature.38 The mean maximum hop limb symmetry was 83.8 and was based on maximum distance achieved and not on the average of three hops. It has been shown from the literature that average results from the hop test underestimate the potential in patients.5,39 Patients show an increase in jump distance as trials progresses. They even improve jump distance from trial to trial, which is not seen in healthy controls.39 Secondly, it was demonstrated in a recent research that using the maximal hop test results in a high ability to discriminate between the hop performance of the involved and the uninvolved side both in patients with an ACL injury and in patients who have undergone ACLR.15 One should keep in mind that our patients had been treated with a BPTB technique; it is possible that the results might differ had a different ACL graft been used. It is recognized that the hop task as used in this study is a pre-planned activity, but was chosen for its high reliability.5 On the other hand, it would be interesting to repeat a jump task experiment with patients after ACLR under unanticipated or fatigued conditions to simulate normal athletic activity. It has been shown that unanticipated cutting tasks lead to a non-specific co-contraction of the muscles to increase joint stiffness.40 This phenomenon is basically what patients in the current study demonstrated. Recently, Wilkstrom et al. demonstrated altered muscle onset times in jump trials in which subjects were not able to maintain balance upon landing.41 Their paper indicated that successful jump landing required an earlier muscle activity in order to land safely.

Perspectives It is remarkable that, although anterior laxity has been (nearly) restored, patients after ACLR still utilize muscle recruitment patterns to increase the stiffness of the knee similar to patients with ACLD knees.42 Movement patterns in the involved limbs were also significantly different from uninvolved limbs. Moreover, they do this by including the control of the swing leg during landing, according to our biomechanical simulations. The asymmetries in muscle onset and movement patterns may predispose to re-injury of the ACL. Future studies with a prospective and longitudinal design should focus on whether and how these asymmetries may change over time and whether they can be improved by rehabilitation. Furthermore, sensitive tests should be developed to determine a safe return to sports.

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Acknowledgements The authors thank Anne Benjaminse P.T. of the Neuromuscular Research Laboratory of the University of Pittsburgh for her assistance with the preparation of the manuscript. In addition, we thank Alieke Drok M.A., who assisted with the measurements as part of fulfillment of her research thesis at the Center for Human Movement Science at the University of Groningen in the Netherlands.

40


REFERENCES 1. Dye SF. The knee as a biologic transmission with an envelope of function: a theory. Clin Orthop Relat Res. 1996(325):10-18. 2. Schmalz T, Blumentritt S, Wagner R, Junge R. [Evaluation with biomechanical gait analysis of various treatment methods after rupture of the anterior cruciate ligament]. Sportverletz Sportschaden. 1998;12(4):131-137. 3. Decker MJ, Torry MR, Noonan TJ, Riviere A, Sterett WI. Landing adaptations after ACL reconstruction. Med. Sci.Sports Exerc. 2002;34(9):1408-1413. 4. Fitzgerald GK, Lephart SM, Hwang JH, Wainner RS. Hop tests as predictors of dynamic knee stability. J Orthop Sports Phys Ther. 2001;31(10):588-597. 5. Clark NC. Functional performance testing following knee ligament injury. Phys Ther Sport. 2001;2 (2):91105. 6. Ernst GP, Saliba E, Diduch DR, Hurwitz SR, Ball DW. Lower extremity compensations following anterior cruciate ligament reconstruction. Phys Ther. 2000;80(3):251-260. 7. Webster KE, Gonzalez-Adrio R, Feller JA. Dynamic joint loading following hamstring and patellar tendon anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004;12(1):15-21. 8. Solomonow M, Krogsgaard M. Sensorimotor control of knee stability. A review. Scand J Med Sci Sports. 2001;11(2):64-80. 9. DeMont RG, Lephart SM, Giraldo JL, Swanik CB, Fu FH. Muscle Preactivity of Anterior Cruciate LigamentDeficient and -Reconstructed Females During Functional Activities. J Athl Train. 1999;34(2):115-120. 10. Pfeifer K, Banzer W. Motor performance in different dynamic tests in knee rehabilitation. Scand J Med Sci Sports. 1999;9(1):19-27. 11. Smith J, Malanga GA, Yu B, An KN. Effects of functional knee bracing on muscle-firing patterns about the chronic anterior cruciate ligament-deficient knee. Arch Phys Med Rehabil. 2003;84(11):1680-1686. 12. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med. 1994;22(5):632-644. 13. Arnold MP, Verdonschot N, van Kampen A. ACL graft can replicate the normal ligament’s tension curve. Knee Surg Sports Traumatol Arthrosc. 2005;13(8):625-631. 14. Irrgang JJ, Anderson AF, Boland AL, et al. Responsiveness of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med. 2006;34(10):1567-1573. 15. Gustavsson A, Neeter C, Thomee P, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):778-788. 16. Clark NC, Gumbrell CJ, Rana S, Traole CM, Morrissey C. Intratester reliability and measurement error of the adapted crossover hop for distance. Phys Ther Sport. 2002;3(3):143-151. 17. van der Harst JJ, Gokeler A, Hof AL. Leg kinematics and kinetics in landing from a single-leg hop for distance. A comparison between dominant and non-dominant leg. Clin Biomech. 2007;22(6):674-680. 18. Hof AL. On the interpretation of the support moment. Gait.Posture. 2000;12(3):196-199. 19. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J.Electromyogr.Kinesiol. 2000;10(5):361-374. 20. Staude G, Wolf W. Objective motor response onset detection in surface myoelectric signals. Med.Eng Phys. 1999;21(6-7):449-467. 21. Otten E. Inverse and forward dynamics: models of multi-body systems. Philos Trans R Soc Lond B Biol Sci. 2003;358(1437):1493-1500. 22. Dyhre-Poulsen P, Simonsen EB, Voigt M. Dynamic control of muscle stiffness and H reflex modulation during hopping and jumping in man. J.Physiol. 1991;437:287-304. 23. Riemann BL, Lephart SM. The Sensorimotor System, Part I: The Physiologic Basis of Functional Joint Stability. J Athl Train. 2002;37(1):71-79.

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Proprioceptive Deficits after ACL Injury. Are they Clinically Relevant? A Systematic Review

A. Gokeler, A. Benjaminse, T.E. Hewett, S.M. Lephart, L. Engebretsen, E. Ageberg, M. Engelhardt, M.P. Arnold, K. Postema, E. Otten, P.U. Dijkstra Br J Sports Med 2012; 46(3):180-192

Chapter 4

ABSTRACT Objective: To establish the clinical relevance of proprioceptive deficits reported after anterior cruciate ligament injury (ACL). Material and Methods: A literature search was done in electronic databases from January 1990 to June 2009. Inclusion criteria for studies were ACL-deficient (ACLD) and ACL-reconstructed (ACLR), articles written in English, Dutch or German and calculation of correlation(s) between proprioception tests and clinical outcome measures. Clinical outcome measures were muscle strength, laxity, hop test, balance, patient reported outcome, objective knee score rating, patient satisfaction or return to sports. Studies included in the review were assessed on their methodological quality. Results: In total 1161 studies were identified of which 24 met the inclusion criteria. Pooling of all data was not possible due to substantial differences in measurement techniques and data analysis. Most studies failed to perform reliability measurements of the test device used. In general the correlation between proprioception and laxity, balance, hop tests and patient outcome was low. Four studies reported a moderate correlation between proprioception, strength, balance or hop test. Conclusion: There is limited evidence that proprioceptive deficits as detected by commonly used tests adversely affect function in patients after ACLD and ACLR. Development of new tests to determine the relevant role of the sensorimotor system are needed. These tests should ideally be used as screening test for primary and secondary prevention of ACL injury.

44

Proprioceptive Deficits after ACL Injury. Are they Clinically Relevant?

INTRODUCTION The anterior cruciate ligament (ACL) is the most commonly injured ligament in the body.1 Instability of the knee often occurs after ACL injury in pivoting type sports and ACL-reconstruction (ACLR) often is recommended.2 Nonetheless, despite ACLR, up to a third of patients will not reach their pre-injury activity level,3 which may be attributed to fear of re-injury.4 Of concern is the incidence of recurrent injury to the operated knee ranging from 3,6% 5 in adults to 17% in patients under 18 years of age.6 An ACL injury increases the risk of osteoarthritis with a prevalence ranging from 0% to 13% for patients with isolated ACL-deficient (ACLD) knees and 21% to 48% for patients with combined injuries.7 Proprioceptive deficits after ACL injury may be a factor related to both giving way and higher incidence of subsequent injuries, which in turn may contribute to the development of osteoarthritis.8 Proprioceptive deficits are claimed to adversely affect activity level,9-11 balance,12,13 re-establishment of quadriceps strength14 and increase the risk of further injury.15 Evidence supporting such claims is not readily available as was revealed by an earlier critical review on this topic.16 The objective of this review is to analyze the correlations between proprioception in patients after ACLD and ACLR and common clinical outcome measurements such as objective scores, strength, laxity, balance, hop tests and patient reported outcomes.

M AT E R I A L S A N D M E T H O D S An electronic search was performed in Medline, Cinahl and Embase on studies published between January 1990 and June 2009. In addition, a manual search was conducted by tracking the reference lists of the included studies. The inclusion criteria in this review were: 1) studies reporting on patients with a rupture of the ACL diagnosed by positive Lachman, pivot shift, KT-1000, MRI or arthroscopy; 2) studies reporting on ACLR using an autograft or allograft; 3) proprioception measures; 4) full text published in English, Dutch or German; 5) outcome measures classified to the World Health Organization (WHO) including a) impairment of body functions: strength, laxity; b) activity limitation: hop test, balance; c) participation restriction: objective or patient reported outcome and 6) correlation reported between proprioceptive tests and outcome measurements as listed above. For this review, the two most commonly methods to quantify proprioception were included. These were defined at the Foundation of Sports Medicine Education and Research Workshop in 1997 as: joint position sense (JPS) and threshold to detection of passive motion (TTDPM).17 JPS is assessed by measuring reproduction of passive

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Chapter 4

positioning (RPP) or active repositioning of the knee (RAP). Studies that analyzed other forms of proprioception were excluded in this review due to reported decreased accuracy.18 The search terms are presented in Table 1. Table 1. Search terms used in the databases of Medline, Embase and Cinahl from January 1990-June 2009. (MeSH, medical subject heading; TI, title; ti,ab, title abstract, MH, medical heading; TX, text) Medline

Embase

Cinahl

1

“proprioception” [MeSH]

‘proprioception’ exploded

proprioception MH

2

“mechanoreceptors” [MeSH]

‘kinesthesis’ exploded

somatosensory disorders MH

3

“sensory thresholds” [MeSH]

‘somatosensory’ exploded

kinesthesis MH

4

“kinesthesis” [MeSH]

‘mechanoreceptors’ exploded

receptors, sensory MH

5

proprioception [TI]

‘proprioception’ in ti,ab

mechanoreceptors MH

6

mechanoreceptors [TI]

‘proprioceptive’ in ti,ab

proprioception TX

7

kinesthesis [TI]

‘kinesthesis’ in ti,ab

proprioceptive TX

8

kinesthesia [TI]

‘kinesthesia’ in ti,ab

kinesthesis TX

9

joint position sense [TI]

kinesthetic’ in ti,ab

kinesthesia TX

10

‘somatosensory’ in ti,ab

kinesthetic TX

11

“anterior cruciate ligament” [MeSH] “knee joint” [MeSH]

‘mechanoreptors’ in ti,ab

somatosensory disorders TX

12

ACL injury [TI]

‘sensory receptors’ in ti,ab

mechanoreceptors TX

13

ACL deficient [TI]

‘ligament’ exploded

sensory receptors TX

14

ACL reconstruction [TI]

‘knee’ exploded

joint position sense TX

‘joint’ exploded

motion perception TX

15 16

anterior cruciate ligament MH

17

knee joint MH

18

anterior cruciate ligament TX

19

ACL TX

20

ACL deficient TX

21

ACL injury TX

22 23

ACL reconstruction TX (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9) AND (#10 OR #11 OR #12 OR #13 OR #14)

(#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11) AND (#12 OR #13 OR #14 OR #15)

(#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15) AND (#16 or #17 or #18 or #19 or #20 or #21 or #22)

A modified version of the Cochrane Methods Group on Screening and Diagnostic Tests Methodology (CM) was used to assess the methodological quality.19 The following criteria were modified: questions 1-4 were replaced by Oxford Center For Evidencebased Medicine (http:www.cebm.net.index.aspx?0=1025) to score the level of evidence from 1 to 5. Level 1 is the highest score and level 5 the lowest score possible. Questions pertaining to inclusion criteria, study design, setting, previous tests/referral time since

46


injury or surgery, co-morbid conditions, description of index test (JPS and TTDPM) and its reproducibility, demographic information, percentage missing were used and a question was added regarding statistical analysis. The maximum score of the modified CM was 16 points. In addition, effect sizes (ES), were calculated where d=0.2-0.5, d=0.5-0.8 and d≥0.8 representing a small, moderate and large effect respectively.20 Correlation coefficients were interpreted as r = 0-0.25 as ‘no correlation’, r = 0.26-0.49 as ‘low’, r = 0.50-0.69 as ‘moderate’, r = 0.70-0.89 as ‘good’ and r = 0.90-1.0 as ‘excellent’. A total of 1161 studies were identified in the databases and 48 duplicates were discarded leaving 1113 studies. Seven studies were retrieved by manual search. Of the total of 1120 studies, four were excluded because of language restrictions.21-24 From the 1116 studies, 83 which were identified as potentially relevant after reading the abstract. The full text of these 83 studies were independently assessed by two observers (AG and AB) after which 59 studies were excluded as they did not meet the inclusion criteria. A consensus meeting was needed on four studies.25-28 Hence, in total 24 studies were included; 20 of which were cross-sectional 25,26,28-44 and four had a prospective design.8,45-47 Reliability was reported in 12 studies,8,26,29,31,34,39-42,44,47,48 of which six were conducted at the same center.8,29,34,41,42,45 In seven studies the same, or part of the patient population was measured but different outcome measures were presented.8,26,29,31,41,42,45 In six studies data on correlation was not provided and the principal author from each study was contacted with a request to provide data , one replied but was not able to provide data,9 four provided data,29,30,39,41 and one author did not reply despite two contact attempts.47

R E S U LT S The methodological quality is presented in Table 2. The mean score on the CM was 8 ± 2 and none of the reviewed studies scored higher than level 5 evidence. Table 3 summarizes the characteristics of included patients.

47

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4

48

Risberg et al. (1999) FischerRasmussen & Jense (2000)

Friden (1999)

1

1

0

1

0

1

1

1

0

0

Borsa (1997)

1

1

0

MacDonald (1996)

1

1

1

0

Wright (1995)

1

0

Co (1993)

1

1

0

0

Borsa et al. (1998) Friden et al. (1998) Beynnon et al. (1999)

0

Oxford Centre for Evidencebased Medicine Levels of Evidence (level 1=5 points; level 2=4 points; level 3=3 points; level 4=2 points; level 5= 1 point)

prospective (1 point) or retrospective series

Harter (1992)

2. Level of evidence

1. Design

Corrigan (1992)

Authors

Table 2. Methodological assessment.

0

0

0

1

0

0

0

0

1

0

0

0

in- and exclusion criteria reported (1 point)

1

1

1

1

1

1

1

1

1

1

1

1

enough information to identify setting (1 point)

3. 4. Selection Setting criteria clearly described

1

1

1

1

1

1

1

1

1

1

1

1

details given about clinical and other diagnostic information as to which the index test is being evaluated (symptomatic or asymptomatic patients) (1 point)

5. Previous tests/referral filter

7. Co-morbid conditions or type of surgery

0

0

0

1

0

1

1

0

0

0

1

0

0

1

1

1

0

1

1

0

1

1

0

0

mean or details median given and SD (1 point) reported (1 point)

6. Time since injury/ surgery

1

0

0

1

0

1

1

0

0

1

1

0

age (mean or median and SD or range) and gender reported (1 point)

1

1

1

1

1

1

1

1

1

1

1

1

test device, patient positioning, speed tested, number of trials (two or more items 1 point )

1

0

1

0

1

0

1

1

0

0

1

1

0

1

1

1

1

1

1

0

0

0

0

0

1

1

1

1

1

1

1

1

1

1

1

1

7

7

9

10

8

9

10

6

7

7

8

6

11. 12. Reliability Percentage total score of index missing (maximum test is 16)

details given reliability all included on mean or reported subjects median, SD or (1 point) measured CI and p-value and if proprioceptive appropriate: tests and missing p-value data or correlation withdrawals (1 point) from study reported or explained (1 point)

8. 9. 10. Demographic Description Statistical information of index test analysis in sufficient detail to permit replication of the test

Chapter 4

1

1

1

0

0

1

Mean (SD)

0

1

0

Muaidi et al. (2009)

1

0

0

1

1

Lee et al. (2009)

1

0

1

1

1

1

0

0

1

Oxford Centre for Evidencebased Medicine Levels of Evidence (level 1=5 points; level 2=4 points; level 3=3 points; level 4=2 points; level 5= 1 point)

prospective (1 point) or retrospective series

1

2. Level of evidence

1. Design

Zhou et al. (2008)

Fremery et al. (2000) Birmingham et al. (2001) Adachi et al. (2002) Reider et al. (2003) Katayama et al. (2004) Roberts et al. (2004) Ageberg et al. (2005) Roberts et al. (2007) Ageberg and Friden (2008)

Authors

0

0

1

1

0

1

0

0

1

0

0

0

in- and exclusion criteria reported (1 point)

1

1

1

1

1

1

1

1

1

1

1

1

enough information to identify setting (1 point)

3. 4. Selection Setting criteria clearly described

Table 2. Methodological assessment (Continued)

1

1

1

1

1

1

1

1

1

1

1

1

details given about clinical and other diagnostic information as to which the index test is being evaluated (symptomatic or asymptomatic patients) (1 point)

5. Previous tests/referral filter

7. Co-morbid conditions or type of surgery

1

1

1

1

0

1

1

0

0

0

1

1

0

1

1

1

1

0

1

1

1

0

0

1

mean or details median given and SD (1 point) reported (1 point)

6. Time since injury/ surgery

1

1

1

1

1

1

0

0

0

0

1

1

age (mean or median and SD or range) and gender reported (1 point)

1

1

1

1

1

1

1

1

1

1

1

1

test device, patient positioning, speed tested, number of trials (two or more items 1 point )

0 0 0 1 0 1 1 1 1 1 0 1

0 1 0 0 1 1 1 1 1 1 1 1

1

1

1

1

1

1

1

1

1

1

1

1

8 (2)

9

9

11

12

9

10

9

7

9

5

8

9

11. 12. Reliability Percentage total score of index missing (maximum test is 16)

details given reliability all included on mean or reported subjects median, SD or (1 point) measured CI and p-value and if proprioceptive appropriate: tests and missing p-value data or correlation withdrawals (1 point) from study reported or explained (1 point)

8. 9. 10. Demographic Description Statistical information of index test analysis in sufficient detail to permit replication of the test


Chapter

4

49

Chapter 4

Table 3. Demographics of subjects. Author

n ACL

Age (SD)

nC

Age (SD)

Design

Time from injury (SD)

Additional injury

28 (N.R.)

c

5.3 (N.R) years

N.R.

18-40 (N.R.)

c

8,7 (N.R.) months 1 meniscus lesion

ACL-D Corrigan et al. (1992) Wright et al. (1995) Borsa et al. (1997)

20 30 (N.R.) 17 (11 analyzed) 9 18-40 (N.R.) 15 29

28.7 (1.7)

c

41.7 (11.7) months

Borsa et al. (1998)

29

28.7 (N.R)

c

41.7 (11.7) months

Friden et al. (1998) Beynnon et al. (1999) Friden et al. (1999)

17

28 (N.R.)

c

N.R

20

40 (7.4)

c

5.5 (6.5) years

16

26 (N.R)

l

1,2 and 8 (N.R.) months

Fischer20 Rasmussen & Jensen (2000) Fremery et al. 10 acute, (2000) 20 chronic Adachi et al. (2002) Katayama et al. (2004) Roberts et al. (2004)

25 (N.R.)

27.0 (4.0) c

N.R.

26.4 (4.8) p

6.3 (3.0) and 12 meniscus 12.4 (3.7) months lesions

32

22.7 20 (3.2) acute 28.4 (4.4) chronic median 27 (N.R.) 25.6 (N.R)

54

28 (N.R.)

c

Ageberg et al. 36 26 (5.0) (2005) (35 analyzed) Roberts et al. 36 26 (5.4) (2007) Ageberg and 67 43 (8) Friden (2008) (56 analyzed) Lee et al. (2009) Muaidi et al. (2009)

50

6 meniscus lesions 15 meniscus, 8 MCL and 4 chondral lesions N.R.

20

29

27.0 (5.0)

40

5 meniscus and 2 MCL grade III lesions 5 meniscus and 2 MCL grade III lesions N.R.

12 23.1 (1.8) (10 analyzed) 20 30.4 (1.4)

c

median 8 (N.R.) months N.R.

c

2.7 (2.7) years

c

3.8 (3.0) years

c

3.8 (N.R.) years

28

42 (9)

c

20

29.5 (1.8) c

N.R. 7 meniscus lesions 39 meniscus, 7 MCL and 7 chondral lesions N.R.

19 meniscus, 6 MCL and 5 chondral lesions 15 (1.4) years 31 meniscus, 25 MCL, 11 chondral lesions 12.8 (3.9) months no n=20 5 weeks, n=1 10 weeks, n=1 7 months, n=1 5 years

13 injuries, mostly meniscus


Table 3. Demographics of subjects. (Continued) Author

n ACL

Age (SD)

nC

Age (SD)

Design

Time from injury (SD)

Additional injury

48

27.6 (6.9)

-

-

c

4.1 (1.7) years

N.R.

10

27 (N.R.)

10

24 (N.R.)

c

16

26.1 (N.R.)

6

30 (N.R.)

c

8 meniscus and 2 MCL lesions N.R.

20

35 (N.R.)

10

33 (N.R.)

c

31.6 (N.R.) months 27.5 (N.R) months 24 (N.R.)

30

27.2 (11.3)

-

-

c

26 25 (N.R) (21 analyzed)

26

25 (N.R.)

p

36

13,0 26.4 (3.9) c

ACL-R Harter et al. (1992) Co et al. (1993) MacDonald (1996) Risberg (1999) Birmingham (2001) Reider (2003)

Zhou et al.(2008) Muaidi et al.(2009)

26 (5.8)

15 (3 months) 30.4 (1.4) 14 (6 months)

20

29.5 (1.8) c

9 mensicus and 2 MCL lesions N.R.

19.4 (14.5) months pre-op to 3 weeks, 6 weeks and 6 months (N.R.) 189 (11.2) days

N.R.

3 and 6 (N.R.) months

13 injuries, mostly meniscus

17 meniscus and 10 chondral lesions

Abbreviations: ACL-D, Anterior Cruciate Ligament Deficient; ACL-R. Anterior Cruciate Ligament Reconstruction; n,number; C, Control subjects; c, cross sectional; MCL, Medial Collateral Ligament

The tests characteristics and correlation between proprioceptive tests and outcome measurements for the patients after ACLD and ACLR are presented in Table 4 and Table 5, for TTDPM and JPS, respectively.

51

Chapter

4

52

N.R.

N.R.

ICC 0.92

ICC 0.92

Wright et al. (1995)

Borsa et al. (1997)

Borsa et al. (1998)

0,5

0,5

0,5

0,3

Reliability Speed (*) °/s

Corrigan et al. (1992)

ACL-D

Author

1.1 (0.1) 1.1 (0.1)

TF 15

TF 45 65 (N.R.)

1.1 (0.1)

TE 45

index score

0.9 (0.1)

3.2 (1.6)

2.6 (1.8)

TTDPM ACL-I (SD)

TE 15

TE 40

TE 35 and TF 35 mean

Direction (°)

Table 4. Results Proprioception: Threshold to Detect Passive Motion

0.9 (0.1)

0.9 (0.1)

1.0 (0.1)

0.8 (0.1)

3.3 (1.9)

1.9 (1.2)

TTDPM ACL-U (SD)

0,2

0,2

0,1

0,1

0,1

0,7

Diff I-U 1.2 (0.4)

1,4

1,9

1,1

2,5

3.5 (2.1)

1.0 (0.5)

0,1

0,2

TTDPM TTDPM Diff C C Left C Right Left(SD) (SD) Right

-0,1 3.4 (1.5)

0,5

ES

Involved leg r=-0.29 (N.R) Involved leg r=-0.40 (N.R.) Involved leg r=-0.07 (N.R.) Involved leg r=-0.34 (N.R.) Involved leg r=-0.19 (N.R.)

Strength - Isometric Quadriceps Hop test - Index single leg hop test distance Balance - KAT 2000 Cincinnati Knee Rating Lysholm

Patient reported outcome

Involved leg TF 45 r=-0.47 (N.R.)

Involved leg TF 15 r=-0.37 (N.R.)

Involved leg TE 45 r=-0.56 (< 0.01)

Involved leg TE 15 r=-0.46 (< 0.05)

Difference involveduninvolved: r=-0.40 (N.R.)

Patient reported outcome Cincinnati Knee Rating Hop test - Index single leg hop test distance

Difference involveduninvolved: r=-0.005 (N.R.)

Controls r=0.25 (0.41)

Uninvolved leg no correlation (NR)

Involved leg r=-0.74 (