Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study

AIM: To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction.DESIGN: Mixed-methods study describing the development of a patient decision aid.SETTING: A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids.PARTICIPANTS: People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group.PRIMARY AND SECONDARY OUTCOMES: Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis.RESULTS: We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms.CONCLUSION: Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.</p

Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture

Anterior cruciate ligament (ACL) rupture occurs most commonly in young and active individuals and can have negative long-term physical and psychological impacts. The diagnosis is made with a combination of patient's history, clinical examination, and, if appropriate, magnetic resonance imaging. The objectives of management are to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life. The three main treatment options for ACL rupture are (1) rehabilitation as first-line treatment (followed by ACL reconstruction (ACLR) in patients, who develop functional instability), (2) ACLR and post-operative rehabilitation as the first-line treatment, and (3) pre-operative rehabilitation followed by ACLR and post-operative rehabilitation. We provide practical recommendations for informing and discussing management options with patients, and describe patient-related factors associated with a worse ACL-rupture outcome. Finally, we define evidence-based rehabilitation and present phase-specific rehabilitation recommendations and criteria to inform return to sport decisions

Activity preferences, lifestyle modifications and re-injury fears influence longer-term quality of life in people with knee symptoms following anterior cruciate ligament reconstruction: a qualitative study

Questions: How do people with knee symptoms describe their quality of life and experiences 5 to 20 years after anterior cruciate ligament reconstruction (ACLR)? What factors impact upon the quality of life of these people? Design: Qualitative study. Participants: Seventeen people with knee symptoms 5 to 20 years after ACLR and high (n = 8) or low (n = 9) quality of life scores were recruited from a cross-sectional study. Methods: Semi-structured telephone interviews were conducted and transcribed. The data obtained from the interventions underwent inductive coding and thematic analysis. Results: Four consistent themes emerged from the interviews as common determinants of quality of life following ACLR: physical activity preferences; lifestyle modifications; adaptation and acceptance; and fear of re-injury. All participants described the importance of maintaining a physically active lifestyle and the relationship between physical activity and quality of life. Participants who avoided sport or activity reported experiencing reduced quality of life. Participants who suppressed or overcame re-injury fears to continue sport participation described experiencing a satisfactory quality of life while taking part in sport despite knee symptoms. For some participants, resuming competitive sport resulted in subsequent knee trauma, anterior cruciate ligament re-rupture or progressive deterioration of knee function, with negative impacts on quality of life following sport cessation. Participants who enjoyed recreational exercise often adapted their lifestyle early after ACLR, while others described adapting their lifestyle at a later stage to accommodate knee impairments; this was associated with feelings of acceptance and satisfaction, irrespective of knee symptoms. Conclusion: Activity preferences, lifestyle modifications and fear of re-injury influenced quality of life in people with knee symptoms up to 20 years following ACLR. People with a preference for competitive sport who do not enjoy recreational exercise might be at heightened risk of poor quality of life outcomes and could benefit from support to facilitate a transition to a physically active, satisfying lifestyle. [Filbay SR, Crossley KM, Ackerman IN (2016) Activity preferences, lifestyle modifications and re-injury fears influence longer-term quality of life in people with knee symptoms following anterior cruciate ligament reconstruction: a qualitative study. Journal of Physiotherapy 62: 103-110]

Physical activity and sedentary behaviour in current and former recreational and elite cricketers : a cross-sectional study

Objective Former sports participants do not necessarily maintain high levels of physical activity (PA) across their lifespan. Considering physical inactivity in former athletes is associated with an increased susceptibility to inactivity-related chronic diseases, research into PA behaviours in cricketers of all playing-standards is needed. The objective was to (1) describe PA and sedentary behaviour in current and former cricketers, and (2) determine the odds of current, former, recreational and elite cricketers meeting PA guidelines and health-enhancing PA (HEPA) compared with the general population. Study design Cross-sectional survey. Setting Questionnaire response, UK. Participants 2267 current and former cricketers (age: 52 +/- 15 years, male: 97%, current: 59%, recreational: 45%) participated. Cricketers were recruited through the Cricket Health and Wellbeing Study and met eligibility requirements (aged &amp;gt;= 18 years; played &amp;gt;= 1 year of cricket). Primary and secondary outcomes Age-matched and sex-matched data from Health Survey for England 2015 (n=3201) was used as the general population-based sample. The International Physical Activity Questionnaire Short-Form assessed PA. Logistic regression, adjusted for age, sex, body mass index, alcohol consumption, smoking, education and ethnicity were used to meet the second aim. Results 90% of current and 82% of former cricketers met UK PA guidelines. Current (OR 1.26, 95% CI 1.06 to 1.49)) and elite (OR 1.35, 95% CI 1.01 to 1.78) cricketers had greater odds of meeting UK PA guidelines, and elite cricketers had greater odds of HEPA (OR 1.19, 95% CI 1.02 to 1.42), compared with the general population. Former cricketers had reduced odds (OR 0.78, 95% CI 0.62 to 0.99) of meeting the UK PA guidelines compared with the general population. Conclusions Elite cricketers had a greater odds of meeting the PA guidelines and HEPA, compared with the general population. Former cricketers demonstrated reduced odds of meeting the PA guidelines compared with the general population. Strategies are needed to transition cricketers to an active lifestyle after retirement, since former cricketers demonstrated reduced odds of meeting the PA guidelines compared with the general population.Funding Agencies|Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis-Sports Grant [HFR02510]</p

Quality of life impairments after hip arthroscopy in people with hip chondropathy

Many young individuals undergoing hip arthroscopic surgery have hip chondropathy. The impact of mild or more severe hip chondropathy 1-2 years following arthroscopy is poorly understood. The purpose of this study was to (i) compare health-related quality of life (HRQoL), anxiety and depression scores between people who underwent arthroscopic treatment for hip chondropathy 1-2 years previously and pain-free controls; (ii) compare HRQoL, hip-related quality of life (QoL) and anxiety/depression scores in people with mild versus severe hip chondropathy and (iii) compare hip-related QoL items between chondropathy groups. The Hip disability and Osteoarthritis Outcome Score (HOOS), International Hip Outcome Tool (iHOT-33), EuroQol-5D and Hospital Anxiety and Depression Scale (HADS) were compared between 71 individuals aged 18-60 years following arthroscopic treatment for hip chondroplasty (12-24 months previously) and 46 healthy controls. Comparisons were also performed between people with mild (Outerbridge grade 1-2) and severe (Outerbridge grade 3-4) hip chondropathy. Participants following arthroscopic treatment for hip chondroplasty reported worse HRQoL, hip-related QoL and anxiety, compared with pain-free controls (all P

The Swedish version of the Anterior Cruciate Ligament Quality Of Life measure (ACL-QOL) : translation and measurement properties

Purpose To translate the ACL-QOL from English to Swedish and evaluate measurement properties for use after surgical and non-surgical management of anterior cruciate ligament (ACL) injury. Methods The ACL-QOL was translated from English to Swedish and data were pooled from 13 cohorts to enable a comprehensive evaluation of measurement properties in line with COSMIN guidelines. We evaluated internal consistency, test-re-test reliability, measurement error, structural validity [confirmatory factor analysis (CFA)], construct validity and responsiveness (hypothesis testing), and floor/ceiling effects. Results were stratified by time since injury (&amp;lt;= 1.5 years; 2-10 years, 15-25 years; &amp;gt; 30 years) and ACL management strategy [surgical (n = 1163), non-surgical (n = 570)]. Results The Swedish ACL-QOL had sufficient internal consistency (total and domain scores) for use in surgically managed (Cronbachs alpha &amp;gt;= 0.744) and non-surgically managed (&amp;gt;= 0.770) ACL-injured individuals at all time-points. Test-re-test reliability was sufficient [intraclass correlation coefficients: all domains &amp;gt; 0.80, total score 0.93 (95% CI 0.86-0.96)]. The standard error of measurement was 5.6 for the total score and ranged from 7.0 to 10.3 for each domain. CFA indicated sufficient SRMR values when using the total score or five domains; however, CFI and RMSEA values did not meet cut-offs for good model fit. Hypothesis testing indicated sufficient construct validity and responsiveness. Floor effects were negligible and ceiling effects were negligible or minor. Conclusion The Swedish version of the ACL-QOL has sufficient internal consistency, test-re-test reliability, construct validity and responsiveness, for use in people with ACL injury managed with or without ACL surgery. Model fit could be improved and investigation into the source of misfit is warranted.Funding Agencies|CAUL; Linkoping University, Sweden; National Health and Medical Research Council (NHMRC) [1194428]</p

Predictors of return to desired activity 12 months following unicompartmental and total knee arthroplasty

Background and purpose — 1 in 5 patients are dissatisfied following unicompartmental or total knee arthroplasty (UKA or TKA). This may be partly explained by failing to return to desired activity post-arthroplasty. To facilitate return to desired activity, a greater understanding of predictors of return to desired activity in UKA and TKA patients is needed. We compared rates of return to desired activity 12 months following UKA vs. TKA, and identified and compared predictors of return to desired activity 12 months following UKA vs. TKA. Patients and methods — Patients were prospectively recruited from 2 hospitals prior to undergoing UKA or primary TKA. Patients reported preoperatively the activity/activities that were limited due to their knee that they wished to return to after arthroplasty. At 12-months postoperatively, patients reported whether they had returned to these activities (‘return to desired activity’). Preoperative predictors evaluated were age, sex, BMI, education, comorbidities, pain expectations, Oxford Knee Score (OKS), UCLA Activity Score, and EQ-5D. Generalized linear models assessed the relationship between potential predictors and return-to-desired-activity. Results — The response rate of all patients eligible for 12-month follow-up was 74%. TKA patients (n = 575) were older (mean (SD) 70 (9) vs. 67 (10)) with a greater BMI (31 (6) vs. 30 (5)) than patients undergoing UKA (n = 420). 75% of UKA and 59% of TKA patients returned to desired activity. TKA patients had a greater risk of non-return to desired activity than patients undergoing UKA (risk ratio (95% CI) 1.5 (1.2–1.8)). Predictors of non-return to desired activity following UKA were worse OKS (0.96 (0.93–0.99)), higher BMI (1.04 (1.01–1.08)), and worse expectations (1.9 (1.2–2.8)). Predictors of non-return to desired activity following TKA were worse EQ-5D (0.53 (0.33–0.85)) and worse OKS (0.98 (0.96–1.0)). Interpretation — UKA patients were more likely to return to desired activity than TKA patients. Predictors of return to desired activity differed following UKA and TKA. Optimizing selection of arthroplasty procedure based on patient characteristics and targeting predictors of poor outcome may facilitate return to desired activity with potential to enhance postoperative satisfaction

Quality of life impairments after hip arthroscopy in people with hip chondropathy

Many young individuals undergoing hip arthroscopic surgery have hip chondropathy. The impact of mild or more severe hip chondropathy 1-2 years following arthroscopy is poorly understood. The purpose of this study was to (i) compare health-related quality of life (HRQoL), anxiety and depression scores between people who underwent arthroscopic treatment for hip chondropathy 1-2 years previously and pain-free controls; (ii) compare HRQoL, hip-related quality of life (QoL) and anxiety/depression scores in people with mild versus severe hip chondropathy and (iii) compare hip-related QoL items between chondropathy groups. The Hip disability and Osteoarthritis Outcome Score (HOOS), International Hip Outcome Tool (iHOT-33), EuroQol-5D and Hospital Anxiety and Depression Scale (HADS) were compared between 71 individuals aged 18-60 years following arthroscopic treatment for hip chondroplasty (12-24 months previously) and 46 healthy controls. Comparisons were also performed between people with mild (Outerbridge grade 1-2) and severe (Outerbridge grade 3-4) hip chondropathy. Participants following arthroscopic treatment for hip chondroplasty reported worse HRQoL, hip-related QoL and anxiety, compared with pain-free controls (all P < 0.05), but no difference in self-care (P = 0.20). There were differences between mild and severe chondropathy groups for pain during sport/recreation [median (IQR) 20 (5-80) versus 60 (25-90) P = 0.01), pain after activity (40 (20-75) versus 75 (50-90) P = 0.01), difficulty maintaining fitness (30 (10-70) versus 75 (35-85) P = 0.02) and reduced hip confidence. Hip chondropathy was associated with significant QoL impairment, with severe chondropathy associated with the greatest impairment. The identification of specific areas of QoL impairment provides avenues to target rehabilitation and support

Health-related quality of life after anterior cruciate ligament reconstruction: A systematic review

Background: Anterior cruciate ligament reconstructions (ACLRs) are frequently performed on young, active patients and can result in persistent knee symptoms and activity limitations that may affect health-related quality of life (HRQoL). To date, there has been no systematic review of HRQoL outcomes after ACLR. Purpose: The objectives of this study were to report HRQoL ≥5 years after ACLR, compare HRQoL outcomes with available population norms, and describe factors that may affect HRQoL in this population. Study Design: Systematic review. Methods: All studies reporting HRQoL ≥5 years after ACLR with hamstring or patellar tendon autografts were eligible for review. Common HRQoL outcomes were pooled using a random-effects meta-analysis and compared with published population norms. The Spearman rank correlation coefficient (r) was used to identify variables associated with HRQoL outcomes. Where insufficient data were available, outcomes were reported descriptively. Results: Fourteen studies were eligible for review, and HRQoL was reported for 2493 patients at a mean of 9 years (range, 5-16 years) after ACLR. Pooling of knee-related quality of life outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS]-QOL) found impairments after ACLR when compared with population norms. In comparison, studies using the Short Form-36 (SF-36) reported similar or better HRQoL compared with normative data. The KOOS-QOL subscores correlated strongly with KOOSsport/ recreation (r = .70, P = .04) and KOOS-pain (r = .85, P = .003) subscores. Severe radiographic osteoarthritis, meniscal injuries sustained after surgery, and revision ACLR were associated with poorer HRQoL outcomes at a minimum 5-year follow-up. The negative influence of concomitant meniscal surgery on HRQoL became apparent more than 10 years after ACLR. Conclusion: This review found that patients assessed using a knee-specific measure (KOOS-QOL) were more likely to report poorer HRQoL values, compared with population norms, than those assessed using a generic HRQoL measure (SF-36). Revision surgeries, meniscal injuries, and severe radiographic osteoarthritis were associated with poorer HRQoL outcomes after ACLR. However, these relationships should be interpreted with caution, as they were only investigated in a small number of studies. Clinical Relevance: These results can be used by clinicians to educate patients about potential long-term outcomes after ACLR and to develop strategies for optimizing postoperative HRQoL

Quality of life and life satisfaction in former athletes:: a systematic review and meta-analysis

Background: sport participation has many physical and psychosocial benefits, but there is also an inherent risk of injury, subsequent osteoarthritis, and psychological challenges that can negatively impact quality of life (QOL). Considering the multifaceted impacts of sport participation on QOL across the lifespan, there is a need to consolidate and present the evidence on QOL in former sport participants.Objective: to evaluate QOL and life satisfaction in former sport participants, and determine what factors are associated with QOL and life satisfaction in this population.Methods: eight electronic databases were systematically searched in 07/2018 to retrieve all articles that evaluated QOL or life satisfaction in former sport participants. Two authors independently screened titles/abstracts and full texts, extracted data and appraised methodological quality using a modified Downs and Black Checklist. Random effects meta-analysis estimated pooled mean and 95% CI for Mental Component Scores (MCS) and Physical Component Scores (PCS) derived from the SF-12, SF-36, VR-12 and VR-36 measures. MCS and PCS were pooled for all former sport participants, as well as professional- and collegiate-athlete subgroups. Data that were inappropriate for meta-analysis (i.e. EQ-5D, PROMIS and life-satisfaction outcomes) were collated and reported descriptively.Results: seventeen articles evaluated QOL or life satisfaction in a total of 6692 former athletes (8 studies (n=4255) former professional athletes; 6 studies (n=1946) former collegiate athletes; 2 studies (n=491) included both) with a mean age ranging from 21-66 years. Most studies were cross-sectional (15 of 17 articles) and 12 studies had a moderate risk of bias (n=1 high-risk, n=4 low-risk). Unpublished data were provided for five studies. Meta-analysis of 7 studies resulted in a pooled PCS mean(95% CI) of 50.0(46.6 to 53.3) (former professional athletes from 2 studies: 46.7(42.1 to 51.2), former collegiate athletes from 5 studies: 51.2(48.4 to 53.9)) and a pooled MCS of 51.4(50.5 to 52.2) (former professional athletes: 52.7(51.3 to 54.2), former collegiate athletes:27 50.9(50.0 to 51.8)). Factors associated with worse QOL or life satisfaction in former athletes included involuntary retirement from sport (3 studies), collision/high-contact sport compared with low/no-contact sport (3 studies), ≥3 concussions compared with no/fewer concussions (2 studies), increased BMI (worse PCS, 3 studies), and osteoarthritis or musculoskeletal issues (worse PCS and MCS, 3 studies; worse PCS but not MCS, 2 studies).Conclusions: former athletes had similar PCS and better MCS, compared to general-population norms. Former athletes with impaired PCS reported better MCS than population norms, highlighting the need to use an instrument that differentiates between physical and mental components of QOL in former sport participants. Factors associated with worse QOL that may explain between-study variation include involuntary retirement, collision/high contact sports, concussion, BMI and osteoarthritis