Publications by authors named "Eva Ageberg"

68 Publications

Motor Imagery to Facilitate Sensorimotor Re-Learning (MOTIFS) after traumatic knee injury: study protocol for an adaptive randomized controlled trial.

Trials 2021 Oct 21;22(1):729. Epub 2021 Oct 21.

Department of Health Sciences, Lund University, Margaretavägen 1B, 222 40, Lund, Sweden.

Background: Treatment following traumatic knee injury includes neuromuscular training, with or without surgical reconstruction. The aim of rehabilitation is to restore muscle function and address psychological factors to allow a return to activity. Attention is often on rehabilitation of knee function, but deficiencies often persist. Specific interventions addressing psychological factors are sparing with varying degrees of success. We have developed a novel training program, MOTor Imagery to Facilitate Sensorimotor Re-Learning (MOTIFS), which integrates simultaneous psychological training into physical rehabilitation exercises. The MOTIFS model individualizes rehabilitation to increase central nervous system involvement by creating realistic and relevant mental images based on past experiences. We hypothesize that a 12-week MOTIFS training intervention will improve psychological readiness to return to activity and muscle function to a greater extent than current neuromuscular training (Care-as-Usual).

Methods: This pragmatic 1:1 single assessor-blinded adaptive cumulative cluster-randomized controlled trial will include 106 knee-injured people with a goal of returning to physical activity. Participants are randomized to either the MOTIFS or Care-as-Usual condition. Primary outcomes are the ACL Return to Sport after Injury Scale and change in injured leg hop performance in a side hop task from baseline to 12 weeks. Secondary outcomes include patient-reported outcomes and assessment of muscle function using a hop test battery and Postural Orientation Errors at 12-week follow-up. At 12-month follow-up, patient-reported outcomes are assessed. A sub-group (7-10 in each group) will be interviewed to gain insight into experiences of rehabilitation.

Discussion: Strengths of this trial include that it is a randomized and pragmatic trial examining commonly under-studied aspects of rehabilitation following a knee injury. The model uses the patient as a reference, creating simultaneous psychological and physical training exercises with easily adopted principles for clinical practice. Limitations include that blinding is limited due to study design, and shifting the clinical paradigm to a more holistic model is a challenge. If successful, the MOTIFS model has implications for a clinically useful, individualized, and patient-relevant method of improving rehabilitation outcomes by integrating psychological training into physical training.

Trial Registration: ClinicalTrials.gov NCT03473821 . Registered March 22, 2018, with ethical approval that has been granted (Dnr 2016/413, Dnr 2018/927).

Trial Status: Trial Status: Protocol Version is 2020, Dec 10 - Version 1.
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http://dx.doi.org/10.1186/s13063-021-05713-8DOI Listing
October 2021

Physical impairments in longstanding hip and groin pain: Cross-sectional comparison of patients with hip-related pain or non-hip-related groin pain and healthy controls.

Phys Ther Sport 2021 Sep 30;52:224-233. Epub 2021 Sep 30.

Department of Health Sciences, Lund University, Lund, Sweden. Electronic address:

Objectives: To compare physical impairments between patients with hip-related pain and those with non-hip-related groin pain, and to compare both patient groups with healthy controls.

Design: Cross-sectional.

Participants: Eighty-one hip and groin pain patients were consecutively included and categorized into having hip-related pain or non-hip-related groin pain. Twenty-eight healthy controls were recruited.

Settings: Tertiary care.

Main Outcome Measures: All participants performed physical impairment testing including hip ROM, muscle function, and functional tasks. An analysis of covariates was used for analysis between patients groups and controls.

Results: Patients with hip-related pain showed reduced hip ROM in internal rotation compared to patients with non-hip-related groin pain and controls (p ≤ 0.026, d -0.65; -0.97). No differences in muscle function or performance in functional tasks were observed between patients with hip-related pain and those with non-hip-related groin pain (p ≥ 0.136, d 0.00; 0.68). Both patient groups had worse muscle function and worse performance in functional tasks compared to controls (p ≤ 0.048, d -0.67; -1.83).

Conclusions: Both patients with and without hip-related pain had worse muscle function and worse performance in functional tasks compared to matched controls but no differences were observed between the patient groups. Only patients with hip-related pain had reduced ROM in internal rotation.
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http://dx.doi.org/10.1016/j.ptsp.2021.09.011DOI Listing
September 2021

Less hip range of motion is associated with a greater alpha angle in people with longstanding hip and groin pain.

Knee Surg Sports Traumatol Arthrosc 2021 Sep 12. Epub 2021 Sep 12.

Department of Health Sciences, Lund University, Lund, Sweden.

Purpose: A higher alpha angle has been proposed to correlate with lower hip range of motion, but the association in people with longstanding hip and groin pain is currently unclear. The aims were to: (1) assess the association between range of motion and alpha angle in patients with longstanding hip and groin pain; (2) examine if a cut-off value in range of motion variables could identify patients with an alpha angle above or below 60°.

Methods: Seventy-two participants were consecutively recruited from an orthopaedic department after referral for hip- and groin-related pain. Passive hip range of motion was measured in flexion, internal rotation with 90° hip flexion, internal rotation in neutral hip position, external rotation with 90° hip flexion, and abduction. The alpha angle was calculated from a frog-leg lateral radiograph. Linear regression examined the association between range of motion and alpha angle, and an ROC-curve analysis was performed to identify the sensitivity and specificity of range of motion cut-offs.

Results: Lower range of motion in internal rotation in flexion, external rotation, and abduction were associated with higher alpha angle. Internal rotation of 27° or less displayed good sensitivity (81%) and specificity (85%) to detect an alpha angle above 60°, while a cut-off of 41° in external rotation and 27° in abduction showed a sensitivity of 72% and specificity of 50% and 60%, respectively.

Conclusion: Less internal rotation in flexion, external rotation, and abduction are associated with a greater alpha angle in a cohort of people with longstanding hip and groin pain. A cut-off of 27° in internal rotation has good sensitivity and specificity to identify people with an alpha angle above or below 60° and have the potential to be used in the clinical setting to identify patients that require further imaging, or that are unlikely to have cam morphology.

Level Of Evidence: II.
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http://dx.doi.org/10.1007/s00167-021-06733-2DOI Listing
September 2021

Postural orientation, what to expect in youth athletes? A cohort study on data from the Malmö Youth Sport Study.

BMC Sports Sci Med Rehabil 2021 Jul 24;13(1):76. Epub 2021 Jul 24.

Department of Health Sciences, Lund University, Lund, Sweden.

Background: Studies investigating postural orientation in uninjured youth athletes are scarce. Understanding how postural orientation during functional performance tests change with age in uninjured athletes has the potential to enhance awareness of changes in performance after injury and to set realistic goals for injured athletes. Thus, the aim of this study was to explore postural orientation during functional tasks at early adolescence, and changes in postural orientation from early to middle adolescence and relate this to sex, type of sport and right leg lean body mass (RLLBM).

Methods: In this cohort study 144 (38% female) youth athletes (mean age 13.5 years, SD 0.3) were included at baseline and 86 of these at follow up 2 years later. Four functional performance tests were visually evaluated for Postural Orientation Errors (POEs) with an ordinal scale, ranging from 0 (good) to 2 (poor), yielding a maximum total POE score of 51, and RLLBM by dual energy X-ray absorptiometry.

Results: Improvements were observed in the total POE score from baseline to follow-up, median difference - 10 and - 7 (p < 0.001) for female and male athletes, respectively. At follow-up, female athletes had lower total POE score (median 18) than males (median 24) (p = 0.01). There were no differences in POE scores between sports type (team, individual, aesthetic) (p = 0.20-0.98) and no relationship between total POE score and RLLBM (r = 0.09, p = 0.42).

Conclusions: POEs appear to be quite common in young athletic population, but improvements are achieved over time. At mid-adolescence, female athletes seem to have less POEs than males. Neither sport type nor RLLBM seem to influence postural orientation.
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http://dx.doi.org/10.1186/s13102-021-00307-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8306364PMC
July 2021

Decompression of the greater occipital nerve improves outcome in patients with chronic headache and neck pain - a retrospective cohort study.

Acta Neurochir (Wien) 2021 09 1;163(9):2425-2433. Epub 2021 Jul 1.

Department of Clinical Sciences Lund, Neurosurgery, Lund University, 221 85, Lund, Sweden.

Background: Compression of the greater occipital nerve (GON) may contribute to chronic headache, neck pain, and migraine in a subset of patients. We aimed to evaluate whether GON decompression could reduce pain and improve quality of life in patients with occipital neuralgia and chronic headache and neck pain.

Methods: In this retrospective cohort study, selected patients with neck pain and headache referred to a single neurosurgical center were analyzed. Patients (n = 22) with suspected GON neuralgia based on nerve block or clinical criteria were included. All patients presented with occipital pain spreading frontally and to the neck in various degree. Surgical decompression was performed under local anesthesia. Follow-up was made by an assessor not involved in the treatment of the patients, by telephone 2-5 years after the surgical procedure and an interview protocol was used to collect information. The data from the follow-up protocols were then analyzed and reported.

Results: When analyzing the follow-up protocols, decreased headache/migraine was reported in 77% and neck pain was reduced in 55% of the patients.

Conclusions: Decompression of GON(s) may reduce neck pain and headache in selected patients with persistent headache, neck pain, and clinical signs of GON neuralgia. Based on the limitations of the present retrospective study, the results should be considered with caution.
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http://dx.doi.org/10.1007/s00701-021-04913-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357752PMC
September 2021

Sex differences in postural orientation errors and association with objective and patient-reported function in patients with ACL injury: an exploratory cross-sectional study.

BMJ Open Sport Exerc Med 2021 19;7(2):e001045. Epub 2021 May 19.

Health Sciences, Lund University, Lund, Sweden.

Objectives: There is limited research on sex differences in postural orientation (ie, alignment between body segments) in people with knee injury measured with a clinically applicable method. An understanding of the relationship between postural orientation and physical function may help guide decision making in rehabilitation. The aims were to evaluate (1) sex differences in visual assessment of Postural Orientation Errors (POEs) and (2) the association between POEs and objective and patient-reported physical function, in men and women with anterior cruciate ligament reconstruction (ACLR).

Methods: Twenty-four women and 29 men (mean 26.7 (SD 6.5) years) with ACLR were included. Six POEs (lower extremity and trunk) were scored from a video of five tasks with varying difficulty to compute POE scores (total and subscores). Objective physical function was evaluated with the single-leg hop for distance and side hop. Patient-reported physical function was evaluated using patient-reported outcome measures (PROMs).

Results: Women had significantly more POEs than men (median difference 5.5-25, p≤0.028). More POEs were associated with shorter hop distance and fewer side hops in women (r= -0.425 to -0.518, p<0.038), but not in men (r<0.301, p>0.05). No associations were found between POE scores and PROMs, in either sex (r< -0.246, p>0.05).

Conclusions: Women with ACLR seem to have more POEs compared with men, indicating worse postural orientation. More POEs were associated with worse hop performance, suggesting that POE scores may be used as criteria for rehabilitation progression. The lack of associations between POE scores and PROMs indicate that these measures complement each other.
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http://dx.doi.org/10.1136/bmjsem-2021-001045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137201PMC
May 2021

Does sensorimotor function predict graft rupture, contra-lateral injury or failure to return to sports after ACL reconstruction? A protocol for the STOP Graft Rupture study.

BMJ Open 2021 01 8;11(1):e042031. Epub 2021 Jan 8.

Department of Community Medicine and Rehabilitation, Umeå Universitet, Umeå, Sweden.

Introduction: People with anterior cruciate ligament (ACL) reconstruction (ACLR) are at high risk of sustaining a graft rupture and/or contra-lateral ACL injury. The main factors that may predispose individuals for subsequent ACL injuries are, however, not established. To reduce the risk of reinjuries, it is of particular interest to identify modifiable risk-factors, for instance, those related to sensorimotor control which are responsive to training. The aim of the current study protocol is to present the design of our prospective cohort study STOP Graft Rupture investigating sensorimotor function as predictors for graft rupture, contra-lateral ACL injury and/or failure to return to sport (RTS) within 3 years following ACLR.

Methods And Analysis: We aim to recruit 200 individuals (15-35 years, ~50% women) with ACLR from Norrland University Hospital, Umeå and Lund University Hospital, Lund, Sweden. Participants will be assessed with a comprehensive test battery for sensorimotor muscle function, including hop performance, muscle strength, muscle activation, hip and ankle range of motion and postural orientation as well as patient-reported function 1 year after ACLR (baseline). For a subgroup of individuals (Umeå cohort), 3D kinematics and joint position sense will also be evaluated. At follow-up (≥3 years post-ACLR), the participants will be asked to answer questions related to new ACL injuries to either knee and about RTS. Separate logistic regression models, adjusting for possible confounders, will be used to evaluate the influence of the different sensorimotor predictors on the prospective outcomes (graft rupture, contra-lateral ACL injury, RTS).

Ethics And Dissemination: This study was approved by the Swedish Ethical Review Board (Dnr 2016/319 and Dnr 2019-04037). The results will be published in international peer-reviewed scientific journals and presented at clinical and scientific congresses.

Trial Registration Number: NCT04162613.
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http://dx.doi.org/10.1136/bmjopen-2020-042031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798666PMC
January 2021

Effect of motor imagery on enjoyment in knee-injury prevention and rehabilitation training: A randomized crossover study.

J Sci Med Sport 2021 Mar 10;24(3):258-263. Epub 2020 Sep 10.

Department of Health Sciences, Lund University, Sweden.

Objectives: The novel MOTor Imagery to Facilitate Sensorimotor Re-Learning (MOTIFS) model takes a uniquely holistic approach by integrating mental and physical aspects into current training programs. The aim of this trial was to evaluate enjoyment of MOTIFS training as compared to Care-as-Usual (CaU) knee injury and/or rehabilitation training. The primary hypothesis was that enjoyment would be greater following MOTIFS training than CaU training.

Design: Block-randomized 2×2 cross-over trial.

Methods: Thirty athletes (18-31years, 50% women) currently or previously active in team ball sports, with no pain or injury preventing jump and/or directional changes. MOTIFS training integrates sport-specific experiences and equipment into physical exercises to increase individualized realism and meaning. The CaU condition included solely physical exercise. The main outcome was the Physical Activity Enjoyment Scale (PACES). Secondary outcomes included Self-Assessment Manikin (SAM; subscales Valence, Arousal, Dominance), Perceived exertion, pulse, duration, and movement quality.

Results: PACES scores were better following MOTIFS training than CaU (point estimate 24.67; 95% CI: 19.0; 30.3). Between-groups differences in SAM Valence (median 2, quartiles 1;3), Arousal (median 1, quartiles 0;2.25), and Dominance (median 0.5, quartiles 0;2), and RPE (median 1, quartiles -0.3;2), training duration (mean 5.34, 95% CI: -0.17; -0.73), and pulse (median 7.50, quartiles 0.25;16.75) were higher following MOTIFS training than CaU training.

Conclusions: Results suggest that the MOTIFS model, which integrates simultaneous physical and psychological interventions, is a clinically plausible method of influencing enjoyment and other psychological outcomes. Further studies may explore effects of the MOTIFS principles on injury prevention and rehabilitation training.
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http://dx.doi.org/10.1016/j.jsams.2020.09.004DOI Listing
March 2021

Do knee abduction kinematics and kinetics predict future anterior cruciate ligament injury risk? A systematic review and meta-analysis of prospective studies.

BMC Musculoskelet Disord 2020 Aug 20;21(1):563. Epub 2020 Aug 20.

Department of Health Sciences, Lund University, Box 157, 221 00, Lund, Sweden.

Background: To systematically review the association between knee abduction kinematics and kinetics during weight-bearing activities at baseline and the risk of future anterior cruciate ligament (ACL) injury.

Methods: Systematic review and meta-analysis according to PRISMA guidelines. A search in the databases MEDLINE (PubMed), CINAHL, EMBASE and Scopus was performed. Inclusion criteria were prospective studies including people of any age, assessing baseline knee abduction kinematics and/or kinetics during any weight-bearing activity for the lower extremity in individuals sustaining a future ACL injury and in those who did not.

Results: Nine articles were included in this review. Neither 3D knee abduction angle at initial contact (Mean diff: -1.68, 95%CI: - 4.49 to 1.14, ACL injury n = 66, controls n = 1369), peak 3D knee abduction angle (Mean diff: -2.17, 95%CI: - 7.22 to 2.89, ACL injury n = 25, controls n = 563), 2D peak knee abduction angle (Mean diff: -3.25, 95%CI: - 9.86 to 3.36, ACL injury n = 8, controls n = 302), 2D medial knee displacement (cm; Mean diff:: -0.19, 95%CI: - 0,96 to 0.38, ACL injury n = 72, controls n = 967) or peak knee abduction moment (Mean diff:-10.61, 95%CI: - 26.73 to 5.50, ACL injury n = 54, controls n = 1330) predicted future ACL injury.

Conclusion: Contrary to clinical opinion, our findings indicate that knee abduction kinematics and kinetics during weight-bearing activities may not be risk factors for future ACL injury. Knee abduction of greater magnitude than that observed in the included studies as well as factors other than knee abduction angle or moment, as possible screening measures for knee injury risk should be evaluated in future studies.
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http://dx.doi.org/10.1186/s12891-020-03552-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7441716PMC
August 2020

Extended Version of a Test Battery for Visual Assessment of Postural Orientation Errors: Face Validity, Internal Consistency, and Reliability.

Phys Ther 2020 08;100(9):1542-1556

Department of Health Sciences, Lund University.

Objective: Undesirable postural orientation may be a risk factor for a second anterior cruciate ligament (ACL) injury. The purpose of this study was to evaluate face validity, internal consistency, and interrater reliability of an extended version of a previous test battery for visual assessment of postural orientation errors (POEs) in patients during the late phase of rehabilitation following ACL reconstruction (ACLR) (ie, when they have initiated jumping exercises).

Methods: This study used a cross-sectional design. Fifty-three patients (45% women) in the late phase of ACLR rehabilitation performed 5 functional tasks of varying difficulty. POEs of the lower extremity and trunk were visually assessed from video and scored on a scale from 0 (good) to 2 (poor).

Results: The side-hop and 2 new POEs (femur medial to shank, femoral valgus) were added to the test battery after expert focus group discussions. Internal consistency was calculated for all tasks (α = .712-.823). Interrater reliability showed fair to substantial agreement for femur medial to shank and femoral valgus during all tasks (K = 0.31-0.815) and almost perfect agreement for side-hop (intraclass correlation coefficient = 0.88).

Conclusions: The good internal consistency and reliability after adding side-hop, femur medial to shank, and femoral valgus suggests that this test battery is a suitable tool to quantify postural orientation throughout ACLR rehabilitation.

Impact: This test battery for visual assessment of POEs was evaluated in a heterogeneous group of patients in different phases of ACLR battery and can be used in clinical practice to measure POEs in patients with ACLR, including in the late phase of rehabilitation to return to sport. This study encourages research on more demanding tasks and additional POEs to cover the entire rehabilitation period after ACL injury or reconstruction.
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http://dx.doi.org/10.1093/ptj/pzaa092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462053PMC
August 2020

Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome.

Knee Surg Sports Traumatol Arthrosc 2020 Oct 25;28(10):3382-3392. Epub 2020 Apr 25.

Department of Health Sciences, Lund University, PO Box 157, 22100, Lund, Sweden.

Purpose: Clinical examination is an important part in the diagnosis of femoroacetabular impingement (FAI) syndrome. However, knowledge on reliability and validity of clinical diagnostic tests is scarce. The aims were to evaluate the inter-rater agreement and diagnostic accuracy of clinical tests to detect patients with FAI syndrome.

Methods: Eighty-one patients (49% women) were recruited. Two experienced raters performed impingement and range of motion (ROM) tests. Three criteria had to be fulfilled for the diagnosis of FAI syndrome: (1) symptoms; (2) CAM and/or Pincer morphology; and (3) being responder to intra-articular block injection. For inter-rater agreement, the Cohen's kappa statistics were used (0.41-0.60 = moderate, 0.61-0.80 = substantial agreement). For diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were calculated.

Results: Anterior impingement test (AIMT), FADIR test and FABER test showed kappa values above 0.6. All passive hip ROM, except extension, had kappa values above 0.4. AIMT and FADIR showed the highest sensitivity, i.e., 80%, with a specificity of 26% and 25%, respectively. Passive hip ROM in internal rotation with neutral hip position had a sensitivity of 29% and a specificity of 94%.

Conclusion: The AIMT, FADIR and FABER tests were reliable between two experienced raters, while results from different raters for hip ROM should be interpreted with caution. The AIMT and FADIR test can only be used to rule out patients with FAI syndrome, while evaluation of ROM in internal rotation with neutral position may be more suitable to rule in patients with FAI syndrome.

Level Of Evidence: II.
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http://dx.doi.org/10.1007/s00167-020-06005-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511272PMC
October 2020

Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018.

Br J Sports Med 2020 Jul 17;54(14):848-857. Epub 2020 Feb 17.

Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5) voting and consensus. Out of 102 articles retrieved, 6 systematic reviews were selected and assessed for quality according to AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Two showed moderate quality. We then updated the most recent review. The updated literature search resulted in 10 additional studies that were included in the qualitative synthesis. The recommendations based on evidence summary and PROMs limitations were presented at the consensus meeting. The group makes the following recommendations: (1) the Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool (iHOT) instruments (long and reduced versions) are the most appropriate PROMs to use in young and middle-aged active adults with hip-related pain; (2) more research is needed into the utility of the HAGOS and the iHOT instruments in a non-surgical treatment context; and (3) generic quality of life measures such as the EuroQoL-5 Dimension Questionnaire and the Short Form Health Survey-36 may add value for researchers and clinicians in this field. We conclude that as none of the instruments shows acceptable quality across various psychometric properties, more methods studies are needed to further evaluate the validity of these PROMS-the HAGOS and iHOT-as well as the other (currently not recommended) PROMS.
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http://dx.doi.org/10.1136/bjsports-2019-101456DOI Listing
July 2020

Planning injury prevention training for youth handball players: application of the generalisable six-step intervention development process.

Inj Prev 2020 04 4;26(2):164-169. Epub 2020 Feb 4.

Centre for Sport and Social Impact, La Trobe University, Melbourne, Victoria, Australia.

Background: Youth handball players are vulnerable to injuries. Because there is no available injury prevention training specifically developed for youth handball players targeting both upper and lower limbs or incorporating psychological aspects of injury, we undertook the 'Implementing injury Prevention training ROutines in TEams and Clubs in youth Team handball (I-PROTECT)' project. We used an ecological participatory design incorporating the perspectives of multiple stakeholders (health beneficiaries, programme deliverers and policy makers). The aim of this paper was to describe the process of developing the I-PROTECT model, featuring injury prevention training and an accompanying implementation strategy.

Design: We used the generalisable six-step intervention development process, outlined to guide researchers when developing implementable, evidence-based sports injury prevention interventions, to develop the I-PROTECT model. The six-step process involves establishing a research-stakeholder collaborative partnership to (1) identify and synthesise research evidence and clinical experience; (2) consult with relevant experts; (3) engage end users to ensure their needs, capacity and values are considered; (4) test the feasibility and acceptability of the intervention; (5) evaluate the intervention against theory; and (6) obtain feedback from early implementers. Two community handball clubs in southern Sweden, offering organised training for youth male and female players, and the district handball federation, participate in the intervention development. Drafts of the I-PROTECT model will be developed and revised with key stakeholder advice and input throughout all six steps.

Conclusion: The I-PROTECT model described will be an end user-driven intervention, including evidence-based, theory-informed and context-specific injury prevention training for youth handball, and an associated implementation strategy.
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http://dx.doi.org/10.1136/injuryprev-2019-043468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146925PMC
April 2020

Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018.

Br J Sports Med 2020 Jun 20;54(11):631-641. Epub 2020 Jan 20.

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia.

There is no agreement on how to classify, define or diagnose hip-related pain-a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion-adduction-internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head-neck radiographs are the initial diagnostic imaging of choice-advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.
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http://dx.doi.org/10.1136/bjsports-2019-101453DOI Listing
June 2020

Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting, Zurich, 2018.

Br J Sports Med 2020 Jun 19;54(12):702-710. Epub 2019 Dec 19.

Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark.

Hip-related pain can significantly impact quality of life, function, work capacity, physical activity and family life. Standardised measurement methods of physical capacity of relevance to young and middle-aged active adults with hip-related pain are currently not established. The aim of this consensus paper was to provide recommendations for clinical practice and research on standardised measurement methods of physical capacity in young and middle-aged active adults with hip-related pain. Four areas of importance were identified: (1) clinical measures (range of motion, muscle strength, functional impairments), (2) laboratory-based measures (biomechanics and muscle function (muscle activity, size and adiposity)), (3) physical activity, and (4) return to sport/performance. The literature was reviewed, and a summary circulated to the working group to inform discussion at the consensus meeting. The working group developed clinical and research recommendations from the literature review, which were further discussed and modified within the working group at the consensus meeting. These recommendations were then presented to all 38 International Hip-related Pain Research Network (IHiPRN) participants for further discussion, refinement and consensus voting. Therefore, the recommendations voted on were based on a combination of current evidence and expert opinion. The consensus meeting voted on 13 recommendations, six of which were clinically orientated, and seven more research specific. We recommended that clinicians working with young and middle-aged active adults with hip-related pain assess strength using objective methods of measurement, and clinically assess performance of functional tasks, including walking and running. Physical activity should be quantified using both self-reported and objective measures, and patient expectations of recovery should be quantified prior to treatment. It was recommended that return to physical activity (including sport and occupation) be quantified, and sport-specific activities should be assessed prior to return to sport. The IHiPRN participants were uncertain regarding recommendations for range of motion assessment. Research recommendations were that the measurement properties of range of motion, strength and functional performance tests be investigated, reported and improved in both clinical and research settings. Reporting of movement-related parameters (biomechanics and muscle function) should be standardised and the relationship among movement-related parameters, symptoms, function, quality of life, and intra-articular and imaging findings should be investigated. Quantification of return to physical activity (including sport and occupational demands) is required in future research, and the return to sport continuum should be used. Future research is required to determine the best criteria for rehabilitation progression and return to physical activity following hip-related pain management.
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http://dx.doi.org/10.1136/bjsports-2019-101457DOI Listing
June 2020

Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018.

Br J Sports Med 2020 May 15;54(9):504-511. Epub 2019 Nov 15.

Musculoskeletal Radiology, Corades, LLC, Brookline, Massachusetts, USA.

The 1st International Hip-related Pain Research Network meeting discussed four prioritised themes concerning hip-related pain in young to middle-aged adults: (1) diagnosis and classification of hip-related pain; (2) patient-reported outcome measures for hip-related pain; (3) measurement of physical capacity for hip-related pain; (4) physiotherapist-led treatment for hip-related pain. Thirty-eight expert researchers and clinicians working in the field of hip-related pain attended the meeting. This manuscript relates to the theme of physiotherapist-led treatments for hip-related pain. A systematic review on the efficacy of physiotherapist-led interventions for hip-related pain (published separately) was conducted and found that strong evidence for physiotherapist-led treatments was lacking. Prior to the meeting, draft consensus recommendations for consideration in the meeting were also developed based on the systematic review. The draft consensus recommendations were presented to all of the meeting participants via email, at least 1 week prior to the meeting. At the meeting, these recommendations were discussed, revised and voted on. Six recommendations for clinical practice and five recommendations for research were included and all gained consensus. Recommendations for clinical practice were that (i) Exercise-based treatments are recommended for people with hip-related pain. (ii) Exercise-based treatment should be at least 3 months duration. (iii) Physiotherapist-led rehabilitation after hip surgery should be undertaken. (iv) Patient-reported outcome measures, measures of physical impairment and measures of psychosocial factors should be used to monitor response to treatment. (v) Physical activity (that may include sport) is recommended for people with hip-related pain. (vi) Clinicians should discuss patient expectations, use shared-decision making and provide education. Recommendations for research were (i) Reporting of exercise programmes: Exercise descriptors such as load magnitude, number of repetitions and sets, duration of whole programme, duration of contractile element of exercise, duration of one repetition, time under tension, rest between repetitions, range of motion through which the exercise is performed, and rest between exercise sessions should be reported. (ii) Research should investigate the optimal frequency, intensity, time, type, volume and progression of exercise therapy. (iii) Research should examine the effect of patient education in people with hip-related pain. (iv) Research should investigate the effect of other treatments used in people with hip-related pain (for example: manual therapy, medications, injections). (v) Research should examine the impact of comorbidities and social determinants on treatment effectiveness in people with hip-related pain. Clinicians and researchers working with young to middle-aged active adults with hip-related pain may use these consensus recommendations to guide, develop, test and implement individualised, evidence-based physiotherapist-led rehabilitation programmes.
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http://dx.doi.org/10.1136/bjsports-2019-101458DOI Listing
May 2020

Hip-related groin pain, patient characteristics and patient-reported outcomes in patients referred to tertiary care due to longstanding hip and groin pain: a cross-sectional study.

BMC Musculoskelet Disord 2019 Sep 14;20(1):432. Epub 2019 Sep 14.

Department of Health Sciences, Lund University, PO Box 157, 22100, Lund, Sweden.

Background: Due to advances in hip arthroscopy, the number of surgical procedures has increased dramatically. The diagnostic challenge in patients with longstanding hip and groin pain, as well as the increasing number of hip arthroscopies, may lead to a higher number of patients referred to tertiary care for consideration for surgery. Therefore, the aims were: 1) to describe the prevalence of hip-related groin pain in patients referred to tertiary care due to longstanding hip and groin pain; and 2) to compare patient characteristics and patient-reported outcomes for patients categorized as having hip-related groin pain and those with non-hip-related groin pain.

Methods: Eighty-one patients referred to the Department of Orthopedics at Skåne University Hospital for longstanding hip and groin pain were consecutively included and categorized into hip-related groin pain or non-hip-related groin pain using diagnostic criteria based on current best evidence (clinical examination, radiological examination and intra-articular block injection). Patient characteristics (gender (%), age (years), BMI (kg/m)), results from the Hip Sports Activity Scale (HSAS), the SF-36, the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain distribution (pain manikin) were collected. Parametric and non-parametric statistics were used as appropriate for between-group analysis.

Results: Thirty-three (47%) patients, (30% women, 70% men, p < 0.01), were categorized as having hip-related groin pain. The hip-related groin pain group had a higher activity level during adolescence (p = 0.013), and a higher pre-injury activity level (p = 0.034), compared to the non-hip-related groin pain group. No differences (mean difference (95% CI)) between hip-related groin pain and non-hip-related groin pain were observed for age (0 (- 4; 4)), BMI (- 1.75 (- 3.61; 0.12)), any HAGOS subscales (p ≥ 0.318), any SF-36 subscales (p ≥ 0.142) or pain distribution (p ≥ 0.201).

Conclusions: Only half of the patients referred to tertiary care for long-standing hip and groin pain, who were predominantly men with a high activity level, had hip-related groin pain. Self-reported pain localization and distribution did not differ between patients with hip-related groin pain and those with non-hip-related groin pain, and both patient groups had poor perceived general health, and hip-related symptoms and function.
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http://dx.doi.org/10.1186/s12891-019-2794-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745069PMC
September 2019

Facilitators to support the implementation of injury prevention training in youth handball: A concept mapping approach.

Scand J Med Sci Sports 2019 Feb 8;29(2):275-285. Epub 2018 Nov 8.

Centre for Sport and Social Impact (CSSI), La Trobe University, Melbourne, Victoria, Australia.

There is a need for research to identify effective implementation strategies for injury prevention training within real-world community sports. The aim of this ecological participatory study was to identify facilitators, among stakeholders at multiple levels, that could help injury prevention training become part of regular training routines in youth team handball. Concept mapping, a mixed-method approach for qualitative data collection and quantitative data analysis, was used. Stakeholders (n = 196) of two community team handball clubs (29% players, 13% coaches, 38% caregivers, 11% club, district and national handball administrators, 9% unknown) participated in a brainstorming process. After the research team synthesized the 235 generated statements, 50 stakeholders (34% players, 22% coaches, 24% caregivers, 20% administrators) sorted 89 unique facilitator statements into clusters and rated them for importance and feasibility. Multidimensional scaling and hierarchical cluster analysis yielded five clusters (stress value 0.231): "Understanding and applying knowledge," "Education, knowledge, and consistency," "Set-up and exercises," "Inspiration, motivation, and routines," and "Club policy and expert collaboration." The cluster "Understanding and applying knowledge" had the highest mean importance (3.17 out of 4) and feasibility (2.93) ratings. The 32 statements rated as both highly important and feasible (Go-zone) indicate action is required at the individual (end-users) and organizational (policymakers) levels to implement injury prevention training. Results suggest that developing evidence-based context-specific injury prevention training, incorporating physiological, biomechanical and psychological components, and an associated context-specific implementation plan in partnership with all stakeholders should be a high priority to facilitate the implementation of injury prevention training in youth team handball.
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http://dx.doi.org/10.1111/sms.13323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380009PMC
February 2019

Agreement between test procedures for the single-leg hop for distance and the single-leg mini squat as measures of lower extremity function.

BMC Sports Sci Med Rehabil 2018 22;10:15. Epub 2018 Aug 22.

Department of Health Sciences, Lund University, Lund, Sweden.

Background: Different test procedures are often used within performance-based measures, causing uncertainty as to whether results can be compared between studies. Thus, the aim of this study was to assess agreement between different test procedures for the single-leg hop for distance (SLHD) and the single-leg mini squat (SLMS), respectively, two commonly used tasks for assessing deficiency in lower extremity muscle function.

Methods: Twenty-three participants (20-42 years) with lower extremity injury performed the SLHD with arms free and with arms behind back, and the Limb Symmetry Index (LSI; injured leg divided by uninjured and multiplied by 100) was calculated. Another group of 28 participants (mean 18-38 years) performed five SLMSs at a pre-defined speed and maximum number of SLMSs during 30 seconds, and were visually observed and scored as either having a knee-over-foot or a knee-medial-to-foot position (KMFP).

Results: No systematic difference between test procedures for the LSI of the SLHD was noted (0.736), Cohen's kappa = 0.42. The Bland & Altman plot showed wide limits of agreement between test procedures, with particularly poor agreement for participants with abnormal LSI (<90%). Ten participants were scored as having a KMFP during five SLMSs at a predefined speed, while five had a KMFP during maximum number of SLMSs during 30 seconds (0.063, Cohen's kappa = 0.56).

Conclusions: The moderate agreement between the two test procedures for the SLHD and the SLMS, respectively, indicate that results from these different test procedures should not be compared across studies. SLHD with arms behind back, and five SLMSs at a pre-defined speed, respectively, were the most sensitive procedures to detect individuals with poor functional performance.
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http://dx.doi.org/10.1186/s13102-018-0104-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103854PMC
August 2018

Arthroscopic Surgical Procedures Versus Sham Surgery for Patients With Femoroacetabular Impingement and/or Labral Tears: Study Protocol for a Randomized Controlled Trial (HIPARTI) and a Prospective Cohort Study (HARP).

J Orthop Sports Phys Ther 2018 Apr;48(4):325-335

Study Design Study protocol for a randomized controlled trial and a prospective cohort. Background The number of arthroscopic surgical procedures for patients with femoroacetabular impingement syndrome (FAIS) has significantly increased worldwide, but high-quality evidence of the effect of such interventions is lacking. Objectives The primary objective will be to determine the efficacy of hip arthroscopic procedures compared to sham surgery on patient-reported outcomes for patients with FAIS (HIP ARThroscopy International [HIPARTI] Study). The secondary objective will be to evaluate prognostic factors for long-term outcome after arthroscopic surgical interventions in patients with FAIS (Hip ARthroscopy Prospective [HARP] Study). Methods The HIPARTI Study will include 140 patients and the HARP Study will include 100 patients. The international Hip Outcome Tool-33 will be the primary outcome measure at 1 year. Secondary outcome measures will be the Hip disability and Osteoarthritis Outcome Score, Arthritis Self-Efficacy Scale, fear of movement (Tampa Scale of Kinesiophobia), Patient-Specific Functional Scale, global rating of change score, and expectations. Other outcomes will include active hip range of motion, hip muscle strength tests, functional performance tests, as well as radiological assessments using radiographs and magnetic resonance imaging. Conclusion To determine the true effect of surgery, beyond that of placebo, double-blinded placebo-controlled trials including sham surgery are needed. The HIPARTI Study will direct future evidence-based treatment of FAIS. Predictors for long-term development and progression of degenerative changes in the hip are also needed for this young patient group with FAIS; hence, responders and nonresponders to treatment could be determined. J Orthop Sports Phys Ther 2018;48(4):325-335. doi:10.2519/jospt.2018.7931.
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http://dx.doi.org/10.2519/jospt.2018.7931DOI Listing
April 2018

Impact of treatment strategy and physical performance on future knee-related self-efficacy in individuals with ACL injury.

BMC Musculoskelet Disord 2018 02 13;19(1):50. Epub 2018 Feb 13.

Department of Health Sciences, Lund University, Box 157, 221 00, Lund, Sweden.

Background: In people with anterior cruciate ligament (ACL) injury, high self-efficacy facilitates recovery, indicated by improved muscle function, reduced knee symptoms and increased physical activity. Impact of treatment on future self-efficacy is however not well investigated. The aims of the study were to 1) investigate knee-related self-efficacy 6 years after acute ACL injury in patients treated with exercise therapy alone or in combination with either early or the option of delayed ACL reconstruction (ACLR), and 2) to investigate associations between single-leg physical performance at various time points after ACL injury and knee self-efficacy at 6 years after injury.

Methods: Participants (n = 121) originated from the KANON-study (ISRCTN84752559), a treatment RCT including active adults with acute ACL injury treated with structured exercise therapy combined with early or the option of delayed ACLR. In this ancillary study, participants with knee self-efficacy data at 6 years (n = 89) were analyzed as treated; exercise therapy alone (n = 20), exercise therapy plus early ACLR (n = 46), and exercise therapy plus delayed ACLR (n = 23). The participants performed physical performance tests (hop, strength and balance) at the end the of exercise therapy (mean 10 (SD 6) months), and at 5 years, and rated their knee self-efficacy using Knee Self-Efficacy Scale (K-SES) questionnaire (0 to 10, worst to best) at 6 years.

Results: Median K-SES score for the total group (n = 89) was 7.8 (IQR 5.9-9.0). There were no differences between treatment groups in K-SES scores at 6 years nor in physical performance at any time point (p ≥ 0.097). Worse knee flexion strength LSI (r = 0.341, p = 0.042) at the end of the exercise therapy, and worse LSI for single-leg hop test (r = 0.310, p = 0.005) at the end of the exercise therapy and at 5 years, correlated moderately with worse knee-related self-efficacy at 6 years. Low associations were observed between the remaining physical performance tests and K-SES scores (r ≤ 0.265, p ≥ 0.045).

Conclusion: Knee-related self-efficacy at 6 years after ACL injury did not differ between those treated with ACLR, performed early or as a delayed procedure, or exercise therapy alone. Good physical performance at the end of the exercise therapy, and at 5 years, appears to have a positive, yet small, impact on future knee-related self-efficacy.
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http://dx.doi.org/10.1186/s12891-018-1973-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809873PMC
February 2018

Weaker lower extremity muscle strength predicts traumatic knee injury in youth female but not male athletes.

BMJ Open Sport Exerc Med 2017 16;3(1):e000222. Epub 2017 Apr 16.

Department of Health Sciences, Musculoskeletal Function, Lund University, Lund, Sweden.

Background: The role of lower extremity (LE) muscle strength for predicting traumatic knee injury in youth athletes is largely unknown.

Aims: The aim was to investigate the influence of LE muscle strength on traumatic knee injury in youth female and male athletes.

Methods: 225 athletes (40% females) from sport senior high schools in Sweden were included in this case-control study. The athletes recorded any traumatic knee injury that had occurred during their high-school period in a web-based injury form. A one repetition maximum (1RM) barbell squat test was used to measure LE muscle strength. The 1RM was dichotomised to analyse 'weak' versus 'strong' athletes according to the median (weak vs strong).

Results: 63 traumatic knee injuries, including 18 ACL injuries, were registered. The majority of injured female athletes were in the weak group compared with the strong group (p=0.0001). The odds of sustaining a traumatic knee injury and an ACL injury was 9.5 times higher and 7 times higher, respectively, in the weak group compared with the strong group in females (p ≤0.011). A relative 1RM squat ≤1.05 kg (105% of bodyweight) was established as the best cut-off value to distinguish high versus low risk of injury in female athletes. No strength-injury relationships were observed for the male athletes (p ≥0.348).

Conclusions: Weaker LE muscle strength predicted traumatic knee injury in youth female athletes, but not in males. This suggests that LE muscle strength should be included in injury screening in youth female athletes.
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http://dx.doi.org/10.1136/bmjsem-2017-000222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5731228PMC
April 2017

Measurement Properties of a Test Battery to Assess Postural Orientation During Functional Tasks in Patients Undergoing Anterior Cruciate Ligament Injury Rehabilitation.

J Orthop Sports Phys Ther 2017 Nov 15;47(11):863-873. Epub 2017 Oct 15.

Study Design Cross-sectional study. Background Visual rating of postural orientation during functional tasks may be a valuable tool to track rehabilitation progress following anterior cruciate ligament (ACL) injury. A valid test battery assessing postural orientation as a separate construct is lacking. Objectives To evaluate measurement properties of a test battery to assess postural orientation in patients with ACL injury. Methods The content validity of functional tasks was assessed by expert focus group discussions. Fifty-one patients (45% women) with ACL injury performed 9 functional tasks of varying difficulty. Interpretability, internal consistency, interrater reliability, and measurement error were assessed for segment-specific postural orientation errors (POEs), within-task POEs, and total POE score. Postural orientation errors were scored on video on an ordinal scale from 0 (no POEs) to 3 (major POEs). Results Stair ascent, deep squat, and crossover hop for distance were excluded in focus group discussions. Postural orientation errors in some tasks were excluded due to floor effects. The mini-squat and drop jump were excluded due to poor internal consistency (α≤.184). Interrater reliability values for segment-specific POEs and within-task POEs yielded fair to almost perfect agreement (κ = 0.429-0.875) and almost perfect agreement for total POE score (intraclass correlation coefficient = 0.842), without systematic differences between raters. The smallest detectable changes were 0.7 and 5 points for groups and individuals, respectively. Conclusion The final test battery (single-leg mini-squat, stair descent, forward lunge, single-leg hop for distance) of 4 POEs (foot pronation, medial knee-to-foot position, hip joint POEs, and trunk segment POEs) demonstrated good measurement properties in people with ACL injury. J Orthop Sports Phys Ther 2017;47(11):863-873. doi:10.2519/jospt.2017.7270.
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http://dx.doi.org/10.2519/jospt.2017.7270DOI Listing
November 2017

Translation, Cross-Cultural Adaptation, and Validation of the Activity Rating Scale for Disorders of the Knee.

Orthop J Sports Med 2017 Sep 25;5(9):2325967117729361. Epub 2017 Sep 25.

Department of Health Sciences, Lund University, Lund, Sweden.

Background: The Activity Rating Scale (ARS) for disorders of the knee evaluates the level of activity by the frequency of participation in 4 separate activities with high demands on knee function, with a score ranging from 0 (none) to 16 (pivoting activities 4 times/wk).

Purpose: To translate and cross-culturally adapt the ARS into Swedish and to assess measurement properties of the Swedish version of the ARS.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: The COSMIN guidelines were followed. Participants (N = 100 [55 women]; mean age, 27 years) who were undergoing rehabilitation for a knee injury completed the ARS twice for test-retest reliability. The Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale (TAS), and modernized Saltin-Grimby Physical Activity Level Scale (SGPALS) were administered at baseline to validate the ARS. Construct validity and responsiveness of the ARS were evaluated by testing predefined hypotheses regarding correlations between the ARS, KOOS, TAS, and SGPALS. The Cronbach alpha, intraclass correlation coefficients, absolute reliability, standard error of measurement, smallest detectable change, and Spearman rank-order correlation coefficients were calculated.

Results: The ARS showed good internal consistency (α ≈ 0.96), good test-retest reliability (intraclass correlation coefficient >0.9), and no systematic bias between measurements. The standard error of measurement was less than 2 points, and the smallest detectable change was less than 1 point at the group level and less than 5 points at the individual level. More than 75% of the hypotheses were confirmed, indicating good construct validity and good responsiveness of the ARS.

Conclusion: The Swedish version of the ARS is valid, reliable, and responsive for evaluating the level of activity based on the frequency of participation in high-demand knee sports activities in young adults with a knee injury.
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http://dx.doi.org/10.1177/2325967117729361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617100PMC
September 2017

Frontal plane kinematics predict three-dimensional hip adduction during running.

Phys Ther Sport 2017 Sep 15;27:1-6. Epub 2017 Jun 15.

Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Australia.

Objectives: To investigate if frontal plane kinematics are predictive of three dimensional (3D) hip adduction and hip internal rotation during running.

Study Design: Cross-sectional.

Setting: Biomechanics laboratory.

Participants: Thirty healthy male runners aged 18-45 years.

Main Outcome Measures: Two dimensional (2D) angles in the frontal plane (peak pelvic obliquity, peak hip adduction, peak femoral valgus, peak knee valgus and peak tibial valgus) and 3D hip adduction and hip internal rotation during stance phase of running were obtained.

Results: Linear regression modelling revealed that peak 2D pelvic obliquity (a drop towards the contralateral leg) and peak femoral valgus significantly predicted 88% of the variance in peak 3D hip adduction (p < 0.001). Frontal plane kinematics however, were not predictive of peak hip internal rotation in 3D (p > 0.05).

Conclusions: Frontal plane kinematics, specifically contralateral pelvic drop and femoral valgus, predicted the vast majority of the variance in 3D hip adduction during the stance phase of running. This indicates that 2D video may have potential as a clinically feasible proxy for measurement of peak 3D hip adduction - a risk factor for patellofemoral pain.
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http://dx.doi.org/10.1016/j.ptsp.2017.05.005DOI Listing
September 2017

Measurement properties of visual rating of postural orientation errors of the lower extremity - A systematic review and meta-analysis.

Phys Ther Sport 2017 Sep 18;27:52-64. Epub 2017 Apr 18.

Department of Health Sciences, Lund University, PO Box 157, SE-221 00 Lund, Sweden. Electronic address:

Objectives: To systematically review measurement properties of visual assessment and rating of Postural Orientation Errors (POEs) in participants with or without lower extremity musculoskeletal disorders.

Methods: A systematic review according to the PRISMA guidelines was conducted. The search was performed in Medline (Pubmed), CINAHL and EMBASE (OVID) databases until August 2016. Studies reporting measurement properties for visual rating of postural orientation during the performance of weight-bearing functional tasks were included. No limits were placed on participant age, sex or whether they had a musculoskeletal disorder affecting the lower extremity.

Results: Twenty-eight articles were included, 5 of which included populations with a musculoskeletal disorder. Visual rating of the knee-medial-to-foot position (KMFP) was reliable within and between raters, and meta-analyses showed that this POE was valid against 2D and 3D kinematics in asymptomatic populations. Other segment-specific POEs showed either poor to moderate reliability or there were too few studies to permit synthesis. Intra-rater reliability was at least moderate for POEs within a task whereas inter-rater reliability was at most moderate.

Conclusions: Visual rating of KMFP appears to be valid and reliable in asymptomatic adult populations. Measurement properties remain to be determined for POEs other than KMPF.
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http://dx.doi.org/10.1016/j.ptsp.2017.04.003DOI Listing
September 2017

Knee extensor strength and body weight in adolescent men and the risk of knee osteoarthritis by middle age.

Ann Rheum Dis 2017 Oct 9;76(10):1657-1661. Epub 2017 May 9.

Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Faculty of Medicine, Lund University, Lund, Sweden.

Objectives: To assess the extent to which knee extensor strength and weight in adolescence are associated with knee osteoarthritis (OA) by middle age.

Methods: We studied a cohort of 40 121 men who at age 18 years in 1969/1970 underwent mandatory conscription in Sweden. We retrieved data on isometric knee extensor strength, weight, height, smoking, alcohol consumption, parental education and adult occupation from Swedish registries. We identified participants diagnosed with knee OA or knee injury from 1987 to 2010 through the National Patient Register. We estimated the HR of knee OA using multivariable-adjusted Cox proportional regression model. To assess the influence of adult knee injury and occupation, we performed a formal mediation analysis.

Results: The mean (SD) knee extensor strength was 234 (47) Nm, the mean (SD) weight was 66 (9.3) kg. During 24 years (median) of follow-up starting at the age of 35 years, 2049 persons were diagnosed with knee OA. The adjusted HR (95% CI) of incident knee OA was 1.12 (1.06 to 1.18) for each SD of knee extensor strength and 1.18 (1.15 to 1.21) per 5 kg of body weight. Fifteen per cent of the increase in OA risk due to higher knee extensor strength could be attributed to knee injury and adult occupation.

Conclusion: Higher knee extensor strength in adolescent men was associated with increased risk of knee OA by middle age, challenging the current tenet of low muscle strength being a risk factor for OA. We confirmed higher weight to be a strong risk factor for knee OA.
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http://dx.doi.org/10.1136/annrheumdis-2016-210888DOI Listing
October 2017

Association between sensory function and hop performance and self-reported outcomes in patients with anterior cruciate ligament injury.

Open Access J Sports Med 2017 19;8:1-8. Epub 2017 Jan 19.

Department of Health Sciences, Lund University, Lund, Sweden.

Background: In patients with anterior cruciate ligament (ACL) deficiency (ACLD) or reconstruction (ACLR), sensory deficits are commonly assessed as knee kinesthesia using time-consuming laboratory equipment. Portable equipment such as that used for evaluation of vibration sense would be preferable. In contrast to kinesthesia, vibration sense is not well studied in these patients.

Objectives: 1) To study the association between kinesthesia and vibration sense to investigate if one sensory measurement can replace the other; and 2) to determine the clinical relevance by investigating associations between the sensory measurements and functional performance and patient-reported outcomes in patients with ACLD or ACLR.

Methods: Twenty patients with ACLD and 33 patients with ACLR were assessed with knee kinesthesia, vibration sense, the one-leg hop test for distance, as well as the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Scale.

Results: There were no significant correlations between kinesthesia and vibration sense (= -0.267, >0.269) or between the sensory measures and hop performance (= -0.351, >0.199). In patients with ACLD, worse knee kinesthesia was associated with worse scores on KOOS subscales pain (= -0.464, =0.046) and activities of daily living (= -0.491, =0.033), and worse vibration sense was associated with worse scores on KOOS subscale quality of life (= -0.469, =0.037) and worse knee confidence (item Q3 from subscale quality of life) (=0.436, =0.054). In patients with ACLR, worse vibration sense was associated with worse scores on KOOS subscales pain (= -0.402, =0.020) and activities of daily living (= -0.385, =0.027).

Conclusion: Kinesthesia and vibration sense cannot be used interchangeably as measures of sensory function in patients with ACLD or ACLR. Both sensory measurements were weakly related to hop performance. Adequate sensory function appears to have importance for perceived function in patients with ACLD or ACLR and may therefore be a factor that needs to be addressed in rehabilitation programs for these patients.
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http://dx.doi.org/10.2147/OAJSM.S120058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5261846PMC
January 2017

Muscle function is associated with future patient-reported outcomes in young adults with ACL injury.

BMJ Open Sport Exerc Med 2016 10;2(1):e000154. Epub 2016 Oct 10.

Department of Health Sciences , Lund University , Lund , Sweden.

Background/aim: Consequences of an anterior cruciate ligament (ACL) injury include worse patient-reported outcomes (PROs) and a decrease in activity level. Muscle function can be improved by targeted exercise. Our aims were to investigate cross-sectional and longitudinal associations among lower extremity muscle function and PROs after ACL injury.

Methods: Fifty-four participants (15 women, mean 30 years) with ACL injury or reconstruction, from the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) trial (ISRCTN84752559), were assessed with hop performance, muscle power and postural orientation 3 years (SD 0.85) after ACL injury. PROs at 3 and 5 years after injury included Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales Function in sport and recreation (KOOS Sport/rec) and Knee-related Quality of life (KOOS QoL), KOOS item Q3 (KOOS Q3), Tegner Activity Scale and Activity Rating Scale (ARS). Partial Spearman's rank-order correlation was used to analyse correlations between muscle function and PROs, controlling for gender and treatment.

Results: Numerous cross-sectional correlations were observed between muscle function and PROs (r≈0.3-0.5, p≤0.045). Worse hop performance and worse postural orientation were associated with worse KOOS scores 2 years later (r≥0.280, p≤0.045). Worse muscle power was associated with lower future ARS scores (r=0.281, p=0.044).

Conclusions: The moderate associations suggest that improving muscle function during rehabilitation could improve present and future PROs.
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http://dx.doi.org/10.1136/bmjsem-2016-000154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125420PMC
October 2016
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