Association between sensorimotor function and visual assessment of postural orientation in patients with ACL injury.

OBJECTIVES: To investigate the association between sensorimotor function and visual assessment of postural orientation during execution of weight-bearing activities in patients with anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: Fifty-two individuals (23 women and 29 men, mean (SD) age 26.5 (6.4)) approximately 7 months after ACLR. MAIN OUTCOME MEASURES: Sensorimotor function (proprioception, ankle dorsiflexion range of motion, and isometric muscle strength of the hip, knee, and trunk) were recorded on the injured leg. Postural orientation errors (POEs) were visually scored from video-recordings of the injured leg during execution of 5 functional tasks, and POE subscales activities of daily living (ADL) and Sport, and Total POE score were used in the analysis. RESULTS: Lower hip external rotation strength was associated with higher Total POE score (B = -24.4, p = 0.041) and higher POE subscale ADL score (B = -24.9, p = 0.03). No associations between sensorimotor function and POE subscale Sport were found. CONCLUSIONS: Decreased hip external rotation strength might contribute to higher scores on the POE subscale ADL and the Total POE score, in men and women following ACLR. Future studies will reveal if strengthening of hip external rotation strength improves postural orientation.

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

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 (rs = 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.

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

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 (rs= -0.425 to -0.518, p<0.038), but not in men (rs<0.301, p>0.05). No associations were found between POE scores and PROMs, in either sex (rs< -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.

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

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.

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

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.

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

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.

Gender differences in knee abduction during weight-bearing activities: A systematic review and meta-analysis.

BACKGROUND: Increased knee abduction during weight-bearing activities is suggested to be a contributing factor for the high knee injury risk reported in women. However, studies investigating gender difference in knee abduction are inconclusive. OBJECTIVE: To systematically review gender-differences in knee abduction during weight-bearing activities in individuals with or without knee injury. METHODS: A systematic review and meta-analysis were conducted according to the PRISMA guidelines. A search in the databases Medline, CINAHL and EMBASE was performed until September 2015. Inclusion criteria were studies that reported (1) gender differences, (2) healthy individuals and/or those with anterior cruciate ligament (ACL) deficiency or reconstruction or patellofemoral pain PFP, and (3) knee abduction assessed with either motion analysis or visual observation during weight-bearing activity. RESULTS: Fifty-eight articles met the inclusion criteria. Women with PFP had greater peak knee abduction compared to men (Std diff in mean; -1.34, 95%CI; -1.83 to -0.84). In healthy individuals, women performed weight-bearing tasks with greater knee abduction throughout the movement (initial contact, peak abduction, excursion) (Std diff in mean; -0.68 to -0.79, 95%CI; -1.04 to -0.37). In subgroup analyses by task, differences in knee abduction between genders were present for most tasks, including running, jump landings and cutting movements. There were too few studies in individuals with ACL injury to perform meta-analysis. CONCLUSION: The gender difference in knee abduction during weight-bearing activities should be considered in training programs aimed at preventing or treating knee injury.

Modifiable Factors Associated with Knee Abduction During Weight-Bearing Activities: A Systematic Review and Meta-Analysis.

BACKGROUND: Increased knee abduction angle during activity is suggested to be a risk factor for sustaining an anterior cruciate ligament (ACL) injury or developing patellofemoral pain syndrome (PFPS). Knowledge of the modifiable mechanisms that are associated with increased knee abduction will aid in the appropriate design of preventive and rehabilitative strategies for these injuries. OBJECTIVE: Our objective was to systematically review modifiable mechanisms contributing to increased knee abduction in healthy people and in individuals with an ACL injury or PFPS. METHODS: We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the databases MEDLINE, CINAHL, and Embase until September 2015. Inclusion criteria were studies in healthy individuals and/or those with ACL injury or PFPS reporting (1) muscle strength, muscle activation, proprioception, and/or range of motion (ROM) and (2) knee abduction angle assessed with either motion analysis or visual observation during weight-bearing activity. RESULTS: In total, 33 articles were included. Reduced trunk strength, reduced gluteus maximus amplitude, decreased ankle ROM, and increased hip external rotation ROM were moderately associated with increased knee abduction angle (r -0.34 or higher, standardized difference in means (SDM) greater than -0.39, p < 0.05, articles n = 3, total sample size n = 101-114) in healthy individuals. Decreased strength of hip abductors, external rotators, and extensors and knee flexors were at most weakly associated with increased knee abduction angle (r ≤ 0.21, p = 0.013-0.426, articles n = 2-9, total sample size n = 80-311). Too few articles included patients with knee injury to be included in any meta-analysis. CONCLUSION: The associations identified in this review indicate that investigation of strengthening of the trunk muscles, and improvement of gluteus maximus activation and ankle ROM to change knee kinematics is merited. Studies on modifiable factors associated with increased knee abduction angle in people with knee injury are needed.