© 2014 John Wiley & Sons A/S.

Scand J Med Sci Sports 2014: ••: ••–•• doi: 10.1111/sms.12212

Published by John Wiley & Sons Ltd

Anterior cruciate ligament injury after more than 20 years: I. Physical activity level and knee function E. Tengman1, L. Brax Olofsson2, K. G. Nilsson2, Y. Tegner3, L. Lundgren3, C. K. Häger1 Department of Community Medicine and Rehabilitation, Section for Physiotherapy, Umeå University, Umeå, Sweden, 2Department of Surgical and Perioperative Sciences Section for Orthopaedics, Umeå University, Umeå, Sweden, 3Department of Health Sciences, Division of Medical Science, Luleå University of Technology, Luleå, Sweden Corresponding author: Eva Tengman, PhD stud, Umeå University, Physiotherapy, SE-90187 Umeå, Sweden. Tel: +46 70 3770680, Fax: +46 90 7869267, E-mail: [email protected]

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Accepted for publication 17 February 2014

Little is known about physical activity level and knee function including jump capacity and fear of movement/ reinjury more than 20 years after injury of the anterior cruciate ligament (ACL). Seventy persons with unilateral ACL injury participated (23 ± 2 years post-injury): 33 treated with physiotherapy in combination with surgical reconstruction (ACLR), and 37 treated with physiotherapy alone (ACLPT). These were compared with 33 age- and gender-matched controls. Assessment included knee-specific and general physical activity level [Tegner activity scale, International Physical Activity Questionnaire (IPAQ)], knee function [Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS)], jump capacity (one-leg hop, vertical jump, side hops), and fear of movement/reinjury [Tampa Scale for Kinesiophobia

(TSK)]. Outcomes were related to degree of osteoarthritis (OA). ACL-injured had lower Lysholm, KOOS, and Tegner scores than controls (P < 0.001), while IPAQ score was similar. ACL-injured demonstrated inferior jump capacity in injured compared with noninjured leg (6–25%, P < 0.001–P = 0.010 in the different jumps), while noninjured leg had equal jump capacity as controls. ACL groups scored 33 ± 7 and 32 ± 7 of 68 on TSK. Lower scores on Lysholm and KOOS symptom were seen for persons with moderate-to-high OA than for no-or-low OA, while there were no differences for physical activity and jump capacity. Regardless of treatment, there are still negative knee-related effects of ACL injury more than 20 years later.

Anterior cruciate ligament (ACL) injuries are frequent (Nordenvall et al., 2012) and occur primarily in active young individuals involved in pivoting sports and activities such as soccer, floorball, and downhill skiing (Swedish ACL Register, 2011). An ACL injury obviously has negative impacts on knee function and the majority of athletes who sustain an ACL injury do not successfully return to their preinjury activity level despite treatment (Kvist et al., 2005; Ardern et al., 2011). A potential contributing cause may be fear of reinjury (Kvist et al., 2005; Ardern et al., 2011). ACL injuries are managed either with physiotherapy in combination with ACL reconstruction or treated with physiotherapy alone. The persons may function apparently well in the first few years (Ageberg et al., 2008; Frobell et al., 2010) but may start to decline after 10 years or more. Few studies have reported physical activity level and knee function 20 years or more after injury. Long-term studies of 15 years or more show various results such as good or slightly reduced knee function measured with Lysholm score and Knee injury and Osteoarthritis Outcome Score (KOOS), normal, or reduced knee-specific activity level on the Tegner

activity scale and that knee osteoarthritis (OA) is present in varying degrees both for persons who have been treated with a combination of physiotherapy and surgical reconstruction (Strand et al., 2005; Drogset et al., 2006; Meunier et al., 2007; Hui et al., 2011; Mihelic et al., 2011; Streich et al., 2011; Widuchowski et al., 2012; Gerhard et al., 2013; Stensbirk et al., 2013) as well as for those treated with physiotherapy alone (Ageberg et al., 2007; Kostogiannis et al., 2007; Meunier et al., 2007; Neuman et al., 2008; Streich et al., 2011). The boundaries between what is normal or reduced function in many of these scores are however not clearly established, which makes interpretations of outcome cumbersome. It is well established that radiological OA is common 15 years after an ACL injury while the long-term consequences with regard to the actual physical capacity is not well described (Ageberg et al., 2007; Hui et al., 2011; Widuchowski et al., 2012; Gerhard et al., 2013; Stensbirk et al., 2013). There is a total lack of studies that directly and comprehensively assess the physical capacity such as jump performance a long time after ACL injury and in relation to degree of OA, while also comparing the performance to that of age- and gender-matched healthy

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Tengman et al. controls. In the few existing long-term follow-ups that have investigated functional performance, the one-leg hop for distance is the most common test. Usually, only limb symmetry index (LSI) is reported (and not the absolute values of hop distance), and often also without comparison to norm values or a control group. These studies nevertheless show that 8–35% of ACL-injured individuals have an unsatisfactory knee function with regard to LSI jump capacity 15–16 years after injury (Ageberg et al., 2007; Hui et al., 2011; Widuchowski et al., 2012; Gerhard et al., 2013; Stensbirk et al., 2013). However, demanding knee-loading activities such as jumps may be influenced by fear of movement/reinjury (Kvist et al., 2005; Ardern et al., 2011) and this should therefore also be taken into account. Aim The main aim of this study was to investigate both kneespecific and general physical activity level, and knee function including jump capacity in three of the most common jump tests and relate this to fear of movement/ reinjury in patients who sustained unilateral ACL injury more than 20 years ago. We wanted to compare these outcome measures in persons who were treated with either physiotherapy in combination with surgical reconstruction or with physiotherapy alone, to those of ageand gender-matched healthy controls. We further aimed to relate the physical activity level, knee function, and jump capacity to degree of radiological knee OA. Our hypotheses were that (a) the injured leg would show lower jump capacity then the noninjured leg in both ACL groups, respectively, (b) the injured leg would have lower jump capacity compared with age- and gender-matched healthy controls, (c) those with higher degree of OA would have less good function, lower physical activity level both generally and knee specifically as well as lower jump capacity than those with no-or-low OA, (d) ACL-injured persons would have reduced knee function and lower physical activity level than healthy controls, and (e) ACLinjured persons would display a high fear of movement/ reinjury on the Tampa Scale for Kinesiophobia (TSK) that in turn is related to their jump capacity. To our knowledge, there is no such prior study that have incorporated these aspects in the long perspective more than 20 years after ACL injury.

severity of injury or activity level demands. This cohort was treated only with physiotherapy (ACLPT). In the other hospital, the indication for surgery was less restrictive and in this cohort all patients had had surgery followed by post-operative physiotherapy (ACLR). Of the 113 eligible patients for the present study, 32 patients were excluded because of bilateral ACL injury, prosthesis, other musculo-skeletal, rheumatologic or neurological pathology; other severe injury or disease to the noninjured leg (Fig. 1). Eleven individuals declined to participate because of far distant living, considered the testing too time consuming or for unknown reasons, these individuals however did not differ in background variables [e.g., age, body mass index (BMI), scores at KOOS, Lysholm and Tegner, and one-leg hop for distance measured clinically with a measuring tape, which were tested for in all 113 participants in the first step of data collection], to those who participated in the present study. Thus, 70 participants with an ACL injury were included in the physiotherapy assessment presented here (Fig. 1). Thirty-three participants had been treated with physiotherapy in combination with ACL reconstruction (ACLR) in one hospital and 37 participants had been treated with physiotherapy alone in the other hospital (ACLPT). In both ACL groups, many of the individuals displayed some form of OA at the time of investigation varying from stage 1 to 4 (Kellgren & Lawrence, 1957) reported in Table 1. A control group consisting of 33 noninjured healthy persons was also tested. All participants were given written and oral information about the study and gave their written informed consent according to the declaration of Helsinki. The project was approved by the Regional Ethical Review Board. Data on isokinetic knee muscle strength measured on the same study population is reported in a parallel paper (Tengman et al., 2014).

Description of treatment ACLR: physiotherapy in combination with surgical reconstruction Participants in the ACLR group were injured between the years 1981 and 1993 and treated with physiotherapy for 3 months pre-operatively and an ACL reconstructive surgery between the years 1987 and 1993, followed by post-operative physiotherapy

Orthopedic and radiology assessment 23 years aŌer injury

n=20 Excluded due to, bilateral injuries (n=15), prosthesis (n=2), illness (n=3),

ACLR n=42

Materials and methods

Declined n=9

Participants The present study is part of a larger cross-sectional study involving 113 persons who suffered an ACL injury on average 23 (range 17–28) years ago. Two cohorts that were treated in two separate hospitals, each in a different geographical region of Northern Sweden, were examined. Both cohorts were initially treated with physiotherapy for at least 3 months. One hospital had a strategy that ACL reconstruction should be restricted only to those who would gain clear benefit from surgery and not merely be indicated based on

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ACLR n=62

FuncƟonal performance tests

ACLR n=33

ACLPT n=51 n=12 Excluded due to, bilateral injuries (n=10), illness (n=2),

ACLPT n=39 Declined n=2

ACLPT n=37

Healthy controls n=33

Fig. 1. Flow chart of the two ACL cohorts; ACL-injured treated with physiotherapy in combination with reconstructive surgery (ACLR) and ACL-injured treated with physiotherapy alone (ACLPT).

Knee function 23 years after ACL injury Table 1. Participants characteristics

Group

Participants (n) Male/female (n) Age at test (years) Years since injury Years between injury – surgery Height (cm) Weight (kg) BMI (kg/m2) Injury side: dominant/nondominant (n) Cause of injury Soccer (n) Alpine (n) Other sports (n) Nonsporting (n) OA K&L 1*c OA K&L 2 OA K&L 3 OA K&L 4

ACLR means (SD)

ACLPT means (SD)

Controls means (SD)

33 21/12 45.6 (4.5) 23.9 (2.8) 3.6 (2.3) 174.0 (9.1) 83.0 (15.6) 27.2 (3.3) 21/12

37 23/14 48.1 (5.9) 23.1 (1.3) – 173.5 (8.0) 87.1 (14.9) 28.9 (4.6) 20/17

33 21/12 46.7 (5.0) – – 176.4 (9.8) 77.4 (14.9)*a 24.6 (2.5)*b –

24 2 6 1 5 12 10 4

25 5 2 5 6 13 9 3

– – – –

Means (SD) are presented where not otherwise indicated. *aACLR – controls P = NS; ACLPT-controls P = 0.025; ACLR – ACLPT P = NS. *bACLR – controls P = 0.014; ACLPT-controls P < 0.001; ACLR – ACLPT P = NS. *cRadiographic OA was graded according Kellgren & Lawrence (K&L). ACLPT, group treated with physiotherapy alone and controls are healthy-knee persons matched to the ACL-injured; ACLR, group treated with physiotherapy in combination with reconstructive surgery; BMI, body mass index; OA, osteoarthritis; SD, standard deviation.

(see below). Nineteen participants received reconstructive surgery with a patellar tendon quadriceps autograft augmented with a synthetic polypropylene braid [Kennedy ligament augmentation device (LAD); Kennedy et al., 1980] placed over the top. Nine participants had a LAD graft placed through a femoral tunnel using an aiming device (Odensten & Gillquist, 1986). Five participants received a bone-patellar tendon-bone autograft (Lipscomb et al., 1981). The post-operative physiotherapy aimed to regain full range of motion and improve strength, coordination, and balance. Functional exercises were performed with a progressive design implementing advancing levels of intensity and difficulty. A knee brace and crutches were used during 14 weeks post-surgery. Full return to sports activities was recommended no earlier than 22 weeks after surgery.

ACLPT: physiotherapy alone Participants in the ACLPT cohort were injured in the period 1983– 1988 and treated with physiotherapy consisting of a tailored six goal-oriented program designed by the physiotherapist and the orthopedic surgeon in charge. The program focused on progressively increased functional stability training and activity modification where some sports, such as soccer, floorball, and wrestling, were advised against. The patient was guided to return to activity and work in a safe way while also regaining functional stability, e.g., avoid give way episodes. The program aimed to achieve an LSI > 90% for strength and functional tests. The rehabilitation was regarded complete when the patient managed to do the final step exercise without instability or other symptoms (Tegner, 1990). The median time to reach this level was 22 weeks (range 12–60 weeks).

controls were age and gender matched to the ACL groups. The controls consider themselves to have healthy knees and a clinical examination was performed to exclude injury of the ACL, other ligaments, or the meniscus.

Assessments Physical activity level Knee-specific physical activity level was assessed according to the Tegner activity scale (0–10, physician administrated; Tegner & Lysholm, 1985). The short form of the International Physical Activity Questionnaire (IPAQ) was used for physical activity of the preceding 7 days, with items for walking, moderate-intensity, and vigorous-intensity activities. Each activity domain was weighted by its energy requirements defined in metabolic equivalent of task (METs) to yield a score in MET-min/week. The amount of activity was classified into three categories: low, moderate, or high physical activity level (IPAQ scoring protocol; IPAQ Consensus Group 2005). The IPAQ was filled out by the participants at home prior to the test occasion.

Knee function Knee function was assessed with the Lysholm questionnaire (physician administrated) estimating limp, support, pain, swelling, instability, locking, stair-climbing, and squatting (0 = worst and 100 = optimal knee function; Tegner & Lysholm, 1985). Participants also rated their knee function on the KOOS ranging between 0 (worst) and 100 (best) on five subscales: pain, symptoms, function in activities of daily living, sports and recreation function, and knee-related quality of life (Roos et al., 1998). The KOOS were filled out by the participants at home.

Controls with healthy knees

Jump capacity

We also recruited 33 noninjured persons through advertisement and convenience sampling via staff and acquaintances. The

We employed three different jump tests, and in all of them, the participants were instructed to stand on one leg in an upright

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Tengman et al. position with arms crossed over the chest; a modification made for optimal kinematic recordings that were used for the assessment (see below). In the one-leg hop for distance, the maximal jump distance (m) is measured (Tegner et al., 1986). The participants were instructed to hop as far forward as possible, land on the same leg, and maintain their balance. Vertical jump is a one-leg jump upwards, where the maximal jump height (cm) is measured. The participants were instructed to jump as high as possible and maintain their balance after landing. Side hops is a coordinative endurance test with as many as possible one-leg jumps sideways across two marked lines on the floor separated 40 cm apart, during a period of 30 s. Hops landing on the line or on the inside of the area defined by the lines were not approved (Gustavsson et al., 2006). The same physiotherapist (E. T.) tested all participants.

Fear of movement/reinjury For the ACL-injured persons, fear of movement/reinjury was assessed by the Swedish version of the TSK (Lundberg et al., 2004). Fear of movement may in this context mostly be attributed to fear of reinjury, but also in a long-term perspective be related to several other potential factors influencing the movement ability, The TSK consists of 17 items on a 4-point Likert scale with outcomes ranging from “strongly disagree” to “strongly agree.” The total score ranges from 17 to 68, with higher scores indicating greater fear of movement. The TSK is considered reliable on patients suffering from chronic low back pain (Lundberg et al., 2004), and has been used in patients with ACL injury to estimate fear of reinjury (cf. Kvist et al., 2005).

Test procedure Participants wore shorts, a training tank top, and were barefoot. The test procedure started with a 6-min warm-up on a bicycle ergometer at a moderate intensity. Thereafter, the participants performed the jump tasks in the order of one-leg hop, vertical jump, and side hop. Each task started on the noninjured leg for the ACL injured and on the dominant leg for controls. Dominant leg was defined as the preferred kicking leg. All participants were allowed some practice before each task. For one-leg hop and vertical jump, the test was performed until three jumps were approved on each leg. The longest jump and the highest jump achieved by each leg were selected for analysis. Between each jump test, there was a rest period of at least 30 s or more if so desired. The side-hop test was only performed once per leg with a minimum of 2-min rest in between.

Calculation of jump distance and jump height The distance and height of the jumps were measured with a threedimensional motion analysis system (8 cameras, Oqus®, Qualisys Medical AB, Gothenborg, Sweden, capture rate 240 Hz). The Qualisys Track Manager software (Qualisys Medical AB, Gothenborg, Sweden,version 2.2) was used to capture and track movements of 42 reflective markers affixed to the body. Visual3D software (C-Motion Inc., Germantown, Maryland, USA, version 4.96) was used to analyze data according to a standardized 6 DOF-model (cf. Grip & Häger, 2013) and detailed kinematic analyses of the jumps will be reported elsewhere. The hop distance for one-leg hop was calculated by measuring the movement of the foot marker placed on the lateral malleolus from take-off to landing. For vertical jump, the height of the jump was calculated by the change of movement of center of mass (COM) between normal standing and at the highest point of the vertical jump.

Data processing and statistics We chose not to make a strict comparison between the ACL groups since the present study is not a randomized controlled trial, but to

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analyze the outcome and compare each ACL group separately to healthy controls. The Statistical Package for the Social Sciences (IBM SPSS Statistics, Armonk, New York, USA), version 20 was used for statistical analyses. The level of significance was set at P < 0.05. All variables were tested for normality distribution using Shapiro–Wilk normality tests, and Levene’s test was used for test of variance. Differences in group means regarding knee function (Lysholm and KOOS) and fear of movement (TSK) were analyzed with parametric statistics. For KOOS, data was missing for one participant in each ACL group, and one participant in ACLR had a missing TSK score. Differences in group means regarding physical activity (IPAQ and Tegner) was analyzed with nonparametric statistics. IPAQ data was processed according to IPAQ’s guidelines (IPAQ scoring protocol; IPAQ Consensus Group 2005) and 11 questionnaires (four ACLR, five ACLPT, two controls) were excluded because of insufficient or “don’t know” responses. Independent t-tests were used to compared jump capacity between ACL-injured and controls. For within group comparisons, the jump capacity was analyzed using linear mixed models. Outcome variables were distance in m (one-leg hop), jump height in cm (vertical jump), and number of jumps (side hop). If a person could not perform any side hop, a zero value was assigned. Fixed factors considered in the models were leg (injured and noninjured), knee OA (no-or-low OA, K&L 0–1 and moderate-to-high OA, K&L2– 4). For the controls, leg dominance (dominant and nondominant) was considered as fixed factor. Both legs were included in the analysis for all participants. All two-way interactions were included in the first model and then all nonsignificant interactions were successively removed to a final model. “Participant” was included in the model as a random effect. For the vertical jump, one participant in ACLPT and one in the control group were excluded from the analysis because of problems with calculating the COM due to hidden markers. The LSI was calculated by dividing the result for the injured leg by that of the noninjured leg (for the controls nondominant by dominant leg) and multiplying by 100. Comparisons between those with no-or-low OA to those with moderate-to-high were made with independent t-tests for knee function (Lysholm and KOOS) and jump capacity (injured leg) while physical activity level were analyzed with Mann-Whitney U-tests. For correlations, we used Spearman’s correlation coefficient. To avoid mass significance for the correlations the alpha-value was divided by the number of comparisons (alpha/n) according to Bonferroni, resulting in P ≤ 0.0042 as significance level.

Results Physical activity and knee function Most patients were injured in sports and the ACL-injured had a significantly higher BMI compared with controls (Table 1). The ACL-injured had a lower knee-specific physical activity level according to the Tegner activity scale compared with controls (P < 0.001; Table 2). The IPAQ on the other hand showed similar general physical activity levels in all three groups. Both ACL groups showed a lower knee function compared with the controls (Lysholm score P < 0.001; and KOOS P < 0.001, Table 2). Jump capacity All participants could perform the one-leg hop and vertical jump, while for the side hops, this was true only for all controls. Six ACL-injured (1 ALCR and 5 ACLPT) could not perform even one approved side hop on the injured leg and two of them also failed on the noninjured leg. Jump capacity is reported in Table 3, while Table 4 displays the

Knee function 23 years after ACL injury Table 2. Self-reported knee function and fear of movement [mean (SD)] and physical activity [median (range)]. Comparisons to controls are reported

Group Mean (SD) Lysholm KOOS Pain Symptoms ADL Sport/Rec QoL TSK Median(range) Tegner before injury Tegner at present IPAQ total* IPAQ ass*

ACLR

ACLPT

Controls

ACLR-controls

ACLPT-controls

78 (18)

69 (17)

100

P < 0.001

P < 0.001

78 (18) 79 (20) 84 (16) 50 (28) 49 (22) 33 (7)

85 (16) 72 (19) 90 (15) 67 (29) 61 (25) 32 (7)

99 (1) 98 (2) 100 99 (2) 98 (3) N/A

P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.001 N/A

P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.001 N/A

N/A

N/A P = 0.001 NS NS

N/A P < 0.001 NS NS

9 (3–10) 4 (3–7) 1563 (480–7572) 2 (1–3)

9 (3–9) 4 (2–7) 1217 (212–7398) 2 (1–3)

6 (3–7) 1893 (499–8958) 2 (1–3)

Independent t-test for knee function and Mann-Whitney U-test for physical activity. *ACLR n = 29; ACLPT n = 32; controls n = 31. ACLPT, group treated with physiotherapy alone and controls are healthy-knee persons matched to the ACL-injured; ACLR, group treated with physiotherapy in combination with reconstructive surgery; ADL, activities of daily living; IPAQ, International Physical Activity Questionnaire; KOOS, Knee injury and Osteoarthritis Outcome Score; N/A, not applicable; QoL, knee-related quality of life; SD, standard deviation; TSK, Tampa Scale for Kinesiophobia. Table 3. Jump capacity are presented in mean (SD). Comparisons to controls are reported

Group Means (SD) One-leg hop (m) Hop length injured leg Hop length noninjured leg LSI one-leg hop (%) Vertical jump (cm)† Jump height injured leg Jump height noninjured leg LSI vertical jump (%) Side hop (number) Injured leg Noninjured leg LSI side hop (%)

ACLR

ACLPT

Controls*

ACLR-controls

ACLPT-controls

1.12 (0.27) 1.19 (0.26) 94 (11)

1.01 (0.28) 1.10 (0.29) 92 (13)

1.08 (0.22) 1.07 (0.24) 100 (9)

NS NS P = 0.024

NS NS P = 0.008

20.2 (0.7) 21.6 (0.7) 94 (2)

17.8 (0.8) 20.0 (0.8) 90 (3)

20.6 (0.7) 21.5 (0.7) 96 (2)

NS NS P = 0.002

P = 0.02 NS P < 0.001

13.6 (1.5) 16.0 (1.5) 83 (23)

9.4 (1.4) 13.3 (1.4) 75 (30)

17.9 (1.3) 19.2 (1.3) 93 (17)

P = 0.029 NS P = 0.017

P < 0.001 P = 0.003 P = 0.002

Independent t-test. *For controls, injured leg is comparable to nondominant leg. † ACLR n = 33; ACLPT n = 36; controls n = 32. ACLPT, group treated with physiotherapy alone and controls are healthy-knee persons matched to the ACL-injured; ACLR, group treated with physiotherapy in combination with reconstructive surgery; LSI, limb symmetry index; NS, not significant.

estimated mean values and the results of the statistical analysis. There were shorter one-leg hops, lower vertical jumps, and fewer side hops for the injured leg compared with the noninjured leg in both ACLR and ACLPT. There was no difference in jump capacity between those who had no-or-low OA compared with those who had moderate-to-high degree of OA (Tables 4 and 5). When comparing the jump capacity of the ACL-injured legs with that of controls, ACLR only had fewer side hops (P = 0.029), while the ACLPT had both fewer side hops (P < 0.001) and lower vertical jumps (P = 0.02, Table 3). When comparing the jump capacity of the noninjured leg of the ACL-injured to that of controls, there were no significant differences for one-leg hop or vertical jump. In contrast, the noninjured leg of ACLPT performed fewer

side hops compared with controls (P = 0.003, Table 3), while no difference was seen between ACLR and controls. Controls showed no differences in jump capacity between the legs in any of the jump tasks. If looking at the proportion of individual participants who displayed an LSI less than 90%, it ranged from 27.3% to 63.6% for ACLR and 43.2% to 76.0% for ACLPT while the range was 27.3% to 57.6% for controls, with the largest proportion in the side hop (Table 6). Fear of movement/reinjury and correlations with knee function ACLR had a total score of 33 ± 7 while ACLPT scored 32 ± 7 out of a maximum 68 on the TSK (Table 2). Fear of movement/reinjury was significantly negatively cor-

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Tengman et al. Table 4. The F-values and P-values from the model are presented together with the estimated marginal means (in m, cm, and n) and confidence interval (CI)

One-leg hop (m)

ACLR ACLPT

Vertical jump (cm)

ACLR ACLPT

Side hop (n)

ACLR ACLPT

Leg

OA*

Interactions

F = 9.4 P = 0.004 Injured 1.11 (1.01–1.21) Noninjured 1.17 (1.08–1.27) F = 12.5 P = 0.001 Injured 0.97 (0.88–1.05) Noninjured 1.07 (0.98–1.15) F = 7.6 P = 0.010 Injured 19.9 (18.4–21.4) Noninjured 21.3 (19.8–22.8) F = 19.7 P < 0.0001 Injured 17.1 (15.8–18.4) Noninjured 19.5 (18.2–20.8) F = 15.5 P < 0.0001 Injured 13.0 (10.0–16.0) Noninjured 15.3 (12.3–18.3) F = 26.8 P < 0.0001 Injured 8.3 (5.6–10.9) Noninjured 12.3 (9.7–15.0)

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

“Participant” was included in the model as a random effect and all models had a significant random effect of “participant.” *Bilaterally radiographic OA was used in the analysis. OA was graded according Kellgren & Lawrence (K&L) and divided into participants with no-or-low (KL 0–1) or moderate-to-high (KL 2–4) degree of OA. ACLPT, group treated with physiotherapy alone and controls are healthy-knee persons matched to the ACL-injured; ACLR, group treated with physiotherapy in combination with reconstructive surgery; NS, not significant; OA, osteoarthritis.

related to knee function for KOOS symptom (P = 0.004, r = − 0.297), Lysholm score (P = 0.004, r = − 0.344) and LSI of side hop (P = 0.016, r = − 0.298). OA in relation to physical activity, knee function and jump capacity The ACL-injured knees with no-or-low OA (K&L grade 0–1) had higher Lysholm and KOOS-s scores compared with those with moderate-to-high OA (K&L grade 2–4), whereas degree of OA had no influence on reported physical activity level or recorded jump capacity (Table 5). Discussion The present study addresses the physical activity level and knee function after more than 20 years post-ACL injury in two cohorts treated either with physiotherapy in combination with surgery, or physiotherapy alone. A randomized trial with regard to treatment at the time of interventions was not considered, why we chose not to make specific comparisons between the groups with ACL injury. The study is nevertheless a unique opportunity to investigate the functional status of the patients treated in the last decades of the 20th century, and provides proof of long-standing consequences after both types of treatment. Regardless of treatment, there are negative long-term consequences more than 20 years after an ACL injury when compared with age- and gender-matched controls. The fact that ACL-injured persons have a decreased

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knee-specific physical activity level while showing a similar general level of physical activity as controls, may indicate that they have chosen activities that pose less load on the knee joint. The ACL-injured persons were sports active prior to their injury (median Tegner of 9) and it is of course impossible to speculate on how active they would be today if they had not suffered an injury. Existing long-term studies on knee-specific physical activity 15 years or more post-injury report Tegner scores between 4 to 6 (Maletius & Messner, 1999; Drogset et al., 2006; Ageberg et al., 2007; Kostogiannis et al., 2007; Meunier et al., 2007; Neuman et al., 2008; Mihelic et al., 2011; Streich et al., 2011; Widuchowski et al., 2012; Gerhard et al., 2013; Stensbirk et al., 2013), which is in parity or slightly higher compared with our results. Studies on controls show a median level of Tegner activity score 5–6 in the age range of 30–60 years (Andersson-Molina et al., 2002; Briggs et al., 2009b), which is in parity compared with our controls. The Tegner activity scale is one of the most commonly used activity scales in ACL rehabilitation (Lysholm & Tegner, 2007), while estimates of a more general physical activity level are less common in studies after ACL injury. The Tegner activity scale, which has been proven to be valid and reliable, provides a reasonable measure of knee-related activity level (Briggs et al., 2009a). However, to reliably capture the general activity level in any population is a challenge (van Poppel et al., 2010). Nevertheless, attempts to quantify physical activity levels in rehabilitation are important as a decrease often leads to weight gain and many other negative health effects. Indeed, the ACL-injured in our study have a

81 (14) 88 (16) 85 (14) 93 (14) 71 (26) 64 (26) 1.05 (0.22) 95 (9) 17.9 (3.0) 92 (17) 10.7 (6.2) 75 (38) 3.5 (3–7) 1179 (594–5252) 2 (1–3)

84 (9)

82 (16) 84 (15) 91 (8) 56 (29) 53 (23)

1.11 (0.23) 95 (6)

20.0 (3.9) 99 (21)

12.8 (4.2) 84 (24)

5 (4–7) 2076 (876–5295) 2 (1–3)

4 (3–7) 1356 (594–5295) 2 (1–3)

11.5 (5.5) 78 (33)

18.7 (3.4) 95 (18)

1.07 (0.22) 95 (8)

86 (16) 85 (14) 92 (12) 65 (27) 60 (22)

82 (12)

4 (3–7) 2069 (480–7572) 2 (1–3)

13.7 (9.2) 83 (23)

20.2 (0.4) 92 (12)

1.12 (0.28) 94 (12)

79 (19) 78 (21) 83 (17) 48 (28) 48 (22)

76 (20)

4 (2–7) 1663 (212–7398) 2 (1–3)

8.7 (9.1) 74 (27)

17.7 (5.1) 88 (16)

0.98 (0.31) 91 (15)

83 (16) 66 (18) 89 (16) 63 (31) 59 (27)

63 (14)

ACLPT (n = 25)

4 (2–7) 1971 (212–7572) 2 (1–3)

11.3 (9.7) 78 (25)

19.0 (4.8) 91 (14)

1.05 (0.30) 92 (14)

81 (17) 72 (20) 86 (17) 56 (30) 54 (25)

70 (19)

Total (n = 51)

NS NS NS

NS NS

NS NS

NS NS

NS P = 0.005 NS NS NS

P = 0.002

Statistical significance

Self-reported knee function and jump capacity are presented in mean (SD) and comparisons analysed by independent t-test. Physical activity level are presented in median (range) and comparisons analyzed by Mann-Whitney U-test. *ACLR n = 29; ACLPT n = 32; controls n = 31. ACLPT, group treated with physiotherapy alone and controls are healthy-knee persons matched to the ACL-injured; ACLR, group treated with physiotherapy in combination with reconstructive surgery; ADL, activities of daily living; IPAQ, International Physical Activity Questionnaire; KOOS, Knee injury and Osteoarthritis Outcome Score; LSI, limb symmetry index; NS, not significant; OA, osteoarthritis; QoL,knee-related quality of life; SD, standard deviation; TSK, Tampa Scale for Kinesiophobia.

Mean (SD) Lysholm KOOS Pain Symptoms ADL Sport/Rec QoL One-leg hop Length (m) LSI Vertical Jump Height (cm) LSI Side hop Number LSI Median(range) Tegner IPAQ total* IPAQ ass*

ACLR (n = 26)

Total (n = 19)

ACLR (n = 7) ACLPT (n = 12)

Moderate-to-high OA

No-or-low OA

Table 5. Self-reported knee function, physical activity level, and jump capacity (injured leg) for those with no-or-low OA (Kellgren & Lawrence 0–1) and with moderate-to-high (Kellgren & Lawrence 2–4), respectively

Knee function 23 years after ACL injury

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Tengman et al. Table 6. Number and percent (%) of participants in the respective groups with a LSI less than 90%. For controls independent of dominance of leg

Group LSI < 90%

ACLR

ACLPT

Controls

One-leg hop Vertical jump Side hop LSI < 90% in all three jumps

9 (27.3%) 15 (45.5%) 21 (63.6%) 5 (15.2%)

16 (43.2%) 23 (59.5%) 28 (76.0%) 10 (27.0%)

9 (27.3%) 12 (36.4%) 19 (57.6%) 2 (6.1%)

ACLPT, group treated with physiotherapy alone and controls are healthyknee persons matched to the ACL-injured; ACLR, group treated with physiotherapy in combination with reconstructive surgery; LSI, limb symmetry index.

higher BMI compared with controls and also in relation to the general population of the same age in the same geographical region who have a BMI of 26.8 for men and 25.9 for women (see Norberg et al., 2010). Another long-term consequence was the reduced knee function where the ACL-injured had lower scores on Lysholm as well as KOOS compared with controls. Our knee-healthy control group all had the highest score on Lysholm while other reference data with similar aged controls show a median scores 100 (range 90–100; Andersson-Molina et al., 2002) and 94 (43–100; Briggs et al., 2009b). Our controls also had higher scores than other reference data regarding KOOS (von Porat et al., 2004). This is probably due to our exclusion criteria regarding no knee problems and hence the knee function of our control group may be better than expected of a true reference group. However, the knee function (Lysholm and KOOS) for ACL-injured in the present study were also lower than other long-term studies about 15 years post-injury for persons treated with ACL reconstruction (Drogset et al., 2006; Meunier et al., 2007; Hui et al., 2011; Widuchowski et al., 2012; Gerhard et al., 2013; Stensbirk et al., 2013) as well as for persons treated with physiotherapy alone (Ageberg et al., 2007; Kostogiannis et al., 2007; Meunier et al., 2007; Neuman et al., 2008; Streich et al., 2011). This indicate that knee function may decrease over even longer time perspective. Thus, still, after on average 23 years, the ACLinjured persons report symptoms and pain from the knee joint. This results in considerable negative effects on knee quality of life as well as sport and recreational activities. It was in these two subscales of KOOS where we observed the largest negative effects, which is also supported by others (von Porat et al., 2004; Meunier et al., 2007). Although the ACL-injured persons, to a large extent, displayed OA and experienced impaired knee function (Lysholm and KOOS) and lower knee-specific physical level, yet they had jump capacity close to our controls. This may reflect their rather high performance level as athletes prior to being limited by the injury. We

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matched the controls by age and gender, but it would have been desirable to match also to activity level, which was our intention, but it turned out to be too difficult, partly because of lack of adequate instruments to judge this well enough. Reference values from a control group are however desirable since there may be bilateral deficits following a unilateral ACL injury (Urbach & Awiszus, 2002). This may result in misleadingly high LSI values. Our participants with ACL injury on the other hand, had equal jump capacity in their noninjured leg compared with the matched controls, which contradicts a general jump capacity reduction in both legs. In the present study, three different types of jumps were chosen, which has been suggested to be more decisive for evaluation of functional performance (Gustavsson et al., 2006; Thomee et al., 2011). Both maximum jumps (e.g., vertical jump and one-leg hop) and hop tests that challenge endurance (e.g., side hop, triple jump, and stair hop) are recommend (Thomee et al., 2011). Studies that investigate jump capacity in the long term after ACL injury are few and have only tested the one-leg hop, showing that 8–35% of the subjects have an LSI less than 90% (Ageberg et al., 2007; Hui et al., 2011; Widuchowski et al., 2012; Gerhard et al., 2013; Stensbirk et al., 2013). For the one-leg hop and vertical jump, our data show relatively good mean LSI values for both ACL groups and good jump capacity compared with controls (Table 3). However, when exploring the individual LSIs, as many as 59% of the ACL-injured have a nonsufficient jump capacity with an LSI less than 90% (Table 6). Our data indicate lower LSI values compared with other long-term studies around 15–16 years post-injury, which may suggest that the side difference increases over an even longer time perspective. When exploring the endurance jump (side hop), an even larger side-to-side difference was seen and as many as 76% of the ACL-injured had an LSI less than 90% (Table 6). In addition, six of the ACL-injured could not perform even one approved side hop while all the controls could perform side hops and ACL-injured showed a clearly inferior performance to controls (Table 3). The side hop may be considered more challenging for the knee joint and therefore more discriminative than jumping for distance or height. Even for healthy controls, this jump is challenging as shown by the fact that 19 controls had an LSI < 90. The ACL-injured can manage reasonably well in some jumps but do less well in the more knee-demanding side hop. Many potential factors may influence jump capacity and knee function during a time period as long as 20 years or more after injury. In the long term after ACL injury, several studies have shown that knee OA is present in varying degrees (von Porat et al., 2004; Strand et al., 2005; Drogset et al., 2006; Meunier et al., 2007; Neuman et al., 2008; Mihelic et al., 2011; Widuchowski et al., 2012; Gerhard et al., 2013) including the present

Knee function 23 years after ACL injury study. This may be reflected by the lower Lysholm and KOOS symptom score for those with moderate-to-high OA compared with those with no-or-low OA. There was however no such distinction observed for physical activity level or jump capacity. Some long-term follow-up studies have reported no association between radiographic knee OA and knee function (e.g., IKDC, Lysholm; Strand et al., 2005; Neuman et al., 2008; Widuchowski et al., 2012) and physical activity (Tegner activity scale; Widuchowski et al., 2012). It is generally difficult in a long-term follow-up to entirely disentangle direct effects of ACL injury vs the contribution of OA, especially since those who display moderateto-high level of OA is often the larger part like in our study. Fear of reinjury may also influence the jump capacity and has been suggested as a plausible explanation for a reduction in physical activity, especially knee-specific challenges, and has been reported as a major cause for failure in returning to sport (Kvist et al., 2005; Ardern et al., 2011). Individuals who did not return to the same level of activity as before injury had a higher TSK score still 3–4 years after injury (Kvist et al., 2005). Our TSK values are even higher than those reported by Kvist et al. and correlations were found between TSK and the LSI for side hops. Side hop was the jump test with largest difference both between legs and compared with controls. This indicates that activities such as jumps may be influenced by fear of movement/reinjury. However, fear of movement/reinjury may not be the only reason for shorter jump distance or fewer side hops. Indeed, in a parallel paper, we report about 10% reduced knee strength in the injured leg compared with the noninjured leg in the same subjects (Tengman et al., 2014). A higher TSK was also correlated to lower score on Lysholm and KOOS symptom. Fear of movement may also be related to pain if present because of mainly knee OA. Our study reflects rehabilitation and ACL reconstructive surgical techniques of the 1980s and early 1990s and these

techniques have progressed since then. Many individuals have however been treated according to these methods, live with the outcome, and will grow old with their knee deficit, which might cause additional challenges. Perspectives Few studies have investigated knee function more than 20 years after an ACL injury and especially with regard to jump capacity. Our data show that regardless of treatment, there are negative long-term consequences after an ACL injury when compared with age- and gender-matched controls. ACL-injured individuals may manage reasonably well in some activities but have an inferior performance in more knee-demanding tasks and therefore choose activities that pose less loading on the knee joint. The decreased knee function, knee-related physical activity level and jump capacity may be associated with fear of movement also in the long-term perspective. Persons with moderate-to-high knee OA had similar physical activity level and jump capacity compared with those with no-orlow OA, while those with moderate-to-high OAhad lower scores on Lysholm and KOOS-symptom. Further studies on functional performance in a long-term perspective are needed as our data indicate that the side differences increase in a longer time perspective. Key words: limb symmetry index, cross-sectional design, jump, movement fear, International Physical Activity Questionnaire.

Acknowledgements The authors would like to acknowledge the funding support from the Swedish Scientific Research Council project nr K2008-70X-2084501-3, K2011-69X-21876-01-3, and CIF P2012-0008, Umeå University (Young Researcher Awardee C. Häger), Västerbotten County Council, Foundation for Medical Research at Umeå University and Ingabritt & Arne Lundbergs Research Foundation. We also thank Helena Grip for assistance in kinematic analysis and Monica Edström for assistance in the data collection.

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Anterior cruciate ligament injury after more than 20 years: I. Physical activity level and knee function.

Little is known about physical activity level and knee function including jump capacity and fear of movement/reinjury more than 20 years after injury ...
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