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Properties of knee joint position sense tests after anterior cruciate ligament injury: A systematic review and meta-analysis
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0002-6715-6208
Department of Physiotherapy, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates.ORCID iD: 0000-0001-5795-3812
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
Department of Health, Learning and Technology, Physiotherapy Section, Luleå University of Technology, Luleå, Sweden.ORCID iD: 0000-0003-3901-0364
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2021 (English)In: The Orthopaedic Journal of Sports Medicine, ISSN 2325-9671, Vol. 9, no 8, article id 23259671211007878Article, review/survey (Refereed) Published
Abstract [en]

Background: Knee proprioception is believed to be deficient after anterior cruciate ligament (ACL) injury. Tests of joint position sense (JPS) are commonly used to assess knee proprioception, but their psychometric properties (PMPs) are largely unknown.

Purpose: To evaluate the PMPs (reliability, validity, and responsiveness) of existing knee JPS tests targeting individuals with ACL injury.

Study design: Systematic review; Level of evidence, 4.

Methods: PubMed, Allied and Complementary Medicine, CINAHL, SPORTDiscus, Web of Science, Scopus, CENTRAL, and ProQuest databases were searched to identify studies that assessed PMPs of knee JPS tests in individuals with ACL injury. The risk of bias for each included study was assessed and rated at the outcome level for each knee JPS test. Overall quality and levels of evidence for each PMP were rated according to established criteria. Meta-analyses with mean differences were conducted using random effects models when adequate data were available.

Results: Included were 80 studies covering 119 versions of knee JPS tests. Meta-analyses indicated sufficient quality for known-groups and discriminative validity (ACL-injured knees vs knees of asymptomatic controls and contralateral noninjured knees, respectively), owing to significantly greater absolute errors for ACL-injured knees based on a strong level of evidence. A meta-analysis showed insufficient quality for responsiveness, which was attributed to a lack of significant change over time after diverse interventions with a moderate level of evidence. Statistical heterogeneity (I 2 > 40%) was evident in the majority of meta-analyses. All remaining PMPs (reliability, measurement error, criterion validity, convergent validity, and other PMPs related to responsiveness) were assessed qualitatively, and they failed to achieve a sufficient quality rating. This was a result of either the study outcomes not agreeing with the statistical cutoff values/hypotheses or the level of evidence being rated as conflicting/unknown or based on only a single study.

Conclusion: Knee JPS tests appear to have sufficient validity in differentiating ACL-injured knees from asymptomatic knees. Further evidence of high methodologic quality is required to ascertain the reliability, responsiveness, and other types of validity assessed here. We recommend investigations that compare the modifiable methodologic components of knee JPS tests on their PMPs to develop standardized evidence-based tests.

Place, publisher, year, edition, pages
Sage Publications, 2021. Vol. 9, no 8, article id 23259671211007878
Keywords [en]
proprioception, reliability, validity
National Category
Physiotherapy
Research subject
Physiotherapy; physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-174977DOI: 10.1177/23259671211007878ISI: 000691348300001PubMedID: 34350298Scopus ID: 2-s2.0-85109867193OAI: oai:DiVA.org:umu-174977DiVA, id: diva2:1466800
Funder
Swedish National Centre for Research in Sports, P2019-0068Swedish Research Council, 2017-00892Region Västerbotten, 7003575Region Västerbotten, VLL-838421Region Västerbotten, VLL-358901Region Västerbotten, 7002795
Note

Originally included in thesis in manuscript form with title "Properties of knee joint position sense tests after anterior cruciate ligament injury: A systematic review and meta-analysis".

Available from: 2020-09-14 Created: 2020-09-14 Last updated: 2022-01-13Bibliographically approved
In thesis
1. Knee function, knee proprioception and related brain activity following anterior cruciate ligament injury
Open this publication in new window or tab >>Knee function, knee proprioception and related brain activity following anterior cruciate ligament injury
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Injury of the anterior cruciate ligament (ACL) may have negative effects on the short- and long-term function and proprioception of the knee joint. However, existing tests of knee function are often sports-related and less relevant for assessment in the very long term and there remains no ‘gold standard’ test of knee proprioception. A growing body of research also suggests neuroplasticity post-ACL injury, but brain response to lower limb proprioception tasks is not established and nor is the potentially related impact of ACL injury. Developing standardised, reliable and valid tests of knee function and proprioception including brain imaging may target rehabilitation interventions more efficiently.

Methods: Paper I assesses knee function ~23 years after ACL injury. One ACL-injured group treated with physiotherapy only (ACLD) and one with additional reconstruction (ACLR) were compared to asymptomatic controls for performance and knee kinematics of the One-leg rise (OLR) test. Paper II is a published protocol for Paper III, which is a systematic review and meta-analysis of the psychometric properties (PMPs) of knee joint position sense (JPS) tests among individuals with ACL injury. Paper IV describes the development of one weight-bearing (WB) and one non-weight-bearing (NWB) knee JPS test using motion capture. Test-retest reliability is assessed and errors are compared between an active ACLR group (~23 months after reconstruction) and two asymptomatic groups of different activity levels. Paper V characterises brain response to a knee JPS test using simultaneous functional magnetic resonance imaging and motion capture among individuals ~2 years after ACL reconstruction and controls.

Results: ACLD performed significantly fewer repetitions of the OLR with both legs compared to controls and displayed significantly greater knee abduction than ACLR and controls. Meta-analyses found sufficient validity for existing knee JPS tests, particularly those of passive movements, by showing that ACL-injured knees produce significantly greater absolute errors than contralateral asymptomatic knees and those of controls. However, the tests were found not to be responsiveness to intervention and the remaining PMPs, such as reliability, require more evidence to better determine their quality. The novel knee JPS tests of paper IV showed mixed reliability but were better for the WB compared to the NWB test and when absolute rather than variable error was the outcome measure. Post-hoc comparisons revealed significantly greater errors for less-active controls compared to the ACLR group. For Paper V, the knee JPS test recruited brain regions such as the parietal cortex, precentral gyrus and insula. Greater knee JPS errors were correlated with greater activation in the insula, as well as the anterior and middle cingula. The ACLR group showed significantly greater response compared to controls for mainly the precuneus, but only at the uncorrected level.

Conclusions: Knee function may be negatively affected more than two decades after ACL injury based on performance and knee kinematics of the OLR test, which offers a clinician-friendly assessment tool of lower limb function but requires further investigation. Existing knee JPS tests seem to discriminate ACL-injured from asymptomatic knees. Passive tests produce greater differences, but current methods are diverse and often poorly reported, complicating recommendation of specific tests for research or clinics. The novel WB and NWB knee JPS tests should be developed for improved reliability, but their outcomes demonstrate the importance of considering activity level when comparing knee JPS between groups, which is rarely done. Brain regions recruited during our knee JPS test have previously been associated with, e.g. sensorimotor processes, interoception and body schema, confirming proprioceptive demands of the task. Correlations between knee JPS errors and response in the insula and cingula suggest they have an important role during such tasks. Subtle differences in brain response between ACLR and CTRL warrant further investigation.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2020. p. 90
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2093
Keywords
anterior cruciate ligament, knee, proprioception, joint position sense, kinematics, injury prevention, sports, functional magnetic resonance imaging, brain, reliability, validity
National Category
Physiotherapy
Research subject
Physiotherapy; Sports Medicine; Rehabilitation Medicine
Identifiers
urn:nbn:se:umu:diva-174980 (URN)978-91-7855-325-9 (ISBN)978-91-7855-324-2 (ISBN)
Public defence
2020-10-09, Triple Helix, Samverkanshuset, Umeå, 13:00 (English)
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Uppgift om ISBN för digitalt format saknas i publikationen.

Available from: 2020-09-18 Created: 2020-09-14 Last updated: 2020-09-22Bibliographically approved

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Strong, AndrewTengman, EvaHäger, Charlotte K.

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