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Knee function, knee proprioception and related brain activity following anterior cruciate ligament injury
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0002-6715-6208
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 [en]
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: urn:nbn:se:umu:diva-174980ISBN: 978-91-7855-325-9 (electronic)ISBN: 978-91-7855-324-2 (print)OAI: oai:DiVA.org:umu-174980DiVA, id: diva2:1466909
Public defence
2020-10-09, Triple Helix, Samverkanshuset, Umeå, 13:00 (English)
Opponent
Supervisors
Note

Uppgift om ISBN för digitalt format saknas i publikationen.

Available from: 2020-09-18 Created: 2020-09-14 Last updated: 2020-09-22Bibliographically approved
List of papers
1. One-leg rise performance and associated knee kinematics in ACL-deficient and ACL-reconstructed persons 23 years post-injury
Open this publication in new window or tab >>One-leg rise performance and associated knee kinematics in ACL-deficient and ACL-reconstructed persons 23 years post-injury
2019 (English)In: BMC Musculoskeletal Disorders, E-ISSN 1471-2474, Vol. 20, no 1, article id 476Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Research indicates reduced knee function and stability decades after anterior cruciate ligament (ACL) injury. Assessment requires reliable functional tests that discriminate such outcomes from asymptomatic knees, while providing suitable loading for different populations. The One-leg rise (OLR) test is common in clinics and research but lacks scientific evidence for its implementation. Our cross-sectional study compared performance including knee kinematics of the OLR between ACL-injured persons in the very long term to controls and between legs within these groups, and assessed the within-session reliability of the kinematics.

METHODS: Seventy ACL-injured individuals (mean age 46.9 ± 5.4 years) treated with either reconstructive surgery and physiotherapy (ACLR; n = 33) or physiotherapy alone (ACLPT; n = 37), on average 23 years post-injury, and 33 age- and sex-matched controls (CTRL) attempted the OLR. Participants completed as many repetitions as possible to a maximum of 50 while recorded by motion capture. We compared between all groups and between legs within groups for total repetitions and decomposed the OLR into movement phases to compare phase completion times, maximum and range of knee abduction and adduction angles, and mediolateral knee control in up to 10 repetitions per participant.

RESULTS: ACLPT performed significantly fewer OLR repetitions with their injured leg compared to the CTRL non-dominant leg (medians 15 and 32, respectively) and showed significantly greater knee abduction than ACLR and CTRL (average 2.56°-3.69° depending on phase and leg). Distribution of repetitions differed between groups, revealing 59% of ACLPT unable to complete more than 20 repetitions on their injured leg compared to 33% ACLR and 36% CTRL for their injured and non-dominant leg, respectively. Within-session reliability of all kinematic variables for all groups and legs was high (ICC 3,10 0.97-1.00, 95% CI 0.95-1.00, SEM 0.93-1.95°).

CONCLUSIONS: Negative outcomes of OLR performance, particularly among ACLPT, confirm the need to address aberrant knee function and stability even decades post-ACL injury. Knee kinematics derived from the OLR were reliable for asymptomatic and ACL-injured knees. Development of the OLR protocol and analysis methods may improve its discriminative ability in identifying reduced knee function and stability among a range of clinical populations.

Keywords
Biomechanics, Clinical assessment, Knee control, Knee function, Knee injury, Lower limb, Motion analysis, Osteoarthritis
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-165230 (URN)10.1186/s12891-019-2887-3 (DOI)000492891600003 ()31653212 (PubMedID)2-s2.0-85074143871 (Scopus ID)
Available from: 2019-11-15 Created: 2019-11-15 Last updated: 2024-01-17Bibliographically approved
2. Psychometric properties of knee proprioception tests targeting healthy individuals and those with anterior cruciate ligament injury managed with or without reconstruction: a systematic review protocol
Open this publication in new window or tab >>Psychometric properties of knee proprioception tests targeting healthy individuals and those with anterior cruciate ligament injury managed with or without reconstruction: a systematic review protocol
Show others...
2019 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 9, no 4, article id e027241Article, review/survey (Refereed) Published
Abstract [en]

Introduction: An anterior cruciate ligament (ACL) injury affects knee proprioception and sensorimotor control and might contribute to an increased risk of a second ACL injury and secondary knee osteoarthritis. Therefore, there is a growing need for valid, reliable and responsive knee proprioception tests. No previous study has comprehensively reviewed all the relevant psychometric properties (PMPs) of these tests together. The aim of this review protocol is to narrate the steps involved in synthesising the evidence for the PMPs of specific knee proprioception tests among individuals with an ACL injury and knee-healthy controls.

Methods and analysis: The Preferred Reporting Items for Systematic reviews and Meta-Analyses will be followed to report the review. A combination of four conceptual groups of terms-(1) construct (knee proprioception), (2) target population (healthy individuals and those with an ACL injury managed conservatively or with a surgical reconstruction), (3) measurement instrument (specific knee proprioception tests) and (4) PMPs (reliability, validity and responsiveness)-will be used for electronic databases search. PubMed, AMED, CINAHL, SPORTDiscus, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials and ProQuest will be searched from their inception to November 2018. Two reviewers will independently screen titles, abstracts and full text articles, extract data and perform risk of bias assessment using the updated COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist for the eligible studies. A narrative synthesis of the findings and a meta-analysis will be attempted as appropriate. Each PMP of knee proprioception tests will be classified as 'sufficient', 'indeterminate' or 'insufficient'. The overall level of evidence will be ascertained using an established set of criteria.

Ethics and dissemination: Ethical approval or patient consent is not required for a systematic review. The review findings will be submitted as a series of manuscripts for peer-review and publication in scientific journals.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2019
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-161462 (URN)10.1136/bmjopen-2018-027241 (DOI)000471157200233 ()30948613 (PubMedID)2-s2.0-85063946520 (Scopus ID)
Funder
Swedish Research Council, K2014-99X-21876-04-4Västerbotten County Council, VLL548501
Available from: 2019-07-09 Created: 2019-07-09 Last updated: 2023-08-28Bibliographically approved
3. Properties of knee joint position sense tests after anterior cruciate ligament injury: A systematic review and meta-analysis
Open this publication in new window or tab >>Properties of knee joint position sense tests after anterior cruciate ligament injury: A systematic review and meta-analysis
Show others...
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
Keywords
proprioception, reliability, validity
National Category
Physiotherapy
Research subject
Physiotherapy; physiotherapy
Identifiers
urn:nbn:se:umu:diva-174977 (URN)10.1177/23259671211007878 (DOI)000691348300001 ()34350298 (PubMedID)2-s2.0-85109867193 (Scopus ID)
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
4. Development of supine and standing knee joint position sense tests
Open this publication in new window or tab >>Development of supine and standing knee joint position sense tests
2021 (English)In: Physical Therapy in Sport, ISSN 1466-853X, E-ISSN 1873-1600, Vol. 49, p. 112-121Article in journal (Other academic) Published
Abstract [en]

Objectives We aimed to assess the test-retest reliability of a supine and standing knee joint position sense (JPS) test, respectively, and whether they discriminate knees with anterior cruciate ligament (ACL) injury from asymptomatic knees. Design Repeated measures and cross-sectional. Setting Research laboratory. Participants For test-retest reliability, 24 persons with asymptomatic knees. For discriminative analysis: 1) ACLR - 18 persons on average 23 months after unilateral ACL reconstruction, 2) CTRL - 23 less-active persons, and 3) ATHL - 21 activity level-matched athletes. Main outcome measures Absolute error (AE) and variable error (VE). Results Test-retest reliability was generally highest for AE of the standing test (ICC 0.64–0.91). Errors were less for the standing compared to the supine test across groups. CTRL had greater knee JPS AE (P = 0.005) and VE (P = 0.040) than ACLR. ACLR knees showed greater VE compared to the contralateral non-injured knees for both tests (P = 0.032), albeit with a small effect size (ηp2 = 0.244). Conclusions: Our standing test was more reliable and elicited lesser errors than our supine test. Less-active controls, rather than ACLR, produced significantly greater errors. Activity level may be a more predominant factor than ACLR for knee JPS ∼2 years post-reconstruction.

Place, publisher, year, edition, pages
Elsevier, 2021
Keywords
Proprioception, Knee, Athletes, Reliability
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-174978 (URN)10.1016/j.ptsp.2021.02.010 (DOI)000640795700016 ()2-s2.0-85101784259 (Scopus ID)
Funder
Region Västerbotten, ALF VLL548501Region Västerbotten, VLL838421Region Västerbotten, VLL358901Konung Gustaf V:s och Drottning Victorias Frimurarestiftelse
Available from: 2020-09-14 Created: 2020-09-14 Last updated: 2023-09-05Bibliographically approved
5. Functional brain response during a knee proprioception test among individuals with anterior cruciate ligament reconstruction and controls
Open this publication in new window or tab >>Functional brain response during a knee proprioception test among individuals with anterior cruciate ligament reconstruction and controls
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-174979 (URN)
Available from: 2020-09-14 Created: 2020-09-14 Last updated: 2020-09-15

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