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Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Activity and Health.ORCID iD: 0000-0002-1793-2133
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Ryhov Cty Hosp, Sweden.ORCID iD: 0000-0002-3811-7381
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.ORCID iD: 0000-0002-1929-0605
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
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2018 (English)In: Knee Surgery, Sports Traumatology, Arthroscopy, ISSN 0942-2056, E-ISSN 1433-7347, Vol. 26, no 8, p. 2401-2409Article in journal (Refereed) Published
Abstract [en]

The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients, roles are in the treatment decision. A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients preferences. Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patients wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patients wishes as important for the decision to recommend ACL reconstruction. Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction. Diagnostic study: Level III.

Place, publisher, year, edition, pages
SPRINGER , 2018. Vol. 26, no 8, p. 2401-2409
Keywords [en]
Knee; Anterior cruciate ligament injury; Treatment decision; ACL reconstruction
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:liu:diva-150231DOI: 10.1007/s00167-018-4846-1ISI: 000439446600026PubMedID: 29411079OAI: oai:DiVA.org:liu-150231DiVA, id: diva2:1240733
Available from: 2018-08-22 Created: 2018-08-22 Last updated: 2019-11-04
In thesis
1. Treatment Decision after Anterior Cruciate Ligament Injury, and Evaluation of Measurement Properties of a Patient Reported Outcome Measure
Open this publication in new window or tab >>Treatment Decision after Anterior Cruciate Ligament Injury, and Evaluation of Measurement Properties of a Patient Reported Outcome Measure
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: After an ACL injury, treatment aims to restore knee function. Evaluation of treatment progress is important, and adequate measurement methods are necessary. The International Knee Documentation Committee- Subjective Knee Form (IKDC-SKF) is a common patient-reported outcome measure (PROM) used after ACL injury. It evaluates symptoms, function and physical activity. The IKDC-SKF had not been translated to Swedish language for use in Swedish clinical and research settings. The measurement properties of the IKDC-SKF had been tested, but no assessment of methodological quality of the studies investigating it, nor compiling of results, was published.

Sooner or later after an ACL injury, a treatment decision must be made. Treatment options are either ACL reconstruction (ACLR) plus rehabilitation, or rehabilitation alone. There are guidelines stating that a decision for ACLR should be made if the patient has high activity demands and/or knee instability. It is unclear which factors orthopaedic surgeons and physiotherapists prioritise when recommending ACLR. It is also unclear when the decision for treatment is taken, on what grounds, and how treatment decision correlates to patients reported symptoms and function.

Aims: The overall aim of this thesis was to evaluate the measurement properties of a patient-reported measure for evaluation of function after ACL injury and treatment, and to overview the treatment decision process after an ACL injury.

Methods: A systematic review was conducted to assess the measurement properties of the IKDC-SKF. The IKDC-SKF was translated from English to Swedish, and the Swedish version was tested for reliability, validity, responsiveness and interpretability.

A survey study was conducted, where 98 orthopaedic surgeons and 391 physiotherapists rated 21 predefined factors based on importance to the decision for ACLR. Orthopadic surgeons and physiotherapists rated how important they considered their own, their counterparts’ and patient’s wishes for treatment decision making.

In a prospective cohort study, patients with an ACL injury were followed from within 6 weeks up to 12 months after injury. Data regarding treatment chosen, when and why, 11were described and compared to patient-reported pre-injury activity level, instability and function.

Results:

The English and Swedish version of the IKDC-SKF had good measurement properties and interpretability.

Swedish orthopaedic surgeons and physiotherapists considered young age, high activity demands, knee-demanding occupation, and knee instability despite adequate rehabilitation indications to recommend ACLR.

An early decision for ACLR was primarily based on high activity demands. A later decision was mainly due to instability and high activity demands. A decision taken later than five months after injury was based mainly on instability.

A decision for non-operative treatment taken and maintained during the first 12 months after injury was mainly due to sufficient function or no instability problems, and patients were older than other groups.

Conclusions:

The patient-reported outcome measurement IKDC-SKF was suitable for evaluation and assessment in patients with ACL injury.

ACLR as treatment after an ACL injury was recommended for young patients and/or those with high activity demands (i.e. knee demanding occupation and/or instability despite adequate rehabilitation).

An early decision for ACLR was more often based on high activity demands, while later decisions were more often based upon perceived instability. Non-operative treatment decisions were often based upon lack of instability problems or sufficient knee function.

Self-reported instability and function during the first three months after ACL injury were no different in patients who chose ACLR treatment or who chose non-operative treatment.

Abstract [sv]

Bakgrund: Efter en främre korsbandsskada syftar behandlingen att återställa knäfunktionen. Utvärdering av framstegen är av vikt, och adekvata mätmetoder för detta är nödvändigt. International Knee Documentation Committtee Subjective Knee Form (IKDC-SKF) är ett patientskattningsformulär som är välanvänt över hela världen vid främre korsbandsskador. Det utvärderar symptom, funktion och fysisk aktivitet. Det har inte funnits tillgängligt på svenska tidigare och det har heller inte funnits någon sammanställning över formulärets mätegenskaper.

Efter en främre korsbandsskada måste förr eller senare beslut om behandling fattas, om patienten ska genomgå en rekonstruktionsoperation för främre korsbandet, med efterföljande rehabilitering, eller enbart rehabilitering. Det finns riktlinjer som gör gällande att en korsbandsrekonstruktion kan vara ett adekvat alternativ när patienten har höga aktivitetskrav eller lider av instabilitet i knäleden. Det är dock ej fastställt vilka faktorer ortopedläkare och fysioterapeuter anser viktiga för att rekommendera rekonstruktionsoperation. Det är inte heller klargjort när efter skada och på vilka grunder faktiska behandlingsbeslut fattas, och hur orsaken till beslutet hänger samman med patientens självrapporterade symptom och funktion.

Syfte: Det övergripande syftet med avhandlingen var att utvärdera mätegenskaper för ett patientskattningsformulär som utvärderar funktion efter en främre korsbandsskada, samt att överblicka beslutsprocessen för behandling efter en främre korsbandsskada.

Metod: En systematisk genomgång utfördes av studier som utvärderat mätegenskaper för IKDC-SKF. Studierna värderades avseende metodologi och resultat. IKDC-SKF översattes till svenska, och den svenska versionens mätegenskaper prövades.

En enkätstudie utfördes där 98 svenska ortopedläkare och 391 svenska fysioterapeuter fick skatta 21 faktorers betydelse för valet att rekommendera rekonstruktionsoperation av främre korsbandet. Ortopedläkare och fysioterapeuter fick även skatta vikten av sin egen och motpartens bedömning samt patientens önskan, i valet av behandling.

I en prospektiv kohortstudie följdes 219 patienter med en främre korsbandsskada, från 6 veckor och upp till 12 månader efter skadan. Data om vilken behandling patienten genomgått, när behandling valdes och grunder för behandling samlades in från patient och ortopedläkare och jämfördes med patientskattad aktivitetsnivå innan skada, instabilitet och funktion.

Resultat: Den systematiska genomgången av IKDC-SKF och prövningen av den svenska versionens mätegenskaper visade att IKDC-SKF uppvisar goda mätegenskaper och går att tolka i kliniken?

Svenska ortopedläkare och fysioterapeuter anser att ung ålder, höga aktivitetskrav, knäkrävande arbete och instabilitet trots adekvat rehabilitering är faktorer som indicerar behov av rekonstruktionsoperation av främre korsbandet. 

Ett tidigt beslut för rekonstruktionsoperation efter främre korsbandsskada fattas i hög grad på grund av höga aktivitetskrav, och dessa patienter har även högre aktivitetsnivå innan skada. Ett senare beslut för rekonstruktionsoperation fattas i hög grad på grund av instabilitet och höga aktivitetskrav, medan ett sent beslut fattas i hög grad på grund av instabilitet. Ett beslut att enbart behandla med rehabilitering fattas i hög grad på grund av att patienten har tillräckligt god funktion eller inte har några besvär från instabilitet. Det var inga skillnader i patientskattad funktion och instabilitet mellan de patienter där rekonstruktionsoperation valdes och de som valde att behandla med enbart rehabilitering.

Sammanfattning: IKDC-SKF visar goda mätegenskaper och kan rekommenderas för användning hos patienter med en främre korsbandsskada och andra knärelaterade diagnoser.

Efter en främre korsbandsskada fattas ett tidigt beslut för rekonstruktionsoperation på grund av höga aktivitetskrav. Ett senare beslut för rekonstruktionsoperation fattas när patienten lider av instabilitet och nedsatt knäfunktion, medan ett beslut för enbart rehabilitering valdes när funktion och knästabilitet var god. Det var inga skillnader mellan patienter där man valt rekonstruktionsoperation och enbart rehabilitering, avseende skattad funktion och instabilitet. Både ortopedläkarens och fysioterapeutens bedömning samt patientens önskan är viktig i valet av behandling.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. p. 93
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1706
Keywords
anterior cruciate ligament injury, ACL, ACL reconstruction, ACLR, choice of treatment, IKDC, measurement properties, evaluation
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-160918 (URN)10.3384/diss.diva-160918 (DOI)9789179299903 (ISBN)
Public defence
2019-11-29, Berzeliussalen, Hus 463, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-11-04 Created: 2019-10-14 Last updated: 2020-01-08Bibliographically approved

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