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Free papers #5

Ready for sport?

Chair: Caroline Bolling

#27 - Return-to-play following acute lateral ankle sprains – A consensus approach to develop a modular test battery

Presenting Author: Hendrik Bloch

Authors & Affiliations: Hendrik Bloch(1), Christian Klein(1), Patrick Luig(2)
(1)   VBG (German Statutory Accident Insurance for the Administrative Sector), Department for Sports Injury Prevention, Hamburg, Germany
(1)    DHB (German Handball Federation), Dortmund

Background: Ankle injuries represent one of the most common injuries in German elite team sports and have a high risk for re-injury. In German elite basketball, ankle injuries are most frequent (18.6 %), while in handball (13.6 %) and football (12.5 %) they occur the second and third most. In the season 2016/17, ankle injuries lead to medical treatment costs of 1.2 million Euro, while the overall burden was 11.000 days of time loss. Once an ankle sprain occurs, up to 80 % will suffer recurrent sprains. However, until now standardized return-to-play guidelines are missing.

Objective(s): In collaboration with the Federal Institute of Sports Science (BISp), the VBG initialized a consensus conference “Return-to-play after ankle sprains”. Therefore, relevant German research groups and accredited experts from German elite team sports such as physicians, physiotherapists, rehab and strength and conditioning coaches were invited. The superordinate aim was to issue a consensus-based test battery.

Design & Methods: Forty attendees followed the invitation to the conference. After an initial discussion of three different “Best-Practice” return-to-play concepts, the expert panel identified conceptual overlaps and commonalities. Furthermore, the group debated superordinate test categories and appropriate tests focusing on the minimal requirements at the return-to-play milestone. Return to play refers to the successful transition from individualized and restricted team training to unrestricted participation in team and competition training. The VBG defined this milestone as the end of short-term disability for work. The aim was to reflect the heterogeneous infrastructures and capacities that are given in real-world sports rehabilitation settings, thereby facilitating the implementation and increasing adherence. Finally, based on the results of the consensus conference and with additional input of the authors, a test manual, describing setup, execution and interpretation of each single test, was generated.

Results: Minimal requirements for six test categories were defined as follows: 

  1. Clinical examination consisting of aspects of pain and swelling, range of motion, skin temperature, clinical tests, muscular activation and persisting instability

  2. Patient related outcomes consisting of the Cumberland Ankle Instability Tool, the Injury-Psychological Readiness to Return to Sport Scale and the Foot and Ankle Disability Index Sport Items

  3. Postural control consisting of the modified Star-Excursion-Balance-Test

  4. Strength consisting of the heel-rise-test and single-leg-squat

  5. Hop tests consisting of the single leg drop jump, figure-of-8-hop and side hop

  6. Change of direction speed consisting of the modified T-test

Conclusions:The return-to-play milestone is of utmost importance as players then progress to unrestricted team training. Therefore, a comprehensive test battery could support physicians to determine the right moment of return-to-play. To evaluate the validity and practicability, in the next project phase the test battery will be implemented multicentrically into real world sports rehabilitation settings.


#28 - Assessment of Patient-Reported Outcomes at Return to Sport Following Lateral Ankle Sprain Injuries: A Report from the Athletic Training Practice-Based Research Network

Presenting Author: Kenneth Lam

Authors & Affiliations: Kenneth C. Lam(1), Ashley Marshall(1)
(1)   Still University, Mesa, AZ

Background: Historically, lateral ankle sprains (LAS) have been characterized as minor injuries, with most athletes returning to sport within seven days after injury. Current best practices advocate for the development of a criteria-based return to sport decision paradigm for LAS injuries, including the use of patient-reported outcomes to assess the patient’s perspective. Single-item patient-reported outcome measures offer a quick and effective way of evaluating the patient’s perspective on all levels of disablement. However, there is limited evidence regarding the assessment of single-item patient-reported outcomes when patients are medically cleared to return to sport (RTS) following a LAS injury.

Objective(s): The purpose of this study was to evaluate self-report of pain (Numeric Pain Rating Scale [NPRS]), function (Global Rating of Function [GROF]), improvement (Global Rating of Change [GROC]), and disablement (Global Rating of Disability [GROD]) at RTS following an LAS injury.

Design & Methods: This was a retrospective review of electronic patient records. Records were created by 119 athletic trainers working in 69 facilities (58 secondary schools, 10 universities, 1 clinic) between 2009-2018. Patients who were diagnosed with a LAS, restricted from sport following injury, and subsequently medically cleared to RTS were included. Descriptive statistics (percentages, frequencies, mean±standard deviation, interquartile range [IQR]) were used to summarize variables as appropriate. Variables included patient demographics, sport, number of days to RTS, number of episodes of care (EOC), and self-reported outcomes at RTS including pain (NRPS=0-10 points), function (GROF=0-100%), improvement (GROC=15-point Likert-scale) and disability (GROD=7-point Likert-scale).

Results: Two hundred thirty-four patients (male=56.4%, age=16.4±2.0 years, height=172.4±12.5 cm, mass=71.4±17.5 kg) were included in the study. Most LAS occurred during basketball (n=65/234, 27.8%), football (n=63/234, 26.9%), or soccer (n=41/234, 17.5%). On average, patients RTS in 8.1±10.2 days (IQR=1-12) and had 2.9±3.3 EOC (IQR=1.0-3.0). At RTS, a majority of patients (n=180/234, 76.9%) reported some level of pain (NPRS=2.0±1.8, IQR=1.0-3.0). Most patients (n=206/234, 88.0%) also reported functional deficits (GROF=86.7±12.9%, IQR=80.0-95.0). Although a majority of patients (n=199/234, 85.0%) reported some level of improvement since injury (GROC>+1), almost half of patients (n=100/234, 42.7%) reported some level of disablement (GROD>0) at RTS.

Conclusions: Despite self-perceived improvements, patients typically RTS with some level of deficits in pain, function, and disablement following a LAS injury. Clinicians should consider the use of patient-reported outcomes aid in RTS decisions. Future research should determine if deficits predispose patient to recurrent injuries, chronic conditions, and/or decreased quality of life.


#29 - criteria-based return to sport decision-making following lateral ankle sprain injury: a systematic review and narrative synthesis

Presenting Author: Bruno Tassignon

Authors & Affiliations: Bruno Tassignon(1), Jo Verschueren(1), Eamonn Delahunt(2,3), Michelle Smith(4), Bill Vicenzino(4), Evert Verhagen(5), Romain Meeusen(1)

(1)   Faculty of Physical Education and Physiotherapy, Human Physiology Research Group, Vrije Universiteit Brussel, Brussels, Belgium
(2)    School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
(3)    Institute for Sport and Health, University College Dublin, Dublin, Ireland
(4)    Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Queensland, Australia
(5)   Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam UMC, Amsterdam, The Netherlands

Background: Lateral ankle sprain (LAS) injury is one of the most frequently incurred musculoskeletal injuries and shows high recurrence rates in individuals participating in sports. This high recurrence rate is hypothesised to be mainly caused by an increased re-injury risk due to previous LAS injury, the persistence of sensorimotor impairments and premature return to sport (RTS) clearance. Therefore, it is indicated to develop and implement evidence-based criteria to guide RTS decisions for individuals with LAS injury.

Objective(s): The aim of this systematic review was to identify prospective studies that used a criteria-based RTS decision-making process for patients with LAS injury.

Design & Methods: The PubMed (MEDLINE), Web of Science, PEDro, Cochrane Library, SPORTDiscus (EBSCO), ScienceDirect, and Scopus databases were searched till 23 November 2018. Studies were included if they prospectively applied a criteria-based RTS decision-making process for patients with LAS injury. Studies were excluded if they merely gathered outcome measures at the RTS time-point. Studies were also excluded if patients were recovering from ankle fracture, high ankle sprain, medial ankle sprain, chronic ankle instability or complex ankle injury.

Results: No studies were identified that used a criteria-based RTS decision-making process for patients with LAS injury. We were unable to conduct a quantitative synthesis or meta-analysis, so we provided a narrative synthesis of 47 relevant questionnaires, as well as 45 clinical and functional assessments commonly used in studies retrieved in the search.

Conclusions: There are currently no evidence-based RTS criteria for patients with an LAS. Future research should aim to reach consensus on RTS variables and apply these within prospective studies. Furthermore, we suggest that complex systems theory and the RTS continuum could be used to develop an RTS decision-making paradigm following LAS.


#30 - Return to Sports Activity After Surgical Treatment of Osteochondral Defects of the Talus: A Systematic Review

Presenting Author: Jari Dahmen

Authors & Affiliations: Jari Dahmen(1,2,3), J Steman(1,2,3), Kay Lambers(1,2,3), Gino Kerkhoffs(1,2,3)

(1)   Amsterdam UMC, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands
(2)    Academic Center for Evidence based Sports medicine (ACES)
(3)    Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center Amsterdam UMC

Background: Osteochondral defects (OCD) of the talus are found subsequent to ankle sprains and fractures. Despite many surgical treatment strategies being available, there is no clear evidence on return to sports (RTS) times and rates.

Objective(s): The objective of this systematic review is to summarize return to sports (RTS) times and rates for talar OCDs treated by different surgical modalities.

Design & Methods: A literature search was performed to identify studies published from January 1996 to November 2018 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors independently screened the search results. First, studies were divided into different treatment groups. Next, RTS rates with and without associated levels of pre-injury activity, as well as mean time to RTS were calculated per study. Where possible, a simplified pooling method was performed to combine studies within one treatment group with same methodological nature.

Results: 62 studies with 2355 talar OCDs were included of which 24 were prospective (4 randomized controlled trials) and 38 retrospective. Mean RTS times ranged from 13 to 26 weeks, though no simplified pooling method was possible. Regardless of levels of sport, the mean pooled RTS rate was 88% [CI 84-91%] for bone marrow stimulation (BMS), 97% [CI 85-99%] for fixation, 90% [CI 86-94%] for autograft transplantation, and 87% [CI 73-94%] for autologous chondrocyte implantation (ACI). Pooled RTS at pre-injury level was 78% [CI 70-85%] after BMS, 72% [CI 60-83%] after autograft transplantation and 69% [CI 54-81%] after ACI.

Conclusions: The surgical treatment options yielded adequate RTS times and rates. Rates decreased when considering return to pre-injury level. These outcomes can be utilized when informing patients about the recovery process and prognosis of the treatment. Future research should aim towards assessing superiority concerning sports outcomes for talar OCD surgery.


#31 - 30 years of ankle sprain RCTs: Exploring the risk of false positive conclusions

Presenting Author: Chris Bleakley

Authors & Affiliations: Chris Bleakley(1,2), J Reijgers(1), James Smoliga(1)
(1)   Department of Physical Therapy, Congdon School of Health Science, High Point University, North Carolina, USA
(2)    School of Health Science, Ulster University, County Antrim, Northern Ireland

Background: Randomized controlled trials (RCT) commonly use null hypothesis significance testing (NHST) to determine if a treatment is effective or not. Recently, it has been suggested that up to 90% of scientific claims are actually false. There is a particular concern that many false positive claims are caused by the misuse of NHST and misinterpretation of p-values. Although the volume of randomized controlled trials (RCT) in lateral ankle sprain (LAS) and chronic ankle instability (CAI) research continues to increase, the risk of false discovery in this field is unclear.

Objective(s): To examine the validity of positive claims of treatment effectiveness made in RCTs involving participants with LAS or CAI. Validity was determined by examining: a priori trial registration, false positive risk, effect size magnitude and its context with measurement error data and minimal clinically important difference (MCID).

Design & Methods: Electronic searching (MEDLINE; PEDro) was supplemented with citation tracking of a recent meta-evaluation. Eligibility criteria were: RCTs of conservative treatments for LAS or CAI participants reporting clinical outcomes. We excluded studies with >2 treatment arms, equivalence/non-inferiority and pilot studies. No restrictions were placed on injury severity, participant demographics or follow up duration. Eligible studies were screened to determine: a priori registration; proportion of between group comparisons resulting in statistical significance (p<0.05), false positive risk (FPR) (assuming a prior probability of 50:50), and the ratio between reported mean differences (MD) and corresponding data on minimal detectable change (MDC) and MCID.

Results: 1027 titles were screened with n=74 RCTs included. 23% of RCTs were classed as null, with the remaining 77% reporting statistically significant findings from at least one outcome measure. Only 19% of studies were prospectively registered. Unregistered studies were more likely to report statistical significance (OR 1.7 CIs 1.2-2.4; p=.004). The median FPR calculated for primary outcomes was 14% (range 0.6-100%) and only 27% of studies (10/39) had FPR <5%. Only 9% of trials made reference to MDC or MCID when making conclusions. We estimated that MD scores exceeded MDC or MCID in 52% and 29% of trials respectively.

Conclusions: There is a high risk of false discovery in this field of research. 77% of trials reported statistically significant findings but few were prospectively registered. The majority of statistically significant findings were associated with FPR >10%. The magnitude of observed effects were rarely compared to MCID or MDC data.