TESTER VID ÅTERGÅNG TILL FOTBOLL EFTER SKADA FOKUS FRÄMRE KORSBANDSSKADA VAD VET VI OM TESTER? VAD SÄGER VETENSKAPEN? THE GOTHENBURG PERSPECTIVE? ERIC HAMRIN SENORSKI, P.T., PH.D. STUDENT DEPARTMENT OF HEALTH AND REHABILITATION, INSTITUTE OF NEUROSCIENCE AND PHYSIOLOGY, UNIVERSITY OF GOTHENBURG ERIC.HAMRIN.SENORSKI@GU.SE Evidens-baserad medicin Evidens-baserad medicin Bästa tillgängliga vetenskapen Klinisk erfarenhet Patientens perspektiv 1
RETURN TO SPORT - JÄMFÖRELSE Evidens-baserad medicin 100 90 80 70 Bästa tillgängliga vetenskapen Klinisk erfarenhet Patientens perspektiv 60 50 40 30 20 10 0 Åter till idrott Åter till tidigare idrott Åter till tävling Primär Revision Elit Barn&Ungdom Ardern CL, Taylor NF, Feller JA, et al. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-52. Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, et al. After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med. 2015;49(20):1295-304. Lai CC, Ardern CL, Feller JA, Webster KE (2017) Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med. Kay J, Memon M, Marx RG, Peterson D, Simunovic N, Ayeni OR. Over 90 % of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2018. OLIKA NIVÅER AV ÅTERGÅNG TILL IDROTT NÄR SKER RE-RUPTURER? Success means different things to different people and is context-dependent and outcome-dependent. 50 % inom 100 dagar efter återgång till idrott NÄR ÄR DU NÖJD? Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British journal of sports medicine. 2016. Kyritsis P, Bahr R, Landreau P, et al. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British journal of sports medicine. 2016;50(15):946-51. 2
NÄR SKER RE-RUPTURER? ÄR BÄTTRE REHAB LÖSNINGEN? 70 % inom 200 dagar efter återgång till idrott For every month that return to sport was delayed, until 9 months after ACL reconstruction, the rate of knee re-injury was reduced by 51%. More symmetrical quadriceps strength prior to return to sport significantly reduced the knee re-injury rate. Kyritsis P, Bahr R, Landreau P, et al. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British journal of sports medicine. 2016;50(15):946-51. Grindem H, Snyder-Mackler L, Moksnes H, et al. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine. 2016. ÄR BÄTTRE REHAB LÖSNINGEN? Patients who passed the RTS criteria showed a not statistically significant 84% lower reinjury rate (HR 0.16 (95% CI 0.02 to 1.20, p=0.075)) ÄR BÄTTRE REHAB LÖSNINGEN? Meeting six specific objective discharge criteria before return to sport after ACL reconstruction rehabilitation was associated with approximately one-quarter the risk of ACL graft rupture. Grindem H, Snyder-Mackler L, Moksnes H, et al. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine. 2016. Kyritsis P, Bahr R, Landreau P, et al. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British journal of sports medicine. 2016;50(15):946-51. 3
PROJEKT KORSBAND? GÖTEBORG OCH PROJEKT KORSBAND Rehabilitation Outcome Registry PROM s Test of muscle function Physical Therapy Clinics Rehabilitation National Knee Ligament Register Surgical factors STATISTIK PÅ HEMSIDAN FÖR KLINIKER FILTER MEDEL FÖRDELNING 4
STATISTIK - FÖRDELNING TESTER PROJEKT KORSBAND MEDEL EXTENSION&FLEXION VERTICAL JUMP HOP FOR DISTANCE SIDE HOP Biodex 90 /s Muscle lab Manuellt Manuellt 5 reps 3 reps 3 reps 1 rep FÖRDELNING Limb symmetry index (LSI) = Resultat av skadat ben Resultat av friskt ben Hamrin Senorski E, Svantesson E, Beischer S, Thomeé C, Grassi A, Krupic F, Thomeé R, Karlsson J, Samuelsson K. One-year recovery of symmetric muscle function after anterior cruciate ligament reconstruction was not associated with concomitant knee injuries a prospective observational study based on 264 patients. Submit. VAD SKA VI PRIORITERA? RELIABILITET - TESTER Isokinetisk styrka i knäextension och knäflexion (skadat/friskt och LSI) 142/165 Nm = 86 % 81/86 Nm = 94 % Om det skulle skilja 15 % på skadat ben 142*1.15/165 Nm = 99 % 83*1.15/86 Nm = 111 % alt. 142*0.85/165 Nm = 73 % 83*0.85/86 Nm = 82 % ANVÄND FLERA TESTER Almosnino S, Stevenson JM, Bardana DD, Diaconescu ED, Dvir Z. Reproducibility of isokinetic knee eccentric and concentric strength indices in asymptomatic young adults. Phys Ther Sport 2012;13(3):156-62. Thomeé R, Neeter C, Gustavsson A, et al. Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012;20(6):1143-51. Hegedus EJ, McDonough S, Bleakley C, Cook CE, Baxter GD. Clinician-friendly lower extremity physical performance measures in athletes: a systematic review of measurement properties and correlation with injury, part 1. The tests for knee function including the hop tests. Br J Sports Med 2015;49(10):642-8. 5
FRISKA BENET? Knäextension Knäflexion 150 250 140 VAD HAR VI LÄRT OSS FRÅN PROJEKT KORSBAND 230 210 190 170 150 130 120 110 100 Män skadat Män friskt Män skadat Män friskt 170 Knäextension 90 Knäflexion 160 150 140 130 85 80 75 120 70 110 65 100 60 Kvinnor skadat Kvinnor friskt Kvinnor skadat Kvinnor friskt ASSOCIERADE SKADOR & MUSKELFUNKTION ASSOCIERADE SKADOR & RTS Assoc. skada försämrade inte sannolikheten att nå >90 % LSI. MEN endast 23 % klarade testerna ett år efter operation. Högre sannolikhet att återgå till idrott fanns hos patienter med manligt kön, yngre ålder, högre aktivitetsnivå, och avsaknad av skada till MCL, menisk (& brosk) Hamrin Senorski E, Svantesson E, Beischer S, Thomeé C, Grassi A, Krupic F, Thomeé R, Karlsson J, Samuelsson K. One-year recovery of symmetric muscle function after anterior cruciate ligament reconstruction was not associated with concomitant knee injuries a prospective observational study based on 264 patients. Submit. Hamrin Senorski E, Svantesson E, Beischer S, Thomeé C, Thomeé R, Karlsson J, Samuelsson K. Patient characteristics and the absence of concomitant injuries to the medial collateral ligament, meniscus, and articular cartilage increases the likelihood of returning to sport one year after Anterior Cruciate Ligament reconstruction data from two registers on 272 patients. Manus. 6
TAKE HOME MESSAGE Använd fler tester för att utvärdera dina patienter efter främre korsbandsskada och rekonstruktion. Se till att dina patienter når >90 % i LSI för samtliga tester. Få dina patienter så starka som möjligt. Glöm inte det friska benet! Hjälp dina patienter att sätta realistiska förväntningar, inte minst dem med associerade skador. ERIC HAMRIN SENORSKI Department of Health and Rehabilitation, Institute of Neuroscience and Physiology The Sahlgrenska Academy, University of Gothenburg eric.hamrin.senorski@gu.se 7