levels (Langford et al., 2009). A recent study by Zarzycki and col- leagues (2018) found a weak association between ACL-RSI scores and knee kinematic asymmetry during gait. Another scale that assesses fear of movement and reinjury from involvement in physical activity is a modified version of the Tam- pa Scale for Kinesiophobia, known as the TSK-11 . (Please note, however, that this scale is not specific to patients with knee pa- thology.) The TSK-11 includes 11 items and has a range of pos- sible scores from 11 to 44. Lower scores indicate lower levels of fear of movement and reinjury. The scale is reliable and demon- strates both construct and predictive validity (Woby, Roach, Ur- mston, & Watson, 2005). TSK-11 scores have been shown to be elevated following ACL reconstruction, and they relate to lower self-report of function and rate of return to preinjury activity levels (Chmielewski et al., 2008; Kvist, Ek, Sporrstedt, & Good, 2005; Lentz et al., 2009). Although scores on the TSK-11 decrease with time following ACL reconstruction, they are associated with knee function only after 6 months following surgery, corresponding to the time frame when return- to-sports activities are often allowed (Barber-Westin & Noyes, 2011b; Chmielewski et al., 2008). Lower scores on the TSK-11 have been associated with increased ACL- RSI scores (Kvist et al., 2013). A reduction of four points on the TSK-11 maximizes the likelihood of correctly identifying patients who have reduced their fear of movement and reinjury (Woby et al., 2005). Recent evidence indicates that patients after ACL re- construction who have higher TSK-11 scores are more likely to re- port lower levels of activity, lower quadriceps strength, and poor- er hop limb symmetry; they may also be at greater risk for second ACL tear (Paterno et al., 2018). It has been suggested that TSK-11 could be shortened to a three-item fear of injury scale (items 1, 2, 10) in the early postoperative phase (less than 12 weeks after surgery), but TSK-11 is not recommended in the late postopera- tive phase (more than 6 months after surgery; Lentz et al., 2012). The Knee Self-Efficacy Scale (K-SES) is a reliable instrument con- sisting of 22 items designed to measure how certain respondents are that they can perform various physical activities (P. Thomeé et al., 2006). K-SES scores are generally higher in males, individu- als who have higher baseline physical activity levels, and younger individuals (P. Thomeé et al., 2007). Improvements in self-efficacy over the first 12 weeks following ACL reconstruction have been associated with improvements in pain and function during that same time frame (Chmielewski et al., 2011). Patients’ scores for self-efficacy of knee function preoperatively have also been shown to predict symptoms, muscle function, and return to ac - ceptable levels of physical activity 1 year after ACL reconstruction (P. Thomeé et al., 2008). Activity scales Beyond patient self-report of general health and knee-specific im- pairment and function, activity scales provide further information regarding intensity and frequency of patient activity levels. The IKDC 2000 activity scale, as previously described, can be used to categorize patients according to sports or work demands (Daniel et al., 1994; Hefti et al., 1993). The Tegner Activity Level Scale is an 11-point grading scale for work and sports activities (Tegner & Lysholm, 1985). The scale rates activity level from 0 (sick leave or disability pension because of knee problems) to 10 (competitive sports such as soccer, foot- ball, or rugby at the national or elite level). The scale was initially developed to measure activity following knee ligamentous injury and has been validated for use following ACL injury. The Tegner Scale has demonstrated acceptable test-retest reliability (intra- class correlation coefficient = 0.80) after ACL reconstruction and is sensitive to change up to 2 years following ACL reconstruction, with a minimally detectable change of 1 indicating true change in patient report (Briggs et al., 2009). The Marx Activity Rating Scale (Marx scale) is a four-item patient- report questionnaire that assesses the frequency of activities such as running, cutting, decelerating, and pivoting but is not intended to assess outcomes following intervention or surgery (Marx et al., 2001). The scale was developed to use in a population with a
& Griva, 2010; van Meer et al., 2013). Higher knee function on the IKDC 2000 is also related to more on-field training sessions and better muscle strength recovery (Villa et al., 2015). The Knee Outcome Survey – Activities of Daily Living Scale (KOS- ADLS) is a patient-reported measure of impairments and function- al limitations experienced during activities of daily living within a population possessing a wide variety of knee pathologies and im- pairments (Irrgang, Snyder- Mackler, Wainner, Fu, & Harner, 1998). It is reliable and uses an ordinal scaling system, with the overall score out of a possible 70 points represented as a percentage (Irrgang et al., 1998). A score of 100% represents the absence of knee impairments or functional limitations with ADLs (Irrgang et al., 1998). The KOOS consists of five subscales assessing patient symptoms, complaints of pain, function in daily life, function during sports and recreational activities, and knee-related quality of life designed for patients with ACL injury, meniscus injury, or posttraumatic knee osteoarthritis (Roos, Roos, Ekdahl, & Lohmander, 1998). The score for each subscale ranges from 0 to 100, with increased scores indi- cating higher subjective knee function (Roos et al., 1998). All sub- scales of the KOOS are reliable within the population for which they were developed (Roos et al., 1998). Higher correlations are seen between the KOOS-ADL and KOOS Sport and Recreation Function subscales with the physical function scales of the SF-36, compared to mental health components of the SF-36 (Roos et al., 1998). KOOS-QoL sub-scores of 74.5 were lower than previously reported healthy population norms with no knee symptoms of 90 and general population norms of 82.4 (Filbay, Ackerman, Russell, Macri, & Crossley, 2013). Meniscus injuries, revision surgery, and severe radiographic osteoarthritis are factors associated with poor KOOS-QoL sub- scores (Filbay et al., 2013). The risk of an ACL re- vision surgery is 3.7-times higher in patients with a 2-year postop- erative KOOS-QoL score of less than 44 compared to those with a score greater than or equal to 44 (Granan, Baste, Engebretsen, & Inacio, 2015). Additionally, for every 10- point drop in KOOS-Qol sub-score, there is a 33.6% higher risk for ACL reconstruction revi- sion surgery (Granan et al., 2015). Although the usefulness of each of the subscales – except for Sport and Recreation Function – has been questioned for the acute ACL-injury and ACL- reconstructed populations (van Meer et al., 2015), the measure is widely used in these populations (Ahldén et al., 2012; Filbay et al., 2013; Granan, Inacio, Maletis, Funahashi, & Engebretsen, 2013; Spindler et al., 2011). The Global Rating Scale of Perceived Function (GRS) consists of a single question that evaluates a patient’s current overall subjec- tive knee function on a scale from 0 to 100. Zero represents the in- ability to perform any activity, and 100 indicates the level of knee function prior to injury (Logerstedt et al. 2013b; Marx, Stump, Jones, Wickiewicz, & Warren, 2001). An analogue GRS was found to be reliable in the ACL population, demonstrating good repeat- ability, with a minimal detectable change of 6.49 representing true change in patient-reported function (Hopper et al., 2002). Psychological questionnaires The ACL – Return to Sport after Injury (ACL-RSI) scale is a patient- reported measure that assesses emotions, confidence in perfor- mance, and risk appraisal associated with return-to-sport activities following ACL reconstruction (Webster, Feller, & Lambros, 2008). The ACL-RSI score ranges from 0 to 100, representing an aver- age of the scores on 12 questions, with lower scores indicating more negative psychological responses in regard to returning to sport (Webster et al., 2008). Scores on the ACL-RSI have been shown to increase with time after ACL reconstruction, with a mini- mal detectable change of 19, and patients who have returned to preinjury sports activity levels score significantly higher on the ACL-RSI (Kvist et al., 2013; Langford, Webster, & Feller, 2009). The ACL-RSI has been shown to be reliable and valid, because patients with increased ACL-RSI scores also score higher on all the KOOS subscales. The use of the ACL-RSI can be used to assess psychological preparedness so that appropriate interventions can be implemented to allow for timely return to competitive sport
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