RATE OF RETURNING TO THE PREINJURY ACTIVITY LEVEL
Although some individuals with ACL injury can return to unrestricted functional activity without undergoing reconstruction surgery, many choose to modify their level of activity to less strenuous activities (Ageberg et al., 2008; Eitzen, Moksnes, Snyder-Mackler, Engebretsen, & Risberg., 2010; Fitzgerald, Axe, & Snyder-Mackler, 2000a; Moksnes & Risberg, 2009; Moksnes et al., 2008; Muaidi et al., 2007; Neeter et al., 2006; Tagesson et al., 2008) or need to undergo reconstructive surgery to return to preinjury activity levels (Logerstedt et al., 2010a). Of potential copers who received specialized neuromuscular training (perturbation training), 72% to 92% of them were successful in returning to preinjury activity level for a limited time (about 6 months) after injury without sustaining dynamic knee instability or modifying their activities (Fitzgerald, Axe, & Snyder-Mackler, 2000b; Hurd, Axe, & Snyder-Mackler, 2008a). A cohort study indicates that patients who opt for nonoperative management are more likely to return to level II sport activities in the first year and to level III sport activates in the second year after ACL injury, while patients who are managed operatively are more likely to return to participate in level I sport activities in the second year after surgery (Grindem, Eitzen, Engebretsen, Snyder-Mackler, & Risberg, 2014). The overall rate of returning to sport at 1 year from baseline testing for patients managed nonoperatively was 68.1%, with 54.8% of them participating in level I sport activities (Grindem et al., 2012). Preinjury activity level is correlated with the level of sport activity at 1 year after in patients with ACL injury who were managed nonoperatively. Patients who participated in level I sport activity prior to the injury demonstrated a lower rate of returning to sport when compared to those who participated in level II prior to the injury (Grindem et al., 2012). One study looked at the return-to-sport rate in adolescents who were managed nonoperatively and found that only 43.75% of adolescent patients returned to sport (K. L. Dunn, Lam, & Mcleod, 2016). Long-term outcomes following nonoperative management are mixed. A study by Kostogiannis and colleagues (2007) reported that only 42% of patients with ACL-deficient knees classified as potential copers were able to return to their preinjury activity level within 3 years after nonoperative ACL management. However, Hurd and colleagues (2008a) indicated that 72% of potential copers had successfully returned to their preinjury activity level 10 years after nonoperative ACL management. The high success rate after nonoperative ACL management in Hurd’s study was attributed to the use of a screening exam to identify appropriate candidates and to the administration of a neuromuscular training (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000c; Hurd, Axe, & Snyder-Mackler, 2008a). When the decision for pursuing nonoperative ACL management to return to high-level activities was based on patient self-selection, only 23% to 42% were able to resume high- level activities (Hughes & Watkins, 2006; Hurd, Axe, & Snyder-Mackler, 2008a). These findings highlight the importance of using a systematic screening exam for patient management following ACL injury. Performing ACL reconstruction does not ensure a return to participation in the same preinjury level of sport. The overall average rate of return-to- sport activities after reconstructive surgery ranges between 44% and 92% (Ardern et al., 2012, 2011b; Ardern, Taylor, Feller, & Webster, 2014; Lai, Ardern, Feller, & Webster, 2017; Nawasreh et al., 2016). This wide range might have resulted from reporting the rate of return to sport for a wide spectrum of sport activities, levels of participation (recreational, competitive, preinjury activity level), patients’ ages, and different time points of following up. An updated systemic review and meta-analysis study reported that returning to any type of sport was as high as 81% after reconstructive surgery, while returning to the preinjury activity level of sport was 65% and to a competitive sport was 55% (Ardern, Taylor,
et al., 2014). Other studies report that up to 65% of patients return to a competitive level of sport activities within the first 2 years of surgery, with only 38% of them maintaining their same sport level more than 2 years after the surgery (Ardern, Taylor, Feller, Webster, 2014; Brophy et al., 2012; Gobbi & Francisco, 2006; Langford et al., 2009). High rates of return to preinjury activity level (of 81% and 84% at 1 and 2 years, respectively) after surgery are reported in patients who meet the return-to- activity criteria before participating in their preinjury activity level (Nawasreh et al., 2016). The rate of return to preinjury sport activity has been reported for patients in different age groups. The rate of return to sport after surgery in adolescents was 92% (K. L. Dunn et al., 2016), high school age was 63%, and collegiate age was 69% (McCullough et al., 2012). Return to preinjury sport was also studied in elite athletes of different sports. A systemic review and meta-analysis revealed that the pooled rate of return to sport in elite athletes is 83% (95% CI: 77% to 88%); the time of returning to sports ranged from 6 to 13 months after surgery (Lai et al., 2017). Between sport activities, the highest rate of return to sport among elite athletes was for those who played soccer (85%), followed by basketball (82%) and American football (75%; Lai et al., 2017). A high rate of return to preinjury activity was 71% for professional soccer athletes, returning within 4 years following surgery (Lai et al., 2017). The rate of return to preinjury sport activities was reported to be higher in men compared to women, with men 1.4-times more likely to return to preinjury level of sport compared to women (Ardern, Taylor, et al., 2014; Ardern et al., 2011a; Brophy et al., 2012; Webster, Feller, Whitehead, Myer, & Merory, 2017). However, Shelbourne, Sullivan, Bohard, Gray, & Urch (2009) reported more high school women returning to play soccer (93%) compared to men (80%) after surgery. With regard to the graft types, patients with bone-patella tendon-bone autograft are 1.2-times more likely return to preinjury level of sport compared to those who had hamstrings tendon autograft (Ardern, Taylor, et al., 2014; Ardern et al., 2011a; Brophy et al., 2012; Webster et al., 2017). Ardern and colleagues (2014) indicated that patients with patellar tendon autograft are more likely to return to preinjury sport level, whereas those with hamstrings tendon are more likely to return to competitive sport. Returning to preinjury level of sport is multifactorial, as it can be attributed to different contextual, physical, functional, and psychological factors (Ardern, Österberg, et al., 2014). Age, sex, and psychological status play a role in return to preinjury level of sport after reconstruction surgery, with young men, elite athletes, and patient psychological readiness all factors contributing to likelihood of return to sport (Ardern, Österberg, et al., 2014). Elite athletes who play at high competitive levels and those who are confident and have less fear due to the injury or surgery are more likely to return to their sports. Men are about 1.5-times more likely to return to preinjury level of sport or competitive sports compared to women (Ardern, Taylor et al., 2014). Although there is no clear evidence to explain why more men return to sport than women, it could be because men are less affected by the ACL injury and demonstrate better functional recovery at the time they are cleared to return to activities postoperatively (Hewett, Ford, & Myer, 2006; Nawasreh et al., 2016; Paterno et al., 2012; Wright et al., 2011). The high rate of return to sport in young athletes might have resulted because they need to maintain their academic scholarship and have a better opportunity to participate in sports. In comparison, the older athlete may have changed their priority with more family, work, and socioeconomic concerns (Ardern, Taylor et al., 2014). A previous study revealed that return to high activity level at 2 years after surgery was associated with participating in high- level activity and lower body mass index at the time of injury,
Page 51
Book Code: PTNJ0824
EliteLearning.com/Physical-Therapy
Powered by FlippingBook