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ObjectiveInvestigate prevention interventions and potential modifiable risk factors (MRFs) for female/woman/girl athletes’ spine, chest, abdominal or pelvic injury and/or pain.DesignSystematic review with meta-analyses, semiquantitative analyses and Grading of Recommendations Assessment, Development and Evaluation.Data sourcesMEDLINE, CINAHL, APA PsycINFO, CDSR, CENTRAL, SPORTDiscus, EMBASE, ERIC.EligibilityPrimary data studies with comparison group(s) assessing the association of prevention interventions and/or MRFs for spine, chest, abdominal and/or pelvic injury/pain with ≥1 female/woman/girl athlete in each study group.ResultsAcross 105 studies (n=11 interventions, n=92 MRFs, n=2 both, n=35 female/woman/girl-specific estimates) including 59 833 participants (23.7% females/women/girls) 9 injury/pain outcomes were assessed (n=74 low-back, n=14 back, n=13 neck, n=5 pelvis, n=3 thoracic, n=3 abdominal, n=3 trunk, n=2 rib, n=1 breast). Three prevention strategies (exercise, equipment, rule-change) and 22 MRFs were identified. High risk of confounding bias (Downs and Black quality assessment tool) was present in 92% and 63% of intervention and MRF studies, respectively. Considering female/woman/girl estimates, we performed meta-analyses (standardised mean-difference) on 4 MRFs (body mass, body mass index (BMI), weekly training hours, spinal flexion) for low-back pain (LBP) and semiquantitative analyses for one intervention (exercise), and 3 MRFs (yearly training load, hip motion, hip strength) for LBP. Very low-certainty evidence suggests no difference in body mass (g=0.28, 95% CI −0.06 to 0.62; I2=67.7%), BMI (g=0.22, 95% CI −0.25 to 0.69; I2=68.2%), weekly training hours (g=0.15, 95% CI −0.29 to 0.58; I2=45.6%) or spinal flexion (g=0.27, 95% CI −0.23 to 0.76; I2=40.4%) between female/women/girls athletes with and without LBP.ConclusionsThere is limited knowledge about prevention interventions or MRFs for female/women/girl athletes’ spine, chest, abdominal and/or pelvic injury/pain.PROSPERO registration numberCRD42024479654.

Background The International Knee Documentation Committee Subjective Knee Form (IKDC) is the most highly recommended patient reported outcome measure for assessing patients with anterior cruciate ligament (ACL) injuries and those undergoing ACL reconstruction (ACLR) surgery. The IKDC was developed as a unidimensional instrument for a variety of knee conditions. Structural validity, which determines how an instrument is scored, has not been definitively confirmed for the IKDC in respondents with ACL injuries, and in fact an alternative two-factor/subscale structure has been proposed in this population. The purpose of this study was to determine the most appropriate structure and scoring system for the IKDC in young active patients following ACL injury. Methods In total, 618 young patients deemed at high risk of graft rupture were randomized into the Stability 1 trial. Of the trial participants, 606 patients (98%) completed a baseline IKDC questionnaire used for this analysis. A cross sectional retrospective secondary data analysis of the Stability 1 baseline IKDC data was completed to assess the structural validity of the IKDC using exploratory and confirmatory factor analyses. Factor analyses were used to test model fit of the intended one-factor structure, a two-factor structure, and alternative four-factor and bifactor structures (i.e., a combination of a unidimensional factor with additional specific factors) of the IKDC, in a dataset of young active ACL patients. Results The simple one-factor and two-factor structures of the IKDC displayed inadequate fit in our dataset of young ACL patients. A bifactor model provided the best fit. This model contains one general factor that is substantially associated with all items, plus four secondary, more specific content factors (symptoms, activity level, activities of daily living, and sport) with generally weaker associations to subsets of items. Although the single-factor model did not provide unambiguous support to unidimensionality of the IKDC based on fit indices, the bifactor model supports unidimensionality of the IKDC when covariance between items with similar linguistic structure, response options, or content are acknowledged. Conclusions Overall, findings of a bifactor model with evidence of a reliable general factor well defined by all items lends support to continue interpreting and scoring this instrument as unidimensional. This should be confirmed in other samples. Clinically, based on these findings, the IKDC can be represented by a single score for young active patients with ACL tears. A more nuanced interpretation would also consider secondary factors such as sport and activity level. Trial registration The Stability 1 trial for which these data were collected was registered on ClinicalTrial.gov (NCT02018354).

Purpose The priorities of patients should be shared by those treating them. Patients and surgeons are likely to have different priorities surrounding anterior cruciate ligament reconstruction (ACLR), with implications for shared decision-making and patient education. The optimal surgical approach for ACLR is constantly evolving, and the magnitude of treatment effect necessary for evidence to change surgical practice is unknown. The aim of this study was to determine (1) the priorities of surgeons and patients when making decisions regarding ACLR and (2) the magnitude of reduction in ACLR graft failure risk that orthopaedic surgeons require before changing practice. Methods This study followed a cross-sectional survey design. Three distinct electronic surveys were administered to pre-operative ACLR patients, post-operative ACLR patients, and orthopaedic surgeons. Patients and surgeons were asked about the importance of various outcomes and considerations pertaining to ACLR. Surgeons were asked scenario-based questions regarding changing practice for ACLR based on new research. Results Surgeons were more likely to prioritize outcomes related to the surgical knee itself, whereas patients were more likely to prioritize outcomes related to their daily lifestyle and activities. Knee instability and risk of re-injury were unanimous top priorities among all three groups. A mean relative risk reduction in ACLR graft failure of about 50% was required by orthopaedic surgeons to change practice regardless of the type of change, or patient risk profile. Conclusion There are discrepancies between the priorities of surgeons and patients, and orthopaedic surgeons appear resistant to changing practice for ACLR. Level of evidence IV.

Objectives: To develop and validate a short form, disease-specific version of the KOOS appropriate for the young active ACL deficient population: the KOOS-ACL. Methods: A baseline dataset of 605 young patients (< 25 years) with ACL tears was divided into a development and validation sample. Exploratory factor analyses were conducted in the development sample to identify the underlying factor structure and reduce the number of KOOS items based on statistical and conceptual indicators. Confirmatory factor analyses were conducted to check fit indices of the proposed KOOS-ACL model in both samples. Structural validity, reliability, and responsiveness to change were assessed in the full sample at five timepoints: baseline and 3 months, 6 months, 12 months and 24 months post-operatively. Results: Two factors were deemed most appropriate for the KOOS-ACL: Functionality and Sport. Fifteen items were removed from the full length KOOS based on discriminant validity (i.e., lack of distinctiveness between some proposed constructs) and another fifteen items were removed for repetitive content. The final KOOS-ACL model showed acceptable structural validity (CFI and TLI > 0.9, RMSEA and SRMR < 0.08), internal consistency reliability (a > 0.8), and responsiveness to change (effect size > 0.8) at all five timepoints in the dataset. The KOOS-ACL showed strong and significant correlations to the original KOOS and IKDC at all timepoints (r > 0.7). Conclusions: The new KOOS-ACL questionnaire contains 12 items and two subscales relevant to young active ACL patients. The KOOS-ACL would reduce patient burden by more than two thirds and provides improved structural validity compared to the full length KOOS while maintaining adequate psychometric properties and relatedness to other popular outcome measures currently used following ACL injuries. The KOOS-ACL may be a more relevant outcome to use with young active ACL patients within the two years of surgery.

Adolescents are particularly vulnerable to inadequate provision of mental health and addictions care, as services have been traditionally conceptualized to serve the needs of children or adults. Additionally, rural communities have been largely excluded from research investigating mental healthcare access and exhibit unique barriers that warrant targeted interventions. Finally, perspectives from the target population will be most important when understanding how to optimize adolescent mental health and addictions care. Therefore, the purpose of this study was to identify what adolescents in a rural town perceive as barriers to accessing mental health services. We conducted a cross-sectional survey study with high school students to generate ranked lists of the top perceived individual-level, community-level, and overall barriers. A total of 243 high school students responded to the survey. Perceived barriers were predominantly at the community level. Overall, the top barriers reported were a lack of awareness and education regarding mental health, resources, and the nature of treatment. Students who had previously accessed mental health services identified primary barriers related to mental health professionals, whereas students who had not accessed care reported fear and uncertainty as primary barriers. Modifiable community-level factors related to (1) mental health literacy and (2) mental healthcare professionals were identified by adolescents as the main perceived barriers to accessing mental health and addiction services in a rural town. The findings of this preliminary study should inform intervention strategies and further rigorous research for this traditionally underserved target population.

Objectives: Machine learning has emerged as a potential tool for improving outcome prediction accuracy in anterior cruciate ligament (ACL) reconstruction (ACLR). A machine learning-based ACL revision prediction model has been developed using data from the Norwegian Knee Ligament Register (NKLR) but lacks external validation outside of Scandinavia. This study aimed to assess the external validity of the previously published ACL revision prediction model (https://swastvedt.shinyapps.io/calculator_rev/) using data from the Stability 1 randomized clinical trial. The hypothesis was that the model's performance would be similar, indicating validity of the algorithm. Methods: This was a level 3 cohort study. The Cox Lasso prediction model from the original study was selected for external validation owing to its superior performance during model development and internal validation testing. The Stability 1 trial was an external randomized controlled trial that assigned patients to receive either hamstring tendon (HT) autograft or HT with lateral extra-articualr tenodesis (LET). Patients from Stability 1 with all 5 predictors required by the Cox Lasso model were included. Since all patients in the Stability 1 trial received hamstring HT plus/minus LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. The different configurations were tested because previous evaluation of the Stability 1 cohort by the Multicenter Orthopaedic Outcomes Network (MOON) suggests failure rates of HT + LET are most similar to the failure rates of patients who receive BPTB. Concordance and calibration were calculated to determine model performance with censoring of the time-to-event outcome. Results: In total, 591 patients from the Stability 1 trial were included, and 39 patients (6.6%) underwent revision surgery within 2 years. Model performance was best when patients randomized to HT + LET were coded as BPTB. Validation concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (Stability: 0.71; NKLR: 0.68-0.69). Concordance CI ranged from 0.63-0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. Conclusions: The most important finding of this study was that when patients in the Stability 1 trial who received HT + LET were coded as BPTB in the Norwegian prediction calculator, the model concordance was similar to the index study. However, the CI for the validation set was wider than the original model, suggesting that more data is required to definitively determine the external validity. The finding that HT + LET behaved most similarly to BPTB supports the notion that the addition of LET can decrease the failure and subsequent revision rate of primary ACLR when HT is used. In addition, if further external validation efforts are consistent with this study, the prediction model may require updating to equate HT + LET to BPTB for the purposes of prospectively estimating revision surgery risk.

Objectives: Investigate how the severity of adverse events encountered during the follow up period of the Stability Study were associated with patient reported outcomes at two years post-operative. Methods: Stability is a pragmatic, multicenter, randomized clinical trial comparing single-bundle hamstring tendon ACLR with combined ACLR + LET. Patients aged 14-25 years with an ACL deficient knee were included (n = 618). Participants completed PROMs (KOOS, IKDC, ACL-QOL), and adverse events were documented pre-operatively and at 3, 6, 12 and 24 months postoperatively. Adverse events were categorized into four groups: none (no adverse event), minor medical (resolved spontaneously or with minimum medical management), minor surgical (event such as meniscus tear or stiffness that required surgical intervention but is not a graft rupture), contralateral ACL rupture, and graft rupture. A generalized linear model was used to compare mean PROM scores with the different levels of adverse events. Results: The rate of minor medical adverse events (11.2%), minor surgical adverse events (7.4%), and ipsilateral (7%) or contralateral (3%) ACL tears at 24 months post-operative were low considering the high-risk patient profile. There was no difference in the proportion of minor medical events, minor surgical events, or contralateral ACL ruptures between the ACLR only and ACLR + LET groups (p>0.05). The ACLR only group had a significantly higher rate of graft rupture (11 vs 4%, p<0.01). Increasing severity of adverse events were associated with lower PROM scores at 24 months post-operative. Patients who experienced any adverse event within the two-year follow up had significantly lower outcome scores than those with no events. When only adverse events in the first year post-operative were included, the influence of minor medical and minor surgical events was largely washed out suggesting the effect on outcomes may be due to recency rather than severity. However, graft tears and contralateral ACL tears within the first year led to significantly lower scores at two-years post-operative in all outcomes (p<0.01). Conclusions: Increasing severity of adverse events were associated with lower patient reported outcome measures at 2 years post-operative. Recent minor medical and minor surgical events worsened PROM scores, but this effect was largely eliminated within a year of the event. Patients who experience a graft rupture or contralateral ACL tear appear to have a significantly lower PROMs at 2 years post- operative, regardless of the time at which the tear occurs. Therefore, the benefit of the LET procedure reducing graft rupture outweighs the potential for less severe events such as hardware irritation/removal which will likely be less detrimental to patient-important outcomes.

BackgroundA lack of clinical practice guidelines and female specific research makes it difficult for both patients and clinicians to navigate a safe and successful return to activity (RTA) postpartum. It is unknown if current exercise interventions being provided and recommended for postpartum women are eliciting improvements in physical activity and cardiorespiratory fitness (CRF) levels.Objectives1) To determine what exercise interventions are being implemented in the postpartum population and 2) To determine if these interventions are effective at improving physical activity levels and/or CRF.DesignSystematic review and meta-analysis.PatientsPostpartum women.InterventionsExercise interventions (i.e., aerobic, strength, pelvic floor etc.) to improve multiple health outcomes (physical and mental) postpartum.Main outcome measurementsPhysical activity levels (i.e., step count, moderate-to-vigorous physical activity (MVPA) minutes) and CRF (i.e., VO2 max) were included in the meta-analysis.Results5852 studies were screened, and 101 were summarized into the systematic review. Of these, 15 (15%) randomized controlled trials (RCTs) included outcomes related to physical activity levels (n=10) or CRF (n=5) and were pooled together in a random-effects meta-analysis. The exercise interventions in these studies were often ill-defined, with frequency, intensity, type, and time largely varying between studies (Table 1). Standardized mean differences (95% CI) indicated a small-moderate improvement in CRF [0.64, (0.20, 1.09), I2=39%] (figure 1a), but no significant improvement in physical activity levels [0.14, ( 0.09, 0.37), I2=67] (figure 1b). Abstract 696 Table 1Parameters of exercise interventionsNI; no information, HR; heart rate, NA; not applicable.Abstract 696 Figure 1Meta-analysis on the effect of exercise interventions on cardiorespiratory fitness levels (a) and physical activity (b) in postpartum women. Weights are from a random effects analysis and overall effects are shown as standardized mean difference + [95% confidence interval (CI)]. SD; standard deviation.ConclusionsDespite a large number of studies using exercise interventions to improve multiple health outcomes postpartum, few measured and elicited improvements in physical activity/fitness levels. Of these 15 studies, exercise parameters were ill-defined and inconsistent. Additionally, there were no significant improvements in physical activity levels. Therefore, it is important to improve guidelines surrounding exercise interventions to elicit positive changes in physical activity and CRF levels and improve RTA for postpartum women.

ObjectiveWomen are often advised to return to activity (RTA) as early as 6 weeks postpartum, despite undergoing significant physical, physiological and psychological changes. Our objective was to examine existing evidence and clinical practice guidelines to navigate a safe and successful RTA or return to sport (RTS) postpartum.MethodsWe searched CINAHL, Embase, Medline, PsycINFO and SPORTDiscus and included any secondary studies with recommendations or guidelines for RTA or RTS postpartum. Grey literature and primary sources were excluded. Four reviewers independently screened titles and abstracts, followed by full-text review for eligibility, with conflicts resolved by a third-party reviewer. One reviewer extracted data, which was cross-referenced by another reviewer.Results5851 studies were screened, and 33 were included in this scoping review. Most studies stated that RTS postpartum can begin once ‘medically safe’, around 6 weeks postpartum, but this term was generally left undefined. In addition, most studies recommended engaging in 150 min of moderate-vigorous physical activity per week after 6 weeks postpartum, but the type of exercise recommended was often non-specific.ConclusionA lack of consistent, evidence-based guidelines exist for RTA or RTS postpartum. Multiple evidence gaps require additional research to inform patient and activity specific guidelines for a safe and successful RTA or RTS postpartum.