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Background: Deciding when patients are ready to return to sport (RTS) after an anterior cruciate ligament (ACL) reconstruction (ACLR) is challenging. The understanding of which factors affect readiness and how they may be related is limited. Therefore, despite widespread use of RTS testing, there is a lack of knowledge about which tests are informative on the ability to resume sports. Purpose: To examine whether there is an association between knee laxity and psychological readiness to RTS after ACLR and to evaluate the predictive value of these measures on sports resumption. Study Design: Cohort study; Level of evidence, 2. Methods: Patients aged ≥16 years engaged in physical activity/sports before injury were recruited at routine clinical assessment 9-12 months after ACLR. Exclusion criteria were concomitant ligament surgery at ACLR and/or previous ACL injury in the contralateral knee. At baseline, a project-specific activity questionnaire and the ACL–Return to Sport After Injury (ACL-RSI) scale were completed. Knee laxity was assessed by use of the Lachman test, KT-1000 arthrometer, and pivot-shift test. Two years after surgery, knee reinjuries and RTS status (the project-specific questionnaire) were registered. Associations between psychological readiness and knee laxity were evaluated with the Spearman rho test, and predictive ability of the ACL-RSI and knee laxity tests were examined using regression analyses. Results: Of 171 patients screened for eligibility, 132 were included in the study. There were small but significant associations between the ACL-RSI score and the Lachman test (rho = −0.18; P = .046) and KT-1000 arthrometer measurement (rho = −0.18; P = .040) but no association between the ACL-RSI and the pivot-shift test at the time of recruitment. Of the total patients, 36% returned to preinjury sport level by 2 years after surgery. Higher age, better psychological readiness, and less anterior tibial displacement (KT-1000 arthrometer measurement) were significant predictors of 2-year RTS (explained variance, 33%). Conclusion: Small but significant associations were found between measurements of psychological readiness and anterior tibial displacement, indicating that patients with less knee laxity after ACLR feel more ready to RTS. ACL-RSI and KT-1000 arthrometer measurements were independent predictors of 2-year RTS and should be considered in RTS assessments after ACLR.

Background: Knowledge about the predictive value of return to sport (RTS) test batteries applied after anterior cruciate ligament reconstruction (ACLR) is limited. Adding assessment of psychological readiness has been recommended, but knowledge of how this affects the predictive ability of test batteries is lacking. Purpose: To examine the predictive ability of a RTS test battery on return to preinjury level of sport and reinjury when evaluation of psychological readiness was incorporated. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 129 patients were recruited 9 months after ACLR. Inclusion criteria were age ≥16 years and engagement in sports before injury. Patients with concomitant ligamentous surgery or ACL revision surgery were excluded. Baseline testing included single-leg hop tests, isokinetic strength tests, the International Knee Documentation Committee (IKDC) Subjective Knee Form 2000, a custom-made RTS questionnaire, and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale. The RTS criteria were IKDC 2000 score ≥85% and ≥85% leg symmetry index on hop and strength test. At a 2-year follow-up evaluation, further knee surgery and reinjuries were registered and the RTS questionnaire was completed again. Regression analyses and receiver operating characteristic analyses were performed to study the predictive ability of the test battery. Results: Out of the 103 patients who completed the 2-year follow-up, 42% returned to their preinjury level of sport. ACL-RSI 9 months after surgery (odds ratio [OR], 1.03) and age (OR, 1.05) predicted RTS. An ACL-RSI score Conclusion: ACL-RSI and age were predictors of 2-year RTS, while functional tests were not informative. Another main finding was that none of the patients who passed the 85% RTS criteria sustained another knee injury.

Virtual reality games are playing a greater role in rehabilitation settings. Previously, commercial games have dominated, but increasingly, bespoke games for specific rehabilitation contexts are emerging. Choice and design of tasks for VR-games are still not always clear, however; some games are designed to motivate and engage players, not necessarily with the facilitation of specific movements as a goal. Other games are designed specifically for the facilitation of specific movements. A theoretical background for the choice of tasks seems warranted. As an example, we use a game that was designed in our lab: VR Walk. Here, the player walks on a treadmill while wearing a head-mounted display showing a custom-made virtual environment. Tasks include walking on a glass bridge across a drop, obstacle avoidance, narrowing path, walking in virtual footsteps, memory, and selection tasks, and throwing and catching objects. Each task is designed according to research and theory from movement science, exercise science, and cognitive science. In this article, we discuss how for example walking across a glass bridge gives perceptual challenges that may be suitable for certain medical conditions, such as hearing loss, when perceptual abilities are strained to compensate for the hearing loss. In another example, walking in virtual footsteps may be seen as a motor and biomechanical constraint, where the double support phase and base of support can be manipulated, making the task beneficial for falls prevention. In a third example, memory and selection tasks may challenge individuals that have cognitive impairments. We posit that these theoretical considerations may be helpful for the choice of tasks and for the design of virtual reality games.

Purpose Evidence is emerging on the importance of psychological readiness to return to sport after anterior cruciate ligament (ACL) reconstruction. The ACL-Return to Sport after Injury scale (ACL-RSI) is developed to assess this. The aim of the current study was to translate ACL-RSI into Norwegian and examine the measurement properties of the Norwegian version (ACL-RSI-No). Methods ACL-RSI was translated according to international guidelines. A cohort of 197 ACL-reconstructed patients completed ACL-RSI-No and related questionnaires nine months post-surgery. One hundred and forty-six patients completed hop tests and 142 patients completed strength tests. Face and structural validity (confirmative factor analysis and explorative analyses), internal consistency [Cronbach’s alpha (α)], test–retest reliability [Intraclass Correlation Coefficients (ICC)], measurement error [Standard error of measurement (SEM) and smallest detectable change at individual (SDCind) and group level (SDCgroup)] and construct validity (hypotheses testing; independent t tests, Pearson’s r) were examined. Results ACL-RSI-No had good face validity. Factor analyses suggested that the use of a sum score is reasonable. Internal consistency and test–retest reliability were good (α 0.95, ICC 0.94 (95% CI 0.84–0.97) and measurement error low (SEM 5.7). SDCind was 15.8 points and SDCgroup was 2.0. Six of seven hypotheses were confirmed. Conclusions ACL-RSI-No displayed good measurement properties. Factor analyses suggested one underlying explanatory factor for “psychological readiness”—supporting the use of a single sum score. ACL-RSI-No can be used in the evaluation of psychological readiness to return to sport after ACL injury. Level of evidence III.

Purpose: To assess muscle strength and the correlation with physical functioning, pain, time interval since surgery and self-reported exercise after reverse shoulder arthroplasty (RSA).Materials an...

Background: Stride-to-stride fluctuations, or gait variability, can be captured easily using body worn inertial sensors. Previously, sensor-measured gait variability has been found to be associated with fall risk and central nervous changes. However, further research is needed to clarify the clinical relevance of this method. Objectives: In this study, we look at how gait variability is associated with muscle strength, measured two years earlier. Design, setting and participants: This is study of longitudinal associations. Participants were community-dwelling volunteers between 70-81 years. Measurements: Participants were tested while walking with a single sensor at their lower back, and they walked back and forth over a distance of 6.5 meters under four conditions: at preferred speed, at fast speed, with an added cognitive task, and while walking across an uneven surface. Gait variability in the anteroposterior (AP), mediolateral (ML) and vertical (V) directions was identified. A muscle strength score was composed by transforming hand grip strength, isometric knee extension strength and the 30 second chair rise-test to z-scores and adding them. Results: 56 individuals were analysed (mean age at baseline 75.8 (SD 3.43), 60 percent women). In a backwards regression method using age, gender and baseline walking speed as covariates, muscle strength predicted gait variability after two years for AP variability during preferred speed (Beta= .314, p=.025) and uneven surface walking (Beta=.326, p=.018). Further, muscle strength was associated with ML variability during preferred speed (Beta=.364, p=.048) and fast speed (Beta=.419, p=.042), and V variability during preferred speed (Beta=.402, p=.002), fast speed (Beta=.394, p=.004) and uneven surface walking (Beta=.369, p=.004). Conclusions: Sensor-measured gait variability tended to be associated with muscle strength measured two years earlier. This finding could emphasize the relevance of this relatively novel measure of gait in older adults for both research and clinical practice.

Background: Patients with hip fracture frequently have sarcopenia and are at great risk of loss of mobility. We have investigated if sarcopenia predicts change in mobility after hip fracture. Methods: This is a prospective, multicenter observational study with one-year follow-up. Patients with hip fracture who were community-living and capable of walking before the fracture were included at three hospitals in Norway (2011–2013). The primary outcome of the study was change in mobility, measured by the New Mobility Score (NMS). Sarcopenia was determined postoperatively by anthropometry, grip strength, and NMS. Results: We included 282 participants and sarcopenia status was determined in 201, of whom 38% (77/201) had sarcopenia, 66% (128/194) had low muscle mass, 52% (116/222) had low grip strength and 8% (20/244) had low pre-fracture mobility (NMS < 5). Sarcopenia did not predict change in mobility (effect 0.2 points; 95% CI –0.5 to 0.9, P = 0.6), but it was associated with having lower mobility at one-year (NMS 5.8 (SD 2.3) vs. 6.8 (SD 2.2), P = 0.003), becoming a resident of a nursing home (odds ratio 3.2, 95% CI 0.9 to 12.4, P = 0.048), and the combined endpoint of becoming a resident of a skilled nursing home or death (odds ratio 3.6, 95% CI 1.2 to 12.2, P = 0.02). Conclusions: Sarcopenia did not predict change in mobility in the year after hip fracture publishedVersion

Background The step length-cadence ratio, also called the walk ratio (WR; cm/steps/min) is a measure of cautious gait, poor balance control or impaired gait, but has not been investigated for both genders in a general population of older adults across different speeds and conditions. Method The participants were community-dwelling volunteers between 70 and 81 years. They walked 6.5 m under four different conditions: At preferred speed, fast speed, during a dual task condition and on an uneven surface. Step length (cm) and cadence (steps/minute) was captured using a body-worn sensor. Both cadence and step lengths were adjusted for body height. Results 70 older adults participated (mean age 75.5 (SD 3.4), 60 percent women). The WR was 0.60 cm/steps/min (SD 0.07) during preferred speed walking, 0.58 cm/steps/min (SD 0.07) during fast walking, 0.68 cm/steps/min (SD 0.18) during dual task-walking and 0.59 cm/steps/min (0.07) during uneven surface-walking. In planned pairwise comparisons, the WR during dual task was significantly different from preferred speed walking (mean difference −0.087 cm/steps/min, 95% CI −0.140, −0.033), from fast speed walking (mean difference −0.098 cm/steps/min, 95% CI −0.154, −0.041) and uneven surface walking (mean difference 0.092 cm/steps/min, 95% CI 0.040, 0.145). There were no gender differences except during the fast walking condition, where women had a significantly lower WR than the men (0.56 cm/steps/min vs 0.61 cm/steps/min, p = 0.002). Discussion We found that the WR is invariant during different speeds, and during an uneven surface condition, but is affected during a dual task-condition, when attention must be divided between a cognitive and a motor task.

To investigate to which degree stroke severity, disability, and physical function the first week post-stroke are associated with preferred walking speed (PWS) at 6 months.Longitudinal observational study.Participants were recruited from a stroke unit and tested within the first week (baseline) and at 6 months post-stroke. Outcome measures were the National Institutes of Health Stroke Scale (NIHSS), the Barthel Index (BI), modified Rankin Scale (mRS), PWS, Postural Assessment Scale for Stroke (PASS), and the Trunk Impairment Scale modified-Norwegian version. Multiple regression models were used to explore which variables best predict PWS at 6 months, and the Receiver Operating Characteristics (ROC) curves to determine the cutoffs.A total of 132 participants post-stroke were included and subdivided into two groups based on the ability to produce PWS at baseline. For the participants that could produce PWS at baseline (WSB group), PASS, PWS, and age at baseline predicted PWS at 6 months with an explained variance of 0.77. For the participants that could not produce a PWS at baseline (NoWSB group), only PASS predicted PWS at 6 months with an explained variance of 0.49. For the Walking speed at baseline (WSB) group, cutoffs at baseline for walking faster than 0.8 m/s at 6 months were 30.5 points on the PASS, PWS 0.75 m/s, and age 73.5 years. For the NoWSB group, the cutoff for PASS was 20.5 points.PASS, PWS, and age the first week predicted PWS at 6 months post-stroke for participants with the best walking ability, and PASS alone predicted PWS at 6 months post-stroke for participants with the poorest walking ability.

Background: Symmetry during stair descent can potentially be used as an early functional measure after anterior cruciate ligament reconstruction (ACLR). We have developed a novel application of a single accelerometer-based inertial motion unit (IMU) to identify foot strikes and calculate step times in an ordinary stairway.Purpose: To examine within-day test-retest reliability and measurement error of step time and step time symmetry measured with a body-fixed IMU during stair descent in subjects early after ACLR and in healthy subjects.Methods: Subjects after ACLR were tested twice 6 weeks (N = 15) and twice 3 months (N = 26) postoperatively. Eighteen healthy subjects were tested twice on one occasion. Subjects descended a flight of stairs at preferred speed. Trunk accelerometry data were collected with an inertial motion unit (IMU). Mean step times (MSTs) and limb symmetry index (LSI) of MSTs were calculated. Clinical trials registration number: NCT01279759.Results: Intraclass Correlation Coefficient (ICC (1,1)) for within test-retest reliability varied from 0.87 to 0.96 for MSTs and from 0.58 to 0.87 for LSIs. The 95% confidence interval (CI) for a true value varied from ± 0.02 seconds (s) to ± 0.05 s for MSTs and from ± 4.6 percentage points (pp) to ± 6.6 pp for LSIs.Conclusion: Mean step times measured with a body-fixed IMU during stair descent and limb symmetry indexes calculated from these mean step times are precise and reliable during early post-operative rehabilitation after ACLR and in healthy subjects.

Background Virtual environments (VE) are increasingly used in rehabilitation settings for gait training, and positive effects are reported. However, little is known about how walking under environmental constraints and solving motor tasks in fully immersive VEs impact gait patterns. Research Question How are gait patterns in healthy adults impacted by walking under environmental constraints and solving motor tasks on a treadmill, in a fully immersive VE? Methods 29 healthy adults (age: 28.9±4.8 yrs) were included. Basic gait parameters (step length, cadence, walk ratio) and gait variability in the anteroposterior, mediolateral and vertical directions were measured using an inertial sensor attached to the lower back. A familiarisation treadmill walk >2 min was performed, followed by 200 m familiarisation walk in the VE with no task or environmental constraints The participants were then exposed to height, two grabbing tasks, a balancing task and narrow-path walking. Gait patterns were captured for 15–25 seconds during each of the conditions. The Simulator Sickness Questionnaire was completed before and after the session. Results Gait regularity decreased when solving all the motor tasks, and under all the environmental constraints, except when being familiarised to height exposure, where regularity returned to pre-exposure levels. Step length and walk ratio decreased, and cadence increased during height exposure and while performing the grabbing tasks and the balancing task. The different tasks and environments appeared to have specific impact on gait patterns. There was no increase in simulator sickness symptoms. Significance Gait patterns were impacted by solving motor tasks, and by environmental constraints, in healthy young adults, suggesting increased need for balance control. We suggest that VE-training on a treadmill holds potential for improving gait and balance control.

Introduction Bioelectrical impedance analysis (BIA) is in widespread use, but there is uncertainty about its validity in patients with metal implants or after acute hip fracture and surgery. We aimed to investigate the use of single frequency tetrapolar BIA in patients with hip fracture by answering the following questions: 1) Are BIA measurements affected by recent hip fracture and surgical repair? 2) Are BIA measurements affected by the presence of metal implants used in hip fracture surgery? Setting Two hospitals in Bergen, Norway. Participants A convenience sample of 203 acute hip fracture patients. Methods Participants had their body composition measured by single frequency, tetrapolar BIA on the fractured and unfractured side of the body in the immediate postoperative period and at follow-up three months after hip fracture. Measurements from fractured and unfractured side and measurements in hospital and at follow-up were compared. BIA readings for hips treated with cannulated screws, compression hip screw and hip arthroplasty were compared. Results Resistance was lower on the side of the fractured hip compared to the unfractured side postoperatively, but not at follow-up. BIA readings did not differ by type of surgical implant. Conclusion Recent fracture and surgery influences single frequency tetrapolar BIA resistance. The presence of surgical implants in the hip do not affect BIA measurements. If BIA is used in acute hip fracture patients, the contralateral side to the fracture should be measured.

Aim The Gait Deviation Index (GDI) is a score derived from three-dimensional gait analysis (3DGA). The GDI provides a numerical value that expresses overall gait pathology (ranging from 0 to 100, where 100 indicates the absence of gait pathology). The aim of this study was to investigate the association between the GDI and different levels of gross motor function [defined as the Gross Motor Function Classification System (GMFCS)] and to explore if age, height, weight, gender and cerebral palsy (CP) subclass (bilateral and unilateral CP) exert any influence on the GDI in children with unilateral and bilateral spastic CP. Methods We calculated the GDI of 109 children [73 % boys, mean age 9.7 years (standard deviation, SD 3.5)] with spastic CP, classified at GMFCS levels I, II and III. Twenty-three normally developing children were used as controls [61 % boys, mean age 9.9 years (SD 2.6)]. Multiple linear regression analysis was performed. Results The mean GDI in the control group was 100 (SD 7.5). The mean GDI in the GMFCS level I group was 81 (SD 11), in the GMFCS level II group 71 (SD 11) and in the GMFCS level III group 60 (SD 9). Multiple linear regression analysis showed that gender, age and CP subclass had no significant correlation with the GDI, whereas height and weight had a slight impact. Conclusion This study showed a strong correlation between the GDI and GMFCS levels. The present data indicate that calculation of the GDI is a useful tool to characterise walking difficulties in children with spastic CP.

Background and purpose Physical activity provides substantial health benefits. Older adults are less physically active than the rest of the population, and interventions that promote physical activity are needed. In this meta-analysis, we investigate how different wearable activity trackers (pedometers and accelerometers) may impact physical activity levels in older adults. Methods We searched MEDLINE, Embase and CINAHL for randomized controlled trials including participants that were ≥65 years, using wearable activity trackers with the intent of increasing physical activity. Studies whose comparator groups were engaged in active or inactive interventions, such as continued a physical therapy program or goal-setting counseling, were not excluded simply for implementing co-interventions. We used random-effects models to produce standardized mean differences (SMDs) for physical activity outcomes. Heterogeneity was measured using I2. Results Nine studies met the eligibility criteria: Four using accelerometers, four using pedometers, and one comparing accelerometers and pedometers, for a total number of 939 participants. Using pooled data, we found a statistically significant effect of using accelerometers (SMD = 0.43 (95%CI 0.19–0.68), I2 = 1.6%, p = 0.298), but not by using pedometers (SMD = 0.17 (95%CI −0.08–0.43), I2 = 37.7%, p = 0.174) for increasing physical activity levels. Discussion and conclusions In this study, we found that accelerometers, alone or in combination with other co-interventions, increased physical activity in older adults however pedometers were not found to increase physical activity. The high risk of bias found in most studies limits these findings. High quality studies that isolate the effects of accelerometers on physical activity changes are needed.

BackgroundSarcopenia is prevalent in older persons and is a risk factor for falls, fractures, and mortality. The aim of this study was to determine a) the feasibility of determining sarcopenia in patients with acute hip fracture, b) the prevalence of sarcopenia and c) associations of sarcopenia with nutritional status and comorbidities.MethodsA multicenter cross-sectional study on sarcopenia in male and female patients with acute hip fracture. Participants were previously ambulatory and living in the community. Sarcopenia was assessed postoperatively with muscle mass estimated by anthropometry using triceps skinfold, arm circumference, height, weight and sex. Grip strength was measured by Jamar dynamometer and pre-fracture mobility was by self-report using the New Mobility Score.ResultsOut of 282 patients, 202 were assessed for sarcopenia of whom 74 (37%) were diagnosed as sarcopenic. Sarcopenia was associated with age, odds ratio (OR) 1.4 per 5 years, 95% confidence interval (CI) [1.1, 1.8], ASA Physical Status Classification System score, OR 2.3 per point, 95% CI [1.3, 4.3] and number of medications at discharge, OR 1.2 per medication, 95% CI [1.0, 1.3] and inversely associated with BMI, OR 0.8, 95% CI [0.7, 0.9] and serum albumin, OR 0.9, 95% CI [0.8,1.0].ConclusionsThirty-seven percent of assessed subjects were diagnosed with sarcopenia. Our data demonstrates that the prevalence of sarcopenia is associated with older age, malnutrition and comorbidities. Determining sarcopenia at the bedside was feasible in postoperative hip fracture patients by using grip strength, estimation of muscle mass by anthropometry and self-reported mobility.

Aim: Hamstring strain injury is common in soccer. The aim of this study was to evaluate the physical capacity of players who have and have not suffered from hamstring strain injury in a sample of semi-professional and professional Norwegian soccer players in order to evaluate characteristics and to identify possible indications of insufficient rehabilitation. Method: Seventy-five semi-professional and professional soccer players (19 ± 3 years) playing at the second and third level in the Norwegian league participated in the study. All players answered a questionnaire, including one question about hamstring strain injury (yes/no) during the previous 2 years. They also performed a 40 m maximal sprint test, a repeated sprint test (8 × 20 m), a countermovement jump, a maximal oxygen consumption (VO2max) test, strength tests and flexibility tests. Independent sample t-tests were used to evaluate differences in the physical capacity of the players who had suffered from hamstring strain injury and those who had not. Mixed between-within subject's analyses of variance was used to compare changes in speed during the repeated sprint test between groups. Results: Players who reported hamstring strain injury during the previous two years (16%) had a significantly higher drop in speed (0.07 vs. 0.02 s, p = 0.007) during the repeated sprint test, compared to players reporting no previous hamstring strain injury. In addition, there was a significant interaction (groups × time) (F = 3.22, p = 0.002), showing that speed in the two groups changed differently during the repeated sprint test. There were no significant differences in relations to age, weight, height, body fat, linear speed, countermovement jump height, leg strength, VO2max, or hamstring flexibility between the groups. Conclusion: Soccer players who reported hamstring strain injury during the previous 2 years showed significant higher drop in speed during the repeated sprint test compared to players with no hamstring strain injury. The maximal speed, leg strength, ability to produce maximal power, endurance capacity, and hamstring flexibility was similar for both groups. Thus, a repeated sprint test consisting of 8 × 20 m could be used as a field-based diagnostic tool to identify players in need of reconditioning programs to ensure complete post-injury rehabilitation.

Older hip fracture patients often have reduced muscle mass, which is associated with adverse outcomes. Dual energy X-ray absorptiometry (DXA) can determine muscle mass, but is not practical in the acute phase. We investigated bioelectrical impedance analysis (BIA) and anthropometry compared against DXA for detecting low muscle mass in hip fracture patients. This was a cross-sectional validation study at two Norwegian hospitals on 162 hip fracture patients aged ≥ 65 years. Appendicular lean mass (ALM) was determined by DXA, BIA and anthropometry 3 months after hip fracture. ALM by BIA was calculated by the Kyle, Janssen, Tengvall and Sergi equations, and ALM by anthropometry by the Heymsfield and Villani equations. The area under the receiver operating characteristic curve (AUC) was used to compare BIA and anthropometry for determining low ALM (≤5.67 kg/m2 for women and ≤7.25kg/m2 for men). Mean age was 79 years (SD 7.9), 74% were female. Mean ALM by DXA was 14.8 kg (SD 2.3) for women and 20.8 kg (SD 4.2) for men and 45% of women and 60% of men had low ALM. BIA (Kyle) in women (AUC 0.81, 95% confidence interval 0.72–0.89) and BIA (Sergi) in men (AUC 0.89, 95% CI 0.80–0.98) were best able to discriminate between low and normal ALM. Anthropometry (Heymsfield) was less accurate than BIA in women (AUC 0.64, 95% CI 0.54–0.75), and equal to BIA in men (AUC 0.72, 95% CI 0.72 0.56–0.87). BIA (Sergi, Kyle and Tengvall) and anthropometry (Heymsfield) can identify low muscle mass in hip fracture patients.