Speaker 6 (00:00)
Off we go!
Speaker 2 (00:00)
⁓
Speaker 5 (00:01)
All right. Make sure everything's working. Yep. All right. Everyone's rolling in. We'll go ahead and get this started so we can fit in as much as possible. Good evening, everyone. I'm Ashley Campbell, not Mike Boyd. I forgot to change my name today. I'm Ashley Campbell, managing editor of IJSPT. ⁓ And I'm going to do some quick housekeeping for you guys for tonight's Journal Club. So let me just quickly share my screen here. If it will. There we go.
So, as I said, welcome to tonight's journal club. Can I get a number from one of the people that
Speaker 3 (00:38)
41
Speaker 1 (00:40)
I think this is 40. great.
Speaker 5 (00:42)
I'll go check in a second. right. Thank you to our sponsors, our title sponsors, AT &T, and Amisca. ⁓ With regards to AT &T Amisca, stick around after if you haven't been on lately, we have a new series, Case in Point, where one of their ⁓ current or recent residency graduates presents a related case or cases to the topics at hand tonight. So we have Delaney on tonight as a guest for that.
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And as a reminder, CEU credits only given for live attendance. You do need to stay on for at least 35 minutes. I send those certificates out through a third party within 24 hours of end of the webinar. If there's any issues with that, please email me. I will send the Google Drive link for the papers in the chat as soon as I turn this off and then use that Q &A feature throughout Journal Club. We will be checking that and answering your questions to the best of our abilities. ⁓ And from there, I will stop my sharing.
and go ahead and turn it over to Rob Manske to get this started.
Speaker 3 (02:08)
All right, thanks Ash, thanks sponsors. I'm Rob Manske from Wichita State University, one of our hosts tonight. We've got several great hosts. We've got two great speakers with us tonight, or guests, I guess. One is Mark Paterno, I'm gonna let him introduce himself in just a moment. Mark's been around with us in sports PT for a very long time. I think Mark and I kind of started much like Mark Phil.
Barb and I kind of all started right around the same time. So we've known each other forever and he's asked Dr. Mielewski to join us. So I'm Rob, like I said, from Wichita State University. I'll let Barb introduce herself real quick.
Speaker 6 (02:49)
All right, quickly, I'm Barb Hugenboom. I hail from Grand Rapids, Michigan, and I'm the editor in chief of IJSPT. So thanks for coming tonight.
Speaker 3 (02:57)
Bill.
Speaker 1 (02:58)
page,
Professor at Fran U, Franciscan University in Baton Rouge, Louisiana. Thanks, Ashley. Thanks for IGSPT and all of our sponsors for putting this together and welcome Mark and Dr. Maluski.
Speaker 3 (03:11)
All right, Mark, do you introduce yourself, tell everybody about yourself and then introduce and let them know about Dr. Miluski.
Speaker 1 (03:18)
Yeah,
thanks so much. So just first of all, I want to thank IJSPT for inviting us to come today to talk about a topic that I think Dr. Maluski and I are pretty passionate about is being returned to sport after ACI reconstruction and psychological readiness and how those, how psychological readiness really interplays into some of that return to sport decision making as well. So I'm a physical therapist. I've been a sports physical therapist for many years, not quite 40, Barb, you beat me by a few, but for quite a few, that's for sure.
⁓ I am currently at Cincinnati Children's Hospital in Cincinnati, Ohio. I'm the Senior Clinical Director of the Division of Occupational Therapy and Physical Therapy and a faculty member in the Division of Sports Medicine. And again, as I mentioned, a lot of my research deals with outcomes after ACL reconstruction. So really excited to chat tonight about it. And I'll just quickly introduce Dr. Matt Maluski. So again, Dr. Maluski and I have gone way back. You know, many years we've worked together in sports medicine realms and pediatric sports medicine realms and
Dr. Maluski right now is at Boston Children's Hospital. He's an orthopedic surgeon ⁓ who just does great work up there and is really, ⁓ I'm excited to have him on, not just because we're friends, but also because he does great work in the space of psychological readiness in a group. ⁓
⁓ of orthopedic surgery. He's an orthopedic surgeon and probably not something that every orthopedic surgeon would address or talk about. So excited to see all the work that he and some of his colleagues at Boston Children's are doing in this space and excited to talk about these articles.
Speaker 2 (04:50)
Thanks for having me.
Speaker 3 (04:51)
Well, thanks for being there. Yeah, thank you very much. ⁓ those of you that don't know Mark, ⁓ Mark is very humble. He is probably one of the best at what he does in researching ACL and multiple different outcomes. He's been doing that kind of stuff for a long time. He's one of the best. We've been wanting to get him on for a long time. So Mark, I'm proud and happy to have you on with us tonight. So thanks for joining us with Doc.
All right, you guys ready to get it? You ready to rock and roll? We're ready. All right. So first study by Tim Sell. Tim Sell and multiple co-authors. I won't even try to list all of them out. the title is Anterior Cruciate Ligament Return to Sport After Injury Scale ACLRSI Scores Over Time After Anterior Cruciate Ligament Reconstruction and Systematic Review with Meta Analysis. So the purpose of this review is to describe ACLRSI
RSI scores over time after ACL injury and investigate factors that may affect ACL RSI scores, including the time between injury and surgery age and biological sex. ⁓ I guess Dr. Mielewski or ⁓ Mark, do you mind, I think probably a lot of people understand what the ACL RSI score is, but do you mind just talking briefly about it? Maybe the history of it, how long it's been used?
How does it work? Do we need to use this in everybody that tears their ACL or are there certain populations that we should use it in maybe more than others or is it like a blanket type score we should be using literally with everybody? Either one of you, whichever one of you wants to take it, that would be great.
Speaker 2 (06:35)
I'll jump in. ⁓ Thanks for having me again. ⁓ ACLRSI ⁓ is a great scale because it's fairly straightforward. It's 12 questions. ⁓ It was developed by Kate Webster and others in about 2008, they published it. And so it's been used for a while now. ⁓ It really measures three different domains, ⁓ emotion, risk appraisal, and confidence. ⁓
And so it targets those types of domains in patients post ACL to sort of understand how folks are feeling about their readiness to return to sports ⁓ and their risk of reinjury. ⁓ Again, it can be used in just about anybody, but I do think for folks who are actually returning to sports, so our younger population, it probably is better served. ⁓ A number of different folks have ⁓ researched this, including myself and Mark.
and found that there are probably slight differences based on ⁓ both gender ⁓ as well as ⁓ age. We've found that our youngest patients, so I do mostly ⁓ kind of 25 and below ⁓ age range for patients, but we found that our youngest age patients, of ⁓ adolescent and preadolescent score better than our like high school age kids and the high school age kids score a little bit better than the adults.
⁓ So there is some age-related changes that we see over time.
Speaker 3 (08:07)
better on this skill a better score is a higher score, correct?
Speaker 2 (08:12)
Correct, yes. So higher score indicates more psychological readiness to return to sport.
Speaker 3 (08:19)
They in this and everybody else, please feel free to hop in if you have questions. So I don't necessarily need to hog the entire night tonight. So if you have other questions that you would like to ask, please feel free to and all of you. Thank you all for joining that. Any of you have questions, please throw them in the question answer force and we can ask Mark and Dr. Mielewski about those as well. But doc does the or Mark does the.
They talk about in this study a 65 score or a 65 out of 100 threshold as where it seems to be kind of safe for people to go back or that's like the number that you want to have at least 65. Does that seem to hold weight do you think most of the time with the patients that you've seen? If you score that, ⁓ that score or better?
Speaker 1 (09:07)
That's an interesting question because, mean, as I read it actually.
And I, you obviously I work at a children's hospital as well. So my population generally is eight to 25 years old. And when we look at our ACLRSI scores, they typically tend to be a little higher than that average of 65. So, but not to say it's wrong. I mean, this data, I mean, to the compliment of the authors in this study, huge amount of data that was included in this study. And I think that does pull in, you know, the many strengths of having a large pool of data. It also pulls in, you know, large populations of data that probably spread
over different ages, different activity levels, different desires to return to sport, you know, but and it pulls all then into one common data set, which, know, is the strength and also sometimes the weaknesses of review and a meta analysis. So for me personally, when I first read it, I thought, boy, that score seems a little low. And so, and so not to say
That's probably an appropriate score for some populations. But I think looking at some more active populations, I would say you might want to get a higher score to determine if someone is psychologically ready. with that too, there's been some other studies. No, no, you're good Rob. There's been some other studies that have looked at cut scores or thresholds related to second injury risk. And generally those numbers are a bit higher. know, and April McPherson and Dr. Webster's group.
published a study that they were quoting more around 76 out of 100 was more of a cut score to be to consider a threshold related to risk of future or second ACL injury. So again, I think that score in certain populations is probably conservative, but it might be appropriate for a general population. And Matt, don't know if you're like, when you do your work too, if you see similar data that that score might be a little higher.
Speaker 2 (10:56)
Yeah, we've recently tried to look at our data and try to figure out what cutoff values sort of seem to matter. And we found that because, at least in young populations, there's such a difference age-wise. ⁓ And to be honest, your risk of re-injury is actually very different from your ACL injury, which is multifactorial. Certainly, psychological ⁓ readiness has a component. ⁓
The bottom line is in our populations, we haven't found a great cutoff value. Maybe I haven't asked the right questions yet, but I don't have a great one for really young folks. I do agree that if you're looking at the literature, 65 sticks out, 76 sticks out from previous literature. But when I've looked at it in young populations, it's a little hard to tease out what really value matters.
Speaker 3 (11:45)
Doc, what age groups are you calling really young?
Speaker 7 (11:49)
I, I, so I divide.
Speaker 2 (11:51)
Usually when I look at my data, I divide it basically into middle school, high school, and then beyond. ⁓
Speaker 3 (11:58)
middle school. Middle school was really young.
Speaker 2 (12:00)
For ACL injuries, yes.
Speaker 3 (12:02)
Yeah, yeah, of course. ⁓ So what are they talk about some modifiable and how modifiable potentially and non-modifiable factors can affect someone's score? Like for example, they were talking about women typically use and you mentioned women always scoring a little bit lower, which begs to ask the question, should our score thresholds? ⁓ So if we have a 65 or 76,
Should the thresholds, ⁓ what do I say this, should our thresholds for the ACL RSI score be different depending on multiple factors like ages, male, female, sex, primary, secondary, ACL, injury risk? Should we have, so I guess what I'm asking is should there not be just one or two cutoff scores? Could we have, should we have potentially five cutoff scores depending on different factors?
Speaker 1 (13:00)
Yeah, I'll chime in, but I'm interested in Dr. Mroewski's thought too. So I think the answer to that is probably yes, but we don't know is the bigger, you know, the bigger elephant in the room is that, you know, although there's, there's variation for many factors that may or may not be modifiable, like you mentioned, sex, age, things like that activity level. ⁓ But I don't know that we could confidently say a certain score in a certain age group is appropriate versus if we looked at a different, different subgroup. So.
Speaker 2 (13:30)
Yeah, I agree. I don't know if there's going to be a clear cutoff value. There may be a way to build a of a nomogram. AI hopefully can help us figure this out. think the more important or maybe the more interesting question is, so why do women seem to score lower than men? And I'll give you my theory. I don't think it's, some people have said, well, it's
difference in psychological readiness. I think it's probably more, at least in my population, females, teenage females, a little bit maybe more honest ⁓ in their question ⁓ answering, particularly when it comes to psychological readiness than maybe some of their male counterparts. ⁓ So it may not be a real difference in psychological readiness, but it may be a difference or bias in how they answer their scores. I don't know if Mark has an opinion.
Speaker 1 (14:24)
Yeah, no, I mean, we see the same thing in our data that it tends to be.
the women tend to score a little bit lower. I do think when you dive into the sub scores too, mean, the majority of the literature just reports the sum score, but I do think it's important to note that the sub scores are confidence, risk appraisal, and emotion. And I do think, honestly, I think a good study and things will do, and I'm sure Dr. Maluski will do is to really try to sub group those, not just by the overall score, but each of those sub scores as well to see if, those factors varying more or less for different populations like women?
women or men. So I think, I mean, there's a lot of good work that needs to be done, could be done. And some of these questions kind of lead right into that. Because again, regardless if we can identify a clear cut cut score or not, it's still informative to clinicians to understand an appropriate range that folks should be in if they could safe, if we would expect them to be able to safely return to activity. So ⁓ I think.
much more to come in that space. And again, I think it's an emerging, it's an emerging area of work, which is exciting.
Speaker 3 (15:33)
doubt. There's always something new to look at. I'm pretty sure this was this study because I had this at least written down. There was something about perceptions of how someone will do in therapy or areas of rehab like pre-surgery or after they're injured before they have surgery and then following surgery. Kind of their pre-perceptions of how they're going to do
after surgery. There are multiple areas. I just know from other areas that I teach and I speak on, there are other areas like the shoulder and knee where there have been studies where they look at someone's preconceived perceptions of how they'll do after surgery. And typically, if someone
feels like they're going to do good after surgery, they do better at certain time frames after surgery, and then someone who actually feels they're not going to do quite as well. Is it the same? Do think it's the same with ⁓ ACL injury? If people feel like they're going to do well, do you think they typically do well, or is that maybe something we still don't know also?
Speaker 7 (16:40)
I that that's true. also think what's an interesting. I studied this a little.
Speaker 2 (16:44)
concept and little bit
⁓ in Connecticut. So I started my orthopedic career at Connecticut Children's ⁓ and UConn and that's where I kind of really got interested in this topic. And so we collected some data there and what we found is also what affects ⁓ RSI is probably the rehab process, meaning how, what patients are told
about how well they're doing ⁓ actually really matters too in terms of how they perceive how they're doing. ⁓ And what we found is that folks who are being ⁓ properly taught technique often involves a lot of correction of some of their landing mechanics and things like that. But there's also then a perception by the receiver, by the patient that
Speaker 3 (17:15)
⁓
Speaker 2 (17:42)
that maybe they're not perfect yet. I think, unfortunately, sometimes ignorance is bliss. And that keep getting told that they're doing great. And then they come to get their functional tests. And then all of a sudden, it's the first time they have sort of a feedback mechanism by which they receive, your strength maybe isn't perfect. Your landing mechanics maybe. All these feedbacks that we give ACL patients now ⁓ sometimes comes ⁓
Speaker 7 (17:50)
folks who.
Speaker 2 (18:11)
comes in kind of heavy and can really affect people.
Speaker 1 (18:15)
Yeah, no, I agree. That's really insightful too. And again, I think it's, you know, as rehab specialists, as you know, oftentimes we focus on the what we do, but not how we do it or how we say it. Right. So, you know, are you doing the right exercise or we do, you know, we addressing the right impairment. But to Matt's point, you know, are there are there factors we consider or delivery methods we consider that may influence some of these other kind of biopsychosocial factors that
We don't measure with a dynamometer or, you know, a Goniometer or anything like that. So I do think it's interesting, but actually to your point too, Rob, think there's probably other measures that better assess what you're asking than the ACLRSI. So if you look into the questions related to the ACLRSI, it's very geared towards somebody who's close to being finished with their rehab. So it'll ask specific questions like, you, you know, do you think you can perform in your sport at this time? So, you know, I, that's one question I've often had, you know, when, and I think this
systematic review nicely showed. The average score preoperatively was 44. I was kind of surprised it was that high. Because you shouldn't be able to perform preoperatively in some of those situations. there's been some data that's been published that talks about that it might not be the best measure early on in rehab, as it's designed more for end stage rehab as well. So again, interesting in this systematic review, you see there's the
The review reports, there's not much change in score from six months on for two years, which is interesting too, considering it's a measure that's designed really for a time that's to be to determine if someone's ready to be released to return to sport. So just interesting to think about what the right timing of it is and the type of questions that are being asked and how it links to what someone's status should be at different points through their rehab process.
Speaker 3 (20:09)
Good points. Good points. Hey, Phil, do you mind talking to us the they describe the risk of bias used in this study? ⁓ Do you mind talking about that briefly? Yes. Yeah, why it's important. And I think they said, if I remember right, there was one of the points they said at the end was there was a pretty most of the studies ⁓ that they found there was a pretty high
risk of bias. Yes, over 70 % of studies were judged to be at a high risk of bias. They're used in this systematic review of meta-analysis. So what is that telling us?
Speaker 1 (20:48)
What's good about, I think that Tim Sell did a really good job with this paper overall and his colleagues. And one of the things that we want to look at is how much potential is there that the results were influenced by something else? And so that's what risk of bias is, is how much ⁓ threat to internal validity do we have in these studies? Internal validity relates to the factors that are directly related to the outcomes.
And so the risk of bias, the higher that risk is, the more influence of outside factors from outside of the study that may have been intrinsic or extrinsic depending on what the factor is. And so what we use are several different tools. When you look at overall quality of a paper, there's two components to quality review. And one of them is risk of bias and the other is reporting checklist.
So on the reporting checklist side, we want to make sure that the authors reported all the necessary information, but the really important one is going to be risk of bias. And in these cases, there were different designs that were used. So you had some randomized controlled trials. You had some observational, non-randomized. Each one of those have inherent bias. So obviously, a non-randomized trial has bias compared to a randomized trial. And so we actually use different tools to
look at risk of bias, the most common for randomized trial would be something like the Cochrane tool that they used. ⁓ Pedro's another one that we can use. And overall, as you said, there was a lot of risk of bias in these studies. So there was a pretty big threat to the internal validity of these. You just take that into consideration as you're interpreting the results as ⁓ a consumer of the literature.
and realized not every study is perfect, but there was a high risk of bias in these studies.
Speaker 3 (22:43)
Great. Thanks, Phil. We have some questions from the participants that are the people that are on with us. One from Gerald Ang. Does it matter if the patient, I think what he's asking essentially is, it matter if the patient does the RSI form from home or in the clinic? So do they maybe score differently depending on where they're at and where do you administer
or where do you have your patients take their forms, Doc and Mark?
Speaker 2 (23:17)
So this is a really interesting question because I have all my patients take the RSI in clinic, but usually I'm collecting it at the six month mark when I do functional test results and I have them take it at nine months when they're usually retaking it and get looking for clearance. And then I usually check it at one year and two years. ⁓ What's really interesting, what I don't think anybody's truly answered yet is particularly when you're giving functional tests.
does the act of taking the functional tests change your perception of your RSI? So I typically administer it after they've taken their functional tests, but I don't know if anybody's done it before and after to see if the actual functional test effect.
Speaker 3 (24:03)
Yeah, yeah. Kind like you said, if they came in thinking that they were doing pretty good, they do their functional tests, find out maybe they're not doing as good as they thought. Would that change their score? It's a great question. You would think it would, but... Yep. Yeah.
Speaker 1 (24:18)
No, I think it could influence it for sure. So that begs, know, that, gets back to from a standardization point, like you should always do at the same time. So, you know, you know, if we, should we always do it before, always do it after, you know, at minimum we should be consistent. ⁓ and I do think that doing it after is probably appropriate, but I would say in our hands, even on a, from a clinical perspective, it probably gets done at a point of convenience during their visit too. So if they're coming in at a busy clinic, you know, it's getting done when they.
when it will get done during the visit, right. But from a research perspective, yeah, we standardize that, and actually typically we do it when they come in. so opposite of what Dr. Maluski does, so we should probably compare our data to see if there's between those two. But I think it's a really excellent point to consider that timing for sure.
Speaker 3 (25:02)
Yeah.
Yeah. Juan Paz, thanks Juan for being on. Did you find literature or have you found literature where someone with a previous ACL injury actually have better scores after their second ⁓ ACL injury or surgery? people typically, I think we're going to talk about that in the next study, right? But I guess you can give a precursor to it,
Speaker 1 (25:32)
I'll let, that's Matt's team that did that. I'll let him answer.
Speaker 2 (25:37)
Yeah, readiness does seem to go down ⁓ after the second ACL injury, ⁓ which probably doesn't surprise folks. Have I looked for the outliers within that data? No, meaning is there somebody in there that maybe is an outlier and more confident after the second ACL? ⁓ Maybe, but I think overall folks
some of that confidence and readiness does go down. ⁓ Some of that may be age related to the patients in general are getting older.
Speaker 3 (26:14)
Yeah, yeah, for sure. So we'll get back to some of these questions online here. I'll tell you what the authors found, what this was with the initial study here. There's evidence, regardless of treatment strategy, whether they had surgery earlier or late, they appear to follow a similar trajectory. Lowest values are seen after injury prior to surgery with an increased score from about three to six months. That's followed by
minimal improvement from six to 12 months. So that's kind of one of the big major findings from this study. So my question to either of you or Barberfield or anyone on, guess, why do we have this lag, this six month lag from six to 12 when that's really, theoretically that's the time that they're really probably becoming stronger.
you know, more agile and hopefully getting closer to returning to sport. Why do we end up with a lag at that time frame where there's not a real increase in their score?
Speaker 6 (27:15)
I just have a guess. My guess would be there's a big reality check going on there. Like, okay, you're six months, you think you're kind of ready. Now we're going to push you a little bit and see what happens. And there's a big reality check. That's a guess. That's totally a guess. Mark, what do you think?
Speaker 1 (27:30)
I know I think it's I think that's a very plausible theory and in all honesty, I do think though that ⁓ you know again thinking at the large pool of data and again it included many different age ranges and activity levels. I would love to redo like to look at a subgroup analysis of this question in different groups say to say hey let's look at the group that is.
committed to going back to activity in a younger age group and see if they look different than, if their trajectory maybe looks different than a group that is happy to get back to everyday activities or maybe recreational activities and getting into that six, nine month range, they feel comfortable with their status at that point. So maybe they plateau there and maybe don't even work from a rehab standpoint to advance beyond that if they've met a certain baseline. So again, I do think it's,
It's interesting, and I think I mentioned earlier on, I was a little surprised by the lower scores, but again, I'm biased by the population I work with, which is a younger population. So I don't know, I'm interested. Again, it had me asking a lot of questions as I read it. Would this comparable data be seen with subgroups within that data set? So maybe more to come.
Speaker 3 (28:29)
Peace.
Did you have anything to add or?
Speaker 2 (28:46)
No, I think Barb kind of hit the nail with the hammer there, which is that ⁓ it gets real during that time point, you know? And I think also when individual studies kind of measure this may vary. So I think it may be a little bit of a wash based on when people are getting cleared and when they're doing their testing, six months, nine months, 12 months.
⁓ methodology wise, it may be pretty similar. We found incremental increases like within our own study, like nine months tends to be better than six months and 12 months tend to be better than nine months. But ⁓ why it sort of washes out with large data, I'm not sure.
Speaker 3 (29:27)
They also found that the readiness, problems with readiness, at least in some of these studies they looked at, even persisted for about two years, they said, which seems kind of a little alarming, I think. ⁓ What do you guys think for them to have like lower scores, I guess, for up to two years or maybe not feel fantastic for two years? Does that seem like a long time or does that seem reasonable?
Speaker 1 (29:54)
Well, I think people recover for up to two years and longer. So it doesn't surprise me that they're that's what their self reporting as well. And also, I think within that subset, you have people who are probably slowly increasing over time, like Dr. Maluski mentioned, and you have other people who are doing more. It's getting real and they're probably starting to score lower over time because there's an appreciation or perception that they're probably not as ready as they may have thought they were before they trialed it to. So, you know, I think I think, you know, again,
That's why I think data like this is interesting and really it should spur more questions as we think about.
Speaker 3 (30:29)
Well, this one is, it? really is. So what so I guess now we know what the study showed what kind of things how can we ⁓ target psychological readiness to potentially improve, help these athletes improve on their scores so that like, we can for sure have them ready by a 12 month timeframe instead of waiting that two years or what is there any way we can
Speaker 1 (30:32)
Yeah, for sure.
Speaker 3 (30:58)
make sure that it's, or try to ensure that it's better at 12 months versus two years.
Speaker 2 (31:04)
Yeah, I think the first thing is just simply asking the questions and then realizing the data. ⁓ And by that, mean what I define super valuable in clinic. ⁓ My current system doesn't spit out the data as quickly as I'd like, but in my prior existence, I used to walk into a patient's room. They'd already taken their IKDC score and they'd taken their RSI score. And it used to be up on a
Speaker 7 (31:14)
East
Speaker 2 (31:32)
computer screen, they would take it in the, and it would be up on the screen. And so I'd come in the room, I'd talk to the patient and very often they'd kind of tell you one story and then you'd look at their data and they say, their IKDT score is great. their RSI is really low. Okay, let's have a little conversation now about why that is. And sometimes just having that data in front of you allows a teenager who, as we know, most teenagers are not super forthcoming with their feelings.
verbally, but if you start asking specific questions, ⁓ sometimes the truth kind of comes out. And so I think just having the data and starting the conversation is a good way to sort of start addressing some of those shortcomings.
Speaker 3 (32:16)
I think I can tell you ⁓ from firsthand knowledge that not all adults are always that forthcoming with their feelings and perception stocks. So it doesn't surprise me that teenagers aren't. ⁓ We have more questions. Do you think there's any concern for athletes that may score very high being overconfident in regard to reinjury? Is some lack of confidence or fear of reinjury normal and better compared to those who've
think they're invincible.
Speaker 1 (32:46)
I'll let Matt chime in, but I've got a strong opinion on that, so go ahead.
Speaker 7 (32:49)
What I was gonna say is...
Speaker 2 (32:51)
That
Mark is the expert in ⁓ this realm in that question, so I was going to defer to him.
Speaker 1 (32:56)
Yeah, no. Back to you. So I think that it's a great question. the reason, you know, we had a publication a few years ago that looked at second injury rates. And what we found was actually that in teenagers who were very active, if you met your return to return to sport criteria, you had an increased risk of injury and all likelihood because you're at a physical capacity to participate at a high level. But then if you were confident on top of that, you were 10 times more likely to suffer a second ACL injury. So again,
In that case, and we didn't use the ACLRSI measures, so I should clarify, we used, there's one question within the COOS quality of life scale that asked if you have knee related confidence issues, and we used that question to determine if kids had any issues with confidence. And again, those that had the highest level of confidence actually had the highest risk of second injury. again, you're in this kind of, you you have to ask, you want to get into a sweet spot? Like you don't want to be too confident and kind of work beyond your means that you have, but.
You and honestly, we had another study that looked at fear. looked at the Tampa scale of kinesiophobia and actually those people who had high fear tended to retear their graft more frequently. So again, you know, you kind of live in different domains of fear.
Speaker 4 (34:08)
Your confidence
Speaker 7 (34:09)
Yeah.
Speaker 3 (34:10)
You got to have that sweet spot that you just tried.
Speaker 1 (34:13)
Yeah.
Speaker 4 (34:13)
know,
but I to- sorry, Mark. But interestingly enough, there were a number of questions about this high score business. And I think you just really hit the nail on the head as well.
Speaker 6 (34:22)
Mm-hmm.
Speaker 7 (34:23)
Exactly.
Speaker 1 (34:24)
So the
question is, what do do with that? Do you want people not to be confident? Or do we need to think about ways to make sure that their confidence level matches their capacity level, right? And that they're able, that what they're feeling and what they're perceiving matches what they can physically do.
Speaker 3 (34:39)
Good point. Good points. ⁓ Laertes Cushing asks, is there a difference based on your clinical experience between a patient having personal goal, personal goal oriented goals versus more like PT setting their goals for return to function? So is it better? Sounds like what they're asking, is it better for the patient to have their own personal goals for getting back to
whatever they need to or a rehab goal set by the therapist.
Speaker 2 (35:11)
I might. Yeah.
Speaker 4 (35:12)
and
Speaker 3 (35:13)
Yeah.
Speaker 7 (35:14)
Yeah.
Speaker 1 (35:16)
I agree completely. Yeah, I mean, think there needs to be rehab guided goals to inform.
again, what a sufficient level of functioning capacity is for people to be successful. But that has to be married with what the patient goal is. So again, if the patient goal is to get back to a high level, professional Olympic level sport, that's a little different than if someone said, I just want to get back to recreational straight line activity, or if I want to be a swimmer, that's going to be different than if I'm going to be a professional soccer player. I do think there's some, it's 100 % what Barb said, it's a yes and on that one.
Speaker 3 (35:51)
Dr. Miliuski, there's some people asking what are you mentioned that you ⁓ usually do the RSI when you bring them back at six months and do some functional tests. What functional tests do you prefer or do you like to have them do?
Speaker 2 (36:08)
⁓ Our three tests include ⁓ isometric strength testing. ⁓ We do ⁓ y balance, and we do the four main hop tests. ⁓ They have to meet certain strength goals to be allowed to jump. ⁓ But that's what we do at six months. In our data, at six months, we don't
clear many folks, about 90 % of folks don't meet most of those criteria in six months. So nine months is usually more of our usual return to sport clearance. But because we had sort of established six months as a usual testing time, it has become not so much a halfway point, but it's become sort of a ⁓ midway point testing for that.
Speaker 3 (37:00)
Good, thank you. Well, have a lot of the, as I was scanning through the questions, guess if Barb, you or Phil or whoever is kind of monitoring too, I think a lot of these we've kind of answered different pieces too. So if you see one that you think we haven't discussed, it should be, why don't you let us know. But I think we're past kind of the halfway point and I would love to get into the study that Dr. Mielewski actually helped with. ⁓ And that is the
Turchala study, I believe. Is that how you say the last name, Dr. Mielewski, Turchala? Turchala. Do you mind giving us a quick overview of the study that you did? Or that you helped them with?
Speaker 2 (37:36)
Torchella.
Speaker 7 (37:44)
Yeah, absolutely. So this was based on our
Speaker 2 (37:46)
data
at Boston Children. ⁓ multiple surgeons, ⁓ but one center. And my partner, Dr. Cristino ⁓ Magdalena was Magda was one of our fellows. ⁓ Dr. Cristino is one of my partners and she's been very passionate about revision ACL reconstruction ⁓ in general, but certainly the psychological component also and
We basically took our revision patients of which we had 30. So these are patients who ⁓ had already had an ACL graft hair had undergone their revision surgery and then had come through our functional testing ⁓ with collection of their data at that point. And then we compared it to a subset of our larger primary group, which we tried to match graph wise as well as age and ⁓ sex wise to kind of
compare apples to apples or as close as we could to kind of see how much does it having a second ACL ⁓ surgery affect some of these outcomes. And what we found is not surprising, know, revision ACL reconstruction patients had lower RSI scores and they had lower ⁓ PD fabs, basically activity scale. So they were going back or expected to go back to less active sport level.
⁓ and they did so with slightly less ⁓ readiness also.
Speaker 3 (39:14)
is the, Doc, you guys use the PROMIS score or scale. Do you mind telling us what that is? How is it different than, the RSI?
Speaker 7 (39:27)
Yeah, so it's good question. So promise.
Speaker 2 (39:30)
or psychological stress experience is another psychological test ⁓ that probably measures more of ⁓ perceived stress ⁓ at the time of testing. ⁓ Basically to try to measure not necessarily anxiety or depression, because there are different promise scales for that, but how stressed these kids are. ⁓ And what we found is
It seems to work better for what we're usually looking at who's ready to go back. These kids do have a fair amount of stress from their age match controls.
Speaker 7 (39:58)
size
sports and activities, but these.
Speaker 3 (40:13)
Yeah. You mentioned that this was a study there at the hospital where you had various physicians. Did you mention protocols? They all have those very similar, well, they can't have really similar, totally similar protocols because they're a fairly large variety of different graft sources. It looks like 59 % hamstring, 10 % bone patella tendon bone, 10 % IT band, 7 quad 10 and 14.
percent akita xalagraft. So you had different physicians, I'm assuming probably some degree of different protocols and different graft sources. Do you think that mix, how does that affect the outcomes and your findings?
Speaker 7 (40:57)
Yeah, so just to clarify, quoted the study well.
Speaker 2 (40:59)
You can't.
That was the primary graft in the revision cohort that failed. not the graft that they got. if you look in table one, the primary graft is what they had the first time and that failed. And then if you look at the revision graft type, it was 70 % BTB, 70 % hamstring. so we then tried to match that cohort.
to our primary core here and we pulled out the graphs that seemed to match so that that graph wouldn't be ⁓ a big confounder. But I think, ⁓ again, you guys are the PT so I won't. I'll do that. I keep most of my protocols ⁓ fairly similar based on graph type. ⁓ The things I change with my rehab protocols ⁓ is usually meniscus repair.
Speaker 7 (41:34)
But exactly.
I'll tell you what at least is zero to
biggest
Speaker 2 (41:55)
initially and then my IT band ACLs which are our youngest ACLs, know kids who are quite young, their rehab is a little bit different. We tend to take them pretty slow. Think of them almost like a meniscus repair. ⁓ We take them pretty slow initially regardless of meniscus tears or not.
Speaker 3 (42:14)
several people have asked ⁓ differing questions, I think, to some degree about the timeframe of testing the RSI and whether six months is a good time to test it. And as I was looking at these two studies, I kind of had that same question. Do we, one of the questions I was wondering, which I think is kind of alluded here, do we, would it, is it actually better? Would it maybe be better? I know you do it at six, but would it, do you ever think maybe it'd be better to get it just a little earlier?
⁓ Or do you obviously you feel six months is adequate. you feel earlier would be of any benefit whatsoever?
Speaker 7 (42:53)
I'll tell you my
Speaker 2 (42:54)
thoughts
and I'd love to hear what Mark does in his study. ⁓ In Connecticut, we used to collect that data at three months and then when they were getting cleared, six months or nine months. What we found is ⁓ early collection of data, both strength data as well as RSI and outcome data was actually very predictive of how they would do. You could identify folks who would do well later by just looking at the people earlier, but you could also identify folks who are going to
be on the struggle bus ⁓ by looking at it earlier. I don't know when do you collect it Mark?
Speaker 1 (43:29)
Yeah, that's a great question. So for, so quad strength, we collect early for short three months. And actually a lot of our data is showing that to your point, how you perform at three months on your quad strength, you've set the, you've set the, the dive for the rest of your rehab. And you can, you have good information about how long it'll take to return and how they'll do after. I think the, I've kind of in my thought process have gone back and forth on the best time to start the ACLRSI. And I think the reason is for the
you know, the comment I made before around, know, the questions are, I think the questions are geared more towards, you ready to return to activity? And so, and especially in a teenage population where sometimes they'll always tell you they're ready, which may be why some of the scores are higher anyways, is because they're overestimating what their, you know, what their status is. So I don't, I don't, I don't have a good answer for the three month mark. I think the six month is very appropriate to do for sure, because I think some, although we don't recommend return to sport that early,
in the majority of populations, people are entering that return to sport continuum phase potentially at six months. So they're getting integrated or introduced to sporting activity. So I think those questions are very appropriate and relatable for kids, especially to say, hey, I tried to do this pivoting cutting thing in clinic and now I don't really know if I feel stable with that or that may give me a pause. I think to Dr. Walensky's point, there could be a lot of value at three months. And again, I never got into that.
because I was worried about the questions. And there is some data that says that even other scales that aren't returned to sports scales are more like fear or some other types of biopsychosocial scales have performed better early on. But again, I wouldn't say not to do it. I think you just have to be mindful of the point in their rehab journey when they're taking it and what it could be telling you.
Speaker 3 (45:24)
Yeah, and I apologize if I was.
If it came across as I was questioning your six, you guys testing at six months, I was definitely not questioning it at all. I agree with that 100%. I was just asking for myself and others who said maybe earlier as, or maybe earlier would be beneficial. So I wasn't discounting anything about the six month timeframe. ⁓ Josh Shaw has, think this is a really good question. I know Mike Voight isn't on here with us tonight, but ⁓ Mike has probably talked to multiple of us on here before.
about ⁓ hip surgeries and or hip patients and using there's like a resiliency score. I guess Ashley might know more about this from talking to Mike than we do, but someone's resiliency score or a grit score. ⁓ you think that would be one of the question is, do you think that would be maybe more insightful than even the RSI type score or or would it be something that ⁓ maybe we should
Consider.
Speaker 1 (46:27)
Yeah, I'll briefly comment, but interested in Dr. Molduski as well. So we have not used grit yet. And I know I think, Matt, you guys have used it a little bit. Or there's been authors that have looked at that. And again, that's.
you passion and perseverance and you know how you're you know, it speaks to your kind of your motivation, which again, for me, when we think about a domain of confidence, that's really interesting because, know, is it somebody that's going to go after it harder, work harder, participate harder that could feed into second injury? ⁓ So we haven't specifically looked at that, although I would be interested in data that looked at that. We one of my colleagues at Since Night Children's has looked at the brief resiliency scale and started to assess that within our
Return to Sport Cohort. So we haven't published on that yet, but it is the scale that we're interested in to see if, again, if it's an appropriate scale to use and what the best timing of it is. But yeah, but I'd be interested in Maths IE as well.
Speaker 7 (47:21)
I have not used.
Speaker 2 (47:22)
grit or resilience scales much. I have a little bit of a bias against grit scales for the following reason. ⁓ I find that, and I'll speak for surgeons ⁓ since I'm the only surgeon here, that I think surgeons have a perception that they have high grit and therefore ⁓ almost ⁓ impose it on their patients.
as a necessary ⁓ portion of their rehab.
Speaker 3 (47:59)
that already? Are you saying you feel like you do that already?
Speaker 2 (48:02)
⁓ I think they do that already and they love to use grit scales because it
Speaker 7 (48:07)
It's so
Speaker 2 (48:08)
selects out of set of patients with high grit, high grit patients are the patients perceived as being harder working, more ready to tackle the hardest things, which is probably true.
I don't think it necessarily serves the greater population of our patients as well, meaning that if patients have a low grit, it's sometimes perceived as being a negative when in fact it's more of a reality of who they are and their personality, unless ⁓ a measure of what kind of rehab or person.
Speaker 3 (48:37)
Yes.
Speaker 7 (48:38)
Yeah.
Speaker 3 (48:46)
And I guess it goes back to what you were talking about. I think this goes back to what you were talking about earlier. If they're told they have low grit, that may actually feed into them feeling like they are not going to put in enough effort or they're not strong enough or they're not good enough. Is that kind of?
Speaker 7 (49:04)
Yeah, I feel like we tell patients
Speaker 2 (49:06)
with low grit that they're not tough enough.
Speaker 3 (49:08)
Yeah, yeah, which could be problematic because like you said, if you're told you're not tough enough for long enough, you're going to believe that you're not tough enough,
Speaker 2 (49:18)
or differently that different level of grit, the in...
Speaker 7 (49:18)
or said, if you have a.
Speaker 2 (49:25)
the things we may need to ⁓ impose on those patients or provide those patients may be different than the folks that we need to do for the high-grade patients. Meaning one of the things I'm working on now is how do we intervene for patients who have low psychological readiness? Like what are the tools that we give them? We've all identified that as a problem. We all identified that it may have influences on outcomes, but how do we actually change that? And who do we intervene for?
And answer is, we probably don't need to intervene for the high-grade people. I'm more concerned about intervening for the low-grade people.
Speaker 3 (50:02)
Yeah, gotcha. Terry Black asked, this seems like it would be kind of intuitive, but I don't know if it is. ⁓ Doc or Mark or Phil or Barb, is the conditioning level prior to surgery? Does that affect someone's outcome? think this is, Terry Black is asking this, and my guess is it's not directed just only to RSI, but to just outcomes, meaning ⁓
Is someone that's in better shape, do we have evidence that they do better ⁓ after surgery? mean, if someone is in better physical condition, I know we always say that they probably will, but do we actually have proof that, know, Mark, if someone's in better shape, if someone's really in good condition prior to surgery, do they always do better?
Speaker 1 (50:51)
So I would say, when you say do better, it depends how we define better, right? So I think it's, could the path be longer? Sure, if they're not in as good of shape. Or if their return to activity goals are not as high or aspirational, maybe success for them may not be at the same level that somebody who was in great shape and have high return to activity goals. So I think that's a little bit.
It's a little bit of a challenging question. mean, the simple thought is, yes, if you're in better shape, it'll be an easier course of rehab and you'll get back sooner. But I think there's other factors that probably mitigate that course.
Speaker 3 (51:31)
What do you think, Phil?
Did Phil say something? didn't hear.
Speaker 1 (51:34)
No, sorry, it was on mute. This is not my area of expertise. I appreciate you trying to do that, but I'm not on the psychological side. You asked me about risk of bias, I'm good. So I'll pass.
Speaker 3 (51:38)
Yeah.
Okay. Have your studies examine ACLRSI before and after psychological interview? No. No, not even have a drink to like stop it.
Speaker 4 (51:57)
Bill, just made a wrong choice!
Speaker 5 (51:57)
There's no
Speaker 1 (52:00)
You
Speaker 6 (52:04)
Amen.
Speaker 1 (52:06)
Hey, I'm just being honest.
Speaker 3 (52:07)
No, you
are. know you are. So they're asking if there are studies that examine the RSI before and after any type of psychological intervention. So ⁓ from a sports psychologist or someone like that, there studies that have looked at that? If someone has a low score, they get an intervention from someone. Do they automatically improve? Or is there even that study out there?
Speaker 2 (52:32)
I'm not aware of there being a study out there. have a study ⁓ about to be published ⁓ probably in next couple of months, which was a prelim study ⁓ looking if we could pull off ⁓ mental skills coaching as part of ACL recovery. ⁓ And I will, I'll spoil it by telling you the punchline, which is that
Speaker 7 (52:35)
that's.
Speaker 2 (52:58)
mental skills training was ⁓ we were able to achieve it and get good compliance. It did not and people subjectively really loved it. ⁓ They reported back that they really enjoyed it and wanted to do it for their other kids and their family and they liked it, but it didn't actually move the needle with RSI as much as you would think. And so the theory I have with that is that
We might, just as Mark has been talking about throughout this hour, which is that the questions are very specific about ⁓ confidence, emotion, and risk appraisal. ⁓ Patients may still have a perception or a fear of injury, ⁓ but that mental skills coaching or psychological ⁓ interventions may...
actually allow you to have better coping ⁓ with your natural or your underlying anxiety about it or fear, it may not actually change whether you perceive there to be a risk of injury or not, if that makes sense. So in other words, I've kind of changed my goals to like, can we make you cope better with your fear rather than get rid of your fear?
Speaker 3 (54:20)
Makes perfect sense. Perfect sense.
Speaker 1 (54:23)
I'd really be interested too in that, sorry. Just I'd be interested too in your work and your work, Matt, to see. So maybe it didn't move the bar on RSI, but maybe there's other factors that it does move the bar on and that are still impactful enough that it can, you that can alter their ultimate outcome. So I'm sure you're reporting that soon.
Speaker 3 (54:42)
Thank you guys. I want to thank both of you for joining us tonight. Dr. Maluski and Mark Paterno. Thank you. This has been very insightful. still have, unfortunately, we have like 20 questions that we're, I don't think we're to be able to get to. Usually we decide if that's, we have that many questions left. That means we need to bring you back again. So, as well.
Speaker 2 (55:06)
It was great to have, great to be here. Thanks for having me. Always happy to come back.
Speaker 1 (55:11)
Thanks so much. Yeah. I think you invite us back, Rob. So that sounds like we can definitely have it. Yeah. sure. Yeah. Perfect.
Speaker 3 (55:18)
We'll get you on. We'll get you. We'll get a date set soon.
Speaker 4 (55:22)
Really good stuff. ⁓
Speaker 2 (55:24)
seconds.
Speaker 4 (55:24)
Right. Yes, I'd like to introduce Delaney Willingham. She's going to present her case in point, which is the feature that we run through Amisca. And Delaney is an HDI recent residency grad within the last two weeks. And so Delaney, if you want to go ahead and share your slides, we're going to have ⁓ a brief discussion of a case in point. We hope you can all hang around.
All right, can you all see that? Yes, thank you. Cool, thank you. All right, so yeah, my name's Delaney. I'm going to be presenting. I have two cases that I wanted to talk about for the sake of comparing and contrasting. So I had two high school football players. Both of them were going into their senior year. Both of them had ruptured their ACL when they were tackled while playing football. One of them had also torn both his medial and lateral meniscus as well.
Both of them were going to PT prior to coming to me just elsewhere. So when I got them, one was three months out and the other one was already at nine months out. He had been going to PT prior, but it stopped. And when he went back to his surgeon to try and get cleared for returning to sport, his surgeon said that he needed to go back to PT and get stronger. So that's when he came to me. When I did get both of them, they both had full range of motion, which was great, but they both just had generally weak quads, poor.
neuromuscular control. And I picked both of these cases because they give a pretty good representation of kind of the two opposite ends of the spectrum as far as physical versus psychological readiness for return to play. And I'll get into that in the next couple of minutes.
So as far as treatment, once I got them, again, they were at very different points in their rehab processes. What they both obviously needed was quad strengthening. And for that, I focused a lot on emphasizing that quad strength throughout their entire range of motion. So trying to work on quad strengthening and more knee flexion so that that knee is a little bit more supported by the quad, regardless of what emphasis.
what's asked of the knee in their various like return to sport activities. So for the differences in treatment, obviously one was three months out. For him, he was dealing with more of a leg lower extremity strength asymmetry, which we'd expect at that time. So I was doing a lot of BFR pretty frequently, and we focused a lot on more single leg strengthening to avoid his non-surgical leg from overcompensating for a surgical.
As he got stronger over the next several weeks, we were able to shift more toward starting some plyometrics and continuing to progress his strength, of course. ⁓ The one who was already nine months out, when he came to me, he was generally just more deconditioned, had bilateral lower extremity weakness. So for him, we did some single leg strengthening, but also just more double leg strengthening in addition to that.
And initially when he came, we were doing kind of 50-50 of plyometrics and strengthening stuff. But for him, the focus shifted back more towards strengthening a little bit later on after his progress started to progress, after his progress started to regress, excuse me. And we just needed to focus more on building up the resilience of that quad. So it was able to support those more plyometric and agility activities. And then.
As far as the three months out, the one who was three months out, our focus for him shifted more ⁓ toward those plyometrics after the strengthening continued to progress. So one kind of more plateaued, one was making kind of more steady progress for the most part at the beginning.
So return to sport testing for both of them, the most recent testing that I did was when one was at seven months out and the other one was at 12 months out. Technically both of their quad strength LSIs were greater than that 90 % that we're looking for. With the top graph, that's going to be the one who was seven months out. You can see that pretty obvious dip in that blue line, which is actually his non-surgical side. So that was kind of interesting.
to see, and I think that part of that, which I'll get into a little bit, was his psychological aspect was kind of more so trying to get his surgical side to appear like it was a bit further along compared to his non-surgical. So it seemed like, obviously you can see that dip and then it kind of stayed around that same decrease in strength. So.
Obviously it's looking like his surgical leg is quite a bit stronger and continuing to climb. So that's good in itself that his surgical leg was getting stronger. But again, I'll get into it a little bit more with what I think went into ⁓ that dip of his left side. With the other one, the bottom graph is the one who was already 12 months out at this time. When he first came to me, he had just had some sort of injury to his
non-surgical leg, which is again the left one, that blue line. So that was a little bit weaker comparatively to his surgical leg, which was interesting. But as you can see with that second data point, both of them, both of those strength levels had improved. And at that time his surgical leg was just slightly weaker than his non-surgical, but so well within that 90 % range. And then back to the, the top graph. So
Even though I don't know for certain where his ⁓ strength symmetry was at this time, I do know that his peak force of his left, non-surgical, which is that second data point, that was 264 pounds. And then the peak force of his surgical leg, which was the last data point of that orange one, 239, that's still right around that 90 % limb symmetry. So in that sense, that's why I say
Technically they were both within that range that we were looking for, but I don't know for certain how, like what that actually limb symmetry was for him. I also did hop testing for both of them at this time. The one who was seven months out didn't do as well, which is more expected given that he's only seven months out. So it was between those, different hop tests he arranged between 64 and 75 % of that LSI. The 12, the one who was 12 months out.
ranged between 92 and 99 % of that LSI. So his was quite a bit more close to what we were looking for as far as returning to sport. But again, he was a bit further out. So that'd be more expected for him. For the Y balance, a little bit more interesting here because the one who was seven months out ranged from 94 to actually quite a bit over 100 % of that limb symmetry. That had to do a lot more with, I think he was just kind of practicing
trying to get the numbers that he thought I was going for, which kind of also aligns with what I was saying about his quad strength data. So I'll get into that a little bit more in just a second. But then the one who was 12 months out on the Y balance was kind of getting close to that 90%, but still not quite there ranging from 85 to 97 with the various directions of the Y balance.
So, as far as psychological versus physical readiness for return to sport, one of them seemed like he was potentially mentally ready for returning, but definitely was not where he needed to be physically. It seemed like he was just getting tunnel vision and was hyper-focusing on returning to sport, regardless of how he was actually feeling. And like I mentioned earlier, I think that that contributed to some of the skewing of that data of his both quad strength and also that wide balance, just getting those numbers that he thought.
needed to be on paper in order for him to go back without really considering how he was actually feeling about everything and also just how like his movement pattern looked. So with the Y balance, for example, he was trying to get that slider as far back as he could each direction, but not taking into account that he was using a lot more hip strategies like trunk forward lean rather than putting his trust and confidence in that knee and allowing it to support him as he was moving in each various direction.
So for him again, he was really just trying to get good at those tests versus actually building up the confidence and resilience that he had in his quad. Because I started to notice that he seemed to be going in that direction of where his mental and physical components were not really aligning as much. We had several conversations about just what it meant to be ready for returning to sport and also the potential for reinjury risk and just.
the impact that could be had on his overall knee health if he didn't have that full physical recovery as well. Unfortunately, I don't think that really got through to him just because it's when you're a senior in high school and it's like somebody's telling you, you can't go back to play. That's a tough thing to hear because it's your last chance. And he was trying to go back and get offers and he had people with scouts looking at him prior, but then he lost some of those and it was a, it was definitely a tough
a mental situation for him. The other one on the opposite end of the spectrum was potentially physically ready. If not, he was getting very close to being ready, but his mental component was just not where it needed to be. I think part of that did have to do with his contralateral knee getting some sort of injury as well, kind of closer to that nine month timeframe when he was post-op.
So for him to try and address that, we were just continuing to focus on that physical component. So continuing to strengthen as much as we can, just working on his confidence with movement, whether it be the strengthening or the agility or plyometric ⁓ movements.
So key points, the psychological and physical readiness can occur independent of each other and they're not always going to align. I think that's important to consider. And then also quality of movement is equally as important as the limb symmetry index. So for my guy who was kind of making those numbers look better on paper, it's as equally as important to see how he's moving and how he's trusting his knee versus trying to get around using his quad.
And return to sport testing alone is not sufficient for full return to sport clearance. And we need that combination of strength, the movement quality and control and the confidence with those movements.
That's all for me.
Thank you, Delaney. Questions from the panel? Anybody want to shoot a question at Delaney real quick?
Speaker 5 (1:06:12)
Delaney, where are these like very, very recent? I think I saw August in there. Do you have an update on where they're at presently?
Speaker 4 (1:06:22)
So I, when I was in my residency, I was at one clinic where both of these kids were going. And so I haven't seen them. Well, one of them, the reason that I said, I think that my conversations didn't get through is cause he went back to play ⁓ prior to being cleared. So he was already back playing football when he was like seven and a half, eight months out, unfortunately. So I don't know where he is at. I hope that he's safe and
not in a bad situation there. The other one, same idea, I didn't get to actually see his full return to sport ⁓ clearance, but ⁓ he was kind of just making very, very slow, sort of steady, of cyclical progress there, so I don't have a good update on him, but I'm hoping that he's continued to progress since I've been gone.
I just had a quick question too, Delaney. that, did you use the ACLRSI? I mean, you're talking about their psychological readiness and what you thought about that, but did you use a tool or anything like the ACLRSI? I didn't, I will be fully honest. So these were my first, before I started my residency, I had seen zero ACL patients. So it was kind of tough. My clinicals were weird, but
So these are, this was my first group. think I had like seven or eight throughout the year that I was here to America with Fancy and I did not use any of those things, but it's, I will at this point. I, I think I was, I was kind of relying on the, the IKDC cause that's just the one that we are like prompted to give them. So that was the most, guess, like objective, ⁓ measurement of, of where they were at physically and mentally. So that's the best that we had, but I did not use the ACLR site.
Thank you. Thank you. Other questions or other thoughts?
Speaker 2 (1:08:22)
Delaney, it was a great, great presentation. I think you picked up on some very key kind of concepts there, which is that strength and sort of perceived readiness don't always go together. But at the same time can affect each other. ⁓ And I think it's really hard sometimes to give repeated tests that we're judging patients to go back to sport on.
namely functional tests, because kids are pretty smart, adults too. And they figure out ways to kind of game the system if they want. I used to have a athletic trainer who did most of our isokinetic testing, HUMAC. And he used to be like the HUMAC whisperer, because he could look at the graph and he could tell when kids were fudging it, know, and not really trying.
And he used to be like, these look equal, Matt, but there's something up. It's hard. You had the right perception there.
Speaker 4 (1:09:31)
Look at the coefficient of variance.
Speaker 5 (1:09:35)
important note too is just, obviously you're a newer, you're a newer clinician and maybe you didn't use all of the tools that we're encouraging people to use and talking about on the external club, but at the same time, using your clinical judgment and your instincts to like make decisions and how you're going to address things is, is still important despite what tools at your disposal. So I think that was really great. So good job to you.
Speaker 4 (1:10:00)
Thank you. Yeah, absolutely. And you read those patients. It sounds like you read the patients. And you talk to them about some of the things that you thought you saw going on. And we can't control them even if we talk to them. yeah. Sure.
Speaker 6 (1:10:13)
you
Speaker 4 (1:10:16)
All right.
Speaker 5 (1:10:17)
I think we lost Mark. was going to give him up. There he's back. Any last comments, Mark?
Speaker 1 (1:10:21)
No, no, was going to, I was going to, yeah, my lighting, there we go. So sorry about that. No, I was going to say, I.
Kudos Delaney on your presentation. I appreciate that you looked kind of globally too, not just at only strength ⁓ and thank you for looking at quality of movement. I think we didn't really talk about that too much tonight because that wasn't the focus, but again, such a key metric and certainly as physical therapists, that's our sweet spot in movement. And I think we can appreciate more and more how important quality movement is in return to sport decision-making. So thank you for making sure we didn't have a journal club without mentioning that. So appreciate it.
Speaker 4 (1:10:58)
And I just want to echo what Mark just said. As physical therapist movement, that's our sweet spot. That is a really good quote, Mark. I'm going have to put that somewhere. I don't know where, but yeah.
Speaker 3 (1:11:10)
Thank you.
Speaker 5 (1:11:13)
All well, I think it's about time to wrap it up. So thank you to all of our guests tonight. It was very insightful. Of course, I always walk away with some sort of pearl, especially when we're not talking about the hip. ⁓ So thanks to everyone. And we will be back next month in November with the general, none other than George Davies and friends to discuss ⁓ another paper. that will... ⁓
Speaker 4 (1:11:34)
You
Speaker 5 (1:11:41)
The signups for that will be out very, very soon. And we look forward to seeing everyone. And thanks for everyone who stuck around all the way to the end. Everyone have a great night. Thank you very much. Bye everyone.
Speaker 4 (1:11:50)
Thanks everybody.
