Proprioception after ACL injury


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Presented at ACL Study Group Meeting.
Phuket, Thailand

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  • Proprioception is beleived to play an important role in the dynamic stabilization of joints through afferent signaling from joint receptors activating a motor response which results in effective muscle contractions to provide stability.
  • It has been stated that proprioceptive deficits after ACL injury may:

    for example
    be a factor related to giving way
    resulting in additional injuries

    Moreover it has been claimed to limit re-establishment of quadriceps strength

    Unfortunately, evidence supporting such claims is not readily available.
  • The two most commonly methods to quantify proprioception were included.

    - TTDPM assesses the ability of a subject to detect the onset of motion of the knee

    - JPS is the ability of a subject te reproduce a predetermined angle

    TTDPM has been found to be more repeatable and precise than JPS, and other methods of assessing proprioception were shown to have poor accuracy.8 F

  • The aim of this review is to summarize the effects of proprioception in ACL-D and ACL-R patients and its relation to common clinical outcome measurements such as:



    hop tests

    patient reported outcome

  • Combined search in Medline, Cinahl and Embase and a manual search resulted in 1120 studies

    4 were excluded because of language restrictions.

    The yield from this search of 1116, left a total of 83 references which were identified as potentially relevant after reading the abstract.

    Subsequently, the full text of these studies were assessed after which a further 59 studies were excluded as they did not meet the inclusion criteria.

  • The methodological quality was independently assessed by a modified score from Cochrane Group and the Oxford Center for Evidence Based Medicine
  • A correlation between proprioception and quadriceps strength was calculated in 5 studies.

    In 2 studies isometric quadriceps strength1 was tested whereas the 3 remaining studies examined isokinetic strength.
    The 2 papers reporting on isometric strength showed a respectively good correlation between proprioception and hamstring/quadriceps ratio whereas a low correlation was found between proprioception and isometric quadriceps strength.

    The studies examining isokinetic quadriceps strength found no, or a low correlation with proprioception

  • Ten studies included in this review reported the correlation between proprioception and laxity.
    Nine of these studies found no correlation. In 3 studies it was stated that there was a non-significant correlation, although the numerical data were not provided.
    In one study a low correlation was found (Muadi)
    The studies included ACL-R and ACL-D patients and revealed that in neither group a correlation was found
  • The correlation between proprioception and hop tests was reported in a total of 7 studies. In general no or a low correlation was found in 5 studies
    and a moderate correlation in 2 studies.
    Six studies reported on ACL-D patients and the remaining study on ACL-R patients.
    Borsa et al reported on the same patients in 2 separate studies but used different calculations of proprioceptive deficits which resulted in low correlation in one study and a moderate correlation respectively in the other.
    Friden et al reported generally low correlations between hop tests except for TTDPM at of 40° of flexion moving into extension which showed a moderate correlation.28

  • Of the 4 studies that examined balance, 1 study paper found a moderate correlation with proprioception, whereas the other 3 studies found no correlation. It should be noted that the study that found a moderate correlation with TTDPM, did not find a correlation when examining JPS in the same patient population.

  • A variety of patient questionnaires were used to determine correlation with proprioception. However, the current validated patient reported outcome such as KOOS, IKDC or Cincinnati were only used in 5 studies.
    Four of these studies found no or a low correlation between proprioception and KOOS, IKDC and the Cincinnati score
    One of the 5 found a moderate correlation with the Cincinnati at 3 months after surgery.
    Interestingly, this changed to no correlation at 6 months after surgery.
  • Summarizing: results show that most frequently either no or a low correlation was found between proprioception and outcome measurements
    Mean score was 8 out of a maximal 16 points indicating room for methodological flaws in majority of studies.

    ␣␣ Strong correlation does not imply causation (i.e. that changes in one variable cause changes in the other variable).
    ␣␣ Example*: There is a strong positive correlation and the average life expectancy for the world’s nations. Does having more TV sets cause longer life expectancy?

  • The mean reported proprioceptive deficits were small in patients with a
    TTDPM mean deficit 0.4° for ACL-D

    Therefore, even in comparison to healthy subjects, the differences are small and not likely representing any clinical relevance. For example, one may ask if a mean proprioceptive deficit of 0.4° for TTDPM could discern between those patients who experience instability and those who do not ????

    (TTDPM mean deficit 0.2° ACL-R
    JPS mean deficit 0.5° for ACL-R patients.
    The difference in healthy subjects is 0.1° for TTDPM and 0.1° for JPS measurements. JPS mean deficit 0.8° for ACL-D)
  • There is clearly a need for better assessment tools given the reported incidence of recurrent injury to the operated knee up to 17% in patients under 18 years of age found in a recent study by Shelbourne.
    And also considering the immediate and short term associated morbidity and costs and increased risk of osteoarthritis (0% to 13% for patients with isolated ACL-deficient (ACL-D) knees and respectively 21% to 48% in patients with combined injuries.46

  • In light of the results of this review we would recommend the development of new tests to determine the relevant role of the sensorimotor system.
    Moving away from peripheral receptors.

  • Strategy could be: to develop new tools to get the relevant answers in analogy to methods used by Hewett et al: first develop lab tests to gain insight in the mechanisms involved.
    later followed by clinical applicable tests preferably as a screeening tool.
  • Strategy could be: to develop new tools to get the relevant answers in analogy to methods used by Hewett et al: first develop lab tests to gain insight in the mechanisms involved.
    later followed by clinical applicable tests preferably as a screeening tool.
  • Strategy could be: to develop new tools to get the relevant answers in analogy to methods used by Hewett et al: first develop lab tests to gain insight in the mechanisms involved.
    later followed by clinical applicable tests preferably as a screeening tool.
  • This is what we are currently doing in the Netherlands: using virtual reality combined with motion analysis system providing real time data to and from the subject tested.
  • Let me end by asking you if there would be any interest in discussing the topic of sensorimotor system in more detail at the next meeting in 2012.
  • Proprioception after ACL injury

    1. 1. Proprioceptive deficits after ACL-injury. Are they clinically relevant ? A systematic review A. Gokeler, A. Benjaminse, S. Lephart, L. Engebretsen, E.Ageberg, M. Engelhardt, M. Arnold, K. Postema, E. Otten, P. Dijkstra
    2. 2. proprioception Andriachi in:
    3. 3. Introduction proprioceptive deficits after ACL injury are claimed to be related to giving way Friden 1996 higher incidence of subsequent injuries Friden 1996, Cooper 2005 adversely affect activity level Barrett 1991 poor balance Bonfim 2003 quadriceps weakness Friden 2001
    4. 4. proprioception Beynnon 2000 Chinese Medical Journal 2008; 121(22):2224-2228! TTDPM %&'! ()*+! )+,! !-! %&'! ./011*+234! 56718.*&+! 7'*90'*)! JPS Zhou 2009 !"$! lephart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t!90.9!BP J$4$#34! ! Figure 1. L..0..=0+9!&%!('&('*&70(9*&+4! Figure 2. L..0..=0+9!&%!*.&R*+09*7!.9'0+29@4!
    5. 5. what is the evidence ?
    6. 6. Material and Methods n=1120 n=4 excluded language n=83 potentially relevant n=59 excluded n=24 included
    7. 7. Methodological Quality maximal score 16 points
    8. 8. Results Correlation Proprioception Strength (n=5) 2 NO Co 1993, Ageberg 2008 2 Low Borsa 1998 , Zhou 2008 1 good Corrigan 1992
    9. 9. Results Correlation Proprioception Laxity (N=10) 9 No Beynnon 1999, Fremerey 1998, Harter 1992, Risberg 1999, Roberts 2004, Wright 1995 Adachi 2002, MacDonald 1996, Reider 2003 1 Low Muaidi 2009
    10. 10. Results Correlation Proprioception Hop Test (n=7) 1 No Ageberg 2008 4 Low Borsa 1998 , Friden 1998, Katayama 2004, Risberg 1999 2 Moderate Borsa 1997, Friden ttdpm 40
    11. 11. Results Correlation Proprioception Balance (N=4) 3 No Ageberg 2005,Birmingham 2001, Borsa 1998, JPS: Lee 2009 1 Moderate TTDPM: Lee 2009
    12. 12. Results Proprioception Patient reported outcome (n=8) No Low Mod IKDC Muaidi 2009 Muaidi 2009 (only 3 Cincinnati Wright 1995 Borsa 1998 months post-op) Risberg 1999, KOOS Agberg 2008 Reider 2003, Borsa Lysholm 1998 Fremerey 1998 Tegner Roberts 2004
    13. 13. Discussion Correlations proprioception and outcome not clinically relevant 32 no or low mean score methodological 7 moderate quality 8 (max 16) 1 good
    14. 14. Discussion lephart, Beynnon 1999 Unstable ? Stable ? 0.4(*) Mean deficit all TTDPM studies ACL-D
    15. 15. Discussion new approach is needed Arthritis Recurrent injury oiestadt 2009 Shelbourne 2009 valid tests to measure the relevant role of the sensorimotor system
    16. 16. Sensorimotor System Lephart 1992 “We can’t prevent what we don’t understand” macLean J Athl Tr 2008
    17. 17. Discussion hewett et al 2002, 2005 Lab Clinical
    18. 18. Discussion hewett et al 2002, 2005 Vol. 37, No. 12, 2009 ACL Deficiency Causes Brain Plasticity 2423 Lab Kapreli 2009 Figure 1. Statistical parametric mapping of control group and anterior cruciate ligament (ACL) group activation. study, the ACL group had diminished activation in several Clinical sensorimotor cortical areas and increased activation in pre-SMA, SIIp, and pITG compared with the control group, indicating modifications of the CNS. An important issue in fMRI methodology in mapping cortical activation is the selection of the participants. To eliminate the intersubject variability, a number of differ- ent factors were taken into account in the current study such as gender, limb dominance, level of physical activity/ motor skill specialization, and neuromusculoskeletal integ- 25
    19. 19. Future directions
    20. 20. Future direction ACLSG 2012?