5/9/2014 Disclosures Y- Balance Testing in Anterior Cruciate • Lau, Tufts, Souza, Li, Feeley, Allen: Injuries and Following Reconstruction – No Disclosures • Ma: Brian Lau 1 MD, Lauren Tufts 2 BS, Richard Souza 2 DPTPhD, Xiaojuan Li 2 PhD, – Educational support from Zimmer Brian Feeley 1 MD , Christina Allen 1 MD , C. Benjamin Ma 1 MD – Research support from Zimmer, Histogenics, Moximed 1. UCSF Department of Orthopaedic Surgery. 2. UCSF Department of Radiology and Biomedical Imaging. • Study Funding: – AOSSM Genzyme Osteoarthritis Grant for Clinical Research – NIH/NIAMS P50 AR060752 Introduction Purpose & Hypothesis Methods Results Discussion Introduction Purpose & Hypothesis Methods Results Discussion P50 ACL Study Introduction • Prospective Study of 50 patients with ACL injury • ACL injuries are common • Study to investigate changes in cartilage health using • ACL-deficient (D) knee leads to instability quantitative imaging, knee kinematics using • Instability related to balance ---> postural control and quantitative MR imaging and kinetic testing using functional performance motion analysis and functional evaluations • Balance testing may be able to assess functional • Longitudinal ACL observational study at baseline (after deficits in ACL-D knees and recovery after injury), then 6 months, 1 year, 2 years, and 3 years reconstruction (after reconstruction) • Goal is to understand the natural history of post- traumatic arthritis following ACL injury and reconstruction and identifying ways to recognize patients earlier in the time course 1
5/9/2014 Introduction Purpose & Hypothesis Methods Results Discussion Introduction Purpose & Hypothesis Methods Results Discussion Introduction Introduction • Static Balance testing has been criticized as not • Star Excursion Balance Test uses 8 different sufficiently challenging enough for physically active patients positions for each leg • Star Excursion Balance Testing (SEBT) is a dynamic test that requires strength, flexibility, and proprioception – Shown to be reliable measure that sufficiently challenges active patients – Used identify chronic ankle instability, assess physical performance, and identify athletes at greater risk of lower extremity injury Introduction Purpose & Hypothesis Methods Results Discussion Introduction Purpose & Hypothesis Methods Results Discussion Introduction Purpose and Hypothesis • Y-Balance testing: Baseline (after ACL injury and prior to reconstruction) - Purpose: To evaluate balance in ACL-D knees, contralateral knees, and – 3 of 8 Positions healthy controls – Equally Effective - Hypothesis : ACL-D patients will have less balance compared to contralateral knees and healthy controls – Improved efficiency and repeatability 6 Months (after ACL reconstruction) – Intrarater reliability - Purpose: To evaluate affect of ACL reconstruction on balance and 0.85-0.91 relationship of Y-balance with other functional tests – Interrater reliabilty - Hypothesis : ACL reconstruction will improve balance and Y-balance will correlate with other functional testing 0.99-1.0 2
5/9/2014 Introduction Purpose & Hypothesis Methods Results Discussion Introduction Purpose & Hypothesis Methods Results Discussion Methods Baseline ACL-D Knee vs Contralateral Knee Baseline ACL-D 6 Months ACL-R Healthy Controls vs Healthy Control Knee N 45 31 14 * * * Age (yrs) 29.2 +/- 8.7 29 +/- 8.6 30.3 +/.- 5.1 * 140 BMI (kg/m2) 23.7 +/- 2.8 23.9 +/- 2.8 23.4 +/- 1.9 Reach Distance (% leg length) ACL-D 120 Healthy Controls Male/Female 24/21 17/14 8/6 *2.76 Contralateral 100 Time from injury to 53.65 +/- 35.2 days baseline evaluation 80 Smallest Detectable (days) Difference: 60 Time from surgery to 189.16 +/- 30.38 Anterior= 6.87 40 evaluation (days) days PM= 8.15 PL=7.11 20 Exclusion Criteria: Other ligamentous injuries, meniscal injury requiring repair, previous history of arthritis, knee trauma, or surgery. 0 * Indicates p < 0.05 Anterior PM PL 1) All patients underwent Y-balance testing- 3 trials (Max) 2) Max Recorded value taken and normalized by leg length ACL-D knee and Contralateral Knee have similar reach 3) Trials done for each leg and have less reach in Posterior Medial and Posterior 4) At 6 months Single Leg Jump (distance) and 6-meter Timed Hop (time) was performed Lateral direction compared to Healthy Controls Introduction Purpose & Hypothesis Methods Results Discussion Introduction Purpose & Hypothesis Methods Results Discussion ACL-Injured Knee Longitudinal 6 Months ACL-R Knee vs Contralateral Knee Baseline to 6 Months Following Reconstruction vs Healthy Control Knee * *4.9 140 Baseline 140 Reach Distance (% leg length) 120 ACL-R Reach Distance (% leg length) 6 Months 120 *3.07 *3.39 Healthy Controls 100 100 Smallest Contralateral 80 80 Detectable Smallest Detectable Difference: Difference: 60 60 Anterior= 6.87 Anterior= 6.87 PM= 8.15 40 PM= 8.15 40 PL=7.11 PL=7.11 20 20 0 * Indicates p < 0.05 * Indicates p < 0.05 Anterior PM PL 0 6 months following ACL reconstruction and rehabilitation Anterior PM PL reach for ACL-R knee and Contralateral knee are similar and Posterior-Medial Reach significantly improved and meet match Healthy Controls Smallest Detectable Difference 3
5/9/2014 Introduction Purpose & Hypothesis Methods Results Discussion Introduction Purpose & Hypothesis Methods Results Discussion Contralateral knee Longitudinal 6 Months Y-Balance Test Correlation with Single Baseline to 6 Months Following Reconstruction Leg Jump and 6-Meter Hop * *6.68 ACL-R Knees Contralateral Knees Healthy Control Knees 140 Single Leg 6 Meter Single Leg 6 Meter Single Leg 6 Meter Baseline 120 Jump Hop Jump Hop Jump Hop Reach Distance (% leg length) 6 Months (N=22) (N=22) (N=31) (N=31) (N=28) (N=28) *2.61 100 Anterior R= 0.52* R= -0.40* R= 0.44* R= -0.31 R= 0.34 R= -0.57* Smallest Reach 80 Detectable Posterior- R= 0.62* R= -0.54* R= 0.46* R= -0.32* R= 0.44* R= -0.62* Difference: 60 Medial Anterior= 6.87 Reach PM= 8.15 40 PL=7.11 Posterior- R= 0.47* R= -0.50* R= 0.49* R= -0.56* R= 0.57* R= -0.75* Lateral 20 * Indicates p < 0.05 Reach * Indicates p < 0.05 0 Reconstructed, Contralateral, Healthy knees: Anterior PM PL Posterior-Medial Reach significantly improved and meet Longer Y-Balance Reach Correlates with Longer Single Leg Smallest Detectable Difference Jump Distance and Shorter 6-Meter Hop Time Introduction Purpose & Hypothesis Methods Results Discussion Discussion References 1) Bollen s. Epidemiology of knee injuries: diagnosis and triage. Brit J sports Med 200;34:227- 8 • Herrington et al demonstrated with Y-balance testing 2) Barret D, Cobb A, Bentley G. Joint proprioception in normal, osteoarthritic and replaced that ACL deficient and Contralateral knees had similar knees. J Bone Jt surg 1991; 73-B:53-6. 3) Lephart S, Fu F. The role of proprioception in the treatment of sports injuries. Sports Sci Inj reach and less than healthy controls at mean 11 months 1995;1:96-102. after injury. 4) Friden T, Zatterstrom R, Lindstrand A, Moritz U. Anterior-cruciate-insufficient knees treated with physiotherapy. Clin Orthop Relat Res 1001;262:190-9. • Our study is unique as it follows patients before and 5) Gribble PA, Hertel J, Plisky P. Using the Star Excusion Balance Test to Assess Dynamic Postural-Control Deficits and Outcomes in Lower Extremity Injury: A Literature and after ACL Reconstruction and demonstrates return of Systemic Review. J Ath Training 2012;47(3):339-357. balance function at mean 8 months after injury (6 6) Hertel J, Miller J, Denegar C. Intratester and intertester reliability during Star Excursion Balance Tests. J Sport Rehabil 2000; 9:104-16. months after reconstruction) and we demonstrate that 7) Kinzey S, Armstrong C. The reliability of the star excursion test in assessing dynamic Y-balance testing correlates with other functional tests balance. J Orthop Sports Phys Ter 1998; 27:356-60. 8) Herrington L et al. A Comparison of Star Excursion Balance Test reach distances between • Y-Balance testing may be a safe and cost effective way ACL deficient patients and asymptomatic controls. The Knee . 2009.16;149-152 to assess functional deficits and recovery for ACL 9) Plisky PJ, Gorman PP, Butler RJ, Kiesel KB, Underwood FB, Elkins B. The reliability of an instrumented device for measuring components of the star excursion balance test. N Am J injuries Sports Phys Ther. 2009 May; 4(2):92-9. 4
5/9/2014 Acknowledgements C. Benjamin Ma, MD Richard Souza, PT PhD Brian Feeley, MD Christina Allen, MD Lauren Tufts, BS Drew Lansdown, MD Musa Zaid, B.S. Xiaojuan Li, PhD UCSF Orthopedic Surgery Residents UCSF Department of Orthopaedic Surgery Musculoskeletal Quantitative Imaging Group UCSF Department of Radiology Funding: AOSSM Genzyme Osteoarthritis Grant for Clinical Research NIH/NIAMS P50 AR060752 5
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