Tag: PRO

‌Low Ankle-GO Score While Returning to Sport After Lateral Ankle Sprain Leads to a 9-fold Increased Risk of Recurrence: A Two-year Prospective Cohort Study

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Blog Post Author Biography: Lauren Forsyth is a Research Associate in the department of Biomedical Engineering at the University of Strathclyde and a Strength and Conditioning Coach. Dr Forsyth’s research aims to develop objective functional assessment techniques and rehabilitation interventions for people with chronic ankle instability.

Citation: Picot B, François Fourchet, Lopes R, et al. Low Ankle-GO Score While Returning to Sport After Lateral Ankle Sprain Leads to a 9-fold Increased Risk of Recurrence: A Two-year Prospective Cohort Study. Sports Medicine – Open. 2024;10(1). doi: 10.1186/s40798-024-00693-w

Take-to-the-clinic message: The Ankle-GO score is an objective assessment of functional performance and self-reported function which can be used to guide return to sport (RTS) decisions after lateral ankle sprain (LAS) and inform clinical management. When patients scored low of the Ankle-GO their 2-year risk of ankle sprain recurrence was nine times higher. Women also tended to have a fourfold higher risk of reinjury within two years, despite an initial Ankle-GO score comparable to men. Clinicians should therefore be more cautious of lower scores for women.

Background: Lateral ankle sprain (LAS) reported as the most common sports-related injury, followed by high recurrence and development of CAI. Despite impairments and residual functional deficiencies, research shows that nearly 50% of patients return to sport (RTS) within three days after LAS, and 80% within a week. However, there is no published evidence-based criteria to guide a patient’s return to sport (RTS), which may explain the high recurrence. The Ankle-GO™ is a valid and reliable score which aims to score patients to facilitate a safe RTS, while minimising the risk of recurrent injuries.

Purpose: The aim of this study was to assess the efficacy of the Ankle-GO – a new functional score for LAS – to distinguish patients at risk of recurrent LAS within two years after the initial injury.

Methods: The study recruited 64 patients (36 Male/28 Female) from the same clinic from January-August 2021. All participants were recruited within one month of initial LAS, and, following consultation, each participant received personalised rehabilitation for 8 weeks.  Two months after LAS each participant completed the Ankle-GO score. The Ankle-GO score includes two self-reported questionnaires (The Foot and Ankle Ability Measure and the Ankle Ligament Reconstruction-Return to Sport after Injury) and four functional tests (single-leg stance test, modified star excursion balance test, side hop test, and figure-of-8 test). Each item is scored with a maximum total score of 25 points. A lower score indicates lower function. The rate of reinjury was recorded two years following the initial injury. Fifty-four participants (23 Male/31 Female) reported whether they had suffered a recurrent LAS (ie. a new LAS of the same location and type), and the mechanism of the reinjury (ie. contact or non-contact).

Results: Eighteen participants suffered a reinjury (33.3%) with non-contact mechanisms at the two-year follow up. The Ankle-GO score at two-months post-LAS was lower in patients with a recurrent LAS (by 3.7 points) and predicted the risk of reinjury. An Ankle-GO score of less than eight points indicated a 9-times higher risk of recurrent LAS. The same cut-off score (8 points) identified a return to preinjury level of sports four months after LAS. Women and men reported comparable Ankle-GO scores, however women tended to have a 4-times higher risk of recurrent LAS after two years.

Rolling the field forward: The Ankle-GO score offers a new objective criterion for RTS after LAS. This can aid clinical decision making to address the high recurrence rates of LAS. These recurring injuries are often explained by a lack of informed guidance to RTS.

Recently the PAASS framework was published to inform the RTS decision (PAASS: Pain, Ankle impairments, Athlete perception, Sensorimotor control, Sport/functional performance). The Ankle-GO is a step to establishing a specific objective criterion. It should be noted that the Ankle-GO does not include all items related to the PAASS framework. Thus, to gain a broader perspective during clinical assessment the Ankle-GO score may need to be used in conjunction with other clinical assessments.

Question for the researchers: The ANKLE-GO was conducted on participants two months following initial injury, and after a personalized rehabilitation plan had been administered. Do the researchers know how the personalized programme affected the Ankle-GO scores, and do they have a recommended time point for clinicians of when the Ankle-GO could be used? As a result, how may this affect the reinjury risk for patients?

Participant-Level Improvements in Health-Related Quality of Life in Those With Chronic Ankle Instability

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Blog Post Author Biography: Dr. Cameron Powden is an Associate Professor in the Department of Athletic Training at the University of Indianapolis. Dr. Powden’s interests include the investigation of clinically relevant interventions for ankle sprains and chronic ankle instability.

Citation: Powden CJ, Koldenhoven RM, Simon JE, et al. Participant-Level Analysis of the Effects of Interventions on Patient-Reported Outcomes in Patients With Chronic Ankle Instability. Journal of Sport Rehabilitation. 2023;32(2):124-132. DOI: 10.1123/jsr.2022-0053

Take-to-the-clinic message: This investigation matches previous literature indicating that the available chronic ankle instability (CAI) interventions are capable of improving self-reported ankle function, global well-being, and injury-related fear at the group level for patients with CAI. This study uniquely assessed individual level responses of patients with CAI to multimodal interventions. Between 13.8% and 53.3% of patients demonstrated improvements, for individual patient-reported outcomes (PROs), that exceeded the minimal detectable change (MDC) of the measure. These findings signify that individually, we may hope to only have about half of our patients have meaningful improvements following intervention.

Background: CAI intervention studies have often focused on improving physical impairments of the ankle complex. Recently, increased emphasis has been placed on the sensory-perceptual impairments associated with CAI. This has resulted in CAI investigations examining the health-related quality of life (HRQoL) through PROs of those with CAI, and the influence of intervention on such PROs. While most studies have assessed self-reported ankle function and through the lens of group level response, there is a need to investigate the impact of interventions on other aspects of HRQoL (such as global well-being and injury-related fears) and the individual level response to treatment within those with CAI.

Purpose: To evaluate improvements in multiple domains of HRQoL, self-reported ankle function, global well-being, and injury-related fear, following multimodal interventions in patients with CAI by using group- and participant-level responder analyses.

Methods: A secondary analysis was completed on a compiled data set of original, participant-level data from seven previously published investigations. Each of the investigations investigated self-reported function in patients with CAI. A total of 136 physically active individuals with self-reported CAI were included in the analysis. These individuals underwent a wide range of multimodal interventions that ranged from 1 to 6 weeks in length, 1 to 12 supervised sessions, and may have included a home intervention component. PROs included were the Foot and Ankle Ability Measure (FAAM) ADL and Sport, Tampa Scale of Kinesiophobia-11 (TSK-11), Fear Avoidance Belief Questionnaire (FABQ) and the Disablement in the modified Physically Active Scale (mDPA) physical summary component (PSC) and the mental summary component (MSC). The research team examined preintervention to postintervention changes in each PRO, as well as effect sizes (ES) and individual-level response rates through changes exceeding published MDCs.

Results: There was significant improvement in ankle-specific function following intervention that was associated with strong ESs and responder rates of 39.0% to 53.3%. There was a significant reduction in injury-related fear following intervention that was associated with moderate to strong effects and responder rates of 13.8% to 51.4%. Finally, there was a significant improvement in global well-being that was associated with strong effects and responder rates of 31.3%. 

Rolling the field forward: This investigation is part of the expanding evidence regarding interventions for those with CAI. It builds on previous multimodal intervention studies by combining various intervention protocols to allow for robust group and individual level analysis. The findings indicate that patients with CAI exhibit holistic HRQoL improvements following varied interventions. This investigation continues the exploration into individual-level responses within the CAI population. Further research is needed to better understand the clinical impact of this new form of analysis. Lastly, to enhance the ability to examine CAI interventions, at the group and individual level, there is a need to identify common clinician-, laboratory-, and patient-oriented outcome measures to allow for robust and comparative analysis.

Question for the researchers: What interventions would be beneficial for CAI patients to enhance aspects of HRQoL? How do researchers and clinicians work to develop common outcome measures to explore? Can the individual level responder analysis be used in clinical practice to examine patient progress?

Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries

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Blog Post Author Biography:  Alexandra DeJong Lempke is an Assistant Professor in the Department of Physical Medicine & Rehabilitation at Virginia Commonwealth University, and has a clinical background as a certified athletic trainer. Dr. DeJong Lempke’s research focuses on biomechanical gait assessments of lower limb and ankle injuries through wearable technologies.

Citation: Kenneth C. Lam, Ashley N. Marshall, R. Curtis Bay, Erik A. Wikstrom; Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries: A Report From the Athletic Training Practice-Based Research Network. J Athl Train. 2023; 58 (7-8): 627–634. doi: https://doi.org/10.4085/1062-6050-0111.22

Take-to-the-clinic message: Athletes across the United States self-reported residual pain, dysfunction, and disability at the time of return to sport after a lateral ankle sprain. Clinicians should implement patient-reported outcomes to catch lingering deficits post-ankle sprain to help guide return to sport decision-making.

Background: Lateral ankle sprains (LAS) are extremely common in sport and are often viewed as insignificant injuries with quick recoveries. Most patients return to sport within 10 days of injury, yet it is not clear if athletes may have lingering symptoms that may affect their long-term health. Understanding how patients with ankle sprains feel at the time of return to sport is important to catch residual problems post-injury and help with clinical decision-making.

Purpose: The purpose of this study was to evaluate self-reports of improvement, pain, function, and disability at return to sport after an LAS injury using single-item patient-reported outcome measures.

Methods: This was a retrospective study of 637 patients with LAS who returned to sport within 60 days of injury. The researchers identified LAS cases from electronic medical records within the 2010-2021 Athletic Training Practice-Based Research Network database (AT-PBRN; 69 clinical practice sites with athletic trainers). The research team assessed pertinent patient details, such as school level, gender, and sport. They also assessed patient-reported outcome measures relevant to LAS at initial injury evaluation and at the time of return to sport:

  • Improvement – Global Rating of Change
  • Pain – Numeric Pain Rating Scale
  • Function – Global Rating of Function
  • Disability – Global Rating of Disability

Results: The LAS patients assessed in this study were about equal genders (53.2% males), were primarily secondary school aged (79.1% of the sample) and participated in field or court sports (78% played in either basketball, football, soccer, or volleyball). Most patients returned to sport within 8 days after LAS. About 2 in every 3 patients reported a meaningful improvement at return to sport, or feeling at least “quite a bit better” on the Global Rating of Change scale. Most patients also still felt they had lingering deficits at return to sport, particularly for lingering pain (~65%), reduced function (~86%), and residual disability (~36%).

Rolling the field forward: This research shows that although LAS patients improve after their injury, many patients still feel like they have not fully recovered when they return to their sport. Clinicians should incorporate objective measures like patient-reported outcomes into return-to-sport decisions to best understand deficits related to LAS and advocate for athlete well-being.

Question for the researchers: Do you think that incorporating patient-reported outcome measures specific to the ankle would have uncovered more lingering deficits at return to sport? How do you think external pressures, such as competition timepoints, may have influenced the findings? Would it be possible to determine if repeat injuries occurred among those with lingering deficits, signaling Chronic Ankle Instability?