A. Strong1, A. Arumugam2, E. Tengman1, U. Röijezon3, C.K. Häger1
1Umeå University, Department of Community Medicine and Rehabilitation – Physiotherapy Section, Umeå, Sweden, 2College of Health Sciences, University of Sharjah, Department of Physiotherapy, Sharjah, United Arab Emirates, 3Luleå University of Technology, Department of Health Sciences – Physiotherapy Section, Luleå, Sweden
Background: Knee proprioception is believed to be deficient following injury of the anterior cruciate ligament (ACL). Tests of joint position sense (JPS) are commonly used to assess knee proprioception, but their psychometric properties (PMPs) are largely unknown.
Purpose: To evaluate the PMPs (reliability, validity and responsiveness) of existing knee JPS tests targeting individuals with ACL injury.
Methods: A protocol narrating the methods of the review has been registered in the PROSPERO database (CRD42018108014) and published in a peer-reviewed journal (doi:10.1136/bmjopen-2018-027241). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were followed to report this review. PubMed, AMED, CINAHL, SPORTDiscus, Web of Science, Scopus, CENTRAL and ProQuest were searched to identify studies that assessed PMPs of knee JPS tests in individuals with ACL injury. The risk of bias (RoB) for each PMP in the included studies was assessed using the updated COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) RoB checklist. Overall quality and levels of evidence for each PMP were rated according to established criteria. Meta-analyses with mean differences (MD) were conducted using random-effects models when adequate data were available.
Results: Eighty studies covering 119 different versions of knee JPS tests were included. Meta-analyses indicated sufficient quality for known-groups and discriminative validity (ACL-injured/reconstructed knees compared to the knees of asymptomatic controls and contralateral non-injured knees, respectively) due to significantly greater absolute errors for ACL-injured knees based on a strong level of evidence. A meta-analysis showed insufficient quality for responsiveness due to a lack of significant change over time following diverse interventions with a moderate level of evidence. Statistical heterogeneity (I2 > 40%) was evident in the majority of meta-analyses. All remaining PMPs (reliability, measurement error, criterion validity, convergent validity and other PMPs related to responsiveness) were assessed qualitatively and they failed to achieve a quality rating of sufficient due to either the study outcomes not agreeing with the statistical cut-off values/hypotheses or the level of evidence being rated as conflicting, unknown or based only on a single study.
Conclusion(s): Knee JPS tests appear to have sufficient validity in differentiating ACL-injured knees from asymptomatic knees. Further evidence of high methodological quality is required to ascertain the reliability, responsiveness and the other types of validity assessed here. We recommend investigations that compare the modifiable methodological components of knee JPS tests on their PMPs to develop standardized tests.
Implications: Our results show that knee JPS tests, especially those including passive elements, are useful to assess proprioception in ACL-injured/reconstructed knees compared to the knees of asymptomatic controls and contralateral non-injured knees. Responsiveness, on the other hand, showed insufficient quality, indicating less sensitivity of knee JPS tests to change after intervention; however, the interventions were diverse, and the level of evidence was moderate. The PMPs of reliability, measurement error, criterion validity, convergent validity and other aspects of responsiveness require further studies of low RoB to increase their respective levels of evidence and better ascertain their quality.
Funding, acknowledgements: The Swedish-Research-Council (2017-00892); Region-Västerbotten(ALF 7003575VLL838421; Strategic-funding-VLL-358901;Project.No 7002795); The Swedish-Research-Council-for-Sports-Science (CIF-P2019-0068), Umeå School of Sport Science; King-Gustaf-V and Queen-Victoria’s-Foundation-of-Freemasons-2019 (Häger).
Keywords: Clinimetric property, Proprioception, ACL
Topic: Sport & sports injuries
Did this work require ethics approval? No
Institution: N/A
Committee: N/A
Reason: This study is a systematic review and meta-analysis.
All authors, affiliations and abstracts have been published as submitted.
