Thesis (MScPhysio)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: The anterior cruciate ligament is the most commonly injured ligament in the knee, with only one third of athletes returning to their pre-injury level of sport. Identifying intrinsic factors associated with an increased likelihood of return to sport may improve the surgical outcome. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. The objective was to systematically appraise publications describing intrinsic factors which may be associated with return to sport, after anterior cruciate ligament reconstruction. A comprehensive eligibility checklist was composed. Methodological quality appraisal of cohort studies revealed that high quality studies were included in the review. A descriptive synthesis of the findings associating intrinsic factors with return to sport was performed. Ten studies were included. The most important finding was the association of fear of re-injury preventing return to sports participation. Knee function did not always correspond with the likelihood of returning to sport. Younger athletes and competitive, male athletes appeared more likely to return. Across these studies, the 141 athletes not returning to pre-injury sport were questioned as to the reason for non return. An average of 35% (49 athletes) cited fear of re-injury as the reason. Fear of re-injury was thus investigated further as it could be considered in the post-operative management of anterior cruciate ligament reconstruction. In a qualitative study with supplemental cross-sectional analysis, factors informing fear of re-injury were explored. Male and female athletes, aged 17-50 years were included (n=59). Reconstruction procedures using any graft type were included; however revision and multi-ligament reconstruction was excluded. Twenty-four participants (41%) did not return to the pre-injury sport. Those citing fear of re-injury as the only reason for not-retuning to sport were interviewed (n=12). Thus, those who did not return to pre-injury type and level of sport despite good knee function. Athletes’ experiences informing fear of re-injury were explored by semi-structured interviews. Data analysis was performed by content analysis. Codes were allocated and categorised and these categories were synthesised into themes. The Qualitative review guidelines – RATS were followed. From the participant interviews, four themes emerged: undergoing the surgery and recovery again, nature of the pre-injury sport imposing risk of re-injury, personality traits, and social priorities. An accelerated rehabilitation programme was suggested to improve the post–operative experience. The supplementary analysis revealed athletes younger than 20 years of age were more likely to return to sport. Modifiable fears include pain, length of rehabilitation, mechanism of injury and psychological aspects. Pain management, motivation and education are important considerations post-operatively and during rehabilitation. Clinicians should be aware of factors informing fear of re-injury on an individual basis to develop a tailored management plan. / AFRIKAANSE OPSOMMING: OPSOMMING Die anterior kruisligament is die mees algemeen beseerde ligamente in die knie, met slegs een derde van die atlete wat terugkeer na hul pre-besering vlak van sport. Identifisering van intrinsieke faktore wat verband hou met 'n verhoogde moontlikheid van terugkeer na sport kan die chirurgiese uitkoms verbeter. 'n Sistematiese oorsig wat die Voorkeur Verslag Items vir Sistematiese oorsig en Meta-ontledingsriglyne volg, is uitgevoer . Die doel was om stelselmatig publikasies, wat intrinsieke faktore beskryf wat verband hou met terugkeer na sport na anterior kruisligament rekonstruksie, te beoordeel. 'n Omvattende kontrolelys is saamgestel. Metodologiese kwaliteit beoordeling van ‘n groep studies het 'n hoë gehalte studie aan die lig gebring, wat ingesluit is in die oorsig. 'n Beskrywende sintese van die bevindinge wat intrinsieke faktore met die terugkeer na sport assosieer, is uitgevoer. Tien studies is ingesluit. Die belangrikste bevinding wat terugkeer na sportdeelname verhinder was die vrees van herbesering. Kniefunksie het nie altyd ooreengestem met die moontlikheid van terugkeer na sport nie. Jonger atlete en wedywerende manlike atlete was meer geneig om terug te keer. In al die ingesluite studies, is die 141 atlete wat nie teruggekeer het na sport voorbesering ondervra oor die rede vir nie terugkeer. 'n Gemiddeld van 35% (49 atlete) het vrees vir herbesering as rede aangevoer. Vrees vir herbesering is dus verder ondersoek, as oorwegende faktor in die post-operatiewe bestuur van anterior kruisligament rekonstruksie. In 'n primêre, kwalitatiewe studie met aanvullende deursnee-analise, is die redes vir die vrees vir herbesering ondersoek. Manlike en vroulike atlete, tussen die ouderdomme van 17-50 jaar is ingesluit (n = 59). Rekonstruksie prosedures deur enige soort oorplanting is ingesluit; hersiening en verskeie ligament rekonstruksie is egter uitgesluit. Vier-en-twintig deelnemers (41%) het nie teruggekeer na die pre-besering sport nie. Diegene wat vrees vir herbesering as die enigste rede vir nie terugkering na sport aanvoer, is onderhoude mee gevoer (n = 12). Dus, diegene wat nie teruggekeer het na pre-besering, tipe en vlak, van sport ten spyte van goeie knie funksie. Die redes vir die vrees vir herbesering is ondersoek deur semi-gestruktureerde onderhoude. Dataanalise is uitgevoer deur die inhoud / tematiese analise. Kodes is toegeken en gekategoreer. Hierdie kategorieë is herverdeel in temas. Uit die deelnemer onderhoude, het vier temas na vore gekom: die operasie en herstel proses, die aard van die prebesering sport as risiko vir herbesering, persoonlikheidseienskappe en sosiale prioriteite. 'n Versnelde rehabilitasieprogram is voorgestel om die post-operatiewe ervaring te verbeter. Die aanvullende analise het getoon dat atlete jonger as 20 jaar oud meer geneig was om terug te keer na die sport. Aanpasbare oorsake van vrees sluit in pyn, die lengte van rehabilitasie, meganisme van besering en sielkundige aspekte. Pyn bestuur, motivering en opvoeding is belangrike oorwegings post-operatief en tydens rehabilitasie. Dokters en fisioterapeute moet bewus wees van die vrees vir herbesering en die veranderbare oorsake daarvan ondersoek op 'n individuele basis om 'n pasient spesifieke bestuursplan te ontwikkel.

The aims of this thesis were to study the incidence, severity and pattern of injury in male and female elite football players; to study time trends in injury risk; to identify risk factors for injury; and to test the effectiveness of an intervention programme aimed at preventing re-injury. All studies followed a prospective design using standardised definitions and data collection forms. Individual training and match exposure was registered for all players participating. Time loss injuries were documented by each team’s medical staff. The amount of training increased by 68% between the 1982 and 2001 Swedish top male division seasons, reflecting the shift from semi-professionalism to full professionalism. No difference in injury incidence or injury severity was found between seasons. The injury incidence was 4.6 vs. 5.2/1000 training hours and 20.6 vs. 25.9/1000 match hours. The incidence of severe injury (absence >4 weeks) was 0.8/1000 hours in both seasons. The Swedish and Danish top male divisions were followed during the spring season of 2001. A higher risk for training injury (11.8 vs. 6.0/1000 hours, p<0.01) and severe injury (1.8 vs. 0.7/1000 hours, p=0.002) was observed among the Danish players. Re-injury accounted for 30% and 24% of injuries in Denmark and Sweden respectively. The Swedish top male division was studied over two consecutive seasons, 2001 and 2002, and comparison of training and match injury incidences between seasons showed similar results. Players who were injured in the 2001 season were at greater risk for injury in the following season compared to non-injured players (relative risk 2.7; 95% CI 1.7-4.3). Players with a previous hamstring injury, groin injury and knee joint trauma were two to three times more likely to suffer an identical injury to the same limb in the following season, but no such relationship was found for ankle sprain. Age was not associated with an increased injury risk. The effectiveness of a coach-controlled rehabilitation programme on the rate of re-injury was studied in a randomised controlled trial at amateur male level. In the control group, 23 of 79 injured players suffered a recurrence during the season compared to 10 of 90 players in the intervention group. There was a 75% lower re-injury risk in the intervention group for lower limb injuries (relative risk 0.25; 95% CI 0.11-0.57). The preventive effect was greatest during the first weeks after return to play. Both the male and female Swedish top divisions were followed during the 2005 season. Male elite players had a higher risk for training injury (4.7 vs. 3.8/1000 hours, p<0.05) and match injury (28.1 vs. 16.1/1000 hours, p<0.001) than women. However, no difference was observed in the rate of severe injury (0.7/1000 hours in both groups). The thigh was the most common site of injury in both men and women, while injury to the hip/groin was more frequent in men and to the knee in women. Knee sprain accounted for 31% and 37% of the time lost from training and match play in men and women respectively. / Serienumret i serien Linköping University medical dissertation är fel. Det korrkta numret är 988. The serial number in the series Linköping University medical dissertation is incorrect. The correct number is 988.

Sammanfattning: Bakgrund: Främre korsbandsskada är en allvarlig men vanlig skada inom idrott som resulterar i psykologiska konsekvenser, en av dessa är oro för att skada sig igen och detta kan påverka deras återgång till idrott negativt. Oro och andra psykologiska konsekvenser mäts vanligtvis med det smärtcentrerade frågeformuläret Tampa scale of kinesiophobia (TSK), även fast idrottare med korsbandsskada sällan upplever smärta senare i rehabiliteringen. Re-injury anxiety inventory (RIAI) belyser ångest och andra psykologiska faktorer inom rehabilitering (RIAI-R) och återgång till tävlingssammanhang (RIAI-C) som idrottare kan uppleva. Detta frågeformulär finns dock inte på svenska, vilket gör att svenska fysioterapeuter saknar ett självskattningsformulär som mäter ångest för att skada sig igen. Syfte: Att översätta och tvärkulturellt anpassa RIAI från originalspråket engelska till svenska och testa den på en mindre målgrupp. Metod: Kvalitativ och kvantitativ studiedesign. Fem-steg: Steg 1: Översättning av enkät: Steg 2: sammanfogning av översättningarna från steg 1. Steg 3: Återöversättning till originalspråk. Två separata översättningar genomfördes vid steg: 1 och 3. Steg 4: en expertkommitté granskade den sammanfogade versionen. Steg 5: Prefinala versionen testades genom intervjuer med 13 personer som hade genomgått främre korsbandsrekonstruktion (ACLR) och slutliga korrigeringar gjordes i enlighet med detta för att skapa den slutliga versionen. En korrelationsanalys med 18 personer genomfördes även av RIAI-SE och TSK. Resultat: Den prefinala versionen bestod efter intervjuerna och en svensk version RIAI-SE skapades. RIAI-SE och TSK jämfördes, det visade ingen signifikant korrelation P>0,093.  Slutsats:  Översättningen och kulturella anpassningen av originalformuläret RIAI, resulterade i en svensk version, RIAI-SE. Inga korrelationer mellan RIAI-SE och TSK bekräftar att de mäter olika begrepp. RIAI-SE kan komma att användas av fysioterapeuter på svenska idrottare med allvarliga skador efter att verktyget har visat sig ha god validitet och reliabilitet.