| 31. |
- Fomin, Sanne, et al.
(författare)
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Short-term recovery of physical activity and knee function after an acute knee injury
- 2020
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Ingår i: BMJ Open Sport & Exercise Medicine. - : BMJ Publishing Group Ltd. - 2055-7647. ; 6:1
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Tidskriftsartikel (refereegranskat)abstract
- ObjectivesTo describe self-reported knee function, participation in physical activity and the number of knee surgeries at 3 and 6 months following acute knee injury.MethodsProspective cohort study. Participants, aged 15-40 years with an acute knee injury sustained no more than 6 weeks prior to inclusion, were recruited. There were 279 participants with ACL injury and 101 participants with other acute knee injuries included. Follow-up questionnaires were sent at 3 and 6 months after injury. Demographic information, activity participation, International Knee Documentation Committee subjective knee form (IKDC-SKF) and the Single Assessment Numeric Evaluation (SANE) score were collected. Additional knee injuries were obtained from self-report and medical charts.ResultsThe IKDC-SKF, SANE and physical activity participation were reduced at 3-month and 6-month follow-up. The number of participants who achieved health-promoting physical activity levels was reduced by 50% at 6-month follow-up compared with before injury. Seventeen per cent of participants with ACL injury and 41% of participants with other acute knee injuries had returned to their preinjury physical activity at 6 months. Participants with ACL injury reported worse knee function, lower physical activity participation and had more surgeries (128 surgeries, including 109 ACL-reconstructions) compared with participants with other acute knee injuries (six surgeries).ConclusionAcute knee injuries, including ACL injuries, affected self-reported knee function and physical activity participation for at least 6 months after index injury. More research is needed to understand how best to help people with acute knee injuries return to physical activity and achieve satisfactory knee function.
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| 32. |
- Fältström, Anne, et al.
(författare)
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Are We Jumping to the Wrong Conclusions? Longer Jumps and More Hops in Female Football Players Who Went on to Sustain a Primary or Secondary ACL Injury Compared to Those Who Did Not
- 2023
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Ingår i: SPORTS MEDICINE-OPEN. - : SPRINGER. - 2199-1170. ; 9:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundDifferent functional performance tests are used to assess patients in the clinic and before return to sport (RTS), where the rehabilitation goal is to reach good strength and jumping ability. A limb symmetry index of >= 90% is a common target in rehabilitation before RTS. The aim of this short communication is to use data from our 2-year prospective cohort study on female football players, either with or without an anterior cruciate ligament (ACL) reconstruction, to discuss whether hop performance in 3 commonly used hop tests can inform safe football participation, that is, with a low risk for ACL injury or reinjury.MethodAt baseline, 117 active female football players (mean age +/- standard deviation, 20 +/- 2 years) were included 19 +/- 9 months after ACL reconstruction as well as 119 matched female knee-healthy players (age 19 +/- 3 years). All players performed a single hop for distance test, 5-jump test and side hop test at baseline and were then prospectively followed for 2 years. Twenty-eight (24%) players sustained a second ACL injury and 8 (7%) sustained a primary ACL injury.ResultsLonger jumps in the 5-jump test (922 cm vs. 865 cm, Cohens d = - 0.60) and more hops in the side hop test for both limbs (41-42 hops vs. 33-36 hops, d = - 0.43 to - 0.60) were seen in players who sustained a second ACL injury compared with those who did not. Longer jumps in the single hop for distance test (both limbs) (139-140 cm vs. 124-125 cm, d = - 0.38 to - 0.44), in the 5-jump test (975 cm vs. 903 cm, d = -0.42) and more hops in the side hop test (both limbs) (48-49 hops vs. 37-38 hops, d = - 0.38 to - 0.47) were seen in players who sustained a primary ACL injury compared with those who did not.ConclusionsThe average hop performance, i.e. longer jumps or more hops, was greater in players who went on to sustain a primary or secondary ACL injury compared to those who did not over a two-year follow-up period. Even though hop tests are not used in isolation to evaluate readiness to RTS, their interpretation needs consideration in the decision-making process of returning to pivoting sports. center dot The average hop performance, i.e. longer jumps or more hops, was greater in female football players who went on to sustain a primary or secondary ACL injury compared to those who did not over a two-year follow-up period.center dot Even though hop tests are not used in isolation to evaluate readiness to RTS, their interpretation needs consideration in the decision-making process of returning to pivoting sports.center dot The relationship between better hop performance and risk of ACL injury is unclear. It is likely not a predictor per se, but better performance could mean more exposure to high risk activities.
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| 33. |
- Fältström, Anne, et al.
(författare)
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Clinical Risk Profile for a Second Anterior Cruciate Ligament Injury in Female Soccer Players After Anterior Cruciate Ligament Reconstruction
- 2021
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Ingår i: American Journal of Sports Medicine. - : SAGE PUBLICATIONS INC. - 0363-5465 .- 1552-3365. ; 49:6, s. 1421-1430
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Tidskriftsartikel (refereegranskat)abstract
- Background: The risk of a second anterior cruciate ligament (ACL) injury when participating in pivoting sports after ACL reconstruction is high. Risk factors associated with a second ACL injury are complex. Purpose: To investigate the combinations of various clinical risk factors associated with second ACL injury in female soccer players with a primary unilateral ACL reconstruction, using Classification and Regression Tree (CART) analysis. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 117 active female soccer players (mean +/- SD age, 20 +/- 2 years) were included. Athletes were enrolled 19 +/- 9 months after ACL reconstruction and were prospectively followed for 2 years. At baseline, all players underwent assessment of knee and ankle joint range of motion (ROM), participated in functional tests (postural control, hop performance, and movement asymmetries in the lower limbs and trunk), and answered questionnaires (patient-reported knee function, knee-related quality of life, psychological and personality factors). A clinical prediction model using CART was developed. Results: A total of 28 players (24%) sustained a second ACL injury (21 ipsilateral and 7 contralateral ruptures) while playing soccer. CART analysis selected 9 of 19 independent variables associated with second ACL injury: the 5-jump test, knee collapse on the non-ACL reconstructed leg in a drop vertical jump, tuck jump, limb symmetry index on side hop and the single hop for distance, side difference in ankle dorsiflexion ROM, and scores for the questionnaires ACL-Return to Sport After Injury and the Swedish Universities Scales of Personality subscales of Stress Susceptibility and Adventure Seeking. The accuracy of the model was 89%, with 100% sensitivity and 76% specificity. CART analysis indicated that the interaction of longer jumps in the 5-jump test (>916 cm) with more side difference in ankle dorsiflexion ROM (>-2.5 degrees) and more knee valgus collapse in the nonreconstructed knee (>-1.4 cm) (relative risk, 4.03; 95% CI, 2.21-7.36) best predicted an increased likelihood of a second ACL injury. Conclusion: The risk profiles selected by CART could accurately identify female soccer players at high risk for a second ACL injury. There was an interaction between functional performance, clinical assessment, and psychological factors, and it is reasonable to include these factors in return-to-sport decisions and in athlete screening after ACL injury.
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| 34. |
- Fältström, Anne, et al.
(författare)
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Factors associated with playing football after anterior cruciate ligament reconstruction in female football players.
- 2016
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Ingår i: Scandinavian Journal of Medicine and Science in Sports. - : Wiley-Blackwell. - 0905-7188 .- 1600-0838. ; 26:11, s. 1343-1352
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Tidskriftsartikel (refereegranskat)abstract
- This study investigated whether player-related factors (demographic, personality, or psychological factors) or the characteristics of the anterior cruciate ligament (ACL) injury were associated with the return to playing football in females after ACL reconstruction (ACLR). We also compared current knee function, knee related quality of life and readiness to return to sport between females who returned to football and those who had not returned. Females who sustained a primary ACL rupture while playing football and underwent ACLR 6-36 months ago were eligible. Of the 460 contacted, 274 (60%) completed a battery of questionnaires, and 182 were included a median of 18 months (IQR 13) after ACLR. Of these, 94 (52%) returned to football and were currently playing, and 88 (48%) had not returned. Multiple logistic regression analysis identified two factors associated with returning to football: short time between injury and ACLR (0-3 months, OR 5.6; 3-12 months OR 4.7 vs reference group > 12 months) and high motivation. Current players showed higher ratings for current knee function, knee-related quality of life, and psychological readiness to return to sport (P < 0.001). Undergoing ACLR sooner after injury and high motivation to return to sports may impact a player's return to football after ACLR.
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| 35. |
- Fältström, Anne, 1970-, et al.
(författare)
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Female Soccer Players With Anterior Cruciate Ligament Reconstruction Have a Higher Risk of New Knee Injuries and Quit Soccer to a Higher Degree Than Knee-Healthy Controls
- 2019
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Ingår i: American Journal of Sports Medicine. - : Sage Publications. - 0363-5465 .- 1552-3365. ; 47:1, s. 31-40
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Tidskriftsartikel (refereegranskat)abstract
- Background:Many patients with anterior cruciate ligament (ACL) reconstruction who return to sport suffer new ACL injuries or quit sports soon after returning.Purpose:To prospectively follow a cohort of female soccer players with primary unilateral ACL reconstruction and matched knee-healthy controls from the same soccer teams to compare (1) the rate of new traumatic and nontraumatic knee injuries and other injuries, (2) the proportion of players who quit soccer, and (3) player-reported activity level and satisfaction with activity level and knee function.Study Design:Cohort study; Level of evidence, 2.Methods:A total of 117 active female soccer players (mean ± SD age, 19.9 ± 2.5 years) 18.9 ± 8.7 months after ACL reconstruction and 119 knee-healthy female soccer players (19.5 ± 2.5 years) matched from the same teams were prospectively followed for 2 years for new knee injuries, other injuries, soccer playing level, activity level according to the Tegner Activity Scale, and satisfaction with activity level and knee function.Results:Players with ACL reconstruction had a higher rate of new ACL injuries (n = 29 vs 8; 19 vs 4 per 100 player years; rate ratio [RR], 4.82; 95% CI, 2.20-10.54; P < .001), other traumatic knee injuries (29 vs 16 per 100 player years; RR, 1.84; 95% CI, 1.16-2.93; P < .01), and nontraumatic knee injuries (33 vs 9 per 100 player years; RR, 3.62; 95% CI, 2.11-6.21; P < .001) as compared with controls. There was no difference in the rate of other (not knee) injuries (43 vs 48 per 100 player years; RR, 0.90; 95% CI, 0.65-1.23; P = .494). During the 2-year follow-up, 72 (62%) players with ACL reconstruction quit soccer, as opposed to 43 (36%) controls (P = .001). The median Tegner Activity Scale score decreased in both groups (P < .001) but more for the ACL-reconstructed group (P < .015).Conclusion:Female soccer players with ACL reconstruction had nearly a 5-fold-higher rate of new ACL injuries and a 2- to 4-fold-higher rate of other new knee injuries, quit soccer to a higher degree, and reduced their activity level to a greater extent as compared with knee-healthy controls.
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| 36. |
- Fältström, Anne, et al.
(författare)
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Functional Performance Among Active Female Soccer Players After Unilateral Primary Anterior Cruciate Ligament Reconstruction Compared With Knee-Healthy Controls
- 2017
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Ingår i: American Journal of Sports Medicine. - : Sage Publications. - 0363-5465 .- 1552-3365. ; 45:2, s. 377-385
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Tidskriftsartikel (refereegranskat)abstract
- Background: Good functional performance with limb symmetry is believed to be important to minimize the risk of injury after a return to pivoting and contact sports after anterior cruciate ligament reconstruction (ACLR).Purpose: This study aimed to investigate any side-to-side limb differences in functional performance and movement asymmetries in female soccer players with a primary unilateral anterior cruciate ligament (ACL)–reconstructed knee and to compare these players with knee-healthy controls from the same soccer teams.Study Design: Cross-sectional study; Level of evidence, 3.Methods: This study included 77 active female soccer players at a median of 18 months after ACLR (interquartile range [IQR], 14.5 months; range, 7-39 months) and 77 knee-healthy female soccer players. The mean age was 20.1 ± 2.3 years for players with an ACL-reconstructed knee and 19.5 ± 2.2 years for controls. We used a battery of tests to assess postural control (Star Excursion Balance Test) and hop performance (1-legged hop for distance, 5-jump test, and side hop). Movement asymmetries in the lower limbs and trunk were assessed with the drop vertical jump and the tuck jump using 2-dimensional analyses.Results: The reconstructed and uninvolved limbs did not differ in any of the tests. In the 5-jump test, players with an ACL-reconstructed knee performed worse than controls (mean 8.75 ± 1.05 m vs 9.09 ± 0.89 m; P = .034). On the drop vertical jump test, the ACL-reconstructed limb had significantly less knee valgus motion in the frontal plane (median 0.028 m [IQR, 0.049 m] vs 0.045 m [IQR, 0.043 m]; P = .004) and a lower probability of a high knee abduction moment (pKAM) (median 69.2% [IQR, 44.4%] vs 79.8% [IQR, 44.8%]; P = .043) compared with the control players’ matched limb (for leg dominance). Results showed that 9% to 49% of players in both groups performed outside recommended guidelines on the different tests. Only 14 players with an ACL-reconstructed knee (18%) and 15 controls (19%) had results that met the recommended guidelines for all 5 tests (P = .837).Conclusion: The reconstructed and uninvolved limbs did not differ, and players with an ACL-reconstructed knee and controls differed only minimally on the functional performance tests, indicating similar function. It is worth noting that many players with an ACL-reconstructed knee and controls had movement asymmetries and a high pKAM pattern, which have previously been associated with an increased risk for both primary and secondary ACL injury in female athletes.
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| 37. |
- Fältström, Anne, et al.
(författare)
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High Risk of New Knee Injuries in Female Soccer Players After Primary Anterior Cruciate Ligament Reconstruction at 5-to 10-Year Follow-up
- 2021
-
Ingår i: American Journal of Sports Medicine. - : SAGE PUBLICATIONS INC. - 0363-5465 .- 1552-3365. ; 49:13, s. 3479-3487
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Tidskriftsartikel (refereegranskat)abstract
- Background: A new anterior cruciate ligament (ACL) injury after ACL reconstruction is a feared outcome. Purpose: To study the risk of new knee injuries in female soccer players 5 to 10 years after primary unilateral ACL reconstruction and to compare players who returned to soccer with (1) players who did not return and (2) knee-healthy soccer players (controls). Study Design: Cohort study; Level of evidence, 2. Methods: Demographic, soccer-specific, and surgical data were recorded at baseline for 317 female soccer players (mean +/- SD age, 20.1 +/- 2.7 years) 1.6 +/- 0.7 years after ACL reconstruction and for 119 matched controls (mean age, 19.5 +/- 2.5 years). Data on new knee injuries and soccer-playing status were collected 5 to 10 years after ACL reconstruction via a questionnaire. Results: Among players with ACL reconstruction, 222 (70%) responded at a mean 6.5 +/- 1.0 years after primary ACL reconstruction. We compared 3 cohorts: (1) among 163 players with ACL reconstruction who returned to soccer, 68 (42%) sustained 44 reruptures and 29 contralateral ruptures; (2) among 59 players with ACL reconstruction who did not return to soccer, 11 (19%) sustained 9 reruptures and 2 contralateral ruptures; and (3) among 113 knee-healthy controls, 12 (11%) sustained 13 ACL injuries. Players who returned had a >2-fold higher risk of a new ACL injury than players who did not return (risk ratio, 2.24; 95% CI, 1.27-3.93; P = .005) and a 4-fold higher risk than controls (risk ratio, 3.93; 95% CI, 2.23-6.91; P <.001). A new ACL, meniscal, or cartilage injury was the most frequent new knee injury. Among players who returned to soccer, 68% reported a new knee injury, and they had a 2- to 5-times higher risk of any new knee injury and knee surgery than players who did not return and controls. Conclusion: Two-thirds of female soccer players with ACL reconstruction who returned to soccer sustained a new knee injury within 5 to 10 years; 42% had a new ACL injury. Their risk of a new knee injury and knee surgery was 2 to 5 times greater than that for players who did not return and for knee-healthy controls. New injury may have negative consequences for long-term knee health and should be a critical consideration in the decision to return to play.
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| 38. |
- Fältström, Anne, 1970-
(författare)
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One Anterior Cruciate Ligament injury is enough! : Focus on female football players
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Anterior cruciate ligament (ACL) injury is a severe and common injury, and females have 2-4 times higher injury risk compared to men. Return to sport (RTS) is a common goal after an ACL reconstruction (ACLR), but only about two thirds of patients RTS. Young patients who RTS may have a 30-40 times increased risk of sustaining an additional ACL injury to the ipsi- or contralateral knee compared with an uninjured person.Aims: The overall aim of this thesis was to increase the knowledge about female football players with ACLR, and patients with bilateral ACL injuries, and to identify predictors for additional ipsi- and/or contralateral ACLR.Methods: This thesis comprises four studies. Study I and II were cross-sectional, including females who sustained a primary ACL rupture while playing football and underwent ACLR 6–36 months prior to study inclusion. In study I, 182 females were included at a median of 18 months (IQR 13) after ACLR. All players completed a battery of questionnaires. Ninety-four players (52%) returned to football and were playing at the time of completing the questionnaires, and 88 (48%) had not returned. In study II, 77 of the 94 active female football players (from study I) with an ACLR and 77 kneehealthy female football players were included. A battery of tests was used to assess postural control (the Star excursion balance test) and hop performance (the one-leg hop for distance, the five jump test and the side hop). Movement asymmetries in the lower limbs and trunk were assessed with the drop vertical jump and the tuck jump using two-dimensional analyses. Study III, was a cohort study including all patients with a primary ACLR (n=22,429) registered in the Swedish national ACL register between January 2005 and February 2013. Data extracted from the register to identify predictors for additional ACLR were: patient age at primary ACLR, sex, activity performed at the time of ACL injury, primary injury to the right- or left knee, time between injury and primary ACLR, presence of any concomitant injuries, graft type, Knee injury and Osteoarthritis Outcome Score and Euroqol Index Five Dimensions measured pre-operatively. Study IV was cross-sectional. In this study, patient-reported knee function, quality of life and activity level in 66 patients with bilateral ACL injuries was investigated and outcomes were compared with 182 patients with unilateral ACLR.Results: Factors associated with returning to football in females were; short time between injury and ACLR (0–3 months, OR 5.6; 3–12 months OR 4.7 vs. reference group >12 months) and high motivation (study I). In all functional tests, the reconstructed and uninvolved limbs did not differ, and players with ACLR and controls differed only minimally. Nine to 49% of the players with ACLR and controls had side-to-side differences and movement asymmetries and only one fifth had results that met the recommended guidelines for successful outcome on all the different tests (study II). Main predictors for revision and contralateral ACLR were younger age (fourfold increased rate for <16 vs. >35-year-old patients), having ACLR early after the primary injury (two to threefold increased rate for ACLR within 3 months vs. >12 months), and incurring the primary injury while playing football (study III). Patients with bilateral ACL injuries reported poorer knee function and quality of life compared to those who had undergone unilateral ACLR. They had a high activity level before their first and second ACL injuries but an impaired activity level at follow-up after their second injury (study IV).Conclusions: Female football players who returned to football after an ACLR had high motivation and had undergone ACLR within one year after injury. Players with ACLR had similar functional performance to healthy controls. Movement asymmetries, which in previous studies have been associated with increased risk for primary and secondary ACL injury, occurred to a high degree in both groups. The rate of additional ACLR seemed to be increased in a selected group of young patients who desire to return to strenuous sports like football quickly after primary ACLR. Sustaining a contralateral ACL injury led to impaired knee function and activity level.
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| 39. |
- Fältström, Anne, et al.
(författare)
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Patient-Reported Knee Function, Quality of Life, and Activity Level After Bilateral Anterior Cruciate Ligament Injuries
- 2013
-
Ingår i: American Journal of Sports Medicine. - : SAGE Publications (UK and US): No SAGE Choice. - 0363-5465 .- 1552-3365. ; 41:12, s. 2805-2813
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Tidskriftsartikel (refereegranskat)abstract
- Background: About 12% of patients who have undergone primary anterior cruciate ligament (ACL) reconstruction sustain a contralateral ACL injury within 5 years. less thanbrgreater than less thanbrgreater thanPurpose: To investigate patient-reported knee function, quality of life, and activity level in patients with bilateral ACL injuries. less thanbrgreater than less thanbrgreater thanStudy Design: Cohort study; Level of evidence, 3. less thanbrgreater than less thanbrgreater thanMethods: A search of hospital records identified 147 patients, aged 18 to 45 years, with bilateral ACL injuries. Of these, 83 met the inclusion criteria, having had their first ACL injury up to 12 years ago with no other major injuries to the knee joint. Sixty-six of these patients (80% of total; 47% female; mean age, 29.1 7.2 years) answered a questionnaire packet. Patients who had undergone unilateral ACL reconstruction (n = 182) were used for comparison. less thanbrgreater than less thanbrgreater thanResults: Patients with bilateral ACL injuries had a median Lysholm knee score of 82 (range, 34-100). The mean EuroQol index (EQ-5D) score of the overall health status was 0.77 +/- 0.22, and the mean EQ-5D visual analog scale score was 75.5 +/- 17.6. The median Tegner activity level was 9 (range, 1-9) before any injuries, 7 (range, 1-9) before the second ACL injury, and 4 (range, 1-9) at the time of follow-up. The activity level before the second injury was higher compared with the follow-up for patients who had undergone unilateral ACL reconstruction. At follow-up, 23% of the patients with bilateral ACL injuries returned to their previous activity, and 12% of patients returned to the same level as before their injuries compared with 43% (P = .004) and 28% (P = .01) in patients who had undergone unilateral ACL reconstruction, respectively. Patients with bilateral ACL injuries had significantly lower values in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales for pain, function in sports and recreation, and knee-related quality of life as well as the ACL Deficiency Quality of Life (ACL-QOL) score compared with patients who had undergone unilateral ACL reconstruction. less thanbrgreater than less thanbrgreater thanConclusion: Patients with bilateral ACL injuries reported poorer knee function and quality of life compared with those who had undergone unilateral ACL reconstruction. Their activities had changed, and they were dissatisfied with their current activity level. They had a high activity level before their first and second ACL injuries but an impaired activity level after their contralateral injury at follow-up.
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| 40. |
- Fältström, Anne, et al.
(författare)
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Poor Validity of Functional Performance Tests to Predict Knee Injury in Female Soccer Players With or Without Anterior Cruciate Ligament Reconstruction
- 2021
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Ingår i: American Journal of Sports Medicine. - : SAGE PUBLICATIONS INC. - 0363-5465 .- 1552-3365. ; 49:6, s. 1441-1450
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Tidskriftsartikel (refereegranskat)abstract
- Background: Various tests have been developed to evaluate athletes functional performance and for use as screening tools for injury prediction. Further validation of their accuracy to predict injury is needed. Purpose: To investigate the validity of predetermined cutoffs used to differentiate between high- and low-risk players in different functional performance tests to predict (1) anterior cruciate ligament (ACL) injury or (2) severe traumatic knee injury in a cohort of female soccer players with a primary unilateral ACL reconstruction and a cohort of knee-healthy players. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 117 active female soccer players (mean age +/- SD, 20 +/- 2 years) an average of 19 +/- 9 months after ACL reconstruction and 119 knee-healthy players (age, 19 +/- 3 years) were prospectively followed up for 2 years for new knee injuries. At baseline, all players underwent tests to assess postural control (Star Excursion Balance Test), hop performance (single-leg hop for distance, side hop), and movement asymmetries in the lower limbs and trunk (drop vertical jump [DVJ], tuck jump). The predictive validity of the test cutoffs to identify players who would sustain an ACL injury or a severe traumatic knee injury (absence from soccer play, >28 days) was assessed. The risk ratio (RR), area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were calculated. Results: A total of 46 players (39%) with ACL reconstruction sustained 48 severe knee injuries, including 28 ACL ruptures. Of the knee-healthy players, 13 (11%) sustained 14 severe knee injuries, including 8 ACL ruptures. No association was found between the predetermined functional performance test cutoffs and the risk of a new ACL injury or severe knee injury in players with ACL reconstruction. In knee-healthy players, the only variable associated with future ACL injury was >= 6.5 cm knee valgus in the frontal plane (any knee) in the DVJ (RR, 4.93; 95% CI, 1.04-23.40; P = .045), but with only fair predictive validity (AUC, 0.7; sensitivity, 0.75; specificity, 0.65). Conclusion: In our cohorts of female soccer players, the validity of commonly used functional performance tests to predict new knee injuries was poor. Only knee valgus during the DVJ was associated with new ACL injuries in knee-healthy players, but with only fair predictive validity.
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