Rehabilitation characteristics and patient barriers to and facilitators of ACL reconstruction rehabilitation: A cross-sectional survey

Association of Patient-Surgeon and Patient-Physical Therapist Relationships With Return to Sports After ACL Reconstruction: The Untested Dimension in Outcome Assessments

Background

The Quality of Patient-Surgeon Relationship (QPASREL) is an 11-item questionnaire developed and validated to assess the relationship between practitioners and patients on recovery and return to work after surgery.

Purpose

To evaluate the association of patient-surgeon relationship (PSR) and patient-physical therapist relationship (PPR), as measured by QPASREL, with a patient's return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR).

Study Design

Case-control study; Level of evidence, 3.

Methods

This study targeted patients who underwent primary ACLR at a specialized sports surgery referral center between January and May 2021. Patients who had revision surgery, multiligamentous knee injury, and sedentary status were excluded from the study. Patients were grouped based on ability to RTS at the preinjury level 1 year postoperatively (RTS group and no-RTS group). The primary outcome was rate of RTS at 1 year postoperatively, and the primary dependent variables were the quality of PSR and PPR as measured by QPASREL scores at 6-month intervals. Secondary outcomes were the correlation and discriminative capacity of the QPASREL compared with the Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scores (collected at 6-month intervals).

Results

The study included 243 patients. Patients in the RTS group exhibited a higher mean PPR QPASREL score (36.6 ± 5.1) compared with no-RTS patients (34.8 ± 5.2; P = .01) as well as a higher mean PSR score (35.7 ± 5.1) compared with no-RTS patients (33.8 ± 5.9; P = .01). Multivariate analysis showed that every 5-point increase in the QPASREL scores for PPR and PSR resulted in a 39% (odds ratio [OR] = 1.39; P = 0.014) and 35% (OR = 1.35, P = 0.021) increased odds of RTS, respectively. A weak yet positive correlation was found between QPASREL and ACL-RSI. The predictive capacity of the QPASREL (area under the curve [AUC] = 0.60 for PPR and 0.61 for PSR), although significant, was less powerful compared with that of the ACL-RSI (AUC = 0.73).

Conclusion

The quality of the PPR and PSR, as measured by QPASREL scores, demonstrated a significant association with RTS rates at 1 year after ACLR. A weak yet positive correlation was found between QPASREL and ACL-RSI.

Cost-Outcome Descriptive Study for Mobile App (UPSCALER) in the Rehabilitation of Anterior Cruciate Ligament (ACL) Injuries After Reconstructive Surgery

Anterior cruciate ligament (ACL) injuries are a significant concern in athletes, often leading to long-term complications and reduced quality of life. Despite advancements in surgical techniques, outcomes following ACL reconstruction remain suboptimal, largely due to poor adherence to postoperative rehabilitation. This study introduces a novel postoperative rehabilitation approach utilizing a smartphone application, UPSCALER, developed by the Universiti Putra Malaysia Sports Injury and Arthroscopic Surgery Center of Excellence. The application delivers a validated accelerated rehabilitation protocol through instructional videos tailored to each patient's recovery phase. Results from the study demonstrate promising outcomes, including improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales post-rehabilitation, potentially attributed to increased adherence facilitated by the application's accessibility. Furthermore, the study explores the cost-effectiveness of this approach compared to conventional methods. In conclusion, smartphone application-guided rehabilitation shows promise in improving ACL reconstruction outcomes, warranting further research to validate its effectiveness and long-term impact on patient recovery and healthcare costs.

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers

Background

While the importance of structured rehabilitation following anterior cruciate ligament reconstruction (ACLR), particularly in the return-to-sport phase, is known, for most patients, supervised physical therapy is often completed before this time point. The recent emergence of telerehabilitation and other digital health interventions has the potential to address this "rehabilitation gap."

Methods

The study was conducted as a cross-section, online survey collecting qualitative and quantitative data from open and closed questions. Inclusion criteria included local qualified physical therapists or other professionals working with ACLR patients.

Results

Eighty-three percent of respondents experienced a "rehabilitation gap" with their ACLR patients. Few reported currently utilizing apps or websites (9.74%). The majority (41/58) reported experience with telerehabilitation, and 84% felt that there was a role for digital rehabilitation strategies to address the "rehabilitation gap." The vast majority (94.74%) of participants felt that standard commercial insurance did not permit sufficient rehabilitation.

Discussion

While the majority of our respondents acknowledged the existence of a "rehabilitation gap," as well as familiarity with and confidence in telerehabilitation, few were using this technique at the time of our survey. This suggests an opportunity for development in this space.

Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study

BACKGROUND

Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes.

PURPOSE

To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS.

RESULTS

Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245).

CONCLUSION

A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.

Impaction Of Rehabilitations And Strengthening Programs before And after Anterior Cruciate Ligament Reconstruction In Return to the Fitness Level

Objectives. Sports injuries are one of the most common orthopedic injuries particularly in young and active populations. Football is the most popular sport among Saudis, and thus, anterior cruciate ligament (ACL) injuries are common in clinics and emergency rooms in Saudi Arabia. The aim of this study was to evaluate the outcomes of patients six months after ACL reconstruction in both hospitals and gym-based rehabilitation services and its impaction on the patients to return to sports and preinjury fitness levels. Methods. This is a retrospective case series of patients who underwent arthroscopically assisted ACL reconstruction using a hamstring autograft at our center. Data were gathered from January 2020 to December 2020. Patients were given a questionnaire about their visits to the orthopedic clinic in the 6th month after surgery. Results. Sixty patients with ACL reconstructions were studied. Noncontact sports were the leading cause of injuries (53.3%). The mean Lysholm score was 84.9 (SD 3.45) out of 100 after six months of follow-up, and the mean Tegner score was 4.77 (SD 1.06) out of 10 points. The Lysholm score was excellent (>90) among 5% (n= 3), good (84–90) among 60% (n= 36), and fair (65–83) among 35% (n= 21). As a result, we observed that the duration of postoperative rehabilitation has a significant relationship with the fitness level (X2= 18.711; $p=0.001$ ).Conclusion. The Lysholm knee scoring scale and the Tegner activity scale showed that arthroscopically assisted ACL reconstruction using hamstring autograft has a successful and functional outcome after which the patient returns to sports or regains the preinjury level of fitness level depends on the rehabilitation.The period and types of preoperative and postoperative rehabilitation have a direct impact on the return to fitness levels and normal daily life activities.

'Such a massive part of rehab is between the ears'; barriers to and facilitators of anterior cruciate ligament reconstruction rehabilitation: a qualitative focus group analysis

Background

Current evidence demonstrates that few patients complete anterior cruciate ligament reconstruction rehabilitation according to evidence-based guidelines. It is important to investigate the viewpoints of our patients to identify patient-reported barriers and facilitators of anterior cruciate ligament reconstruction rehabilitation. Qualitative analysis can provide insight into potential methods for improving the delivery of rehabilitation services.

Methods

In this qualitative study, utilising a social constructionism orientation, viewed through the social phenomenological lens, three focus groups were conducted with individuals 1–20 years post anterior cruciate ligament reconstruction (n = 20, 9 males, 11 females, mean 6.5 years post-surgery, 19–51 years old). Utilising a semi-structured interview guide, participants were asked about their experiences during anterior cruciate ligament reconstruction rehabilitation. Focus groups were recorded, transcribed, and coded using an inductive semantic thematic analysis methodology.

Results

Five organising themes were identified (consisting of 19 sub-themes) to provide a framework to present the data: psychological, physiological, rehabilitation service, rehabilitation characteristics, and interaction with others. Each theme details aspects of rehabilitation, such as exercise delivery, informational support, frequency, and duration of care, kinesiophobia, weight management and interactions with teams and coaches, which present barriers or facilitators for patients to adhere to and participate in rehabilitation. Example quotes are provided for each theme to provide context and the patient’s voice.

Conclusions

This qualitative investigation identified key aspects of a patient's rehabilitation in which they encounter a variety of barriers and facilitators of ACL reconstruction rehabilitation. These aspects, such as the rehabilitation characteristics, service delivery, psychological and physiological factors, and interactions with others, were consistently identified by this cohort as factors which affected their rehabilitation. The themes may provide targets for clinicians to improve rehabilitation and deliver patient-centred care. However, the themes must be evaluated in future trials to assess whether interventions to remove barriers or enhance facilitators improves subsequent outcomes such as return to sport and re-injury rates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00499-x.

Biopsychosocial Model Domains in Clinical Practice Guidelines for Return to Sport After ACL Injury: Systematic Review Using the AGREE II Checklist

CONTEXT

The current status of return-to-sport (RTS) criteria can be understood from the International Classification of Functioning, Disability, and Health (ICF), which emphasizes an individual-centered approach and inclusion of all domains of human functioning, and ensures the multifactorial and biopsychosocial nature of decision-making.

OBJECTIVE

To analyze the inclusion of biopsychosocial model domains in clinical practice guidelines (CPGs) for RTS after anterior cruciate ligament (ACL) injury, as well as the quality of these CPGs.

STUDY DESIGN

Systematic review of CPGs.

LEVEL OF EVIDENCE

Level 1.

SEARCH STRATEGY

Two independent reviewers developed the search strategy, and a third reviewer corrected and compiled the developed strategies used.

DATA SOURCES

Ovid/Medline, Embase, and PEDro without restriction dates.

STUDY SELECTION

CPGs for RTS after ACL injury at any age or sport level, and published in English.

DATA EXTRACTION

Two independent reviewers codified the RTS criteria recommended in the CPGs according to the ICF domains, and the Appraisal of Guidelines for Research and Evaluation II (AGREE II Checklist) was used for critical appraisal.

RESULTS

A total of 715 records were identified, and 7 CPGs were included. Frequency distribution of the biopsychosocial model domains was as follows: body functions (37.77%), activity and participation (20.00%), body structure (13.33%), environmental factors (11.11%), and personal factors (8.88%). In the AGREE II Checklist, the lowest mean domain scores were for rigor of development (37.86 ± 36.35) and applicability (49.29 ± 22.30), and 71.42% were of low or moderate quality.

CONCLUSION

The CPGs cannot address the biopsychosocial model domains satisfactorily and some do not address all the ICF conceptual model components, emphasizing body functions and activity and participation domains. Therefore, the functioning model advocated by the World Health Organization has not yet been adequately incorporated into the recommendations for RTS after ACL injury. Moreover, most CPGs are of limited quality.

Rehabilitation after ACL injury and reconstruction from the patients' perspective

OBJECTIVES

To describe and compare patients' appraisal of the rehabilitation and adherence to the rehabilitation program after acute ACL injury treated with (ACLR) or without (non-ACLR) reconstruction.

DESIGN

Prospective cohort study.

PARTICIPANTS

275 patients (143 females; mean age 25 ± 7 years) with acute ACL injury, of whom 166 patients had ACLR within 24 months.

MAIN OUTCOME

Adherence to rehabilitation was assessed using the modified Sports Injury Rehabilitation Adherence Scale (SIRAS).

RESULTS

Appraisal of rehabilitation was higher in the post-ACLR group compared to the non-ACLR group at 3 months (91% compared to 70% scored rehabilitation as necessary, p = 0.025) and at 6 months (87% compared to 70% scored it as necessary, p = 0.017). SIRAS score did not differ between 3 and 6 months for the non-ACLR group (median (IQR) 13 (2) vs 13 (2)) or the post-ACLR group (14 (1) vs 14 (2), p > 0.05). The post-ACLR group had a higher SIRAS score than the non-ACLR group at 3 and 6 months (p ≤ 0.001).

CONCLUSION

Patients treated with ACLR reported valuing their rehabilitation more and rated greater adherence to the rehabilitation programme than non-surgically treated patients. As rehabilitation is essential for good knee function, strategies to improve adherence after non-ACLR treatment should be implemented.

LEVEL OF EVIDENCE

Prospective cohort study, level II.

Perspectives on the Gamification of an Interactive Health Technology for Postoperative Rehabilitation of Pediatric Anterior Cruciate Ligament Reconstruction: User-Centered Design Approach

Background

Pediatric and adolescent athletes are a large demographic undergoing anterior cruciate ligament reconstruction (ACL-R). Postoperative rehabilitation is critical, requiring patients to complete home exercise programs (HEPs). To address obstacles to HEP adherence, we developed an interactive health technology, interACTION (iA), to monitor knee-specific rehabilitation. iA is a web-based platform that incorporates wearable motion sensors and a mobile app that provides feedback and allows remote monitoring. The Wheel of Sukr is a gamification mechanism that includes numerous behavioral elements.

Objective

This study aims to use a user-centered design process to incorporate behavioral change strategies derived from self-management theory into iA using the Wheel of Sukr, with the aim of influencing patient behavior.

Methods

In total, 10 athletes aged 10-18 years with a history of ACL-R were included in this study. Patients were between 4 weeks and 1 year post–ACL-R. Participants underwent a 60-minute triphasic interview. Phase 1 focused on elements of gaming that led to high participation and information regarding surgery and recovery. In phase 2, participants were asked to think aloud and rank cards representing the components of the Wheel of Sukr in order of interest. In phase 3, the patients reviewed the current version of iA. Interviews were recorded, transcribed, and checked for accuracy. Qualitative content analysis segmented the data and tagged meaningful codes until descriptive redundancy was achieved; next, 2 coders independently coded the data set. These elements were categorized according to the Wheel of Sukr framework. The mean age of participants was 12.8 (SD 1.32) years, and 70% (7/10) were female. Most participants (7/10, 70%) reported attending sessions twice weekly. All patients were prescribed home exercises. Self-reported HEP compliance was 75%-100% in 40% (4/10), 50%-75% in 40% (4/10), and 25%-50% of prescribed exercises in 20% (2/10) of the participants.

Results

The participants responded positively to an app that could track home exercises. Desirable features included exercise demonstrations, motivational components, and convenience. The participants listed sports specificity, competition, notifications, reminders, rewards, and social aspects of gameplay as features to incorporate. In the Wheel of Sukr card sort exercise, motivation was ranked first; self-management, second; and growth, esteem, and fun tied for the third position. The recommended gameplay components closely followed the themes from the Wheel of Sukr card sort activity.

Conclusions

The participants believe iA is a helpful addition to recovery and want the app to include exercise movement tracking and encouragement. Despite the small number of participants, thematic saturation was reached, suggesting the sample was sufficient to obtain a representative range of perspectives. Future work will implement motivation; self-management; and growth, confidence, and fun in the iA user experience. Young athlete ACL-R patients will complete typical clinical scenarios using increasingly developed prototypes of the gamified iA in a controlled setting.