Patient and Parent Perceptions of Rehabilitation Factors That Influence Outcomes After Anterior Cruciate Ligament Reconstruction and Clearance to Return to Sport in Adolescents and Young Adults

Booster visits in the management of the acute musculoskeletal injuries: Transforming care to improve outcomes-A perspective review

The current healthcare delivery system for patients with acute musculoskeletal injury is failing. Current rehabilitation management of acute musculoskeletal injury typically includes physical therapy, focused on management of impairments, with an eventual transition to functional activities and release to prior level of function. At that point, formal physical therapy is often discontinued, despite the knowledge that a high percentage of patients fail to maintain preinjury level of activity and often reduce participation in regular physical activity. Further, for those who attempt to return to prior levels of pivoting and cutting activities, there is a high second injury rate. The long-term human experience is compromised by the current model of care which terminates at the point of transition to activity. This model of care fails to meet the continued needs of these patients and may result in long term deficits and potential disability. Extended care models include intermittent follow up visits after discharge from an acute episode of care and have been efficacious and cost effective in some patient populations with musculoskeletal conditions. Specifically, a type of extended care model, labeled "booster sessions," represents an opportunity to provide structured, intermittent care to assist in a smooth transition back to function, following an acute episode of care and promote a healthier life outcome. This perspective review will discuss the opportunity to transform acute musculoskeletal care to booster visit care model in an attempt to develop a more efficacious and cost-effective system of care which could be generalizable to all musculoskeletal conditions.

Shoulder Instability-Return to Sports After Injury (SIRSI) Scale Shows That Lack of Psychological Readiness Predicts Outcomes and Recurrence Following Surgical Stabilization

PURPOSE

This study aimed to evaluate the predictive ability of psychological readiness to return to sports on clinical outcomes and recurrences in athletes who return to sports following shoulder instability surgery.

METHODS

A retrospective analysis was performed of patients who underwent shoulder instability surgery between September 2020 and October 2021 (arthroscopic Bankart repair or Latarjet procedure) with a minimum follow-up of 2 years. Patients were grouped according to the achievement of psychological readiness to return to play using the SIRSI scale (≥ 55 points) measured at 6 months following surgery. Recurrences were measured and functional outcomes were evaluated by the Visual Analogue Scale (VAS), Rowe, and Athletic Shoulder Outcome Scoring System (ASOSS). The minimal clinically important difference (MCID) for the VAS and Rowe scores was calculated using the distribution-based method of ½ standard deviation of the delta (difference between postoperative and preoperative scores). The patient acceptable symptomatic state (PASS) for the VAS scale was set at 2.5 based on previous literature. To evaluate the predictive ability of SIRSI a regression model analysis and a receiver operating characteristic (ROC) curve were used.

RESULTS

A total of 108 who achieved psychological readiness (PSR) and 41 who did not (NPSR) met the study criteria. PSR achieved significantly higher percentages of MCID and PASS thresholds for VAS than NPSR (MCID: 68.5% vs 48.7%, p=0.026; PASS: 92.5% vs 58.5%, p<0.001). However, there were no differences in the percentage of patients achieving MCID for the Rowe score between groups (98.1% vs 100%, p=0.999). The only strongest independent predictor of postoperative outcomes was being psychologically ready to return to sports. The SIRSI scale had an excellent predictive ability for recurrences (area under curve 0.745, 95% CI 0.5-0.8). Of those who sustained a recurrence, 20% were not psychologically ready compared to 4.3% who were (p= 0.002). A power analysis was not conducted for this study.

CONCLUSION

The SIRSI scale is associated with postoperative clinical outcomes and recurrences in patients who returned to sports following shoulder instability surgery. Patients who were not psychologically ready following shoulder instability surgery had worse clinical outcomes with fewer patients achieving clinically significant outcomes (PASS and MCID) for pain, and a higher risk of recurrence.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Greater changes in self-reported activity level are associated with decreased quality of life in patients following an anterior cruciate ligament reconstruction

OBJECTIVE

To determine the association between change in physical activity level, as defined as the change from pre-to post-operative Tegner Activity Scale, and quality of life (QOL) after anterior cruciate ligament reconstruction (ACLR), before patients are cleared for return to sport.

PARTICIPANTS

1198 participants (42.9% male; 18.7 ± 3.6 years; 7.1 ± 3.7 months post-ACLR).

MAIN OUTCOME MEASURES

Surveys included Knee Injury and Osteoarthritis Outcome Score QOL (KOOS-QOL) subscale and Tegner Activity Scale. KOOS-QOL score ≥62.5 is considered as meeting a previously established patient acceptable symptom state.

RESULTS

The acceptable KOOS-QOL group reported a significantly smaller decrease in activity level from pre-injury to time of data collection (median: 2.00, IQR: 2.00) than the unacceptable KOOS-QOL group (median: 3.00, IQR: 3.00). Across the full cohort, for every one-point larger decrease in Tegner score from pre-to post-ACLR, there is a 52% increase in the odds of having an unacceptable KOOS-QOL score. For adolescents, the odds increase to 60% while the odds for adults were lower at 39%.

CONCLUSIONS

Following ACLR, greater decreases in physical activity level are associated with poorer QOL for both adolescents and adults at short-term follow-up, and this effect is larger amongst adolescents.

To achieve the unachievable-Patients' experiences of opting for delayed anterior cruciate ligament reconstruction after trying rehabilitation alone as primary treatment: A qualitative study

INTRODUCTION

About 50% of patients who sustain an anterior cruciate ligament (ACL) injury are treated without ACL reconstruction (ACL-R). A significant proportion of these patients opt for late ACL-R. Patients' experience of changing treatment has not yet been investigated and presented in the scientific literature.

AIM

To explore patients' experiences before and after changing treatment from ACL rehabilitation alone to ACL-R.

METHOD

Fifteen patients were interviewed in semi-structured interviews, which were recorded, transcribed, and analyzed with qualitative content analysis, based on the method described by Graneheim and Lundman. Patients were between 26 and 58 years old, and had tried rehabilitation for a minimum of 9 months prior to ACL-R.

RESULTS

Two themes, "Expecting what could not be achieved: the struggle to recover and not becoming stable", and "Internal completeness: expectations can be achieved", emerged from the analysis. Each theme was supported by three main categories and 5-6 subcategories. The first theme represents the journey before ACL-R, where patients experienced getting stronger, but perceived the knee as unstable. The second theme represents the journey after ACL-R, where patients expressed that they felt whole after their ACL-R, and where able to achieve their expections. Patients experienced a greater support from the healthcare system, and ultimately expressed a feeling of having achieved the unachievable after ACL-R.

SUMMARY

Patients who cross over from ACL rehabilitation to ACL-R experienced rehabilitation alone as insufficient to achieve the desired outcomes, which resulted in a need to opt for delayed ACL-R. Healthcare providers need to support patients, who primarily choose to undergo rehabilitation alone and later opt for ACL-R, throughout the whole rehabilitation process.

Validation of a Survey to Characterize Barriers to Physical Activity After Anterior Cruciate Ligament Reconstruction

CONTEXT

Although 84% of patients expected to return to activity within 1 year of anterior cruciate ligament (ACL) reconstruction (ACLR), as few as 24% will return to their preinjury level of activity. By considering a patient's perceptions of reengagement in activity after ACLR, clinicians and researchers may be better equipped to implement interventions that are patient centered.

OBJECTIVE

To describe the validation of the ACL Reasons survey, a tool to aid clinicians and researchers in understanding patient perceptions of barriers to physical activity (PA) engagement after ACLR.

DESIGN

Cross-sectional study.

PATIENTS OR OTHER PARTICIPANTS

The ACL Reasons survey was administered via Qualtrics to 78 patients 6 to 24 months after primary, unilateral ACLR. Patients were categorized as active, more challenging, or less active based on their responses to the ACL Reasons.

MAIN OUTCOME MEASURE(S)

Development of the ACL Reasons survey occurred via an iterative process of drafting and revising based on feedback from a team of external expert reviewers. Tegner activity level, Marx activity score, the Knee injury and Osteoarthritis Outcomes Score (KOOS), ACL Return to Sport after Injury score, and Tampa Scale of Kinesiophobia score were compared among groups using analysis-of-variance and Kruskal Wallis tests.

RESULTS

Groups differed based on Tegner activity level (P < .001), Marx activity score (P = .01), KOOS pain score (P = .02), KOOS symptom score (P = .04), KOOS sports and recreation score (P < .001), KOOS quality of life score (P < .001), ACL Return to Sport after Injury score (P < .001), and Tampa Scale of Kinesiophobia score (P < .001), with the less active group performing worse on each. Knee symptoms, fear of knee symptoms or movement, and fear of injury were the most common reasons for the change in PA engagement.

CONCLUSIONS

These results support the validity of the ACL Reasons survey as a tool for identifying barriers to PA engagement after ACLR. This tool may help facilitate communication between patients with ACLR and their health care providers to enhance patient-centered care.

Prevalence and Predictors of Postoperative Depression and Anxiety After Anterior Cruciate Ligament Reconstruction

PURPOSE

Preoperative mood disorders influence postoperative outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR), but the prevalence and risk factors associated with postoperative depression/anxiety development remain unknown. The purposes of this study were to quantify the prevalence of postoperative diagnoses of depression or anxiety following ACLR in patients under the age of 25 and assess the interplay between patient sex and ACL reoperation on the prevalence of a depression or anxiety diagnosis following ACLR.

METHODS

ACLR patients under the age of 25 years old were identified in the Truven Healthcare Marketscan database. Patients with incomplete coverage +/- one year of the index surgical procedure were excluded. Patients were categorized by the presence of preoperative, postoperative, or no depression/anxiety using the International Classification of Diseases, Ninth Revision (ICD-9) codes. We compared patient demographics and reoperation rates following the index ACLR between the depression and anxiety categories. Additionally, logistic regression was fit to assess the interaction between sex and either ipsilateral or contralateral ACL surgery on postoperative depression/anxiety diagnosis.

RESULTS

Of the 42,174 patients, 10.7% had a new depression/anxiety diagnosis after ACLR. Postoperative depression/anxiety was nearly twice as prevalent for females (F: 14.4%, M: 7.6%) despite having similar rates of secondary ACLR (F: 15.5%, M: 13.0%). Those with postoperative depression/anxiety had a considerably greater prevalence of reoperation (18.8%) than those without depression/anxiety (13.7%) and those with pre-existing preoperative depression/anxiety (12.9%). Sex and reoperation were independently associated with postoperative depression/anxiety diagnosis.

CONCLUSION

Female sex and secondary ACL surgery are independently associated with an increased prevalence of postoperative depression/anxiety. Nearly one in seven young females are diagnosed with depression/anxiety after ACLR. Similarly, a greater proportion of patients who suffer a secondary ACL surgery are subsequently diagnosed with depression/anxiety. The orthopedic community must be cognizant of the increased risk of postoperative depression/anxiety for females and those who suffer a secondary ACL surgery, and screening for depression/anxiety in these at-risk populations with referrals to mental health professionals may be warranted.

The Association of Physical Competence With Psychological Response Among Young Athletes at Time of Return to Sport After ACL Reconstruction

BACKGROUND

The traditional index of return-to-sport (RTS) readiness after anterior cruciate ligament reconstruction (ACLR) is the achievement of physical competence criteria. Emerging research indicates that psychological response and self-perceptions of physical competence may be critical mechanisms for successful RTS among young athletes.

HYPOTHESIS

Young athletes with higher actual physical competence (APC) and perceived physical competence (PPC) will demonstrate a more positive psychological response at the time of RTS after ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 41 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. APC was measured with isokinetic knee extension strength, single-limb crossover hop for distance, and the Knee injury and Osteoarthritis Outcome Score. PPC was measured with the Athletic Competence subscale of the Self-Perception Profile. Criteria for APC and PPC were based on established age- and activity-relevant cutoff scores. Different constructs of psychological response were assessed with the adapted Sport Motivation Scale, Brief Resilience Scale, and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) total and subscale scores (Emotions, Confidence, and Risk Appraisal). Multiple linear regression analyses were used to determine differences in measures of psychological response based on achievement of APC and PPC, while adjusting for age and sex.

RESULTS

Of the 41 participants, 10 (24.4%) met all criteria for APC and 22 (53.7%) met the PPC criteria. The regression models estimating the ACL-RSI score (P < .001; adjusted R2 = 0.331), ACL-RSI Emotions score (P < .001; adjusted R2 = 0.427), and ACL-RSI Risk Appraisal score (P = .013; adjusted R2 = 0.212) were statistically significant. Although APC was not associated with any measure of psychological response, meeting PPC criteria, younger age, and male sex were found to be associated with a more positive psychological readiness to RTS, but not with motivation or resilience.

CONCLUSION

Meeting PPC criteria was associated with higher psychological readiness to RTS among young athletes after ACLR, while meeting APC criteria was not associated with any construct of psychological response.

The Presence of a 'Sentinel' Vessel as an Anatomical Reference during Hamstring Tendon Harvesting-A Prospective Study

BACKGROUND

The identification of the branch of the inferior medial genicular artery (bIMGA) in anterior cruciate ligament reconstructions (ACLRs) has previously been considered a landmark by some surgeons, but its consistency remains debated. The aim of this investigation was to evaluate the variability in the appearance and location of bIMGA and to assess its validity as a reliable landmark during hamstring tendon harvesting procedures.

METHODS

This prospective, single-center study comprised 213 patients who underwent ACLR over a period of two years. The surgical procedures were conducted by the same surgical team, maintaining uniformity in the approach. The study sought correlations between patient demographics, level of activity, and the potential for successful identification of the bIMGA.

RESULTS

A statistically significant association between patient activity levels and successful identification of the bIMGA (p = 0.035) was observed. No significant correlations were found concerning patient demographic characteristics. bIMGA demonstrated a substantial degree of anatomical variability, rendering its consistent identification in the surgical field challenging.

CONCLUSIONS

Given the observed variability and the associated difficulty in its identification, the use of the bIMGA as a dependable anatomical reference during ACL graft harvesting is not recommended. This study confirms the inconsistency of bIMGA as a traditional landmark, underscoring the need for research aimed at identifying more consistent and reliable anatomical references to enhance the precision of surgical interventions in ACLR.

Factors That Affect Return to Sports After an Achilles Tendon Rupture: A Qualitative Content Analysis

Background

Achilles tendon rupture is common among physically active individuals, yet a high percentage fail to return to their former activity after the injury. Quantifiable factors such as type of treatment, hours of rehabilitation, and age have not been associated with return-to-play rates. A factor that influences recovery is the participant's experience before and throughout the rehabilitation process, which can be explored using a qualitative content analysis.

Purpose

To explore and describe what influences the participant to return to physical activity after an Achilles tendon rupture.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Twenty participants (14 men; mean age, 46 years) were interviewed as part of this study. All participants had ruptured their Achilles tendon 4 to 6 years before the interviews. From the interviews, codes were extracted that evolved into 19 subcategories, 6 categories, and 1 theme.

Results

The overarching theme that emerged was "Help me and then I can fix this." The 6 categories were (1) one's own drive to succeed, (2) having a supportive social network, (3) trusting the support from the health and social systems, (4) receiving and adapting information from others drives persistence in returning to activity, (5) impact of the injury on psychological factors; and (6) influence of physiological aspects.

Conclusion

To be able to recover properly from an Achilles tendon rupture and return to activity, the study participants described the importance of obtaining the support needed to be able to gain optimal rehabilitation. In the participants' opinion, for a greater chance of successful treatment and rehabilitation, it was vital to be provided with good support.

Anxiety state impact on recovery of runners with lower extremity injuries

This prospective cohort study examined the impact of high anxiety levels on psychological state and gait performance during recovery in runners with lower body injuries. Recreational runners diagnosed with lower body injuries who had reduced running volume (N = 41) were stratified into groups using State Trait Anxiety Inventory (STAI) scores: high anxiety (H-Anx; STAI ≥40 points) and low anxiety (L-Anx; STAI <40 points). Runners were followed through rehabilitation to return-to-run using monthly surveys. Main outcome measures included kinesiophobia (Tampa Scale of Kinesiophobia, TSK-11), Positive and Negative Affect Schedule (PANAS; Positive and negative scores), Lower Extremity Function Scale (LEFS), running recovery (University of Wisconsin Running Injury and Recovery Index [UWRI]) and CDC Healthy Days modules for general health, days of anxiety/tension, disrupted sleep and work/usual activities. Running biomechanics were assessed at baseline and the final visit using 3D motion capture and a force-plated treadmill. The time to return-to-running for was 5.0±3.1 and 7.9±4.1 months for L-Anx and H-Anx, respectively and participants who withdrew (n = 15) did so at 7.7±6.2 months. L-Anx maintained low anxiety and H-Anx reduced anxiety from baseline to final visit (STAI = 31.5 to 28.4 points, 50.4 to 37.8 points, respectively), whereas the withdrawn runners remained clinically anxious at their final survey (41.5 to 40.3 points; p < .05). Group by time interactions were found for PANAS positive, LEFS UWRI, general health scores, and days feeling worry, tension and anxiety (all p < .05). Final running performance in L-Anx compared to H-Anx was most improved with cadence (8.6% vs 3.5%; p = .044), impact loading rate [-1.9% vs +8.9%] and lower body stiffness [+14.1% vs +3.2%; all p < .05). High anxiety may identify runners who will experience a longer recovery process, health-related functional disruptions, and less optimization of gait biomechanics during rehabilitation after a lower extremity injury.

The effect of kinesiophobia on functional outcomes following anterior cruciate ligament reconstruction surgery: an integrated literature review

PURPOSE

Evaluate the effect of kinesiophobia on functional outcomes following anterior cruciate ligament reconstruction (ACLR).

MATERIALS AND METHODS

A three-phase, integrated mixed-methods review of observational and qualitative studies was undertaken. (1) Systematic search of studies with participants over 12 years old, following ACLR and focusing on kinesiophobia, using the Tampa Scale of Kinesiophobia (TSK) for observational studies. Exclusion criteria included ipsilateral knee surgery and the involvement of elite athletes. (2) Critical appraisal for both design types was undertaken. (3) Synthesis occurred in five stages. Results were reported as a relationship between the TSK and other functional outcome measures. Finally, qualitative results were integrated to explain the results.

RESULTS

Twenty-four studies (1174 participants) were included with no exclusion based on the quality appraisal. Six themes were identified: (1) return to sport (RTS); (2) activities of daily living; (3) knee-related quality of life; (4) gait; (5) reinjury; and (6) knee disability and physical function. The highest strength of evidence was the negative association between increased TSK scores and both decreased activity levels and RTS.

CONCLUSIONS

Kinesiophobia affects a range of functional outcomes. Further research is required to identify screening tools and interventions for patients with kinesiophobia.IMPLICATIONS FOR REHABILITATIONKinesiophobia affects the effectiveness of rehabilitation following anterior cruciate ligament reconstruction, therefore addressing kinesiophobia both pre- and post-ACLR is important to optimise rehabilitation.Validated screening tools are required to identify kinesiophobia in individuals early to allow appropriate rehabilitation.Physiotherapists need to use a range of physiotherapeutic techniques, such as motor imagery and prehabilitation to assist individuals to overcome their kinesiophobia and improve their functional outcomes post-ACLR.

Factors That Foster Therapeutic Alliance in Pediatric Sports and Orthopedics: A Systematic Review

Therapeutic alliance has been defined as building rapport between provider and patient in order to enhance patient motivation to improve outcomes. The purpose of this systematic review was to identify factors that patients look for that help build a strong therapeutic alliance in their pediatric sports or orthopedics healthcare provider, to identify if these factors differ across healthcare professions, and to identify any differences in therapeutic alliance between patients and their provider regarding in-person and telehealth visits. Scientific databases were searched from inception until August 2022. The search strategy resulted in 2195 articles with 11 studies included in the final analysis. The main attributes adolescents look for in their pediatric sports healthcare provider were shared decision making and understanding patients' sports and goals. These factors were found to differ among parents, sex, race, and socioeconomic status. The top factors improving therapeutic alliance in telehealth were having an already established relationship with the provider, visits lasting longer than 30 min, and having an English-speaking provider for English-speaking patients. The available literature highlights factors that contribute to the development of a stronger therapeutic alliance in the pediatric sports and orthopedics population. As these factors differ among adolescents, parents, sex, race, and socioeconomic status, this review provides insight in what patients and families look for in their provider when seeking care.

Adolescent Patient, Parent, and Clinician Perceptions of Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Qualitative Study

CONTEXT

Rehabilitation after anterior cruciate ligament reconstruction (ACLR) is challenging for adolescent patients concurrently experiencing growth and development, changes in attitudes and social interactions, and a gradual shift toward independence.

OBJECTIVE

To examine the perceptions of information sharing and interpersonal communication among adolescent patients going through ACLR, their parents, and physical therapists (PTs) treating adolescent patients with ACLR.

DESIGN

Cross-sectional study.

SETTING

University-affiliated sports medicine clinic.

PATIENTS OR OTHER PARTICIPANTS

Nine adolescent patients who had recently completed physical rehabilitation after ACLR, one of their parents, and PTs who treated adolescent patients with ACLR were recruited and enrolled.

MAIN OUTCOME MEASURE(S)

Participants completed semistructured interviews. The interview scripts for patients, parents, and PTs intentionally addressed the same topics, with only minor modifications in wording as appropriate for each role. All interviews were recorded, transcribed verbatim, and analyzed using a hybrid of deductive and inductive coding by trained members of the study team.

RESULTS

Patients, parents, and PTs perceived that interpersonal dynamics (eg, communication, external motivation) and stakeholder knowledge (eg, understanding of the psychological consequences of injury) influenced intrapersonal experiences (eg, emotional response, intrinsic motivation) during rehabilitation after ACLR. Additionally, patients and parents indicated that a lack of information about the rehabilitation process hindered their ability to obtain additional information from the PT and surgeon.

CONCLUSIONS

Participants from all stakeholder groups reported that orthopaedic surgeons and other members of the health care team may consider being more consistent when setting expectations, physical restrictions, and recovery timelines.

A Psychological Support Intervention to Help Injured Athletes “Get Back in the Game”: Design and Development Study

Background

After a serious knee injury, up to half of athletes do not return to competitive sport, despite recovering sufficient physical function. Athletes often desire psychological support for the return to sport, but rehabilitation clinicians feel ill-equipped to deliver adequate support.

Objective

We aimed to design and develop an internet-delivered psychological support program for athletes recovering from knee ligament surgery.

Methods

Our work for developing and designing the Back in the Game intervention was guided by a blend of theory-, evidence-, and target population–based strategies for developing complex interventions. We systematically searched for qualitative evidence related to athletes’ experiences with, perspectives on, and needs for recovery and return to sport after anterior cruciate ligament (ACL) injury. Two reviewers coded and synthesized the results via thematic meta-synthesis. We systematically searched for randomized controlled trials reporting on psychological support interventions for improving ACL rehabilitation outcomes in athletes. One reviewer extracted the data, including effect estimates; a second reviewer checked the data for accuracy. The results were synthesized descriptively. We conducted feasibility testing in two phases—(1) technical assessment and (2) feasibility and usability testing. For phase 1, we recruited clinicians and people with lived experience of ACL injury. For phase 2, we recruited patients aged between 15 and 30 years who were within 8 weeks of ACL reconstruction surgery. Participants completed a 10-week version of the intervention and semistructured interviews for evaluating acceptability, demand, practicality, and integration. This project was approved by the Swedish Ethical Review Authority (approval number: 2018/45-31).

Results

The following three analytic themes emerged from the meta-synthesis (studies: n=16; participants: n=164): (1) tools or strategies for supporting rehabilitation progress, (2) barriers and facilitators for the physical readiness to return to sport, and (3) barriers and facilitators for the psychological readiness to return to sport. Coping strategies, relaxation, and goal setting may have a positive effect on rehabilitation outcomes after ACL reconstruction (randomized controlled trials: n=7; participants: n=430). There were no trials of psychological support interventions for improving the return to sport. Eleven people completed phase 1 of feasibility testing (technical assessment) and identified 4 types of software errors, which we fixed. Six participants completed the feasibility and usability testing phase. Their feedback suggested that the intervention was easy to access and addressed the needs of athletes who want to return to sport after ACL reconstruction. We refined the intervention to include more multimedia content and support access to and the use of the intervention features.

Conclusions

The Back in the Game intervention is a 24-week, internet-delivered, self-guided program that comprises 7 modules that complement usual rehabilitation, changes focus as rehabilitation progresses, is easy to access and use, and includes different psychological support strategies.

'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.

Rehabilitation After Anterior Cruciate Ligament Injury: Review of Current Literature and Recommendations

PURPOSE OF REVIEW

Anterior cruciate ligament reconstruction (ACLR) is a common surgical procedure with an estimated 120,000 cases performed in the USA each year. Physical therapy plays a critical role in the successful recovery of both surgically and non-surgically managed patients. Interestingly, ACL rehabilitation protocols vary greatly with little consensus among practitioners. Nonetheless, there has been agreement over the last decade to shift from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences. This review summarizes the most recent trends, opinions, and modalities in ACL rehabilitation research, with a specific focus on novel methods to treat the specific psychosocial needs of ACL deficient patients.

RECENT FINDINGS

We found that new protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as neuromuscular electrical stimulation and blood flow restriction. We also found a recent trend toward the use of clinical milestones to determine when a patient is ready for the next phase of a "step-up" rehabilitation program. One particularly nascent topic of research is the inclusion of methods to treat the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport. Rehabilitation strategy has become increasingly patient-dependent, and the new modalities being utilized are accelerating patient recovery. Return to sport is a particularly important factor for many ACLR patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings.

The Effect of Mobile Care Delivery on Clinically Meaningful Outcomes, Satisfaction, and Engagement Among Physical Therapy Patients: Observational Retrospective Study

Background

Musculoskeletal care is now delivered via mobile apps as a health care benefit. Although preliminary evidence shows that the clinical outcomes of mobile musculoskeletal care are comparable with those of in-person care, no research has examined the features of app-based care that secure these outcomes.

Objective

Drawing on the literature around in-person physical therapy, this study examines how patient-provider relationships and program engagement in app-based physical therapy affect clinically meaningful improvements in pain, function, and patient satisfaction. It then evaluates the effects of patient-provider relationships forged through in-app messages or video visits and timely, direct access to care on patients’ engagement in their recovery.

Methods

We conducted an observational, retrospective study of 814 pre- and postsurveyed participants enrolled in a mobile app physical therapy program where physical therapists prescribed workouts, education, and therapeutic activities after a video evaluation from February 2019 to December 2020. We estimated generalized linear models with logit functions to evaluate the effect of program engagement on clinical outcomes, minimal clinically important differences (MCIDs) in pain (ΔVisual Analogue Scale ≤−1.5) and function (ΔPatient Specific Functional Scale ≥1.3), and the effects of patient-provider relationships and clinical outcomes on patient satisfaction—participant reported likelihood to recommend the program (Net Promoter Scores of 9-10). We estimated Poisson generalized linear models to evaluate the effects of stronger patient-provider relationships and timely access to physical therapy within 24 hours on engagement including the number of weekly workouts and weeks in the program.

Results

The odds that participants (N=814) had a pain MCID increased by 13% (odds ratio [OR] 1.13, 95% CI 1.04-1.23; P=.003) with each weekly workout and the odds of a function MCID by 4% (OR 1.04, 95% CI 1.00-1.08; P=.03) with each week in the program. Participants with MCIDs in function and large changes in pain (Δ Visual Analogue Scale ≤−3.5) were 1.85 (95% CI 1.17-2.93; P=.01) and 2.84 times (95% CI 1.68-4.78; P<.001) more satisfied, respectively. Those with video follow-up visits were 2 to 3 times (P=.01) more satisfied. Each physical therapist’s message increased weekly workouts by 11% (OR 1.11, 95% CI 1.07-1.16; P<.001). Video follow-up visits increased weekly workouts by at least 16% (OR 1.16, 95% CI 1.04-1.29; P=.01) and weeks in the program at least 8% (OR 1.08, 95% CI 1.01-1.14; P=.02). Access was associated with a 14% increase (OR 1.14, 95% CI 1.05-1.24; P=.003) in weekly workouts.

Conclusions

Similar to in-person care, program engagement positively affects clinical outcomes, and strong patient-provider relationships positively affect satisfaction. In app-based physical therapy, clinical outcomes positively affect patient satisfaction. Timely access to care and strong patient-provider relationships, particularly those forged through video visits, affect engagement.

Self-Reported Symptoms of Depression and Anxiety After ACL Injury: A Systematic Review

Background:

Depression and anxiety symptoms can occur in patients following an anterior cruciate ligament (ACL) injury, and the presence of these symptoms has been associated with poorer self-reported knee function in this type of injury.

Purpose:

To investigate the prevalence and severity of self-reported symptoms of depression and anxiety following an ACL injury.

Study Design

Systematic review; Level of evidence, 4.

Methods:

PubMed, Cochrane Library, Embase, PsycINFO, AMED, and PEDro databases were searched using a combination of keywords relating to ACL, depression, anxiety, and their synonyms. Inclusion criteria were clinical studies written in English that reported on patients with an injured and/or reconstructed ACL and assessed symptoms of depression and/or anxiety. Data extraction was performed independently by 2 authors. Data synthesis was performed using an emergent synthesis approach. The quality of the included studies was assessed using the methodological index for non-randomized studies or the Mixed-Methods Appraisal Tool. Certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation.

Results:

After abstract screening, 37 studies were assessed in full text, of which 16 were included. The studies comprised 682 patients (417 male [61%]). The depression symptoms appeared to be more severe in elite athletes compared with recreational athletes. Symptoms decreased over time from moment of ACL reconstruction to up to 2 years postoperatively. The prevalence of self-reported symptoms of anxiety after an ACL injury was reported in 1 study (2%). There were no differences in anxiety symptoms between professional and amateur athletes or between adolescents and adults. The overall quality of the studies was low or very low.

Conclusion:

Patients who sustain an ACL injury can suffer from symptoms of depression, especially during the first 6 weeks after ACL reconstruction. Depressive symptoms are more common among professional versus nonprofessional athletes. Levels of anxiety symptoms were not above the cutoffs for a diagnosis of anxiety after an ACL injury.

Balance, reframe, and overcome: The attitudes, priorities, and perceptions of exercise-based activities in youth 12-24 months after a sport-related ACL injury

Attitudes, priorities, and perceptions of exercise directly influence exercise behaviors. Despite the benefits of exercise-based activities for future health, little is known about how youth who experience an ACL injury view exercise-based activity beyond the immediate recovery period. A qualitative (interpretative description) approach with one-to-one semistructured interviews was used to probe the current attitudes, priorities, and perceptions of exercise-therapy, physical activity, and sport participation with a purposive sample of youth from an ongoing inception cohort study who experienced an ACL tear or reconstruction in the past 12-24 months. Analyses followed an inductive approach guided by an analytic interpretative description process. Reflexive journaling, memoing, and a detailed audit trail promoted data trustworthiness. A patient-partner was involved throughout. Ten youth (six women, four men), 15-19 years of age, and a median of 20-months (16-26) from injury were interviewed. Three overarching themes were identified. 'Balancing physical activity and future knee health' highlighted ongoing negotiations between what were perceived to be competing priorities for return-to-sport and future knee health. 'Reframing the value of exercise-therapy and physical activity' reflected the importance of reshaping attitudes toward exercise as positive and was linked to exercise adherence. 'Overcoming unforeseen exercise challenges' encompassed persisting psychological and physical challenges perceived to limit exercise-based activities. Clinical significance: reframing exercise-based activities in a positive light and leveraging motivation for return-to-sport and life-long knee health may be important strategies for encouraging ongoing exercise therapy and physical activity following a youth ACL injury.

Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

Level of Evidence

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.

Assessing implementation, limited efficacy, and acceptability of the BEAST tool: A rehabilitation and return-to-sport decision tool for nonprofessional athletes with anterior cruciate ligament reconstruction

OBJECTIVES

To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes.

DESIGN

Prospective cohort.

PARTICIPANTS

43 nonprofessional pivoting sport athletes with ACLR.

MAIN OUTCOME

Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability).

RESULTS

The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely).

CONCLUSION

The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

Psychological impairments after ACL injury - Do we know what we are addressing? Experiences from sports physical therapists

Psychological impairments can follow an anterior cruciate ligament (ACL) injury and can impact the rehabilitation process. Our aim was to investigate experiences of sports physical therapists (PTs) in addressing psychological impairments in patients after ACL injury. We conducted four focus group interviews with fourteen sports PTs. The PTs' experiences of working with psychological impairments after ACL injury were summarized in four main categories: (1) "Calling for a guiding light", where PTs stated that the most common method of acquiring knowledge on addressing psychological impairments was through discussions with colleagues, and, at the same time, PTs expressed an insufficient knowledge of how to address psychological impairments; (2) "Meeting the burden of psychological impairments" where PTs stated that psychological impairments are greater than physical; (3) "Trying to balance physical and psychological aspects" where patient education and assessments were reported to be important in order to understand psychological impairments during rehabilitation; and (4) "Goal setting: a helpful challenge" where sports PTs expressed a need for specific knowledge of the rehabilitation of psychological impairments following ACL injury. To help provide the current best practice, we encourage researchers to develop psychologically centered interventions for rehabilitation after an ACL injury, and PTs to stay up-to-date with the literature published on the subject, including to implement eventual interventions.

A qualitative assessment of return to sport following Achilles tendon repair

Studies have demonstrated successful return to sport rates following Achilles tendon rupture and repair. The purpose of this study is to understand the subjective intrinsic and extrinsic motivational factors influencing an athlete's return to pre-injury level of sport following Achilles tendon repair. Qualitative, semi-structured interviews of 23 athletes who had undergone Achilles tendon repair were conducted and analyzed to derive codes, categories, and themes. Three major themes affecting return to sport were elucidated from the interviews: personal motivation, shift in focus, and confidence in healthcare team. These findings can direct healthcare teams on how to better guide patients post-operatively.

Patient expectations and perceived social support related to return to sport after anterior cruciate ligament reconstruction in adolescent athletes

OBJECTIVE

Examine the relationship between pre-operative competitive status and return to sport expectations post-operatively among adolescents undergoing ACL reconstruction. Assess the association between perceived levels of social support and doubts in returning to sport after ACL reconstruction.

DESIGN

Cross-sectional.

SETTING

Outpatient sports medicine clinic at a single institution.

PARTICIPANTS

12-18 years old with an ACL tear who were planning to undergo ACL reconstruction.

MAIN OUTCOME MEASURES

Psychovitality questionnaire responses and Multidimensional Scale of Perceived Social Support (MSPSS) questionnaire scores.

RESULTS

86% of participants expected to return to sports in six months or less after surgery; there was no significant difference in expected time to return to sport between competitive vs. recreational athletes. Competitive athletes were less likely to be content returning to a lower activity level after surgery compared to recreational athletes. There were no significant differences in MSPSS scores between those who did and did not report doubts in their ability to return to their previous sports.

CONCLUSION

Most of our adolescent athlete population expected to return to sport after ACL reconstruction within six months of surgery. Those with and without doubts in their ability to return to sports did not significantly differ in levels of perceived social support.

Chaos and confusion with confidence: Managing fear of Re-Injury after anterior cruciate ligament reconstruction

OBJECTIVES

To explore strategies enabling competitive athletes to manage re-injury fears or anxieties, facilitating return to competitive sport following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Qualitative study.

SETTING

University.

PARTICIPANTS

Ten athletes with ACLR within the last 5 years who had returned to competitive sport with a minimum 7/10 Tegner Activity score.

METHODS

Semi-structured interviews, recorded, transcribed and analysed using interpretive description.

RESULTS

Three main themes. "Driving reasons to return to sport" included the athletic identity, the competitive team spirit and commitment; "Preparation of body and mind" encompassed connectedness with health professionals, coaches, the sports team and family, graded exposure and progression of physical tasks, and psychological or cognitive skills to improve mental toughness; "Risk Acceptance" entailed situational risk analysis, problem solving, and avoidance of unacceptable risk and acceptance of risk and responsibility.

CONCLUSION

Participants described intrinsic and extrinsic motivators as drivers for rehabilitation. Interactions with therapists, coaches and team members enhanced confidence, supported by both physical rehabilitation and psychological influences. Psychological strategies were essential for several participants to return to sport. Graded sports exposure, leading towards total immersion in training and competition, appears important to manage re-injury fear following ACLR.

The Influence, Barriers to and Facilitators of Anterior Cruciate Ligament Rehabilitation Adherence and Participation: a Scoping Review

Background

Outcomes following anterior cruciate ligament (ACL) reconstruction are considered poor. There are many factors which may influence patient outcomes. As such, the purpose of this review was to report on the influence, barriers to and facilitators of rehabilitation adherence and participation after ACL reconstruction, providing information to help clinicians and patients make quality decisions to facilitate successful rehabilitation.

Methods

A systematic search of five electronic databases was undertaken in identifying studies from inception to 18 July 2019. The search included English language articles reporting on the influence, barriers to and facilitators of adherence and participation in rehabilitation of patients who have undergone ACL reconstruction. Data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 180) were assessed for eligibility following screening of titles and abstracts (n = 1967), yielding 71 studies for inclusion. Forty-four articles investigated ‘rehabilitation prescription and participation’ and 36 articles investigated ‘rehabilitation barriers and facilitators’. The results indicate that a moderately or minimally supervised rehabilitation program is at least as effective as a fully supervised high-frequency rehabilitation program, although a longer duration of supervised rehabilitation is associated with improvement in a multitude of functional outcomes. A number of psychological factors associated with rehabilitation adherence were also identified. The most commonly investigated concepts were self-motivation, athletic identity and social support. Patients perceived the therapeutic relationship, interaction with family and friends, self-motivation, fear of reinjury, organisation/lack of time and interpersonal comparison as the most common barriers to and facilitators of rehabilitation.

Conclusions

A longer duration of supervised rehabilitation is associated with an increased chance of meeting functional and return to sport criteria; however, the optimal supervised rehabilitation frequency is yet to be determined. Identification of the barriers to and facilitators of adherence and participation in ACL rehabilitation provides an opportunity for further research to be conducted to address personal, environmental and treatment-related factors, with the aim to improve rehabilitation outcomes.

Comparison of efficacy and safety of different fixation devices for anterior cruciate ligament reconstruction: A Bayesian network meta-analysis protocol

BACKGROUND

Anterior cruciate ligament (ACL) injury is a common ligament injury to the knee joint, and often lead to limited function, osteoarthritis after knee trauma, secondary damage to meniscus and cartilage, and impaired quality of life. ACL reconstruction is the gold standard surgical treatment for ACL injury, and ligament fixation after reconstruction is the key factor of ACL reconstruction success. However, the optimal fixation device for ACL reconstruction remains unclear. This study aims to evaluate the efficacy and safety of different fixation devices and to find the best fixation device for ACL reconstruction.

METHODS

The PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese Biomedicine Literature will be searched to identify relevant studies from inception to December 2018. We will include randomized controlled trials (RCTs) comparing the effects of different fixation devices fixed on the femoral side in arthroscopically assisted ACL reconstruction. Risk of bias assessment of the included RCTs will be conducted according to the Cochrane Handbook 5.1.0. A Bayesian network meta-analysis (NMA) will be performed using R software.

RESULTS

The results of this NMA will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This NMA will summarize the direct and indirect evidence to evaluate the effect of different fixation devices for ACL reconstruction.