Implementing a shared decision-making intervention to support treatment decisions for patients following an anterior cruciate ligament rupture - a protocol for the POP-ACLR feasibility study.

BACKGROUND: Treatment for anterior cruciate ligament (ACL) rupture may follow a surgical or nonsurgical pathway. At present, there is uncertainty around treatment choice. Two shared decision-making tools have been codesigned to support patients to make a decision about treatment following an ACL rupture. The shared decision-making tools include a patient information leaflet and an option grid. We report the protocol for a mixed-methods feasibility study, with nested qualitative interviews, to understand feasibility, acceptability, indicators of effectiveness and implementation factors of these shared decision-making tools (combined to form one shared decision-making intervention). METHODS: A single-centre non-randomised feasibility study will be conducted with 20 patients. Patients diagnosed with an ACL rupture following magnetic resonance imaging will be identified from an orthopaedic clinic. The shared decision-making intervention will be delivered during a clinical consultation with a physiotherapist. The primary feasibility outcomes include the following: recruitment rate, fidelity, acceptability and follow-up questionnaire completion. The secondary outcome is the satisfaction with decision scale. The nested qualitative interview will explore experience of using the shared decision-making intervention to understand acceptability, implementation factors and areas for further refinement. DISCUSSION: This study will determine the feasibility of using a newly developed shared decision-making intervention designed to support patients to make a decision about treatment of their ACL rupture. The acceptability and indicators of effectiveness will also be explored. In the long term, the shared decision-making intervention may improve service and patient outcomes and ensure cost-effectiveness for the NHS; ensuring those most likely to benefit from surgical treatment proceed along this pathway. TRIAL REGISTRATION: Pending registration on ISRCTN.

Preoperative predictors for return to physical activity following anterior cruciate ligament reconstruction (ACLR): a systematic review.

BACKGROUND: Rates of return to physical activity after anterior cruciate ligament reconstruction surgery are sub-optimal. Optimising presurgical treatment may improve return rates. The purpose of this systematic review was to identify modifiable preoperative predictors for return to physical activity after anterior cruciate ligament reconstruction. METHODS: Seven electronic databases (CINAHL, MEDLINE and SPORTDiscus via EBSCOhost, AMED, PsycINFO and EMBASE via OVID and Web of Science) were searched from inception to 31 March 2023. The population of focus was adults aged 18-65 who had undergone primary anterior cruciate ligament reconstruction. Studies needed to identify at least one potential modifiable preoperative predictor variable and the relationship between the predictor(s) and return to physical activity. All time-points of assessment and study designs were included. Data extraction was completed by one reviewer and verified by a second reviewer. Two reviewers completed the risk of bias assessment using the Quality in Prognostic Studies tool and Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The search identified 2281 studies, eight met the inclusion criteria. Five studies scored 'high', and three studies scored 'moderate' risk-of-bias. All preoperative predictors were of very low-quality evidence. Five different outcome measures were used to assess return to physical activity including Tegner, Marx, Physical Activity Scale, return to play at the elite level and return to preinjury level (undefined). This was measured between 1- and 10-years post-surgery. Nine preoperative physical, six psychosocial and five demographic/clinical factors were assessed and four were found to be predictive. These included quadriceps strength, psychological profile, patient estimated ability to return and graft type (patella tendon, BPTB). CONCLUSION: Very-low level evidence suggests that increasing quadriceps strength, managing patient expectations of their treatment outcomes, improving motivation to resume preinjury activity levels and considering the use of a BPTB graft will support return to physical activity after ACLR. TRIAL REGISTRATION: This study was prospectively registered in PROSPERO: CRD 42020222567.

Current preoperative physiotherapy management strategies for patients awaiting Anterior Cruciate Ligament Reconstruction (ACLR): A worldwide survey of physiotherapy practice.

BACKGROUND: Anterior cruciate ligament ruptures are the most common ligament injury to the knee with surgical reconstruction considered standard treatment. This study aimed to explore the current physiotherapy management strategies used during the preoperative phase of rehabilitation for patients awaiting anterior cruciate ligament reconstruction (ACLR). METHODS: An anonymous survey was disseminated online via Twitter and the 'interactive Chartered Society of Physiotherapy' message board. Practising physiotherapists who treated at least one patient prior to ACLR in the past year were invited to take part. Responses were collected over a 4-week period in March 2020. Data were analysed using descriptive statistics. RESULTS: In total, 183 respondents replied; 122 completed the full survey. Responses were collected from 20 countries across 3 settings, NHS/public health services, private and sports. Most respondents reported prescribing exercises, advice and education to patients during prehabilitation. Up to 40% also utilised passive treatments including manual therapy, taping/bracing and electrotherapy. The frequency of recommended exercise completion and length of treatment varied. Most respondents (n = 103/84.4%) felt that many patients waiting for ACLR did not receive prehabilitation. Many physiotherapists reported that patients expressed concerns regarding their readiness for surgery (n = 61/50%) and return to preinjury levels of physical activity (n = 112/91.8%). Almost all respondents would discuss non-operative management with patients (n = 112/91.8%) if they had returned to their preinjury level of physical activity before their ACLR. CONCLUSION: Overall, this survey provides some insight as to how physiotherapists manage patients awaiting ACLR. Areas of uncertainty in physiotherapy practice have also been highlighted that require further high-quality research.

The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review.

BACKGROUND: To explore the effectiveness of preoperative rehabilitation programmes (PreHab) on postoperative physical and psychological outcomes following anterior cruciate ligament reconstruction (ACLR). METHOD: A systematic search was conducted from inception to November 2019. Randomised controlled trials (RCTs) published in English were included. Risk of bias was assessed using Version 2 of the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence. RESULTS: The search identified 739 potentially eligible studies, three met the inclusion criteria. All included RCTs scored 'high' risk of bias. PreHab in all three RCTs was an exercise programme, each varied in content (strength, control, balance and perturbation training), frequency (10 to 24 sessions) and length (3.1- to 6-weeks). Statistically significant differences (p < 0.05) were reported for quadriceps strength (one RCT) and single leg hop scores (two RCTs) in favour of PreHab three months after ACLR, compared to no PreHab. One RCT reported no statistically significant between-group difference for pain and function. No RCT evaluated post-operative psychological outcomes. CONCLUSION: Very low quality evidence suggests that PreHab that includes muscular strength, balance and perturbation training offers a small benefit to quadriceps strength and single leg hop scores three months after ACLR compared with no PreHab. There is no consensus on the optimum PreHab programme content, frequency and length. Further research is needed to develop PreHab programmes that consider psychosocial factors and the measurement of relevant post-operative outcomes such as psychological readiness and return to sport. TRIAL REGISTRATION: PROSPERO trial registration number. CRD42020162754 .