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.

Beyond guidelines: A qualitative clinical stakeholder study of optimal management of anterior cruciate ligament rehabilitation.

AIMS: This study gathered expert perspectives in the management of anterior cruciate ligament (ACL) rehabilitation to explore current practice, variations in care and optimal management strategies. MATERIALS AND METHODS: This was a qualitative semi-structured interview study. The participants' experiences were considered in terms of their roles as employees, managers, clinicians and professional gatekeepers. Purposive and snowball sampling were used to recruit physiotherapists and orthopaedic surgeons. Participants were included if they had a proven record in clinical management or research involving ACL patients. Persons were excluded if they could not speak English. Interviews were conducted in person, via skype or over the phone at a time convenient to the participant. Data was analysed using a framework analysis and critical realist approach. RESULTS: Results included 24 interviews that were conducted with 19 physiotherapists and 5 surgeons. Themes of variation in current care and optimal care were explored including subthemes of patient centred practice, evidence based medicine, resources, self-management, multidisciplinary teamwork, training and expertise were explored. Participant's perceptions of current care were that it was a location 'lottery' that significantly varied for patients across the UK. CONCLUSIONS: Stakeholders identified that optimal management should be patient centred and incorporate adequate equipment, specific training for physiotherapists and a closely communicating multidisciplinary team. Research is needed to explore cost effective models of optimal rehabilitation that include return to sport strategies.

Feasibility randomised controlled trial comparing TRAK-ACL digital rehabilitation intervention plus treatment as usual versus treatment as usual for patients following anterior cruciate ligament reconstruction.

OBJECTIVES: To evaluate the feasibility of trialling taxonomy for the rehabilitation of knee conditions-ACL (TRAK-ACL), a digital health intervention that provides health information, personalised exercise plans and remote clinical support combined with treatment as usual (TAU), for people following ACL reconstruction. METHODS: The study design was a two-arm parallel randomised controlled trial (RCT). Eligible participants were English-speaking adults who had undergone ACL reconstruction within the last 12 weeks, had access to the internet and could provide informed consent. Recruitment took place at three sites in the UK. TRAK-ACL intervention was an interactive website informed by behaviour change technique combined with TAU. The comparator was TAU. Outcomes were: recruitment and retention; completeness of outcome measures at follow-up; fidelity of intervention delivery and engagement with the intervention. Individuals were randomised using a computer-generated random number sequence. Blinded assessors allocated groups and collected outcome measures. RESULTS: Fifty-nine people were assessed for eligibility at two of the participating sites, and 51 were randomised; 26 were allocated to TRAK-ACL and 25 to TAU. Follow-up data were collected on 44 and 40 participants at 3 and 6 months, respectively. All outcome measures were completed fully at 6 months except the Client Service Receipt Inventory. Two patients in each arm did not receive the treatment they were randomised to. Engagement with TRAK-ACL intervention was a median of 5 logins (IQR 3-13 logins), over 18 weeks (SD 12.2 weeks). CONCLUSION: TRAK-ACL would be suitable for evaluation of effectiveness in a fully powered RCT.

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Patients.

BACKGROUND: Evidence shows that after anterior cruciate ligament (ACL) reconstruction, patients may have varied access to physical therapy. In particular, physical therapy input may end many months before patients reach full recovery. Telerehabilitation may provide an opportunity to address this rehabilitation gap and improve access to evidence-based rehabilitation alongside physical therapy at all stages of care. OBJECTIVE: This study aims to understand the opinions of patients who have undergone ACL surgery and rehabilitation on the use of telerehabilitation as part of ACL care and define the population and explore their experiences and views on the acceptability of telerehabilitation after ACL reconstruction. METHODS: This study was a cross-sectional, voluntary, web-based survey combining both closed and open questions. Ethical approval was obtained from the Yale School of Medicine Institutional Review Board. Participants were aged 16 years or older at the time of recruitment and had undergone ACL reconstruction within the past 5 years. A 26-item survey was developed using the Qualtrics survey platform. No items were mandatory. Responses were multiple choice, binary, and qualitative. The CHERRIES (Checklist for Reporting Results of Internet E-Surveys) was used to ensure the quality of reporting of surveys in the medical literature. Data were analyzed using Stata version 15. Qualitative data were analyzed using NVivo 11. The theoretical framework for this analysis is based on the Capability, Opportunity, and Motivation-Behavior model of behavior change. RESULTS: A total of 100 participants opened the survey. All completers were unique. The participation and completion rates were each 96% (96/100). Patients reported their physical therapy care ended at an average of 6.4 months and that they felt fully recovered at an average of 13.2 months. Only 26% (25/96) of patients felt fully recovered at the end of physical therapy. Of these 96 patients, 54 (60%) were younger than 30 years, 71 (74%) were recreational athletes, 24 (24%) were competitive athletes, 72 (75%) had private insurance, 74 (77%) were not familiar at all with telerehabilitation, and 89% (85/96) felt capable. They preferred to use telerehabilitation at different stages of care. Reported benefits included resource saving, improved access to care, improved learning, and greater engagement. Concerns included incorrect performance of exercises or unmanaged pain being missed and less access to manual therapy, motivation, and opportunities to ask questions. Participants' priorities for a future telerehabilitation intervention included its use as an adjunct to physical therapy rather than a replacement, with content available for each stage of care, especially return to sports. Participants stressed that the intervention should be personalized to them and include measures of progress. CONCLUSIONS: These findings helped understand and define the ACL reconstruction population. Participants found telerehabilitation acceptable in principle and highlighted the key user requirements and scope of future interventions.

Acceptability of a digital health intervention alongside physiotherapy to support patients following anterior cruciate ligament reconstruction.

BACKGROUND: Physiotherapy rehabilitation following surgical reconstruction to the Anterior Cruciate Ligament (ACL) can take up to 12 months to complete. Given the lengthy rehabilitation process, a blended intervention can be used to compliment face-to-face physiotherapy with a digital exercise intervention. In this study, we used TRAK, a web-based tool that has been developed to support knee rehabilitation, which provides individually tailored exercise programs with videos, instructions and progress logs for each exercise, relevant health information and a contact option that allows a patient to email a physiotherapist for additional support. The aim of this study was to evaluate the acceptability of TRAK-based blended intervention in post ACL reconstruction rehabilitation. METHODS: A qualitative research design using semi-structured interviews was used on a convenience sample of participants following an ACL reconstruction, and their treating physiotherapists, in a London NHS hospital. Participants were asked to use TRAK alongside face-to-face physiotherapy for 16 weeks. Interviews were carried out, audio recorded, transcribed verbatim and coded by two researchers independently. Data were analyzed using thematic analysis. RESULTS: Of the 25 individuals that were approached to be part of the study, 24 consented, comprising 8 females and 16 males, mean age 30 years. 17 individuals used TRAK for 16 weeks and were available for interview. Four physiotherapists were also interviewed. The six main themes identified from patients were: the experience of TRAK rehabilitation, personal characteristics for engagement, strengths and weaknesses of the intervention, TRAK in the future and attitudes to digital healthcare. The main themes from the physiotherapist interviews were: potential benefits, availability of resources and service organization to support use of TRAK. CONCLUSIONS: TRAK was found to be an acceptable method of delivering ACL rehabilitation alongside face-to-face physiotherapy. Patients reported that TRAK, specifically the videos, increased their confidence and motivation with their rehabilitation. They identified ways in which TRAK could be developed in the future to meet technological expectations and further support rehabilitation. For Physiotherapists time and availability of computers affected acceptability. Organization of care to support integration of digital exercise interventions such as TRAK into a blended approach to rehabilitation is required.

Taxonomy for the Rehabilitation of Knee Conditions (TRAK), a Digital Intervention to Support the Self-Care Components of Anterior Cruciate Ligament Rehabilitation: Protocol of a Feasibility Study.

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is common, especially in the active population. In defining the problem of ACL rehabilitation, this study draws from the knowledge that improved self-care, strength, and fitness are associated with better outcomes. Traditional rehabilitation involves regular physiotherapy, but it is not clear what the optimal way for delivering rehabilitation is, and it varies widely across the world. Evidence for treatments are discussed in the literature, however standard length of rehabilitation and frequency of appointments are unknown. Additionally, current rehabilitation models in the National Health Service (NHS) struggle with catering to large volumes of patients and the lengthy time span over which rehabilitation is delivered. The use of eHealth (the Internet in health care) has been successful at delivering behavior change to a number of diverse patient groups. In physiotherapy, problems such as exercise compliance, exercise technique, and managing a broad program of rehabilitation and advice can be challenging. An eHealth intervention called Taxonomy for the Rehabilitation of Knee Conditions (TRAK) to support self-management and behavior change has been developed by patients and clinicians, and acceptability studies have yielded positive results. TRAK is not an exercise rehabilitation protocol; it is a tool to support ACL rehabilitation with personalized plans, prompts, and logs to help adherence and videos and instructions to improve quality and address queries. The patients have their own log-ins and can email their physiotherapist through the website. This novel platform is directly in line with current NHS England, National Institute for Health and Care Excellence, and NHS Improvement agendas that call for rehabilitation initiatives using both technology and supported self-management for patients. This study forms part of a research platform to identify a best practice model of ACL care from the literature and opinions of key stakeholders. Patients' exercise programs and duration of treatment are still based on individual needs, but use of the website may offer improved self-management and function and reduced health resource use. OBJECTIVE: This is a feasibility study to establish recruitment, retention, sample size estimates, and practicality of collecting outcome measures to inform a future trial comparing the TRAK intervention, which has been rigorously designed to address the challenges of ACL rehabilitation, to usual care. METHODS: This is a feasibility study comparing 2 groups: standard care and standard care plus eHealth. It will use convergent parallel mixed methods where both qualitative and quantitative data are sought for a more thorough understanding of the objectives. Primary outcomes relate to feasibility, including recruitment, retention, and usage. Secondary outcomes relate to health resource use and patient-rated outcome measures. RESULTS: This research expects to establish the feasibility of a full-scale randomized controlled trial to explore whether patients who use an eHealth intervention to support ACL rehabilitation have better outcomes plus improved self-efficacy and reduced health resource use than a usual care group. CONCLUSIONS: The study will provide essential information to support the development and powering of a future clinical trial of eHealth and physiotherapy for patients with ACL reconstruction in the NHS.

Cylindrical micelles of controlled length with a π-conjugated polythiophene core via crystallization-driven self-assembly.

Solution self-assembly of the regioregular polythiophene-based block copolymer poly(3-hexylthiophene)-b-poly(dimethylsiloxane) yields cylindrical micelles with a crystalline P3HT core. Monodisperse nanocylinders of controlled length have been prepared via crystallization-driven self-assembly using seed micelles as initiators.

Water-soluble alkylated bis{4'-(4-pyridyl)-2,2':6',2''-terpyridine}ruthenium(II) complexes for use as photosensitizers in water oxidation: a complementary experimental and TD-DFT investigation.

A series of N-alkylated derivatives [RuL(2)][PF(6)](4) has been prepared from [Ru(pytpy)(2)][PF(6)](2) (N-alkyl substituent = 4-cyanobenzyl, 4-nitrobenzyl, ethyl, cyanomethyl, allyl, octyl). Solution NMR spectroscopic, electrochemical and photophysical properties are reported, along with the single crystal structure of [Ru(4)(2)][PF(6)](4)·H(2)O (4 = 4'-(4-(1-ethylpyridinio))-2,2':6',2'-terpyridine). Anion exchange leads to the water-soluble [RuL(2)][HSO(4)](4) salts (N-alkyl substituent = benzyl, 4-cyanobenzyl, 4-nitrobenzyl, ethyl, cyanomethyl, allyl, octyl) and the NMR spectroscopic signatures of pairs of hexafluoridophosphate and hydrogensulfate salts are compared. The change in anion has little effect on the energies of absorptions in the electronic spectra, although for all complexes, decreases in extinction coefficients are observed. The emission spectra and lifetimes for the hexafluoridophosphate and hydrogensulfate salts show similar trends; all exhibit an emission close to 720-730 nm (λ(ex) = 510 nm). For a given ligand, L, the emission lifetime decreases on going from [RuL(2)][PF(6)](4) to [RuL(2)][HSO(4)](4). However, trends are the same for both salts, i.e. the longest lived emitters are observed for N-ethyl, N-octyl and N-benzyl derivatives, and the shortest lived emitters are those containing cyano or nitro groups. Significantly, in the absorption spectra of the complexes, there is little variation in the energy of the MLCT band, suggesting that the character of the ligand orbital involved in the transition contains no character from the N-substituent. We have addressed this by carrying out a complementary DFT and TD-DFT study. Calculated absorption spectra predict a red shift in λ(max) on going from [Ru(pytpy)(2)](2+) to [RuL(2)](4+), and little variation in λ(max) within the series of [RuL(2)](4+) complexes; these results agree with experimental observations. Analysis of the compositions of the MOs involved in the MLCT transitions explain the experimental observations, showing that there is no contribution from orbitals on the N-alkyl substituents, consistent with the fact that the nature of the N-substituents has little influence on the energy of the MLCT band. The theoretical results also reveal satisfactory agreement between calculated and crystallographic data for [Ru(1)(2)](4+) (1 = 4'-(4-(1-benzylpyridinio))-2,2':6',2'-terpyridine) and [Ru(4)(2)](4+).

Insights into photoinduced electron transfer between [Ru(mptpy)2]4+ (mptpy = 4'(4-methylpyridinio)-2,2':6',2''-terpyridine) and [S2O8]2-: computational and experimental studies.

The mechanism and electron transfer dynamics of the reaction [Ru(II)(mptpy)(2)](4+) + hnu + [S(2)O(8)](2-) --> [Ru(III)(mptpy)(2)](5+) + SO(4)(2-) + SO(4)(-*) were studied using various computational (density functional and exciton interaction theories) and experimental (transient absorption, static and time-resolved fluorescence spectroscopy, and other) techniques. The results were compared with those recently reported for [Ru(bpy)(3)](2+) dye [ref 18]. It was found that the excitation energy of [Ru(mptpy)(2)](4+) is about 0.4-0.5 eV smaller than that of [Ru(bpy)(3)](2+), which is consistent with the measured absorption maxima of 445 and 507 nm, for [Ru(bpy)(3)](2+) and [Ru(mptpy)(2)](4+), respectively. The smaller excitation energy in [Ru(mptpy)(2)](4+) correlates with much slower electron transfer rates to persulfate compared to [Ru(bpy)(3)](2+). The quenching of the photoexcited [Ru(mptpy)(2)](4+) by [S(2)O(8)](2-) occurs via a unimolecular mechanism with formation of a weak ion-pair complex {[Ru(mptpy)(2)](4+)...([S(2)O(8)](2-))(n)}, where n = 1 and 2. The initial photon is absorbed by the [Ru(mptpy)(2)](4+) fragment forming an MLCT state, e.g., the bright singlet state S1. This S1 state undergoes a fast spin-orbit coupling induced intersystem crossing to a lower-lying triplet and rapid subsequent relaxation down to the lowest triplet T1 via internal conversion and collisions with solvent molecules. At this stage, the electron transfer from [Ru(mptpy)(2)](4+) to a loosely attached [S(2)O(8)](2-) occurs in a dark reaction via elongation of the O-O peroxo bond of the oxidant [S(2)O(8)](2-). The electron transfer lifetimes in water are calculated to be 1/kappa(1) = 199.4 ns and 1/kappa(2) = 108.4 ns, for the 1:1 and 1:2 complexes, respectively. The computed electron transfer lifetimes (1/kappa(1)) are in reasonable agreement with their experimental values of 298 and 149 ns for the 1:1 and 1:2 complexes, respectively. The effect of solvent polarity on electron transfer rates is found to be significant: the less polar acetonitrile slows the rate by an order of magnitude compared to water.

Photochemical switching of luminescence and singlet oxygen generation by chemical signal communication.

Photoluminescence in the far red spectral region and photosensitised generation of singlet oxygen, with associated near-IR emission, are reversibly controlled by near-UV or violet light in a communicating ensemble of molecular switches.

All-optical integrated logic operations based on chemical communication between molecular switches.

Molecular logic gates process physical or chemical "inputs" to generate "outputs" based on a set of logical operators. We report the design and operation of a chemical ensemble in solution that behaves as integrated AND, OR, and XNOR gates with optical input and output signals. The ensemble is composed of a reversible merocyanine-type photoacid and a ruthenium polypyridine complex that functions as a pH-controlled three-state luminescent switch. The light-triggered release of protons from the photoacid is used to control the state of the transition-metal complex. Therefore, the two molecular switching devices communicate with one another through the exchange of ionic signals. By means of such a double (optical-chemical-optical) signal-transduction mechanism, inputs of violet light modulate a luminescence output in the red/far-red region of the visible spectrum. Nondestructive reading is guaranteed because the green light used for excitation in the photoluminescence experiments does not affect the state of the gate. The reset is thermally driven and, thus, does not involve the addition of chemicals and accumulation of byproducts. Owing to its reversibility and stability, this molecular device can afford many cycles of digital operation.

Vectorial property dependence in bis {4'-(n-pyridyl)-2,2':6',2"-terpyridine}iron(II) and ruthenium(II) complexes with n = 2, 3 and 4.

A comparative structural and spectroscopic investigation of the complexes [M(1)2]2+, [M(2)2]2+ and [M(3)2]2+ in which M = Fe or Ru, and ligands 1, 2 and 3 are 4'-(2-pyridyl)-, 4'-(3-pyridyl)- and 4'-(4-pyridyl)-2,2':6',2"-terpyridine, respectively, is reported. The complexes [Ru(1)2]2+, [Ru(2)2]2+ and [Ru(3)2]2+ undergo mono- and bis-N-methylation. The consequences of methylation on the absorption spectra and electrochemical properties are discussed; the solid-state structure of the bis(N-methylated) derivative of [Ru(2)2][PF6]2 is presented.

Expanded ligands: bis(2,2':6',2''-terpyridine carboxylic acid)ruthenium(ii) complexes as metallosupramolecular analogues of dicarboxylic acids.

Ligands in which multiple metal-binding domains are linked by a metal-containing moiety rather than a conventional organic group are described as "expanded ligands". The use of 4,4'-difunctionalised {Ru(tpy)(2)} units provides a linear spacer between metal-binding domains and we have extended this motif to expanded ligands containing two carboxylic acid metal-binding domains. In this paper, we describe the synthesis and structural characterisation of ruthenium(ii) complexes of 2,2':6',2''-terpyridine-4'-carboxylic acid and 4'-carboxyphenyl-2,2':6',2''-terpyridine. The ability of the ruthenium(ii) centre to charge compensate deprotonation of the carboxylic acid leads to Zwitterionic complexes and three representative compounds have been structurally characterised.

Structural development of free or coordinated 4'-(4-pyridyl)-2,2':6',2''-terpyridine ligands through N-alkylation: new strategies for metallamacrocycle formation.

A series of N-alkylated derivatives of [Ru(pytpy)(2)]2+ (pytpy=4'-(4-pyridyl)-2,2':6',2''-terpyridine) has been synthesised and characterised. These include both model and functionalised complexes that complement previously reported iron(II) analogues. Reaction of [Ru(pytpy)(2)]2+ with bis[4-(bromomethyl)phenyl]methane leads to the formation of a [2+2] ruthenamacrocycle. Related ferramacrocycles could not be accessed by this route, and instead were prepared in two steps by first reacting bis[4-(bromomethyl)phenyl]methane or 4,4'-bis(bromomethyl)biphenyl with two equivalents of pytpy, and then treating the resulting bis(N-alkylated) product with iron(II) salts.