Current perspectives of Australian therapists on rehabilitation and return to sport after anterior cruciate ligament reconstruction: A survey

Rehabilitation and return-to-sport after anterior cruciate ligament injury and reconstruction: Exploring physical therapists' approaches in Argentina

OBJECTIVES

To investigate the current clinical practice regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional design. Online survey.

SETTING

Survey platform.

PARTICIPANTS

Argentinian physical therapists (PTs).

OUTCOME MEASURES

The survey consisted of a combination of 39 open- and closed-ended questions, divided across 3 sections: (1) demographic and professional information, (2) clinical practice and rehabilitation strategies, and (3) return-to-running (RTR) and RTS.

RESULTS

A total of 619 PTs completed the survey. Considerable variability was observed in preoperative rehabilitation, criteria used for rehabilitation progression and RTS decision-making criteria used by PTs. From the total surveyed, 336 (54.3%) carried out RTS assessment in their clinical practice. Most of PTs (53.3%) use visual estimation to assess knee range of motion. Only 20% of the PTs reported incorporating patient-reported outcome measures in their decision-making. From PTs who use strength assessment as a criterion of RTS (68.8%), 16.6% extrapolate this from jump tests and 15.3% use manual muscle testing. Less than the 50% of the PTs recommended nine months or more to allow patients to RTS.

CONCLUSIONS

Current rehabilitation practices of Argentinian PTs following ACLR are largely variable and not aligned with current evidence and scientific guidelines. To achieve better rehabilitation and RTS practices better knowledge dissemination and implementation are required.

Functional Outcomes in Anterior Cruciate Ligament (ACL) Reconstruction: A Nine-Month Follow-up Study Using Lysholm Score in a Rural Tertiary Care Center in India

Introduction The knee joint, an extraordinary feat of biomechanics, is prone to injuries, with the anterior cruciate ligament (ACL) often being a common victim. The intricate coordination of joint movements relies heavily on the ACL's screw-home mechanism, a crucial element for synchronizing knee movement with neighboring joints. Despite its indispensable role, the ACL is susceptible to injury, necessitating surgical intervention. While many patients experience positive outcomes following ACL reconstruction surgeries, a significant proportion face the challenge of procedure failure. The key to success lies in the healing process within the tibial and femoral bone tunnels. The post-ACL reconstruction phase introduces its own set of challenges, particularly in the context of returning to sports (RTS), underscoring the importance of reinstating neuromuscular and motor function. The trajectory of rehabilitation is influenced by factors such as graft healing, patient age, gender, pain levels, and concurrent injuries. Materials and methods This prospective observational study spanned 2.5 years, enrolling 71 patients with diagnosed ACL injuries. Arthroscopic reconstruction utilized hamstring autografts and peroneus longus autografts. A nine-month post-surgery follow-up employed the Lysholm scoring system for comprehensive evaluations. Results Over 2.5 years, 87.3% of male and 12.6% of female participants underwent arthroscopic reconstruction. Lysholm scores revealed 28.1% excellent, 45.0% good, and 26.7% fair outcomes, with no participants in the unsatisfactory range. Lysholm scores demonstrated positive outcomes, indicating the efficacy of arthroscopic reconstruction in enhancing knee function. Findings align with existing literature, emphasizing positive results from ACL reconstruction techniques and specific implants. Comparisons with related studies highlight challenges in standardized return-to-sport guidelines and underscore the need for outcome measure standardization. Conclusion The study contributes nuanced insights into ACL reconstruction outcomes, emphasizing positive functional recovery trends at the nine-month follow-up. Lysholm scores indicate favorable outcomes, supporting the procedure's effectiveness. Consideration of specific implants adds practical value. Despite limitations, this study enriches ACL reconstruction research, promoting advancements in patient care and outcomes. Ongoing research with extended follow-ups and larger cohorts will enhance understanding and refine ACL reconstruction strategies.

Current Rehabilitation Practices and Return to Sports Criteria After Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists in Saudi Arabia

CONTEXT

With the high prevalence of anterior cruciate ligament rupture among young and active individuals, rehabilitation after the injury and surgery should meet the current evidence-based recommendations to restore knee function and reduce the risk of further injury. This study aimed to investigate the current rehabilitation practices and return to sports (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) among physical therapists in Saudi Arabia.

DESIGN

Online cross-sectional survey-based study.

METHODS

A total of 177 physical therapists in Saudi Arabia participated in this survey. The survey included questions about the preferred postoperative timing and frequency of rehabilitation, current views on the importance of preoperative and postoperative rehabilitation to the overall outcomes, the timeframe of RTS, and the decision-making process to RTS.

RESULTS

Most therapists (96.6%) believed preoperative rehabilitation was essential/important to postoperative outcomes. Two-thirds encouraged patients to start rehabilitation program within 1 to 4 days immediately post-ACLR. RTS was permitted 6 to 9 months post-ACLR by 60% of therapists if satisfied with patient progress and capacity. Factors considered before RTS included knee strength (72.9%), functional capacity (86.4%), lower limb and trunk mechanics (62.7%), and psychological readiness (42.2%). Knee strength was assessed by manual muscle testing (39%), handheld dynamometry (15.3%), and isokinetic dynamometer (13.6%). While 60% of the therapists used single-limbed hop for distance for evaluating functional capacity, only 27.1% used a hop test battery.

CONCLUSIONS

The surveyed physical therapists in Saudi Arabia demonstrated variations in the current rehabilitation practices and RTS criteria post-ACLR. Over half of the surveyed therapists considered preoperative rehabilitation essential to postoperative outcomes. However, the therapists should update their perspective with current evidence-based practice regarding the RTS timeframe, psychological readiness assessment for RTS, and knee strength evaluation using objective measurements.

Comparative analysis of high-intensity interval training and traditional rehabilitation programs for accelerated recovery from musculoskeletal injuries

BACKGROUND

Musculoskeletal injuries, such as strains, are prevalent across all age groups and have a substantial impact on daily functioning and quality of life.

OBJECTIVE

To examine the effectiveness of high-intensity interval training (HIIT) with traditional rehabilitation programs on pain, range of motion (ROM), muscular strength, and functional changes in promoting accelerated recovery from musculoskeletal injuries.

METHODS

A total of 80 participants (54 males, 26 females; mean age 35.6 years) with various musculoskeletal injuries were randomly assigned to either the HIIT group (n= 40) or the traditional rehabilitation group (n= 40). The HIIT group underwent a six-week supervised program, with three sessions per week. The traditional rehabilitation group followed a similar six-week program emphasizing low to moderate intensity exercises and traditional rehabilitation techniques. Outcome measures, including pain levels, ROM, muscular strength, and functional outcomes, were assessed pre- and post-intervention.

RESULTS

Significant improvements were observed in both the HIIT and traditional rehabilitation groups. However, the HIIT group demonstrated superior outcomes. Participants in the HIIT group experienced a greater reduction in pain levels compared to the traditional rehabilitation group (mean visual analog scale (VAS) score decrease of 5.2 vs. 3.8, respectively, p< 0.05). Functional outcomes significantly favored the HIIT group, with participants achieving faster completion times in the Timed Up and Go test (mean reduction of 2.1 seconds vs. 1.5 seconds, respectively, p< 0.01) and longer distances in the Single Leg Hop test (mean increase of 32 cm vs. 25 cm, respectively, p< 0.05).

CONCLUSION

HIIT showed superior effectiveness over traditional rehabilitation in accelerating recovery from musculoskeletal injuries, with greater pain reduction and improved functional outcomes. Incorporating HIIT into rehabilitation protocols may offer an efficient approach for expedited recovery and enhanced functional capacity.

Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport

OBJECTIVES

To investigate current clinical practice of Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction (ACLR) from pre-operative rehabilitation until return to sport (RTS). We assessed optimisation strategies in daily practice and the perceived barriers to these optimisations, and evaluated whether there was a relevant difference in clinical practice for physiotherapists with post-graduate certification in sports physiotherapy or deep clinical experience and those without such experience.

DESIGN

Cross-sectional survey.

SETTING

Online survey platform.

PARTICIPANTS

Swiss physiotherapists.

MAIN OUTCOME MEASURES

The survey comprised six sections: participant information, pre-operative rehabilitation, post-operative rehabilitation, RTS, re-injury prevention, and optimisation strategies and barriers.

RESULTS

A minority of physiotherapists treated ACLR patients pre-operatively. Overall, 91% included quadriceps open kinetic chain exercise in their treatment, 37% used patient-reported outcomes measures (PROMs) and 39% considered psychological criteria when making decisions about RTS. Most physiotherapists (67%) felt limited due to the time available, the number of prescriptions and the tariffication system.

CONCLUSION

This study highlights areas within ACLR rehabilitation practice in Switzerland that could be improve. Improvements in understanding of the barriers to implementation of best evidence in practice and a redefinition of the clinical process around ACLR rehabilitation in Switzerland are necessary.

Smoking and secondary ACL rupture are detrimental to knee health post ACL injury-a Bayesian analysis

PURPOSE

To identify potential prognostic factors for patient-reported outcomes in an Icelandic cohort of ACL injured subjects.

METHODS

All knee MRI reports written in Iceland between the years 2001 to 2011 were read to identify individuals with a possible ACL injury. These individuals were contacted and asked to complete an online questionnaire regarding their injury and current knee related health. The questionnaire collected information on years since surgery, injury circumstance, brace use, physiotherapy, ACL surgery, second ACL injury and current smoking status. In addition, the baseline status of their meniscii were assessed from the original MRI report and medical records were used to identify any subsequent, non-ACL surgery. The patient-reported Knee Osteoarthritis and Injury Outcome Score (KOOS) was used assess current knee related health. A Bayesian proportional odds model was used to assess the effect of all potential prognostic factors above as well as age and sex on KOOS outcomes.

RESULTS

A total of 408 subjects completed the questionnaire indicating that they did rupture their ACL. The following variables were associated with worse outcomes across all KOOS subscales: having a subsequent arthroscopy, reinjury to your ACL, and smoking. Having physiotherapy for 9 months was associated with worse KOOS pain scores than having 6 months of physiotherapy. Conversely KOOS pain score tended to be higher if you injured your knee during sports.

CONCLUSION

Reinjuring your ACL, smoking and having subsequent (non-ACLR) surgery predict your knee related health following an ACL injury. Strategies should be implemented to reduce the risk of secondary ACL injury, and patients should be strongly advised not to smoke.

Lower Patellofemoral Joint Contact Force During Side-Step Cutting After Return-to-Sports Clearance Anterior Cruciate Ligament Reconstruction

BACKGROUND

Low patellofemoral joint (PFJ) contact force has been associated with PFJ osteoarthritis. Quadriceps force and knee flexion angles, which are typically altered after an anterior cruciate ligament reconstruction (ACLR), primarily influence PFJ contact forces. It is still inconclusive whether differences in PFJ contact forces are present during high knee flexion tasks such as side-step cutting after clearance to return to sports (RTS) after ACLR.

PURPOSE

To explore PFJ contact forces in the ACLR limb and compare them with those of the contralateral and control limbs during side-step cutting tasks after clearance to RTS.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 26 male athletes with ACLR who were previously cleared to RTS were matched with 23 healthy men serving as the control group. Three-dimensional motion capture and force plate data were collected while both groups performed anticipated side-step cutting tasks. Joint kinematics, kinetics, muscle forces, and PFJ contact forces were calculated using musculoskeletal modeling.

RESULTS

Peak PFJ force was lower in the ACLR limbs compared with the contralateral limbs (mean difference [MD], 5.89 body weight [BW]; 95% CI, 4.7-7.1 BW; P < .001) and the control limbs (MD, 4.44 BW; 95% CI, 2.1-6.8 BW; P < .001). During peak PFJ force, knee flexion angle was lower in ACLR limbs compared with the contralateral (MD, 4.88°; 95% CI, 3.0°-6.7°; P < .001) and control (MD, 6.01°; 95% CI, 2.0°-10.0°; P < .002) limbs. A lower quadriceps force compared with the contralateral (MD, 4.14 BW; 95% CI, 3.4-4.9 BW; P < .001) and control (MD, 2.83 BW; 95% CI, 1.4-4.3 BW; P < .001) limbs was also found.

CONCLUSION

Lower PFJ contact forces and a combination of quadriceps force deficits and smaller knee flexion angle were found in the ACLR compared with the contralateral and control limbs even after clearance to RTS.

CLINICAL RELEVANCE

Despite rehabilitation and subsequent clearance to RTS, differences in PFJ contact forces are present after ACLR. Current rehabilitation and RTS battery may not be effective and sensitive enough to identify and address these differences.

Australian physiotherapists' perceived frequency of contact with clients experiencing distress: A cross-sectional survey

BACKGROUND

Previous research suggests physiotherapists' perceived frequency of contact with clients experiencing psychological distress is common; however, there is significant variation in the frequency of such contact.

OBJECTIVE

The study aimed to 1) investigate Australian physiotherapists' perceived frequency of contact with clients experiencing various forms of psychological distress; 2) identify potential factors that predict perceived frequency of contact; and 3) explore physiotherapists' beliefs regarding their role and self-reported capability to identify and assess psychological distress.

METHODS

A nationwide online survey of 340 Australian physiotherapists was conducted, and the data were analyzed using descriptive analysis and regression analysis.

RESULTS

Physiotherapists' perceived frequencies of contact with psychologically distressed and severely distressed clients expressed as proportions of all clients seen each week were 36.1% and 15.6%, respectively. Factors related to the clinical setting were stronger predictors of the perceived frequency of contact (Cohen's f2 = 0.16) than factors related to the physiotherapists themselves (Cohen's f2 = 0.03). Despite believing that identifying psychological distress was within their scope of practice, the physiotherapists in the study felt that assessing and managing this distress fell outside or on the boundary of their scope of practice.

CONCLUSION

Australian physiotherapists frequently encounter clients they perceive to be experiencing psychological distress. Future research into physiotherapists' capability to assess and respond to client psychological distress, using non-self-reported measures, is required.

Functional outcomes after anterior cruciate ligament reconstruction: unravelling the role of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries

BACKGROUND

Numerous individual, temporal, injury- and surgery-specific factors impact the functional capacity during rehabilitation, return to sports (RTS), and re-injury prevention after an anterior cruciate ligament (ACL) reconstruction.

PURPOSE

This multicentre cohort study evaluated the isolated and interactive contributions of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries as to inertial sensor-assessed motor function after ACL reconstructions in multiple linear mixed model regressions.

METHODS

Anonymized data were retrieved from a nationwide German registry. In this cohort study, patients with an acute unilateral ACL rupture, with or without concomitant ipsilateral knee injuries, and having passed an arthroscopically assisted anatomic reconstruction were included. Potential predictors were age [years], gender/sex, time since reconstruction [days], time between injury and reconstruction [days], concomitant intra-articular injuries (isolated ACL tear, meniscal tear, lateral ligament, unhappy triad), graft type (hamstrings, patellar, or quadriceps tendon autograft), and pain during each measurement (visual analogue scale 0-10 cm). Repeated inertial motion unit-assessments of a comprehensive battery of classic functional RTS test were performed in the course of the rehabilitation and return to sports: Joint position sense/kinesthesia (Angle reproduction error [degrees]), Dynamic Balance Composite score [cm] of the Y-Balance test), drop jumps (Knee displacement [cm]), Vertical hop (Hopping height [mm]), Speedy jumps (Duration [seconds]), Side hops (Number of hops [n]), single leg hop for distance (hopping distance [cm]). Repeated measures multiple linear mixed models investigated the impact and nesting interaction of the potential predictors on the functional outcomes.

RESULTS

Data from 1441 persons (mean age 29.4, SD 11.8 years; 592 female, 849 male) were included. Most had an isolated ACL rupture: n = 938 (65.1%). Minor shares showed lateral ligament involvement: n = 70 (4.9%), meniscal tear: n = 414 (28.7%), or even unhappy triad: n = 15 (1%). Several predictors such as time between injury and reconstruction, time since reconstruction (estimates for n_days ranged from + .05 (i.e., an increase of the hopping distance of 0.05 cm per day since reconstruction occurs) for single leg hop for distance to + 0.17 for vertical hopping height; p < 0.001), age, gender, pain, graft type (patellar tendon graft: estimates between + 0.21 for Y-balance and + 0.48 for vertical hop performance; p < 0.001), and concomitant injuries contribute to the individual courses of functional abilities of the reconstructed side after ACL reconstruction. The unimpaired side was mostly influenced by sex, age, the time between injury and reconstruction (estimates between - 0.0033 (side hops) and + 0.10 (vertical hopping height), p < 0.001)), and time since reconstruction.

CONCLUSIONS

Time since reconstruction, time between injury and reconstruction, age, gender, pain, graft type, and concomitant injuries are not independent but nested interrelating predictors of functional outcomes after anterior cruciate ligament reconstruction. It might not be enough to assess them isolated; the knowledge on their interactive contribution to motor function is helpful for the management of the reconstruction (earlier reconstructions should be preferred) deficit-oriented function-based rehabilitation (time- and function based rehabilitation instead of solely a time- or function based approach) and individualized return to sports strategies.

Association of COVID-19 Lockdown With Increased Rate of Cyclops Syndrome in Patients With Unexpected Home-Based Self-Guided Rehabilitation After ACL Reconstruction

Background

The risk of cyclops syndrome increases significantly after anterior cruciate ligament (ACL) reconstruction (ACLR) if complete extension is not recovered before the sixth postoperative week. The lockdown in France due to the COVID-19 pandemic led to an absence of supervised rehabilitation, requiring unexpected self-rehabilitation in patients who underwent ACLR just before lockdown.

Purpose

To determine the rate of cyclops syndrome after ACLR in patients who underwent self-rehabilitation during lockdown.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 75 patients receiving a hamstring graft for ACLR during the COVID-19 pandemic between February 10, 2022, and March 16, 2020, carried out self-rehabilitation during part of their first 6 postoperative weeks using exercise videos on a dedicated website. Clinical examination was performed at a minimum 1-year follow-up with International Knee Documentation Committee (IKDC), Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI) scores. This group was compared with a matched-pair control group of 72 patients who underwent surgery in 2019 and completed postoperative supervised rehabilitation with a physical therapist. Rates and reasons for second surgery (arthrolysis, meniscal procedure) were also recorded.

Results

In the COVID group (n = 72; 3 patients were lost to follow-up), the mean follow-up was 14.5 ± 2.1 months (range, 13-21) and rate of reoperation for clinical cyclops syndrome was 11.1% (n = 8). The rate of cyclops syndrome was significantly lower (1.4%) in the control group (P = .01). In the COVID group, 8 patients underwent anterior arthrolysis at a mean of 8.6 months after the primary surgery, and 4 patients underwent another surgical intervention (meniscal procedure [n = 3], device removal [n = 1]). In the COVID group, mean Lysholm was 86.6 ± 14.1 (range, 38-100), Tegner was 5.6 ± 2.3 (range, 1-10), subjective IKDC was 80.3 ± 14.7 (range, 32-100) and ACL-RSI score was 77.3 ± 19.7 (range, 33-100).

Conclusion

The rate of cyclops syndrome after ACLR was significantly greater in the COVID group versus the matched controls. The dedicated website was not effective at supporting self-guided rehabilitation and could benefit from interactive improvements so it is at least as effective as supervised rehabilitation.

Return to sports after ACL injury 5 years from now: 10 things we must do

Background

The outcome after ACL reconstruction (ACLR) is in general disappointing with unacceptable number of athletes that do not return to pre-injury level of sports, high re-injury rates, early development of osteoarthritis and shorter careers. Athletes after ACLR have high expectation to return to sports which is in contrast with the current outcomes. The aim of this manuscript is to present an overview of factors that are needed to be incorporated and to personalize the rehabilitation process for an athlete who has undergone an ACLR.

Level of evidence

4.

'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.

Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts

PURPOSE

To compare patient reported outcomes and functional knee recovery following anterior cruciate ligament (ACL) reconstruction using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft.

METHODS

Thirty-five QT patients (age 20; range 15-34 years) participated in this study and were matched for gender, age and pre-injury activity level to 70 HT (age 20; range 15-32 years) patients. The following assessments were performed at 6 and 12 months post-operatively; standardized patient-reported outcome measures (IKDC, KOOS-QOL, ACL-RSI, Marx activity, anterior knee pain), knee range of motion (passive and active), anterior knee laxity, hop tests (single and triple crossover hop for distance), and isokinetic strength of the knee extensors and flexors. All dependent variables were analysed using a two-way mixed ANOVA model, with within (Time; 6 and 12 months) and between-subject (Graft; QT and HT) factors.

RESULTS

Patient reported outcome measures and hop performance improved between 6 and 12 months (p < 0.001), however no significant differences in either patient-reported outcomes or hop performance were found between the two grafts. Isokinetic strength testing showed both groups improved their peak knee extensor strength in the operated limb between 6 and 12 months (p < 0.001), but the QT group had significantly lower knee extensor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.001) and 180 deg/s (p < 0.01). In contrast, the QT group had significantly greater knee flexor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.01) and 180 deg/s (p = 0.01), but knee flexor strength limb symmetry did not significantly improve over time in either group.

CONCLUSION

Recovery of knee function following either QT or HT ACL reconstruction continues between 6 and 12 months after surgery. However, knee extensor strength deficits in the QT group and knee flexor strength deficits in the HT persisted at 12 months. This may have implications for decisions regarding return to sport.

LEVEL OF EVIDENCE

III.

Rehabilitation and Return to Sport Testing After Anterior Cruciate Ligament Reconstruction: Where Are We in 2022?

Athletes who sustain an anterior cruciate ligament (ACL) injury often opt for an ACL reconstruction (ACLR) with the goal and expectation to return to sports at the preinjury level. The proportion of athletes who successfully return to preinjury-level sport is low and disappointing, whereas the rate of second ACL injury in athletes under the age of 20 has been reported to be as high as 40% after return to sport (RTS). Although in recent years, new insights pertaining to RTS have been published, the lack of validity of RTS criteria after ACLR remain. The purpose of this clinical commentary is to present a critical overview of the current literature on RTS testing after ACLR.

ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline

CONTEXT

Anterior cruciate ligament (ACL) reconstruction (ACLR) and postoperative rehabilitation continues to be a multidisciplinary focus in both research and clinical environments. Recent research on ACLR warrants a reexamination of clinicians' current rehabilitation practices to optimize the strikingly variable clinical outcomes after ACLR and return to sport. The purpose of the article and updated guidelines is to use contemporary evidence to systematically revisit our practice guidelines and validate our clinical milestones with data from our university-based practice.

EVIDENCE ACQUISITION

Using the PubMed search engine, articles that reported on ACLR rehabilitation and protocols, guidelines, graft type, healing and strain, return to sport, psychological considerations, and secondary injury prevention published from 1979 to 2020 were identified using the search terms ACLR protocols, guidelines, ACLR rehabilitation, ACL graft, ACL open kinetic chain (OKC) exercise and closed kinetic chain (CKC) exercise, ACLR return to sport, ACLR psychological factors, and ACL injury prevention.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Clinical milestones after ACLR were validated using clinical data collected from 2013 to 2017 at a university-based practice. Variables including knee joint range of motion, effusion, Knee Outcome Survey-Activities of Daily Living Scale, and quadriceps strength index were tracked throughout rehabilitation and analyzed to help inform an updated ACLR rehabilitation guideline.

CONCLUSION

Incorporating the latest research, combined with direct clinical data, provides a current, realistic, and clinically benchmarked strategy for ACLR rehabilitation. Commonly held clinical beliefs regarding rehabilitation after ACL injury must be challenged by the latest research to improve patient outcomes and decrease the risk of reinjury. Key updates to the practice guidelines include the use of frequent and accurate quadriceps strength testing, delayed return-to-sport timeline, immediate use of open kinetic chain exercise, criterion-based progressions for running, sprinting, plyometrics, agility, cutting/pivoting, return to competition, and the inclusion of a secondary prevention program after return to sport.

STRENGTH OF RECOMMENDATION TAXONOMY (SORT)

B.

Current perspectives of New Zealand physiotherapists on rehabilitation and return to sport following anterior cruciate ligament reconstruction: A survey

OBJECTIVE

To investigate the clinical beliefs and practices of New Zealand physiotherapists regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Online cross-sectional survey.

METHODS

A survey was adapted from a previously published survey and disseminated to New Zealand physiotherapists who were considered more likely to be involved in post-ACLR rehabilitation.

RESULTS

The number of completed surveys was 318. Most physiotherapists (85%) preferred to first consult patients within 14 days of ACLR. In the first six weeks following ACLR, 89% of physiotherapists see patients at least once per week. Between 3- and 6-months post-ACLR, 76% of physiotherapists see patients at least once a fortnight. Pre-operative rehabilitation and post-operative rehabilitation exceeding six months are considered essential or important to patient outcomes by over 95% of physiotherapists. While 63% of physiotherapists support RTS 9-12 months after ACLR, 11% permit RTS within 6-9 months of surgery. Common RTS considerations include functional capacity, movement quality during functional tasks, time from ACLR, and knee strength.

CONCLUSION

The survey revealed variability in the beliefs and practices of NZ physiotherapists regarding post-ACLR rehabilitation, and these beliefs and practices are at times inconsistent with best practice recommendations.

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.

Current perspectives and clinical practice of physiotherapists on assessment, rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction. An online survey of 538 physiotherapists

OBJECTIVES

To evaluate the perspectives and clinical practice of physiotherapists regarding rehabilitation after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Online survey.

SETTING

Survey platform.

PARTICIPANTS

Greek physiotherapists.

OUTCOME MEASURES

The survey consisted of 7 sections: participant demographics, importance of ACLR rehabilitation, clinical measurements, practice, criteria to progress rehabilitation, return to running and return to sport.

RESULTS

Significant variability in measures and criteria used for clinical decision-making were found including: limb symmetry in strength and function, knee range of motion and effusion, progression, and return to sport criteria. The majority of the practitioners (28.3%) extrapolate knee strength from hop capacity. Return to running ranged from 3 to 5 months post-operatively reflecting that this was tied to physical capacities, not time from surgery. 70.0% of the Greek physiotherapists would allow return to sport ≤9 months after ACLR. Agreement was found in using: physical measures, function, and dynamic stability in ACLR rehabilitation, but the mode and interpretation varied substantially. Less than 29.0% of the physiotherapists reported using patient-reported outcome measures in their decision-making.

CONCLUSION

Current ACLR rehabilitation practices in Greece are largely not aligned with the contemporary scientific evidence and guidelines.

Is resistance training intensity adequately prescribed to meet the demands of returning to sport following anterior cruciate ligament repair? A systematic review

Objective

To identify, critique and synthesise the research findings that evaluate the use of resistance training (RT) programmes on return to sport outcome measures for people following ACL repair (ACLR).

Design and data sources

This systematic review included a comprehensive search of electronic databases (EBSCO health databases (CINAHL, MEDLINE, SPORTDiscus), Scopus and Pedro) performed in June 2020 and was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Studies were appraised using the Downs and Black checklist.

Eligibility criteria

Randomised and non-randomised controlled trials, longitudinal cohort studies and case series were considered for inclusion where an adequate description of the RT intervention was provided as a part of the study's ACLR rehabilitation protocol. Articles that did not include outcome measures related to return to sport criteria were excluded.

Results

Eleven articles met the inclusion criteria and were subjected to appraisal and data extraction. Study quality ranged from poor to excellent. RT intensity varied considerably among studies (between 5% and >80% of one repetition maximum). Only one identified study specifically investigated the effect of a low-intensity versus high-intensity RT protocol. The majority of studies reported participant outcomes that would not meet commonly used return to sport criteria.

Conclusion

There appears to be considerable variation in the intensity of RT prescribed in research for people following ACLR. Furthermore, in most of the identified studies, RT protocols promoted muscle endurance and hypertrophy without progressing to strength or power-based RT. The findings of this review provide insight into potential factors limiting returning to sport and contributing to reinjury for people following ACLR.

Immediate and 6-week effects of wearing a knee sleeve following anterior cruciate ligament reconstruction: a cross-over laboratory and randomised clinical trial

Background

Rehabilitation following anterior cruciate ligament (ACL) reconstructions is based mainly on comprehensive progressive exercise programmes using a multi-dimensional approach. Elastic knee sleeves may be useful adjuncts to rehabilitation. The aim of this study was to determine the immediate and 6-week effects of wearing a knee sleeve on person-reported outcomes and function in participants who had undergone an ACL reconstruction and who had residual self-reported functional limitations.

Methods

Individuals with ACL reconstruction in the previous 6 months to 5 years were recruited. Immediate effects of a commercially-available elastic knee sleeve on single-leg horizontal hop distance were explored using a cross-over design. Following this first session, participants were randomised into a Control Group and a Sleeve Group who wore the sleeve for 6 weeks, at least 1 h daily. Outcome measures for the randomised clinical trial (RCT) were the International Knee Documentation Classification Subjective Knee Form (IKDC-SKF) score, the single-leg horizontal hop distance, and isokinetic quadriceps and hamstring peak torque. Linear mixed models were used to determine random effects. Where both limbs were measured at multiple time points, a random measurement occasion effect nested within participant was used.

Results

Thirty-four individuals (16 women) with ACL reconstruction completed the cross-over trial. Hop distance for the injured side during the sleeve condition increased by 3.6 % (95 % CI 0.4–6.8 %, p = 0.025). There was no evidence of differential changes between groups for the IKDC-SKF (Sleeve Group n = 15; Control Group n = 16; p = 0.327), or relative improvement in the injured side compared to the uninjured side for the physical performance measures (Sleeve Group n = 12, Control Group n = 12; three-way interaction p = 0.533 [hop distance], 0.381 [quadriceps isokinetic peak torque], and 0.592 [hamstring isokinetic peak torque]).

Conclusions

Single-leg hop distance of the ACL reconstructed side improved when wearing a knee sleeve. Wearing the knee sleeve over 6 weeks did not lead to enhanced improvements in self-reported knee function, hop distance and thigh muscle strength compared to the control group.

Trial registration

The trial was prospectively registered with the Australia New Zealand Clinical Trials Registry No: ACTRN12618001083280, 28 June 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04540-x.

Single leg hop for distance symmetry masks lower limb biomechanics: time to discuss hop distance as decision criterion for return to sport after ACL reconstruction?

Background

We evaluated the lower limb status of athletes after anterior cruciate ligament reconstruction (ACLR) during the propulsion and landing phases of a single leg hop for distance (SLHD) task after they had been cleared to return to sport. We wanted to evaluate the biomechanical components of the involved (operated) and uninvolved legs of athletes with ACLR and compare these legs with those of uninjured athletes (controls).

Methods

We captured standard video-based three-dimensional motion and electromyography (EMG) in 26 athletes after ACLR and 23 healthy controls during SLHD and calculated lower limb and trunk kinematics. We calculated lower limb joint moments and work using inverse dynamics and computed lower limb muscle forces using an EMG-constrained musculoskeletal modelling approach. Between-limb (within ACLR athletes) and between-group differences (between ACLR athletes and controls) were evaluated using paired and independent sample t-tests, respectively.

Results

Significant differences in kinematics (effect sizes ranging from 0.42 to 1.56), moments (0.39 to 1.08), and joint work contribution (0.55 to 1.04) were seen between the involved and uninvolved legs, as well as between groups. Athletes after ACLR achieved a 97%±4% limb symmetry index in hop distance but the symmetry in work done by the knee during propulsion was only 69%. During landing, the involved knee absorbed less work than the uninvolved, while the uninvolved knee absorbed more work than the control group. Athletes after ACLR compensated for lower knee work with greater hip work contribution and by landing with more hip flexion, anterior pelvis tilt, and trunk flexion.

Conclusion

Symmetry in performance on a SLHD test does not ensure symmetry in lower limb biomechanics. The distance hopped is a poor measure of knee function, and largely reflects hip and ankle function. Male athletes after ACLR selectively unload the involved limb but outperform controls on the uninvolved knee.

Submaximal Elastic Resistance Band Tests to Estimate Upper and Lower Extremity Maximal Muscle Strength

Muscle strength assessment is fundamental to track the progress of performance and prescribe correct exercise intensity. In field settings, simple tests are preferred. This study develops equations to estimate maximal muscle strength in upper- and lower-extremity muscles based on submaximal elastic resistance tests. Healthy adults (n = 26) performed a maximal test (1 RM) to validate the ability of the subsequent submaximal tests to determine maximal muscle strength, with elastic bands. Using a within-group repeated measures design, three submaximal tests of 40%, 60%, and 80% during (1) shoulder abduction, (2) shoulder external rotation, (3) hip adduction, and (4) prone knee flexion were performed. The association between number of repetitions and relative intensity was modeled with both 1st and 2nd order polynomials to determine the best predictive validity. For both upper-extremity tests, a strong linear association between repetitions and relative intensity was found (R² = 0.97–1.00). By contrast, for the lower-extremity tests, the associations were fitted better with a 2nd order polynomial (R² = 1.00). The results from the present study provide formulas for predicting maximal muscles strength based on submaximal resistance in four different muscles groups and show a muscle-group-specific association between repetitions and intensity.

Rehabilitation strategies of Flemish physical therapists before and after anterior cruciate ligament reconstruction: An online survey

OBJECTIVES

The primary objective of the study was to investigate rehabilitation strategies of Flemish physical therapists before and after anterior cruciate ligament (ACL) reconstruction. Secondly, we aimed to investigate physical therapists' preferences on continuing education and evaluate their self-rated confidence and competence when treating patients before and after ACL reconstruction.

DESIGN

Survey-based study.

SETTING

Online survey platform.

PARTICIPANTS

Flemish physical therapists (n = 283).

MAIN OUTCOME MEASURES

The online survey consisted of a combination of 40 open- and closed-ended questions, divided across 5 sections: (1) participant demographics and clinical practice information, (2) patient population information, (3) continued education practices, (4) rehabilitation strategies, and (5) physical therapist self-rated confidence and competence to treat patients with ACL reconstruction.

RESULTS

A wide variability in rehabilitation strategies were found across the whole ACL rehabilitation continuum, which were in general not in line with best available evidence. Nevertheless, the overall self-rated confidence and competence of physical therapists treating patients before and after ACL reconstruction were high.

CONCLUSION

Our findings indicate a need to improve rehabilitation practices before and after ACL reconstruction. Advanced research dissemination and implementation are required to achieve better rehabilitation outcomes.

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

OBJECTIVES

To investigate patient-reported rehabilitation characteristics and barriers to and facilitators of ACL reconstruction rehabilitation.

DESIGN

Survey-based study.

SETTING

Online survey platform.

PARTICIPANTS

Adults 1-20 years post ACL reconstruction (n = 304).

MAIN OUTCOME MEASURES

1) rehabilitation characteristics, 2) barriers to and facilitators of rehabilitation.

RESULTS

Fear of re-injury (43.8%) was the highest rating barrier to rehabilitation adherence, while a good relationship with your rehabilitation provider was regarded as the most important factor (83.6%) in facilitating rehabilitation. Rehabilitation frequency reduced across the duration of rehabilitation from most commonly 1 x week (38.2%) in the first three months to once every month (26%) from 6 to 9 months. Almost all participants (95.7%) consulted a rehabilitation provider for the first six months. Only 43.4% of respondents returned to their previous level of sport. The exploratory analysis identified that low barriers to rehabilitation and a longer duration of supervised rehabilitation are associated with a faster return to sport, greater likelihood of return to previous level of sport and fewer reported ongoing problems with the knee.

CONCLUSIONS

This cross-sectional survey provides insight into the patient's experience of rehabilitation practices and a patient's perspective on the key barriers to and facilitators of ACL rehabilitation adherence and participation.

Functional progression milestones following anterior cruciate ligament reconstruction are more appropriate than time-based criteria: a survey among the ESSKA

PURPOSE

The aim of this study was to report current rehabilitation recommendations after ACL reconstruction in ESSKA community, with a particular focus on the specific criteria utilized to guide activity progression METHODS: A web-based survey was developed to investigate preferences between time-based and functional ACL reconstruction rehabilitation progression milestones of ESSKA community.

RESULTS

Eight hundred and twenty completed questionnaires were received. Responders were from 86 different countries worldwide, 63% of them from European countries. Functional criteria were considered more appropriate to decide if a patient can start specific activities/exercises by 67% of the responders. Good core and lower extremity neuromuscular control were the most often used functional criteria for decision-making regarding readiness for sport-specific rehabilitation (66%), sport-specific drills without (65%) and with contact (66%). Strength assessed with an isokinetic dynamometer was considered by about half of the responders a determinant to initiate sport-specific drills without (51%-isokinetic strength, LSI > 80%) and with contact (58%-isokinetic strength, LSI > 85-90%). To determine readiness for sport-specific drills, hop tests were used by 40% of respondents for drills without contact and 48% of respondents for drills with contact.

CONCLUSION

The results of this survey involving mainly orthopaedic surgeons indicate that functional measures are considered more appropriate than milestones based on time from surgery to guide progression through the postoperative rehabilitation process after ACLR. The main clinical relevance of this study is that updated information on collective agreement could be useful for clinicians and physiotherapists to delineate their postoperative treatments after ACLR. These results should be interpreted with caution, as this sample represents only a small portion of ESSKA community involved in knee surgery and treating patients following ACLR.

LEVEL OF EVIDENCE

III.

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 .

Isokinetic Dynamometry as a Tool to Predict Shoulder Injury in an Overhead Athlete Population: A Systematic Review

Prospective and cross-sectional studies have used pre-season isokinetic dynamometry strength and endurance measurements of shoulder internal rotation (IR) and external rotation (ER) to determine if they can be correlated to injury. However, to date, no review has provided a synthesis of all available literature on this topic. The aim of this systematic review was to identify isokinetic dynamometry studies that assess shoulder IR and ER strength and endurance in the overhead athletic population in relation to shoulder injury. Electronic databases (PubMed, CINAHL, and SportDiscus) were searched through September 2019 using pre-determined search terms. Both prospective and cross-sectional studies were included in this review. Studies were assessed for quality using either Appraisal Tool for Cross-sectional Studies (AXIS) or Critical Appraisal Skills Programme (CASP). Data on outcome measures of strength and endurance peak torque (PT) and ratios (ER:IR) were extracted and further analysed using a best evidence synthesis approach. A total of 13 articles met the inclusion criteria. Conflicting evidence was found when reviewing all studies without differentiating by study type. Prospective study designs revealed strong evidence that reduced IR endurance and reduced strength ratios are predictive of shoulder injury. Cross-sectional literature showed only conflicting and limited evidence for all outcome measures. At this stage, more research is needed in individual sporting populations using prospective cohort designs.

Who's Afraid of the Big Bad Wolf? Open-Chain Exercises After Anterior Cruciate Ligament Reconstruction

Restoring quadriceps muscle strength is integral to recovery following an anterior cruciate ligament reconstruction. We argue that clinicians should re-evaluate their beliefs about open-chain exercises and measure this important variable to improve outcomes for their patients. J Orthop Sports Phys Ther 2020;50(9):473-475. doi:10.2519/jospt.2020.0609.

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.

Current clinical practice and return-to-sport criteria after anterior cruciate ligament reconstruction: a survey of Brazilian physical therapists

BACKGROUND

Adherence to the use of recommended measures/criteria for return to sport clearance after anterior cruciate ligament reconstruction is crucial for successful rehabilitation.

OBJECTIVES

The purpose of this study was to describe the current clinical practice of Brazilian physical therapists that treat patients after anterior cruciate ligament reconstruction, including the measures/criteria used to support the decision-making process regarding return to sport. The secondary aim was to investigate factors associated with the use of the most recommended measures/criteria for return to sport.

METHODS

An electronic survey questionnaire was sent to Brazilian physical therapists. The survey consisted of questions about demographics and professional and clinical practice data related to anterior cruciate ligament reconstruction postoperative rehabilitation and return to sport criteria. Descriptive statistics and chi-square tests were used for analyses.

RESULTS

A sample of 439 professionals participated in the survey. Only 6.4% of the physical therapists use the most recommended measures/criteria for return to sport after anterior cruciate ligament reconstruction. Professional certification in Sports Physical Therapy was the only factor associated with the use of these recommended measures/criteria (p=0.02). The measures most used for return to sport clearance were related to physical factors (65.3% to 75.1%), such as range of motion and muscle strength. A small number of professionals use questionnaires to assess functional (16.6%) and psychological (19.1%) aspects of their patients to support the decision-making process.

CONCLUSION

In their clinical practice, most Brazilian physical therapists do not use the recommended measures/criteria for return to sport after anterior cruciate ligament reconstruction.