BackgroundPhysiotherapy 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.MethodsA 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.ResultsOf 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.ConclusionsTRAK 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.

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.

ObjectivesTo 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.MethodsThe 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.ResultsFifty-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).ConclusionTRAK-ACL would be suitable for evaluation of effectiveness in a fully powered RCT.

Background: The Anterior Cruciate Ligament (ACL) stabilises the knee and is commonly injured in sport. Surgical repair and rehabilitation are common. However, rehabilitation randomised controlled trials do not always report the resources used to deliver ACL rehabilitation. This may lead to suboptimal availability of resources for evidence based care. Objective: To identify the resources used to deliver multimodal ACL rehabilitation in randomised controlled trials Methods: Comprehensive searches, combining 'anterior cruciate ligament', and 'rehabilitation' with the Cochrane RCT filter, were conducted of Medline, Embase, Cinahl, PeDro, Sports Discus and the Cochrane Library. Adults post ACL reconstruction were included. The intervention and comparator were physiotherapy for post-operative rehabilitation. Outcomes were the resources required to deliver rehabilitation, and study type was randomised controlled trials. Papers were screened against the criteria; data were charted and narrative synthesis applied. Results: Fourteen studies reported on 599 patients. The interventions ranged from 4 to 36 weeks. Physiotherapy was typically an hour and ranged from 1 to 5 sessions/week. Resources included a gym environment with rehabilitation equipment such as resistance machines, free weights, cardiovascular and neuromuscular control equipment, and an experienced physiotherapist. Conclusions: Implications for future studies include the need for a more detailed report of the resources used in RCTs. Accurate reporting would help healthcare decision makers to effectively manage resources when implementing evidence based care. Findings can be considered as criteria against which to audit resource provision.

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BackgroundRupture 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.ObjectiveThis 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.MethodsThis 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.ResultsThis research expects to establish the feasibility of a full-scale randomized controlled trial to explore wheth...

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.

BACKGROUND Evidence shows that patients after anterior cruciate ligament (ACL) reconstruction may have varied access to physical therapy rehabilitation. In particular physical therapy input is known to end many months before patients are likely to be fully recovered. Tele-rehabilitation (TR) may provide an opportunity to address this “Rehabilitation Gap’” and improve access to evidence based rehabilitation content alongside physical therapy at all stages of care. OBJECTIVE To understand the opinions of patients who have had ACL surgery and rehabilitation on the use of tele-rehabilitation as part of ACL care. To define the population and explore their experiences and views on the acceptability of tele-rehabilitation after ACLR. METHODS This study was a cross-sectional, voluntary on-line survey combining both closed and open questions. Ethical approval was obtained through the Yale School of Medicine, Institutional Review Board (IRB). Participants were aged 16 or over at the time of recruitment, who had undergone ACL reconstruction within the last 5 years. The 26 item survey was developed using the Qualtrics survey platform. No items were mandatory. Responses were multiple choice, binary and qualitative. The Checklist For Reporting Results Of Internet E-Surveys, known as the CHERRIES statement was used to ensure the quality of reporting of surveys in the medical literature. Data were analysed using Stata Version 15. Qualitative data were analysed using NVIVO 11. The theoretical basis for this analysis is based on the COM-B (Capability, Opportunity and Motivation - Behaviour), model of behaviour change. RESULTS 100 participants opened the survey. All completers were unique. The participation rate was 96%. Completion rate was also 96%. Patients reported PT care ended at an average of 6.4 months and feeling fully recovered at an average of 13.17 months. Only 11% of patients felt that they were fully recovered at the end of PT. 60% of patients were under 30. They were recreational athletes (74%) or competitive athletes (24%). 75% had private insurance. 77% reported that they were ‘Not Familiar At All’ with tele-rehabilitation. 89% felt capable. They preferred to use TR 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, as well as less access to manual therapy, motivation and opportunities to ask questions. Participant’s priorities for a future intervention included use as an adjunct to PT rather than instead, with content for each stage of care and especially return to sport. Importantly the intervention should be personalised to them and include measures of progress. CONCLUSIONS This data contributes understanding and defining the ACL reconstruction population. Participants found TR acceptable in principle and highlighted key user requirements and scope of a future intervention.