Influence of Demographics and Utilization of Physical Therapy Interventions on Clinical Outcomes and Revision Rates Following Anterior Cruciate Ligament Reconstruction

Abstract

Study Design Retrospective cohort from the Intermountain Healthcare system, January 2007 to December 2014. Background Recent evolutions in health care delivery are putting physical therapists in the forefront to be more responsible for providing high-quality rehabilitation care in a more cost-effective manner. Studies investigating the association between physical therapy visit utilization and outcomes in vulnerable patient populations following anterior cruciate ligament (ACL) reconstruction may provide useful insights. Objectives To examine the relationship between patient age, sex, physical therapy visit utilization, and physical therapy intervention charges with revision rates and patient-reported outcomes in individuals following primary ACL reconstruction. Methods A sample of 660 patients who had an ACL reconstruction was identified through an electronic medical record database. Age and physical therapy visit utilization were categorized to examine effects between groups (20 years of age or younger, 21 to 34 years of age, 35 years of age or older; fewer than 9 visits, 9 to 14 visits, 15 or more visits). Multilevel mixed-effects linear models were conducted to compare differences between revision rates and patient-reported outcomes during the episode of care. Receiver operating characteristic curve analyses were also used to determine visit-number and charge-per-visit cut points to discriminate patients who achieved at least a minimal clinically important difference on the patient-reported outcomes. Results Of 660 patients, 22 (3.3%) had revision surgery. Compared with patients 20 years and younger, the incidence rate ratio of ACL reconstruction revision was lower in patients who were 35 years and older (85%) and 21 to 34 years (59%). Of 470 patients who attended physical therapy for longer than 3 months, change in Knee Outcome Survey activities of daily living subscale score was significantly lower among patients 20 years of age and younger and in the lowest visit category. Conclusion Achievement of favorable outcomes following ACL reconstruction may require categorization of patients beyond surgical diagnosis alone. Younger patients (aged 20 years or less) attending fewer physical therapy visits (fewer than 9) were more likely to have ACL revision surgery and had inferior patient-reported outcomes compared to older patients and those with higher physical therapy visit utilization. The study design of a retrospective cohort limits the ability to identify causal relationships. Additionally, this study was conducted in only 1 geographic region within a single health care delivery system, which may limit the generalizability of the results. Level of Evidence Prognosis, level 2c. J Orthop Sports Phys Ther 2017;47(11):834-844. Epub 9 Oct 2017. doi:10.2519/jospt.2017.7048.

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

“…Age may also play a role in the frequency of supervision required. Younger patients, particularly under 18, may require a higher frequency to achieve successful outcomes by providing extra guidance on exercises, goals and motivation to adhere to post-operative rehabilitation [ 43 , 46 , 64 ].…”

“…The number of studies in each category were as follows; five studies used at least one hop test [30,33,36,40,46], eight studies used an isokinetic dynamometry strength measure [30,31,34,37,38,40,42,45] and 18 different patient-reported OMs were utilised in 12 different studies [30, 32-39, 43, 44, 46]. Eighteen different clinical-based assessments (pain, range of motion, atrophy, effusion, laxity, Lysholm knee score, Tegner activity scale and international knee documentation committee knee evaluation) were used in 15 studies [31-38, 40, 43-48] and 14 other OMs (RTS status/activity level, re-rupture, gait analysis, functional movement screen, surgery satisfaction, imaging and demographics) were utilised in 10 studies [38,39,[41][42][43][44][46][47][48][49]. Methodological quality refers to the outcome of the quality appraisal undertaken by the review not the authors of this study.…”

“…Outcome measure use was investigated by grouping the type of OM into the following categories: hop tests, isokinetic dynamometry, patient reported OMs, clinical-based OMs and other OMs. The number of studies in each category were as follows; five studies used at least one hop test [ 30 , 33 , 36 , 40 , 46 ], eight studies used an isokinetic dynamometry strength measure [ 30 , 31 , 34 , 37 , 38 , 40 , 42 , 45 ] and 18 different patient-reported OMs were utilised in 12 different studies [ 30 , 32 – 39 , 43 , 44 , 46 ]. Eighteen different clinical-based assessments (pain, range of motion, atrophy, effusion, laxity, Lysholm knee score, Tegner activity scale and international knee documentation committee knee evaluation) were used in 15 studies [ 31 – 38 , 40 , 43 – 48 ] and 14 other OMs (RTS status/activity level, re-rupture, gait analysis, functional movement screen, surgery satisfaction, imaging and demographics) were utilised in 10 studies [ 38 , 39 , 41 – 44 , 46 – 49 ].…”

“…The intervention period was labelled according to the stages of rehabilitation the intervention spanned; early-stage (0–3 months), mid-stage (0–6 months) and late-stage (0–6 months+). Eight studies investigated through to the late phase [ 32 , 35 , 39 , 40 , 44 , 45 , 48 , 49 ], nine mid-stage [ 30 , 31 , 33 , 36 , 41 – 43 , 46 , 47 ] and two early-stage [ 37 , 38 ]. Only five studies had a follow-up assessment period longer than the intervention period [ 31 , 34 , 37 , 41 , 47 ].…”

“…Studies utilising a retrospective methodology found an association between higher rehabilitation utilisation and significantly higher patient reported outcomes (Knee Outcomes Survey–Activities of Daily Living (KOS-ADL) scale [ 32 , 43 ], Knee Injury and Osteoarthritis Outcome Score subscales [ 39 ], patient satisfaction [ 47 ] and numerical pain rating scale [ 43 ]), greater return to pre-operative activities [ 39 , 47 ] and improved Lysholm knee score [ 39 , 47 ]. Finally, in a cross-sectional study, Dempsey et al (2019) found a weak positive correlation with isokinetic knee extension torque and level of supervision [ 30 ], while Darain et al (2015) demonstrated a successful return to sport at 6 months with a high frequency of supervised rehabilitation in a case report [ 33 ].…”