Physiotherapy Treatment and Patient Outcomes Following Anterior Cruciate Ligament Reconstruction Surgery in New Zealand
An anterior cruciate ligament (ACL) rupture is a devastating injury that frequently occurs during sporting activities. Surgical reconstruction of the disrupted ligament, followed by extended rehabilitation, is often undertaken as a means to restore pre-injury functional ability. Rehabilitation, which typically includes physiotherapy treatment, can have a significant impact on patient outcomes following ACL reconstruction (ACLR) surgery; however, the relationship between treatment and outcome is not clear. Therefore, we undertook a series of four studies to determine the nature of the relationship between the quantity and duration of post operative physiotherapy treatment and patient outcomes following primary ACLR in New Zealand (NZ).
In study one, physiotherapy treatment data from the Accident Compensation Corporation of NZ revealed NZ ACLR patients received between 8-12 physiotherapy treatments over 143-161 days following surgery. The absence of patient outcome data did not allow the relationship with physiotherapy treatment data to be determined.
Study two was a systematic review of previous literature, which showed no clear relationship between the quantity and duration of post-operative physiotherapy treatment and patient outcomes following primary ACLR could be established.
In study three, we used patient outcome data from the NZ ACL Registry and physiotherapy treatment data from ACC to show physiotherapy treatment in the first 12 months after ACLR increased the likelihood of achieving a patient acceptable symptom state on the Knee Injury and Osteoarthritis Outcome Score questionnaire. However, post-operative physiotherapy treatment did not increase the likelihood of achieving a normative Marx Activity Rating Scale score in the 24 months following ACLR. Also identified was that NZ ACLR patients received less than 12 physiotherapy treatments over an average of 185 days following surgery.
In study four, we surveyed NZ physiotherapists regarding their beliefs and practices on ACLR rehabilitation, in an attempt to understand possible reasons for the dosage of treatment patients receive following surgery. The dosage of physiotherapy treatment NZ physiotherapists believe they are providing is not consistent with the dosage of treatment NZ ACLR patients are receiving, and the utilisation of patient-reported outcome measures and validated objective methods to assess patient outcomes by NZ physiotherapists following ACLR is low.
Although NZ ACLR patients received a low dosage of physiotherapy treatment following surgery, the absolute quantity of treatment does not appear to have a significant effect on patient outcomes, with other factors (patient age, gender, delay to ACLR) possibly having greater impacts. Physiotherapy treatment following ACLR can, however, increase a patients acceptance of any ongoing post-surgical symptoms and functional limitations. Multiple factors, including ACC policy and processes, likely influence the dosage of physiotherapy treatment received by NZ ACLR patients. Regular assessment of the patients status and function by the physiotherapist during ACLR rehabilitation may increase adherence to the rehabilitation programme, potentially increasing the dosage of treatment received and improving patient outcomes. NZ physiotherapists may need to increase their knowledge and skills regarding end-stage ACLR rehabilitation to effectively manage their patient throughout a return to pre-injury activities.