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  • Survey Finds 'Considerable Variation' in Postsurgery ACL Rehab

    Authors of a new study say that while guidelines exist for rehabilitation after anterior cruciate ligament (ACL) reconstruction, there remains "a large degree of variation in rehabilitation progression" among physical therapists (PTs), particularly when it comes to timing of the progression, strength assessment, and use of patient-reported outcome measures

    Those conclusions, published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free) were based on results of an online survey of 1, 074 members of APTA’s Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical Therapy, and Private Practice Section. Authors believe that this is the first time PTs' private practice patterns in this area have been studied.

    As for the respondent pool, the majority of PTs treated patients in a private practice or hospital-based outpatient facility. Just over half (52.5%) held American Board of Physical Therapy Specialties certifications in either orthopaedic or sports physical therapy, and 92.5% were APTA members. Authors of the study also classified respondents by the volume of post anterior cruciate ligament repair (ACLR) patients they treated annually, with 32.3% falling into the "low volume" category of 1 to 5 per year, 28.8% grouped into a "medium volume" category of 6 to 10 patients per year, and 37.9% categorized as "high volume," with 11 or more post-ACLR patients per year. Researchers also tracked respondents by years in practice.

    Here's what they found:

    • Overall 56% of respondents reported the duration of supervised physical therapy at 5 or fewer months.
    • Regarding the length of time PTs would wait before recommending a patient initiate sports activity, 58% said 3-4 months for jogging, 50% said 4-5 months for modified sports activity, and 40% said 9-12 months for unrestricted sports participation. Given that most respondents reported treatment periods of 5 months or less, the number of PTs who don't recommend unrestricted participation until after 9 months postsurgery "imply that there may be a long gap between the discontinuation of supervised rehabilitation and return to activity," authors write.
    • Over 80% of respondents used strength and functional measures to assess patients during rehabilitation. Most PTs used manual muscle testing (MMT) to assess strength before progressing patients to jogging (80.6%) or modified sports (74.3%). Of those, 56% relied solely on MMT as a mode of assessment—a potential concern, according to authors, because MMT "may lack the sensitivity to detect residual strength deficits that may be present at this phase of recovery, leading to poorly informed decision making." The tendency to rely solely on MMT was more prevalent among low-volume providers and uncertified PTs.
    • Before progressing patients to jogging or modified sports, most respondents assessed knee strength, function and balance, knee range of motion, and degree of knee effusion. However, there was significant variation among PTs regarding limb strength criteria for functional advancement. Authors speculate this may be due to a lack of clear evidence.
    • Only 45.3% of respondents reported using patient-reported outcome measures to quantify functional deficits. The most common measure was the Lower Extremity Functional Scale, used by 39.2% of respondents, with fewer than 10% of respondents reporting use of measures related to fear or athletic confidence. Authors describe the lower usage rates of patient-reported outcomes as "regrettable," writing that "it has become clear that physical recovery alone is not sufficient to ensure successful return to sports, and many authors have emphasized the importance of assess¬ing psychological readiness and fear of reinjury." The lack of attention to patient-reported fear and readiness "[neglects] the holistic framework highlighted within the biopsychosocial approach to patient management," they add.

    According to authors, across the survey areas reviewed, 1 consistent element emerged: PTs who treated a large volume of post-ACLR patients, more recent graduates, and those with specialty certifications were more likely to report practice patterns "that were more consistent with current best evidence."

    Authors caution that the results should be understood within the limitations of the study itself. Among those limitations: the survey instrument was not validated before dissemination, there were no questions that addressed the possible influence of payment systems on treatment patterns, and the respondents were overwhelmingly APTA members—a fact that authors believe may hide even greater variability among the entire PT population.

    Overall, however, authors call the results "surprising," and note that "one of the most noticeable findings was the degree of variability in clinical testing and decision making, particularly within the later phases of rehabilitation, during the transition back to sports activity." The variation, they write, points to the possibility that at least when it comes to on-the-ground PT practice, "there is no consensus about the ideal postoperative rehabilitation program."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • Excellent, realistic, dialogue! Thank you! I wear many hats: Ski coach; Avid outdoor enthusiast; PT; and have put my science and creative forces together to build a medical device that addresses this very scenario. Customized medicine is what I am seeking for these teams of health care providers and motivated, unique, individuals. There is a better way to address unique goals, I believe through 3D printing etc of more product lines.

      Posted by Megan Hanrahan on 11/13/2018 10:08 PM

    • You offer conflicting statements regarding return to jogging. If 56% of physical therapists rely solely on manual muscle testing to assess readiness, then how can, "most respondents assess knee strength, function and balance, knee range of motion, and degree of knee effusion before progressing patients to jogging"?

      Posted by David Nielsen on 11/14/2018 2:57 PM

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