We can do better. A mixed methods approach to the optimisation of anterior cruciate ligament reconstruction rehabilitation

  • Adam Walker

Student thesis: Doctoral Thesis


Anterior cruciate ligament (ACL) injury and subsequent reconstruction is one of the most common knee sports injuries. Although there have been significant advances in surgical technique, the outcomes following anterior cruciate ligament reconstruction (ACLR) continue to be reported as sub-optimal. Many athletes fail to return to their previous level of sport or reinjure the same or contralateral knee. Participation in ACLR rehabilitation is considered critical to facilitate return to sport. Growing evidence suggests that due to inadequacies in current rehabilitation programs, patients are returning to sport too early and with large deficits in knee function, risking reinjury and long-term impairments. Despite our improved understanding of what components need to be included within evidence-based ACLR rehabilitation (progressive goal-driven strength, neuromuscular and agility training), little consideration is given to why patients cease rehabilitation and the barriers which patients face in their rehabilitation journey. This thesis outlines a series of mixed methods research completed to achieve the objective; to design, implement and evaluate an ACLR rehabilitation program based on best evidence rehabilitation principles which addresses the barriers and facilitators for patients to adhere to evidence based ACLR rehabilitation.

The studies in the thesis are presented across two phases: the developmental phase (Chapters3, 4 and 5) and implementation phase (Chapters 6 and 7). The development phase investigates the influence of the patient-reported barriers and facilitators to participating and adhering to ACLR rehabilitation. The results indicated that a moderately or minimally supervised rehabilitation program is at least as effective as a fully supervised high-frequency rehabilitation program. However, a longer duration of supervised rehabilitation is associated with improved functional outcomes. Numerous psychological factors and barriers to rehabilitation were identified in the research, including patient factors, such as psychological and physiological considerations; system factors, such as rehabilitation service limitations; therapist-related factors, such as exercise delivery and the therapeutic relationship; and external influences, such as interactions with medical professionals and personal relationships.

The implementation phase (Chapters 6 and 7) tested the feasibility and effectiveness of rehabilitation programs on patient outcomes. The findings suggest that an ACLR rehabilitation program based on best-evidence rehabilitation principles that consider the barriers and facilitators of rehabilitation in community-level athletes, may facilitate a longer duration of supervised rehabilitation and higher physical function and patient satisfaction, but is insufficient to increase the likelihood of patients passing a return to sport testing battery. The integration of quantitative and qualitative data highlighted the applicability of overcoming barriers to facilitate rehabilitation participation and adherence.

Effective and successful rehabilitation is characterised by the ability to restore physical function, facilitate a safe and timely return to sport and promote long-term joint health. This thesis is the first to take a unique look at the contextual and patient-related factors in implementing effective rehabilitation while evaluating functional outcomes. It provides opportunities for practising clinicians to adopt and adapt their clinical practice to improve the care of individuals following ACLR. Significant challenges exist in the development and adoption of evidence-based rehabilitation strategies. This body of work has provided evidence-based content through which existing and developing protocols can be refined to optimise ACLR rehabilitation.
Date of Award2024
Original languageEnglish
SupervisorWayne Hing (Supervisor), Anna Lorimer (Supervisor) & Larissa Sattler (Supervisor)

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