TITLE: Rehabilitation following Anterior Cruciate Ligament (ACL) Reconstruction – The
Missing Piece of the Jigsaw?
BACKGROUND: In a recent review of the author’s NHS Trust ACL rehabilitation class, of
the 37 patients that were discharged within the previous 5 months, almost half (40.54%) did
not complete their course of rehabilitation. Of the 600 scheduled class appointments within
this 5 month period over a quarter (27%) were not attended.
AIM: The aim of this service development initiative was to make recommendations in
relation to best practice of the delivery of ACL rehabilitation within the author’s NHS Trust
with the intention of improving attendance rates, compliance with rehabilitation, patient
experience and overall clinical outcomes.
METHODOLOGY: An extensive literature search was carried out to determine the most
effective management strategies for the rehabilitation of ACL reconstruction. Literature was
critically analysed and appraised, and a literature review essay was written. Sub-topics
identified from the literature search included the exercise content of rehabilitation, structure
and delivery elements (such as location and frequency), and factors relating to adherence to
and completion of rehabilitation. Findings were bench-marked against current practice from
different clinical settings including world leaders in the ACL rehabilitation arena (Fares
Haddad, Lee Herrington, Greg Myers, Kate Webster, Timothy Hewett).
RESULTS: The content, structure and time-frames of the physiotherapy-led ACL
rehabilitation class were considered to be within current best practice recommendations. The
literature highlighted the following key findings which were not being addressed within the
Trust’s programme:
Several psychological factors can have an impact on adherence and outcomes of
rehabilitation.
The literature suggests that psychological factors can influence
outcomes, independently from adherence to rehabilitation (Brewer, Van Raalte,
Cornelius & Petitpas, 2000). (Figure 1, pathway C).

Patients who have undergone competent surgery and rehabilitation achieving good
objective outcomes may not be returning to their pre-injury level of function primarily
due to psychological reasons (Ardern, Webster, Taylor & Feller, 2011).

Psychological screening to identify patients at risk of poor outcomes is not routinely
carried out in clinical practice even though literature on the topic highlights its
importance (Webster, Feller & Lambros, 2008).

Targeted intervention to address the identified psychological factors has been the
focus of research with promising results (Wiese-Bjornstal, 2010).

The factors found to be predictive of rehabilitation adherence and outcomes are selfmotivation, self-efficacy, health locus of control, fear of re-injury, athletic identity
and negative mood (Ardern, Taylor, Feller, Whitehead & Webster, 2013; Brewer et
al., 2000).
Figure 1: The influence of psychological factors on adherence and outcomes of
rehabilitation (Adapted from Brewer et al., 2000).
CLINICAL IMPLICATIONS: The following changes have been incorporated into clinical
practice in order to address the above findings:
Psychological screening has been introduced to identify patients at risk of poor
outcomes.

Training of orthopaedic and out-patient physiotherapists involved in the care pathway
of ACL patients has been carried out to increase awareness of findings.

6 week, 3 month and 6 month review sessions have been extended and tailored to the
individual depending upon the results of their screening.

Patient rehabilitation booklets have been redesigned to address psychological issues
highlighted in the literature. These topics include:o Patient engagement and control of rehabilitation.
o Focussed self-directed goal setting in alignment with core values of patient.
o Addressing patients’ expectations and increasing awareness of timeframes and
milestones.
o Education and reassurance regarding re-injury rates and risk factors.
o Promotion of social support network.
o Promotion of athletic identity.
The above changes to service delivery have been introduced within the last 3 months to
ensure evidence-based best practice of ACL rehabilitation whilst also incorporating
innovative solutions to a key problem that has been highlighted in the literature but is not
routinely addressed within clinical practice. Current class data including functional and
objective outcome measures and patient satisfaction are being recorded and will be compared
to previous data within future audit in order to measure effectiveness of the changes.
References:
Ardern, C.L., Taylor, N.F., Feller, J.A., Whitehead, T.S. & Webster, K.E. (2013). Psychological
responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction
surgery. The American Journal of Sports Medicine, 41 (7), 1549-1558.
Ardern, C.L., Webster, K.E., Taylor, N.F. & Feller, J.A. (2011). Return to sport following anterior
cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play.
British Journal of Sports Medicine, 45 (7), 596-606.
Brewer, B.W., Van Raalte, J.L., Cornelius, A.E. & Petitpas, A.J. (2000). Psychological factors,
rehabilitation adherence, and rehabilitation outcome after anterior cruciate ligament reconstruction.
Rehabilitation Psychology, 45 (1), 20-37.
Webster, K.E., Feller, J.A. & Lambros, C. (2008). Development and preliminary validation of a scale
to measure the psychological impact of returning to sport following anterior cruciate ligament
reconstruction surgery. Physical Therapy in Sport, 9 (1), 9-15.
Wiese-Bjornstal, D.M. (2010). Psychology and socioculture affect injury risk, response, and recovery
in high-intensity athletes: a consensus statement. Scandinavian Journal of Medicine and Science in
Sports, 20 (2), 103-111.