Impact of a three-phase ACLR post-operative rehabilitation pathway on patient drop-out rates and return to sport outcomes.

Purpose

Anterior cruciate ligament reconstruction (ACLR) is commonly recommended for patients aiming to return to level 1 sports (sports that involve cutting, jumping and pivoting). Completion of ACLR surgery does not guarantee patients will return to sports due to a spectrum of biopsychosocial factors. Large NHS patient referral volumes can make it challenging to balance the quality and quantity of sports-specific rehabilitation. Service evaluation offers an opportunity to review and propose innovative ways of working.

A recent service evaluation at Guys and St Thomas' NHS Foundation Trust (GSTFT) showed a high amount of ACLR patients drop out of physiotherapy 6 months post-operatively and do not progress to sports-specific rehabilitation; the goal which underpinned the original decision to undergo surgery. True return to sport rates post-ACLR is acknowledged to be variable.

The aim of the project was to implement a new ACLR post-operative rehabilitation pathway at GSTFT to optimise return to sport outcomes.  

37/45 (82.22%) ACLR patients dropped out of physiotherapy
Between November 2nd 2016 - 26th April 2017
8/46 (17.4%) patients dropped out of the late phase rehabilitation class
Between January 21st 2019 - 8th April 2019
14 patients were able to meet discharge criteria returning to sports
with 9/14 (64.29%) returning to level 1 sports

Approach

The ACLR post-operative pathway was remodelled to three rehabilitation phases; early, middle and late. Previously, weekly ACLR rehabilitation classes were provided for all patients two weeks post-ACLR onwards.

This was divided to an early phase rehabilitation class (0-3 months) and late phase rehabilitation class (6 months onwards). Patients in the middle phase (3-6 months) were educated and empowered to complete unsupervised rehabilitation away from the NHS setting. Patients attended for late phase rehabilitation only if they were aiming for level 1 sports participation and were able to achieve middle phase outcome measures. The late phase rehabilitation class comprises of two exercise circuits focusing on strength/power, impact/landing control and concludes with group-based agility drills.

Progression through rehabilitation phases and subsequent return to sport was based on outcome measure performance. Patient drop-out rates and return to sport outcomes were reviewed for the late phase rehabilitation class in the first 12 weeks of implementation (January 21st 2019 - 8th April 2019) to all ACLR patients who entered the previous ACL rehabilitation classes between November 2nd 2016 - 26th April 2017.

Outcomes

Between November 2nd 2016 - 26th April 2017 37/45 (82.22%) ACLR patients dropped out of physiotherapy, with their final attendance 25.49 weeks post-surgery. Of the 8 patients formally discharged, 5/8 (11.11%) met discharge criteria and returned to level 1 sports.

Between January 21st 2019 - 8th April 2019 8/46 (17.4%) patients dropped out of the late phase rehabilitation class. 14 patients were able to meet discharge criteria returning to sports, with 9/14 (64.29%) returning to level 1 sports.  

This data shows that service evaluation and subsequent change in service provision, enabled the ACLR post-operative service to reduce drop-out rate by 65% and has allowed a near 6-fold increase in patients returning to level 1 sports.

Implications

This three phase (early, middle, late) post-operative ACLR Pathway implemented at GSTFT could be utilised in other NHS settings that see high volumes of ACLR patients looking to optimise return to sport outcomes.

Fund acknowledgements

No additional funding was received during the service redesign, implementation or evaluation period.

Additional notes

This work was presented at Physiotherapy UK 2019.