Return to sport decision-making following anterior cruciate ligament reconstruction surgery. An online survey of current United Kingdom based physiotherapy practice

Purpose: Rates of return to pre-injury level and competitive level sport following ACLR surgery are low, with current research reporting return rates of 63% and 44% respectively. Post-surgical rehabilitation is commonly governed by an ACLR specific guideline/protocol and overseen by a physiotherapist. Current robust evidence suggests that the use of RTS criteria is important in aiding the decision-making process. Knowledge of physiotherapists’ use of RTS criteria is limited. The aim of this study was to investigate the current practice of UK-based physiotherapists’ RTS decision-making following ACLR to determine concordance with the best available evidence. Specific objectives were to:
(1)
Investigate current use of, and RTS criteria within, ACLR rehabilitation guidelines/protocols.

(2)
Investigate current use of subjective and objective outcome measures to facilitate post-ACLR RTS decision-making.

(3)
Investigate relationships between respondent's professional characteristics and variation in post-ACLR RTS outcome measure use.


Methods: Following ethical approval, an observational, cross-sectional, anonymous online survey of UK-based physiotherapists was conducted, using Bristol Online Surveys software. The survey was designed based on existing systematic reviews and expert consensus. Following a pilot study, the survey was open from 02/03/2017 to 20/04/2017. Sampling consisted of convenience, purposive, opportunistic and snowball methods. Data was exported to IBM SPSS (version 23) and analysed using descriptive statistics, Chi-square and Fisher's Exact tests with significance set at p < 0.05.

Results:

97.4% (191/196) of respondents used a guideline/protocol and 61.3% (117/191) of guidelines/protocols included RTS criteria.

Consistency in practice was identified with frequent use of hop tests (92.9%, 182/196) and muscle strength tests (84.2%, 165/196), moderate use of RTS test batteries (63.3%, 124/196), patient reported outcome measures (PROM's) (54.6%, 107/196), agility tests (53.1%, 104/196) and ACL laxity tests (39.8%, 78/196), and infrequent use of performance quality assessment tools (PQAT's) (26.5%, 52/196) and psychology-specific PROM's (26%, 51/196).

Statistically significant variation in practice was identified, with the infrequent use of agility tests by the majority of respondents other than those working in professional sport (88.2%, 15/17, p = 0.037), and the infrequent use of PQAT's other than those working in professional sport (70.6%, 12/17, p < 0.001) and those with over 20 years of ACLR rehabilitation experience (63.6%, 7/11, p = 0.004).

Conclusion(s): The majority of respondents used guidelines/protocols to direct RTS decision-making. One-third of guidelines/protocols did not include specific RTS criteria, aligning with one-third of respondents ‘never’ using a RTS test battery, despite research indicating the importance of these. Respondents’ RTS decision-making reflects current evidence with frequent use of hop tests and muscle strength tests, and moderate/infrequent use of tests related to less developed areas within the literature. Variation in practice was identified in relation to respondent's work setting and years of ACLR rehabilitation experience.

Implications: This study has highlighted variation in UK physiotherapy practice for RTS decision-making following ACLR. More widespread use of RTS criteria, including test batteries and outcome measures such as agility tests, PQAT's, PROM's and psychology-specific PROM's is recommended. Future research should focus on the efficacy of these outcome measures, and translational activities to promote the use of RTS criteria by physiotherapists post-ACLR is warranted. Due to potential self-selection bias and non-probability sampling, findings should be interpreted with caution.