‘Such a massive part of rehab is between the ears’; barriers to and facilitators of anterior cruciate ligament reconstruction rehabilitation: a qualitative focus group analysis

Abstract

Background Current evidence demonstrates that few patients complete anterior cruciate ligament reconstruction rehabilitation according to evidence-based guidelines. It is important to investigate the viewpoints of our patients to identify patient-reported barriers and facilitators of anterior cruciate ligament reconstruction rehabilitation. Qualitative analysis can provide insight into potential methods for improving the delivery of rehabilitation services. Methods In this qualitative study, utilising a social constructionism orientation, viewed through the social phenomenological lens, three focus groups were conducted with individuals 1–20 years post anterior cruciate ligament reconstruction (n = 20, 9 males, 11 females, mean 6.5 years post-surgery, 19–51 years old). Utilising a semi-structured interview guide, participants were asked about their experiences during anterior cruciate ligament reconstruction rehabilitation. Focus groups were recorded, transcribed, and coded using an inductive semantic thematic analysis methodology. Results Five organising themes were identified (consisting of 19 sub-themes) to provide a framework to present the data: psychological, physiological, rehabilitation service, rehabilitation characteristics, and interaction with others. Each theme details aspects of rehabilitation, such as exercise delivery, informational support, frequency, and duration of care, kinesiophobia, weight management and interactions with teams and coaches, which present barriers or facilitators for patients to adhere to and participate in rehabilitation. Example quotes are provided for each theme to provide context and the patient’s voice. Conclusions This qualitative investigation identified key aspects of a patient's rehabilitation in which they encounter a variety of barriers and facilitators of ACL reconstruction rehabilitation. These aspects, such as the rehabilitation characteristics, service delivery, psychological and physiological factors, and interactions with others, were consistently identified by this cohort as factors which affected their rehabilitation. The themes may provide targets for clinicians to improve rehabilitation and deliver patient-centred care. However, the themes must be evaluated in future trials to assess whether interventions to remove barriers or enhance facilitators improves subsequent outcomes such as return to sport and re-injury rates.

Patient acceptance of knee symptoms and function after anterior cruciate ligament reconstruction improves with physiotherapy treatment

“…Multiple factors likely contribute to patients receiving a low dosage of physiotherapy treatment following ACLR, including low motivation to complete rehabilitation (Thorstensson et al, 2009), a lack of patient education regarding post-ACLR rehabilitation (Cailliez et al, 2012), or a lack of surgeon endorsement of rehabilitation (Ebert et al, 2019b). Patients also report frustration and disappointment with a physiotherapist's ability to manage late-stage ACLR rehabilitation (Walker et al, 2022), which could lead to patients prematurely disengaging in physiotherapy, resulting in a low number of treatments.…”

The Influence of Psychosocial Factors on Patients Undergoing Anterior Cruciate Ligament Reconstruction

“…If this leads to changes in confidence, self-efficacy, goals, kinesiophobia, or mental status, it is likely to affect recovery progression. 5,23,68,74 Numerous studies agree psychosocial factors such as emotion often intertwine with decision-making and influence future outcomes.…”

“…Patients' descriptions of feelings include: burden, worry, frustration, hopelessness, devastation, and isolation. 23,30,36,52,68 Mental health conditions, such as anxiety and depression, may increase in severity in response to injury and be detrimental to outcomes. 46 Schaffer et al 58 observed outcomes of patients stratified into 3 cohorts: clinical diagnosis of depression, situational depression, and no depression.…”

To achieve the unachievable—Patients' experiences of opting for delayed anterior cruciate ligament reconstruction after trying rehabilitation alone as primary treatment: A qualitative study

“…Thus, the rehabilitation setting seems to influence the rehabilitation process more than expected. 6 More than 5 years after their ACL-R, patients either experience symptom resolution or feel forced to accept the negative aspects of necessary lifestyle changes as a result from the ACL injury. 7 Regardless of treatment, rehabilitation after ACL injury is typically considered long and demanding, including both physical and psychological challenges.…”

“…Factors that affected rehabilitation as expressed by patients were the rehabilitation characteristics, service delivery by the physical therapist, physiological and psychological factors, and interaction with others. Thus, the rehabilitation setting seems to influence the rehabilitation process more than expected 6 . More than 5 years after their ACL‐R, patients either experience symptom resolution or feel forced to accept the negative aspects of necessary lifestyle changes as a result from the ACL injury 7 .…”