Exercise-therapy following anterior cruciate ligament reconstruction: a pilot randomised clinical trial

Individuals 6-15 months post-ACLR will be randomised to the SUpervisied Patient Education and Rehabilitation (SUPER) group or CONTROL group. The SUPER group will complete 1 x face-to-face physiotherapy session (duration 30 minutes) and 1 x small group session (duration 60 minutes) per week for 12 weeks with an experienced musculoskeletal or sports physiotherapist. These will occur following a baseline assessment session with a research assistant. Physiotherapy in this pilot RCT will have a distinct focus on functional retraining split into “progressive phases”. These phases are similar to a neuromuscular retraining intervention that has led to clinically meaningful changes in self-reported functional and quality of life outcomes in knee injury populations (articular cartilage lesions) with ongoing functional deficits following a similar period of rehabilitation. There are 8 main "tasks" or exercises: 1. Quadriceps strength 2. Hip extension strength (hamstrings and gluteals) 3. Balance 4. Movement retraining (jumping, landing and cutting strategies) 5. Calf strength 6. Trunk strength 7. Hip abduction strength 8. Sport-specific/cardiovascular Each task will have progressive phases within it. For example, “Quadriceps strength” will start at phase one of a bilateral isometric wall sit, then once the pass criteria is met (60sec hold at 90 degrees knee flexion, nil pain or response in the knee), they move to a double leg squat with increasing weights, then to an assisted and unassisted single-leg squat with increasing weights, then to a weighted squat jump power exercise. The 8th task of "sport specific/cardiovascular exercise," is also phased. For example, participants may not have begun running, so phase 1 starts at walking/bike/swimming, then once they have passed the criteria (range of strength, control and balance tests) they may move to running. The SUPER exercise-therapy program targets the strength and functional impairments typically seen post-ACLR, and will be matched to each patient’s preferences, goals, clinical presentation (e.g. strength, pain severity, personal, sporting, work and functional needs), presence of comorbidities (e.g. other musculoskeletal pain) and progressed based on response to exercise. Strengthening exercises will utilise strength training principles (e.g. ~70-80% 1 repetition maximum; 3-4 sets x 8-10 reps), supplemented with neuromuscular exercises and plyometrics. The physiotherapist will supervise and progress exercises from the 8 key tasks, each with 3-5 phases of increasing difficulty, based on strengthening principles criteria, and provide feedback during each visit. Self-managed additional exercise sessions will be encouraged 2 x week. These home exercise sessions will be approximately 30-45 minutes depending on the level of the patient. The PhysiTrack® and PhysiApp® app, a web-application compatible with smartphones, tablets and computers, and designed for physiotherapists and patients, will provide photos, videos and instructions of exercises to be played out in real time. Individualised health education regarding expectations and goals, improving adherence, long-term outcomes, weight control, and appropriate physical, occupational and sporting activity promotion, will be delivered during the physiotherapy treatment sessions. Specific topics include understanding of the increased osteoarthritis risk after knee injury and its pathology and progression, benefits of physical activity, optimising strength and importance of SUPER program, fear avoidance and criteria for a graduated return to activities with patient-specific goal setting. Participants will also be encouraged to enhance their physical activity using a targeted, graduated cardiovascular retraining program adhering to World Health Organisation and Australian Physical Activity Guideline. Participants will be required to keep a "log book" to measure compliance of their home exercise program via the PhysiApp® on their smart device/computer. They will also have the option of paper version if not able to use the app. In addition to compliance, use of medications, other treatments, and symptoms will be monitored. Physiotherapists will also mark attendance at each of the physiotherapy sessions. They will also perform standardised assessment (balance, strength, function) at each physiotherapy session, which may improve adherence. This will be recorded by the physiotherapists in a log book. Participants will be asked to refrain from other physiotherapy/rehabilitation interventions but stable drug doses will be permitted. To minimise participant burden, study physiotherapists will be located at clinics across greater Melbourne. Treating physiotherapists will undergo a 4-hour training session provided by the research team, with treatment manuals that have been designed by the researchers with input from experienced clinicians, and fidelty checks via auditing of treatment notes. Our initiatives to optimise standardisation include examples of exercise videos, frequently asked questions, and being available to address queries promptly via phone/e-mail. The treating physiotherapists will record per protocol treatment and any co-interventions in a log book.