A novel web-support intervention to promote recovery following Anterior Cruciate Ligament reconstruction: A pilot randomised controlled trial

Highlights

• The internet based intervention is a useful tool for reminder and reinforcement.

• The internet based-intervention was an important motivator for exercise adherence.

• Physiotherapists were considered to be important motivators and supporters.

• No differences were observed between the groups on patients reported outcomes.

• The use of dialogue support and improve device compatibility may enhance usage.

Abstract

Background

Self-efficacy is positively associated with adherence behaviours and rehabilitation outcomes following Anterior Cruciate Ligament (ACL) reconstruction. An internet resource can be an effective way to provide information, goal setting, patient monitoring and hence support overall self-management.

Purpose

This study examined the feasibility of a three month ‘internet-based intervention’ (mobile-oriented site) to enhance recovery for patients following ACL reconstruction. The potential effect of the internet-based intervention on knee pain, function, self-efficacy and fear of pain were also assessed.

Method

This was a pilot randomised controlled trial (RCT) with pre and post intervention design (assessments at one week and three months following ACL reconstruction) comparing: (1) a control group and (2) an intervention group (internet-based intervention). A set of qualitative and quantitative assessments were included to evaluate potential improvements in self-efficacy, pain and function and perception of the internet intervention.

Results and conclusion

Seventeen participants were available for analysis (n = 10 intervention and n = 7 control group). Participants reported the internet-based intervention to be a useful tool for information, reminder and reinforcement for performing their exercise rehabilitation with 30.3% (±35.3%) adherence to the internet-based intervention. No differences were observed between the groups over time on the outcome questionnaires (p > 0.05).

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001379404.

Introduction

Anterior Cruciate Ligament (ACL) injury is a common sports-related knee injury, often treated with ACL reconstruction surgery. ACL injury is especially prevalent through adolescence and early adulthood, and the number of ACL reconstructions performed in Australia is estimated to be over 10,000 per year (Janssen, Orchard, Driscoll, & van Mechelen, 2012). Estimated surgery and hospital costs associated with ACL reconstructions is over AU$75 million per year (Janssen et al., 2012). Post-operative rehabilitation requires frequent physiotherapy sessions for both treatment and education (Risberg, Grindem, & Oiestad, 2016). Rehabilitation protocols should be adjusted for individual patients to allow for variations in the rate of their progress and the level of supervision they require (Glass, Waddell, & Hoogenboom, 2010). This results in a significant investment of resources in public hospital physiotherapy departments (Janssen et al., 2012).

Although studies have reported successful outcomes following surgery based on function, symptoms, and performance-based test scores, the number of patients who successfully return to their pre-injury physical activity participation is relatively low (Ardern et al., 2011, Biau et al., 2007). Positive psychological responses before reconstruction surgery and early in recovery after surgery predicted returning to sport at 12 months post surgery (Ardern, Taylor, Feller, Whitehead, & Webster, 2013). Psychological factors, such as perception of readiness to return to sport and attitude towards recovery, have been shown to influence whether an individual will return to sport or to their pre-injury activity (Langford, Webster, & Feller, 2009). These factors include adjustment issues following physical trauma that result in temporary disability and complex psychological sequelae (e.g. anxiety, depression, amotivation), physical activity avoidance, cognitive reappraisal (e.g. shifts in self-efficacy perception or movement of locus of control, pain catastrophising and kinesiophobia) (Brand and Nyland, 2009, Everhart et al., 2015). These issues may hinder patients’ recovery following ACL reconstruction surgery and their readiness to return to sport (Brand & Nyland, 2009).

Self-efficacy refers to the perception of the individual of their potential ability to carry out a task, with higher self-efficacy positively associated with adherence behaviours and rehabilitation outcomes following ACL reconstruction (Mendonza, Patel, & Bassett, 2007). Hence, self-efficacy is a significant mediator of successful surgery and rehabilitation. Strategies to enhance patients' self-efficacy, such as modelling interventions (educational self-management strategies), seem to also reduce anxiety and increase patients’ self-confidence (Maddison, Prapavessis, & Clatworthy, 2006). Consequently, interventions with a focus on improving self-management (and hence self-efficacy) following surgery may improve patient outcomes, satisfaction and enhance recovery.

The internet has been recognised as a potentially valuable tool for acquiring health information for the provision of online care and services and is a rapidly growing resource (Rains, 2008). Moreover, with almost 50% of the world's population using the internet (Internet World Class, 2017), it has great potential for public health impact due to its easy access, viability, low (or no) cost, and availability. The average age of people undergoing ACL reconstruction in Australia is around early to mid-twenties (Janssen et al., 2012). This age group is likely to use the internet via mobile, tablet or computer on a daily basis (Australian Bureau of Statistics, 2016) and as such, this mode of interaction is particularly attractive. Therefore, an innovative web-support resource for this patient group can provide an interactive means of following patients' recovery in a way that is easily accessible. This project aimed to develop a ‘reflexive’ web-support resource (mobile-oriented site) designed to facilitate patients' self-management of their recovery following ACL reconstruction.

The primary aim of this pilot randomised controlled trial was to examine the feasibility of a three month internet-based intervention for enhancing recovery following ACL reconstruction. As such, assessment of adherence (access to the website) and drop out as well as patients’ perceptions of the potential benefits via interviews were collected. Measures of knee pain, function, self-efficacy and fear of pain were also assessed before and after the intervention to examine potential benefits. The study would provide preliminary results around feasibility, which could then help to determine whether such an intervention is appropriate for further testing on a larger scale (Bowen et al., 2009).