shared decision making - la trobe sport and exercise...

Shared decision making following anterior cruciate ligament reconstruction

Patient

EvidenceClinician

@Knee_Howells

Brooke Patterson PhD CandidateSupervisors: Prof Kay Crossley, Dr Adam Culvenor, Dr Christian Barton

Sports and Exercise Medicine Research Centre

Sport & Exercise Medicine

Research Centre (LASEM)BACKGROUND

• Return to sport (RTS) decisions should be ‘’shared”

• Based on best available evidence(Ardern 2016)

- Include RTS testing (impairment, functional & psychological based)

- 9-12 months of rehabilitation(Van Melick 2016)

Figure 1. Based on 3 pillars of evidence based practice (Sackett 1996)

Patient

EvidenceClinician

RTS decision making


Research Centre (LASEM)AIMS

Describe (in an Australian ACL reconstructed population):

• Duration of formal rehabilitation (i.e. physiotherapy)

• Frequency of formal RTS testing

• Who was involved in RTS decision (i.e. patient/surgeon/physiotherapist)

• Patient beliefs - who should be involved in the RTS decision making

N=111 Patient Reported Outcomes

1 year post primary ACLR

N=91 Patient Reported Outcomes

5 year post-ACLR

N=72 included for analysis

60% M 40% F Mean age 35+9


Research Centre (LASEM)METHODS

Excluded:n=1 did not complete patient reported outcomes n = 18 not participating in level 1 or 2 sports previously*


Research Centre (LASEM)METHODS: Customised Questions

1. Physiotherapy

“When did you cease formal physiotherapy? (0-1, 1-6, 6-12, >12 months)”

2. Formal return to sport testing

“Did you undergo any formal return to sport assessments with your physiotherapist at any

stage throughout your rehabilitation?”

I.e. greater than 3 assessments i.e. physical tests or questionnaires which gave you an objective

score(Van Melick 2016)

Webster et al., (2008)

METHODS Customised Questions

“Who was involved in the decision when/if you should

return your pre-injury level of sport?”

Note – can be singular or combination answer

Me, Physiotherapist,

Surgeon, or other health professional?

At the time of RTS

METHODS: Customised questions

“Reflecting on your experience who do you think should be

involved in the decision when/ifyou should return to your pre-

injury level of to sport?”

Note – can be singular or combination answer

Me, Physiotherapist,

Surgeon, or other health professional?

At 5 years


Research Centre (LASEM)RESULTS - DEMOGRAPHICS

n=72 1-year post-ACLR 5-year post-ACLR

Age, median (range), years 26 (18-45) 32 (23-51)

Sex no. male (%) 44 (61%) 44 (61%)

BMI, median (range), kg/m2 26 (19-35) 26 (20-35)

Menisectomy/cartilage defect at time

of surgery, no. (%)36 (50%) 36 (50%)


Research Centre (LASEM)RESULTS: RTS

Pre-Injury 1-year post-ACLR 5-year post-ACLR

Sports activity level, no. (%) (Grindem et al., 2012)Level 1. Jumping, cutting pivoting sportsLevel 2. Lateral movement sportsLevel 3. Straight line activitiesLevel 4. Sedentary

54 (69%)18 (23%)

6 (8%)0 (0%)

19 (24%)10 (13%)19 (24%)30 (39%)

25 (32%)11 (14%)32 (41%)10 (13%)

Time of RTS, median (range), months NA NA 14 (6-48)

Return to sport status, no (%)Pre injury (same sport, level of competition and frequency)

Any competitive sport (other type of level 1 or 2 sport excluding running, or training in same sport but not competing)

No competitive sport

NA

21% (n=15)

32% (n=23)

47% (n=34)

40% (n=29)

22% (n=16)

38% (n=27)

RESULTS – PARTICIPATION IN PHYSIOTHERAPY

90% had physiotherapy- 10% other (i.e. exercise

physiology, personal training)

Duration of physiotherapy:

NONE

<1 MONTH

1-6 MONTHS

6-12 MONTHS

>12 MONTHS

• 1/3 1-6 months

• 1/3 > 6months

• 1/3 <1 month

RESULTS: How many completed RTS testing?

Completed RTS testing =

24% (n= 17)*

*Definition = At least 3 assessments (physical or psychological readiness

measures)7

Webster et al., (2008)

RESULTS: RTS decision making

Patient

Physiotherapist

Surgeon

Physiotherapist & Surgeon

Patient & Surgeon

Patient & Physiotherapist

Patient, Surgeon, & Physiotherapist

At 5 years

Patient

Physiotherapist

Surgeon

Physiotherapist & Surgeon

At the time of RTS

Patient

Physiotherapist

Surgeon

Physiotherapist and Surgeon

Patient & Surgeon


Patient, Surgeon, &

Physiotherapist

39%

At 5 years

RESULTS: SHARED DECISIONS

Patient

Physiotherapist

Surgeon


10%

90% RTS based purely on:decision of 1 health professional

ORwithout guidance from a health professional at all

= Patient + 1 other clinician

At the time of RTS

PATIENT INVOLVEMENT

Patient

Physiotherapist

Surgeon


39%

Patient

Physiotherapist

Surgeon

Physiotherapist and SurgeonPatient &

Surgeon


Patient, Surgeon, &

Physiotherapist

72%

At 5 years At the time of RTS

PHYSIOTHERAPY INVOLVEMENT

Patient

Physiotherapist

Surgeon

Physiotherapist and SurgeonPatient &

Surgeon


Patient, Surgeon, &

Physiotherapist

60%

Patient

Physiotherapist

Surgeon


46%

At 5 years At the time of RTS

SURGEON INVOLVEMENT

42%

At 5 yearsAt the time of RTS

42%


Research Centre (LASEM)LIMITATIONS

Novel, retrospective data, future research should:

Investigate evidence – clinical practice gaps further I.e. Larger cohorts/multi-centresI.e. Include barriers for participation, duration, and type of rehabilitation

(Ebert, Edwards et al. 2017, Nawasreh, Logerstedt et al. 2017)


Research Centre (LASEM)FUTURE RESEARCH

Investigate whether intervention and what type can improve outcomes I.e. additional end stage rehabilitation and/or education to increase shared decision making, formal rehabilitation and return to sport testing?


Research Centre (LASEM)SUMMARY OF RESULTS

1. Short duration of formal physiotherapy

2. Low frequency of RTS testing

3. Shared decision making rarely occurred at the time of return to sport


Research Centre (LASEM)SUMMARY OF RESULTS

Patient reflections Do they agree with consensus statements?(Ardern 2016)

- >70% patient involved - Only 39% said should be shared

Remember shared decision making is also a personal preference….


Research Centre (LASEM)CLINICAL IMPLICATIONS

1. Patient education Value of RTS criteria and testingExpected amount of supervised therapy Shared decision making process

2. Identify barriers for patients Fear of reinjury – motivation in therapy Cost effectiveness of end stage rehabilitation

3. Identify barriers for clinicians Value of education & assessment as ongoing treatment Referral to strength and conditioning / up-skilling for end stage


Research Centre (LASEM)

@Knee_Howells

Latrobe Sports and Exercise Medicine Research Centre Blog: http://semrc.blogs.latrobe.edu.au

THANK YOU AND QUESTIONS


Research Centre (LASEM)REFERENCES

1. Ardern, C. L., M. Bizzini and R. Bahr (2016). "It is time for consensus on return to play after injury: five key questions." Br J Sports Med50(9): 506-508.

2. van Melick, N., R. E. van Cingel, F. Brooijmans, C. Neeter, T. van Tienen, W. Hullegie and M. W. Nijhuis-van der Sanden (2016). "Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus." Br J Sports Med 50(24): 1506-1515.

3. Sackett, D. L., W. M. Rosenberg, J. A. Gray, R. B. Haynes and W. S. Richardson (1996). "Evidence based medicine: what it is and what it isn't." BMJ 312(7023): 71-72.

4. Ebert, J. R., P. Edwards, L. Yi, B. Joss, T. Ackland, R. Carey-Smith, J. U. Buelow and B. Hewitt (2017). "Strength and functional symmetry is associated with post-operative rehabilitation in patients following anterior cruciate ligament reconstruction." Knee Surg Sports Traumatol Arthrosc.

5. Nawasreh, Z., D. Logerstedt, K. Cummer, M. Axe, M. A. Risberg and L. Snyder-Mackler (2017). "Functional performance 6 months after ACL reconstruction can predict return to participation in the same preinjury activity level 12 and 24 months after surgery." Br J Sports Med.

6. Webster, K. E., J. A. Feller and C. Lambros (2008). "Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery." Phys Ther Sport 9(1): 9-15.

7. Grindem, H., I. Eitzen, H. Moksnes, L. Snyder-Mackler and M. A. Risberg (2012). "A pair-matched comparison of return to pivoting sports at 1 year in anterior cruciate ligament-injured patients after a nonoperative versus an operative treatment course." Am J Sports Med 40(11): 2509-2516.

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