Beyond guidelines: A qualitative clinical stakeholder study of optimal management of anterior cruciate ligament rehabilitation

Aims: This study gathered expert perspectives in the management of anterior cruciate ligament (ACL) rehabilitation to explore current practice, variations in care and optimal management strategies. Materials and methods: This was a qualitative semi ‐ structured interview study. The participants' experiences were considered in terms of their roles as employees, managers, clinicians and professional gatekeepers. Purposive and snowball sampling were used to recruit physiotherapists and orthopaedic surgeons. Participants were included if they had a proven record in clinical management or research involving ACL patients. Persons were excluded if they could not speak English. Interviews were conducted in person, via skype or over the phone at a time convenient to the participant. Data was analysed using a framework analysis and critical realist approach. Results: Results included 24 interviews that were conducted with 19 physiothera-pists and 5 surgeons. Themes of variation in current care and optimal care were explored including subthemes of patient centred practice, evidence based medicine, resources, self ‐ management, multidisciplinary teamwork, training and expertise were explored. Participant's perceptions of current care were that it was a location ‘lottery’ that signiﬁcantly varied for patients across the UK. Conclusions: Stakeholders identiﬁed that optimal management should be patient centred and incorporate adequate equipment, speciﬁc training for physiotherapists and a closely communicating multidisciplinary team. Research is needed to explore cost effective models of optimal rehabilitation that include return to sport strategies.

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| INTRODUCTION
Rupture of the anterior cruciate ligament (ACL) is a common injury, especially in the active population (Moses et al., 2012). In the UK the incidence is estimated at 30 per 100,00 (Bollen, 2000). This study was focussed on rehabilitation after surgical reconstruction which is still the most common management strategy for a ruptured ACL (Anderson et al., 2016;Bollen, 2000;Spindler & Wright, 2008) with estimates as high as 75% choosing surgery (Swirtun et al., 2006).
Recovery can be a lengthy physical and psychological process (C. L.  with an estimated 55% returning to the same pre-injury activity levels (Ardern et al., 2014;Grindem et al., 2016).
The evidence on which treatments are effective for promoting functional recovery has evolved substantially in recent years. Passive strategies like bracing and continuous passive motion are no longer routinely advised, while strength and neuromuscular training, to enable control of the body in complex movements, have emerged as cornerstones of rehabilitation (Agre et al., 1987;Kruse et al., 2012;Lobb et al., 2012;van Melick et al., 2016;Wright et al., 2008aWright et al., , 2008b. Despite this knowledge and the availability of a number of published rehabilitation protocols to guide practice (Herrington et al., 2013;Myer et al., 2006), there is no UK consensus on management of ACL rehabilitation. As with many soft tissue surgeries, much may be left to clinician decision making which may be influenced by experience, local service priorities such as cost and staffing levels, and interpretation of the evidence. Research shows that effective rehabilitation depends on specific resources such as gym equipment, time with patients (per session and duration of care) as well as availability of specifically skilled clinicians (Dunphy et al., 2020). It is evident that lack of access to these components may contribute to significant variation in how ACL rehabilitation is delivered (Beard, 2017;Greenberg et al., 2018;Kapoor et al., 2004).
While some variability in care arises from patients themselves who experience physiotherapy in different ways (Bernhardsson et al., 2017;MacDonald et al., 2013;Östlund et al., 2001) other factors worthy of exploration may be local culture, values and team structure in physiotherapy and orthopaedics (Côté et al., 2009;Nilsen & Bernhardsson, 2013;Scurlock-Evans et al., 2014). This study therefor focuses on the opinions of physiotherapists and orthopaedic surgeons to illuminate the 'grey information' which is information generated in clinical practice that is not commonly documented in the literature but may none the less be an important part of understanding factors affecting optimal ACL rehabilitation (Adams et al., 2016).
It has been suggested that variability in practice may contribute to suboptimal outcomes in this population (Fausett et al., 2022;Greenberg et al., 2018;von Aesch et al., 2016). This highlights the need to explore variability in current practice and to identify unwarranted variability as well as what participants consider to be optimal care. In this context 'optimal' refers to the most favourable criteria for delivering rehabilitation, taking into account the needs of the patient, the evidence base and the capacity of the service. In the absence of published evidence on how rehabilitation after surgery for a ruptured ACL is delivered in the National Health Service (NHS), experts and experienced clinical staff are best placed to provide insights into current practice.
This study aimed to collate expert perspectives on ACL rehabilitation care in the UK, to identify variations in care, underlying factors and explore optimal care strategies. The objectives were: � To explore current practice in ACL rehabilitation � To understand orthopaedic surgeon and physiotherapist participants' views on the contextual factors that influence care, including barriers to, and facilitators of, optimal care � To use these data to suggest a set of criteria for optimising rehabilitation after ACL surgery.

| Design
This was a qualitative semi-structured interview study. It took place in the National Health Service, which is a healthcare system in the UK designed to be free at the point of entry, as well as associated private clinics commissioned to provide care to NHS patients. The study was based on the ontology of critical realism, whereby known realities are weighed with a knowledge of how people interpret external realities through their own thoughts and feelings about them and synthesised to give the deepest level of understanding (Archer et al., 2017;Fletcher, 2017). The participants' experiences and opinions were considered in terms of their expertise in management of adult ACL post-operative rehabilitation and their many competing roles such as team leaders, clinicians and gatekeepers of professional ideals, aiming to identify a set of criteria to optimise care. It was reported in line with the Consolidated criteria for Reporting Qualitative research criteria (Tong et al., 2007).

| Patient and public involvement (PPI)
This research was designed under the advisement of the NIHR CLAHRC Patient and public Involvement (PPI) group. A data analysis PPI clinic was also conducted and participant's analysis was included in the findings.

| Eligibility criteria
Inclusion: Physiotherapists and surgeons with expertise in clinical management or research involving ACL patients.
Exclusion: Persons were excluded if they were unable to speak and read English or provide informed consent.

| Sampling
Purposive sampling was used to recruit participants with expertise in ACL management in the NHS, or seeing NHS patients in the private sector (Palinkas et al., 2015;Ritchie et al., 2013). Some participants were identified by their reputation where they had published relevant work or had a reputation through on line online content/blogging, others were identified through the National Ligament Registry (NLR) and a snowball method where one participant come recommend another, was used (Biernacki & Waldorf, 1981

| Data collection
Interview questions were informed by systematic reviews in the field and clinical experience of authors. The topic guide was focussed on answering the objectives and was pilot tested twice and refined (Appendix 1). It covered the areas of current practice, barriers and facilitators of optimal care and supporting selfmanagement.
Interviews were conducted in person, via skype or over the phone by the lead researcher (ED, physiotherapist). Although the phone and skype mediums had limitations, they were useful in overcoming geographical boundaries. The interviews were audio recorded on an encrypted dictaphone. The lead author kept a reflexive diary of each interview and analysis to inform consistency and rigour.

| Interviews
Interviews lasted approximately 40 min. Data saturation was discussed in the team after 21 interviews and agreed at 24.
Details of participants are in Table 1. Given that the community of professionals in the UK who specialise in this field is small, we have elected not to include further identifiable data. Sixteen interviews were undertaken by phone, five face-to-face and three by video.

| Data analysis
Data were analysed using The Framework Analysis method as described by Gale et al. (Box 1) (Gale et al., 2013).

�
Step 4 -Developing a working analytical framework. � Step 5 -Applying the analytical framework. � Step 6 -Charting the data into the framework matrix. coded the manuscripts to identify themes and synthesise data. A coauthor (KB) independently reviewed the data and a sample of coding was checked by three independent qualitative researchers. The analytical framework was developed based on the ACL evidence base. Inductive and deductive reasoning was used to code data to the appropriate theme and give depth to the framework. The process was still thematic and allowed for the inclusion of a more inductive process where ideas that emerge from the data can be added to the framework if not already included. Codes, acategories and themes were reviewed within the research team and discussed with two PPI representatives. We interrogated the key concepts and looked to understand relationships in the data and potential causality.

| Themes
Anterior cruciate ligament rehabilitation was perceived to vary significantly across the UK ( Figure 1). Based on their experience participants described a location 'lottery' for patients that notably affected the care they received. Most clinicians were confident that they provided quality care; however, they identified challenges to delivering what they believed to be optimal care. These challenges included insufficient time with patients, inadequate availability of equipment, a poorly communicating multidisciplinary team (MDT) or DUNPHY ET AL.
-3 lack of specific expertise in ACL rehabilitation (Box 2). Discussion centred on ways to manage these challenges and optimise ACL rehabilitation care.

Box 2. Themes
� Pathways of rehabilitation -current practice.
� Optimal Care Evidence-based practice Patient-centred practice.

� Multidisciplinary teamwork.
� Training in advanced rehabilitation skills.

| Pathways of rehabilitation
The participants were asked to describe their current practice and pathways of care in their locale to satisfy objective 1. Their experiences showed that there were multiple pathways into ACL rehabilitation and that there were a variety of local norms regarding time available/scheduled with a physiotherapist (Figure 1). Some pathways were dedicated to ACL rehabilitation where other ACL patients were managed in groups of patients with a range of conditions ( Figure 1).

| Optimal care-Evidence-based practice
Most participants felt their service was driven by evidence-based practice, validated outcome measures and clinical audit. They frequently cited research guidelines and were knowledgeable on the depth of literature for standards and outcomes. They also expressed a knowledge of the limitations of the evidence base, which is sometimes criticised for poor quality or unclear reporting.
You very rarely see any data in the paper on how many times the patient attended, for instance, and what their compliance was with the home programme. 21P.
The literature has demonstrated efficacy of a criteria-based progression, where progress is based on individual ability, rather than time since surgery. The former approach is safer and encourages engagement with rehabilitation at each stage. Clinicians and managers described that criteria-based progression can present challenges for service planning with some patients taking much longer than others to reach goals. Some clinics appear to blend the two strategies while others undoubtedly retained the time-based approach to care which troubled one participant.
You've had your six classes in the intermediate class.
You're moved on to the advanced. Sometimes they will struggle, have problems. Maybe not have achieved their goals. They've got to get the basics or the fundamentals so they're achieving full extension or a good range of movement in flexion, improving muscle control.
Whereas they're just moved on very quickly. 24 PM.
In cases where patients are progressed according to time without an individual assessment, deficits are masked which could lead to pain, reduced function and satisfaction with the knee.
The problem of not measuring … clinics will invest in electrotherapy but not have any way to measure strength. Leg extension etc. There was some person come in and she was doing loads of stuff … because she was at 6 months. She was doing all this stuff because that was the marker where she should have been at.
There was a 40% deficit in her quads! She was doing loads of jumping and running and turning and stuff and she wasn't able to cope with it. She had lots of anterior knee pain. 1 PM.

| Patient-centred practice in rehabilitation
Patient-centred practice (PCP) was seen as an essential components of good quality care. Patient-centred practice included individualised goal setting, assessment and rehabilitation. Clinicians highlighted the heterogeneity of the patient group despite their seeming similarities.  "we've got one which is a very small cottage hospital … They haven't got the space, they haven't got the facilities or the equipment. So, they are trying to make the best of a bad job with the facilities they've got really. On the flip side, in *********, you've got two very big gyms, very well equipped. 24 PM.
One participant described that they were picking up patients from out of area because they were rumoured to be the only one in the area with the resources for rehabilitation. This participant was concerned that this could stress their resources even further. They

| Training in advanced rehabilitation skills
Physiotherapy participants highlighted the importance of skilled clinicians and the need to train and supervise staff who may only take on ACL patients for a short time. They also described beliefs and preferences in their teams that influence how rehabilitation is delivered across the service. Participants identified that advanced rehabilitation skills are not a priority in all services and local culture may influence whether or not physiotherapists are trained to deliver advanced rehabilitation.
Clinical staff often move through different roles every 6-9 months, known as rotations. Clinicians were sympathetic to the learning needs of 'rotational' junior staff but reflected on the implications for the patients.
Are we expecting band five and sixes to just know?
I know I was a band five, expected to just rehabilitate someone back to sports, which is not really… is that acceptable really? Is that fair to the patients? 10P.
One participant discussed a cultural shift, where he noted some junior physiotherapists identified more strongly with their role as discharge planners than having responsibility for advanced rehabilitation, regardless of patient goals.
It's that sort of end stage stuff, isn't it? And I think there is a bit of controversy about where the NHS starts and stops with that. Certainly our juniors, it's really interesting when they come in as newbies and they say, "I think I should stop now," and you say, "But the patient hasn't achieved what they came here to do.
Why are you stopping?" And then they're like, "That's not my role." 24 PM.
Another participant explained that he already employs sports therapists to deliver rehabilitation for NHS ACL patients. The participant explained that sports therapists were trained in advanced rehabilitation concepts and he suggested that for many physiotherapists, they did not consider this part of their role.
I think also, there are not many trained strength and conditioning physios around. It's a bit more of a new movement to consider strength and conditioning within physio. 12 PM.
For other physiotherapists, exercise prescription and rehabilitation are seen as the most fundamental skills of physiotherapy. Some participants argued that in a time when evidence for effectiveness of other modalities has changed practice, exercise therapy and rehabilitation are cornerstones of the profession.
It was always important, movement and things, but now…your ability to assess and prescribe exercise is, potentially, more important than your ability to do manual therapies, or other complementary side of things, I'm not sure that that's always been there. 3P.
In fact, I've been, anecdotally, with my colleagues now, saying for years that if we paid as much attention into how we assess and prescribed exercise, as to how many forces and angles and neurophysiological effects and that, that we pay to manual therapy in such a way, I think that our profession would be in a better state. 19 PM.

| Principal findings
Participants shared a broad agreement about the principles that should underpin optimal care in ACL rehabilitation. The patient should be at the heart of care. Communication between physiotherapists and orthopaedics is vital. Adequate resourcing of care substantially impacts ability to deliver evidence-based practice.
Evidence-based management strategies required proper resourcing for positive outcomes and the prevention of long term sequelae and further injury risk (Ardern, 2015;Button et al., 2006;Culvenor et al., 2016;Frobell, 2012;Frobell et al., 2015). Within clinical teams an uncomfortable relationship was suggested between pressure to discharge patients from care and a lack of knowledge of advanced rehabilitation. Where resources and knowledge are lacking, participants have identified a culture of early discharge without responsibility for return to sport goals. Although the management of capacity and demand is delicate, the relationship between these contextual factors may prove key in identifying services with operational barriers to optimal rehabilitation.

DUNPHY ET AL.
A previously unidentified contextual factor was the challenge and frustration that clinicians express when reconciling their roles as professional gatekeepers of orthopaedic and physiotherapy specialities with their role as leaders in a cost conscious health care environment. Participants' experiences depict that some are troubled by the perceived schism from the long held principle of patient-centred goals and evidence-based practice. Local health policy and clinical resources were implicated as a causal mechanism for services that felt limited in their ability to deliver evidence-based practice. One participant summarised that the progressive defunding of local services caused him to question how physiotherapy care is now valued in his Trust. Though this account might not be unique to ACL rehabilitation, it was a noteworthy reflection on the experience of progressive defunding.
The relationships between orthopaedics and physiotherapy was seen to be at an all-time high, due to extended scope roles and physiotherapists often working in orthopaedics clinics. Participants highlighted this as a critical factor in the provision of good care and sited the combined clinics as the ideal environment to foster teamwork.

| How this research fits with and builds on previous literature
Other studies that focussed on clinician opinion of ACL management identified similar findings of variation in care and inconsistent application of the evidence (Fausett et al., 2022;McRae et al., 2011), as well as the importance of joined up physiotherapy-orthopaedic care and ambiguity around return to sport rehabilitation (von Aesch et al., 2016). This study uniquely explores the extent of variety in care models and how clinical staff identify and work to reconcile the gap between guidelines for ACL rehabilitation and essential resources such as time, equipment and adequately trained staff. This 'grey information' (Adams et al., 2016) is rarely reported in ACL clinical trials and descriptions of interventions but it is fundamental to understanding how rehabilitation practice is conducted in the real world.
The principles of biopsychosocial and PCP are well established.
Putting the patient and their goals at the heart of care (Weston, 2005;World Health Organization, 2001). Previous surveys of clinical opinion on ACL management also emphasised the importance of biopsychosocial patient-centred care (Fausett et al., 2022;von Aesch et al., 2016), however this UK-based study explored the challenges associated with reconciling PCP with limited resources. In some cases, the long term implications of resource management appeared to have created a cultural shift within physiotherapy teams where resource management is prioritised over evidence-based later-stage rehabilitation and patient-centred care. The move to earlier discharge and patient self-management is not well understood or well described in the literature and requires further research to be better understood.
The evidence-based approach to ACL care is criteria-based progression through phases of care that align with biological and functional recovery (Adams et al., 2012;Grindem et al., 2016;Kruse et al., 2012;Myer et al., 2006;van Melick et al., 2016). Other qualitative and survey studies show that variation and inconsistency are common in ACL rehabilitation management and may be contributing to suboptimal outcomes (Fausett et al., 2022;McRae et al., 2011;von Aesch et al., 2016). This study was the first to show that adherence to evidence-based practice was just a part of what constitutes optimal care. Clinicians identified the need for adequate gym equipment and depth of rehabilitation knowledge to deliver ACL rehabilitation.
Consistent application of the guidelines requires these resources. The correlation between strength, motor control and positive outcomes were cited by participants as justification (Grindem et al., 2016;van Melick et al., 2016) as well as the need to monitor and measure progress towards known criteria (Lynch et al., 2015). It was known that those who pass return-to-sport criteria significantly reduce the risk of re-injury to the graft (Kyritsis et al., 2016;Paterno et al., 2012; Webster & Hewett, 2019); but testing return-to-sport criteria requires strength equipment and other modalities for physical outcomes (Clare L Lynch et al., 2015). This illustrated the importance of availability of resources as a tool of assessment and monitoring against known criteria for progression in ACL care.
Participants also discussed supporting patient self-management as part of optimising care, by using technology for patient education and advice, for exercise technique, instructions and for recording outcome measures. Evidence shows other rehabilitation models where digital has been used as an alternative to access 'hard to reach' populations or offer a cost effective alternative to face to face follow ups (Chughtai et al., 2019;Farmer et al., 2017;Ottaviano et al., 2011). In trusts where face-to-face or personalised care was significantly limited due to resources, integrated use of digital health tools could go some way to supporting the patients to access the best evidence and information and to self-manage. Although much of the technology discussed in this study was used in ad hoc way rather than integrated fully into the care plan.
In line with previous research, participants clearly valued a multidisciplinary approach to orthopaedic rehabilitation (Momsen et al., 2012;Speerin et al., 2014)  This was supported by evidence that hospitals where physiotherapists work collaboratively in orthopaedic clinics were not only cost effective but had improved inter-professional understanding (Comans et al., 2014;Hattam, 2004

| Strengths and limitations
The strength of this study is that qualitative interview methodology allows the exploration of critical issues that are affecting ACL care in order to explore the phenomena that may be causal. By purposively DUNPHY ET AL. -9 targeting clinical leads, experts and researchers around the country, the interview methodology facilitates a wide-ranging exploration of the factors that are influencing the variations in care. The use of snowball sampling methodology as part of this study, regarding recruiting orthopaedic surgeons, has potentially biased the sample.
The surgeons that recommended one another may hold similar professional values and attitudes.

| Implications for clinical practice and policy
Local strategies to ensure appropriate training and adequate rehabilitation equipment are needed in services that manage patients after ACL surgery. Clinics that are treating patients without this, may be apt to advise patients of the limits of their care environment and suggest alternatives including digital tools. A cooperating and well communicating MDT was strongly emphasised. Physiotherapist roles in orthopaedic clinics are noted to be particularly favoured by participants in fostering teamwork and communication, towards higher quality care. Research is needed to explore cost effective models of rehabilitation that include return to sport strategies.