Title: Development of a model of service delivery to standardise anterior cruciate ligament rehabilitation in the NHS and testing the feasibility of an E-Health intervention to support delivery of this model.
Funder: Health Education England

Abstract: Background Rupture of the anterior cruciate ligament (ACL) is common, especially in the active population (1-3). Most patients ate still managed surgically and rehabilitation is essential but the optimal way for delivering rehabilitation is not clear (1-7). This study addresses how current methods of service delivery in the NHS struggle to cater for large volumes of patients and the lengthy time span over which rehabilitation is delivered (8-10) We cannot reasonably cost ACL rehabilitation while there is no consensus on use of clinician time. Although the National Ligament Registry records outcomes of some ACL patients, they do not record the parameters of rehabilitation that could inform a retrospective analysis of service delivery(11). It is possible that E- Health, the use of the internet in healthcare, when used as a tool to support greater self-management could improve ACL service delivery in a cost effective way. E-Health is not an exercise rehabilitation package, it is an adjunct to improve self-management and behaviour change that contains an individualised exercise package (12). Current NHS England, NICE and NHS Improvement agendas call for initiatives around rehabilitation using both increased technology and increased support for patients to self-manage (13-15). To date, the use of E-Health has been successful at delivering behaviour change to a number of diverse patient groups(16-19) An E-Health intervention called TRAK (Taxonomy for the RehAbilitaion of Knee conditions) specifically for knee conditions has been developed. I am currently the chief investigator of an acceptability study of this website in the ACL population with positive preliminary results (20). The next stage is therefore to address how ACL rehabilitation is and should be delivered in an NHS setting and how E-Health may support this through a self-management approach. Research Question: What is the feasibility of E-Health to support delivery of ACL rehabilitation in the NHS, based on a new standard model of care that emerges from the literature and opinions of experts.Aims: Characterise best practice in service delivery for post-reconstruction rehabilitation by: Identifying, summarising and synthesising the available literature Identifying, summarising and synthesising expert opinion. Explore whether the available E-Health intervention supports self-care as determined in the literature. Plan of Investigation This study will use convergent parallel mixed methods. It will involve: A systematic review of the literature exploring current evidence of service delivery in ACL rehabilitation where it will aim to build a picture of standard care by reviewing the number of treatments, duration, group or individual, frequency and in what environment. A qualitative study using semi-structured interviews with experts in physiotherapy, E-Health, orthopaedics, self-management and service delivery, to discuss the literature and inform models of service delivery to reflect best practice. This will inform how web based interventions may be used to support face-to-face care in an NHS setting. The feasibility of studying an E-Health intervention to support a combined model of self-management and face to face rehabilitation in ACL rehabilitation. Potential Benefits: In 5 years we can change practice through: The development of a model of standardised care for ACL rehabilitation in the NHS. The development of a full scale non-inferiority randomised control trial to explore whether patients who use an E-Health intervention to support ACL rehabilitation have better or equal outcomes plus improved self efficacy and reduced health resource use. Facilitating outcomes to be gathered further into the rehabilitation process thus generating more meaningful data on function for future studies.

Lay abstract: Background This research aims to find out the best way to standardise physiotherapy treatment (rehabilitation), within the NHS, for patients following an operation to repair an important soft tissue in the knee, the anterior cruciate ligament (ACL). The ACL helps to make the knee stable during everyday activities and sport. After ACL repair, rehabilitation will go on for over a year on average and can be expensive for the NHS. Exercise is an important part of the rehabilitation process and although experts agree broadly on which exercises to do, there is no agreement on how often patients should see the physiotherapist, for how long, or in what environment. There seems to be too much variation in the research on ACL rehabilitation, which may mean too much variation in how patients are treated. The NHS currently lacks a standardised way to deliver ACL rehabilitation that could be applied across different patient groups and localities, ensuring equal access to care according to the best evidence. E-Health refers to the use of the internet to support treatment, so this research looks at the role of a specially developed website for rehabilitation of ACL patients. Its purpose is to support the patient throughout the process so that they feel confident with their exercise plan, care instructions and managing their knee in between their physiotherapy appointments. Using this website in a combination of face-to-face physiotherapy and self-managed rehabilitation, would make ACL services more affordable for the NHS. This means that when confident, patients could attend less and extend their physiotherapy over a longer period of time, without increasing the amount of clinician time they need.Finally, this research will look at the feasibility of studying the website i.e. whether patients are willing to join the study, use the website and provide feedback throughout the study. This will suggest whether a larger scale study is worthwhile to look more deeply at standardising ACL rehabilitation across the NHS and using E-Health to support service delivery. This study aims to: Examine the literature that is available and the opinions of experts on how ACL rehabilitation should be delivered. Explore the feasibility of a website to support ACL rehabilitation in the NHS, i.e. whether patients are willing to join the study, use the website and provide feedback through questionnaires and discussions of their experience throughout their rehabilitation. Methods and Design To address the study aims, the research is divided into 3 key work packages. 1) A detailed review of the literature to analyse rehabilitation service delivery, i.e. how often do patients attend rehabilitation treatment session length total duration of rehabilitation treatment setting (gym, clinic, home) group or individual treatment 2) An interview study to explore the opinions of experts in physiotherapy, self-management, orthopaedic surgery, E-Health and service provision. They will be interviewed in person or via Skype, discussing what a standardised rehabilitation service is and the potential role of E-Health. 3) A feasibility study aims to explore the practicalities of the study, such as would patients sign up to the study, use the website and provide feedback throughout their experience. We aim to record a variety of data such as the number of times patients log in to the website, and complete questionnaires as well as interviews about patient experience.Patient and Public Involvement (PPI) Over several years, the patients of the ACL group at a North London Hospital have contributed to the development of ideas on how to make the service better and more cost effective. They contributed to the creation of the website content and participated in filming of exercises. Several rounds of PPI in Cardiff provided feedback that has led to modifications of the website, such as personal exercise programmes and information. Patient representatives provided feedback about the readability of this plain English summary. A PPI group at CLARHC North Thames provided written feedback. A patient steering group will be established to run throughout the study and patients will continue to be involved at every stage. Dissemination Presentations will be offered throughout the project or by request for commissioners and managers information. Workshops will be conducted for the patients, managers and clinicians at key stages of the study to keep everyone involved and informed. The website, will be used to convey findings back to participants and physiotherapists. Local media, Twitter and Facebook can be used for mass dissemination of key messages. Conferences and journal publications will be used to convey messages to researchers and clinicians.

Research activity codes: 6.7 PHYSICAL
Health categories: MUSCULOSKELETAL