Shared decision-making needed for ACLs

 

A collaborative approach between surgeons, physiotherapists, allied health primary practitioners and patients could be the key to ensuring Australia achieves best practice for anterior cruciate ligament (ACL) injury management.

The proposal for shared decision-making in deciding management pathways for ACL injury is one of 10 recommendations from Jane Rooney (pictured), FACP, following an intensive Churchill Fellowship in which she investigated contemporary conservative management programs for ACL knee injuries in six countries.

Jane, an APA Specialist Sports Physiotherapist (as awarded by the College of Physiotherapists in 2009), has more than three decades experience in sports medicine in Australia and Europe. Her fellowship considered ACL injury management algorithms, prehabilitation, non- operative, ACL prevention and long-term ACL management rehabilitation programs in Denmark, Sweden, Norway, Netherlands, UK and the US, compared with the standard practice undertaken in Australia. The study is an extension of her work with elite athletes at state, national and international levels in swimming, netball, athletics, soccer, AFL and cycling.

‘The ACL injury is serious, causing short- and long-term pain, disability activity limitation, and significant quality of life changes due to accelerated osteoarthritic change. The ACL rarely heals following a complete rupture, resulting in a spectrum in instability with twisting movements,’ says Jane, who will outline her report at this month’s Victorian Branch Breakfast and facilitate a panel discussion about women in sport.

‘Australia has the highest rates of ACL injury in the western world, which is probably due to a combination of the sports we play, the climate and, therefore, some of the grass types we play on,’ Jane says. ‘The standard accepted ACL injury management here is to have early reconstructive surgery, whereas current world best practice is to undergo an initial physical rehabilitation program for three months (prehabilitation) followed by a shared decision-making process to undertake a non-operative or operative management pathway.’

Considerations informing this decision are very individual, she says, including but not limited to desired level of sporting participations, functional knee stability, occupational requirements, financial and time restraints and patient and practitioner knowledge and beliefs.

‘Current research indicates weak evidence to suggest superiority of ACL reconstruction surgery over non-operative management. Surgical reconstruction costs the federal government $75 million per year in co- payments,’ she says. ‘The approximate operative rates in the countries I visited are 50 per cent compared with Australian rates at 90 per cent. This is despite individuals in those countries being advised to undertake surgery to return to pivoting sports.’

Making prehabilitation a priority post-injury could not only reduce medical costs but also improve patients’ long-term outcomes. The implementation of ACL prevention programs and a national ACL register would also enable accurate data collection of injury, prevalence and management, which is integral to other healthcare systems highlighted in her report.

‘Prehabilitation periods also enable practitioners to identify the small percentage of people who develop dynamic knee stability, despite having an ACL-deficient knee. It’s possible that time also enables people to consider their knee function and their life priorities, enabling them to make a more informed choice about their individual management pathways.’

Jane has introduced prehabilitation programs to her Prahran Sports Medicine Centre practice and has been actively educating physiotherapists in world’s best practice treatment for ACL injury.

‘I believe educating medical and allied health primary practitioners involved in the triage of acute knee injury of best practice would be helpful. Advocating referral to prehabilitation early post-injury is great pre-operative preparation, the beginning of a non-operative program and, most importantly, gives the patient time to consider their knee functionality … [however] physiotherapists need to be clear in explaining the advantages and disadvantages of each management pathway so patients can make a proper, informed choice and decision.’

Read Jane’s ACL research from her Churchill Fellowship at churchilltrust.com.au.

 

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