Effect of physiotherapy attendance on outcome after anterior cruciate ligament reconstruction: a pilot study

J A Feller, K E Webster, N F Taylor, R Payne and T Pizzari

British Journal of Sports Medicine

2004, Vol 38, pages 74-77.

Academic researchers at La Trobe University, Melbourne, Australia have undertaken a study to establish whether there was any difference in outcome between a group of patients who attended physiotherapy regularly after ACL reconstruction and a group who attended only infrequently.

The findings cast doubt on the effectiveness of physiotherapy, as the authors concluded that some patients who chose to attend physiotherapy on a very limited basis after ACL reconstruction can achieve satisfactory, if not better, outcomes than patients who attend physiotherapy regularly.

Initially, Feller et al had planned to compare a rehabilitation programme incorporating regular physiotherapy attendance with a home based programme directed by the treating surgeon and not involving any physiotherapy attendance. Surprisingly, this research design, with physiotherapy treatment withheld, was granted ethical approval by the university ethics board. However, the researchers abandoned this design when insufficient patients were willing to go without physiotherapy.

Instead of ‘no physiotherapy' the authors then compared regular physio attenders with ‘minimal physiotherapy' attenders. This was done by examining attendance records retrospectively. Patients were then classified into groups according to the number of physiotherapy attendances during the first six months after surgery: minimal physiotherapy (three or less attendances), intermediate attendance (4–11 attendances), and regular physiotherapy (12 or more attendances). There were 10 patients in the minimal attendance group, each of whom was matched with a patient from the 69 in the regular physiotherapy group on the basis of age, sex, graft-type, occupational rating, and sports activity level before injury. These 20 patients were the final participants of the study. The authors don't say how then 10 regular ‘subjects' were selected from the 69 regular patients. This is a major flaw. By not selecting the ten randomly, there is a potential for selection bias. The authors may have retrospectively picked the ‘worst' ten patients who attended regularly.

Participants in the minimal physiotherapy group attended physiotherapy for a median of two visits (mean 1.9, range 0–3) in the first six months after surgery, whereas those in the regular physiotherapy group attended physiotherapy for a median of 23 visits (mean 26.5, range 15–50). The authors found that at twelve months after ACL reconstruction, patients in both the minimal and regular physiotherapy groups had few symptoms and good function of the reconstructed knee. Both groups were said to have resumed sport at levels similar to those before their injury, although this was only subjectively reported by the patients.

Feller et al claim that, “the main benefit of this study is that it has shown that certain patients may do well with minimal attendance at physiotherapy. This suggests that there may be a role for ACL rehabilitation programmes to be more individualised.” There is no evidence to back this assertion, as the authors did not examine the extent to which rehab programmes were individualised.

The authors also suggest, “a physiotherapist could individualise the programme by working closely with patients when setting goals and by adjusting the programme to the patient's situation and progress”. Of course, this is one of the long established and valuable roles of the physiotherapist. By portraying the physiotherapist as a technician who supervises exercises which are prescribed by the surgeon, the authors demonstrate an outdated attitude towards the modern musculoskeletal rehabilitation team.

Overall, the authors question the value of regular post ACL reconstruction physiotherapy, based on a flawed study design (non randomisation of subject selection) and an extremely small sample group (20). While it is very important for those planning healthcare provision to establish an optimal level of attendance at physiotherapy for those undergoing rehabilitation from ACL reconstruction, this study contributes little to the existing body of evidence.

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