developing a standardised pre- operative physiotherapy programme to improve the outcomes of

343 Pages·2016·4.46 MB·English

DEVELOPING A STANDARDISED PRE-
OPERATIVE PHYSIOTHERAPY PROGRAMME TO
IMPROVE THE OUTCOMES OF PATIENTS
UNDERGOING ANTERIOR CRUCIATE
LIGAMENT RECONSTRUCTION IN RIYADH
(KSA)

SHADY ABDULLAH ALSHEWAIER

A thesis submitted in partial fulfilment of the requirements of the
Manchester Metropolitan University for the degree of
Doctor of Philosophy (PhD)

Manchester Metropolitan University
December 2016
Abstract
Background: Anterior cruciate ligament (ACL) injury is associated with pain, limited
function and reduced quality of life (QoL), with prevalence associated with sports
participation, which represents a clinical and financial burden to patients and healthcare
systems. ACL reconstruction is the main treatment and pre-operative physiotherapy
potentially plays a role in preparing patients for surgery and improves post-surgery
health outcomes. Its effectiveness on patients’ health outcomes pre- and post-surgery
and awareness of patients and healthcare professionals have not been investigated in the
Kingdom of Saudi Arabia (KSA). There is a lack of standardised protocols used in
practice for pre-operative physiotherapy management of patients undergoing ACL
reconstruction, and the clinical and financial effects have not been investigated.
Aims: This thesis aims to develop a standardised pre-operative physiotherapy
programme for patients undergoing ACL reconstruction based on clinical and literature
evidence, and to investigate the effectiveness of the developed protocol in KSA.
Methods: This study included three inter-related phases. Phase 1 - a survey of the
prevalence of ACL injury in Riyadh, KSA, and of pre-operative physiotherapy
awareness of healthcare professionals and ACL-deficient patients. A sample of 200
patients and 200 practitioners was surveyed and the Ministry of Health and 3 hospitals
were contacted about ACL injury cases. Phase 2 - a systematic review of literature on
pre-operative physiotherapy programmes and effectiveness in ACL injury management.
Phase 3 - a quasi-randomised clinical trial of a standardised pre-operative protocol,
using Phase 1 and 2 findings. This protocol was administered to ACL-deficient patients
undergoing reconstruction in KSA. Two patient groups were included: an intervention
group (n = 39), who received the developed pre-operative programme; and a control
group (n = 45), who did not receive pre-operative physiotherapy. The primary outcome
measures were based on the Knee injury and Osteoarthritis Outcome Score (KOOS), and
secondary outcomes included range of motion, quadriceps and hamstring muscle
strength, health status (using the EQ-5D-5L tool), pain score, QoL and resource use.
Results: Phase 1 showed ACL injury is the most prevalent knee related injury (53%),
with young, active participants being mostly affected (60%). The prevalence in Riyadh
(31 per 100,000) was similar to international figures. 82% healthcare professionals were
aware of pre-operative physiotherapy, whereas 55% of surveyed patients were aware.
Phase 2 suggested that pre-operative physiotherapy is beneficial to ACL injury patients.
Phase 3 demonstrated that primary and secondary outcomes were improved prior to
surgery in the intervention group compared to baseline (p < 0.01). Post-surgery outcome
measures were better in the intervention group than the control group (p < 0.05) except
function in sports activity, which was similar. The incremental cost-effectiveness ratio
(ICER) related to pre-operative physiotherapy intervention was estimated at 13449 SR
(£2241) per QALY gained and the intervention was cost-effective.
Conclusions: The findings showed the clinical and cost-effectiveness of the developed,
evidence-based pre-operative protocol in preparing patients for ACL reconstruction and
improving health outcomes post-surgery. Therefore, pre-operative physiotherapy for
ACL injury should be integrated routinely into the Saudi healthcare system.
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Declaration

No portion of this work referred to in the thesis has been submitted in support of an
application for another degree or qualification of this or any other university or other
institution of learning.

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Dedication

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Acknowledgements
I would to express my sincerest gratitude and appreciation to my supervisory team, Dr.
Francis Fatoye, Dr. Gillian Yeowell and Prof. Mark Slevin. Your guidance and efforts
made this research project possible. Your advice and support throughout this PhD course
is much appreciated.
I would also like to extend my thanks to Manchester Metropolitan University for
providing the facilities necessary for this project. Efforts by the members of staff who
assisted in facilitating the programme are also appreciated.
My thanks also go to Al-Majma’ah University, the Saudi Ministry of Health and Saudi
Cultural Bureau for supporting this PhD project.
I would also like to extend my deepest appreciation and thanks to the hospitals which
participated in this research study, including Ministry of Health hospitals, Security
Forces Hospital, Prince Sultan Military Medical City Hospital and King Abdulaziz
Medical City Hospital. Thanks are also extended to the orthopaedic surgeons who had
an immense contribution to this PhD study. In addition, appreciations are extended
Physiotherapists and patients who participated in this research and without whom this
study would not have been possible.
I would also like to acknowledge and thank Al-Majma’ah University for financial
support towards this project.
Finally, my sincerest and deepest thanks go to my family for their support before and
during this project, my parents, my brothers, sister and my wife. Thank you ever so
much for always being there for me.
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Table of Contents
ABSTRACT .................................................................................................................................. 2
DECLARATION.......................................................................................................................... 3
DEDICATION.............................................................................................................................. 4
ACKNOWLEDGEMENTS ........................................................................................................ 5
TABLE OF CONTENTS ............................................................................................................ 6
LIST OF FIGURES ................................................................................................................... 11
LIST OF TABLES ..................................................................................................................... 14
LIST OF APPENDICES ........................................................................................................... 16
LIST OF ABBREVIATIONS ................................................................................................... 17
CHAPTER ONE: INTRODUCTION ...................................................................................... 19
1.1 BACKGROUND TO THE STUDY ........................................................................................... 19
1.2 AIMS AND OBJECTIVES OF THE STUDY .............................................................................. 25
1.2.1 Primary aim................................................................................................................ 25
1.2.2 Secondary aims .......................................................................................................... 25
1.3 STRUCTURE OF THE STUDY ................................................................................................ 26
1.4 OUTLINE OF THE THESIS .................................................................................................... 27
1.5 SUMMARY .......................................................................................................................... 29
CHAPTER TWO: ANTERIOR CRUCIATE LIGAMENT INJURY .................................. 31
2.1 INTRODUCTION .................................................................................................................. 31
2.2 ANATOMY AND BIOMECHANICS OF THE KNEE .................................................................. 31
2.3 MUSCLES OF THE KNEE ..................................................................................................... 35
2.4 CAUSES AND MECHANISMS OF ACL INJURY ..................................................................... 39
2.5 PREVALENCE OF ACL INJURY ........................................................................................... 42
2.6 CLINICAL FEATURES OF ACL INJURY ............................................................................... 48
2.7 PHYSIOTHERAPY AND RECONSTRUCTION THEORY FOR ACL INJURY .............................. 53
2.8 ECONOMIC BURDEN OF ACL INJURY ................................................................................ 56
2.9 CONCLUSION ...................................................................................................................... 59
CHAPTER THREE: MANAGEMENT OF ANTERIOR CRUCIATE LIGAMENT
INJURY: DIAGNOSIS AND TREATMENT ......................................................................... 60
3.1 INTRODUCTION .................................................................................................................. 60
3.2 GENERAL ASSESSMENT OF ACL INJURY ........................................................................... 60
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3.3 KNEE FUNCTION TESTS...................................................................................................... 62
3.4 RADIOGRAPHIC ASSESSMENT ............................................................................................ 65
3.5 MANAGEMENT OF ACL INJURY ......................................................................................... 66
3.5.1 ACL reconstruction surgery ....................................................................................... 68
3.5.1.1 Timing of ACL reconstruction ............................................................................ 69
3.5.1.2 Grafts used in ACL reconstruction ..................................................................... 71
3.5.2 Physiotherapy rehabilitation for ACL injury ............................................................. 74
3.5.2.1 Physiotherapy rehabilitation in combination with surgery ................................. 76
3.5.2.1.1 Pre-operative physiotherapy rehabilitation .................................................. 77
3.5.2.1.2 Post-operative physiotherapy rehabilitation ................................................ 82
3.5.3 Cost-effectiveness of management interventions of ACL injury ................................. 83
3.5.4 Awareness about physiotherapy management ........................................................... 87
3.6 CONCLUSION ...................................................................................................................... 90
CHAPTER FOUR: ANTERIOR CRUCIATE LIGAMENT INJURY IN RIYADH, KSA:
PREVALENCE OF INJURY, AND AWARENESS OF PRE-OPERATIVE
PHYSIOTHERAPY ................................................................................................................... 92
4.1 INTRODUCTION .................................................................................................................. 92
4.2 OPERATIONAL DEFINITIONS .............................................................................................. 94
4.3 MATERIALS AND METHODS ............................................................................................... 96
4.3.1 Study setting ............................................................................................................... 98
4.3.2 Sample size estimation ............................................................................................... 99
4.3.3 Investigation of prevalence of ACL injury ................................................................. 99
4.3.3.1 Data extraction form ......................................................................................... 100
4.3.3.2 Data extraction procedure ................................................................................. 100
4.3.3.3 Direct contact with establishments for prevalence data collection ................... 101
4.3.4 Investigation of awareness of healthcare professionals and patients about ACL injury
........................................................................................................................................... 102
4.3.4.1 Questionnaire development .............................................................................. 102
4.3.4.2 Questionnaire pre-piloting ................................................................................ 105
4.3.4.3 Questionnaire piloting ....................................................................................... 106
4.3.4.4 Sampling of healthcare professionals and patients for the survey .................... 106
4.3.4.5 Survey procedure .............................................................................................. 108
4.3.5 Ethical considerations .............................................................................................. 109
4.3.5.1 Ethical approval for access to hospitals and health centres .............................. 110
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4.3.5.2 Ethical approval to conduct the research .......................................................... 110
4.3.6 Data analysis ............................................................................................................ 110
4.4 RESULTS ........................................................................................................................... 112
4.4.1 Prevalence of ACL injury among patients in Riyadh, KSA ...................................... 112
4.4.2 Awareness of patients with ACL injury and healthcare professionals about pre-
operative physiotherapy management ............................................................................... 115
4.4.2.1 Characteristics of patient participants ............................................................... 115
4.4.2.2 Characteristics of practitioner participants ....................................................... 116
4.4.2.3 Awareness of patients about pre-operative physiotherapy ................................ 117
4.4.2.4 Awareness of practitioners about pre-operative physiotherapy ........................ 117
4.4.2.5 The pre-operative physiotherapy programme ................................................... 118
4.5 DISCUSSION ...................................................................................................................... 121
4.5.1 Prevalence of ACL injury among the Riyadh population ......................................... 123
4.5.2 Awareness of pre-operative physiotherapy among patients and practitioners ........ 128
4.5.3 Pre-operative rehabilitation programmes ................................................................ 130
4.6 CONCLUSION .................................................................................................................... 132
CHAPTER FIVE: THE EFFECTIVENESS OF PRE-OPERATIVE EXERCISE
PHYSIOTHERAPY REHABILITATION ON THE OUTCOMES OF TREATMENT
FOLLOWING ANTERIOR CRUCIATE LIGAMENT INJURY: A SYSTEMATIC
REVIEW ................................................................................................................................... 134
5.1 INTRODUCTION ................................................................................................................ 134
5.2 MATERIALS AND METHODS ............................................................................................. 136
5.2.1 The search strategy .................................................................................................. 136
5.2.2 Assessment of quality of the studies ......................................................................... 137
5.2.3 Data collection and extraction ................................................................................. 139
5.3 RESULTS ........................................................................................................................... 142
5.3.1 Methodological quality of the selected studies ......................................................... 142
5.3.2 Participant characteristics ....................................................................................... 145
5.3.3 Types and duration of interventions ......................................................................... 151
5.3.4 Outcome measures ................................................................................................... 153
5.4 DISCUSSION ...................................................................................................................... 155
5.5 CONCLUSION .................................................................................................................... 158
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CHAPTER SIX: DEVELOPMENT OF A STANDARDISED PRE-OPERATIVE
PHYSIOTHERAPY PROGRAMME FOR PATIENTS UNDERGOING ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION ................................................................ 159
6.1 INTRODUCTION ................................................................................................................ 159
6.2 MATERIALS AND METHODS ............................................................................................. 161
6.2.1 Developing a pre-operative exercise programme .................................................... 161
6.2.2 Details of the developed protocol ............................................................................. 163
6.2.3 Pre-piloting and piloting the developed protocol .................................................... 173
6.2.4 Inclusion and exclusion criteria ............................................................................... 173
6.2.5 Research design........................................................................................................ 174
6.2.5.1 Patient recruitment ............................................................................................ 175
6.2.5.2 Sample size determination ................................................................................ 176
6.2.5.3 Procedure of the study ...................................................................................... 176
6.2.5.4 Ethical consideration ......................................................................................... 178
6.2.6 Assessment of rehabilitation outcomes..................................................................... 179
6.2.6.1 Primary outcomes ............................................................................................. 180
6.2.6.2 Secondary outcomes ......................................................................................... 181
6.2.7 Data analysis ............................................................................................................ 186
6.2.7.1 Descriptive statistical analysis .......................................................................... 186
6.2.7.2 Inferential statistical analysis ............................................................................ 187
6.2.7.3 Cost-effectiveness evaluation ........................................................................... 187
6.3 RESULTS ........................................................................................................................... 188
6.3.1 General characteristics of the participants .............................................................. 189
6.3.2 Comparisons of outcomes between Control and Intervention groups post-surgery 192
6.3.2.1 Primary outcomes ............................................................................................. 193
6.3.2.2 Secondary outcomes ......................................................................................... 195
6.3.2.3 Economic evaluation ......................................................................................... 200
6.3.3 Comparison between baseline and pre-surgery outcome measures in the Intervention
group ................................................................................................................................. 202
6.4 DISCUSSION ...................................................................................................................... 206
6.4.1 Differences in post-surgery outcome measures between Control and Intervention
groups ................................................................................................................................ 207
6.5 CONCLUSION .................................................................................................................... 213
CHAPTER SEVEN: OVERALL DISCUSSION .................................................................. 215
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7.1 INTRODUCTION ................................................................................................................ 215
7.2 FINDINGS AND DISCUSSION ............................................................................................. 216
7.3 LIMITATIONS OF THE STUDY ............................................................................................ 235
7.4 SUMMARY ........................................................................................................................ 239
CHAPTER EIGHT: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ...... 241
8.1 INTRODUCTION ................................................................................................................ 241
8.2 SUMMARY AND KEY FINDINGS ........................................................................................ 242
8.3 SUMMARY OF CLINICAL IMPLICATIONS .......................................................................... 244
8.4 CONCLUSIONS .................................................................................................................. 245
8.5 RECOMMENDATIONS FROM THE STUDY .......................................................................... 247
8.5.1 Recommendations for clinical practice .................................................................... 247
8.5.2 Recommendations for policy .................................................................................... 248
8.5.3 Recommendations for future research ..................................................................... 248
REFERENCES ......................................................................................................................... 251
APPENDICES .......................................................................................................................... 299

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