The patient-physiotherapist tango: a personalized approach to ACL recovery – a qualitative interview study

Key Points

1. In late stages of anterior cruciate ligament (ACL) rehabilitation, patients with ACL reconstruction reported being seen, heard, and having ‘center stage’ of the rehabilitation process as positive facilitators of ACL recovery.
2. Patient-centered care from a patient’s perspective during ACL recovery included patient involvement and a strong physiotherapist-patient alliance.

BACKGROUND & OBJECTIVE

Person-centered care has been touted as an essential cornerstone of rehabilitation and healthcare, yet implementing this into practice has been challenging (1). In order to improve recovery after anterior cruciate ligament reconstruction (ACLR), it is essential to understand what factors fosters a person-centered care environment.

Therefore, the aim of this study was to explore patients’ rehabilitation experience from a person-centered perspective in late stages of ACLR rehabilitation (8-12 months).

Person-centered care has been touted as an essential cornerstone of rehabilitation and healthcare, yet implementing this into practice has been challenging.

Physiotherapists should take extra time and care to implement strategies to promote the therapeutic relationship as this appears to be the cornerstone of patient-centered care.

METHODS

This qualitative study recruited patients aged 18-65 years registered in a local physiotherapy registry from Sweden who were 8-12 months post-ACLR. Purposive sampling was used to ensure equal representation of patients across age and sex.

Patients were interviewed via ZOOM in 2022 using an interview guide. Patients were asked questions about their connection with their physiotherapists and thoughts on person-centered care and to provide examples of this during their rehabilitation. The Consolidated criteria for Reporting Qualitative research (COREQ) checklist was used to ensure transparency with reporting.

RESULTS

• 14 patients (eight female, six males) were interviewed.

• The median (range) age was 20 (18-57) years, with most patients receiving a hamstring autograft.

• Most patients were a median (range) of 8 (8-12) months post-ACLR surgery.

• One overarching theme with three main categories and six sub-categories were generated and reported in Table 1 (see Table 1).

LIMITATIONS

• Methodological issues: Lack of details on how the interview was conducted (e.g. semi-structured), lack of coherence of methods (i.e. constructivist paradigm but using a descriptive content analysis approach).
• Misleading interview questions: It may have been easier to have patients describe person-centered care in their own words and have more of an open-ended conversation versus defining it for patients. Some questions on the interview guide could have been misleading. For example, instead of asking patients ‘what made you sad’ asking patients ‘what emotions did you experience during rehabilitation’ would have created more neutral questions.
• Transferability: Qualitative research needs to always be interpreted in the context of patients’ experiences and the interviews. Therefore, the findings may be unique to the Swedish healthcare system and other patients with ACLR may have different experiences in different healthcare systems. However, some of the findings are most likely transferable and relevant to patients with time-loss and ACL injuries.

CLINICAL IMPLICATIONS

Recovery after ACLR is a long and arduous road that often requires hours spent with the rehabilitation team, specifically physiotherapists. Therefore, it is critical that a strong relationship between the patient and the physiotherapist is established.

Growing research has supported that the therapeutic relationship/alliance can influence rehabilitation outcomes in patients with musculoskeletal (2) and traumatic knee injuries (3), and this study reinforces these findings in an ACLR population. Physiotherapists should take extra time and care to implement strategies to promote the therapeutic relationship as this appears to be the cornerstone of patient-centered care.

While the therapeutic relationship is a complex phenomenon, previous research has established that engagement, bond, and connection are three pillars needed to establish a strong therapeutic relationship (4). This study provided some examples for facilitating a therapeutic relationship. For example, therapists can facilitate engagement by showing patients they are invested in their rehabilitation, or connection by creating an open and honest communication stream.

Patient-centered care extends beyond just having the patient be the ‘main actor’ but requires active engagement and interest of the treating physiotherapist. As such, patient-centered care may be a misnomer and perhaps physiotherapists should view this dyad as a patient-physiotherapist/clinician centered approach where both parties need to come to the table for a successful rehabilitation. It is also not both parties meeting in the middle, but taking time to understand when the patient will take the reins to rehabilitation, or when the physiotherapist may lead.

This study reminds us that simply addressing physical outcomes is not evidence-based. Physiotherapists are viewed not just as experts but as a mentor, guide, and supporter. It is time we embrace that the core component and unique aspect of working with a patient with an ACL injury is that we get time (maybe years) to build a relationship. So, let’s be okay with sharing this challenging journey with our patients and not be a passive audience, but be part of the show!

+STUDY REFERENCE

Piussi R, Brandt E, Johansson A, Snaebjornsson T, Thomee R, Samuelsson K, Senorski H (2024) The Patient-Physiotherapist Tango: a Personalized Approach to ACL Recovery – a Qualitative Interview Study. International Journal of Sports Physical Therapy, 19.

SUPPORTING REFERENCE

1. JESUS, T. S., PAPADIMITRIOU, C., BRIGHT, F. A., KAYES, N. M., PINHO, C. S. & COTT, C. A. 2021. Person-Centered Rehabilitation Model: Framing the Concept and Practice of Person-Centered Adult Physical Rehabilitation Based on a Scoping Review and Thematic Analysis of the Literature. Archives of Physical Medicine and Rehabilitation, 106-120.
2. KINNEY, M., SEIDER, J., BEATY, A. F., COUGHLIN, K., DYAL, M. & CLEWLEY, D. 2018. The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 1-13.
3. TRUONG, L. K., MOSEWICH, A. D., MICIAK, M., LOSCIALE, J. M., LI, L. C. & WHITTAKER, J. L. 2024. Social support and therapeutic relationships intertwine to influence exercise behavior in people with sport-related knee injuries. Physiotherapy Theory and Practice, 1-14.
4. MICIAK, M., MAYAN, M., BROWN, C., JOYCE, A. S. & GROSS, D. P. 2019. A framework for establishing connections in physiotherapy practice. Physiotherapy Theory and Practice, 35, 40-56.