ACL Reconstruction Rehabilitation With Exercise and Psychological Support

The ACL Return to Sport after Injury (ACL-RSI) scale has 12-items in the domains of emotions, confidence, and risk appraisal. Scores range from 0 to 100, and higher scores indicate greater psychological readiness for sport. ACL-RSI has acceptable validity and test-retest reliability.

International Knee Documentation Committee (IKDC) subjective form assesses self-reported knee symptoms and function. It is responsive and reliable across knee pathologies, including ACL reconstruction, and has been used as an outcome in federally-funded ACL reconstruction registries and clinical trials. IKDC scores range from 0 to 100 points, and higher scores indicate better knee function.

TSK-11 has 11-items on kinesiophobia, or pain-related fear of movement/re-injury. Scores range from 11 to 44 points, and higher scores indicate greater kinesiophobia. TSK-11 has demonstrated validity for patients with ACL reconstruction.

The Numeric Pain Rating Scale (NPRS) will be used to assess pain at rest and pain with a countermovement jump, if applicable. The scale ranges from 0 (no pain) to 10 (highest imaginable pain).

Knee range of motion (flexion and extension) will be assessed bilaterally in a supine position with a goniometer. Interlimb symmetry will be computed as (non-surgical knee motion - surgical knee motion).

Isometric quadriceps strength will be measured bilaterally on an isokinetic dynamometer (CSMi Solutions, Stoughton, MA) with the knee in 60° of flexion. Peak knee extensor torque (N-m) from 3 trials will be recorded. The interlimb symmetry index for isometric quadriceps strength will be computed as [(surgical limb measure/non-surgical limb measure) * 100].

If the study participant meets clinical criteria, a countermovement jump will be performed on a force platform (Hawkin Dynamics, Westbrook, ME). Jump height, bilateral braking impulse index, bilateral propulsion impulse index, modified reaction strength index and landing stiffness will be recorded.

Single leg hop testing will include three hop tests: single hop, triple crossover hop, and lateral timed hop. Subjects will receive verbal instruction and visual demonstration followed by 1 or more practice trials. Subjects will then perform three test trials on each leg, and the best performance (distance or time) will be recorded and expressed as a percentage (involved/uninvolved x 100). This outcome will be calculated as the average limb symmetry index across the three tests with scores ranging from 0 to 100. Higher scores reflect better symmetry and increased function.

Patient will stand on a force plate and perform a squat. Two trials will be collected and two metrics will be reported Left/right average force asymmetry (%) and Left/right peak force asymmetry (%).

Feasibility of implementing REPS after ACL reconstruction will be measured by calculating the percentage of patients who enrolled in the trial from the number screened for eligibility. This will be reported as a single point estimate with the denominator being the number of patients screened, larger than the sample size used for other outcome measures.

Feasibility of of implementing REPS after ACL reconstruction will be measured by calculating the percentage of enrolled patients who withdraw from the study before the end of the intervention period.

Patient reported acceptability of implementing REPS after ACL reconstruction will be assessed from responses to the question "I like learning about how my mind responds to my injury" as part of the 6-month post-surgery REPS patient experience survey. The percentage of REPS intervention patients who report either "Strongly agree" or "Somewhat agree" will be reported. This outcome will only be measured in patient randomized to the REPS study arm.

The Consultation and Relational Empathy (CARE) measure is a 10-item patient-assessed questionnaire that captures empathetic support provided for patients in clinical and general medical settings. Items assess how well the patient felt their doctor listened, was positive and compassionate. CARE scores range from 1 to 50 points, and higher scores indicate higher empathy in the consultation process.

The Working Alliance Inventory-Short Revised (WAI-SR) measure is a 12-item patient-assessed questionnaire that captures key aspect of the therapeutic alliance. WAI-SR scores range from 15 to 60 points, and higher scores indicate stronger therapeutic alliance.

Delivery of patient training will be measured throughout the post-surgery period via proportion of scheduled visits attended. The average attendance will be summarized from treatment documentation templates in the electronic medical record at 6 months post-surgery and calculated separately for the REPS and comparison arms.