The Lived Experience of Rehabilitation Following Anterior Cruciate Ligament Reconstructive Surgery: A Social Ecological Analysis

Abstract

Purpose:

To identify, using a social ecological model, the multi-level facilitators and barriers that shape the lived experience of rehabilitation following anterior cruciate ligament reconstructive (ACLR) surgery.

Method:

Semi-structured interviews with 12 adults who experienced rehabilitation following ACLR surgery. Thematic analysis of qualitative data was completed following Braun and Clarke's framework.

Results:

The experience of rehabilitation was influenced by intrapersonal, interpersonal, physical, institutional, community, and policy level factors.

Conclusions:

A patient's ability to successfully complete a rehabilitation program, particularly home exercises, can be situated within a social and ecological context in ways that could improve patient adherence and compliance.

An anterior cruciate ligament (ACL) tear is the most common knee ligament injury and 75%–98% of people with ACL injury in the United States undergo surgery to repair it.^1–3 A full recovery following an anterior cruciate ligament reconstruction (ACLR) can take up to one year of regular rehabilitation.⁴ However, there is a high attrition rate, patients require support to engage in and stay consistent with rehabilitation, and only 33% of people return to their prior level of physical activity after ACLR.^4–6 The reasons cited in the literature for the lack of a return to prior activities and a low rehabilitation adherence rate are fear of re-injury, pain while completing rehabilitation exercises, perceived lack of time, lack of available equipment, lack of motivation, lack of enjoyment, and a lack of health insurance or the ability to pay for rehabilitation services.^4–8 In addition, low self-efficacy, poor social support, the lower importance that an individual places on exercising, and depression and anxiety are also cited as reasons why an individual does not continue with reha-bilitaiton.^5,7 Considering the long duration of rehabilitation and observed low adherence rates, patients require support to engage in and stay consistent with their rehabilitation following ACLR surgery.

In general, compliance and adherence are often conceptualized at the individual level with insufficient consideration of the broader social contexts.^7,8,21 Thus, to better understand and support patients during ACLR rehabilitation, we must situate the patient and the desired behaviour within a broader social and temporal context by examining the lived experience of rehabilitation via a social ecological (SE) model. This qualitative study adds to the existing literature by using an SE model to identify the multilevel facilitators and barriers that shape the lived experience of rehabilitation following ACLR.

Social ecological models conceptualize individuals as embedded within and shaped by their environment, and interactions between individuals and their environments inform health outcomes and behaviour change.⁹ McLeroy and colleagues¹⁰ identified five levels of influence on health behaviour: intrapersonal (knowledge, attitudes, behaviour, skills, psychological and biological factors, development); interpersonal and social processes (relationships with family, friends, coworkers); institutional (e.g., companies, schools, health agencies, health care facilities); community (relationships between institutions, social networks); and public policy levels (local, national, and supranational laws and policies).^9,11 Sallis and colleaguesl⁹ built on this framework by adding the physical and social settings that may facilitate, limit, or prohibit physical activity. Stokols¹² further noted that these levels interact with and reinforce each other.

Method

This research is based on an intrinsic case study of the lived experience of adults who have had ACLR and are undergoing rehabilitation, including the provision of a mobile application (app). This qualitative approach is appropriate because it uses data from interviews and surveys to develop in-depth descriptions and analyses of cases and pays particular attention to the specific context of the cases.¹³ The present study is based on interview data drawn from 12 individuals aged 18–39 years who had ACLR within the last 4–24 months, and were available to participate in a semi-structured interview for 60 minutes. They were a convenience sample recruited via word of mouth, posters, and research information letters available at the reception area of the second author's workplace, a rehabilitation clinic based at a post-secondary institution in Ontario, Canada. The second author was not treating any of the participants at the time of the study.

All participants were given a free mobile app that included exercise reminders, videos, weekly protocols, and a range of motion measurement tool. Initially, the purpose of the study was to assess how app use influenced rehabilitation. During data analysis, it became clear the participants’ lived experiences of rehabilitation were complicated and required a more nuanced examination. The role of the app in rehabilitation is the focus of future work.

At the time of the interview, the average time since their most recent ACL injury was 13 months with a range of 5–24 months. For all but two of the participants this was their first ACLR surgery. Six participants were female and six were male, and four were intercollegiate athletes (three former, one current). The mean age of participants was 27.5 years old with a range from 18–39 years. Six participants were post-secondary students and six were working full- or part-time jobs (Table 1).

Table 1.

Overview of Research Participants

Pseudonym	Gender	Age	Pre-injury sport	Pre-injury physical activity	Months since ACL injury
Adam	Male	31	Basketball	Cycling, CrossFit, beach volleyball	16
Beth	Female	39	Ball hockey, jiu jitsu, soccer	Walking	15
Conner	Male	25	Basketball	Resistance training	6
Donna	Female	30	Soccer, field hockey, lacrosse, boxing	Weightlifting, jogging, running	8
Erika	Female	22	Ultimate Frisbee	N/A	7
Fin	Female	21	Cheerleading, badminton	Gym workout	7
Gao	Male	27	Basketball	Boxing, Muay Thai, gym workout	5
Harriet	Female	18	Volleyball	Gym class	12
Ian	Male	28	Basketball	Running,various sports	24
Jaabir	Male	31	Soccer	Basketball, softball, gym workout	8
Kennedy	Female	28	Soccer, beach volleyball, yoga	Cycling	24
Lamar	Male	27	Basketball	Working out	24

A semi-structured interview guide was created that explored the rehabilitation journey, beginning with onset of injury. This was developed and modified by the primary and secondary authors with input from the interviewers. Questions were crafted to prompt participants to share the diverse factors that influenced their rehabilitation and included recollections of moments when interviewees encountered challenges with rehabilitation, moments when they felt a sense of accomplishment and progress, factors that hindered and facilitated their rehabilitation, and how they coped with difficulties. Interviews were conducted by senior undergraduate student members of the research team who had completed at least one course on qualitative methods. Each interviewer was trained in three 1-hour sessions by the primary and secondary author to conduct semi-structured interviews. Training included techniques to probe for more in-depth responses, and to engage in dialogue with participants. Interviews were recorded and transcribed. One interview was not recorded due to a technology failure; notes were taken immediately after. Data collection was stopped once we reached data saturation after 12 semi-structured interviews were conducted.

Data were analyzed using Braun and Clarke's¹⁴ thematic analysis. Specifically, inductive analysis was undertaken with no pre-existing coding frame. The first and second authors read and re-read the transcripts several times separately (phase 1). Resultant themes were data driven and identified at the latent level. Preliminary codes (phase 2) were also generated separately. Once identified, the initial codes were compared and finalized. In phase 3, codes were collated into potential themes. Data were reviewed again in relation to the coded extracts and the entire data set (phase 4). A thematic map of analysis was generated, and an overarching analytic narrative was developed (phase 5). We subsequently sought existing frameworks that would align with the thematic map and narrative, an approach to theory inclusion in qualitative research outlined by Sandelowski,¹⁵ identifying an SE model for physical activity and health behaviour. The full report was produced collaboratively (phase 6).

Trustworthiness was established by meeting the criteria of credibility and confirmability.^16,17 Credibility refers to the believability of the data.¹⁷ Strategies used to achieve credibility were having more than one researcher involved in interpretation of the data, and reaching agreement on the themes and sub-themes. Confirmability, or ensuring results closely represented the experiences of participants, was achieved through member checking of transcripts by the participants.

Ethical approval was received from the second author's institutional affiliation's ethics review board. All procedures for the study were in accordance with the standards of the review board responsible for human research and with the Helsinki Declaration of 1975 (as revised in 2005). All participants received a research information letter and signed an informed consent form to participate in research prior to their semi-structured interview. Ten interviews were conducted in person, and two via telephone due to participant preference. All names are pseudonyms.

Results

Individual/intrapersonal

Individual responsibility: Interviewees believed rehabilitation is the individual’s responsibility. For example, Adam described that after surgery, rehabilitation is “on me now.” Likewise, Beth stated that “the only thing stopping me from recovery, at least to prior function at this point, is me.” Rehabilitation was also seen as controllable. Adam believed he “had the ability to control how many times [he] did the exercise,” a sentiment echoed by others like Gao, Kennedy, and Jaabir.

Motivation: Motivation was integral to rehabilitation. Conner said pushing himself was more critical than physiotherapy appointments, and Lamar repeatedly described “attacking” rehabilitation “aggressively.” Motivation was reinforced by setting goals, such as accomplishing an exercise by a certain date (Kennedy), or “to walk […] be able to move […] to use my leg” (Beth). Achieving goals and being able to complete specific tasks were evidence of progress according to Erika, Gao, Fin and Harriet, who noted that when she “started running and jumping […] that was when [she] finally felt like, ‘okay, like I can actually start playing” her sport again.

Predictably, failing to achieve goals was demotivating, or as Beth described as a feeling “like I was regressing.” Staying motivated was a “mental battle” (Lamar), as “it's easy to talk myself out of pushing it” (Donna). Ian stated he became increasingly inconsistent with exercising as the months progressed and thus, “I wasn’t getting huge return. So, I was like is it even worth it?”

Other factors that hindered motivation and reduced adherence to rehabilitation included pain, fatigue, and time. For example, pain was a “huge deterrent” (Donna) and led to feelings of frustration (Harriet). Painkillers, though, caused drowsiness and inattention. Fatigue hampered completion of prescribed exercises. Erika, Harriet, and Conner described physiotherapy appointments as “an excursion” after which they felt “drained, I can’t do the exercises” (Conner). Fatigue increased upon returning to work and school. Jaabir found it difficult to complete exercises because “your leg is already tired because you’ve been walking around and all that all day.” Lastly, time negatively influenced rehabilitation. Initially, individuals found the duration of expected rehabilitation to be “daunting” and overwhelming (Donna). Later, exercise sessions were “really time-consuming” (Fin) and participants needed to manage time wisely.

Overall, the interviewees emphasized their individual effort with rehabilitation. Nonetheless, other factors beyond the individual shaped rehabilitation experiences.

Interpersonal and social processes

Interpersonal and social processes influenced ACLR rehabilitation experiences and involved relationships with partners, family, friends, and strangers. The most critical relationship was with their physiotherapists. They were described as “a lifesaver” (Beth), “very impor-tant,”“crucial” (Conner) to recovery, and the individual “most invested in my rehab” (Kennedy). Specifically, the physiotherapist was thought to have specialized expertise through working with other ACLR patients or their own personal experience. This expertise instilled within participants a sense of confidence in their therapist (e.g., Kennedy, Conner), comfort and trust (e.g., Lamar).

The relationship with their physiotherapist supported rehabilitation in four ways. First, physiotherapists provided instructions and advice, particularly regarding pain. Second, physiotherapists encouraged participants. Third, physiotherapists provided specific feedback, such as correcting any errors with exercises or confirming “proper mechanics in the movements” (Adam). Participants also valued feedback on progress. Kennedy, for example, was grateful to have worked with her physiotherapist to “see what [her] knee is capable of.” Fourth, physiotherapists served as assurance of normal rehabilitation, such as confirming whether any symptoms and their progress were within normal parameters.

Family, partners, and friends also facilitated the rehabilitation process, especially when interviewees were less mobile and needed assistance with transportation (e.g., driving to appointments), food (e.g., groceries, preparation), and daily living. Sometimes, this required staying with parents or partners. Family and friends also provided emotional support when participants were experiencing pain, and encouragement to complete exercises.

Interviewees sought out individuals who had also undergone the surgery. For example, Donna described:

connecting with [a colleague who had the surgery] and lamenting on the same crap that we both dealt with, that did help. It was an unexpected sense of comfort and understanding […] It was useful having someone who had gone through the same experiences, to be like yes, that is annoying when that happens, yes, you are going to have weird nerve tingling.

Donna even recommended developing a “mentorship type of thing or knowing others who have been through it.” Likewise, Beth joined a Facebook group of individuals undergoing ACLR rehabilitation to get information and hear about people's experiences. Even people with whom interviewees had limited interaction served as resources. For example, Jaabir indicated he would compare himself to other people receiving treatment at the clinic to determine his progress and for motivation. In Lamar's case, professional athletes were a source of motivation, explaining that “there's a lot of people who have torn their ACLs and there's a lot of people who have come back to be better than they were before. So you can rely on that.”

Interpersonal relationships could also be complicated as time passed. Kennedy recalled how it became difficult to continue asking for help, feeling like she was “a burden to them,” especially as she improved and those around her presumed she could manage on her own. This assumption of mobility was challenging for Donna when taking public transit. When she was no longer using crutches, she found it “difficult to manoeuvre and difficult to get around.” Even when sitting, she found that her leg would be in the way and described how “People have to step over you or they bump into you.” She felt scared and preferred “to keep the crutch because it was at least a visual indicator that [she] wasn’t fully mobile.”

Physical environment

Another factor was physical environments in which interviewees lived and exercised. Kennedy and Harriet were both able to walk to their physiotherapy appointments. Lamar stayed with his girlfriend during the initial stage because her home was within walking distance from the physiotherapy clinic. These individuals were therefore able to attend appointments without paying for transportation.

The spaces in which individuals exercised also shaped rehabilitation. For example, Beth stated she would “have to move furniture for every exercise” which “doesn’t make things very easy.” Exercising outdoors was not an option because it was winter and she had already slipped walking on the ice and snow. Lack of equipment was also a barrier for the few interviewees without basic exercise equipment.

Institutional level

Institutional factors shaped interviewees’ ability to attend physiotherapy appointments and to complete prescribed exercises. In most cases, regulations and procedures were in place to support the recovery of participants by offering health insurance that included physiotherapy care. Unfortunately, the amount of coverage was insufficient to include the usual duration of ACLR rehabilitation. Kennedy recalled that she “ate through my physiotherapy … like whatever coverage I had, pretty quickly.” Similarly, Beth described that “I was just like bleeding out money. I mean my physiotherapy, my benefits at work cover $700. And I was going to physio three times a week, and each time was $80. So, I blew through that in like a month.”

Some of the research participants attending post-secondary school could access support, such as accommodation with assignments and exams, or subsidized transportation throughout the campus. Individuals in the workforce could take advantage of formal supports, such as short-term disability, while others noted there were informal practices that facilitated their recovery. For example, Beth's employer allowed her to leave work early to attend physiotherapy appointments, while Adam and Kennedy could wear casual attire, or do rehabilitation at work with the use of workplace exercise equipment, elevating their knee when seated. Nonetheless, the return to work could hinder rehabilitation. Adam regretted returning to work so quickly and Jaabir found it hard to find time to complete his exercises. Return to work could also come with the expectation of shouldering a full workload. Donna, for example, shared her frustration with returning to work and feeling pressure to complete tasks quickly. She recalled having “to stay late on days that I could barely move.”

Community and policy levels

Factors at the community level did not greatly influence the rehabilitation experience among the research participants who were already in the workforce. There were no relationships between their workplace, health care institutions, and other organizations that impacted their recovery. In contrast, those individuals who were post-secondary students noted they had to obtain medical notes from their health care provider to receive accommodations at school. Fin felt this process “was also very complicated” because she had to book an appointment with her health care provider to receive the note, and then provide a copy to her instructors. Despite the need for integration between health-related information and services provided by their schools, there was no pre-existing relationship to facilitate communication, and, instead, the relationship was created by the participants’ communications with each institution and their request to have their needs met to facilitate their recovery.

One participant mentioned a policy level factor, specifically the Ontario Health Insurance Plan (OHIP), a plan operated by the Ontario provincial government that pays for a variety of health care services. Physiotherapy, however, is not included within this plan. Thus, all the study participants needed to use their own funds, or, if available, access private health insurance to pay for physiotherapy and pay out of pocket when this coverage was maximized. This finding suggests that lack of government-funded physiotherapy is a key gap in health policy that impacts and shapes the rehabilitation experience, particularly for those who do not have private health insurance.

Discussion

The present study explores the lived experience of 12 participants who underwent ACLR and subsequent rehabilitation and identifies various barriers and facilitators for their adherence and compliance with prescribed exercises specifically and their rehabilitation generally. Research has found a low adherence rate to ACLR rehabilitation and lack of a return to prior activities resulting from fear of re-injury, pain during rehabilitation exercises, and lack of time, equipment, motivation, enjoyment, and health insurance or means to pay for rehabilitation.^4–8 Low self-efficacy, poor social support, perceived lack of importance of exercise, depression, and anxiety are also cited as reasons individuals discontinue their rehabilitaiton.^4–7 While lack of health insurance and social support are extrinsic barriers, the other factors focus on the individual, thus neglecting the effects of broader social and physical constraints. By using an SE model, this study takes seriously Rhodes and Fiala's¹⁸ recommendation to expand the scope of potential factors that influence rehabilitation and that could potentially be modified to improve patient adherence. It also expands on Resnick and colleagues’¹⁹ work by including additional factors such as environmental and policy factors.

As with previous research, pain, lack of time, available equipment, and motivation were noted as mediating factors. All study participants framed rehabilitation as their individual responsibility. Any lapses, therefore, were framed as their own fault and participants blamed themselves for any setbacks. This emphasis on individual factors was clear, even when individuals recognized external factors, such as the environment, and despite the data suggesting that other factors beyond their control both supported and hindered their rehabilitation. These factors included interpersonal relationships, especially with their physiotherapists for expertise and support, as well as family, partners, and friends to fulfil immediate needs, such as transportation and food, and to meet long-term needs, such as emotional support. Interpersonal relationships ranged from proximal to distal relations and shifted over time. This finding is similar to Resnick and colleagues’ findings¹⁹ insofar as illustrating how different relationships may be called upon at different points in the rehabilitation process. Interestingly, despite centring individual effort and responsibility, a mentorship or a social support network with other patients undergoing the same rehabilitation was also suggested by some participants. They found it helpful to commiserate and confirm experiences. This finding parallels Resnick and colleagues’¹⁹ finding that social support for exercise from peers also exercising could improve exercise behaviour among the women they studied by improving self-efficacy. Likewise, Burke and colleagues²⁰ also identified that relationships with peers who were at a similar state of disease progression served as a source of support, compared to being surrounded by peers perceived to be healthy. Interestingly, where the current study identified physical therapists as a key source of support in various forms but especially for their expertise, Burke and colleagues²⁰ and Resnick and colleagues¹⁹ found that social support from experts was negatively related to self-efficacy after 6 months.

Within this theme of interpersonal relationships, a macrosystem level factor was significant in how the research participants experienced their rehabilitation. Bronfenbrenner describes the macrosystem as “cultural beliefs and values that influence both the microsystem and the macrosystem.”^10(p.354) The specific belief and value in the case of this research study was the notion of normal and how normalcy was linked to progress. Participants regularly sought out confirmation of normal from their physiotherapist, be it the state of their stitches, swelling, or even abilities as the weeks progressed. They also compared themselves with others, be it those who were also undergoing therapy generally or had experienced ACLR specifically in the past. They were relieved when told by others, whether those with expertise or with personal experience, that what they were experiencing was in fact normal. There was a clear connection between the microsystem, specifically the study participants’ values and their actions, their interrelationships (mesosystem), and the connection between normal and progress. Additional research could explore how the notion of normal is constructed in enabling ways (as motivation or indication of progress in this case), or constraining ways specific to the individual patient's sense of identity and definition of ability (e.g., what does normal mean for an athlete and how does this impact perceptions of recovery and progress?).

Clinicians should be mindful of how they use the term normal when discussing patient progress and/or probe what information patients are seeking when asked if their progress, symptoms, pain, or other ACLR-related issues are normal. Not surprisingly, the physical environment could also impact rehabilitation. For some, living close to their physiotherapy clinic as well as other amenities made recovery easier because they could walk to their appointment instead of taking public transit or paying cab fare. Others spoke specifically of their homes, such as having to manage stairs, the lack of a washroom on the ground floor, or the lack of space to exercise. Climate was also mentioned, particularly the hazards associated with snow and ice.

The participants also identified institutional factors that influenced their rehabilitation, particularly private health insurance through their workplace or their post-secondary school. Informal procedures, such as being more accommodating or flexible, to meet the needs of study participants were also noted. Students specifically benefited from their school's accessibility services which provided them with subsidized transportation across campus and accommodation with assignments. Community and policy level factors were not as prominent in the interviews, except for the post-secondary students who had to navigate relationships between their school and health care provider. The lack of physiotherapy coverage by OHIP was an implicit but nonetheless profound gap in health policy that greatly impacted the participants’ rehabilitation. Those who exceeded the coverage of their private health care plans had to pay for rehabilitation on their own. Unlike previous work that found the lack of health insurance or ability to pay for rehabilitation as a reason for stopping rehabilitation, the participants in this study did not discontinue rehabilitation. They either had private health care plans that provided full coverage or had the means to pay the additional costs when these plans were insufficient.

Limitations

The limitations of this study include the retrospective approach for collecting data. Most participants had already completed their rehabilitation and were recalling their experience in response to interview questions. This approach can lead to errors in recall. However, the consistency in findings across the participants’ interviews in terms of the complexity of the rehabilitation experience suggests this limitation likely did not have a significant impact on the results. An additional limitation was found in the age range of our participants, which is from ages 18–39, as well as two of our participants for whom their ACL was their second ACL surgery. These limitations were because we chose a convenience sampling method from one sports medicine clinic. The use of convenience sampling is also a general limitation since saturation determined the completion of data collection. The convenience sample is not representative of the population of patients undergoing ACLR and, therefore, saturation may have been sooner in our participants. Moreover, due to the qualitative nature of this study, the results cannot be generalized to all individuals undergoing ACLR rehabilitation. The strength of qualitative research, though, is demonstrated by the richness of the data, and the complexity of the lived experience captured through the lens of the SE model.

Conclusion

A patient's ability to successfully complete a rehabilitation program, particularly home exercises, can be situated within a social and ecological context in ways that could improve patient adherence and compliance. Physiotherapists could support policy changes, like access to safe green spaces to exercise, re-listing physiotherapy under provincial health care plans, or greater physiotherapy private insurance coverage. Examining physiotherapy through an SE model could improve clinical research, outcomes, and professional and ethical praxis.

Key Messages

What is already known on this topic

In physiotherapy, there are some scholars who use the SE model to explore rehabilitation. For example, Resnick and colleagues¹⁷ examined the factors that influenced exercise behaviour among older adult women after hip fracture. They focused specifically on intra- and interpersonal factors and concluded that future research should consider other factors within the SE model. Likewise, Burke and colleagues²⁰ used an SE framework to explore factors that influenced physical activity participation within hospice care and identified facilitators and barriers operating at all five levels of the SE model. Thus, they illustrated the complexities of physical activity behaviour, and demonstrated the utility of the SE model for designing a multi-pronged intervention. Other studies have also employed SE approaches to illustrate how interventions could be designed in more effective ways.¹⁹ Nevertheless, the discussion of SE models within physiotherapy literature remains relatively narrow and there is no known study that considers ACLR and post-ACLR rehabilitation from an SE lens.

What this study adds

This study illustrates the importance of physiotherapists understanding their patients’ broader context and intersecting social locations and the value of being sensitive to the complexity of health behaviour change and patients’ everyday live. This will help to ensure prescribed exercises are manageable, and that clinicians are able to identify potential facilitators. These intricacies come into view via an SE model. The SE model adds nuance to our understanding of health behaviour, rather than putting the responsibility exclusively on the individual. By applying the SE model, this study helps to expand our understanding of fostering patient compliance and adherence, and the challenges of following prescribed home exercises.