Biopsychosocial Model Domains in Clinical Practice Guidelines for Return to Sport After ACL Injury: Systematic Review Using the AGREE II Checklist

Abstract

Context:

The current status of return-to-sport (RTS) criteria can be understood from the International Classification of Functioning, Disability, and Health (ICF), which emphasizes an individual-centered approach and inclusion of all domains of human functioning, and ensures the multifactorial and biopsychosocial nature of decision-making.

Objective:

To analyze the inclusion of biopsychosocial model domains in clinical practice guidelines (CPGs) for RTS after anterior cruciate ligament (ACL) injury, as well as the quality of these CPGs.

Study Design:

Systematic review of CPGs.

Level of Evidence:

Level 1.

Search Strategy:

Two independent reviewers developed the search strategy, and a third reviewer corrected and compiled the developed strategies used.

Data Sources:

Ovid/Medline, Embase, and PEDro without restriction dates.

Study Selection:

CPGs for RTS after ACL injury at any age or sport level, and published in English.

Data Extraction:

Two independent reviewers codified the RTS criteria recommended in the CPGs according to the ICF domains, and the Appraisal of Guidelines for Research and Evaluation II (AGREE II Checklist) was used for critical appraisal.

Results:

A total of 715 records were identified, and 7 CPGs were included. Frequency distribution of the biopsychosocial model domains was as follows: body functions (37.77%), activity and participation (20.00%), body structure (13.33%), environmental factors (11.11%), and personal factors (8.88%). In the AGREE II Checklist, the lowest mean domain scores were for rigor of development (37.86 ± 36.35) and applicability (49.29 ± 22.30), and 71.42% were of low or moderate quality.

Conclusion:

The CPGs cannot address the biopsychosocial model domains satisfactorily and some do not address all the ICF conceptual model components, emphasizing body functions and activity and participation domains. Therefore, the functioning model advocated by the World Health Organization has not yet been adequately incorporated into the recommendations for RTS after ACL injury. Moreover, most CPGs are of limited quality.

Anterior cruciate ligament (ACL) injury has a major effect on the individual. ⁴³ It causes physical and functional limitations, as well as psychological and social consequences, leading to losses in human functioning and long periods of absence from training, competition, and work.^6,18,36,45 In the United States, it is estimated that 200,000 ACL injuries occur annually, costing $24,707 per patient for ACL reconstruction (ACL-R).^9,23 The goal of this surgery and postoperative rehabilitation is to regain knee joint stability, facilitating return to activities and return to sport (RTS) at the same preinjury level and with minimal risk of reinjury.^28,47

Playing sports is a complex biopsychosocial activity with demands across all functional aspects. ¹¹ Thus, RTS requires a positive interaction between the injury characteristics, sociodemographic factors, physical factors, psychological factors, social/contextual factors, and functional performance. ⁵ Therefore, individuals with RTS intentions need a biopsychosocial assessment that covers all these factors.

Biopsychosocial approaches are common in health settings. ⁵ In the context of sports injuries, they provide a framework for considering the biological, psychological, and social factors that might influence the treatment or readiness for RTS in a dynamic and comprehensive approach.^{5,11,15,18,29,39} Furthermore, the International Classification of Functioning, Disability, and Health (ICF), a universal instrument proposed by the World Health Organization (WHO), based on the biopsychosocial model, presents a theoretical framework that understands human functioning as a result of the positive interaction of its domains, which includes body functions, body structures, activity and participation, environmental factors, and personal factors, disability being the antagonist.^17,39,40 From its conception, the ICF has become the international standard for describing and monitoring human functioning. Currently, clinical practice guidelines (CPGs) linked to the ICF are being developed, seeking to ensure comprehensive patient care.^24,33,40

CPGs are recommendations designed to assist healthcare practitioners, and to offer ways to reduce evidence-to-practice gaps.^32,35 CPGs need to be contemporary, of high quality, and to cover all domains of human functioning.^18,24,31 CPGs for RTS after an ACL injury are designed to gather factors related to this injury, and provide criteria that need to be reached by an individual before RTS.^11,14,28 Individuals who pass these criteria have a lower risk of ACL graft rupture (78%), any second ACL injury (75%), or any other knee injury (72%). ¹⁴ However, further evidence is needed to refine the RTS criteria and provide greater certainty regarding a successful RTS. ¹⁴

The current status of the RTS criteria can be understood from the ICF, which emphasizes an individual-centered approach and inclusion of all domains involved in human functioning,^11,17,39,40 ensuring the multifactorial and biopsychosocial nature of decision-making. ⁵ Thus, reviewing the RTS criteria by checking the inclusion of biopsychosocial model domains in CPGs for RTS after an ACL injury, and assessing the quality of these CPGs, enables planning of assessment processes that are more suitable for the treatment purpose. This can help reduce the risk of bias contained in the recommendations compiled in CPGs, and might contribute to the development of future CPGs that cover an individual in a comprehensive way. This study aimed to analyze the inclusion of biopsychosocial model domains in CPGs for RTS after ACL injury, as well as the quality of these CPGs.

Methods

Study Design and Registration

A systematic review of CPGs was performed according to the updated recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. ³⁸ In addition, we followed the PICAR elements for research question formulation, as recommended by the methodological guide to conduct systematic reviews of CPGs. ²⁷ The review protocol was registered on the PROSPERO database (CRD42020213784).

Search Strategy

Two independent reviewers developed the search strategy. A third reviewer corrected and compiled the developed strategies used. The searches were conducted in 3 databases: Ovid/MEDLINE (Daily update; from 1946 to the first week of June, 2020), Embase, and Physiotherapy Evidence Database (PEDro). We also manually searched the reference lists of each study. We did not restrict articles by publication date. The search strategies were conducted between April 2020 and June 2020.

• Ovid/MEDLINE:

•  ○ #1 ACL Injuries.mp OR Anterior Cruciate Ligament Injury.mp OR ACL Reconstruction.mp OR ACL Rupture.mp.

•  ○ #2 Guidelines.mp OR Consensus.mp OR Considerations.mp OR Recommendations.mp OR Standard of Care.mp.

•  ○ #1 AND #2

• Embase:

•  ○ #1 (“anterior cruciate ligament injury”/exp OR “anterior cruciate ligament injury” OR “anterior cruciate ligament reconstruction”/exp OR “anterior cruciate ligament reconstruction” OR “anterior cruciate ligament rupture”/exp OR “anterior cruciate ligament rupture”).

•  ○ #2 (“practice guideline”/exp OR “practice guideline”).

•  ○ #1 AND #2

• PEDro: Anterior Cruciate Ligament* Injury* [Advanced search].

Study Selection

The search results were imported into the Rayyan systematic review website, in which all duplicate articles were removed. ³⁷ The inclusion/exclusion of articles was carried out by 2 independent reviewers. Disagreements were resolved by a third reviewer. The first screening was followed by reading the titles and abstracts of the original articles. Subsequently, the studies were assessed for eligibility by reading the full text.

Eligibility Criteria

All articles were examined according to the following inclusion criteria: (1) CPGs published in their latest version, (2) published in the English language, and (3) focused on recommendations for RTS after ACL injury in any age group and at any sport level. These criteria were defined to ensure the inclusion of CPGs in their last updated version with global reach, and designed for the entire population affected by this injury.

Data Extraction and Appraisal

Risk-of-Bias Assessment

Each CPG was appraised independently by 2 reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Checklist. ¹ This instrument assesses the quality of CPGs in 6 domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence, and it is subdivided into 23 items. Each item is ranked on a 7-point scale (1, strongly disagree; 7, strongly agree). Its implementation is supported by a user manual, training tools, and a web-based platform available at https://www.agreetrust.org/. ¹

Before appraisal, the reviewers completed the training available on the AGREE II website. The score for each domain was calculated as a percentage, using the following equation^1,10:

$$\frac{\mathrm{Obtained}\mathrm{score}-\mathrm{Minimum}\mathrm{possible}\mathrm{score}}{\mathrm{Maximum}\mathrm{possible}\mathrm{score}-\mathrm{Minimum}\mathrm{possible}\mathrm{score}}\times 100$$

The mean and standard deviation (±) of the percentages of each domain were identified. Interrater agreement was determined using intraclass correlation coefficients (ICCs). We classified the reliability level according to Cicchetti (1994) as: poor (ICC <0.40), fair (ICC, 0.40-0.59), good (ICC, 0.60-0.74), or excellent (ICC, 0.75-1.00). ¹⁶

Quality Classification

Each domain with ≥60% assessment score was considered as being effectively addressed. ²⁷ High-quality CPGs scored ≥60% in at least 3 of 6 AGREE II domains, including Domain 3 (rigor of development). Moderate-quality CPGs scored ≥60% in at least 3 of the 6 AGREE II domains, except Domain 3. Low-quality CPGs scored <60% in 2 or more domains and <50% in Domain 3. ²⁷ We follow the methodological guide to conduct systematic reviews of the CPGs. ²⁷

ICF Domains

To classify the RTS criteria recommended in the CPGs according to the biopsychosocial model domains pointed out by the ICF, we extracted the significant concepts in the CPGs, according to the already established link rules. ¹⁷ The content of the items of each CPG was extracted and codified by 2 independent reviewers, and disagreements resolved by a third researcher. Agreement between the 2 reviewers was assessed using the Cohen’s kappa coefficient. We classified the agreement level according to the classification by Landis and Koch ³⁰ : poor (<0.00), slight (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), and perfect (0.81-1.00). After the classifications were defined, the concepts were summed up and then divided by the domains. Next, the percentage of concepts by the domains in each of the CPG was made. The total frequency distribution of the domains included in the recommendations was also calculated.

Statistical Package for the Social Sciences version 22 for Windows was used for statistical analysis (IBM Corp.).

Results

Searches identified 715 records: 355 at Ovid/Medline, 356 at Embase, and 4 at PEDro. Before beginning screening, 46 duplicates were excluded. After applying the criteria, 7 CPGs were included (Figure 1).^{2,4,22,26,41,44,47}

Figure 1.

Flowchart of selected CPGs. CPG, clinical practice guideline.

Characteristics of Included CPGs

The CPGs consider adult and pediatric populations with ACL-R. International collaborations occurred in 57.14% of the CPGs.^2,4,22,44 Most CPGs (85.71%) were compiled by medical societies,^2,4,22,26,41 and others (14.28%) were developed by research groups bound to universities.^44,47

CPG Appraisal

Interrater reliability was good for the CPGs from the European Board of Sports Rehabilitation Recommendations and the Arthritis Research UK Center for Sport, Exercise, and Osteoarthritis.^22,44 Reliability was excellent for all other CPGs (Table 1). ¹⁶

Table 1.

Interrater reliability to assess CPG quality

CPG	ICC (95% CI)
EBSR recomendations 44	0.70 (0.28-0.87)
Yabroudi a 47	0.96 (0.91-0.98)
American Academy of Orthopedic Surgeons 2	0.88 (0.73-0.95)
American College of Sports Medicine 41	0.93 (0.85-0.97)
International Olympic Commitee 4	0.78 (0.43-0.91)
Arthritis Research UK, Centre for Sport, Exercise and Osteoarthritis 22	0.71 (0.10-0.83)
Japanese Orthopedic Association 26	0.78 (0.50-0.90)

CPG, clinical practice guideline; EBSR, European Board of Sports Rehabilitation; ICC, intraclass correlation coefficient.

^aFirst author has given where there is no stated organization.

The mean overall score for all the CPGs was 59.47% (±31.18%). The lowest domain score was for the rigor of development (Domain 3) with a mean score of 37.86 (±36.35). Applicability (Domain 5) had the next lowest score with a mean of 49.29 (±22.30). The highest overall scores were for editorial independence (Domain 6) and scope and purpose (Domain 1), with 78.43 (±38.47) and 69.14 (±24.77), respectively (Table 2).

Table 2.

AGREE II domain scores (%) and quality assessment

CPG	Scope and Purpose (69.14 ± 24.77)	Stakeholder Involvement (54.00 ± 30.12)	Rigor of Development (37.86 ± 36.35)	Clarity of Presentation (68.00 ± 22.81)	Applicability (49.29 ± 22.30)	Editorial Independence (78.43 ± 38.47)	Quality
EBSR recomendations 44	55	19	3	61	25	0	Low
Yabroudi 47 a	22	22	2	47	35	54	Low
American Academy of Orthopedic Surgeons 2	97	86	92	100	87	100	High
American College of Sports Medicine 41	72	47	8	33	47	100	Low
International Olympic Committee 4	69	100	59	72	50	95	Moderate
Arthritis Research UK, Centre for Sport, Exercise and Osteoarthritis 22	86	52	71	83	70	100	High
Japanese Orthopedic Association 26	83	52	30	80	31	100	Moderate
Overall mean score of domains 59.47 (±31.18)

AGREE II. Appraisal of Guidelines for Research and Evaluation II; CPG, clinical practice guideline; EBSR, European Board of Sports Rehabilitation.

^aFirst author has given where there is no stated organization.

Most CPGs were of low or moderate quality (71.42%).^{4,26,41,44,47} Only 2 (28.57%) CPGs were of high quality: the American Academy of Orthopedic Surgeons and Arthritis Research UK, Centre for Sport, Exercise and Osteoarthritis CPGs (Table 2).^2,22 Among the high-quality CPGs, editorial independence (Domain 6) had the highest score domain, with a mean of 100 (±0.00). Scope and objective (Domain 1) was the next highest 91.50 (±7.77). Clarity of presentation (Domain 4) and rigor of development (Domain 3) had mean scores of 91.50 (±12.02) and 81.50 (±14.84), respectively. The lowest scoring domains were applicability (Domain 5) 78.50 (±12.02) and stakeholder involvement (Domain 2) 71.50 (±20.50). In high-quality CPGs, each domain achieved a score of ≥60%.

RTS Criteria and ICF Domains Included in the CPGs

On evaluating the inclusion of biopsychosocial model domains in the CPGs, the Cohen’s Kappa coefficient presented a value of 0.83 (P = 0.0001*/95% CI), a perfect agreement between the 2 reviewers. ³⁰

The list of RTS criteria recommended in the CPGs has increased. In 2011, 3 criteria were recommended. ⁴⁴ In 2019, 12 criteria were presented.^22,26 The number of ICF domains included in the CPGs has also increased over the years.

Only 60% of the ICFs domains were included in the CPGs between 2011 and 2014.^2,44,47 In 2017 and 2018, 80% of the ICF domains was covered.^4,41 All domains were covered by at least 1 CPG, but only 2 CPGs included all ICF domains, and the CPGs published in 2019 (Table 3).^22,26 The frequency distribution of the ICF domains approach in these CPGs was as follows: body functions (35.71%), activity and participation (28.57%), environmental factors (14.28%), personal factors (14.28%), and body structure (13.33%).

Table 3.

International classification of functioning, disability, and health domains covered in the CPG

Author (Year)	Title	Organization	RTS Criteria	ICF Domains Covered
Thomeé (2011) 44	Muscle strength and hop performance criteria prior to return to sports after anterior cruciate ligament (ACL) reconstruction	EBSR	Symmetry of muscle function (strength of knee extensors and flexors) of 100% for pivot, contact, and competitive sports and ≥90% for noncontact and recreational sports Symmetry index between members (performance on the hop test) ≥90% Report on the RTS must be accompanied by a detailed description of the type and level of sport	Body functions (67%) a Activity and participation (33%)
Yabroudi (2013) 47	Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction	The University of Pittsburg	Quadriceps symmetry index ≥85% Achieve ROM, endurance, and proprioception criteria Tolerate full effort running, cutting, turning, and jumping exercises Progression of a partial return to practice, going through the levels of preparation for daily life activity, occupational activities, athletic activity, and RTS Total return to training until return to competition	Body functions (40%) Activity and participation (60%)
Shea (2014) 2	The American Academy of Orthopedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries: evidence-based guideline	The American Academy of Orthopedic Surgeons	The limited strength evidence does not support waiting for a specific time of surgery/injury or reaching a specific functional goal before RTS	Environmental factors (50%) Body functions (50%)
Sepúlveda (2017) 41	Anterior cruciate ligament injury: return to play, function and long-term considerations	The American College of Sports Medicine	Symmetry index between members ≥90% and 100% for high-demand sports Surgery time Psychological readiness (Tampa scale for kinesiophobia) ROM Abscess and edema Graft type Graft tension	Body functions (37%) Body structures (50%) Environmental factors (12%) Personal factors (12%)
Ardern (2018) 4	The 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of pediatric ACL injuries	The International Olympic Committee	Active extension ≥120 degrees of knee flexion Little to no effusion Ability to maintain knee extension during unipodal support ≥90% symmetry of the limbs in muscle strength tests Ability to run for 10 minutes in good shape and without subsequent spillage Psychologically ready to RTS ≥90% symmetry between the limbs in muscle strength tests Adequate strategy and quality of movement Sport-specific training with gradual progression Confidence in knee function Knowledge of knee positioning at high risk of injury Ability to maintain knee positioning at low risk in advanced sport-specific actions	Body functions (64%) Environmental factors (9%) Activity and participation (9%) Personal factors (18%)
Filbay (2019) 22	Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture	The Arthritis Research UK, Centre for Sport, Exercise and Osteo-arthritis	Joint swelling Knee pain Psychological factors, such as autonomy, competence, and fear of reinjury Quadriceps isokinetic symmetry index ≥90% Symmetry index between the lower limbs in the hop test ≥90% ≥90 points on the Knee Outcome Survey ADLS agility test	Body structures (11%) Body functions (33%) Activity and participation (22%) Environmental factors (11%) Personal factors (22%)
Ishibashi (2019) 26	The Japanese Orthopedic Association 2019 guidelines for anterior cruciate ligament injuries (3rd edition)	The Japanese Orthopedic Association	Muscle strength Balance ROM Psychological factors Knee joint stability Surgery time ≥6 months	Body functions (33%) Body structures (17%) Environmental factors (17%) Activity and participation (17%) Personal factors (17%)

^aDomain frequency in CPG.

ADLS, activities of daily living scale; CPG, clinical practice guideline; EBSR, European Board of Sports Rehabilitation; ROM, range of motion; RTS, return to sport.

In all the CPGs, the frequency distribution of the ICF domains covered was as follows: body functions (37.77%), activity and participation (20.00%), body structures (13.33%), environmental factors (11.11%), and personal factors (8.88%) (Figure 2).

Figure 2.

Frequency distribution of the ICF domains in all CPGs for RTS after ACL injury. ACL, anterior cruciate ligament; CPG, clinical practice guideline; ICF, International Classification of Functioning, Disability, and Health; RTS, return to sport.

Furthermore, all CPGs covered the body function domain.^{2,4,22,26,41,44,47} Environmental factors,^2,4,22,26,41 and activity and participation domains,^2,4,22,26,44 were covered in 71.42% of the CPGs. The personal factors and body structure domains were included in 57.14% and 42.85% of the CPGs, respectively.^4,22,26,41

Discussion

Main Findings

There was an increase in the number of RTS criteria and ICF domains included in the CPGs, showing that the list of criteria has grown, approaching other domains of human functioning. Thus, in 2019, all the ICF domains were covered in the CPGs.^22,26 These CPGs are closest to the WHO-recommended method of measuring functioning.^17,39,40 However, the RTS criteria focuses mainly on body functions and activity and participation domains. The body structures, personal factors, and environmental factors domains have largely not been explored, highlighting the current biomedical perspective. Therefore, despite the start of the ICF in 2001, human functioning after ACL injury is still understood in a reductionist way by placing body functions and activity and participation domains in a perspective of greater importance, contrary to the ICF, which seeks to approach its domains equally.^17,39 Therefore, the growth of the number of ICF domains included has not yet ensured the incorporation of the biopsychosocial model in the CPGs for RTS after ACL injury.

This systematic review highlights that the concept of human functioning advocated by the WHO has not yet been incorporated adequately into the CPGs for RTS after ACL injury. This fact emphasizes the need for the current literature to address the biopsychosocial model among the ACL injury population, since the CPGs depend on the literature to compile the recommendations. The need to increase the quality of these CPGs is also highlighted; only 2 CPGs were of high quality, directly interfering with the risk of bias contained in the recommendations.

Contemporary Approach to RTS After ACL Injury and Incorporation of the Biopsychosocial Model

Previous studies have shown that the measures used mostly by Brazilian physiotherapists for RTS after ACL injury were physical factors, such as ROM and muscle strength (65.3%-75.1%). A small number of professionals used questionnaires to assess psychological (19.1%) and functional aspects (16.6%). ³ Among members of the American Academy of Sports Physical Therapy and Private Practice Section of the American Physical Therapy Association, single-limb hop testing was the most reported measure for RTS after ACL-R (89%). ²⁵

Among Australian physiotherapists, the common RTS considerations were functional capacity (98.7%), muscle strength (87.0%), lower limb and trunk mechanics (96.0%), and psychological readiness (87.9%). For functional evaluation, 84.3% of the physiotherapists employed a hop battery (≥2 hop tests). ²⁰ Furthermore, the current Australian Knee Society perspectives for RTS are time (90.4%), functional capacity (90.4%), and muscle strength (78.1%). ²¹ These current approach to RTS after ACL injury are focused mainly on the body function domain, corroborating this systematic review in which we identified this as the predominant ICF domain in the RTS criteria.

According Burgi et al ¹¹ , time and impairment-based measures dominated the RTS criteria. The time was used in 178 (85%) studies, and in 88 (42%) studies, time was the sole RTS criteria. Strength tests were reported in 86 (41%) studies. A total of 16 different hop tests were used in 31 (15%) studies. Clinical examination was used in 54 (26%) studies, patient report in 26 (12%) studies, and performance-based criteria in 41 (20%) studies. ¹¹ These findings show that the current literature does not include the biopsychosocial model; therefore, the CPGs will not be able to address the biopsychosocial model. Confirming these data, Barber-Westin and Noyes ⁸ showed that the most common criterion for RTS after ACL injury was lower extremity muscle strength, followed by lower limb symmetry, knee examination parameters of ROM, and effusion.

In contrast, the psychosocial factors are those reported most consistently by patients as barriers to RTS.^{6,12,13,15,45,46} The feeling that sport was now associated with injury, a persistent sense of uncertainty regarding full recovery, comparison with others with ACL-R by parents or coaches, postoperative motivation, confidence in the treated knee, clinical resource availability, proper relationship with your provider, and social support are often reported. Expectations or priority changes also influence recovery.^12,19 Among the patients who do not achieve RTS, 64.7% cited psychological reasons for not returning. Fear of reinjury (76.7%) and lack of confidence in the treated knee (14.8%) are the most reported. ³⁶

This failure to understand and apply the biopsychosocial model begins with professional education. Kaye et al. ²⁹ showed that physiotherapy students have a superficial understanding of the biopsychosocial model and reported barriers to implementing the biopsychosocial model, including the application of theory to practice when working with patients after ACL injury. Furthermore, physiotherapy students are aware of the possible benefits of incorporating the biopsychosocial model but feel inadequately trained, exposing the need for curriculum review. ²⁹

Practice Implications and Recommendations

Knowledge of psychosocial factors provides a more comprehensive approach that allows a better understanding of RTS readiness by creating a positive and successful rehabilitation setting, which can further help improve RTS rates and reinjury after ACL injury.^5,12,19 Therefore, the RTS CPGs must be updated to approach all variables associated with RTS while considering the biopsychosocial model, ensuring that care uniformly involves all factors related to human functioning.^5,19,24 Therefore, it is necessary to understand the bidirectional relationship between health conditions and psychosocial factors, and contemporary literature must be based on the biopsychosocial model.

Lin et al ³¹ showed poor overall quality of the CPGs for more common musculoskeletal pain conditions. In our systematic review, only 1 high-quality CPG approached all the ICF domains: Arthritis Research UK, Centre for Sport, Exercise and Osteoarthritis being the most recommended. ²²

We also highlight that CPGs must enhance quality and applicability, since 71.42% of the CPGs are of low or moderate quality,^{4,26,41,44,47} and only 2 have an applicability score >60%,^2,22 the minimum score to claim that the domains were must be addressed effectively. ²⁷

Poor applicability is a barrier to the uptake of CPG recommendations into practice. Therefore, more attention to the implementation strategies and active dissemination of CPGs that are more targeted at practitioners is needed. In this context, new emerging methods to facilitate access to CPGs are needed, including mobile technologies, applications, and websites. In addition, the inclusion of information on the quality of CPGs in the databases can improve the applicability of high-quality recommendations.^34,35 The CPGs can still describe facilitators and barriers to its application and provide advice and/or tools on how the recommendations can be put into practice.

Another factor that reduces the CPGs for RTS after ACL injury use is ambiguous information, such as “Little to no effusion” or “Mentally ready to return to sport.” This can be reduced by presenting clear, simple, and specific instructions, approaching the item statement of recommended actions, identification of the intent or purpose of the recommended action, identification of the relevant population, caveats or qualifying statements, and interpretation and discussion of the evidence (Item 15, Domain 4). ¹ The CPG developers can also use the Guideline Implementability Appraisal (GLIA), a tool developed to identify obstacles to CPG implementation. ⁴²

Regarding CPGs quality, developers should consider the AGREE II criteria when developing and publishing CPGs, highlighted in particular by the low scores found for rigor of development (Domain 3). Rigor of development is an important domain for CPG quality, as it assesses the methodological rigor with which the recommendations were compiled.

Finally, to ensure inclusion of biopsychosocial model domains in the CPGs for RTS after ACL injury, we recommended that CPGs be developed and linked to the ICF, including the CPG for ACL injury prevention. ⁷ We still recommended that CPG developers should follow the AGREE II Domain 2 items (stakeholder involvement), since multidisciplinary and patient views can help include the biopsychosocial model.

The main limitation of this study was the inclusion of CPGs published only in English. However, this study has a prominent characteristic, whereby functioning is an important indicator for assessing an individual’s health, CPGs quality assessment has gained emphasis in the current literature, and CPGs linked to ICF are being developed.^{7,10,17,24,31} Furthermore, the results of this study may play a key role in the development of future CPGs.

Conclusion

Most CPGs are of limited quality, and among the CPGs that approach all the ICF domains, only the Arthritis Research UK, Centre for Sport, Exercise and Osteoarthritis CPG is of high quality and the most recommended. However, CPGs cannot address the biopsychosocial model domains satisfactorily and some do not address all components of the ICF conceptual model, the emphasis being on body functions and activity and participation. Therefore, the functioning model advocated by the WHO has not yet been incorporated adequately into the recommendations for RTS after ACL injury.