Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Patients

Background Evidence shows that after anterior cruciate ligament (ACL) reconstruction, patients may have varied access to physical therapy. In particular, physical therapy input may end many months before patients reach full recovery. Telerehabilitation may provide an opportunity to address this rehabilitation gap and improve access to evidence-based rehabilitation alongside physical therapy at all stages of care. Objective This study aims to understand the opinions of patients who have undergone ACL surgery and rehabilitation on the use of telerehabilitation as part of ACL care and define the population and explore their experiences and views on the acceptability of telerehabilitation after ACL reconstruction. Methods This study was a cross-sectional, voluntary, web-based survey combining both closed and open questions. Ethical approval was obtained from the Yale School of Medicine Institutional Review Board. Participants were aged 16 years or older at the time of recruitment and had undergone ACL reconstruction within the past 5 years. A 26-item survey was developed using the Qualtrics survey platform. No items were mandatory. Responses were multiple choice, binary, and qualitative. The CHERRIES (Checklist for Reporting Results of Internet E-Surveys) was used to ensure the quality of reporting of surveys in the medical literature. Data were analyzed using Stata version 15. Qualitative data were analyzed using NVivo 11. The theoretical framework for this analysis is based on the Capability, Opportunity, and Motivation-Behavior model of behavior change. Results A total of 100 participants opened the survey. All completers were unique. The participation and completion rates were each 96% (96/100). Patients reported their physical therapy care ended at an average of 6.4 months and that they felt fully recovered at an average of 13.2 months. Only 26% (25/96) of patients felt fully recovered at the end of physical therapy. Of these 96 patients, 54 (60%) were younger than 30 years, 71 (74%) were recreational athletes, 24 (24%) were competitive athletes, 72 (75%) had private insurance, 74 (77%) were not familiar at all with telerehabilitation, and 89% (85/96) felt capable. They preferred to use telerehabilitation at different stages of care. Reported benefits included resource saving, improved access to care, improved learning, and greater engagement. Concerns included incorrect performance of exercises or unmanaged pain being missed and less access to manual therapy, motivation, and opportunities to ask questions. Participants’ priorities for a future telerehabilitation intervention included its use as an adjunct to physical therapy rather than a replacement, with content available for each stage of care, especially return to sports. Participants stressed that the intervention should be personalized to them and include measures of progress. Conclusions These findings helped understand and define the ACL reconstruction population. Participants found telerehabilitation acceptable in principle and highlighted the key user requirements and scope of future interventions.


IRB approval
Mention whether the study has been approved by an IRB.
Informed consent Describe the informed consent process.
Where were the participants told the length of time of the survey, which data were stored and where and for how long, who the investigator was, and the purpose of the study?
Data protection If any personal information was collected or stored, describe what mechanisms were used to protect unauthorized access.

Development and testing
State how the survey was developed, including whether the usability and technical functionality of the electronic questionnaire had been tested before fielding the questionnaire.

Checklist for Reporting Results of Internet E-Surveys (CHERRIES) Item Category Checklist Item Explanation
responses to other items) to reduce number and complexity of the questions.

Number of Items
What was the number of questionnaire items per page? The number of items is an important factor for the completion rate.

Number of screens (pages)
Over how many pages was the questionnaire distributed? The number of items is an important factor for the completion rate.

Completeness check
It is technically possible to do consistency or completeness checks before the questionnaire is submitted. Was this done, and if "yes", how (usually JAVAScript)? An alternative is to check for completeness after the questionnaire has been submitted (and highlight mandatory items). If this has been done, it should be reported. All items should provide a non-response option such as "not applicable" or "rather not say", and selection of one response option should be enforced.

Review step
State whether respondents were able to review and change their answers (eg, through a Back button or a Review step which displays a summary of the responses and asks the respondents if they are correct). The number of people agreeing to participate (or submitting the first survey page) divided by the number of people submitting the last questionnaire page. This is only relevant if there is a separate "informed consent" page or if the survey goes over several pages. This is a measure for attrition. Note that "completion" can involve leaving questionnaire items blank. This is not a measure for how completely questionnaires were filled in. (If you need a measure for this, use the word "completeness rate".)

Preventing multiple entries from the same individual
Cookies used Indicate whether cookies were used to assign a unique user identifier to each client computer. If so, mention the page on which the cookie was set and read, and how long the cookie was valid. Were duplicate entries avoided by preventing users access to the survey twice; or were duplicate database entries having the same user ID eliminated before analysis? In the latter case, which entries were kept for analysis (eg, the first entry or the most recent)?
IP check Indicate whether the IP address of the client computer was used to identify potential duplicate entries from the same user. If so, mention the period of time for which no two entries from the same IP address were allowed (eg, 24 hours). Were duplicate entries avoided by preventing users with the same IP address access to the survey twice; or were duplicate database entries having the same IP address within a given period of time eliminated before analysis? If the latter, which entries were kept for analysis (eg, the first entry or the most recent)?
Log file analysis Indicate whether other techniques to analyze the log file for identification of multiple entries were used. If so, please describe.

Item Category Checklist Item Explanation
Registration In "closed" (non-open) surveys, users need to login first and it is easier to prevent duplicate entries from the same user. Describe how this was done. For example, was the survey never displayed a second time once the user had filled it in, or was the username stored together with the survey results and later eliminated? If the latter, which entries were kept for analysis (eg, the first entry or the most recent)?

Handling of incomplete questionnaires
Were only completed questionnaires analyzed? Were questionnaires which terminated early (where, for example, users did not go through all questionnaire pages) also analyzed?
Questionnaires submitted with an atypical timestamp Some investigators may measure the time people needed to fill in a questionnaire and exclude questionnaires that were submitted too soon. Specify the timeframe that was used as a cut-off point, and describe how this point was determined.
Statistical correction Indicate whether any methods such as weighting of items or propensity scores have been used to adjust for the nonrepresentative sample; if so, please describe the methods.