Group Telerehabilitation in the COVID-19 Era: a New Approach

Person-centred experience for telerehabilitation following Anterior Cruciate Ligament Reconstruction


The rationale for this project is to co-design (1) alternative ways of engaging with patients using telehealth frameworks (2) and provide person-centred rehabilitation post-surgical reconstruction for anterior cruciate ligament injury (ACL-R).

Rationale for “Group” Telerehabilitation Following Anterior Cruciate Ligament Reconstruction

Anterior Cruciate Ligament Reconstruction (ACL-R) surgery is a common procedure. (3)  However, despite around 80% of ACL-R patients returning to some kind of sporting activities, only 65% return to their pre-injury level and 55% to competitive sport (4).  Inadequate rehabilitation has been cited alongside poor preparation for return to sport as factors which could limit sporting performance and predispose to re-injury (5)(6) (7).  A systematic review with meta-analysis by Wiggins et al. (2016) estimated approximately 20% of those returning to sport following ACL-R experience a second ACL injury(8).  With a heterogeneous selection of ACL-R rehabilitation protocols available online (9) and within the literature, (10) in conjunction with the disruption to physiotherapy rehabilitation services during the COVID-19 pandemic, it could be argued that a perfect storm has been created for poor provision for those rehabilitating from ACL-R.  This could be exacerbated as orthopaedic services resume without the follow through capacity to adequately rehabilitate post-surgery.

Co-design of Novel Telerehabilitation Products and Processes Following ACL-R

Use of co-design in healthcare environments is relatively new (11) with no standard model for doing so being applied.  Indeed, it is noted by Brocklehurst et al. (2018) that many different methodologies could be used (12) with co-design involving collaborative and evolving processes with ownership and a practical focus being key according to some(13).  With involvement of stakeholders to broaden the range of available ideas and gain their views being central in underpinning patient-centred rehabilitation (14) (15) post ACL-R it was deemed prudent to harvest patients’ views in constructing the novel telerehabilitation products and processes.  This was initially done via an on-line survey, link below:

From the survey results face-to-face consultations with a physiotherapist was as important to patients as the home exercise plan delivered during ACL-R rehabilitation (Figure 1).  One-to-one rehabilitation sessions with a physiotherapy support worker were viewed as more important than a telephone consultation with a physiotherapist, and Near Me Video consultations did not feature at all as a preferred rehabilitation mode (Figure 1).  The rationale for this comes across in patients’ comments from the survey:

  • “I liked meeting up face to face so the physiotherapist could see my progress and advise me on the next stage of home exercise plan”.
  • “One to one physio sessions have been the most useful. We get taught the exercises then can take it home to work on”.
Figure 1: Preferred Rehabilitation Post ACL-R

Also from the survey results:

  • 100% said they would use Physiotherapist led videos of exercises during ACL-R rehabilitation
  • 100% would like a Smartphone APP with ACL-R rehabilitation exercises prescribed by a physiotherapist

Patient’s comments included:

  • Videos of exercises, a chat function”.
  • “videos going over technique – chat box feature”.
  • “To describe all the different exercises for each stage of the rehabilitation”.

On-line video resources with pertinent points of the rehabilitation exercises are currently being produced as this was identified from survey results by patients as an important part of their ACL-R rehabilitation particularly during ongoing COVID-19 pandemic with a continuing reduced capacity for face-to-face physiotherapist engagement.  An example of these is provided in the link below:

Anterior Cruciate Liagament Reconstruction Telerehabilitation Phase 1 Exercises for Strength Exercises 8a) & b) Double Leg Bridges

Figure 2: Double Leg Bridges and Progressions

As this pilot for “Group” telerehabilitation post ACL-R is rolled out, support for patients is provided via video conferencing using Near Me Video facilities within NHS settings.  This allows appropriate regressions or progressions to be made for the patient within an evidence based post ACL-R protocol which both the physiotherapist and patient have access too.  Patient education plays a key part.

As part of the monitoring, the Knee Injury and Osteoarthritis Outcome Score (KOOS) is known to have validity and reliability in measuring the functional status and quality of life for patients following ACL-R and is valid for research purpose with competitive athletes (16).

For those patients wanting to return to sport the Strategic Assessment of Risk and Risk Tolerance (StARRT) Framework established in 2016 (17) is a good starting point for making return to play decisions post ACL-R.

Figure 3: Strategic Assessment of Risk and Risk Tolerance Framework (Arden, Glasgow, Schneiders et al. 2016)

Return to play should be criteria based and be multi-disciplinary in nature (18) but exactly which criteria and how they should be used is controversial as discussed recently in BJSM Blog  regarding the usefulness or otherwise of hop tests in ACL-R criteria (19).

Figure 4: Quality of Landing in Hop Test During ACL-R Rehabilitation (BJSM Blog 2021 Kotsifaki R, Whiteley R, van Rossom S, et al. 2020)


  • Telerehabilitation post ACL-R could address the difficulties associated with adequately preparing individuals for return to sport during COVID-19 pandemic.
  • Future work is needed to evaluate this pilot and further develop telerehabilitation products and processes based on participant co-design.

Acknowledgements: Thank you to National Education for Scotland (NES) @NESnmahp for award of fellowship funding in order to undertake this project and for the support of NHS Fife @NHSFife

Writer Info:

Jim Scanlan MSc; Pg Dip Orth Med; Pg Dip Injection Therapy; HCPC; CSP; ACPSEM: Silver Accreditation

NHS Fife Advanced Practitioner Physiotherapist Musculoskeletal & Orthopaedics


Follow on Twitter: @jim_physio


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  1. Ardern C, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016;50:853-862
  2. van der Horts N, Backx FJG, Goedhart EA, et al. Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making. Br J Sports Med 2017;51:1583-1591
  3. Kotsifaki R, Whiteley R, van Rossom S, et al. Single leg hop for distance symmetry masks lower limb biomechanics: time to discuss hop distance as decision criterion for return to sport after ACL reconstruction. BJSM. 2020. (accessed 09 Jun 2021)

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