Knowledge, Attitude and Practices about cross bracing protocol in ACL injury : A Survey on Physiotherapist

doi:10.21203/rs.3.rs-5326377/v1

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Knowledge, Attitude and Practices about cross bracing protocol in ACL injury : A Survey on Physiotherapist

https://doi.org/10.21203/rs.3.rs-5326377/v1

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Purpose: Anterior Cruciate Ligament injuries are the most commonly seen injuries in the athletes, not all of these injuries need to be operated and can be treated conservatively, while many of them choose surgical intervention there is no certainty of the person returning to pre injury level without proper rehabilitation. Here Cross-Bracing protocol plays an important role, which tends to heal the ACL without surgical intervention by usage of brace for a particular period of time while taking regular physiotherapy rehabilitation. There is a limited knowledge of the same among Physiotherapists, so our study aimed to check awareness about this protocol among the Physiotherapists.

Methods: A google form questionnaire was circulated among the Physiotherapists via mail and all social media platforms and data was collected for a period of 8 months. Calculated sample size was 80. Descriptive statistics, including frequencies and percentages, were used to analyze the survey responses.

Results: A total of 82 participants (34 males, 48 females), with ± 4 years of practice completed the survey, where varying levels of awareness about ACL injury management and cross bracing protocols was observed. With 16.9% incorporating the protocol in regular practice.

Conclusion: The survey highlights that physiotherapists recognize the value of managing ACL injuries and using cross bracing, giving desired outcomes. Despite its perceived benefits, only few physiotherapist consistently use cross bracing in treatment plans, indicating a need for further education on clinical guidelines and its long-term advantages, especially for high-risk groups.

Sports Medicine and Kinesiology

ACL Injury

Cross bracing

Physiotherapists

Rehabilitation

Athletes.

Anterior cruciate ligament (ACL) injuries are among the most common sports-related injuries, and they severely impair a patient's level of activity and quality of life [1]. These injuries are frequently caused by sports that require players to pivot, cut, and jump [2]. Furthermore, the chance of sustaining further injury to the knee's intra-articular structures increases if physical activity is resumed following an ACL tear which goes unattended on time [3].

ACL injuries, which are on an increase in our country, can render a person financially and functionally incapacitated because of the high cost of treatment and reduction in the number of days the person can work after the injury [4]. In large metropolitan areas, 20 to 100 ACL repair procedures are reported yearly, despite the fact that the epidemiology of this surgery is not regularly documented in India [5]. Most of the people believe that postoperative therapy is an essential aspect of the healing process after an ACL injury in order to maximize function and reduce the risk of recurrence or subsequent ACL injuries [6.] However, a significant proportion of patients experience long-term knee-related quality of life issues, and thirty-five percent experience tibiofemoral symptomatic osteoarthritis ten years after ACL repair. Additionally, not all patients return to playing sports. After undergoing an ACL repair, about 80% of patients return to sports, but only 65% return to their pre-injury level and 55% return to competitive sports [7].

Furthermore after surgical repair of the ligament functional knee bracing is recommended to the person, which is useful in treating patients with ACL reconstruction and deficit, according to a study’s conclusion. Functional knee bracing should be part of a comprehensive rehabilitation program designed to return the injured athlete to their pre-injury level in the case of anterior cruciate ligament reconstruction or anterior cruciate ligament deficiency [8]. A thorough research reveals that the advantages of functional bracing following ACL replacement include protecting the healing tissue, aiding the return to sports, restoring normal joint mechanics, and increasing patient confidence [9].

It is widely believed by researchers, clinicians, and the general public that an ACL rupture cannot heal. This idea has resulted in a marked rise in the number of ACL reconstructions at considerable medical cost; however, an investigation found that 90% of patients exhibited healing on a 3-month MRI after receiving treatment for ACL rupture using a special bracing method (continuity of the ACL). Higher healing grades were associated with improved quality of life and knee function [10].

Better patient outcomes are strongly correlated with ACL healing, and while an injured ACL can heal without surgery, an inventive bracing strategy may accelerate ACL recovery beyond what would be possible with rehabilitation alone [11]. Even physiotherapists and physicians may not be aware of the cross bracing strategy for patients with ACL injury. The study aims to explore the knowledge, attitude, and application of the cross-bracing technique among physiotherapists treating ACL injuries. Physiotherapists play a critical role in the healing and rehabilitation of patients; however, little is known about their level of expertise, adoption barriers, and educational requirements. The information gathered was useful for future clinical guidelines, patient outcomes, and training initiatives. This could lead to a more standardized approach to conservative ACL damage care.

This observational study aimed to assess the knowledge, attitude, and practices of physiotherapists regarding the cross bracing protocol in anterior cruciate ligament (ACL) injury management. Specifically, it sought to determine physiotherapists' level of knowledge about the protocol, their attitude toward its application, and how they incorporate it into their clinical practice. The study involved 82 physiotherapists who have been involved in clinical practice for at least one year, selected through convenient sampling via

PROCEDURE

The proposed study was submitted to Sumandeep Vidyapeeth Institutional Ethical Committee (SVIEC) for ethical approval. After obtaining approval from ethical committee, Google form questionnaire was made, consisting of consent form and participant information sheet. The questionnaire was validated by the experts and then was further circulated among Physiotherapists who were involved in clinical practice via E-mail, bulk mail, WhatsApp and all form of social media. The data was collected.

STATISTICAL ANALYSIS

The data was entered in Microsoft excel sheet WPS - Release Version v12.2.0.18283 and was analysed using descriptive analytical method.

There were 82 participants in the survey on physiotherapists' knowledge, attitude, and practices about the cross-bracing protocol in ACL injuries (34 males and 48 females). There was variation in the educational backgrounds of the respondents: 2 PhDs, 45 MPTs, and 35 BPTs. The average length of time spent practicing was about 4 years.

Knowledge

Regarding the significance of prompt intervention and appropriate rehabilitation for ACL injuries, the replies were divided as follows: A total of 30.5% of respondents thought it avoided atrophy and weakness in the muscles, 23.2% stated improved functionality, another 23.2% mentioned reducing secondary problems, and 20.7% highlighted joint stability being restored. Just 2.4% of respondents gave additional explanations (SD=0.093).

When asked if they thought the cross-bracing protocol worked well for treating ACL injuries, 67.2% said it was best left conservative, and 37.3% said it was best left surgical (SD = 0.127). The types of braces utilized in the care of ACLs were as follows: 42.4% selected hinged braces, 27.1% preferred patellar- stabilizing braces, 28.2% used knee immobilizers, and 1.7% selected neoprene sleeves (SD = 0.147).61% of athletes with a history of numerous ACL injuries were identified as the population most likely to benefit from cross-bracing in ACL rehabilitation, whereas 28% of people with partial ACL tears were recognized. Merely 6.8% and 3.4% of respondents, respectively, thought it was most appropriate for patients with meniscus tears and older persons with degenerative knee problems (SD = 0.229). Cross braces are said to aid in the biomechanical mechanism of ACL management by reducing excessive knee valgus by 25.4%, preventing hyper-extension of the knee by 35.6%, limiting knee flexion by 30.5%, and preventing excessive internal tibial rotation by 8.5% (SD = 0.101).

Attitude

Functional goals were the main factor that physiotherapists considered (40.7%) when deciding whether to use cross-bracing; other factors were activity level (23.7%) and injury severity (33.9%) (SD = 0.147). The majority of respondents (83.1%) thought that cross-bracing's main advantage was stabilizing the knee joint. Lower percentages mentioned boosting blood flow (3.4%), enhancing range of motion (10.2%), and building muscle (3.4%)(SD=0.336).

In terms of opinions on cross-bracing, 59.3% concurred that it is a crucial part of ACL recovery. However, 25.4% voiced caution and examined specific patient circumstances, while 5.1% did not propose cross- bracing due to a lack of data. 10.2% of respondents (SD = 0.211) did not have a strong view.

Practice

Practice-wise, 73.2% of physiotherapists saw arthroscopic ACL procedures regularly, autografts 22% of the time, and double-bundle repairs 24% of the time (SD = 0.288). In the preliminary assessments, 91.5% of participants gave the most priority to evaluating integrity and stability, whereas 8.5% concentrated on proprioception (SD = 0.415).

In terms of the kinds of braces worn, functional braces accounted for 54.9% of the usage, followed by rehabilitative braces (31.7%) and prophylactic braces (13.4%) (SD = 0.169). Clinical assessment and guidelines were the most popular strategy (67.8%) for deciding on the right amount of bracing; smaller groups used trial and error (5.1%) and patient preferences (22%) (SD = 0.256).

Regarding the use of cross braces, 52.5% advised doing so for six weeks, 30.5% for three weeks, and 3.4% for six months (SD = 0.191). Regarding frequency, 39% of physiotherapists stated that they used cross- bracing in their treatment plans often, compared to 32.2% who did so infrequently, 16.9% who did so constantly, and 11.9% who did so infrequently (SD = 0.110). The majority of physiotherapists (65.9%) saw 0–2 patients per week with ACL injuries, but other physiotherapists saw 3–4 (13.4%), 5–6 (11%), or more than 7 (9.8%) patients per week (SD = 0.236).

The purpose of the study was to evaluate physiotherapists' understanding, attitude, and practices with reference to the cross-bracing protocol for treating anterior cruciate ligament (ACL) injuries. The survey's findings offer insightful information about the state of knowledge regarding this conservative treatment strategy, as well as the perceived advantages and obstacles to its widespread use in physiotherapy practices. According to an analysis of 82 physiotherapists, 42.4% of them used hinged braces, and 67.2% thought that cross bracing was a good conservative treatment for ACLs. Cross-bracing is thought to be most beneficial for athletes with repeated ACL injuries (61%), with partial ACL tears (28.8%) also favoring it. Restricting knee flexion and avoiding hyperextension were the primary biomechanical advantages. During ACL rehabilitation, the majority of physiotherapists saw arthroscopic procedures; stability and integrity were

emphasized. Only 16.9%, nevertheless, consistently used cross-bracing. It is known that 50% of those who took survey have knowledge about the protocol but have not been practising it on regular basis. They believed that this treatment protocol can help person recover for an ACL injury without surgical intervention.

Several studies have explored the non-surgical treatment of anterior cruciate ligament (ACL) injuries, focusing on the potential for ACL healing observed through MRI and the outcomes of conservative management strategies like the Cross Bracing Protocol (CBP).

One study involving 26 participants, with an average age of 26 and 39% female, many of whom had concurrent meniscal injuries, applied the CBP for non-surgical ACL management. Results showed that 90% of patients exhibited signs of ACL healing on MRI after three months. Participants with Grade 1, 2, and 3 injuries reported improved quality of life and knee function, with Grade 1 patients more frequently returning to pre-injury sports and demonstrating better knee flexibility than those with Grade 2 and 3 injuries.

However, 14% of the participants experienced an ACL re-injury during the trial. Overall, the 90% recovery rate on MRI suggested that CBP was effective in supporting ACL healing [10].

Another study examined 232 ACL patients, of whom 48 were treated non-surgically with bracing and physical therapy due to intact ACL continuity and minimal instability seen on MRI. The study found that 87% of these patients achieved grade 0 on the Lachman test, indicating no joint laxity, while 76% showed no instability on the pivot shift test. Additionally, MRI results revealed that 95.8% of patients had recovered ACL continuity, emphasizing the effectiveness of non-operative treatment for ACL injuries with mild instability, and suggesting that surgery is not always necessary[12].

In another case, researchers looked at 13 patients with ACL injuries treated conservatively with an extension block soft brace without anterior stabilization. After 16.1 months, 74% of patients showed knee stability, and MRI scans indicated a sustained but less intense ACL connection in 21 out of 23 cases. However, 26% of the patients required surgery due to continued instability, highlighting that conservative treatment, even without anterior stabilization, can still be effective for some patients[13].

A separate study investigated the spontaneous healing of complete ACL ruptures in 14 athletes who received no surgical intervention, bracing, or structured rehabilitation. All patients showed "end-to-end" ACL continuity on MRI, indicating spontaneous repair. Clinical evaluations confirmed restored knee stability, with negative results on the pivot shift test. Patients also returned to their pre-injury levels of high- intensity physical activity, with an average Lysholm-Gillquist score of 97. However, two patients experienced re-rupture and eventually required surgery[14].

A case study demonstrated how Cross Bracing Protocol (CBP), a non-surgical therapy for ACL injuries, worked. By immobilizing the knee with customized bracing and encouraging natural healing, this technique presented a viable substitute for open surgery. The patient chose the CBP despite being sceptical about surgery after an MRI revealed an ACL tear and showed promising results for recovery. Although the protocol's efficacy is still being investigated, it places a strong emphasis on an immobilization-based rehabilitation method that lets the ligament recover spontaneously. Improved knee stability, less discomfort, and a progressive return to normal function were all signs of the patient's recovery [15].

Since there are many evidences available stating effectiveness of cross bracing protocol in an ACL injury there are limited studies which determined the knowledge of physiotherapists in regards to this protocol. The findings demonstrate a notable discrepancy between clinical application and awareness, with just 16.9% of physiotherapists routinely implementing the technique in their practice, despite 67.2% of them acknowledging its advantages. This disparity implies that even if cross-bracing has been shown to have therapeutic benefits, its frequent implementation may be hindered by things like a lack of clinical guidelines,

inadequate training, or insufficient data. The study also suggests that cross-bracing's supposed advantages aren't fully exploited in practice, which calls for further educational initiatives to better enlighten physiotherapists on the protocol's long-term advantages, especially for ACL repair that doesn't require surgery.

Limitations

The small sample size of 82 individuals in the study may introduce bias and may not accurately represent the whole range of physiotherapy techniques, which limits the validity of the study's conclusions. Because the study was restricted to Indian physiotherapists, it might not have captured differences in knowledge, attitude, and practices among various regions or healthcare systems. Self-reported data may potentially contain bias since individuals may exaggerate or underestimate their familiarity with and application of cross-bracing in the workplace. Furthermore, the study did not assess patient outcomes directly, which would offer a better picture of how successful cross-bracing is in real-world situations.

The survey highlights the obvious need for physiotherapists to get better instruction and training on the cross-bracing procedure for ACL injuries. Although most participants agreed that this conservative strategy had merit, its limited adoption in clinical practice suggests that there are still gaps in the translation of information. Wider use of cross-bracing may be facilitated by expanding the distribution of clinical recommendations that are supported by solid research, especially for patients who could benefit from non- surgical ACL care. It is advised that more study be done to evaluate long-term patient outcomes and the possibility of cross-bracing being widely used in a variety of therapeutic contexts.

Conflict of interest: Authors declare no conflict of interest

Financial interests: This was a self funded study

Ethical approval: This study was reviewed and approved by Sumandeep Vidyapeeth Institutional Ethical Committee (SVIEC/IN/PHYS/RP/March/24/6), approval was obtained on 14^th March 2024.

Informed consent: You are invited to participate in research study of "Knowledge, Attitude and Practices about cross bracing protocol in ACL injury : A Survey on Physiotherapist. " One of the most frequent injuries in sports is an Anterior Cruciate Ligament (ACL) damage, which severely impairs a patient's capacity for activity and quality of life. There are several guidelines available for the rehabilitation of ACL injuries, including guidelines endorsed by particular health professional bodies and procedures specific to surgeons. It has been recommended that both surgery and non-operative ACLR therapy follow a gradual, staged, and organized rehabilitation protocol. Rehabilitation seeks to address neuromuscular impairments, strength and range of motion (ROM) deficits, motor control, balance, and knee functional stability. The ultimate goal of rehabilitation is to safely return to sport (RTS). The distance from the ACL's origin to its insertion is the shortest, 90°–135° of knee flexion. The new Cross Bracing Protocol (CBP), which immobilizes the knee at 90° of flexion for 4 weeks following acute ACL rupture in an effort to promote tissue bridging and healing between the torn ACL remnants, intends to shorten the gap between the ligament remnants. ACL bracing protocol promises better knee function and quality of life, less passive knee laxity, and a higher rate of return to sports.

Hence, need of study is to check the awareness about bracing protocol after ACL injury among Physiotherapists. If you decide to participate, please complete the following survey. Your completion of this survey indicates your consent to participate in this research study. It will take about five minutes to complete this survey. You will be asked to answer questions about you and your experience about ACL Injury and how do you manage?. No benefits accrue to you for answering the survey, but your response will be used to examine the recent scenario regarding ACL Injury management among Physiotherapist? There are no risks to you related to this study. Data will be collected using internet; no guarantees can be made regarding the interception of data sent via the internet by any third party. Confidentiality will be maintained to the degree permitted by the technology used. Your Decision whether or not to participate will not affect your future relationship with our institute. If you decide to participate, you are free to stop at any time; you may also skip questions if you don't want to answer them or you may choose not to return the survey.

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Tables 1 to 4 are available in the Supplementary Files section

The authors declare no competing interests.

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