| Summary: | Background: Anterior cruciate ligament (ACL) injury is associated with pain, limited function and reduced quality of life (QoL), with prevalence associated with sports participation, which represents a clinical and financial burden to patients and healthcare systems. ACL reconstruction is the main treatment and pre-operative physiotherapy potentially plays a role in preparing patients for surgery and improves post-surgery health outcomes. Its effectiveness on patients’ health outcomes pre- and post-surgery and awareness of patients and healthcare professionals have not been investigated in the Kingdom of Saudi Arabia (KSA). There is a lack of standardised protocols used in practice for pre-operative physiotherapy management of patients undergoing ACL reconstruction, and the clinical and financial effects have not been investigated. Aims: This thesis aims to develop a standardised pre-operative physiotherapy programme for patients undergoing ACL reconstruction based on clinical and literature evidence, and to investigate the effectiveness of the developed protocol in KSA. Methods: This study included three inter-related phases. Phase 1 - a survey of the prevalence of ACL injury in Riyadh, KSA, and of pre-operative physiotherapy awareness of healthcare professionals and ACL-deficient patients. A sample of 200 patients and 200 practitioners was surveyed and the Ministry of Health and 3 hospitals were contacted about ACL injury cases. Phase 2 - a systematic review of literature on pre-operative physiotherapy programmes and effectiveness in ACL injury management. Phase 3 - a quasi-randomised clinical trial of a standardised pre-operative protocol, using Phase 1 and 2 findings. This protocol was administered to ACL-deficient patients undergoing reconstruction in KSA. Two patient groups were included: an intervention group (n = 39), who received the developed pre-operative programme; and a control group (n = 45), who did not receive pre-operative physiotherapy. The primary outcome measures were based on the Knee injury and Osteoarthritis Outcome Score (KOOS), and secondary outcomes included range of motion, quadriceps and hamstring muscle strength, health status (using the EQ-5D-5L tool), pain score, QoL and resource use. Results: Phase 1 showed ACL injury is the most prevalent knee related injury (53%), with young, active participants being mostly affected (60%). The prevalence in Riyadh (31 per 100,000) was similar to international figures. 82% healthcare professionals were aware of pre-operative physiotherapy, whereas 55% of surveyed patients were aware. Phase 2 suggested that pre-operative physiotherapy is beneficial to ACL injury patients. Phase 3 demonstrated that primary and secondary outcomes were improved prior to surgery in the intervention group compared to baseline (p < 0.01). Post-surgery outcome measures were better in the intervention group than the control group (p < 0.05) except function in sports activity, which was similar. The incremental cost-effectiveness ratio (ICER) related to pre-operative physiotherapy intervention was estimated at 13449 SR (£2241) per QALY gained and the intervention was cost-effective. Conclusions: The findings showed the clinical and cost-effectiveness of the developed, evidence-based pre-operative protocol in preparing patients for ACL reconstruction and improving health outcomes post-surgery. Therefore, pre-operative physiotherapy for ACL injury should be integrated routinely into the Saudi healthcare system.
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