Comparative Effectiveness of Tele-Rehabilitation vs In-Person Physiotherapy for ACL Rehab Outcomes

Thesis Abstract

The rapid expansion of tele-rehabilitation has transformed access to post-operative physiotherapy, yet its comparative effectiveness for anterior cruciate ligament (ACL) rehabilitation relative to traditional in-person care remains inadequately defined. This study addresses the problem of uncertain outcomes, adherence, and patient satisfaction in tele-rehabilitation for ACL rehab, with implications for clinical guidelines and resource allocation. The aim is to compare functional outcomes, adherence, patient-reported experience, and cost-effectiveness between tele-rehabilitation and in-person physiotherapy following ACL reconstruction. Specific objectives include (1) to evaluate knee function using the International Knee Documentation Committee (IKDC) subjective knee form and Lysholm score at 3, 6, and 12 months post-surgery; (2) to compare quadriceps strength, hop test performance, and range of motion between groups at identical time points; (3) to assess adherence to prescribed exercise programs and home exercise compliance via electronic monitoring and self-report; (4) to examine patient-reported experience measures (PREMs) and satisfaction; (5) to analyze health economics through direct and indirect costs from a societal perspective; and (6) to identify moderating effects of sociodemographic variables and baseline functional status. A parallel-group, non-inferiority randomized controlled trial will be conducted with 260 participants undergoing ACL reconstruction across three regional sports medicine centers. Participants will be randomly allocated (11) to either a 12-week tele-rehabilitation program delivered via synchronous video consultations and a digital exercise platform, or conventional in-person physiotherapy, with standard care protocols and progression criteria. Blinded assessors will collect outcome data at 3, 6, and 12 months post-operatively. Primary data will include IKDC and Lysholm scores; secondary data will comprise isometric quadriceps strength (dynamometry), single-leg hop distance, knee range of motion, adherence metrics from the digital platform, and standardized PREMs. Economic evaluation will entail a cost-utility analysis from the payer and societal perspectives, calculating incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) gained. Data analysis will apply intention-to-treat principles. Non-inferiority will be tested using mixed-effects regression models for continuous outcomes, adjusting for baseline values, age, sex, graft type, and rehabilitation intensity. Repeated-measures ANOVA will explore trajectory differences across time points. Mediation analyses will investigate whether adherence mediates the relationship between rehabilitation modality and functional outcomes. Cost-effectiveness will be analyzed using bootstrapped (5,000 iterations) probabilistic sensitivity analyses and cost-effectiveness acceptability curves. Subgroup analyses will examine differential effects by age groups (<25 vs ?25), sex, urban vs rural residency, and baseline motivation scores. Theoretical framing will be guided by the Self-Determination Theory to interpret adherence and motivation dynamics and the Health Belief Model to contextualize perceived barriers and benefits of tele-rehabilitation. The study will adhere to CONSORT guidelines for non-inferiority trials and TREND guidelines for non-randomized aspects of economic evaluation, with ethical approval obtained from participating institutions’ review boards. Expected findings anticipate that tele-rehabilitation will be non-inferior to in-person physiotherapy in functional outcomes at 12 months, with comparable IKDC and Lysholm scores, similar or superior adherence rates due to digital scaffolding, and cost savings attributable to reduced travel and facility use. It is anticipated that tele-rehabilitation may yield higher PREMs scores in convenience and accessibility but similar satisfaction regarding therapeutic alliance. Subgroup analyses may reveal marginally better adherence and outcomes among rural residents due to reduced travel burden, while urban participants may show similar outcomes across modalities. The study contributes to knowledge by providing robust, high-quality evidence on the clinical equivalence and economic viability of tele-rehabilitation for ACL recovery, informing clinical guidelines, payer policies, and future research on remote musculoskeletal rehabilitation. The main conclusion is that tele-rehabilitation is an effective and efficient alternative to traditional physiotherapy for ACL rehabilitation, with implications for expanding access, optimizing resource allocation, and personalizing rehabilitation pathways. Recommendations include integrating tele-rehabilitation as a standard option in ACL recovery protocols, investing in user-centered digital platforms to support adherence, and conducting longer-term follow-up studies to assess outcomes beyond 12 months and to explore integration with home-based neuromuscular training programs.