Comparative Efficacy of Tele-Rehabilitation vs In-Person Physiotherapy for ACL Recovery

Thesis Abstract

This study addresses the clinical and access-related challenges in ACL rehabilitation by comparing the efficacy of tele-rehabilitation (TR) delivered via synchronous video sessions and mobile apps versus traditional in-person physiotherapy (IP) across the initial 12-week postoperative period. The aim is to determine whether TR yields non-inferior outcomes in functional recovery, pain modulation, quadriceps strength, and return-to-activity timelines relative to IP, while also evaluating adherence, patient satisfaction, and cost-effectiveness. Specific objectives include (i) comparing functional outcomes using the International Knee Documentation Committee (IKDC) subjective knee form and the Lysholm score at 6 weeks, 12 weeks, and 6 months; (ii) assessing muscle strength symmetry via isokinetic dynamometry at 60 and 180 degrees per second; (iii) evaluating patient-reported pain on a numeric rating scale and activity level using the Marx Activity Rating Scale; (iv) examining adherence to exercise prescriptions through session attendance, completion rates, and wearable-tracked activity; (v) exploring psychosocial factors and therapeutic alliance through the Working Alliance Inventory-Short Form; and (vi) conducting a cost-effectiveness analysis from the healthcare system perspective. A multicenter, randomized controlled trial with a non-inferiority design will be conducted, enrolling 240 adult patients (aged 18–45) undergoing primary ACL reconstruction across three orthopedic centers. Participants will be randomized 11 to TR or IP physiotherapy, stratified by center and baseline IKDC score. TR will comprise synchronized video-guided sessions three times weekly for 12 weeks, supplemented by a validated home-exercise program delivered through a mobile application with real-time feedback and remote monitoring. IP participants will receive standard face-to-face sessions with identical exercise content and progression guidelines. Data will be collected at baseline (preoperative or immediate postoperative), 6 weeks, 12 weeks, and 6 months. Instruments will include IKDC, Lysholm, Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, isokinetic dynamometry for quadriceps and hamstring peak torque, range of motion measurements, patient satisfaction surveys, adherence logs, and economic data from billing records. Validity and reliability will be ensured by using previously validated French/English translation where applicable and calibrating dynamometers across sites. Statistical analyses will adhere to intention-to-treat principles. Non-inferiority margins will be predefined (a 6-point difference on the IKDC). Primary analysis will test non-inferiority of TR versus IP for the change in IKDC score from baseline to 12 weeks using mixed-effects linear models with fixed effects for group, time, and group-by-time interaction, and random intercepts for participants and centers. Secondary outcomes will be analyzed using repeated-measures ANOVA for continuous variables and generalized estimating equations for binary outcomes (e.g., adherence benchmarks). Isokinetic strength data will be analyzed with repeated-measures ANOVA, adjusting for baseline strength and sex. Regression analyses will explore moderators such as baseline activity level, psychosocial factors, and access to technology. A cost-utility analysis will estimate incremental cost-effectiveness ratio (ICER) using quality-adjusted life years (QALYs) derived from the EQ-5D-5L instrument. Expected findings include non-inferiority of TR to IP in functional recovery and strength at 12 weeks and sustained advantages in accessibility and patient satisfaction, with higher adherence linked to interactive features and timely feedback. Tele-rehabilitation is anticipated to be more cost-effective due to reduced travel and facility utilization, though equipment and data costs may partially offset savings. The study contributes to knowledge by providing robust, multicenter evidence on the clinical and economic viability of tele-rehabilitation in ACL recovery, clarifying the role of therapeutic alliance and technology-enabled monitoring in postoperative rehabilitation, and informing policy on scalable rehabilitation models. The main conclusion is that well-structured TR for ACL rehabilitation can deliver equivalent functional outcomes to IP therapy, with added benefits in accessibility and patient engagement, underlying the potential for TR to become a standard adjunct or alternative in postoperative care. Recommendations include the adoption of TR protocols with standardized progression criteria, investment in user-friendly platforms to enhance adherence, training for therapists in remote communication strategies, integration of objective remote monitoring tools, and consideration of TR as a viable option in health systems aiming to expand access while optimizing costs.