Improving Identification of ACL Tears in Primary Care...The Consequences of an ACL Tear Short & Long term consequences of ACL tear ACL Injury Re-injury Inactivity Osteoarthritis 15-23%

JL Whittaker, Physiotherapy Alberta – May 21, 2020

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Improving Identification of ACL Tears in Primary CareJackie Whittaker PT, PhDAssistant Professor, Department of Physical Therapy, University of British ColumbiaResearch Scientist, Arthritis Research Canada

@jwhittak_physioMay 21, 2020

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Background – ACL injuries & their consequences1

Presentation Overview

Study 2 – Canadian ACL 1o Care Survey (CAPS)3

4 Discussion Points

2 Study 1 – Improving ACL Dx in 1o Care

@jwhittak_physio

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How Common are ACL Tears?General Population – ACL Tear Incidence

Prodromos et al 2007, Sanders et al 2016, Poulson et al 2019

• 1 ACL tear / ~1,458 persons per year~250,000 per year~24,000 per year

• up to 98% undergo surgery

General Population

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How Common are ACL Tears?Sporting Populations – ACL Tear Incidence & Rates

• ~1 in 29 females per season (peak occurrence 14-18 years)

• ~1 in 50 males per season (peak occurrence 19-25 years)

*Sex disparity is independent of participation level

Sporting Population

Montalvo et al 2019

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Paterno et al 2012, Aujed et al 2014, Baltich et al 2015, Suter et al 2017, Toomey et al 2017, Whittaker et al 2019

The Consequences of an ACL TearShort & Long term consequences of ACL tear

ACL Injury Exercise Therapy +/- Surgery

+/-

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Obesity

Paterno et al 2012, Aujed et al 2014, Suter et al 2017, Toomey et al 2017, Whittaker et al 2019, Montalvo et al 2019

The Consequences of an ACL TearShort & Long term consequences of ACL tear

ACL Injury Re-injury Inactivity Osteoarthritis

15-23%re-injury

2.1x’s >odds of inactivity

2.4x’s >odds of obesity

20% lifetimerisk of OA

Women are 2-10x’s more likely to have an ACL injury then men playing the same sportWomen have an increased risk of knee osteoarthritis after 55 years of age

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Healthcare costs(imaging, opiods,

consultations, surgery etc.)Workforce productivity

Murphy et al 2008, Wright et al 2010, Hawker et al 2014, Hunter et al 2014, Abbot et al 2017, King et al 2018

The Consequences of an ACL TearWhat is the big deal about Osteoarthritis?

Osteoarthritis

PainDisabilityInactivity Obesity

QoLComorbidities

Premature death

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OA Prevention & Treatment

Optimizing the Care of ACL InjuriesWhat can be done better @ each step to mitigate the long-term consequences?

ACL Injury ACL Diagnosis

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ACL Treatment

Who? When? How?

• ED, MD, PT, Specialist ?• Early – Late ?• Imaging or not ?

What? When? How?

• Exercise therapy, Sx ?• Early – Late ?• Individual, group, coverage ?

What? When? How?

• Muscle Strength, Adiposity• Early – Late ?• Individual, group, in-person

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Delayed or misdirected rehabilitation, physician & specialist visits

ACL Injury

Only 15% of ACL tears are diagnosed at the first medical

appointment

Missed & False Diagnosis of ACL TearsIndividual & Healthcare System Consequences

Aratsu et al 2015, Sanders et al 2016, Filbay et al 2017, Sommerfledt et al 2018, Zadro et al 2018

Long specialist & imaging wait lists

Poor patient outcomes

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Improved outcomes (return to work, sport, activity, etc.)

ACL Injury

Early & accurate diagnosis

Improved Diagnosis in Primary CareTimely & Appropriate Management

Aratsu et al 2015, Sanders et al 2016, Filbay et al 2017, Sommerfledt et al 2018, Zadro et al 2018

What combination of patient-reported and/or clinical exam

components are most valuable for ACL tear diagnosis?

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ACL Injury

Develop & internally validate preliminary statistical models to predict full thickness ACL tears using the best combination of;

Patient reported (online triage system) = Model 1Patient reported & Clinician generated (clinical decision tool) = Model 2

Whittaker et al 2020

Study #1 Improving the Diagnosis of ACL tears Purpose

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Electronic Records Included• 15-45 years of age• ICD-9 knee injury code • +/- ACL tear (diagnosis by surgeon +/- MRI) • January 2014 - June 2016

Electronic Records Excluded• Injury prior to study date• Chronic ACL deficiency or re-tear• Knee osteoarthritis

Data Source


Study #1 Improving the Diagnosis of ACL tears Methods

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• Demographic (age, sex, BMI, sport)• Injury details (date, diagnosis date, time since)• Diagnostic Details (ICD-9, MRI etc.)• Potential ACL tear diagnostic indicators

(mechanism of injury, history & exam elements)

Practitioner Survey (n=17)• PT, SEM MD & Orthopaedic

surgeon

Search of Relevant Evidence

Data Source Procedures



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Data Source Procedures Analysis

Univariable Analyses• Logistic regression

(95%CI) = univariable comparisons (p=0.001) evidence, survey & data availability

Multivariable Models• Multivariable logistic

regression (95%CI) = most promising predictors from univariable regression (p<0.10)

Validation• Performance assessed

by accuracy rate, sensitivity/specificity & +/- LR (95%CI)

70% of data = multivariable models30% of data = evaluated models



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1,512 Eligible Electronic Records

725 Electronic Records Included

497 Complete Electronic Records

Exclusion Reasons • No data sharing agreement (n=133)• Injury prior to study (n=373)• Chronic ACL (n=114)• ACL Re-injury (n=37)• Osteoarthritis (n=68)• Mis-coding (n=76)

289 ACL-436 ACL+

176 ACL-321 ACL+

No difference in sex or age between those eligible & included


• Incomplete records (n=228)

Study #1 Improving the Diagnosis of ACL tears Results – Electronic Records

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48%

Age (median: range): 26 (15-45)Injury Assessment

Time (median: range): 176 days (10-798)

MRI = 90% Surgery = 40%Sport = 87%Whittaker et al 2020

Study #1 Improving the Diagnosis of ACL tears Results – Demographics

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Practitioner Survey Univariable Comparisons Univariable Logistic Regression

Lachman Test Lachman Test Lachman Test (+ or -)

Immediate pop Immediate pop, pain & swelling Immediate Swelling (<4 hours)

Instability Instability Sport-related injury (Y/N)

Plant/pivot MOI Family History Family History (Y/N)

Age <25 years Inability to return to sport Age (<25 years)

Pivot Shift Test

Anterior Drawer Test

MOI = Mechanism of Injury,


Study #1 Improving the Diagnosis of ACL tears Results – Variables Associated with an ACL tear

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Patient + Clinician Model

+Age | Sport-relatedImmediate swelling | Family history | Lachman test

Patient Only ModelAge | Sport-relatedImmediate swelling Family history

Accuracy = 84% (95% CI 77,90)Sensitivity = 60% (95%CI 44,74)

Specificity = 95% (95% CI 89,98)+ve LR = 5.5 (95% CI 2.3,12.4)-ve LR = 0.91 (95%CI 0.12,0.30)

Accuracy = 94% (95% CI 90,98)Sensitivity = 94% (95%CI 88,98)Specificity = 95% (95% CI 82,99)+ve LR = 9.5 (95% CI 4,22)-ve LR = 0.03 (95%CI 0.01,0.1)

+

vs.


Study #1 Improving the Diagnosis of ACL tears Results – Variables Associated with an ACL tear

vs.

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Two Stage ACL Tear Diagnosis ?

Injury Clinical ExamOnline Triage Timely & Accurate Diagnosisü Age < 25 years

ü Sport-related injuryü Immediate Swellingü Family History of ACL

ü Lachman Test

Study #1 Improving the Diagnosis of ACL tears Discussion

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Limitations• Retrospective analysis• Data not collected for this purpose• Incomplete electronic records• Unable to consider variables found

helpful by others;Popping sensation at time of injuryPivot mechanism of injuryPivot Shift test

• Preliminary models ≠ Clinical Decision tool

Decary et al 2018, Whittaker et al 2020

Study #1 Improving the Diagnosis of ACL tears Limitations

Whittaker JL, Chan M, Pan B, Hassan I, Defreitas T, Hui C, Macedo L, Otto D. Towards improving the identification of ACL tears in primary point-of-care settings. BMC Musculoskeletal Disorders 2020

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Prospective Study Clinical Decision Tool

Development

Clinician & Administrator

Interviews (Priorities)

Clinician & Administrator

Interviews (Priorities)

Next StepsImproving the Diagnosis of ACL Tears in Primary Care

Inform the development, external validation & implementation strategies of a clinical decision tool for identifying ACL tears in primary practice.

1-Preliminary statistical models, most valuable predictors2-Explore EMR data quality and completeness3-Observe clinical processes4-Foster clinical and research collaborations

Chart Review ✓

Practitioner Survey ✓

External Validation

Study

Translate into Clinical

Settings

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ACL Injury

Gain a better understanding of current practice patterns for ACL tear diagnosis & management by Canadian primary care practioners

Describe current practice patternsCompare current practice patterns to evidence-base guidelinesExplore barriers to ACL tear diagnosis & management in 1o care

Study #2 Canadian ACL Primary Care Survey (CAPS)Purpose

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Canada-wide Survey• Licensed (Canada) PT’s, general practice MD,

SEM MD, ED MD that encounter ACL tears• REDCap secure web application• January –July 2020

Data Source

Study #2 Canadian ACL Primary Care Survey (CAPS)Methods – Data Source

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• Eligibility Criteria (profession, license, ACL)• Demographics (age, sex, practice length & setting)• ACL tear Diagnosis (criteria used & frequency)• ACL tear Management (progression & return to

activity criteria)• Perceived barriers to Dx & management

Data Source Survey

Study #2 Canadian ACL Primary Care Survey (CAPS)Methods - Survey

Search of Relevant Evidence

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Data Source Procedures Analysis

Descriptive Statistics• Demographics• Survey responses for

ACL Dx & management• Disaggregated by

profession

Thematic Analysis• Open ended questions• Question related to

barriers & facilitators for Dx & management

Compare• Practice patterns to

evidence-based guidelines & recommendations

Study #2 Canadian ACL Primary Care Survey (CAPS)Methods - Analysis

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Study #2 Canadian ACL Primary Care Survey (CAPS)Methods – Evidence-based Guidance for ACL Tear Dx & Management

Meuffels et al 2012, Huston et al 2014, Van Melick et al 2016, Decary et al 2017, Andrade et al 2019, Filbay et al 2019

Diagnosis• Comprehensive history & exam• History (MOI, pop, inability to resume activity, early effusion,

giving away & instability)• Exam (Lachman +/- AD or PS)• No immediate diagnostic imaging

Timing of Treatment• Exercise therapy should be the 1st line of treatment• ACLR only if instability persists or unable to return to activity

despite exercise therapy, or patient preference• If ACLR, then prerehab & rehab

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Study #2 Canadian ACL Primary Care Survey (CAPS)Methods – Evidence-based Guidance for ACL Tear Dx & Management

Meuffels et al 2012, Huston et al 2014, Van Melick et al 2016, Decary et al 2017, Andrade et al 2019, Filbay et al 2019

Rehabilitation• Immediate (week 1) ROM, muscle activation (open & closed chain)• Progress to high load muscle capacity & control through full ROM• Criterion vs. time-based progression• Once > 80% strength focus on occupation & recreation/sport• Consider a PROM (Knee Injury & OA Score – KOOS)• Educate on long-term consequences

Return to Activity• Rarely prior to 9-months• Symptom free with occupation or recreation• > 90% quadricep strength symmetry• Psychological readiness to return (ACL Return to Sport Index)

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205 Respondents

124 Physiotherapists

106 with full or partial responses

Breakdown• 124 PT’s• 9 SEM MD• 4 ER MD• 68 Other - excluded

44 Early Career (< 5 years)62 Middle/Late Career (≥ 5 years)


• 18 = Incomplete records did not progress beyond eligibility criteria

Study #2 Canadian ACL Primary Care Survey (CAPS)Preliminary Results – PT Respondents (April 15, 2020)

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Study #2 Canadian ACL Primary Care Survey (CAPS)Survey Link – PLEASE COMPLETE AND SHARE WIDELY

www.bit.ly/ACLtear_survey

LIMITATIONS – PRELIMINARY DATA – CAUTION WITH CONCLUSIONS

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4 Discussion Points


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Discussion PointsImproving the Diagnosis of ACL Tears in 1o Care

ACL Diagnosis Evidence-Based PracticeNo single diagnostic indicator of an ACL tear Important that entry to practice PT degrees &

clinical placements emphasize EBP

Patient & clinician generated information is superior to identifying ACL tears vs. patient generated information alone

Need to update entry to practice PT courses & provide opportunities for clinical preceptors based on current evidence

A high % of ACL- persons can be identified by considering age, injury setting, immediate swelling & family history

Need to get patients to PT earlier to start exercises that target key muscles

Need to consider differences in practice settings (time from injury, % of case load)

Strategies for keeping patient engaged in rehab up to 9 months. Access & coverage?

Need for clinical decision tools Support to assess patient preferences and readiness to return to activity

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Sudeepta Aruka PTDeclan Norris MScPT

RESEARCH ASSISTANTS

RESEARCH COORDINATORS

Acknowledgements

FUNDING (Study #1);Glen Sather Sports Medicine Clinic Research Development Fund

Division of Orthopaedic Surgery, University of Alberta

Hillary Short MSc

CONSULTATION

CO-INVESTIGATORSMichelle Chan PhDBo Pan MScImran Hassan PhDTerry Defreitas SEM MDCatherine Hui MD Ortho SxLuciana Macedo PT, PhDDavid Otto MD Ortho SxJayden Horochuk MPT StudentCassidy Swenson MPT StudentDeanna Barnes MPT StudentKaylene England, MPT StudentLinda Truong PT, PhD StudentChristina Le PT, PhD CandidateAlison Ezzat PT, PhDAllison Hoens PT, MSc

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Documents

Improving Identification of ACL Tears in Primary Care...The Consequences of an ACL Tear Short & Long term consequences of ACL tear ACL Injury Re-injury Inactivity Osteoarthritis 15-23%