Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers

Background: While the importance of structured rehabilitation following anterior cruciate ligament reconstruction (ACLR), particularly in the return-to-sport phase, is known, for most patients, supervised physical therapy is often completed before this time point. The recent emergence of telerehabilitation and other digital health interventions has the potential to address this “rehabilitation gap.” Methods: The study was conducted as a cross-section, online survey collecting qualitative and quantitative data from open and closed questions. Inclusion criteria included local qualified physical therapists or other professionals working with ACLR patients. Results: Eighty-three percent of respondents experienced a “rehabilitation gap” with their ACLR patients. Few reported currently utilizing apps or websites (9.74%). The majority (41/58) reported experience with telerehabilitation, and 84% felt that there was a role for digital rehabilitation strategies to address the “rehabilitation gap.” The vast majority (94.74%) of participants felt that standard commercial insurance did not permit sufficient rehabilitation. Discussion: While the majority of our respondents acknowledged the existence of a “rehabilitation gap,” as well as familiarity with and confidence in telerehabilitation, few were using this technique at the time of our survey. This suggests an opportunity for development in this space.


Introduction
2][3][4] The overall age-and sex-adjusted annual incidence of ACL tears was 68.6 per 100,000 person-years, making it a common orthopedic injury. 5Surgical reconstruction is commonly used to treat ACL injury with the goal of returning to sports. 6Between 2004 and 2014, surgeries increased 5.7-fold. 7The cost is estimated at >3 billion dollars annually, not including the psychosocial costs incurred by patients, their families, and clinical teams involved. 81][12][13][14][15][16][17] It takes most patients 9 to 12 months after surgery to pass the return-to-sports criteria. 9,18owever, it has been demonstrated that two-thirds of patients have not returned to preinjury level of competitive sport 12 months after surgery. 19][22] It includes complex decision making around when and how to progress through physical and psychological challenges to facilitate optimum function and minimize the risk of reinjury. 20,23It requires appropriate return-to-sport tests that recreate the physical challenges of sports in a controlled way and measure the individual's ability to perform the necessary physical tasks of their sport. 12,20,21Delaying return to sports until an individual passes these return-to-sport milestone tests helps prevent reinjury. 3,24,25Navigating this without a supervising physical therapist presents challenges, particularly as evidence suggests there is a difference between athletes' perceived and actual readiness to return to sports. 26 recent web-based survey of >1000 American physical therapists found that rehabilitation practice varied significantly in terms of the content and duration of supervised care.23 Specifically, regarding the length of treatment, supervised physical therapy (PT) ranged from 1 to 3 months (15% of respondents) to 12 months (11% of respondents).Overall, 56% of respondents reported 3 to 5 months or less of supervised PT.Another survey-based study was performed on 304 adults 1-20 years following ACLR. 27Patients were seen most commonly once a week for the first 3 months (38%) to once every month (26%) from 6 to 9 months.The exploratory analysis identified that longer durations of supervised rehabilitation are associated with a faster return to sport, greater likelihood of return to previous level of sport, and fewer reported ongoing problems with the knee.Unfortunately, 90% of PT visits are in the first 16 weeks after surgery.28 These data suggest that many patients leave supervised care before participating in return to sports rehabilitation or achieving a return to sports.9 This demonstrates that for many patients, there is a rehabil-itation gap between the end of care and completion of rehabilitation, including return to sports.Greenberg et al. 23 concluded that this gap may contribute to patient confusion and suboptimal outcomes.
Telerehabilitation and other digital health interventions (DHIs) may provide options to address this rehabilitation gap.0][31] Some can facilitate accurate measurement of range of motion. 31,32owever, the challenges of physical assessment and obtaining objective measures are an important limitation despite innovations in this area.This technology has the potential to improve adherence to rehabilitation by engaging with mechanisms of behavior, including personalized features, such as prompts, goal setting, and exercise logs. 33,34elerehabilitation was comparable to conventional inperson rehabilitation in improving clinical outcomes, following knee replacement. 33Some of these interventions are wearable, 35 app or website-based, 33,34 and some are machines that may be delivered to patient's homes for the rehabilitation period. 36The latter study used a three-dimensional camera to facilitate communication between the physical therapists and the patients. 36owever, the burden of equipment delivery and maintenance in these models present challenges.
A further challenge exists in managing the potential for digital exclusion if patients have limited knowledge or access to technology.Twenty-three percent of Americans may not have access to home broadband. 37lthough multiple innovations in this area are available to both patients and physical therapists, this article is unique in its exploration of clinician opinions of the role of telerehabilitation for the rehabilitation gap in the management of ACL patients Digital rehabilitation methods are variously called digital health, eHealth, or mobile health; the term telerehabilitation is increasingly used to describe digital tools that include video consultation.However, in this article, we use the term telerehabilitation as a catch-all term to describe digital rehabilitation strategies that may or may not include video consultations.
Patients have previously used telerehabilitation for knee injuries with high fidelity and noted improved confidence and motivation with their rehabilitation. 22,33,36A recent systematic review found that telerehabilitation following joint replacement was less expensive than in-person therapy, with equivalent outcomes and patient satisfaction. 38s the rehabilitation gap appears to be often caused by patients only being allowed (or able to afford) a certain number of PT appointments, using telerehabilitation through the rehabilitation process as an adjunct to face-to-face care may create an opportunity to prolong PT by stretching the allocated appointments over a longer period.
The attitudes of ACLR patients toward the use of telerehabilitation were examined in a 2020 survey. 39eported benefits included resource saving, improved access to care, improved learning, and greater engagement.Concerns included incorrect performance of exercises or unmanaged pain being missed and less access to manual therapy, motivation, and opportunities to ask questions. 39The attitude of providers toward this technology after ACLR is unknown.

Objectives
1. Explore PT experiences of delivering ACL care.2. Explore opinions of the rehabilitation gap between end of care and recovery/return to sport.3. To understand PT experiences of and opinions of the role of telerehabilitation in ACL care.

Design
This study is a cross-sectional, online survey collecting qualitative and quantitative data from open and closed questions.

Ethics
The survey and study plan were reviewed by the Yale School of Medicine Institutional Review Board and was deemed exempt from review.

Survey development
The survey was developed using the Qualtrics survey platform at Yale University.The authors conducted a similar study on the experiences and opinions of patients who had ACLR with regard to telerehabilitation. 39his study was adapted to explore professional opinions, but for consistency, the same language was used in the questions where possible.The closed questionnaire was designed based on the evidence base and the professional experience of the authors.Clinical peers were consulted on the content through e-mail, but few changes were recommended.The layout of the questionnaire was constructed by a Qualtrics expert at Yale University and the study was piloted with four physical therapists and an orthopedic surgeon.A pati-ent group reviewed the survey and was influential in the decision to include the open ended as well as closed data.There were 26 questions in the survey, some of which had multiple parts (Appendix A1).It ran on four screen pages but was responsive to phone screens also.Ten questions provided demographic characteristics of the population such as age, gender, ethnicity, professional identity, years qualified, number of ACLRs managed, type and location of practice, and whether or not Medicaid is included.There were seven questions that pertained to participants' experiences of managing patients with ACLR and there were nine questions about their experiences and opinions of DHIs.Likert scales were used in three questions.The methodological justification and analysis of these was outlined in the earlier article and will not be repeated in this study. 39The questions were not randomized, and adaptive questions were not used.Respondents could go back and change their answers if they wished.Time spent on the survey was recorded per question.Items were weighted equally.No incentives were offered to complete the survey.
No survey questions were mandatory to allow participants the choice not to answer a question, although participants were prompted to complete the question once before clicking through.Survey questions were predominantly multiple choice; for those questions where ''other'' was offered as an option, it was followed by an open text answer option.The survey concluded with three open, qualitative questions.

Participants, recruitment, and survey distribution
The inclusion criteria were qualified physical therapists or other profession working with ACLR patients, including orthopedic surgeons.People were contacted by e-mail and given a Participant Information Sheet (Appendix A1) outlining the study protocol and consent information highlighting that the participation was entirely voluntary.No formal sample size calculation was used in this formative study. 40urvey distribution was facilitated by providing a unique electronic link to survey online through Yale Qualtrics.It was initially sent on April 23, 2021, to the Orthopedic Manual Therapy Special Interest Group (SIG) of the American Physical Therapy Association.Follow-up e-mails were sent on May 26, 2021 through the Orthopedic SIG.The purpose of the survey was reiterated with each e-mail.E-mails were sent to 22 physical therapists.It was our intention to also distribute the survey through the American Orthopedic Society for Sports Medicine, however, this request was declined.Survey was available online from May 2021 until February 2022.Respondents represented 47 unique American postcodes.

Data analysis
The results are analyzed according to a complete case analysis method.Data were pseudonymized.The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used as a reporting standard 41 (Appendix A2).Responses were collected through the Yale Qualtrics online software, and they were downloaded as an Excel document.The data were prepared for analysis by author E.D.
Data were analyzed using Stata version 17 (Stata-Corp LLC, College Station, TX, USA).The primary analysis was conducted with descriptive statistics and findings were described in frequencies and percentages.Inferential statistics were also used to explore any relationships between participant demographics, such as age, gender, or years of practice and answers on multiple choice questions.Categorical data were analyzed using Fisher's Exact or Chi-Squared tests.To compare continuous data with categorical data a Kruskal-Wallis (more than two groups) or Wilcoxon rank-sum (two groups) was used.To compare two variables of continuous data, a Spearman's rank correlation was used.
For further exploration, a binary category of ''years of practice'' was created by dividing participants into 5 or <5 years and >5 years of practice.Five years was chosen by the investigating authors/clinicians as a clinically relevant benchmark of clinical experience.
The qualitative data were analyzed using a pragmatic thematic analysis. 42Team members coded the data independently and then subsequently agreed on themes.The analysis is both inductive and deductive where responses are analyzed in relation to the research question, however, new or unexpected topics are included in the analysis. 43The themes that arose from each question were grouped and the more developed and discussed themes are emphasized and weighted accordingly.Quotes from participants are used to illustrate themes and to directly relay the participant opinion. 43The analysis was conducted using NVivo 11 (QSR International).

Data protection
Only pseudonymized personal identifying data were collected.The zip code of respondents was recorded but this was removed before the analysis.Qualtrics automatically generated individual identifiers for each respondent based to ensure unique respondents.Identifiers were not assigned to individual computers through the use of cookies.Data were protected by the Yale University firewall.An anonymized dataset with no identifiers or zip codes was sent to University College London for analysis where researcher E.D. is based.

Results
All survey responses were collected utilizing the provided electronic link.Of those participants who started the survey, all completed it (Table 1).Unfortunately, we do not have a definitive number of potential participants, as survey distribution was through a third-party (APTA Orthopedic Manual Therapy SIG), who was unable to provide us with that information.

Opinions of physical therapy after ACLR
Participants felt that PT after ACLR should last longer for athletes (8.87 months, standard deviation [SD] 2.73) than for those who were recreationally active (6.47 months, SD 2.37).The measure of association between Years of Practice and Length of PT for recreationally active patients was p = 0.0493 (À0.2593) indicating a significant association whereby participants with more experience thought less rehabilitation was needed.However, the correlation coefficient is low indicating that the negative relationship is not a strong one.For PT after ACLR for athletes, the trend was the same showing participants with fewer Years of Practice thought that more rehabilitation was needed after ACLR, but the relationship was weak and should be interpreted cautiously.
The qualitative responses (Box 1) reflected a concern that length of rehabilitation be determined by individual factors such as ''activity the patients wish to return to.''Participants further expressed a wish to make rehabilitation length dependent on criteria-based progressions rather than time, referring to ''being able to take the patient through all the appropriate stages'' and ''pass return to sports testing.''They also referred to limits of insurance coverage: ''most insurances stop when the patient is functional but never get to work on cutting or sports-related drills.''One participant offered approaches to reducing need for therapy later in care pathway if the patient can access their own gym: ''later stages of therapy are able to be at a reduced frequency, assuming the patient has access to appropriate strengthening equipment.''They identified that to fully ''recover,'' recreational active people need an average of 10.67 (4.39 SD) months, whereas athletes needed an average of 13.42 months (5.09SD).Results also showed that those with fewer years of practice thought more recovery time was needed ( p = 0.026; 12 [12-18]; 12 [10-12]).Likewise, people with fewer years of practice thought athletes need longer to recover ( p = 0.0164 [0.3112]).The vast majority of 94.74% (54/57) participants felt that standard commercial insurance did not permit sufficient rehabilitation after PT.Whereas, the participants were more evenly split on whether Medicaid provided enough rehab with 21/45 (46.67%) saying yes and 24/45 (53.33%) saying no.When asked about other limiting factors for physiotherapy, Copays, Work/School Schedules, and Insurance were of some concern to most participants, however, the group was less concerned about Transportation (Table 3).Ten users completed the question around ''other'' factors, but did not elaborate in comments as to what those other factors were.The significant measure of association between people who had managed more ACLRs in the last 2 years and ''transport'' ( p = 0.015) is likely by chance.
Forty-nine out of 59 participants (83.05%) experienced a ''Rehabilitation Gap'' between the end of the care they offer and the patients' full recovery.Participants managed those patients in end-stage rehabilitation by various means, guiding them on how to progress with verbal advice and education (43/195), written advice or handouts (51/195), apps and websites (19/195), by referring them on to personal/athletic trainers (44/195), or continuing to see them as selfpayors (29/195).The denominator of 195 does not reflect a change in participant number, but rather that participants were allowed to click more than one option so there were 195 responses in total.
A further 9 participants clicked ''Other,'' which include, ''the school pays for ongoing rehab,'' ''the patient pays for ongoing care with strength and conditioning coach,'' ''videos on their phone,'' ''space the appointments out so they do last to the end,'' ''provide e-mail for questions,'' ''provide screening at milestones,'' although for the latter it is unclear if this is pro bono work.
When asked if there was a role for digital rehabilitation in filling the ''Rehabilitation Gap'' 84.48% (49/58) participants said ''Yes.''Most preferred to use it in the late phase 41.67% (30/72) although there was a wide variation in the Likert responses as to how suitable each phase was (Table 4).Participants with more years of practice (0-5 years and >5 years) were marginally less likely ( p = 0.049) to see telerehabilitation as suitable in the mid stage of care-return to function.

Views on the acceptability of digital health in ACLR: qualitative data
There were three open-text, qualitative questions included in the survey (Table 5).The first question was ''What would you need from a digital health intervention to make it successful for you to use?''Four key themes arose: high-quality technology, what the patient needs at home, usability and acceptability, and a fourth  theme reflects that 3 participants refuted the idea that DHIs were acceptable in any instance.Box 2 explores the patient quotes that best illustrated these themes.A significant weight of responses described technological features that a DHI should have from quality twoway images to biometric functions to measure range or quality of movement.Participants also required ease of use for both patients and clinicians.There were clear concerns that patients would have access to the space, equipment, and environment suitable for rehabilitation even within their own home to engage in telerehabilitation.This included WiFi and good connections.Patients who did not agree with digital rehabilitation did not elaborate on why.
When asked what their primary concerns were about using DHI, the resounding concern was for clinical safety.In Box 3, participant quotes demonstrate concern that important clinical issues such as wound care, swelling, normal range of motion, or proper movement patterns may not be accurately assessed through DHI.Participants also lamented a perceived loss of the therapeutic relationship and in particular, the potential of touch to guide and reassure movement, the ability of communication to reassure, motivate, and engage.The third theme of concern was focused on the quality of the technology and the suitability of environment in which the patient will use it.Hardware and connectivity as well as rehabilitation equipment were discussed.
Participants strongly emphasized the potential of DHI to go some way toward bridging the rehabilitation gap (Box 4).There was also a strong emphasis on the ability of DHI to manage patients over a large geographical area.The experiences of pandemic were referenced by multiple participants as having created distance and the potential of DHI to overcome this.Some participants discussed DHI in terms of having cost-saving potential, although they did not clearly elaborate on how.It was thought that patients themselves might be empowered by conducting their rehabilitation at their own home and therefore somewhat on their own terms.Finally, participants saw the potential of DHI to track and monitor outcome measures in a way that would be clinically very useful.

Discussion
Over recent decades, despite advances in surgical technique and technology, the time until return to play following ACLR has been lengthened.With greater study of postoperative rehabilitation, acknowledgment of the persistence of functional, psychological, and strength limitations has led many practitioners, both physical therapists and orthopedic surgeons, to often delay their patient's return to unrestricted activity until closer to 9-12 months (or achievement of return to sport criteria, which usually takes a similar time), with the goal of limiting retears and further injury. 9,18he purpose of this investigation was to first query physical therapists' experiences in treating ACL postoperative patients, to explore if a ''rehabilitation gap'' exists and how clinicians experience it and finally to understand clinician attitudes toward alternatives, such as telerehabilitation.A review of the demographics of our responding providers, revealed that 58/68 (85.29%) were younger than 40 years of age.This is worth noting, since our population largely trained during the era of greater appreciation for return to play criteria.As such, much our population may not have practiced in the time when return to play at 6 months was the norm.
With regard to their recent professional experience with ACLR patients, 58/68 (86.56%) of our respondents had treated <25 ACLR patients in the last 2 years.This suggests that our physical therapist population likely represents general rather than a specialist group.This would confer greater generalizability to the broader PT provider population.
Our respondents felt that it takes a recreational athlete less time (10.67 months, SD 4.39) to fully recover from ACLR, than competitive athletes (13.42  Theme 1. Facilitates longer follow up to limit the rehabilitation gap ''Intermittent checks ins during end stage of care.Ability to progress over longer durations.'' ''Increased length of time to check in with patients and maintain some level of assistance'' ''Bridging gap before return to play'' ''I think it'd be very helpful to use in conjunction with in person visits during the early and mid stages of rehab to 1) save visits to more sport specific (if required) activity in later stages and 2) easier for pt to perform less skilled interventions (especially if insurance/transportation gaps are a concern)'' ''Reducing amount of visits used initially to promote better coverage at the back end'' Theme 2. Overcomes distance ''Reach more people in rural locations or when quarantined'' ''Being able to help more people that are not able to come in person from other areas of your state, region or nationally/internationally'' ''May help with transportation barrier'' ''During COVID we used Telehealth to gain access to our patients (especially at the college level) to assist with their rehab process while they were quarantined to homes all over the country.''Theme 3. Affordability ''Cost effective'' ''May be more cost effective for those who cannot afford personal training or advanced RTS programs.''''Long-term cheap follow-up and easy tool to monitor patients progress'' Theme 4. Benefits for patient ''Easier for patient to build into schedule'' ''Building a dialogue with patients in the comfort of their home in the early stages post op'' ''Psychosocial emphasis can still be address, patient independence and confidence building'' Theme 5. Improved tracking and monitoring ''More 1:1 care.You're able to give patients 1:1 attention and progress/regress more appropriately.Buy in is higher, compliance is higher'' ''Easy tool to monitor patients progress'' ''Tracking home/gym workouts'' Gardner, et al.; Telemedicine Reports 2024, 5.1 http://online.liebertpub.com/doi/10.1089/tmr.2023.0022SD 5.05).As these two populations are specifically differentiated based upon the demands of their activities, it is logical that competitive athletes would take longer to achieve full recovery.Current literature suggests that return to play criteria are typically not met until 9-12 months, 9,20,44 and return to sports before 9 months increases the risk of reinjury by 51%. 21One respondent suggested, especially for competitive athlete that there is ongoing progress, perhaps necessitated by the environment of unrestricted play, which occurs after a postoperative athlete is allowed to return to sport: ''Competitive athletes go back contact at 9 months typically but don't feel fully recovered until closer to a year with competition under their belt.''Qualitative responses regarding time to full recovery emphasized two primary themes.The first, that this time is in part defined by the goals of the patient, is seen in the difference between our two athlete populations.The second, that the duration of complete recovery is in part guided by evidence, suggests an appreciation that not all aspects of ''healing'' or ''recovery'' can be readily physically appreciated.For example, ongoing research into the process of ligamentization, 45 neuromuscular retraining, 46 and psychological readiness 47 has likely contributed to this appreciation.There are researchers who have suggested that return to sports should be delayed for up to 2 years due to ongoing biological and functional considerations. 28or both recreational athletes and competitive athletes, there was a significant effect of years in practice with the opined time until full recovery.Specifically, physical therapists with 5 or less years of continuous practice responded that longer time to recovery was necessary.It should be noted that longer duration of practice does not necessarily equate with more experience treating ACL postoperative patients.The reason for this effect is unclear.It could be postulated that a generally less-experienced physical therapist may be more cautious in risk tolerance.Alternatively, physical therapist with a longer duration of practice may have practiced during the time when it was accepted that patients were ''recovered'' around 6 months after surgery.
Our respondents' perspective regarding the ideal duration of supervised PT following ACLR follows a similar pattern as above.Specifically, they felt that recreational athletes required on average 6.47 months of PT, whereas competitive athletes needed 8.87 months.A 2018 survey of American Physical Therapy Association members reported that the majority of their respondents treated their postoperative ACL patients for 4-5 months (40.6%) and 6-8 months (32.1%). 48s with return to sport timing, physical therapists with 5 or fewer years of continuous professional practice felt that patients in both groups needed a longer course of supervised PT treatment.This same effect was seen in the aforementioned survey of American Physical Therapy Association members. 48The authors have theorized that perhaps physical therapists with longer treatment experience feel that they are better able to impart their knowledge, or that more experienced practitioners may have a more established network of community-based alternative providers (such as personal trainers/coaches or athletic trainers).Interestingly in their study, high-volume practitioners and certified specialists also advocated for a longer duration of supervised care.This association with volume was not seen in our population.
Prior study of the actual duration of PT following ACLR has been sparse.Two large database studies, both utilizing the PearlDiver database, have been reported. 49,50Both have reported an average of 17 postoperative PT sessions per patient.Patients completed a mean of 52% of their visits in the first 6 weeks, 75% in the first 10 weeks, and 90% in the first 16 weeks after surgery. 49rior investigation has suggested that from the perspective of the patient, there may be many reasons for the cessation of formal PT, including the financial cost to and time constraints of the patient and insurance coverage. 23,39hemes expressed regarding the optimal duration of supervised PT were similar to those about overall patient recovery with one exception -the impact of ''resources'' on the duration of treatment, specifically, the impact of insurance coverage on the ability of patients to access PT.This effect was further investigated with direct questions on the topic.Nearly all respondents, 54/57 (94.74%) who answered the question, felt that standard commercial insurance did not permit sufficient PT after ACLR.
It should be noted that in a prior study, 77% of patients felt that they had sufficient PT after ACLR, despite only 11% of patients feeling that they had fully recovered at the end of their PT sessions. 39nterestingly, our study population was more split regarding adequacy of PT for Medicaid/state insurance patients, with nearly half of respondents feeling that this population does receive sufficient access to PT.There has been no formalized study of the access of patients to PT based upon their insurance coverage, which limits interpretation of this finding.Additionally, Medicaid visit restrictions vary by state and diagnosis, making it difficult to generalize our findings, as all respondents to our survey were located in a single state.

Rehabilitation gap
However, despite known ongoing physical deficits, most patients are discharged from supervised PT well before they are cleared for return to unrestricted physical activity, creating what has been referred by these authors as a ''rehabilitation gap.'' 39While other rehabilitation professionals, such as school athletic trainers, may help to assume treatment during this time, a 2015 study reported that only 37% of public secondary schools provide full-time athletic training services, 51 never mind the population of older patients who are no longer in secondary school.
When asked directly, 83.05% of our respondents felt that there is a ''rehabilitation gap'' present between the completion of their supervised care and the full recovery of their patient.The most popular strategies to manage this were verbal advice/education, written/printed handouts, and referral to a personal or athletic trainer.While 84.48% of our respondents felt that there is a role for DHIs to fill the ''rehabilitation gap,'' only 9.74% reported the use of websites or apps, suggesting an opportunity for development in this space.
In the post-COVID19 era, when medical practitioners of all types, including physical therapists, were asked to make rapid adjustments to their practice styles, facilitating the adoption of virtual treatment strategies such as telehealth and websites.In our population, 70.69% of respondents had utilized telerehabilitation with video and 56.36% have referred to websites.Only 33.93% have utilized apps, perhaps suggestive of the lack of developed app resources.Study of both patients and physical therapists have found both groups to be receptive to virtual therapy sessions. 52eparate studies have reported the acceptability 29 and feasibility 33 of a web-based digital health tool to complement traditional in-person treatment.Our study reported that the majority of practitioners had only minor concerns regarding the potential for leak of sensitive medical information.
The majority of respondents stated that the late phase of rehabilitation, specifically around return to play, would be particularly amenable to the use of DHIs.This is in contradistinction to the opinion of many patients-in prior research by these authors, 60% of survey postoperative patients expressed that they would prefer the use of telerehabilitation early in treatment, to save in-person visits for later. 39Many patients did note the potential for telerehabilitation as a maintenance tool following discharge from PT.It is important to note that these patient surveys were collected before the COVID-19 pandemic.

Limitations
Like all survey studies, our results are limited to the data gathered.Ours had a relatively small sample size, which was limited to a single state, which limits the generalizability to the rendered opinions.One respondent was a sports medicine-trained orthopedic surgeon.At the time of study inception, it was intended that this survey would be distributed to a population of both physical therapists treating postoperative ACL patients, as well as orthopedic surgeons who perform ACLR.However, potentially due to a sudden increase in survey studies during the COVID19 pandemic, distribution of this study through several orthopedic societies was declined.Therefore, the respondent population was limited to physical therapists.The opinion of this important stakeholder population would greatly add to this conversation.

Conclusions
In an attempt to limit the risk of ACL reinjury, the duration of the return to recreational and competitive sport phase of rehabilitation has lengthened postoperatively.However, the duration of supervised PT has not increased, suggesting that many patients are discharged before full recovery, creating a ''rehabilitation gap.''There is great variation in current management of this time period, and DHIs have been identified as one possible resource.Further investment in the development of evidence-based virtual or web-based rehabilitation resources could be a key tool for practitioners and patients alike.Guide them on how to progress with verbal advice and education Guide them on how to progress with written or printed handouts Guide them on how to progress using websites or apps The number of people submitting the last questionnaire page, divided by the number of people who agreed to participate (or submitted the first survey page).This is only relevant if there is a separate ''informed consent'' page or if the survey goes over several pages.This is a measure for attrition.Note that ''completion'' can involve leaving questionnaire items blank.This is not a measure for how completely questionnaires were filled in.(If you need a measure for this, use the word ''completeness rate.'')Preventing multiple entries from the same individual Cookies used Indicate whether cookies were used to assign a unique user identifier to each client computer.If so, mention the page on which the cookie was set and read, and how long the cookie was valid.Were duplicate entries avoided by preventing users' access to the survey twice; or were duplicate database entries having the same user ID eliminated before analysis?In the latter case, which entries were kept for analysis (e.g., the first entry or the most recent)?IP check Indicate whether the IP address of the client computer was used to identify potential duplicate entries from the same user.If so, mention the period of time for which no two entries from the same IP address were allowed (e.g., 24 h).
Were duplicate entries avoided by preventing users with the same IP address access to the survey twice; or were duplicate database entries having the same IP address within a given period of time eliminated before analysis?If the latter, which entries were kept for analysis (e.g., the first entry or the most recent)?

Log file analysis
Indicate whether other techniques to analyze the log file for identification of multiple entries were used.If so, please describe.

Registration
In ''closed'' (non-open) surveys, users need to login first and it is easier to prevent duplicate entries from the same user.Describe how this was done.For example, was the survey never displayed a second time once the user had filled it in, or was the username stored together with the survey results and later eliminated?If the latter, which entries were kept for analysis (e.g., the first entry or the most recent)?

Analysis
Handling of incomplete questionnaires Were only completed questionnaires analyzed?Were questionnaires, which were terminated early (where, e.g., users did not go through all questionnaire pages), also analyzed?Questionnaires submitted with an atypical timestamp Some investigators may measure the time people needed to fill in a questionnaire and exclude questionnaires that were submitted too soon.Specify the timeframe that was used as a cutoff point, and describe how this point was determined.

Statistical correction
Indicate whether any methods, such as weighting of items or propensity scores, have been used to adjust for the nonrepresentative sample; if so, please describe the methods.
Authorship Contribution Statement E.C.G.: Conceptualization, methodology, validation, investigation, data curation, writing-original draft, writing-review and editing, and visualization.C.P.: Validation, investigation, date curation, writingoriginal draft, and writing-review and editing.E.D.: Conceptualization, methodology, validation, formal analysis, resources, investigation, data curation, writing-original draft, and writing-review and editing, visualization.(Appendix continues /) How long do you think that physical therapy should last after ACL reconstruction surgery for the average patient?Please comment if helpful.For recreationally active patients (number of months), for competitive athlete patients (number of months) Comments: How long do you think it takes the average patient to fully ''recover'' after ACL reconstruction surgery?For recreationally active patients (number of months) For competitive athlete patients (number of months) Comments On average, do you think that standard commercial insurance permits sufficient physical therapy after ACL reconstruction surgery?Yes No I Don't Know On average, do you think that Medicaid/state insurance permits sufficient physical therapy after ACL reconstruction surgery?Yes No I Don't KnowHow much do you think that your patients' access to physical therapy is limited by any of the following: a ''Rehabilitation Gap'' in your practice between when you have completed care and when your patient is fully recovered?Yes No Evidence suggests that most patients have completed face-to-face physical therapy 5 months after surgery.How do you manage your patients during the final stages?(Select as many as apply)

Table 2 .
Characteristics of Participants Box 1. Opinions and experiences of anterior cruciate ligament rehabilitation Part 2: Qualitative responses ACLR, anterior cruciate ligament reconstruction; DPT, doctor of physical therapy; PT, physical therapy; SD, standard deviation.

Table 3 .
Opinions and Experiences of Anterior Cruciate Ligament Rehabilitation Part 1 Quantitative Responses

Table 4 .
Opinions and Experiences of Digital Health

Table 5 .
Qualitative Themes months, Box 2. What would you need from a digital health intervention to make it successful for you to use? (RPE-rate of perceived exertion) Box 4. What, if any, do you see as potential benefits to the use of digital health interventions following anterior cruciate ligament reconstruction surgery ''Minimally efficient for post-op patients'' ''I don't agree with telehealth, I think the patient is at a disservice'' ''Better to have the patient in person'' It is technically possible to do consistency or completeness checks before the questionnaire is submitted.Was this done, and if ''yes,'' how (usually JAVAScript)?An alternative is to check for completeness after the questionnaire has been submitted (and highlight mandatory items).If this has been done, it should be reported.All items should provide a nonresponse option such as ''not applicable'' or ''rather not say,'' and selection of one response option should be enforced.Review stepState whether respondents were able to review and change their answers (e.g., through a Back button or a Review step, which displays a summary of the responses and asks the respondents if they are correct).Response ratesUnique site visitor If you provide view rates or participation rates, you need to define how you determined a unique visitor.There are different techniques available, based on IP addresses or cookies or both.Requires counting unique visitors to the first page of the survey, divided by the number of unique site visitors (not page views!).It is not unusual to have view rates of <0.1% if the survey is voluntary.Count the unique number of people who filled in the first survey page (or agreed to participate, e.g., by checking a checkbox), divided by visitors who visit the first page of the survey (or the informed consents page, if present).This can also be called ''recruitment'' rate.