To brace or not to brace after ACL reconstruction with Dr Christina Le

In this episode with Dr Christina Le, we discuss her Research Review of a recent article which looked at a bracing protocol vs going brace-free for the first 6 weeks post ACL reconstruction with hamstring autograft. We discuss the strengths and limitations of the paper as well as what we as clinicians should take away from the paper and use in our own clinical practice.

See Christina’s full Research Review here - https://physio.network/reviews-le

Dr Christina Le is a physiotherapist and completed her PhD in 2022 at the University of Alberta in Edmonton, Canada. As a clinician, she primarily treats individuals with anterior cruciate ligament (ACL) injuries. Having sustained a previous ACL injury herself, she has developed an interest in understanding health-related quality of life (HRQOL) following a sport-related knee injury in youth.

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Our host is @James_Armstrong_Physio.

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Transcript

SPEAKER_01 0:05

So here in Canada, a custom ACL brace, so one that's like custom fitted to you is about$1,800, which is around 1,200 pounds, something like that. And I always say I'd much rather you spend that on a gym membership because that's going to be way more effective for you getting back into playing your sport at a high level, continuing to play it, reducing your injury risk, all that kind of stuff. That's usually my tagline when people ask me about that.

SPEAKER_02 0:33

In today's episode we talk to Christina Lee all about bracing in ACL reconstruction patients. Christina has recently reviewed an interesting paper on the use of bracing for ACL reconstruction patients for the Physio Network Research Reviews and today we dive straight into some of the key findings and takeaways of this paper but interestingly we talk more widely around the state of the research and bracing for this patient population. Christina is a self I'm James Armstrong and this is Physio Explained. Christina, it is wonderful to have you on the podcast today. Thank you so much for coming on and joining us.

SPEAKER_01 1:37

Thank you so much for having me. I'm excited to have a chat.

SPEAKER_02 1:40

Brilliant. So today we're going to be talking about the really interesting subject. We're going to dive straight into this about use of brace in rehabilitation, particularly from ACL re and rehabilitation. And surrounding that, you recently reviewed a paper for the Physio Network on the research reviews. So that will come into today's conversation as well. So should we dive straight in, Christina, about bracing in rehabilitation? What are we talking about?

SPEAKER_01 2:07

Yeah, so the recent paper that I reviewed for the Physio Network was looking at a randomised control trial using a brace within the first about six weeks or so after ACL reconstruction surgery with hamstring tendon autocore. for this paper said that there was no difference in using a brace in the early stages after surgery compared to not using a brace. And I think there's a decent amount of evidence out there that's also pointing that right direction too.

SPEAKER_02 2:35

We're talking about bracing in the early stages postoperatively. Where's that come from? And give us a bit of a history around that.

SPEAKER_01 2:42

So this would be way back in the 1980s, I believe, when obviously ACL reconstruction surgery was very different than the keyhole kind of arthroscopic surgery that we have now. And the protocol back then would have been to put people in a range of motion brace in the 80s, early 90s type of an idea after reconstruction surgery. The thought process being that they didn't want to make the... However, the tendon reconstruction at that point to make it any weaker or introduce any laxity to that graft in those early stages. So what they did was they put people in the brace. And I believe it was Dr. Shelburne. And in the early 90s in the States, his patients who were non-compliant actually, so the ones who wanted to get rid of the brace a little bit faster than usual, were having better early outcomes than the people who were listening to all the instructions to the T. So they ended up doing Thank you so much for joining us. So I think that's just where a lot of these studies have kind of come from now is trying to figure out, is there a bracing option in those early stages that could be helpful? We know that maybe the range of motion restriction stuff isn't helpful, but what could be helpful, I suppose?

SPEAKER_02 4:13

Interestingly, I think the listeners are probably getting a really good idea that there's a frustration there in terms of we seem to be going over this bracing procedure when arguably there's enough evidence to say that actually there's no difference, if not a detriment to bracing patients after. So with the evidence that's out there, why do you think this is still being talked about?

SPEAKER_01 4:33

Great question. There was a systematic review done in 2019 about the effect of early post-op bracing as well. And it also found that there were no differences on Leva's knee lacks the function and pain in the long term, the two years post-op. And then more recently in the Optiny consensus group, Adam Kovner led the rehabilitation strategies after ACLR systematic review and also found the same idea. There's Probably actually a decent amount of evidence. Again, good, high quality evidence, I should say, moderate quality evidence that supports a brace-free approach. I've got to say I'm a little perplexed as to why we're still doing trials that are looking at this early post-up bracing when we have a mounting amount of evidence and evidence. rather good quality evidence as well that is pointing us into this direction of weight bearing is tolerated, don't have to restrict range of motion, all that kind of stuff. I guess the caveat I should say is that I'm assuming all of these are just isolated ACL reconstruction surgeries. There's potentially no meniscus repair, root repair type of stuff going on. So I think that's where it gets a little bit gray.

SPEAKER_00 5:42

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarise the latest and most clinically relevant research for instant application in the clinic, so you can save time and effort keeping up to date. Click the link in the show notes to try PhysioNetwork's research reviews for free today. I'm

SPEAKER_02 6:05

going to throw a bit of a curveball in here now, Christina, actually. We haven't spoken about this pre-recording, but am I right in thinking there's been some bit more research more recently around cross-bracing and how would that sit into here?

SPEAKER_01 6:18

I honestly am not the expert in the cross-bracing field. I definitely would bring Steph Filbey on or something like that to have a chat with it. Having said that, I know her relatively well. So I've been able to kind of talk to her a little bit about the cross-bracing protocol. And it sounds like the early outcomes of the initial few patients that they put through that protocol have had good results. It's kind of like everything with ACL injuries. We know that generally everybody ends up hopefully at kind of the same spot two to five years down the line, regardless if they go surgery or non-surgery, maybe brace or non-brace. So it'll be interesting to just see as they get a few more numbers in their studies, what do those first one to two years look like? And are they different than going through surgery in those first one to two years and whatnot? It looks promising, but I'm hoping that there's a few more numbers that can be released and we can dive in a little bit better.

SPEAKER_02 7:09

It's interesting. And of course, just for listeners, just to highlight, obviously that cross-bracing there is a non-surgical management. And today we're talking more about that post-operative bracing. So let's just have a chat about this review, because obviously you reviewed it for the Physio Network, so it's probably worth just having a bit more of a dive into this. So the randomised control trial that was done was looking at bracing after rehabilitation. Again, like you say, repeating quite a lot that's already been done. What was good about the study? Was there anything that was worthwhile coming out of the study?

SPEAKER_01 7:37

I mean, they had a good amount of people in it. So they had a total of 139 participants and they randomized, which is hopefully going to be one of your more robust ways of looking at one intervention versus another intervention. So I think that they had some of their methods were well done or their study design was well done. They all went through the same rehabilitation protocols. They're hopefully minimizing some of their biases there. Yeah. So I think those would be the highlights, the good parts of this paper.

SPEAKER_02 8:06

is a good, well-designed study that, again, adds to the already mounting evidence around bracing. And then limitations on this, because there were some limitations with this paper, wasn't there?

SPEAKER_01 8:17

Definitely. I would say that there's limitations to every paper and there's probably not going to be many papers in sport medicine specifically that are being perfect because it's hard to control all the variables that can kind of go into these things. So I'd say the biggest limitation was it wasn't actually quite clear how often the brace group had to wear the brace. Is it something that they're wearing it every hour unless they're showering type of thing? Or is it something where they're allowed to take it off when they're sitting or when they're doing their rehab exercises? So that wasn't quite clear. The rehabilitation protocol itself wasn't described very well either. So it's a little bit challenging to figure out what was the rationale behind. They kind of used a little bit more of a time-based criteria. It sounds more of a time-based criteria than a criterion-based progressions. So I don't know if that would have impacted things as well. The return to sport time was quite short. So it was a mean of 22 to 33 weeks, which is bordering on that kind of six to seven month timeline and There's definitely a few things that maybe could have been a bit better, but it's hard to say. I'm not entirely sure when this study was actually done. Maybe it was done in the 2010s and they're just publishing this data now. So it's hard to say.

SPEAKER_02 9:35

Of course. As we've said today, this is just adding to the already good amount of evidence that's showing that there isn't a good enough difference to be warranting bracing. And I think in your research review that you did for PhysioNetwork, I think the finishing sections are the best to read, I think, in terms of clinical implications and how you've really nicely said there that actually the cost involved in the bracing could be spent perhaps a little bit better elsewhere.

SPEAKER_01 10:00

It's usually a question I think we get as physios a lot from patients and And maybe even some doctors as well about when to get braces and all that sort of stuff. So obviously early stages, I hope that whoever's listening is now picking up that early bracing is not really necessary. There's no benefit. It's not making anything better. Return to sport type bracing, I think there's still inconclusive evidence if it's helpful or not in terms of helping re-injury rates or whatnot. So here in Canada, a custom ACL brace, so one that's like custom fitted to you is about$1,800, which is, I don't know, I want to say maybe like around 1,000, maybe 1,200 pounds, something like that. And I always say I'd much rather you spend that on a gym membership because that's going to be way more effective for you getting back into your sport, playing your sport at a high level, continuing to play it, reducing your injury risk, all that kind of stuff. That's usually my tagline when people ask me about that.

SPEAKER_02 10:56

And I suppose over here in the UK, when we look at braces often supplied by the NHS, the cost could then potentially by that department be used towards better facilities, classes and equipment as well.

SPEAKER_01 11:11

Absolutely. Yeah. Again, I think there's a time and place for it, but I don't think it's the blanket approach by any means. And I guess if it was, if it was this like you know, amazing panacea type of treatment, then everybody would be in a brace after an ACL reconstruction surgery. So I think there's a time and a place, not necessary for everybody.

SPEAKER_02 11:30

Brilliant. Well, Christine, I think this has been a really good episode. I think it highlights that research does tend to sometimes continue when it doesn't need to continue, but it's good to hear your perspectives. And for the listeners, if you're interested in, and I'm sure you are after this, reading some of Christina's research reviews for the Physio Network and around the bracing and ACL reconstruction and ACL rehabilitation and hundreds of other reviews from other leading experts, then do click in the show notes to try out the Physio Network research review Christina, thank you so much for your time. We will no doubt get you back on for another dive into one of your research reviews.

SPEAKER_01 12:07

Thank you so much, James.