Episode 2: Evidence Based ACL management with the 'Rockstar Researcher' Stephanie Filbay
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There is probably no one on the planet who has researched the best practice management of ACL injuries as extensively as Dr Stephanie Filbay.
Stephanie is a physiotherapist graduate from La Trobe University in Melbourne in 2010 and was awarded her Ph.D. in 2016 on Longer-Term Outcomes after ACL injuries with a specific focus on quality of life. Stephanie was also based in Oxford University in the UK where she was a Senior Research Associate in Orthopaedics, Rheumatology and Musculoskeletal Sciences. She is currently a senior research associate and NHMRC fellow at the University of Melbourne and her research focuses on optimising outcomes for people with ACL injury and knee osteoarthritis.
In this episode we speak with Stephanie about all aspects of ACL management.
We delve into the research behind the common beliefs around ACL reconstructive surgery (ACLR)
Does ACLR reduce osteo-arthritis?
Does ACLR reduce the chance of meniscus tears on return to sport ?
What are the impacts of quality of life post ACL rupture?
Psychological aspects of ACL healing.
Can the ACL Heal?
Optimal timing of the ACL surgery post injury. Shared decision making process for ACL management and how to choose a surgeon.
See the links below to read the papers we discuss in the interview.
www.sciencedirect.com/science/article/pii/S1521694219300191?via%3Dihub
bjsm.bmj.com/content/bjsports/early/2017/05/17/bjsports-2016-097124.full.pdf
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Bevan Colless
If a patient suffered an ACL tear, there are many paths they catake. And it's become apparent that probably the most popular and well trodden path may not be the correct one for everyone. And that path is: First book into see a GP, then get referred for an MRI and to see a knee surgeon, take the MRI to the knee surgeon who makes the final diagnosis of an ACL rupture, then the patient is booked in for the first available appointment for ACL reconstructive surgery. Now this may be correct for some patients, but there are other options available. So we want to bring these other management options to a wider audience and empower anyone who's sustained an ACL injury to come to the right management decision for them. So to delve deeper into the best practice management for ACL injuries, we begin our interview series with our first guest Dr. Stephanie Filbay. Dr. Filbay is one of the world's best read and published researchers on the anterior cruciate ligament. There's probably no one on the planet who has researched the best practice management of ACL injuries as extensively is Dr. Filbay.
Stephanie is a physiotherapy graduate from Latrobe University in Melbourne in 2010, and was awarded her PhD in 2016 on longer term outcomes after ACL injuries with a specific focus on quality of life. Stephanie was also based in Oxford University in the UK for some time, where she was a senior research associate in orthopedics, rheumatology and musculoskeletal sciences. She's currently a senior research associate, and NHMRC fellow at the University of Melbourne, and her research focuses on optimizing outcomes for people with ACL injury and knee osteoarthritis. Stephanie is a prolific author of research papers with a particular focus on the ACL. I tried to count all the papers Stephanie's authored, but I gave up once I got to about 35. But you can be sure if you do a PubMed or Google Scholar search on ACL injuries, you will see a lot of papers with Filbay appear as the titled author in your search results.
Her papers are featured in many of the world's leading medical journals, including the British Journal of Sports Medicine, the Journal of orthopedic and sports, physical therapy, the American Journal of Sports Medicine, Scandinavian Journal of Medicine and Science in Sports, Orthopedic Journal of Sports Medicine and more. One of my colleagues recently said to me that Dr. Filbay is a ‘true scientist’ who will find a statement and forensicly and impartially research it to find out how much substance there is behind it. And I'm not the only one who refers to Stephanie as a Research Rockstar. Stephanie, thanks very much for joining us.
Stephanie Filbay
Well, thank you for that very generous, maybe overly generous introduction.
It's great to be here today.
Bevan Colless
Thanks, Stephanie. Can you tell us a little bit about yourself?
Stephanie Filbay
So in relation to how I got into ACL injury research.
I first got into research during an honours year in my physio degree, and that's when I discovered a real passion for research. Then after some clinical experience, which included managing some patients with ACL injury, both for sporting team and in private practice, I was offered to do a PhD in the topic of quality of life after ACL injury.
At the time, I had just ruptured my first ACL when I was 18. And I went on to have additional knee surgery to remove a cyclops lesion. I then re-tore my ACL graft again after I returned to sport, had an additional surgery to remove the screw in my in my tibia because it was unscrewing itself. And then I rerouted the graft a third time.
I then went on to develop osteoarthritis at a fairly young age, and I do have knee pain and some functional limitations now.
So this area really aligns with my own personal experience, but also an area that I was very interested in managing patients, particularly because it can have such a substantial impact on people's quality of life. So, I think I have the trifecta. I'm interested in the research, my personal experience, but also in managing patients as well.
Bevan Colless:
It's interesting that a lot of people get into physiotherapy because they've had their own injury and got an understanding of what's involved in the profession. But you've really taken it to the next level with ACL management, which is terrific.
Stephanie Filbay:
Yeah, I think I first ruptured my ACL in the first week of my physio course, so not quite long enough to have the knowledge yet to manage it myself. But certainly having played quite a lot of sports before then, and having a range of injuries, probably got me interested in the physio profession, for sure.
Bevan Colless:
I actually did my ACL, my first season working here in Japan. So it gave me a good idea of what's involved as well. And kind of wish I knew then what I need, what I know now.
So let's talk a little bit about the different pathways for ACL management. And I wanted talk about ACL injuries and osteoarthritis. So when people are researching the best way to manage their injury, there's a few conversation stoppers that tends to lead people towards surgery. And one of those is, is that if you don't have a reconstructive surgery, you're more likely to get early on onset osteoarthritis. And many clinicians, and patients strongly believe that this is true: if you don't get the ACL reconstruction, you're going to get out early onset arthritis and eventually need a knee replacement. So Stephanie, how much truth is there behind this statement and this belief?
Stephanie Filbay
Yeah, so this one isn't true. It's a common misconception. And there's a number of them, and I'm sure we'll discuss some of them today. So there are multiple systematic reviews, which, if performed properly, a systematic review is the best evidence we have available, because it reviews all the studies that there is on a topic, and it should critically appraise them based on both the quality of the studies and the potential bias within the studies to answer a specific question. So there's actually multiple, quite a large number of systematic reviews that have answered this question and looked at osteoarthritis following reconstruction and management with rehabilitation alone. And the majority of those have found no difference in osteoarthritis. So there's been no difference in rates of tibia femoral OA, between the shin bone and the femur, the main knee joint, although there has been some reviews that found actually higher rates of kneeca OA after reconstruction, compared to rehab only. But something to consider is that most studies have just looked at structural OA on X-ray and haven't considered the symptoms. And there's actually a mismatch between what we see on X ray and what people experience. So even though, potentially, there's more chance of arthritis around the kneecap after surgery, we don't know if that actually relates to worse patient outcomes or symptoms. So we need further studies in that area.
Bevan Colless
Do you think that there's enough evidence to almost conclusively answer that question that the rates of arthritis are very similar for people that do or don't have a reconstructive surgery? Or do you think there's generally still more research needed and we're not quite sure?
Stephanie Filbay
Well, the highest quality, randomized controlled trial with the longest term follow up, there's only two randomized control trials published, but one of them The KANON trial showed no difference in osteoarthritis outcomes at five years. And they're very soon to publish their 10 year outcomes. So that will be a very interesting one to watch out for. Because that is the best research designed to answer this question. Because people were randomly allocated, reconstruction or rehab. So there's no difference between those two groups and the groups aren't biased at all.
Bevan Colless
So we'll keep an eye out for the findings, the ten year findings when they come out, but based on other studies, designs are fairly consistent that there are similar rates of osteoarthritis between groups. And those rates of osteoarthritis are elevated for both groups. Isn't that correct?
Stephanie Filbay
It is. Yeah, that's correct.
Bevan Colless
So if you've had an ACL tear, unfortunately, you you are more likely to get early onset osteoarthritis with or without the surgery.
Stephanie Filbay
Yes. And if you have damage to your meniscus at the time of ACL rupture that places you at greater risk than if you've only injured your ACL.
Bevan Colless
So for listeners who don't know about the meniscus, the meniscus is a shock absorber that sits on the top of your tibia or shinbone that acts to disperse the ground reaction forces when we run or, or twist or pivot. And one of the other commonly held beliefs in ACL management is that if you return to sports, involving cutting, or pivoting that without having an ACL reconstruction, that your risk of getting a new meniscus injury is higher. So a lot of people think, well, I want to play soccer again, if I do that, without an ACL, it kind of intuitively makes sense that the ACL is keeping my femur and tibia together, if that's not there, there's going to be more movement in the joint, and I'm much more likely to tear my meniscus. So what's the evidence behind that belief?
Stephanie Filbay
Yeah, so this belief is probably even more common than the osteoarthritis one. And it's actually also common amongst a lot of researchers, and particularly, it features in a lot of conclusions in pedigree articles within orthopedic journals. I published an editorial in the BJSM, in 2018; looking at these studies that have said that there's an increased risk of minutes, because injury, if you don't have ACL reconstruction early on. I actually delved into all the references that they used to support that statement. And what I found was that the studies used to support that statement weren't the right studies at all to inform on that topic. So the issue was that the studies used to support that belief was studies that compared the rate of meniscus damage, and people who present for a reconstruction early after injury, compared to people who come to a surgeon months or years after injury, with unknown treatment, they may have had no treatment, no supervised rehab, or they may have tried rehabilitation, but represent that group who don't do very well and then go to surgery.
So that's a very biased comparison group, but it isn't comparing everyone who has rehabilitation with people who have early reconstruction. And most of those studies, were actually a cross sectional review of surgeon’s records. So they didn't have any of that information before they came for surgery. So that type of study design is subject to bias, and it shouldn't be used to recommend early reconstruction over management with evidence based rehab. But as far as I can see, that is all the studies that have been used to recommend that statement. So it isn't based on the best available evidence.
Bevan Colless
And this was one that you researched in your 2017 paper, which I thought was a terrific title ’Early ACL reconstruction is required to prevent additional knee injury: A misconception not supported by high quality evidence is that the study you're referring to your delved into that research?
Stephanie Filbay
Yes, that study was the editorial sort of summarizing the key issues with the papers that have been used to reference that belief?
Bevan Colless
One of the other papers, which has recently been published on meniscal tears was the 2020 paper by Ekas among others including your fellow researcher, I believe you've done a few papers with Claire Arden, which was on meniscal tears and ACL injuries. Could you run us through that paper and the key findings that they found in their research?
Stephanie Filbay
So this multidisciplinary group of research does including orthopedic surgeons, and sports physician and physios based in Norway, they addressed a real need, because we really did need a systematic review in this area. So they reviewed all the studies on this topic and critically appraised the quality of the evidence and the risk of bias. And what they found was that the evidence is too weak to determine whether ACL surgery reduces the rate of additional meniscus injury. So this was a high quality systematic review and it was an accurate reflection of the evidence at the time.
Since then, there has been a second randomized control trial published, which is called the COMPARE trial. And this trial actually found more surgical interventions for a meniscal tear in the early reconstructive group compared to people managed with rehab and optional delayed reconstruction. So they actually had more meniscal problems if they had the operation. So more surgical interventions for meniscus tear. Yeah, which may not reflect all meniscal injuries, just that they had more meniscal surgical interventions.
Stephanie Filbay
But nevertheless, overall, the majority of studies are still low quality with an inappropriate design to answer the question. So we need more research, before any clinical recommendations are made for one treatment strategy or the other based on the risk of subsequent meniscal injury, the evidence just isn't there.
Bevan Colless
So, on that COMPARE study, one of the findings that I found interesting was that there was an increased rate of episodes of instability in the conservative /non-operative group of 15%. And in the groups that had the operation, those episodes of instability reported were only 2.5%. And you do come across this in your practice where people say, ”I I just felt my knee giveway slightly as I was wading into the sea, or as I was changing direction, and I just decided I don't want to live with that feeling of instability. So I've decided to go for the operative route. And that's a common reason that people give as to why they chose to have an operation. What do you what do you think about that finding? Do you think that is a valid reason for somebody choosing to have an operation?
Stephanie Filbay
Yeah, so that is the most common indication for switching over to a delayed surgery, despite starting with rehabilitation. I guess, giving away of the knee, despite appropriate supervised rehab, is what's an indication for reconstruction. So if you haven't had any treatment, or rehab, and you've experienced that giving way before you go and strengthen your muscles and perform appropriate exercises that may not reflect the fact that you're likely to have an unstable knee. But if you have, say, had physio supervision, undergoing appropriate rehab, but still have an unstable name, then that is a good indication that you may benefit from reconstruction.
And the people who undergo delayed reconstruction because they experience an unstable knee, they don't actually report different long term outcomes compared to those who have surgery early. So that's what was shown in in the clinical trial, for example. But it may be that the supervision component is actually really important. So identifying an unstable knee early, rather than allowing recurrent episodes of instability could explain why these people don't experience worse outcome.
In terms of surgery or reconstruction, it's not surprising that people who've had surgery have less giving away. But we also need to consider, you know, other aspects, the fact that people can suffer from persistent swelling or range of motion deficits, or knee stiffness after surgery. So there are pros and cons or risks and benefits to consider with each treatment option. The potential for a given way episode is certainly something that should be factored into the decision-making process. It's certainly not an easy decision for sure.
Bevan Colless
So I wanted to talk a little bit about a paper that was published earlier this year on the PANTHER symposium that I'm sure you're aware of. For listeners who are unfamiliar with this study, there was a consensus group of 66 ACL experts from 18 different countries were brought together to analyze a collection of statements related to ACL management. This group of experts included surgeons, physiotherapist and exercise physiologists. They came to conclusions on a list of statements using the Delphi method of gaining consensus, which is a well respected method of gaining consensus in a group of experts where there might not be conclusive evidence to exist to make clear decisions. So what was your thought on that paper and one of the statements which gained 100% consensus in that group which was, “For active patients wishing to return to jumping, cutting and pivoting sports; returning to the sports without surgery places the knee at risk of second injury (meniscus and cartilage). And so that statement got 100% consensus. What did you think about that paper and that conclusion specifically?
Stephanie Filbay
Yeah.
So I guess what I'm saying is, you know, there were a lot of high quality prospective studies showing no difference in return to sport rates between rehab only and ACL reconstruction. But it doesn't appear that they were used to inform these statements.
Bevan Colless
And obviously, the rehab techniques have improved a lot since the 1960s for conservative management.
Stephanie Filbay
Exactly right. And you would never choose a study of 19 athletes anyway. It's just too small doesn't have the power, or an appropriate study designed to answer that sort of research question. So in an area with so many contrasting opinions and vested interests, it's really important that we base consensus statements on robust systematic reviews and high quality evidence, rather than on an opinion alone. So in other processes, where lots of smaller groups work on running systematic reviews that's then used to inform the original consensus statements before they're voted on. I think that's particularly important and in the area of ACL research.
Bevan Colless
And now we want to dig into some evidence and literature on returning to high level sports. A lot of patients and clinicians believe that if you want to return to a really good level of sport, or even many patients believe to any level of sport that you need an ACL reconstruction. What are your thoughts on this Stephanie?
Stephanie Filbay
It's another really common belief, which, surprisingly, isn't supported by high quality evidence. You know, one of the studies in this area that I think is quite interesting study by Hege Grindem and her colleagues where they randomly allocated patients to reconstruction or rehabilitation and those who had rehabilitation were actually told or advised not to return to high level cutting and pivoting sports. But despite their recommendation by one year, the exact same number of people, which was 68%, had returned to the highest level of sports one year after the injury in both groups. And there's a range of examples like this, as well as high quality studies that do show similar return to sport rates following rehabilitation alone and ACL reconstruction. And it is important when you look at research, it is comparing based on an evidence based supervised rehab rather than a group that had surgery or a group that didn't have any treatment. Anotherconsideration is the likelihood of tearing your meniscus or having further knee damage if you return to sport.
And there's evidence to show that returning to pivoting and cutting sports increases your chance of additional knee injury with ACL reconstruction, but also without ACL reconstruction. And another consideration is the really high rate of graft rupture after ACL surgery, which is actually more common than you might think. So, for example, a study found that one in three young female soccer players that returned to soccer after ACL surgery, re-ruptured their ACL
Bevan Colless
One in three!
Stephanie Filbay
And yet 90% of people who then damage their meniscus or cartilage at that point of re-injury. So this highlights that actually, additional knee injury is also rather common after ACL surgery, but that's often not considered. So we do need further studies, as mentioned earlier, to look at the additional rates of knee injury. But irrespective we know that returning to high level sports has an increased knee injury risk.
Bevan Colless
With or without the operation?
Stephanie Filbay
With or without yes, there's more of a sense of following reconstructions, just because there's a lot more studies that are following ACL reconstruction, but the size that exists suggests similar rates in both treatment groups. So yeah, I guess it's important that first of all, the patients are made aware of this, so they can make an informed decision about returning to sport or not, but maybe they might want to modify the activity or or return to a slightly lower risk sport. It's also important that we make sure that patients are both psychologically and physically ready to return to sport because that can help to reduce that risk of re-injuring the knee.
Bevan Colless
For sure.
Stephanie Filbay
Just managing patient expectations is critical, because a lot of the time people just think, ‘Oh, if I have an ACL reconstruction, I've got a new ACL, and my knee’s going to be as good as new. And I can, and I'll be the same as I was before I tore my ACL’. But unfortunately, that's often not the case.
Bevan Colless
Yeah, exactly. Okay. So I want to talk a little bit about quality of life, which you were leading into earlier. Competing in sport is a very important for many of our patients. And this area of quality of life post ACL injury, is one that you've researched extensively, and you're possibly one of the world's leading experts on. Your 2015 systematic review was titled ‘Quality of life in anterior cruciate ligament deficient individuals, a systematic review and meta-analysis’. And this produced some great results on people's quality of life contrasting people who had the operation and people who didn't have the operation. Can you talk a little bit about what you found in that study? And how an ACL injury affects people's quality of life post injury?
Stephanie Filbay
Yes, sure. One of the things about research studies is that they tend to report just an average score from a whole group of people. But with a systematic review, we pulled all the studies. So, we found all the studies that reported quality of life more than five years after injury, and that range from five to 23 years after an injury, for me the surgical or non surgical management, and then we brought them all together. So we could look at all those data and look at how that looked over time, and between the two treatment groups. So yeah, I mean, on average, quality of life is impaired. But of course, for some people, it's very impaired. And for some people, it's not impaired. And the mean, or the average score is somewhere in between those two extremes that we see. By comparing treatment techniques, there was no difference whether someone were given an ACL reconstruction or whether they weren't. But it is relevant that most studies in the review didn't provide participants with evidence based rehabilitation. So that's why we call it ACL deficient, because actually, they had mixed treatment strategies, some of them are known treatment strategies. So we're, we're really kind of comparing ACL reconstruction with non reconstruction.
Bevan Colless
And the key finding, in average, was no difference between groups and quality of life in the long run. Okay, interesting. And then you also published a 2019 paper on evidence based recommendations for the management of anterior cruciate ligament rupture, which was a great summary of the research you've done on outcomes post ACL tears, what what would be the key recommendations that came out of out of this paper?
Stephanie Filbay
Yeah, so we did target this at clinicians, but, you know, multidisciplinary clinicians, including GPs, or sports physicians, and we hope that we did write that probably in a fairly understandable way for patients to read as well. So yeah, we outline three main treatment options. So that being, Rehab first, followed by reconstruction, if they develop functional instability, reconstruction first followed by post rehab, or pre-operative rehab, with the plan to then have reconstruction. And so we talk a lot about the evidence and the outcomes following it to those three treatment options. And one of the other key things is that we summarize what we believe the aim of ACL treatment should be: To restore function, to address psychological barriers to activity participation, one that was discussed today to prevent further knee injury and osteoarthritis, and to optimize long term quality of life. So they should really be the same no matter what treatment strategy you choose. And we really wanted to ensure these recommendations were supported by the best available evidence at the time. So we provide an overview of evidence in that paper as well.
Bevan Colless
Great. So the best available evidence is that quality of life post injury is very similar, if you choose to have an operation or not. But there's still there's still likely to be problems further down the track either way.
Stephanie Filbay
Yes, most of the evidence shows no difference following reconstruction or rehabilitation, which is what the KANON trials found a two year and five year follow up. And once again, we're waiting for the 10 year follow up. But in saying that, that is on average. So there is a group of people that do poorly with either treatment. And one of the things we're looking to do now in research is to try to identify the characteristics, the people who will do best with one of the treatment strategies over the other. So we can improve outcomes for people.
Bevan Colless
Yeah, for sure. And that sort of leads us into the psychological aspect of ACL tears, which, in our clinics in Japan, we're always really well aware of, and one of our mantras is for patients to ‘Trust the knee’, we say, because once a person feels that horrible instability feeling without an ACL, it tends to enter into this feedback loop where they don't trust, their knee becomes more unstable, they're not using their knee and the knee gets weaker, and therefore more unstable. So how important do you think the psychological aspect of of ACL tears is?
Stephanie Filbay
Yeah, it's really important. And in particular, fear of injury, which we know is really prevalent after ACL injury. We're completing a study that will soon be published in physical therapy journal. And we looked at fear of re-injury over time after reconstruction compared to rehab alone. And how that changed over time. And the fear of re-injury was fairly similar after reconstruction, and in rehab alone, except it was higher in those who decided to have a delayed surgery. So it seems to be perhaps one of the factors that then cause someone to say, actually, you know, I'm afraid that I'll damage my knee and I think I want to have surgery. We know that fear of injury is the number one reason that people don't return to sport.
Bevan Colless
Yes, ‘I don't want to go through that again’, obviously.
Stephanie Filbay
Yeah. But something to consider is that for some people, that fear is actually realistic, because particularly in sports involving contact, pivoting and cutting, if they do return to sport, that risk of re injury is likely real. But in a qualitative study that we did, we found that people can actually experience further injury for everyday activities. So there was examples of patients who explained that they were afraid to play in the backyard or afraid to run at night because of dim lights, that they might reinjure the knee or be afraid to play with their dog. So it can become very impactful on quality of life in a negative way, if that fear of reinjury isn't addressed early on.
Bevan Colless
Yeah, for sure. One of the things we talk about with our patients here, we ask them, ‘How often do you think about your knee when you're skiing?’ And often, for people that have had an ACL injury, the answer is ‘All the time’. And if you're not trusting your knee, and if you're worried about it the whole time, you're not going to be skiing or performing your best either.
Stephanie Filbay
Exactly. Knee awareness is an interesting one, because someone could be aware of the knee and because of that, they maybe make some better choices or maintain a more active lifestyle. Or they could be more aware of the knee and feel more fear, more anxiety and have negative impacts. So certainly, as clinicians, we really need to delve into the impacts of this potential fear or being more heightened awareness of the need to see what sort of impact that's having on the person's life.
Bevan Colless
Yeah, so as for us healthcare professionals, and patients, how can we work towards minimizing the psychological damage of suffering an ACL injury?
Stephanie Filbay
Yeah, so identifying and reducing re-injury fears early. And if the clinician doesn't have those tools in their toolbox, knowing when to refer to a sports psychologist. Activity participation is intimately linked with quality of life after ACL injury. So understanding a patient's values and the types of activities that they rely on for fulfillment, and if they can't return or decide not to return to that activity. Clinicians have an important role in helping them find an alternative sport or form of activity that can satisfy those needs. Because some people adopt a completely inactive lifestyle, that can have more negative mental and physical health impacts. So keeping people active even if they don't return to sport, there's also some psychological strategies that can be effective like you using a role model that the patient can relate to. After the acute period, things like mental practice goal setting, relaxation techniques may be effective. And I'd also say, performing a longer term follow up. So for patients, keeping in mind that they can go back and see their clinician, even after the return to sport if it's two years or three years down the track. Because the ACL journey, it's up and down, and the knees unlikely to ever be as it was before injury. So it's important as new concerns or issues arise with the knee that they're sort of managed and treated at that early stage, rather than just putting up with it for five or 10 years, which can have quite a negative mental impact on someone's quality of life.
Bevan Colless
So one of the concepts of ACL management that's become popular in the last few years is this division amongst people that have had an ACL injury into being either ‘Copers’ or ‘Non-Copers’, or ‘Adapters’. Where copers are people that seem to do very well without an ACL, and are functioning at a high level, and Non-copers, obviously are people who are who are not coping so well after their injury. And adapters are a group of people that choose some other sports, maybe they'll take up running or triathlon after they've done their ACL playing soccer. So it tends to be the non-copers who are more likely to be surgical candidates, because they're not doing so well without an ACL. And I've always seen it as our role as clinicians to try and turn these non-copers into copers. And obviously, these divisions aren't set in stone and people can move from one to the other. And we want as many as possible to be to be coping well post injury. Do you notice any ways to identify these copers or people that are going to do well? And any ways to try and turn non-copers into copers or adapters?
Stephanie Filbay
A study that comes to mind here is one that was based on the Delaware-Oslo cohort. I think the first author of this one was Louise Thoma. And what they found was that the Coper classification early after an ACL injury actually changed with rehabilitation. And in this study, the rehabilitation comprised neuromuscular and strength training. And that's pretty typical of most recommended rehab strategies. So, they found that nearly half of those classified initially as not copers actually became potential copers after rehabilitation. And those who were classified as copers after rehab had the best outcomes. So they had around three times greater odds of a successful outcome compared to non copers who had early reconstruction. And that was irrespective of whether they went on to have reconstruction, or stayed managed with rehabilitation alone. So, this highlights that there is potential for change, and that those who do change have much better outcomes. So in terms of, you know, how do we know what's the signs of someone may be a coper or non-coper. It's not black and white. But you know, in that particular study, they used a criteria that involved a particular score on a questionnaire that reflects their self-perceptions of their knee function, and the overall rating of the knee. A test that assesses their ability to help on their engineer and how that compares to the other side, as well as the fact that they hadn't had any giving-way episodes. So, there's a range of other studies that have slightly different coping criteria, but there's a lot of overlap. So, it generally features a hop-test of some sort. So, knee function appears to be important. Strength can often feature, particularly quadricep strength, as well as their own perception of the knee. And of course, giving way, so that seems to be some common themes in terms of whether someone will do well or won't.
Bevan Colless
Yeah, and for listeners out there or clinicians who might have a patient or someone who has suffered an ACL injury and they could see that I feel like ‘I'm a non-coper, I'm not doing well here. I want to be a coper’, do you have any tips on how they can turn themselves into being a coper? I already mentioned strengthening, obviously and quadricep strength but any other tips for these people to manage their injury a little bit better?
Stephanie Filbay
Yes, I mean, like they say, physios make the worse of patients. And I must admit, I didn't do much of my exercises after some of my surgeries, and it can be really hard to do them. And that's one advice I'd offer is, actually doing the rehabilitation, of course, that can make a big difference doing the strength work during the retraining of your knee. And it's when you've done that, as prescribed by someone with appropriate experience, that you still aren't having the outcomes that you'd like, that's when you may be a good candidate for surgery instead. But if you feel like it absolutely, I haven't really given this a good shot. You know, I haven't, I could do a lot more strength work, I could have done a lot more things that I was asked to do that it may be worth giving another go and really putting a lot of effort into that to see if you can turn some of these things around.
Bevan Colless
For sure. And yeah, it’s never too late, if they didn't do a very good job rehabbing it in the early-stage post injury, then there's no reason that they can't give it another go, even a few months down the track, or even sometimes a year or two down the track.
Stephanie Filbay
Well, the main thing we don't want is recurrent instability. So you know, if you're not doing any rehabilitation exercises, but your knee feels unstable, and it's kind of giving way over and over again, we don't want in that instance, you're probably better off to have surgery, if you're not able to stick to the rehabilitation, or if you've done the appropriate rehab, but your knees still unstable and giving way that suggests that a reconstruction is probably a really good option for you as well. So, we just want to avoid that. So I'd caution against feeling like you can do nothing for two years, but be having instability and then go into rehab, because you may have already done some damage to your meniscus and other structures in the knee.
Bevan Colless
For sure. It's much better to do it earlier. And that concept of stability is obviously a huge one in in deciding whether to go for the operating for route on or not.
Stephanie Filbay
Yeah, and it's even hard to quantify, you know, like, what does someone mean by instability? Yeah, because your muscles are often quite weak after injury. Because the muscles are weak, that's not true instability. Or if you have a bit of swelling, that can cause your knee to buckle as well. But that isn't true instability either. So, we need to sort of delve into the actual experience and see if it's because of a structural instability that's causing the need to give way during activity or not. So basically, if you knee is calm, it's not swollen, you've worked really hard on your rehab after your injury. Your quads, strengthen your whole lower limb strength is similar to the other side, but you're still unstable and you're still knees still buckling, then you might be more likely to decide to go for the operation.
And you'd want to speak to your clinician, as soon as you experience a giveaway episode, you don't want to allow that to happen multiple times. Reason I say, with appropriate rehab is because you do hear stories, you know, you're maybe managing someone, only two weeks after injury. And they said, I know I wasn’t supposed to, but I went and played a game of soccer. And my knee gave way, that's doing something that isn't recommended too soon. So it's hard to know whether that person would have gone on to develop adequate neuromuscular control and stability, because they were putting it under stresses a lot too early before that rehabilitation can see results. So it's also important to listen to advice and not do too much too early until you can work out some of the strength and control around your knee.
Bevan Colless
I know, it's not your specific area of expertise, but I wanted to talk about ACL healing and, the ACL’s ability to actually regrow or reattach. Do you have any thoughts on that? It's an area that's kind of gaining a little bit more traction recently. Do you think the ACL can heal?
Stephanie Filbay
Yeah, so this is actually an area of research that I have moved into and I'm currently active in and interested in, so it's an interesting question. I mean, it's been assumed that a ruptured ACL cannot heal. And that is really a key component of the reasoning for ACL surgery. It's hard to believe the lack of high-quality studies that have actually looked at the potential for the ACL to heal. There's not much out there. There’s a couple of small studies in specific samples that are not high quality or adequately powered. And that's really it. So yeah, I'm working on two studies at the moment exploring the potential for a ruptured ACL to heal without surgery. And without giving too much away before the results are published, the findings suggest that a ruptured ACL can heal after treatment with rehabilitation alone, and that this may result in similar or better outcomes than those who didn't heal those who had early surgery or those who crossed over to delayed surgery. Now, these are only preliminary findings, and we do need a lot more research in this area. But so far, they're very promising. We're also evaluating healing and clinical outcomes after a novel non-surgical bracing intervention. And the preliminary findings for this look very positive. A high proportion of patients have ACL healing, as seen on MRI. They're reporting excellent patient outcomes. They're returning to high level pivoting and cutting sports with a healed ACL on MRI. So we hope to have the findings published soon. But it's a very exciting new area of research. It shouldn't be a new area of research. But it is.
Bevan Colless
It's crazy.
Stephanie Filbay
It is. It is crazy. And the other question, it's not just ‘Can the ACL heal?’ It’s ‘Does healing on MRI represent better function or even normal knee function?’. Because we don't know that either. So there's multiple questions around this that need to be answered. But I do see in the future, a paradigm shift. Management strategy is actually aimed to facilitate healing of a torn ACL. And to identify patients who are most likely to experience ACL healing. So it's, it's likely to become an important aspect of the ACL treatment decision making process in the future.
Bevan Colless
It's really exciting times ahead. I noticed one Japanese study from 2016. I think it was Iwata and Kuwano. That showed in their protocol, they didn't publish exactly what their protocol was in the study, but they had healing rates of up to 80% in a group of over 100 people. In other words, 180 out of 100, had a fully healed ACL after they went through their protocol, which is, which is amazing, considering, as you say that the, you know, common belief is that the ACL doesn't have any ability to heal.
Stephanie Filbay
Exactly, yeah, it is a new area of research. So there will be some delay before this starts to impact or should start to impact clinical practice. One of the areas is we need a reliable way of actually telling whether an ACL is healed on MRI. So in different studies, people may classify that very differently. So, yeah, there's a lot of work to be done. But it's certainly looking very promising. And within the next few months, we hope to release some studies in this area.
Bevan Colless
Watch this space. Okay, great. So one of the other things I wanted to talk about was the timing of when to have the surgery. Like I said, traditionally, it's been: let the knee calm down, wait a couple of weeks until the swelling has gone down, and then just get in and get the surgery done, between two and four weeks, because it's going to be too tiresome to go through the whole rehab process twice. What do you think about the best timing for an operation after injury is?
Stephanie Filbay
Yeah, so I'd say don't be afraid to delay a surgical decision and start managing with rehabilitation. This is common practice in some parts of the world, like a lot of countries in Scandinavia. In particular, the standard approach is generally to trial three-months of rehab and then make a decision about surgery or not. So even if you decide then to have an ACL reconstruction, once you've started rehab, as long as your rehab is appropriately supervised and evidence based, you're likely to have similar or better outcomes than if you were to have a reconstruction straightaway. And the reason for this is that doing pre-rehabilitation before surgery actually improves post-operative outcomes. So it's kind of a win-win. Except, of course, one consideration, is that if you were trying to get back to sports really quickly, you sort of get away. Or if you were successful in rehab, you'll get to return to sport faster than having surgery, than if you start rehab, and then have surgery that will prolong your return to sport. So it's a bit of a gamble, really, if your main goal is to get back to sport as soon as possible, such as what it is for a lot of elite athletes.
Bevan Colless
There’s often seasonal considerations out there, do you want to miss the winter or the summer, or there's a lot of factors involved. But I think it's an important message for that you mentioned earlier that that strengthening work that you do after the injury and before the operation is not totally wasted time because a strong knee going into the surgery is a strong need coming out. Generally, people with a strong and stable knee preoperatively tend to be off crutches and just do a lot better in their post-operative recovery.
Stephanie Filbay
And that's what we found in a study we did in the in the Canadian randomized control trial, we looked at prognostic factors for people who do worse in the long run. And people that have worse, patient reported outcomes with pain and swelling at the start, before they have surgery, they do worse. But the people that also have more pain and swelling, but then have rehab, they didn't do worse. So, you know, maybe something to do with having surgery early, which is really a second trauma to the knee on a knee that's already quite inflamed and angry without first allowing that initial inflammation and swelling to settle down. And for some strength to come back before you then go into surgery. We don't know. It's just a hypothesis. But there may be some benefit from delaying that surgery to allow an angry knee to calm down first.
Bevan Colless
So three months is not a bad rule of thumb to give it your all for that three months post injury. And then decide.
Stephanie Filbay
Because you may be doing very well. And yet, you may even surprise yourself, you may have the intention of having surgery. But after that three months, you're so happy with the way your knees going, that you change your mind. Or you may decide to do rehabilitation only, but you're very unhappy with the way your knees progressing and decide to go down a third cool route. It just gives you more information to make an informed decision, I think,
Bevan Colless
Often you'll hear patients three or four weeks post injury, say ‘My knee is still weak, still unstable? There's no way I can live my life with this level of knee function. So I'm just going to book in for the operation’. But if they hold off, and then you say as they improve over that, that next couple of months, by three months post injury, they might be saying okay, well, I’m doing pretty well now, maybe I can live my life with this level of knee function.
Stephanie Filbay
I mean, you don’t want a bit of a false expectation, you know, surgery isn't a quick fix. Certainly in the acute post-operative period, it's generally a lot more pain and swelling than you actually experienced after the initial injury. And it can put someone out of action for quite a while as well. And really, it's important, rehab is important whether you choose to have surgery or not, because having post-operative rehab, and that could continue generally for up to 12 months is actually really important to have good outcomes after surgery, as well as it being important to have good outcomes with rehabilitation alone. Some people have false beliefs that oh, you know what, I can't be bothered doing rehab. I'll just go and have surgery. But those people are probably not very likely to do well with surgery, either. Because rehabs an important component of that treatment strategy as well.
Bevan Colless
I think one of the things that people don't realize is that their function post-surgery is often lower than their function was post injury or a couple of weeks post injury, it sets you a long way. It's a long road back from the surgery, even a longer pathway than if you choose not to have the operation correctly.
So I wanted to talk about the decision making process in in trying to decide whether to have an operation or not, or when to have the operation. And as we've discussed, it's a complex and multifaceted decision to make and I understand you're about to publish a paper on the shared decision making process, who should be involved in in these decisions and what are the important factors to consider?
Stephanie Filbay
Yeah, so, yeah, we're actually working on developing a decision-aid to facilitate informed decision making between clinicians and the patient about ACL treatment options. So this decision-aid will provide a balanced evidence-based overview of both treatment options so patients can choose the one that aligns with their values and preferences. So that needs to feature things like pros and cons and the risks and benefits of each treatment option, the cost of each treatment option, and that needs to be based on the best available evidence. But in the meantime, before, something like that exists, we must have the patience is to be cautious of one-sided opinions, because there are pros and cons of both treatment options. So find a clinician who's aware of the evidence for both treatment options, and can assist you in making an informed and non-biased decision by providing you with the necessary information to choose the best option for you. And so there's a range of important factors to consider that will incorporate into this decision aid. For example, you know, the timing, so the fact that surgery requires a period of immobilisation and pain, time of work caregiving duties, school and other activities, and to consider the potential for surgical complications and the high rate of reentry, after surgery, especially if you returned to sport, you also need to think about the chance of having to have a delayed reconstruction, if you do choose the rehab route, or if rehab alone is successful, the fact that you might return faster than if it isn't successful. As mentioned before, rehab and hard work is required to do either treatment pathways. And some, people actually will experience ACL healing with rehabilitation. Although this is an emerging area of research, these people are likely to have fairly positive outcomes. And maybe that's factored into your decision-making process, as well as the surgical costs. And if you don't have private health insurance, potential public waiting lists, which can take some time to get into have ACL surgery as well. This is just a snapshot of some of the many pros and cons that should be considered, as well as the evidence around long-term outcomes and considering your likelihood of certain outcomes with certain treatment options.
Bevan Colless
It’s not an easy decision. And as you say, there's so many factors to weigh up when you you're making these life-altering decisions, that there's not something someone should rush in or not somebody something that people should just take one person's word on. You know, I guess traditionally they will go and see a knee surgeon. And if that knee surgeon is a high-profile knee surgeon who operated on their local elite sporting team, they'll often just do whatever that person says and go straight down that pathway. But we need to counsel our patients to think a little bit more about it, and also counsel the patients that either way you go, there's no easy path, you have to do the hard work with your rehab, no matter what route you choose. So we're just summing up, what are the pros and cons? Do you think of having an operation verse conservative? Management? I guess there's so many to go into, but just a sort of a brief snapshot of the pros and cons for people who might be trying to make that decision?
Yeah, so I think I probably mentioned some cons around cost around timing around, it seems like an obvious one. But some people have a fear of surgery, or fear of hospitals. And that should be factored in naturally, if you're really afraid of having surgery, maybe rehab is a good thing to try first. And previously successful or unsuccessful treatments. Some people may have injured their ACL on the other leg and had a very positive outcome, which maybe supports the same treatment again, or they may have had a very unsuccessful outcome, which may support trying a different treatment option. And there's quite a lot of pros and cons. Really, I think I mentioned some of the main ones, but we could probably talk about them for quite some.
Bevan Colless
Yeah, it's not an easy decision for sure. So with yourself, Stephen, you said you had two ACL reconstructions on the same day. Is that correct?
Stephanie Filbay
Yeah. And then I really ruptured it again, after the second after revision surgery.
Bevan Colless
So now you're living without an ACL in that knee? Is that correct?
Stephanie Filbay
That's correct. Yeah, we've quite a lot of meniscus damage. And yeah, I'll see arthritis and some other things going on in here. But, yeah, I’ve had arthritis from the age of 25. Osteoarthritis, which we commonly see after ACL injury, that can be a real concern, considering it's a chronic condition that can serve across the lifespan. So we do need more strategies for reducing the risk of arthritis after an ACL injury, something the research world's working on, but we've got a long way to go.
Bevan Colless
So if you did your ACL in your other knee at your age now, with your future sporting goals, and knowing what you know, now, would you have an operation or not?
Stephanie Filbay
I’d definitely try rehabilitation first. And in an ideal world, if I could go back in time, I would have chosen to do rehabilitation first before thinking about whether surgery is a good option to me. At the time, when I was 18, I wasn’t aware that, you know, rehabilitation was an option. When I tore my ACL, I remember back to the conversation I had with my surgeon and he said, Unless I was satisfied running in straight lines for the rest of my life, I should have surgery to fix my ACL. So in my mind, I was very keen sportsperson, there was no decision to be made. Of course, I want to get back to sports. So, I must have the surgery. And this experience, you know, receiving this one-sided kind of overview of treatment options, is actually still really common today, very common. We're performing a survey of people who had ACL injury in the last five years now that's still running. But if, you know, I took a look at the results from the first 460 people to complete that survey. And interestingly, they reported that 50%, who saw an orthopedic surgeon said the surgeon only discussed ACL surgery as a treatment option. They didn't discuss rehabilitation, and 74% were advised that ACL surgery has better outcomes than rehab alone. And 93% of surgeons said to patients that ACL surgery was the best option if they wanted to return to sport. So we also questioned physios, the discussions I had with physios who were more likely to discuss both treatment options. But the majority still held belief that ACL surgery has better outcomes. So, I guess there's a long way to go, both in terms of changing practice, educating clinicians, and also educating the general public so that ACL management can closely align with what's reflected in the evidence.
Bevan Colless
You can see in the media that somebody's done their ACL, it's just almost a given that, oh, that person's going to need an operation. And often if they're elite athletes, they might, but then I guess the general public sees that that's what high level athletes do. So therefore, I should do the same thing. You do ACL have the operation? That's just the way it goes. And I guess that is still the predominant way of thinking about it. As I understand rates of ACL reconstruction, currently are at the highest ever, in Australia, anyway, is that correct?
Stephanie Filbay
Yeah, particularly amongst young people, even children. So it's increasing at a very fast rate in children and adolescents, but as are the rates over revision surgeries. So, second, and third surgeries are becoming much more common with time.
Bevan Colless
well. Yeah, yeah. Okay. Yeah. So just any last words of advice for listeners who might have recently torn their ACL, and they're wondering what they should do?
Stephanie Filbay
Yeah, so I guess, when it comes to evidence for ACL treatment options, just be aware that there is a lot of false information out there, especially on the internet, if you were just to Google something. And you also can't believe everything you read in a research article, particularly in the conclusion. So research needs to be critically appraised, including the quality and the potential bias and the research, which can be quite difficult to do. So hopefully, you have a clinician with those skill sets who can help to really decipher what research is useful for your particular condition. And also ask yourself, ‘does this person or organization have something to gain either financially or otherwise from strongly recommending a specific treatment’? As I said, we'd be cautious of really one sided opinions, because there are pros and cons of both options. So, if a clinician isn't offering the other treatment option to you, or even discussing that I'd be a little bit cautious and perhaps get a second opinion. Also, find a clinician who's aware of evidence or both treatment options so they can assist you in making an informed decision and provide you with the necessary information so that you can choose the best treatment option for you.
Bevan Colless
Terrific, great advice. I think that's probably enough, Stephanie. We've been at it for over an hour. And thanks very much for giving so much of your time. And I really hope this message goes out to people who really need it, and that it's starting to continue this important discussion that that needs to occur in this sort of paradigm shift in ACL management.
Stephanie Filbay
And thanks so much for the invitation to speak to you. So it's a topic that I love to talk about and can probably talk about all day, but it's fantastic that you're sitting up a podcast dedicated to knee injury and any management. That's terrific. So thank you very much.
Stephanie Filbay
Thanks, Stephanie. Okay, we'll speak again. So there you have it. Our first interview on the knee gurus podcast, I trust, you took some valuable lessons from Dr. Stephanie Filbay today,
