الفهرس 
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Abstract
Musculoskeletal disorders have made enormous and growing public health impact worldwide. They cause impairments in body functions and /or structure; such as pain, reduces muscle strength, range of joint motion and joint instability resulting in moderate to severe limitation in walking, stair climbing and transfers such as rising from a chair, getting in and out of the car. These activity limitations frequently lead to limited participation in remunerative employment, community life, recreation and leisure activities.
The anterior cruciate ligament (ACL) is one of four ligaments in the knee. These ligaments work together to stabilize the knee during activities. Unfortunately, tears of the ACL are common, occurring with twisting activities (such as skiing, basketball, tennis and soccer) and direct blow injuries (such as football). When people tear their ACL, it is usually a sudden event often accompanied by a “pop.” There is swelling over the next few hours and there is difficult walking comfortably. The knee can feel unstable. Physical examination and MRI examinations will confirm the tear. When the ACL is completely torn it has no significant capability of repair and thus the ligament function is lost.
The correct choice of treatment depends on assessment of three patient factors as age, function disability and function requirements. The treatment consists of non-surgical or surgical intervention. After ACL reconstruction surgery, many patients become inactive, sometimes because of the pain, other times because of fear of reinjury or making pain worse. Inactivity leads to weak muscles, makes it harder to get back to normal activity. A vicious cycle develops, therefore the need for rehabilitation before and after ACL reconstruction surgery is the most important part of the management. So, in ACL reconstruction patients need highly specialized multidisciplinary team cooperation to act effectively and efficiently.
Rehabilitation is very important and has a significant impact on decreasing the complications. The nurse becomes an important part of the rehabilitation program. Rehabilitation begins immediately after surgery, which involves walking with crutches, contracting the thigh muscles, and attempting to lift the leg independently.
The comprehensive rehabilitation program is a core in the success of ACL reconstruction. It preserves and maintains range of motion, strength of muscles of the lower extremities, provides the patients with a sense of functional independence, and improves the activities of daily living. It also promotes the overall quality of life from all physical, psychological, social, and spiritual aspects.
The aim of this study was
To evaluate the effect of a nursing rehabilitation program on patients’ health outcomes after anterior cruciate ligament reconstruction.
Materials and method
The study was carried out in the Orthopedic Departments at El Hadara Traumatology, Orthopedic University Hospital, Alexandria and the affiliated Outpatients Clinics. The sample of this study comprised 40 adult patients of both sexes with anterior cruciate ligament injury and planned for knee arthroscopic ACL reconstruction.
Tools of the study
Three tools were used for data collection in this study:
Tool I: Arthroscopic ACL reconstruction patients’ knowledge assessment sheet
This tool was developed by the researcher to assess patient’s knowledge about anterior cruciate ligament injury and reconstruction.
The tool consisted of two parts:
Part I: Bio-Socio demographic data
A. Patients socio demographic data: as patient’s age, sex, marital status,area of residence, level of education, occupation and income.
B. Medical data and Health history information: it was utilized to obtain information about clinical history of studied patient as past history (previous hospital admission, medical history, and surgical history), present history (mechanism of injury, present health problem, preoperative physiotherapy and sport practicing).
Part II: Arthroscopic (ACL) reconstruction structured interview schedule used to assess the patient’s knowledge of anterior cruciate ligament injury and treatment.
Tool II: Anterior knee pain scale (AKPS)
This scale was adopted from Kujala 1999 (129). The scale was specifically designed for patients with patellofemoral pain to evaluate the degree of pain. It was categorized from 0 as a minimum to 10 as maximum point.
Tool III: Objective outcome evaluation measures for anterior cruciate ligament reconstruction, it consisted of four parts related to the following:
Part I: Muscles strength assessment scale
This part was adopted from Karen 2011(130). It was used in the present study by the researcher to assess the strength of the intrinsic knee muscles. This scale is graduated from 0 to 5 grads.
Part II: Knee range of motions assessment sheet
This scale was adopted from Luttgen and Hamilton 1997 (55). It was used in the present study by the researcher to measure knee range of motion in (flexion and extension) by using a goniometer.
Part III: Knee Outcome Survey Activities of Daily Living Scale (ADLS)
This scale was adopted from Irrgang 1998 (131). It was used in the present study by the researcher to evaluate patient’s activity of daily living.
Part IV: Complications assessment sheet
This part was developed by the researcher to assess the presence of complications or problems post ACL reconstruction (18, 71, 132).
Data collection
Tools of the study were tested for content validity by a jury of five experts’ in the field of medical-surgical nursing for content validity, correction and clarifying of needed items were done. A pilot study was conducted before actual study and was done on four adult patients to test the feasibility and applicability of the tool and modification was done. After securing the administration approval, data collection was started and continued for a period of 12 months from February 2017 to January 2018.
Statistical Analysis: After the data were collected, they were coded and transferred into specially designed formats, so as to be suitable for computer feeding. Data were analyzed using the Statistical Package for Social Sciences ’’ IBM SPSS’’ version 22.
The study was carried out in four phases
1. Assessment phase
Initial assessment was carried out preoperatively using the three study tools to collect baseline data before program implementation.
2. Planning phase
Based on the data collected from the assessment phase and literature review, the program goals, priorities contents, and expected outcomes were developed by the researcher according to the individual needs and problems. In addition illustrated colored booklet was developed by the researcher and was distributed to each patient in the implementation phase.
3. Implementation phase:
The developed rehabilitation program was conducted and applied individually to each patient in the patient department and was continued in the outpatient clinic, using demonstration, redemonstration and colored booklet.
• The program consisted of five sessions as follows:
The first session: At the beginning of this session, the researcher introduced herself to the patient and explained the general and specific objectives the rehabilitation program, time schedule, benefits of the rehabilitation program and simple information, It included a simple introduction about the nature of the anatomy of the knee, ACL injury and treatment, and patient was instructed about the recommended group I exercises during the first postoperative week.
The second session: the researcher contacted each patient of study group at the end of the first week postoperatively to observe the patients performance of the group I exercises and correct if needed, and she instructed him the recommended group II exercises.
The third session: the researcher contacted each patient of study group at the end of the four weeks postoperatively to observe the patient’s performance of the group II exercises and correct if needed, and then she taught him recommended group III exercises.
The fourth session: the researcher contacted each patient of study group at the end of the six the week postoperatively to observe the patients performance of the group III exercises and correct if needed, and then taught the patient group IV exercises.
The fifth sessions: the researcher contacted each patient of study group at the end of the eight weeks postoperatively to observe the patient’s performance of the group IV exercise and correct if needed, and then she taught group V exercise.
4. Evaluation phase: Patients were evaluated 3 times preprogram, immediate post, and post 3months from intervention program using all study tools.
The main results of the study were
• More than two- thirds (67.5%) of studied patients were aged between 20-30 years with a mean age 28.45-5.58 years.
• The highest percentage of studied patients (85%) were males.
• Around two -thirds (57.5%) of studied patients had secondary education.
• More than half (60%) of studied patients were single.
• Around two- thirds (67.5%) of studied patients were manual workers.
• More than (60%) of studied patients were from urban areas.
• Contact injury was the main causes of ACL injury among studied patients, than two- thirds (80%) of studied patients.
• There was statistically significant improvement of studied patients knowledge about ACL reconstruction surgery throughout program intervention phases (P<0.001*).
• There was statistically significant difference in pain intensity throughout all program intervention phases (P<0.001*).
• There was statistically significant difference in knee range of motion throughout all program intervention phases (P<0.001*).
• There was statistically significant difference of studied patients activity of daily living throughout all program intervention phases (P<0.001*).
• Low percentages of studied patients had health problems post ACL reconstruction.
• There was statistically significant difference between bio-socio-demographic characteristics of studied patients and their total knowledge about ACL reconstruction surgery post three months from intervention program.
• There was statistically significant difference in studied patients total knowledge score and health outcome criteria after ACL reconstruction surgery post three months from intervention program.
The main recommendations are
• Apply the developed rehabilitation program for all patients with ACL reconstruction in order to reduce pain, improve knee muscles strength, ROM, level of independence in performing activities of daily living and prevent postoperative complication and health problems.
• The developed colored illustrated educational booklet should be available and distributed to all patients with arthroscopic ACL reconstruction.
• On job training program should be carried out for nurses working in orthopedic department about types, frequency and benefits of exercise for patients with ACL reconstruction.