Biopsychosocial Model Domains in Clinical Practice Guidelines for Return to Sport After ACL Injury: Systematic Review Using the AGREE II Checklist

Abstract

Context: The current status of return-to-sport (RTS) criteria can be understood from the International Classification of Functioning, Disability, and Health (ICF), which emphasizes an individual-centered approach and inclusion of all domains of human functioning, and ensures the multifactorial and biopsychosocial nature of decision-making.

Objective: To analyze the inclusion of biopsychosocial model domains in clinical practice guidelines (CPGs) for RTS after anterior cruciate ligament (ACL) injury, as well as the quality of these CPGs.

Study design: Systematic review of CPGs.

Level of evidence: Level 1.

Search strategy: Two independent reviewers developed the search strategy, and a third reviewer corrected and compiled the developed strategies used.

Data sources: Ovid/Medline, Embase, and PEDro without restriction dates.

Study selection: CPGs for RTS after ACL injury at any age or sport level, and published in English.

Data extraction: Two independent reviewers codified the RTS criteria recommended in the CPGs according to the ICF domains, and the Appraisal of Guidelines for Research and Evaluation II (AGREE II Checklist) was used for critical appraisal.

Results: A total of 715 records were identified, and 7 CPGs were included. Frequency distribution of the biopsychosocial model domains was as follows: body functions (37.77%), activity and participation (20.00%), body structure (13.33%), environmental factors (11.11%), and personal factors (8.88%). In the AGREE II Checklist, the lowest mean domain scores were for rigor of development (37.86 ± 36.35) and applicability (49.29 ± 22.30), and 71.42% were of low or moderate quality.

Conclusion: The CPGs cannot address the biopsychosocial model domains satisfactorily and some do not address all the ICF conceptual model components, emphasizing body functions and activity and participation domains. Therefore, the functioning model advocated by the World Health Organization has not yet been adequately incorporated into the recommendations for RTS after ACL injury. Moreover, most CPGs are of limited quality.

Keywords: ACL injury; AGREE II; biopsychosocial model; clinical practice guidelines; return to sport.

Figure 1.

Flowchart of selected CPGs. CPG, clinical practice guideline.

Figure 2.

Frequency distribution of the ICF domains in all CPGs for RTS after ACL injury. ACL, anterior cruciate ligament; CPG, clinical practice guideline; ICF, International Classification of Functioning, Disability, and Health; RTS, return to sport.