1. Reconstruction Surgery
Psychological Responses and Return to Play Following Anterior Cruciate Ligament
Reconstruction Surgery
Hayley Russell1, Diane Wiese-Bjornstal2, Elizabeth Arendt2, & Julie Agel2
1The Pennsylvania State University – Altoona Campus 2University of Minnesota, Twin Cities
background
Procedure & Measures
Results (CONT’D)
Approximately 50% of athletes who tear their anterior cruciate ligament (ACL) do not return to previous level of participation in sport or physical activity post-ACL reconstruction and rehabilitation despite objectively meeting physical demands (Ardern et al., 2011)
Conceptual models of return to play prescribe a multidimensional approach (Creighton et al., 2010) to understanding return to play outcomes following ACL surgery and rehabilitation.
Cognitive, behavioral, and affective responses have been found to influence return to play post-ACL reconstruction (te Weirke et al., 2013, see Figure 1)
Limitations of previous literature
Few longitudinal studies including return to play time period
Limited use of athlete-specific measures
Examining dynamic patterns of specific psychological responses, across the latter time course of ACL rehabilitation is necessary to understand how they relate to outcomes, specifically return to play.
Participants were recruited from a comprehensive orthopaedic medicine center in the Greater Minneapolis area
Measures were selected based on a comprehensive review of literature on psychological factors related to ACL rehabilitation outcomes (see Figure 1)
Participants completed the follow measures via survey (Qualtrics) at 4-, 6-, and 9-months post-surgery
Knee Self-Efficacy Scale (Thomeé et al., 2006)
Item from the Emotional Response of Athletes to Injury Questionnaire to assess perceived percent recovery (Smith et al., 1990)
Re-injury Anxiety Inventory (Walker et al., 2010)
Patient Health Questionnaire-4 (Kroenke et al., 2009)
Perceived Limitations to Ability item from the Activities Scale (Agel, 2013)
A repeated measures MANOVA was used to explore the difference between psychological responses of returners and non-returners over the latter part of rehabilitation from ACL reconstruction
Interaction between return status and time F(5,24) = 2.14,
p = .067, ƞ2=.45
Significant main effect for time F(5, 28) = 61.75, p<.001, ƞ2 = .96.
Significant main effect for group F(5,28) = p<.01, ƞ2 = .48.
Re-injury Anxiety
Perceived Limitations
Results
Rehabilitation adherence
Return to play
Disablement
Fear of re-injury
Mental health
Knee self-efficacy
Perceived recovery
Perceived limitations to ability
Cognitions
Affects
Behaviors
Outcomes
Figure 1. Psychological variables that have been found to influence recovery outcomes post-ACL reconstruction. Derived from te Weirke et al., 2013, Flanigan et al., 2013, adapted from Wiese-Bjornstlal, 2010.
Participants were categorized as “returners” or “non-returners” based on self-report of return status at 9-months post-surgery and follow-up qualitative responses about their return status.
Gender
Competitive Level N
Age(SD)
Male
Female
Competitive
Non-Competitive
Returners 20
25.10 (11.22) 11 9
Non-Returners 19
31.16 (12.79) 10 8
Conclusions
Psychological responses change differently across the latter course of ACL rehabilitation in those who return and those who do not return to play
Psychological distress appears to improve most from 4- to 6-months post-surgery and less from 6- to 9-months
Returners endorse lower re-injury anxiety and perceived limitations to ability and higher perceived percent recovery than non-returners.
This research provides support for Creighton et al.’s (2010) multidimensional approach to medically clearing athletes to return to play following ACL reconstruction.
Research Question
Do psychological responses to injury change over the course of latter ACL rehabilitation differently in participants who return to play as compared to those who do not return to play at 9-months post-surgery?
Returners
Mean (SE)
Non-Returners 4 6 9
K-SES
6.77 (.40)
6.37 (.32)
6.13 (.26)
5.81 (.45)
5.47 (.36)
6.47 (.29)
PPR
7.53 (.41)
8.11 ( .24)
7.52 (.41)
6.33 (.46)
7.27 (.27)
PLA
7.26 (.70)
6.16 (.83)
2.37 (.63)
10.40 (.79)
7.40 (.93)
7.20 (.71)
RIAI
28.25 (1.95)
15.90 (2.15)
8.95 (1.94)
34.53 (2.19)
15.60 (2.42)
19.53 (2.18)
PHQ-4
4.68 (.29)
1.05 (.50)
.37 (.27)
5.67 (.32)
1.13 (1.13)
1.15 (1.47)
References
Participants
Surgical treatment of first ACL tear
Self-reported intention of return to sport or physical activity
n = 43 (21 males, 22 females)
Mage= years (SD = 12.77)
20 competitive athletes, 23 recreational athletes
Self-predicted return M= 7.02 months (SD = 1.84)
Agel, J. (2013). Activity scale, Unpublished manuscript.
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Notes. 4, 6, and 9 represent months since surgery, higher scores on Knee Self-Efficacy Scale (K-SES) represent higher knee self-efficacy, higher scores on Perceived Percent Recovery (PPR) represent higher perceived percent recovery, higher scores on Perceived Limitations to Ability (PLA) indicate higher perceived limitations to ability, higher scores on Re-injury Anxiety Inventory (RIAI) indicate higher re-injury anxiety, higher scores on the Patient Health Questionnaire (PHQ-4) indicate more symptoms of anxiety and depression.