Attributions for recovery and adherence to rehabilitation following anterior cruciate ligament reconstruction: A prospective analysis

Perceptions of personal control and treatment efficacy of sport-related concussions in collegiate athletes

OBJECTIVE

The purpose of this study was to examine healthy collegiate athletes' perceptions of personal control and beliefs regarding the treatment efficacy related to sport-related concussion (SRC) along with identifying factors that may be associated with these perceptions.

METHODS

This cross-sectional study included collegiate athletes (n = 956) between the age of 18-26 years. Participants completed a 10- to 15-min survey regarding their demographics, diagnosed SRC history, SRC knowledge, and Perceptions of Concussion Inventory for Athletes (PCI-A). Chi-squared analysis and multivariable logistic regressions were conducted to identify factors associated with the PCI-A outcomes of personal control and treatment efficacy perceptions.

RESULTS

24.2% of respondents reported higher perceptions of personal control, while 77.3% reported higher perceptions of treatment efficacy. The multivariable logistic regression revealed males had higher odds of greater perceptions of personal control (OR = 1.50; 95% CI: 1.10-2.03), while those with a history of diagnosed SRC had lower odds of having favorable treatment efficacy beliefs (OR: 0.69; 95% CI: 0.50-0.96).

CONCLUSIONS

This study established that collegiate athletes generally have lower perceptions of personal control and higher perceptions of treatment efficacy related to SRC recovery. Comprehensive SRC education should be expanded for individuals to understand that they have power over their own health outcomes and that SRC is a treatable injury.

Behaviour Change Techniques to promote self-management and home exercise adherence for people attending physiotherapy with musculoskeletal conditions: A scoping review and mapping exercise

BACKGROUND

Many patients with musculoskeletal problems do not adhere to home exercises or self-management advice provided by physiotherapists. This is due to numerus factors, many of which can be targeted by Behaviour Change Techniques.

OBJECTIVES

1) Undertake a scoping review to identify the modifiable determinants (barriers and facilitators) of home exercise adherence and self-management for the physiotherapy management of people with musculoskeletal problems and map them to the Theoretical Domains Framework and Behaviour Change Techniques. 2) For determinants with supporting evidence from ≥2 studies, provide examples of Behaviour Change Techniques for clinical practice.

DESIGN

This review follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

METHOD

Four electronic databases were searched from inception to December 2022. Two independent reviewers carried out manuscript selection, data extraction, quality assessment, and mapping, the latter using the Theory and Techniques Tool.

RESULTS

Thirteen modifiable determinants were identified in 28 studies. The most frequently identified were self-efficacy, social support, and task appreciation. Determinants were mapped to 7 of 14 Theoretical Domains Framework categories, which in turn mapped onto 42 of 93 Behaviour Change Techniques, the most common being problem solving and instruction on how to perform behaviour.

CONCLUSIONS

By identifying determinants to home exercise adherence and self-management and mapping these to Behaviour Change Techniques, this review has improved understanding of their selection, targeting, and potential application to musculoskeletal physiotherapy practice. This provides support for physiotherapists targeting the determinants of importance for the patient in front of them.

The Influence, Barriers to and Facilitators of Anterior Cruciate Ligament Rehabilitation Adherence and Participation: a Scoping Review

Background

Outcomes following anterior cruciate ligament (ACL) reconstruction are considered poor. There are many factors which may influence patient outcomes. As such, the purpose of this review was to report on the influence, barriers to and facilitators of rehabilitation adherence and participation after ACL reconstruction, providing information to help clinicians and patients make quality decisions to facilitate successful rehabilitation.

Methods

A systematic search of five electronic databases was undertaken in identifying studies from inception to 18 July 2019. The search included English language articles reporting on the influence, barriers to and facilitators of adherence and participation in rehabilitation of patients who have undergone ACL reconstruction. Data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 180) were assessed for eligibility following screening of titles and abstracts (n = 1967), yielding 71 studies for inclusion. Forty-four articles investigated ‘rehabilitation prescription and participation’ and 36 articles investigated ‘rehabilitation barriers and facilitators’. The results indicate that a moderately or minimally supervised rehabilitation program is at least as effective as a fully supervised high-frequency rehabilitation program, although a longer duration of supervised rehabilitation is associated with improvement in a multitude of functional outcomes. A number of psychological factors associated with rehabilitation adherence were also identified. The most commonly investigated concepts were self-motivation, athletic identity and social support. Patients perceived the therapeutic relationship, interaction with family and friends, self-motivation, fear of reinjury, organisation/lack of time and interpersonal comparison as the most common barriers to and facilitators of rehabilitation.

Conclusions

A longer duration of supervised rehabilitation is associated with an increased chance of meeting functional and return to sport criteria; however, the optimal supervised rehabilitation frequency is yet to be determined. Identification of the barriers to and facilitators of adherence and participation in ACL rehabilitation provides an opportunity for further research to be conducted to address personal, environmental and treatment-related factors, with the aim to improve rehabilitation outcomes.

Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review

Objective

To explore the role of psychological, social and contextual factors across the recovery stages (ie, acute, rehabilitation or return to sport (RTS)) following a traumatic time-loss sport-related knee injury.

Material and methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and Arksey and O’Malley framework. Six databases were searched using predetermined search terms. Included studies consisted of original data written in English that identified or described a psychological, social or contextual factor related to recovery after a traumatic time-loss sport-related knee injury. Two authors independently conducted title–abstract and full-text reviews. Study quality was assessed using the Mixed Methods Appraisal Tool. Thematic analysis was undertaken.

Results

Of 7289 records, 77 studies representing 5540 participants (37% women, 84% anterior cruciate ligament tears, aged 14–60 years) were included. Psychological factors were investigated across all studies, while social and contextual factors were assessed in 39% and 21% of included studies, respectively. A cross-cutting concept of individualisation was present across four psychological (barriers to progress, active coping, independence and recovery expectations), two social (social support and engagement in care) and two contextual (environmental influences and sport culture) themes. Athletes report multiple barriers to recovery and valued their autonomy, having an active role in their recovery and diverse social support.

Conclusion

Diverse psychological, social and contextual factors are present and influence all stages of recovery following a traumatic sport-related knee injury. A better understanding of these factors at the time of injury and throughout rehabilitation could assist with optimising injury management, promoting RTS, and long-term health-related quality-of-life.

What Is the Relationship of Fear Avoidance to Physical Function and Pain Intensity in Injured Athletes?

BACKGROUND

Fear avoidance can play a prominent role in maladaptive responses to an injury. In injured athletes, such pain-related fear or fear avoidance behavior may have a substantial influence on the recovery process. Specifically, it may explain why some are able to reach their preinjury abilities, whereas others are unable to return to sport.

QUESTIONS/PURPOSES

(1) Is fear avoidance in athletes associated with decreased physical function after injury? (2) To what degree is fear avoidance associated with athletes' pain intensity?

METHODS

In a cross-sectional study, we recruited injured athletes-defined as patients with sports-related injury, weekly engagement in sport activities, participation in competitive events as part of a team or club, self-identification as an athlete, and a desire to return to sport after recovery-from an orthopaedic sports medicine center at a major urban university hospital. Of 130 approached patients, 102 (84% men; mean ± SD age 25 ± 8.5 years) met the inclusion criteria. Participants completed a demographic questionnaire, the Athlete Fear Avoidance Questionnaire, which assesses injury-related fear and avoidance behavior specifically in an athletic population, the Pain Catastrophizing Scale, the Hospital Anxiety and Depression Scale, and two Patient-Reported Outcomes Measurement Information System measures: Physical Function Computerized Adaptive Testing (CAT) and Pain Intensity CAT.

RESULTS

After controlling for age, injury region (upper versus lower extremity), catastrophic thinking, and emotional distress, we found that an increase in athletes' fear avoidance was associated with a decrease in physical function (b = -0.32; p = 0.002). The model explained 30% of the variation in physical function with 7.3% explained uniquely by fear avoidance. After controlling for initial appointment/followup, surgery for the current condition, multiple pain conditions, history of prior sport-related injury/surgery, pain medication prescription, catastrophic thinking, and emotional distress, athletes' fear avoidance was not associated with pain (b = -0.14; p = 0.249). The model explained 40% of the variation in pain intensity and pain catastrophizing (b = 0.30; p = 0.001) uniquely explained 7.1% of this variation.

CONCLUSIONS

In injured athletes, fear avoidance is independently associated with decreased physical function, whereas pain catastrophizing is associated with high pain intensity. Both level of an athlete's fear avoidance and catastrophic thinking about pain should be accounted for in clinical interventions aimed at helping athletes improve recovery and return to sport.

LEVEL OF EVIDENCE

Level II, prognostic study.

Psychological rehabilitation from anterior cruciate ligament-medial collateral ligament reconstructive surgery: a case study

BACKGROUND

Research has shown that some of the more common psychological responses to injury (ie, depression, anger, anxiety) are amplified in cases of traumatic injury.

HYPOTHESIS/PURPOSE

An 18-year-old male scholarship soccer player who, owing to a perceived deliberate injurious tackle by an opposition player, tore the medial collateral ligament and anterior cruciate ligament of his right knee. A psychological case perspective is presented.

STUDY DESIGN

Retrospective case report.

RESULTS

Various personal and situational factors can compound negative psychological response to injury. A number of extreme responses are explored, including posttraumatic stress, depression, and fear of reinjury.

CONCLUSIONS

Practitioners should be willing and able to facilitate referral in the instance of more extreme psychological response to anterior cruciate ligament injury.

Attributions and affirmations for overcoming anxiety and depression

Individuals who struggle with anxiety or depression often turn to experts for help in overcoming these disorders. In this study, we consult three expert 'populations': the popular self-help literature, well-respected therapists, and individuals who believe that they have successfully recovered from either anxiety or depression for their recommendations to those who are currently anxious or depressed. In Part I, we content-analyse recommendations from 10 current self-help books on anxiety and 10 on depression. In Part II, we asked 17 respected therapists and 18 individuals who believed that they have recovered from anxiety and 23 individuals who believe they have recovered from depression what they believe are the 'keys' for recovery. We also asked them to rate the efficacy of seven popular affirmations. Through content analysis and descriptive statistics, we summarize their collective wisdom. Among the main findings are the recommendations for anxious and depressed individuals to actively seek help from multiple people and interventions, as well as to being open to trying innovative self-tailored interventions. Affirmations relating to 'not being crazy' in relation to anxiety and that the depression will subside in time were deemed most helpful for recovery. Discussion focuses on practical application.

Psychologic stress related to injury and impact on sport performance

Injury rates are high among children and adolescent athletes. Psychosocial stressors, such as personality, history of stressors, and life event stress can influence injury occurrence. After injury, those same factors plus athletic identity, self-esteem, and significant others-such as parents, coaches, and teammates-can affect injury response, recovery and subsequent sport performance. Goal setting, positive self-talk, attribution theory, and relaxation or mental imagery are psychologic interventions that can help injured athletes cope with psychosocial stressors. Medical professionals should be aware of the potential influence that psychosocial stressors and psychologic interventions can have on injury occurrence, injury recovery, and sport performance.

Recovery attributions: explicit endorsement of biomedical factors and implicit dominance of psycho-social factors

Two studies assessed lay people's bio-medical and psycho-social attributions for recovery, using implicit and explicit methods, and one of them, Study 2, also measured individual differences in health locus of control. Participants were presented with a vignette of a patient with a severe disease for which chances of recovery vary widely, who had high or low levels of medical care and high or low psycho-social resources. They estimated his chances to recover from his illness (implicit attributions), and then, imagining another patient with the same disease, evaluated the relative importance of medical, psycho-social and other factors for his chances for recovery (explicit method). Findings show a moderation effect by assessment method: the explicit method pointed to dominance of biomedical attributions and the implicit method indicated dominance of psycho-social attributions. In addition, internal health locus of control was positively correlated with psycho-social attributions and external health locus of control (powerful others and chance) was correlated with biomedical attributions for recovery. The findings are discussed in relation to dual-process models of reasoning and self-serving defensive processes.

Psychophysiological Response to Severe Sport Injury Among Competitive Male Athletes: A Preliminary Investigation

Features of posttraumatic distress have been associated with treatment noncompliance and delayed surgical recovery among general medical and trauma populations. Although cognitive-affective and behavioral features of posttraumatic distress have been demonstrated among adult and adolescent athletes with injuries, physiological responses associated with posttraumatic distress have not yet been examined in this population. The objective of this study was to examine psychophysiological stress reactivity to orthopedic trauma among male athletes who sustained a severe sport injury. Athletes with injuries (n= 7) and non-injured athlete controls (n= 5) completed self-report measures of psychological distress and were then shown injury video footage while heart rate and skin conductance measures were recorded. After exposure to orthopedic trauma-related video footage, athletes with injuries demonstrated significantly greater skin conductance reactivity and subjective distress compared to controls. As demonstrated among other medical and trauma populations, athletes with injuries exhibit exaggerated stress reactivity profiles when primed with orthopedic trauma stimuli.

Adherence to sport injury rehabilitation programmes: a conceptual review

It is widely acknowledged that the importance of sound theoretical guidance is essential to any academic discipline. A common recommendation within the adherence literature related to sport injury rehabilitation has been the need to establish clear theoretical frameworks to guide research and practice. As such, an increasing amount of literature has employed conceptual models that include protection motivation theory, health action process approach, cognitive appraisal models, and attribution theory. Therefore, the purpose of this review is to critically evaluate these contemporary theoretical approaches that have been utilised within the sport injury rehabilitation adherence literature. Alongside this, practical implications emerging from this research base are outlined and future recommendations are suggested that may be of benefit to sports medicine practitioners and researchers alike.

Psychological Skills and Adherence to Rehabilitation after Reconstruction of the Anterior Cruciate Ligament

Objective:

To examine the relationship between self-reported use of psychological skills and rehabilitation adherence.

Design:

Prospective correlational design.

Setting:

Outpatient physical-therapy clinic specializing in sports medicine.

Patients:

Fifty-four patients (17 women and 37 men) undergoing rehabilitation after anterior-cruciate-ligament reconstruction.

Main Outcome Measures:

An abbreviated version of the Sports Injury Survey (Ievleva & Orlick, 1991) was administered approximately 5 weeks after surgery to assess use of goal setting, imagery, and positive self-talk. Four adherence measures were obtained during the remainder of rehabilitation: attendance at rehabilitation sessions, practitioner ratings of patient adherence at rehabilitation sessions, patient self-reports of home exercise completion, and patient self-reports of home cryotherapy completion.

Results:

Goal setting was positively associated with home exercise completion and practitioner adherence ratings. Positive self-talk was positively correlated with home exercise completion.

Conclusions:

Use of certain psychological skills might contribute to better adherence to sport-injury rehabilitation protocols.