"Not always a straight path": patients' perspectives following anterior cruciate ligament rupture and reconstruction

Impact of Psychological Factors on Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

Anterior cruciate ligament (ACL) tears are a common orthopaedic injury, and the incidence of ACL reconstruction (ACLR) continues to increase. Current clinical practice guidelines (CPGs) recognize the role of psychological factors in rehabilitation, but patient-reported outcome measures (PROs) and psychological readiness are rarely incorporated into rehabilitation.

OBJECTIVE

The purpose of this review was to highlight the importance of psychological health after ACL injury, understand the current metrics used to monitor psychological recovery, and outline how psychological recovery can be better incorporated in current CPGs.

DATA SOURCES

A systematic review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA); 63 studies were identified with a PubMed search using the term "ACL Injuries/psychology".

STUDY SELECTION

Exclusion criteria included lack of consideration of psychological effects or studies validating PROs after ACLR. Studies were reviewed by multiple reviewers, and a total of 38 studies were included after applying exclusion criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 3b.

DATA EXTRACTION

Two independent reviewers analyzed the included articles to extract sample size, psychological readiness scale or other measures used, and key results.

RESULTS

Psychological outcomes, especially kinesiophobia and fear of reinjury, are seen commonly after ACLR. Psychological factors were shown to impede return to sport (RTS), alter measurable knee biomechanics, and potentially increase the risk for re-rupture. Targeted interventions such as kinesiotaping, knee bracing, and imagery training can help improve psychological and functional testing after ACLR.

CONCLUSION

ACLR is often complicated by psychological factors. Psychological readiness is a crucial yet often unincorporated part of rehabilitation. Patients with higher levels of kinesiophobia and lower psychological readiness to RTS specifically should be identified to allow for administration of interventions, such as imagery training, knee bracing, or kinesiotaping, that can mitigate the negative effects of psychological outcomes and improve recovery.

Athletes' perspectives on return to sport after anterior cruciate ligament reconstruction and their strategies to reduce reinjury risk: a qualitative interview study

BACKGROUND

Insights derived from athletes who have completed the final phase of rehabilitation and successfully returned to their respective sports after anterior cruciate ligament (ACL) reconstruction could potentially contribute to the enhancement of therapeutic strategies. Therefore, the aim of this study was to explore athletes' experiences, thoughts, and behaviours of final phase rehabilitation and return to sport after ACL reconstruction and to describe their thoughts about the risk of reinjury.

METHODS

This qualitative interview study included individual semi-structured interviews with 15 athletes after ACL reconstruction. All athletes were aged between 15 and 35 years (median, 23 years), had returned to their preinjury contact sport at elite or recreational competitive level, rehabilitated with different physioterapists (working in hospital, primary care or sport clinics), and had undergone primary ACL reconstruction between 14 and 59 months (median, 23 months) before the interviews. Data were analysed using qualitative content analysis.

RESULTS

Analysis of the data resulted in the following 4 main categories related to athletes' experiences of the return to sport process and their thoughts about the risk of reinjury: Athletes' strategies for safe return to sport; Support during rehabilitation and return to sport; The rehabilitation journey was worthwhile to be able to play again; and Reinjury is beyond one's control.

CONCLUSIONS

Athletes described strategies for a safe return to sport after ACL reconstruction, emphasizing continuous increased load, not forcing return to sport, injury prevention exercises, and seeking support from professionals and coaches. Despite loving their sport, the athletes had mixed feelings about undergoing additional rehabilitation if reinjured. The athletes recognized the high reinjury risk, attributing it to fate. These findings enhance understanding of athletes' return to sport experiences after ACL reconstruction, their strategies to minimize reinjury risk, which might help optimizing care for this patient group.

'It's just my knee': a qualitative study investigating the process of reframing and young athletes' perceived quality of life between anterior cruciate ligament injury and surgery

OBJECTIVES

To understand the factors influencing young athletes' perceptions of quality of life (QOL) following an anterior cruciate ligament (ACL) rupture, prior to reconstructive surgery.

DESIGN

Qualitative descriptive study using semi-structured interviews and thematic analysis of data.

SETTING

Tertiary sports medicine clinic with patients recruited from the practices of three specialist orthopaedic surgeons.

PARTICIPANTS

Twenty athletes aged 14-25 provided consent to participate in the study and completed interviews prior to their ACL reconstruction surgery. Participants were eligible to participate if they were scheduled to undergo ACL reconstruction, were 25 years of age or younger, identified as athletes (participated in any level of organised sport), could communicate in English and agreed to be audio recorded. Participants were not eligible if they had experienced a multiligament injury or fracture.

RESULTS

Young athletes shared common factors that made up their QOL; social connections and support, sport, health, and independence. However, participants' perceptions of their current QOL were quite variable (13-95/100 on a Visual Analogue Scale). Participants who were able to reframe their injury experience by shifting focus to the positive or unaffected aspects of their lives tended to have more favourable perceptions of their QOL than participants who shifted focus to the losses associated with injury.

CONCLUSIONS

Young athletes who have experienced an ACL injury define their QOL based on social support, sport, health and independence. Individual processes of adaptation and cognitive reframing in response to an ACL injury may exert a greater influence on postinjury QOL than the physical ramifications of the injury itself. Understanding individual perceptions may help target potential interventions or supports to enhance athletes' adaptation to injury.

Preoperative Rehabilitation Enhances Mental and Physical Well-Being in Anterior Cruciate Ligament-Injured Individuals: A Mixed Methods Study

CONTEXT

Rehabilitation after an anterior cruciate ligament injury is recommended to be started soon after the injury. When surgery is required, research supports the delivery of physiotherapy before anterior cruciate ligament reconstruction (prehabilitation) to optimize recovery and positive outcomes. Individuals attending prehabilitation have never been questioned regarding their adherence to prehabilitation, perception of utility in meeting needs, upcoming events, or anticipated recovery goals.

DESIGN

Mixed methods cross-sectional study: Methods: 25 individuals before anterior cruciate ligament reconstruction (43% of eligible individuals from 12 clinics during the delivery period) were surveyed on their mindset and recovery expectancies. Semistructured interviews conducted in 9 of 25 participants assessed their lived experience of prehabilitation.

RESULTS

Participants reported that preventing a reinjury (96% of responses) and feeling confident during daily activities about their knee (92%) were the higher rating expectations at this stage of their treatment course. Three themes were developed from the interviews and analyses. (1) Participants reported that prehabilitation was a period full of challenges with memories of the injury and uncertainties. (2) They viewed prehabilitation as a step to move forward by finding support and self-motivating. (3) They believed that prehabilitation would have positive impacts on the treatment outcomes. Participants were confident that prehabilitation would accelerate the recovery of muscle volume (88%) and strength (84%).

CONCLUSION

Participants had positive experiences of prehabilitation, aligning with the findings on functional outcomes in the existing literature on prehabilitation.

To achieve the unachievable-Patients' experiences of opting for delayed anterior cruciate ligament reconstruction after trying rehabilitation alone as primary treatment: A qualitative study

INTRODUCTION

About 50% of patients who sustain an anterior cruciate ligament (ACL) injury are treated without ACL reconstruction (ACL-R). A significant proportion of these patients opt for late ACL-R. Patients' experience of changing treatment has not yet been investigated and presented in the scientific literature.

AIM

To explore patients' experiences before and after changing treatment from ACL rehabilitation alone to ACL-R.

METHOD

Fifteen patients were interviewed in semi-structured interviews, which were recorded, transcribed, and analyzed with qualitative content analysis, based on the method described by Graneheim and Lundman. Patients were between 26 and 58 years old, and had tried rehabilitation for a minimum of 9 months prior to ACL-R.

RESULTS

Two themes, "Expecting what could not be achieved: the struggle to recover and not becoming stable", and "Internal completeness: expectations can be achieved", emerged from the analysis. Each theme was supported by three main categories and 5-6 subcategories. The first theme represents the journey before ACL-R, where patients experienced getting stronger, but perceived the knee as unstable. The second theme represents the journey after ACL-R, where patients expressed that they felt whole after their ACL-R, and where able to achieve their expections. Patients experienced a greater support from the healthcare system, and ultimately expressed a feeling of having achieved the unachievable after ACL-R.

SUMMARY

Patients who cross over from ACL rehabilitation to ACL-R experienced rehabilitation alone as insufficient to achieve the desired outcomes, which resulted in a need to opt for delayed ACL-R. Healthcare providers need to support patients, who primarily choose to undergo rehabilitation alone and later opt for ACL-R, throughout the whole rehabilitation process.

Understanding Fear after an Anterior Cruciate Ligament Injury: A Qualitative Thematic Analysis Using the Common-Sense Model

Fear is a significant factor affecting successful return to sport following an anterior cruciate ligament (ACL) injury. However, there is a lack of understanding of the emotional drivers of fear and how fear beliefs are formed. This study qualitatively explored the contextual and emotional underpinnings of fear and how these beliefs were formed, with reference to the Common-Sense Model of Self-Regulation. Face-to-face online interviews were conducted with ACL-injured participants (n = 18, 72% female) with a mean age of 28 years (range 18-50 years). Participants were either 1 year post ACL reconstruction surgery (n = 16) or at least 1 year post injury without surgery (n = 2) and scored above average on a modified Tampa Scale of Kinesiophobia. Four participants were playing state-level sport or higher. Five themes emerged describing factors contributing to fear: 'External messages', 'Difficulty of the ACL rehabilitation journey', 'Threat to identity and independence', 'Socioeconomic factors', and 'Ongoing psychological barriers'. A sixth theme, 'Positive coping strategies', provided insight into influences that could reduce fear and resolve negative behaviors. This study identified a broad range of contextual biopsychosocial factors which contribute to fear, supporting the notion that ACL injuries should not be treated through a purely physical lens. Furthermore, aligning the themes to the common-sense model provided a conceptual framework conveying the inter-related, emergent nature of the identified themes. The framework provides clinicians with a means to understanding fear after an ACL injury. This could guide assessment and patient education.

Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction

BACKGROUND

The risk of sustaining a graft rupture after anterior cruciate ligament reconstruction (ACLR) is high. Contributing risk factors are, however, still not clearly identified.

OBJECTIVE

The aim of this systematic review was to identify and quantify risk factors for graft rupture after ACLR.

METHODS

A systematic review with meta-analysis (PROSPERO CRD42020140129) based on PRISMA guidelines was performed. MEDLINE, CINAHL and EMBASE were searched from inception to September 2021. Prospective and retrospective studies addressing risk factors for graft rupture after ACLR in males/females of all ages were considered. Meta-analyses using a random effect model (effect measure: odds ratio [OR] with 95% confidence interval [CI]) were performed. The GRADE tool was used to assess evidence quality.

RESULTS

Following full-text screening of 310 relevant papers, 117 were eventually included, incorporating up to 133,000 individuals in each meta-analysis. Higher Tegner activity level (≥ 7 vs < 7) at primary injury (OR 3.91, 95% CI 1.69-9.04), increased tibial slope (degrees) (OR 2.21, 95% CI 1.26-3.86), lower psychological readiness to return to sport (RTS) (OR 2.18, 95% CI 1.32-3.61), early surgery (< 12 vs ≥ 12 months) (OR 1.87, 95% CI 1.58-2.22), RTS (pre-injury level) (OR 1.87, 95% CI 1.21-2.91) and family history of ACL injury (OR 1.76, 95% CI 1.34-2.31) were all associated with increased odds of graft rupture. Higher age (OR 0.47, 95% CI 0.39-0.59), female sex (OR 0.88, 95% CI 0.79-0.98), fewer self-reported knee symptoms pre-reconstruction (OR 0.81, 95% CI 0.69-0.95) and concomitant cartilage injuries (OR 0.70, 95% CI 0.62-0.79) instead decreased the odds. Meta-analysis revealed no association between body mass index, smoking, joint laxity, RTS time, knee kinematics, muscle strength or hop performance and graft rupture.

CONCLUSION

Conspicuous risk factors for graft rupture were mainly sports and hereditary related. Few studies investigated function-related modifiable factors or included sports exposure data.

An Investigation of the Nature of Fear within ACL-Injured Subjects When Exposed to Provocative Videos: A Concurrent Qualitative and Quantitative Study

Fear is a factor contributing to poor return to sport after an anterior cruciate (ACL) injury, however the identification and assessment of fear is challenging. To improve understanding of fear, this study qualitatively and quantitatively assessed responses to videos depicting threat to knee stability in people who had experienced an ACL injury. ACL-injured participants who had above average fear on the Tampa Scale of Kinesiophobia and were at least 1-year post-injury/surgery were eligible. Participants were shown four videos depicting sequentially increasing threat to their knee stability (running, cut-and-pivot, feigned knee injury during cut-and-pivot, series of traumatic knee injuries). Qualitative interviews explored participants feeling related to viewing the videos. Participants quantitatively self-rated fear and distress in response to each video. Seventeen participants were included in this study (71% female, with an average time since last ACL injury of 5 ½ years). Five themes were identified: (1) Evoked physiological responses, (2) Deeper contextualisation of the meaning of an ACL injury influencing bodily confidence, (3) Recall of psychological difficulties, (4) Negative implications of a re-injury, and (5) Change to athletic identity. Quantitatively, direct proportionality was noticed between threat level and reported fear and distress. Specifically, participants reported increasing levels of fear and distress as the videos progressed in threat level, with the largest increase seen between a cut-and-pivot movement to a feigned injury during a cut and pivot. The results support the notion that in addition to being a physical injury, an ACL injury has more complex neurophysiological, psychological, and social characteristics which should be considered in management. Using video exposure in the clinic may assist identification of underlying psychological barriers to recovery following an ACL injury, facilitating person-centred care.

A Psychological Support Intervention to Help Injured Athletes “Get Back in the Game”: Design and Development Study

Background

After a serious knee injury, up to half of athletes do not return to competitive sport, despite recovering sufficient physical function. Athletes often desire psychological support for the return to sport, but rehabilitation clinicians feel ill-equipped to deliver adequate support.

Objective

We aimed to design and develop an internet-delivered psychological support program for athletes recovering from knee ligament surgery.

Methods

Our work for developing and designing the Back in the Game intervention was guided by a blend of theory-, evidence-, and target population–based strategies for developing complex interventions. We systematically searched for qualitative evidence related to athletes’ experiences with, perspectives on, and needs for recovery and return to sport after anterior cruciate ligament (ACL) injury. Two reviewers coded and synthesized the results via thematic meta-synthesis. We systematically searched for randomized controlled trials reporting on psychological support interventions for improving ACL rehabilitation outcomes in athletes. One reviewer extracted the data, including effect estimates; a second reviewer checked the data for accuracy. The results were synthesized descriptively. We conducted feasibility testing in two phases—(1) technical assessment and (2) feasibility and usability testing. For phase 1, we recruited clinicians and people with lived experience of ACL injury. For phase 2, we recruited patients aged between 15 and 30 years who were within 8 weeks of ACL reconstruction surgery. Participants completed a 10-week version of the intervention and semistructured interviews for evaluating acceptability, demand, practicality, and integration. This project was approved by the Swedish Ethical Review Authority (approval number: 2018/45-31).

Results

The following three analytic themes emerged from the meta-synthesis (studies: n=16; participants: n=164): (1) tools or strategies for supporting rehabilitation progress, (2) barriers and facilitators for the physical readiness to return to sport, and (3) barriers and facilitators for the psychological readiness to return to sport. Coping strategies, relaxation, and goal setting may have a positive effect on rehabilitation outcomes after ACL reconstruction (randomized controlled trials: n=7; participants: n=430). There were no trials of psychological support interventions for improving the return to sport. Eleven people completed phase 1 of feasibility testing (technical assessment) and identified 4 types of software errors, which we fixed. Six participants completed the feasibility and usability testing phase. Their feedback suggested that the intervention was easy to access and addressed the needs of athletes who want to return to sport after ACL reconstruction. We refined the intervention to include more multimedia content and support access to and the use of the intervention features.

Conclusions

The Back in the Game intervention is a 24-week, internet-delivered, self-guided program that comprises 7 modules that complement usual rehabilitation, changes focus as rehabilitation progresses, is easy to access and use, and includes different psychological support strategies.

'I was young, I wanted to return to sport, and re-ruptured my ACL' - young active female patients' voices on the experience of sustaining an ACL re-rupture, a qualitative study

Background

Despite anterior cruciate ligament (ACL) re-ruptures being common, research on patient experiences after knee trauma has primarily focused on the time after primary ACL reconstruction. Integrating qualitative research and patient experiences can facilitate researchers and clinicians in understanding the burden of an ACL re-rupture. The aim of the study was to explore the experiences of an ACL re-rupture journey in young active females aiming to return to knee-strenuous sports after primary ACL reconstruction.

Method

Fifteen young (19[range 16–23] years old) active females who suffered an ACL re-rupture were interviewed with semi-structured interviews. Qualitative content analysis using deductive approach based on Wiese-Bjornstal’s ‘integrated model of response to sport injury’ was used.

Results

The results are presented in two timelines 1) from first ACL injury to ACL re-rupture, and 2) from ACL re-rupture to present day, and further stratified according to the domains of the ‘integrated model of psychological response to injury’. Results in the first timeline are summarised into seven categories: Finding hope for the journey; Accepting my ACL injury; I succeeded; What matters now? Who am I?; Where will this end? What is going to happen? In the second timeline, eight categories were identified: Fighting spirit; A helping hand; Working hard; I am a new me; I am destroyed; Loneliness; Painful changes; and, I could have made it to the pro´s.

Conclusion

Young active females who suffered an ACL re-rupture did not express any positive experience following their first ACL injury, however, in contrast, expressed positive experiences and personal growth after going through the ACL re-rupture journey, characterized by a lot of struggling, and ultimately led to the experience of becoming a new, stronger person.

Disrupted knee - disrupted me: a strenuous process of regaining balance in the aftermath of an anterior cruciate ligament injury

Background

Individuals describe both short and long term consequences after an anterior cruciate ligament (ACL) injury. Functional impairments are well documented while psychological, social and contextual factors need to be further investigated. By the use of a qualitative method incorporating a biopsychosocial lens, we aimed to explore individuals’ experiences of living and coping with an ACL rupture with a specific focus on experiences significant to overall life, activity in daily living and physical activity more than one year after injury.

Methods

Twelve participants were chosen strategically by a purposive sampling. Four men and eight women (19–41 years) with an ACL rupture 2–25 years ago, were included. Semi-structured interviews were used and analysed with qualitative content analysis.

Results

The results consisted of one overarching theme: ‘A strenuous process towards regaining balance’ which built on three categories ‘Disrupted knee’, ‘Disrupted me’ and ‘Moving forward with new insights’. The overarching theme captures the participants’ experiences of a strenuous process towards regaining both physical and mental balance in the aftermath of an ACL injury. The results illuminate how participants were forced to cope with a physically ‘disrupted knee’, as well as facing mental challenges, identity challenges and a ‘disrupted me’. By gradual acceptance and re-orientation they were moving forward with new insights – although still struggling with the consequences of the injury.

Conclusions

Individuals with an ACL injury experience both physical, psychological, and social challenges several years after injury. In addition to the functional impairments, diverse psychological, social and contextual ‘disruptions’ and struggles may also be present and influence the rehabilitation process. It is important that physiotherapists identify individuals who face such challenges and individually tailor the rehabilitation and support. A biopsychosocial approach is recommended in the clinical practice and future studies focusing on psychosocial processes in the context of ACL rehabilitation are warranted.

"I don't opt out of things because I think I will get a sore knee, but I don't expose myself to stupid risks either": patients' experiences of a second ACL injury-an interview study

PURPOSE

The purpose of this qualitative study was to describe women's experiences with anterior cruciate ligament reconstruction (ACLR) and a subsequent ACL rupture, and to identify potential facilitators and barriers for coping with rehabilitation after the second injury.

METHODS

Eight women between 17 and 36 years (mean 26, SD 6.5) who had experienced ACLR, followed by another ACL rupture, participated in the study. Semi-structured interviews were conducted, and data were analyzed using qualitative content analysis.

RESULTS

One overarching theme, "Rehabilitation after a second ACL injury-A lifelong adaptive coping process", emerged from analyses. Undergoing a second rehabilitation is described as a process of adaptation, beginning with the first injury and still ongoing, more than 5 years later. Participants applied different coping strategies to adapt to these life-altering injuries, but the common denominator was of major life adjustments with no return to previous activity levels. Initially, after the reinjury, it was about coping with the catastrophe of the dreaded second injury. Over time, they accepted their "new" life and reset their recovery/rehabilitation goal not just as "return to sport" but rather as a "personal life goal".

CONCLUSION

Undergoing a second ACL injury is a long process that challenges the patient's coping skills. Given these results, rehabilitation programs need to be more person centred according to the patients-adjusted life goals.

Retrospective experiences of individuals two decades after anterior cruciate ligament injury - a process of re-orientation towards acceptance

PURPOSE

Individual perspectives of long-term consequences decades after anterior cruciate ligament (ACL) injury are unexplored. We addressed experiences and the impact on life of former athletes >20 years post-ACL injury.

METHODS

Individual interviews, analysed using Grounded Theory, were conducted with 18 persons injured mainly during soccer 20-29 years ago.

RESULTS

A theoretical model was developed with the core category Re-orientation towards acceptance, overarching three categories illustrating the long-term process post-injury. Initially the persons felt like disaster had struck; their main recall was strong pain followed by reduced physical ability and fear of movement and re-injury. In the aftermaths of injury, no participant reached the pre-injury level of physical activity. Over the years, they struggled with difficult decisions, such as whether to partake or refrain from different physical activities, often ending-up being less physically active and thereby gaining body weight. Fear of pain and re-injury was however perceived mainly as psychological rather than resulting from physical limitations. Despite negative consequences and adjustments over the years, participants still found their present life situation manageable or even satisfying.

CONCLUSION

ACL injury rehabilitation should support coping strategies e.g., also related to fear of re-injury and desirable physical activity levels, also with increasing age.IMPLICATIONS FOR REHABILITATIONMore than 20 years after the ACL injury, the individuals despite re-orientation towards acceptance and a settlement with their life situation, still had fear of both pain and re-injury of the knee, with concerns about physical activity and gaining of body weight.Patients with ACL injury may need better individual guidance and health advice on how to remain physically active, to find suitable exercises and to maintain a healthy body weight.Education related to pain, treatment choices, physical activity, injury mechanisms in participatory discussions with the patient about the ACL injury may be beneficial early in the rehabilitation process to avoid catastrophizing and avoidance behaviour.ACL injury rehabilitation needs to address coping strategies incorporating the psychological aspects of suffering an ACL injury, including fear of movement/secondary injury, in order to support return-to-sport and/or re-orientation over time.

Immediate and 6-week effects of wearing a knee sleeve following anterior cruciate ligament reconstruction: a cross-over laboratory and randomised clinical trial

BACKGROUND

Rehabilitation following anterior cruciate ligament (ACL) reconstructions is based mainly on comprehensive progressive exercise programmes using a multi-dimensional approach. Elastic knee sleeves may be useful adjuncts to rehabilitation. The aim of this study was to determine the immediate and 6-week effects of wearing a knee sleeve on person-reported outcomes and function in participants who had undergone an ACL reconstruction and who had residual self-reported functional limitations.

METHODS

Individuals with ACL reconstruction in the previous 6 months to 5 years were recruited. Immediate effects of a commercially-available elastic knee sleeve on single-leg horizontal hop distance were explored using a cross-over design. Following this first session, participants were randomised into a Control Group and a Sleeve Group who wore the sleeve for 6 weeks, at least 1 h daily. Outcome measures for the randomised clinical trial (RCT) were the International Knee Documentation Classification Subjective Knee Form (IKDC-SKF) score, the single-leg horizontal hop distance, and isokinetic quadriceps and hamstring peak torque. Linear mixed models were used to determine random effects. Where both limbs were measured at multiple time points, a random measurement occasion effect nested within participant was used.

RESULTS

Thirty-four individuals (16 women) with ACL reconstruction completed the cross-over trial. Hop distance for the injured side during the sleeve condition increased by 3.6 % (95 % CI 0.4-6.8 %, p = 0.025). There was no evidence of differential changes between groups for the IKDC-SKF (Sleeve Group n = 15; Control Group n = 16; p = 0.327), or relative improvement in the injured side compared to the uninjured side for the physical performance measures (Sleeve Group n = 12, Control Group n = 12; three-way interaction p = 0.533 [hop distance], 0.381 [quadriceps isokinetic peak torque], and 0.592 [hamstring isokinetic peak torque]).

CONCLUSIONS

Single-leg hop distance of the ACL reconstructed side improved when wearing a knee sleeve. Wearing the knee sleeve over 6 weeks did not lead to enhanced improvements in self-reported knee function, hop distance and thigh muscle strength compared to the control group.

TRIAL REGISTRATION

The trial was prospectively registered with the Australia New Zealand Clinical Trials Registry No: ACTRN12618001083280 , 28 June 2018.

Exploring what is important to patients with regards to quality of life after experiencing a lower limb reconstructive procedure: a qualitative evidence synthesis

BACKGROUND

Patient reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction surgery on patients' quality of life (QOL). Existing measures have not been developed to specifically capture patient experiences amongst adults with lower limb conditions that require reconstruction surgery. This review aimed to synthesise qualitative evidence to identify what is important to patients requiring, undergoing, or following reconstructive surgery for lower limb conditions.

METHODS

MEDLINE, Embase, PsychINFO and Cinahl were searched from inception until November 2020. Studies were included if they employed qualitative research methods, involved patients requiring, undergoing or following lower limb reconstruction and explored patients' experiences of care, treatment, recovery and QOL. Mixed methods studies that did not separately report qualitative findings, mixed population studies that were not separately reported and studies in languages other than English were excluded. Included studies were analysed using thematic synthesis. The Critical Appraisal Skills Programme qualitative studies checklist was used to undertake quality assessment.

RESULTS

Nine studies met the inclusion criteria. The thematic synthesis identified two overarching themes: (1) areas of living key to QOL for lower limb reconstruction patients and (2) moving towards a new normal. The way in which lower limb reconstruction affects an individual's QOL and their recovery is complex and is influenced by a range of inter-related factors, which will affect patients to varying degrees depending on their individual circumstances. We identified these factors as: pain, daily functioning and lifestyle, identity, income, emotional wellbeing, support, the ability to adapt and adjust and the ability to move forwards.

CONCLUSIONS

The way patients' QOL is affected after a lower limb reconstruction is complex, may change over time and is strongly linked to their recovery. These findings will aid us in developing a conceptual framework which identifies the outcomes important to patients and those that should be included in a PROM. Further research is then required to establish whether the range of factors we identified are captured by existing PROMs. Depending on the outcome of this work, a new PROM for patients following lower limb reconstruction may be required.

Psychological impairments after ACL injury - Do we know what we are addressing? Experiences from sports physical therapists

Psychological impairments can follow an anterior cruciate ligament (ACL) injury and can impact the rehabilitation process. Our aim was to investigate experiences of sports physical therapists (PTs) in addressing psychological impairments in patients after ACL injury. We conducted four focus group interviews with fourteen sports PTs. The PTs' experiences of working with psychological impairments after ACL injury were summarized in four main categories: (1) "Calling for a guiding light", where PTs stated that the most common method of acquiring knowledge on addressing psychological impairments was through discussions with colleagues, and, at the same time, PTs expressed an insufficient knowledge of how to address psychological impairments; (2) "Meeting the burden of psychological impairments" where PTs stated that psychological impairments are greater than physical; (3) "Trying to balance physical and psychological aspects" where patient education and assessments were reported to be important in order to understand psychological impairments during rehabilitation; and (4) "Goal setting: a helpful challenge" where sports PTs expressed a need for specific knowledge of the rehabilitation of psychological impairments following ACL injury. To help provide the current best practice, we encourage researchers to develop psychologically centered interventions for rehabilitation after an ACL injury, and PTs to stay up-to-date with the literature published on the subject, including to implement eventual interventions.

USING A BIOPSYCHOSOCIAL APPROACH WITHIN ACL REHABILITATION: AN EXPLORATION OF STUDENT PHYSIOTHERAPISTS` PERCEPTIONS AND EXPERIENCES

Background: Supporting the psychological needs of the patient during Anterior Cruciate Ligament Reconstruction (ACLR) rehabilitation is of paramount importance in order to optimize function and return to sport. Despite this, the amount of psychological training physiotherapists receive is inadequate.Purpose: the central aim of this study was to gain valuable insight, through the lens of the student physiotherapist, in relation to biopsychosocial practices used within ACL rehabilitation.Method: A phenomenological design using an inductive approach through purposive sampling was used. The study conducted semi-structured interviews, which involved ten undergraduate and postgraduate physiotherapy students from a UK University institution. The study identified perceptions, experiences and training surrounding a biopsychosocial approach within ACL rehabilitation. Data analysis included thematic analysis with triangulation and an audit trail to enhance confirmability and credibility.Results: Participants demonstrated a superficial understanding of the biopsychosocial approach, psychological symptoms and the significance of applying a patient-centered approach. Nonetheless, participants consistently reported barriers to implementing this approach, including the application of theory to practice when working with patients following ACL surgery.Discussion: Findings were consistent with previous research surrounding inadequate biopsychosocial education and training within ACL rehabilitation. The application of theory of the model to clinical practice was absent from the students' training.Conclusion: These findings suggest that student physiotherapists are aware of the possible benefits of incorporating psychological interventions but feel inadequately trained, highlighting a need for a review of the curriculum. Future research focusing on pedagogy-based strategies to effectively equip students to apply biopsychosocial theory to practice is of critical importance to prepare students for contemporary ACL rehabilitation and practice.

Low knee-related quality of life and persistent physical asymmetries in participants up to 10 years post-ACL reconstruction - A cross-sectional study

OBJECTIVE

To compare self-report and functional outcomes between participants with anterior cruciate ligament reconstruction (ACLR) with age and activity matched controls.

DESIGN

Cross-sectional study.

SETTING

University laboratory-based study.

PARTICIPANTS

Twenty-five participants (30.8 ± 9.7 years; 13 women), two to ten years post anterior cruciate ligament reconstruction; 24 controls (31.0 ± 10 years, 13 women).

MAIN OUTCOME MEASURES

Knee Osteoarthritis and Injury Outcome Score (KOOS), Tegner, Marx Activity and Fear of Re-injury scales, and SF-12; isokinetic quadriceps and hamstring peak torque and single-leg hop distance.

RESULTS

There were no between-groups differences for the Tegner and the Marx Activity Scales. The ACLR group had lower KOOS dimensions (p < 0.001), SF-12 Physical Component Scores (p = 0.008), and higher Fear of Reinjury Scores (<0.001) than the controls. No significant differences were found for physical performance measures between the ACLR and the control groups. Significant between-side differences for the ACLR group were evident for concentric quadriceps (p < 0.001) and concentric hamstring peak torque (p = 0.002), and hop distance (p < 0.001).

CONCLUSION

Knee-specific symptoms and function, activity and quality of life were lower, and fear of re-injury was higher for participants with ACLR than controls. Side-to-side thigh muscle strength and hop distance deficits were evident for the ACLR group.

Chaos and confusion with confidence: Managing fear of Re-Injury after anterior cruciate ligament reconstruction

OBJECTIVES

To explore strategies enabling competitive athletes to manage re-injury fears or anxieties, facilitating return to competitive sport following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Qualitative study.

SETTING

University.

PARTICIPANTS

Ten athletes with ACLR within the last 5 years who had returned to competitive sport with a minimum 7/10 Tegner Activity score.

METHODS

Semi-structured interviews, recorded, transcribed and analysed using interpretive description.

RESULTS

Three main themes. "Driving reasons to return to sport" included the athletic identity, the competitive team spirit and commitment; "Preparation of body and mind" encompassed connectedness with health professionals, coaches, the sports team and family, graded exposure and progression of physical tasks, and psychological or cognitive skills to improve mental toughness; "Risk Acceptance" entailed situational risk analysis, problem solving, and avoidance of unacceptable risk and acceptance of risk and responsibility.

CONCLUSION

Participants described intrinsic and extrinsic motivators as drivers for rehabilitation. Interactions with therapists, coaches and team members enhanced confidence, supported by both physical rehabilitation and psychological influences. Psychological strategies were essential for several participants to return to sport. Graded sports exposure, leading towards total immersion in training and competition, appears important to manage re-injury fear following ACLR.

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.

Perceptions of Rehabilitation and Return to Sport Among High School Athletes With Anterior Cruciate Ligament Reconstruction: A Qualitative Research Study

BACKGROUND

Adolescent athletes struggle to return to sport following anterior cruciate ligament reconstruction (ACLR) for physical and psychosocial reasons. The ability to integrate contextual evidence obtained directly from patients with the growing body of quantitative rehabilitation research may aid clinicians in taking an evidence-based approach to rehabilitation and return to sport within the adolescent population.

OBJECTIVES

To assess perceived barriers to return to sport, as well as positive and negative factors influencing recovery, among high school athletes with recent history of ACLR.

METHODS

This phenomenographic cross-sectional study included a sample of 10 high school-aged individuals (7 female, 3 male; mean ± SD age, 16.8 ± 1.1 years; time since surgery, 5.5 ± 1.4 months) who underwent ACLR and had not returned to sports. Participants completed a semi-structured interview focused on attitudes related to return to sport, perceived physical or psychosocial barriers to physical activity and return to sport, and rehabilitation characteristics that may facilitate or hinder return to sport.

RESULTS

Participants reported psychosocial barriers to return to sport with greater consistency than physical barriers. Consistently reported barriers included the feeling that sport-based activities were now associated with injury, a persistent sense of uncertainty regarding full recovery, and the sense that comparison to others with ACLR by parents or coaches hindered their ability to make progress in rehabilitation.

CONCLUSION

Early identification of athletes at risk for persistent psychosocial barriers, such as fear of reinjury and uncertainty regarding full recovery, and establishment of peer mentoring groups to facilitate psychosocial support throughout the rehabilitation process may be key components of a gradual, patient-centered approach to improving mental and physical readiness for return to sport. J Orthop Sports Phys Ther 2018;48(12):951-959. Epub 22 Jun 2018. doi:10.2519/jospt.2018.8277.