What is the evidence to support a psychological component to rehabilitation programs after anterior cruciate ligament reconstruction?

Psychosocial interventions seem redact kinesiophobia after anterior cruciate ligament reconstruction but higher level of evidence is needed: a systematic review and meta-analysis

PURPOSE

Psychosocial interventions have shown potential in reducing the fear of re-injury after anterior cruciate ligament reconstruction (ACLR), but this has not been systematically reviewed. The aim of this study was to assess the available evidence on the effect of psychosocial interventions on kinesiophobia after ACLR.

METHODS

Two independent researchers conducted a systematic search in the electronic databases including Scopus, PubMed, Web of Science (WOS), SPORTDiscus, PsycINFO, and CINAHL from their inception until May 2022. They included studies that utilised a randomised controlled study design with a control group, and measured kinesiophobia using the Tampa Scale for kinesiophobia in patients who underwent primary ACLR. The outcome of interest was the mean and standard deviation of kinesiophobia. Extracted data were analysed using Comprehensive Meta-Analysis software, version 3.0 (CMA.V2), employing a random-effects model to calculate the overall effect estimates of psychosocial interventions on Kinesiophobia. The standardised mean difference with 95% confidence intervals (CIs) was computed based on the mean and standard deviation in each group.

RESULTS

This systematic review and meta-analysis included 5 randomised controlled trials with a total of 213 patients who underwent ACLR. The results of the meta-analysis showed that psychosocial intervention was more effective than non-psychosocial comparators in reducing kinesiophobia among patients who underwent a primary ACLR (5 trials, MD 0.56, 95% CI 0.28-0.83, p < 0.001). The heterogeneity score was zero (I2 = 0%; n.s. for Cochran's Q test), indicating no significant variation among the studies.

CONCLUSIONS

Psychosocial interventions can alleviate kinesiophobia in patients with primary ACLR. Although the limited number of reviewed studies and their methodological limitations precludes drawing a definitive conclusion regarding the effectiveness of psychosocial interventions on kinesiophobia, these promising findings can serve as a basis for developing psychological strategies to manage kinesiophobia in patients with primary ACLR and can also guide future research this issue.

LEVEL OF EVIDENCE

II.

TRIAL REGISTRATION

This trial is registered in PROSPERO on December 2021 (CRD42021282413).

Correspondence and Concordance of Retrospective and Concurrent Responses to Physiotherapists and Sport Psychology Questionnaire Items

Orthopedic and sport-related injuries are a major public health concern and a common reason for referral to physical therapy. The use of psychological techniques by physical therapists has been assessed in research studies primarily with retrospective self-report questionnaires that have not been validated against concurrent assessments of the same behaviors. The primary purpose of this study was to examine the extent to which the results obtained from physical therapists’ retrospective self-reports of their use of psychological techniques reflect their use of the techniques assessed concurrently. Physical therapists (N = 14) completed the Physiotherapists and Sport Psychology Questionnaire (PSPQ) at the beginning of this study and a checklist based on the PSPQ at the end of the sessions with patients (N = 306). Patients also completed the checklist at the end of the sessions. Across 12 psychological techniques, the physical therapists’ retrospective (PSPQ) responses showed relatively weak correspondence (mean r = 0.31) and poor concordance with their concurrent (checklist) responses. Compared to the physical therapists’ checklist responses, the patients’ checklist responses showed weaker correspondence (mean r = 0.03) and better concordance with the physical therapists’ PSPQ responses. The findings suggest that retrospective self-reports may not accurately reflect the use of psychological techniques by physical therapists and, consequently, that physical therapists should consider documenting their use of psychological techniques as close to their implementation as possible. Suggestions for improved assessment are provided.

The modifying factors that help improve anterior cruciate ligament reconstruction rehabilitation: A narrative review

BACKGROUND

The goal of a rehabilitation programme after anterior cruciate ligament (ACL) reconstruction is to manage a patient's goals and expectations (i.e., returning to physical activities and sports) while minimizing the risk of new injury, particularly a new ACL injury. Although general rehabilitation programmes have been proposed, some factors can lead to adapting each programme to each patient.

OBJECTIVE

To describe how different variables, including surgical techniques, sports participation, psycho-social and contextual factors can modify the rehabilitation programme.

METHODS

We performed a narrative review with input from experts in the field (level of evidence 5).

CONCLUSIONS

Modifying factors of the ACL rehabilitation programme are related to the initial lesion or surgery, to sports, or to psychological or social aspects. Regarding the type of graft, the rehabilitation is mainly different in the early postoperative phase; the other phases are not graft-based but rather goal-based rehabilitation. Depending on the meniscal or cartilage repair, the rehabilitation protocol will initially take priority over the anterior cruciate ligament reconstruction protocol. The ACL reconstruction rehabilitation programme should meet the requirements of the anticipated sports, to optimize the athlete's ability to return to the expected level and minimize the risk of reinjury. Psycho-social and contextual factors must also be considered in rehabilitation care to individualize and optimize each patient's programme.

A comprehensive scoping review of tibial cysts after anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to perform a scoping review of published literature reporting on surgical management of tibial cysts which developed after ACLR.

METHODS

A scoping review was conducted following the Arksey and O'Malley framework for scoping studies and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. A search strategy using the terms ["Tibial Cyst" AND "ACL"], ["Pretibial Cyst" AND "ACL"] was applied to the PUBMED database.

RESULTS

Thirty-seven studies published between 1990 and 2019 were a part of this scoping review. Non-absorbable implants for tibial graft fixation were used in 10 studies (comprising a total 21 patients), while bio-absorbable implants were used in 27 studies (comprising a total 115 patients). Incidence of tibial cyst was reported in 3 studies (434 primary ACLRs) from whom 3.9% (n = 17) developed tibial cyst. Tibial cyst development in relation to use of bio-absorbable screws for tibial ACL graft fixation was reported in 16 studies (42.1%). Use of bio-absorbable screws with another factor was found to be related to tibial cyst development in another 1 study (2.6%). Most common symptoms were presence of mass or swelling, pain, tenderness, drainage, instability and effusion.

CONCLUSION

This scoping review demonstrated that tibial cysts is more frequently related to bioabsorbable screws, however it can also occur due to other causes. Current literature on tibial cyst after ACLR is of low-quality evidence. Future research is required to better understand aetiology, risk factors for cyst formation and the best possible mode of management.

LEVEL OF EVIDENCE

IV.

Is Fear of Harm (FoH) in Sports-Related Activities a Latent Trait? The Item Response Model Applied to the Photographic Series of Sports Activities for Anterior Cruciate Ligament Rupture (PHOSA-ACLR)

Background: Fear of Harm (FoH) predicts return to sports in Anterior Cruciate Ligament Reconstruction (ACLR) and can be assessed using the Photographic Sports Activities for ACLR (PHOSA-ACLR). This study was conducted to determine whether FoH assessed using the PHOSA-ACLR is a latent trait, and to analyze differences in PHOSA-ACLR in athletes with or without an ACL rupture. Methods: Three convenience samples completed the PHOSA-ACLR: (1) ACLR patients (n = 58; mean age 25.9 years; range 17–56; SD = 8.2; 43% male); (2) first year Physical Therapy (PT) students (n = 169; mean age = 19.2; SD = 2.0; 48% male), and (3) junior football players (n = 30; mean age = 18.3; range 17–20; SD = 3.2; 94% males). ACLR patients additionally reported functioning and Fear of Movement. PHOSA-ACLR items were analyzed with Item Response Theory using the Graded Response Model (GRM). Differences between three groups of participants were analyzed using Univariate Analysis of Variance. Results: Data fitted the two-parameter GRM, and therefore the items of the PHOSA-ACLR constitute a latent trait. There was a significant difference between the three groups in PHOSA-ACLR after controlling for age and gender (F (2, 255) = 17.1, p < 0.001). PT students reported higher levels of FoH compared to either ACLR patients or healthy soccer players. Conclusions: PHOSA-ACLR items constitute a latent trait of FoH for ACLR-specific movements. Contrary to expectations, PHOSA-ACLR is higher in first year physiotherapy students compared to patients rehabilitating from ACLR, and healthy junior soccer players.

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.

Cross-cultural adaptation and measurement properties of the Dutch knee self efficacy scale (K-SES)

Background

Self-efficacy is related to outcome after anterior cruciate ligament (ACL) tears. The Knee Self Efficacy Scale (K-SES) available in Swedish and English, was developed to measure self-efficacy in present (K-SES_present) and future (K-SES_future) functioning. The objective of this study was to determine measurement properties of the K-SES in Dutch patients.

Methods

The K-SES was translated and structural validity, internal consistency, test-retest reliability, and measurement error were assessed in three patient samples: one group completed the questionnaire and additional measures pre-surgery (N = 200), and one group post-surgery (N = 58). The third group (post-surgery) completed the K-SES twice (N = 50).

Results

Exploratory factor analysis distinguished two underlying important factors: K-SES_present and K-SES_future. However, the distinction was not confirmed in Confirmatory Factor Analysis (CFA). Internal consistency for both subscales was excellent (Cronbach’s alpha > .80). Test-retest reliability absolute agreement was 0.95. A-priori formulated hypotheses on the relation between Knee Self Efficacy Scale Dutch (K-SES-D) and related constructs were confirmed. Moderate to high correlations (r > 0.50) were reported with Knee Injury and Osteoarthritis Outcome Score (KOOS) before reconstruction. High negative correlation was found with fear of movement and pain catastrophizing (r < − 0.60), and low correlation (r < 0.50) with locus of control and measures of distress.

Conclusion

Acceptability, internal consistency and test-retest reliability of the K-SES-D subscales are satisfactory. Construct validity of both subscales was confirmed by exploratory factor analysis and hypothesis testing. However, construct validity was not confirmed in CFA. Further research is needed to test responsiveness.

Electronic supplementary material

The online version of this article (10.1186/s13102-019-0115-y) contains supplementary material, which is available to authorized users.

Psychological and Functional Readiness for Sport Following Advanced Group Training in Patients With Anterior Cruciate Ligament Reconstruction

BACKGROUND

Decreased psychological readiness for sport may contribute to poor return-to-sport rates after anterior cruciate ligament reconstruction (ACLR). Though advanced rehabilitation is used to improve functional readiness for sport after ACLR, the effect of advanced rehabilitation on psychological readiness is unknown.

OBJECTIVE

To examine changes in psychological and functional measures and readiness for sport based on these measures in patients with ACLR following advanced group training.

METHODS

In this retrospective cohort study, patients with primary ACLR enrolled in a 5-week group training program after completing traditional physical therapy. Data collection pretraining and posttraining included demographic information, the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, and single-leg hop testing (single, triple, crossover triple, and timed hops). Readiness for sport was based on criteria for the ACL-RSI scale score (low threshold, 56 points or greater; high threshold, 75 points or greater) and hop tests (90% or greater limb symmetry).

RESULTS

Fifty-eight patients (21 male) participated. Mean ACL-RSI scale scores, mean hop test limb symmetry, and the proportion of patients meeting ACL-RSI and hop test readiness-for-sport criteria significantly improved from pretraining to posttraining. Posttraining ACL-RSI scale scores were correlated with single hop (r = 0.269) and triple hop (r = 0.275) limb symmetry, yet changes in the measures were not significantly correlated. After training, only 53.4% (lower ACL-RSI threshold) or 37.9% (higher ACL-RSI threshold) of the sample met both psychological and functional readiness criteria.

CONCLUSION

Advanced group training following ACLR improved psychological and functional outcomes; however, further, individualized intervention may be needed to address residual deficiencies in some patients.

LEVEL OF EVIDENCE

Therapy, level 2b. J Orthop Sports Phys Ther 2018;48(11):864-872. Epub 12 Jun 2018. doi:10.2519/jospt.2018.8041.

Decision to Return to Sport Participation After Anterior Cruciate Ligament Reconstruction, Part II: Self-Reported and Functional Performance Outcomes

CONTEXT

  Anterior cruciate ligament (ACL) reconstruction (ACLR) is the most commonly used method for helping athletes regain function and return to preinjury activity levels after ACL injury. Outcomes after ACLR have suggested that athletes return to a level of function that would support a return to sport participation; however, in a recent meta-analysis, pooled return rates were only 55%. It is unclear whether this discrepancy is a result of functional impairments.

OBJECTIVE

  To compare patient-reported outcomes (PROs), dynamic balance, dynamic functional performance, strength, and muscular endurance in athletes who returned to sport (RTS) and athletes who did not return to sport (NRTS) after ACLR.

DESIGN

  Case-control study.

SETTING

  University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Two groups of participants with primary unilateral ACLR: 18 RTS individuals (7 males, 11 females; age = 23 ± 11 years, height = 163.58 ± 40.41 cm, mass = 70.00 ± 21.75 kg, time since surgery = 4.02 ± 3.20 years) and 12 NRTS individuals (5 males, 7 females; age = 26 ± 13 years, height = 171.33 ± 48.24 cm, mass = 72.00 ± 21.81 kg, time since surgery = 3.68 ± 2.71 years).

INTERVENTION(S)

  The PROs consisted of the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, Tegner Activity Scale, and Marx Activity Scale. Functional performance outcome measures were the anterior and posteromedial reach on the Star Excursion Balance Test, a battery of single-legged-hop tests, isokinetic quadriceps and hamstrings strength at 60°/s and 180°/s, and a novel step-down-to-fatigue test. All measures were taken during a single laboratory session.

MAIN OUTCOME MEASURE(S)

  The Limb Symmetry Index was calculated for all functional performance measures. Mann-Whitney U tests were used to compare measures between groups ( P < .10).

RESULTS

  Compared with the RTS group, the NRTS group had lower scores on the International Knee Documentation Committee Subjective Knee Evaluation Form (RTS median = 92.52, range = 66.67-97.70; NRTS median = 82.76, range = 63.22-96.55; P = .03) and Knee Injury and Osteoarthritis Outcome Score Symptoms subscale (RTS median = 88, range = 54-100; NRTS median = 71, range = 54-100; P = .08). No differences were observed for any functional performance measures.

CONCLUSIONS

  The NRTS athletes displayed lower PROs despite demonstrating similar function on a variety of physical performance measures. These results further support existing evidence that physical performance alone may not be the ideal postoperative outcome measure. Measures of patients' symptoms and self-perceived physical function may also greatly influence postoperative activity choices.