Updated: Jan 4
Only about half of all people return to the same level of competitive sport after an ACL reconstruction and the rate of re-injury in those under 25 years old is a horrendously high 23%; the overall picture we have for an ACL injury is a fairly grim picture, which is only now being properly unearthed (Ref, Ref). Through this blog I want to take a brief look at the psychological considerations of an ACL injury and give you insight into what we may be able to do differently, with (as always) an review of the evidence but also with personal experience into the complexities of these issues.
How much are we getting wrong (or right) when we approach the psychological components of an ACL injury? How big an impact do the psychological aspects of an injury have on the eventual outcome? What could we do differently?
We are beginning to develop a better framework to manage the athlete after an injury in a biopsychosocial manner. The following key points should help patient and therapist work towards a better long-term outcome.
1. Find out the real underlying drivers and values
Time and effort are two keys in this first pearl. An ACL injury is rarely a stand-alone incident without complex relationships with the identity of a patient. As one of the most notable, prolific and devastating injuries to occur in an athlete, even the simplest cases are incredibly complex soul-searching affairs that cause the athlete to really question who or what she or he is and what they really want in life. Things are also rarely static; goals come and go in an injury process that generally last at least a year.
This largely leads to a 'life-values' discussion; they are the anchor for how rehabilitation will unfold. As health professionals, it should be a prerequisite that we are able to have difficult conversations and a meaningful impact on a patient's life. We need to recognise and accept this responsibility and not shy away from having difficult conversations.
Given ACL re-injury rate is so high (Ref, Ref), and this is shared equally among those who have a surgical reconstruction compared to those that don't (Ref, Ref), it may be that it is ultimately the injury itself - not the management - this has a life-changing effect. There is certainly a high chance of a very successful outcome for many, but making the approach with athletes realistic, liquid and - most importantly - based around what they really want in life is a great way to ensure expectations aren't violated and the experience can be a positive one. This does take time and effort by both parties, but it is the first most crucial step. Some simple examples of ways to find patient values, and prompts to encourage adherence to these, can be found below.
2. Understanding the journey from beginning to end
This definitely means discussing and understanding the complexities of returning to play early-on, but in my opinion, this is actually a small (but pivotal) component of the entire journey itself. It may be where most stress, fear and anxiety are held by the patient, but it isn’t the entire picture.
ACL injuries are unfortunately becoming more and more common in the younger age bracket; the prevalence is highest and the rate is increasing the fastest in those under 17 years old (Ref). In what is already - and becoming increasingly so - a confusing, pressure-filled and daunting time in life, when a confusing and complex injury like an ACL tear or rupture is added it becomes a lot for the system to handle. What is needed here is clarity, or as much clarity as possible. Our job is to outline a series of clear paths from which to choose, with demonstrated milestones along the way. Rehabilitation is a stage-based (not time-based) process and it is becoming easier and easier to provide a clear outline of what these stages will look like. This daunting time can be quite easily clarified with journey maps like the one below along with clear instructions of what might be expected at each stage like these videos here. You can then begin the process of instilling the capacity of making an informed decision around their future.
3. Building autonomy and the capacity to make an informed decision
In BPS care, the patient is at the very centre of everything, it means an educated and informed person is able to make the best possible decisions for them regarding their own care. They guide the process and choose the team they want to have involved. ACL injuries must be no different to any other aspect of musculoskeletal care.
In creating an empowered and informed patient, the health professional’s job isn’t just as easy as - provide facts and stand back and watch. We need to make sure these facts have been processed and can contribute to decision making in a meaningful way (no easy task). In youth athletes, this is made all the more difficult as there will inevitably be more ‘hands in the pot’ in the form of parents or caregivers. I think we need to think about this capacity for decision-making much like the capacity for anything physical we give our patients - it needs to be built.
It starts with promoting autonomy, which can be done in a series of ways like starting with small decisions (like choosing an exercise, or helping build part of the program) and progressing to larger ones (like whether or not they will opt for surgery) (Ref). We also need to be sure the information is being processed and retained; closed-loop communication and session reviews where you get the patient to repeat what has been covered are easy ways to begin this process.
“So, what were your main takeaways from today’s session?” or “Let’s re-cap!”
Ultimately, patients and athletes will need to make their own decision, but once again what this does not mean is that we sit idly by and ‘let things happen’. In fact, in a shared decision-making model framework, we are very active participants - I would say leaders. And as part of the leadership position we hold, we need to work very hard on ensuring the decisions our athletes and patients make is in the best interest for them at all times.
4. Build a social buffer
Lastly, as part of a BPS framework, we need to be aware that social connectedness is also acutely threatened in an ACL injury. Sport is a healthy and commonly used means of building key social skills, a social network and developing as a person; this is paramount in youths, but not worthless in older age ACL injured patients either.
As a member of the treating team, it is our responsibility to identify and ensure our patients are also aware of this fact. Some simple strategies for dealing with this important aspect of rehabilitation are to encourage participation in elements of the sport wherever possible or even suggest alternatives should that be required. Understanding the impact a loss of a ‘social support buffer’ can have on an athlete or patient is not simple, however, as the diagram below suggests (Ref). But, we can safely say that, in most musculoskeletal problems, introducing a ‘buffering system’ of social connectedness is an easy intervention that has limited downsides.
A note on fear
Fear of re-injury is known to be associated with worse outcomes - that is, it is reported by those people who do not return to sport in some large cohorts, but not in more recent (perhaps more well conducted) studies (Ref, Ref, Ref, Ref). So, the evidence is mixed.
It seems that fear of re-injury is also more complex than once assumed - it could be a symptom of other cognitive processes going on and certainly can be context or questionnaire dependent, it may mediate an outcome or may actually be a moderator, where high levels of catastophising and negative affect at the outset may simply lead to less motivation to progress (Ref, Ref, Ref). It may be that the anxiety related to fear of re-injury is actually more sensitive to measure, a more concrete phenomenon and more actionable from a rehabilitation perspective (Ref).
Symptom or discrete entity, addressing fear and anxiety is an important aspect of care. A simple tip is to make mindfulness practice regular with things like mental imagery and using apps like Headspace - in order to identify and address the thoughts and feelings associated with anxiety around the injury. Therapists need to be skilled in digging deep enough to understand thoughts and feelings associated with anxiety, which may be barriers to further success in rehabilitation. This is a process, which takes time, but is worth the effort.
What tests are useful?
Some data is always better than no data, so here are some helpful tests that you can use with your patients, or if going through the process yourself.
Assessing Fear: Shortened Tampa Kinesiophobia Scale (TSK-11): here. Or the Pain Catastrophising Scale (PCS): here. Remembering that fear of re-injury is complex and the more you know about it the better (Ref).
Assessing Autonomy: Sport Rehabilitation Locus of Control scale (SRLC): here.
Assessing self-efficacy: Sports Injury Survey (SIS): here.
As you can see, it can become very lengthy and onerous, very quickly and I recommend you become familiar with these and use a clinically relevant few or selection of key questions from which you may gain the most important information. I would direct the reader to an excellent summary of the main psychological factors you may want to know about in a piece by Kieran Richardson - here.
So, what does the evidence say?
On a general note, the quantitative evidence we have for psychological aspects of ACL injuries is poor, only a small amount of prospective cohort studies are available - the rest being retrospective or cross-sectional analysis. We can pretty accurately say that there are a multitude of factors that combine together to contribute to worse outcomes after an ACL injury and surgery - these being things like age, other work and life commitments (Ref) - but what can we rely on to reliably predict better outcomes as a result of surgery? Well, from the evidence available evidence we have two somewhat stable personality traits, that if higher in individuals after ACL surgery, seem to lead to better outcomes.
Factors that contribute to a patient’s general belief or confidence in a successful outcome have demonstrated a good predictive ability for higher rates of return to play and better surgical outcomes (Ref, Ref). Readiness to return to play, as measured by the ACL-RSI - seems to be a good way to measure this and has been used in two higher quality prospective cohort studies (Langford 2009 and Ardern et al 2015).
Two more, lower quality trials, have demonstrated self-efficacy - particularly the ability to self-motivate and adhere to rehabilitation - has been shown to be associated with better outcomes following surgery (Ref, Ref). These include things like goal setting, completion of home exercises and positive self-talk.
This brings us to a somewhat logical conclusion about what psychological factors are currently known to be associated with better outcomes. They are the belief in a positive outcome and the motivation to achieve a better outcome. But we should be cautious about the ability of these outcome measures to detect real outcomes in each ACL patient at this point in time, as it may be an oversimplification of a fluid, dynamic system. Simply testing someone once, and using this as ‘discharge criteria’ is probably not a smart use of your time. Potentially trends over time should guide your efforts into what is necessary to work on - i.e., if someone has low motivation, we work to encourage better levels of motivation throughout rehab.
What don’t we know?
Put plainly, we really don’t know a lot about what factors might have significant bearings on the outcomes of ACL injury. Given the return to competitive sport is so low, we really don’t know how this may be improved from a psychological perspective. We certainly don’t have enough data on the outcome measures that we are using yet and it may be that these outcome measures don’t appropriately garner the dynamic nature of the problem.
It is important to note, however, that believing in a positive outcome and being more motivated to adhere to a structured rehabilitation process (one in which the patient has to work very hard, and be willing to do so) may result in a better outcome. And hopefully the ‘tips’ outlined above can also contribute to more positive psychological outcomes in patients. But what is apparent is that we need more effort to manage this important side of ACL injury, to ensure that even if athletes don’t return to sport, they can be psychologically well in life after sport - because, like it or not, life is not only about sport!