Psychological readiness to return to sport after ACL reconstruction Kate Webster

1. Psychological readiness to return to sport after ACL reconstruction • Kate Webster • Professor, School of Allied Health • Director Sport, Exercise and Rehabilitation Research Focus Area • La Trobe University, Melbourne Australia

2. Psychology and sport injury • Many athletes do not return to their previous level of pre-injury sport following ACL reconstruction • Despite having good knee function • Other factors which influence return to sport • A psychological component to ACL injury recovery

3. Psychology and sport injury Psychological response to injury continues long after the injury has occurred Effect on rehabilitation and return to sport outcomes

4. Psychological readiness What is it? Why does it matter?

5. Psychological readiness • Number of ‘definitions’ – some consensus that influenced by • Emotions • Confidence • Belief in rehab program/ injury completely healed (Podlog 2015) • Perform at same level (Podlog 2015, Forsdyle 2016, Webster 2008)

6. Psychological readiness – measures

7. Measuring psychological readiness: ACL-RSI scale • Emotional response • Confidence in knee and the ability to perform • Appraisal of the risk of returning to sport Phys Ther Sport 2008

8. Psychological readiness • Factors that constitute psychological readiness (n=635) • Male • Younger age • Shorter interval between injury and surgery • Higher frequency of pre-injury sport participation • Better functional performance (LSI hop tests) • Higher self-rating of knee function AJSM, 2018

9. Why does psychological readiness matter? • Psychological readiness can be used to predict: 3 1 2 Return to pre-injury level of performance Further ACL injury Return to sport

10. Psychological readiness and return to sport 187 athletes (65% male; 71% competitive sports) • Psychological readiness to return to sport (ACL-RSI scale) • Fear of re-injury (Tampa Scale for Kinesiophobia) • Emotions (Emotional Responses of Athletes to Injury Questionnaire) • Mood (Incredibly Short Profile of Mood States) • Locus of control (Sport Rehabilitation Locus of Control scale) • Recovery expectations (athlete estimate of number of months to return to sport) • Assessed pre-operatively, 4 months post-operatively AJSM, 2013

11. Psychological factors associated with returning to pre-injury level sport at 12 months • Three variables predicted return to sport by 12 month • Psychological readiness to return to sport (ACL-RSI) • Recovery expectations (estimate of months to return to pre-injury level sport) • Locus of control • Psychological readiness only measure predictive of RTS both preop and 4 mths post • Preop • Score of ≥ 56 points → 4XINCREASED odds of returning to sport • 4 month • Score of ≥ 56 points → 8XINCREASED odds of returning to sport

12. Psychological readiness and sport performance Question: Do patients who have higher psychological readiness to return to sport perform better when they return?

13. ACL-RSI scores and sport performance • 368 patients (143F, 225M) ACLR and RTS • Completed ACL-RSI : pre-op and at 12 months • At 2 years (min) were asked to report self perceived performance Do you feel as though you can play (perform) as well as before your ACL injury? April McPherson: Australia-America Exchange Program Supervised by: Webster, Hewett and Feller 2018

14. ACL-RSI scores and sport performance • 53% reported YES could play as well (52%F; 54%M) • Higher ACL-RSI scores pre-op and 12 month sig. associated with a return to pre-injury performance from 2 years • ROC analysis 12 month ACL-RSI • Cut-off score of 57 points • 81% sensitivity, 54% specificity • 81% certain that a patient who returns to pre-injury performance scores above cut-off

15. Psychological readiness and second ACL injury Question: Do patients who have lower psychological readiness to return to sport scores have a greater incidence of second anterior cruciate ligament (ACL) injury? Focus: Younger patients who have higher second injury rates McPherson, Feller, Hewett & Webster, 2018 AJSM In Press

16. ACL-RSI scores and second ACL injury • Prospective study (429 patients in total) • 329 patients (118F, 211M) ACLR • Completed ACL-RSI (Short Form) pre-op and 12 months • All RTS (excluded 100 not RTS) • Followed for minimum 2 years (range 2-4) document further ACL injury (either knee)

17. ACL-RSI scores and second ACL injury • 52 (16%) patients had a second ACL injury • Pre-operative ACL-RSI not sig different injured vs. non injured • 12mth ACL-RSI scores lower in injured groups

18. ACL-RSI scores and second ACL injury • ROC analysis determine cut-off score • Cut-off score of 77 points • 90% sensitivity, 47% specificity for younger patients • (76% sensitivity all ages) • 90% certainty that a patient who has a second ACL injury scores below this cut-off

19. ACL-RSI scores and second ACL injury • Change in score and injury risk • Little improvement for those that re-injure • Be aware of pre – post surgery drop in psychological readiness (15% of those injured decreased scores)

20. Summary • Psychological factors play a significant role in the sequence of ACL injury and reconstruction, rehabilitation and return to sport. • Can be measured by tools such as the ACL-RSI scale • Psychological readiness to return to sport is strongly associated with the RTS decision • Preliminary evidence that psychological readiness also plays a role in return to sport performance and reinjury • Psychological factors are potentially modifiable and should therefore be considered

21. Melbourne, Australia