Monday, July 2, 2018

Psychological Measures for Return to Play Following ACLR

Over the history of this blog, we have focused a lot on movement and functional performance measures we should be doing with athletes to determine return to play.  Why is that?  Holm et al Am J Sport Med 2012 showed that 20% of athletes that return to play following ACLR re-injure within the first 2 years.  Further, Wiggins et al Am J Sport Med 2016 showed that one in four youths who tear their ACL will suffer another ACL injury at some point throughout their athletic career.  With odds like this, we have to do something to help improve the odds and more importantly protect our athletes as they prepare to return to play.

Traditionally and in a majority of athletic settings, return to play means just assessing the athlete's strength and endurance and maybe performing some movement assessments or functional assessments.  However, all too often we forget about the psychological factors that are associated with return to play.  In the last couple of years however, there has been a tremendous amount of work done in this area. 

One of the most common aspects talked about when determining return to play is kinesiophobia or fear of movement.  Amy times, as the result of the athlete's initial injury, there is a lack of confidence in the injured limb and therefore a fear of reinjuring upon return to play.  There has been several studies in the last couple of years that show that athletes that have higher levels of kinesiophobia are in fact at greater risk of injury.  In a systematic review done by Everhart et al in Knee Surg Sports Traum Artho 2015, the authors showed a high correlation to kinesiophobia and re-injury rates in ACLR patients.  In a recent study by Noehren et al Orth J Sport Med 2017 the authors looked at athletes that were returning to sport and for those that demonstrated kinesiophobia if there was any correlation to the way they moved and potential injury risk.  What the authors found was that athletes that demonstrated higher levels of kinesiophobia demonstrated lower weightbearing in the reconstructed limb. 

Although assessed differently than in this study, this is a similar pattern we see, especially when assessing an athlete's squatting motion.  What is demonstrated is a significant lateral shift to the contralateral limb (uninvolved side) and away from the involved side.  The authors of this study found similar results where the athlete was shifting their weight to the univolved side during vertical jumping and landing activities.  The authors compared these results to a measure of kinesiophobia and found a strong correlation between the two.  Meaning athletes that shifted weight away from the involved side scored high on the kinesiophobia scale.

With all the studies coming out showing similar corelations with risk and kinesiophobia, then how do we measure this in our athletes?  Is this an overally complex measure and is this something that requires a psychologist to do?  The answer to both those questions is no.  Simply, we can implement at Tampa Kinesiophobia Form as a part of our evaluation process.  For those that have not seen it, the Tampa Scale is below is scored on a 1-4 scale for each question.  A total score is calculated after inverting the individual scores on 4, 8, 12, and 16. 
Adding up all the scores and dividing by the total possible score (68) points.  Higher the percentage the higher the individual's kinesiophobia or fear of movement.   Paterno et al Sport Health 2018 showed that athletes who have a score of 19 (27.9%) or greater at the time of RTPlay are 13 times more likely to suffer a second ACL injury.  Based on the findings of Noehren et al, that makes sense.  Based on those studies, one could hypothesize that the higher the percentage of kinesiophobia then the greater the displacement would be to the contralateral or non-involved limb. 

Based on these results, it is high suggestive that this type of form be used in helping us make a return to play decision for our athlete.  We hope you have enjoyed this discussion and we will continue with this next week as we evaluate how we can impact kinesiophobia and and additional scales we can use for return to play.   #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu.