Psychological Measures for Return To Sport Following ACLR - Part II

Last week we learned that kinesiophobia (fear of movement) is bad, especially if an athlete exhibits kinesiophobia when returning to sport following an ACL reconstruction.  According to the Paterno et al Sport Health 2018 athletes who score 19 or above on the Tampa Scale for Kinesiophobia, they are 13xs more likely to reinjure themselves with return to play.  For those of us that have treated ACL patients, this is nothing new but we now have better ways of assessing it.  Rather than just being something we see anecdotally in our athlete, we now have tools, like the Tampa Scale for Kinesiophobia, where we can objectively measure this.  For a copy of this form, please refer back to our previous blog on 3/16/20.

Another scale often talked about to determine an athlete's fear with return to sport is the ACL-RSI.  This is also a great tool however, a recent study by O'Connor et al Am J Sport Med 2020 showed their was a trivial correlation with results on this patient reported outcome and strength, power and limb symmetry index.  Considering the strong correlation to quadriceps symmetry (Smith et al Am J Sport Med 2015) and quadriceps strength and kinesiophobia (Ho et al J Physio 2015), the O'Connor study would suggest that the ACL-RSI is not capturing this.  Since the TSK-11 does, this is another reason that this is the scale of preference for this author.

But measuring kinesiophobia is one thing, what you do with that information is something entirely different.  One thing that can lead to increased kinesiophobia is an athletes lack of sport locus of control.  Sport Locus of Control is the athlete's feeling or perception that they are in control of their destiny.  For most athletes, throughout their athletic career, they have been in charge of their athletic destiny.  How hard they trained, their personal effort they put forth, how they performed as an individual or as a part of a team was determined by them.  However, once an athlete has an injury, many times for the first time in their athletic career, their sport locus of control is passed onto someone else.  It is the orthopedic surgeon that tells them when they can take the brace off, start running or return to play that has some of this.  It is the physical therapist or athletic trainer that tells them what exercise they can and can't do, how they will progress with running or sport specific activities that has some of this.  So, for the first time, the athlete is depended on others for their sport locus of control, for their sports destiny.  For many, this can have big psychological impact.  With that loss of control over one's destiny comes fear.  Ardern et al Am J Sports Med 2103, showed that sport locus of control was one of the indicators that determined an athlete's successful return to play.  Therefore, it is up to us to make sure the first thing we do is we give that back to the athlete.

Well that sounds easy but how do we do that?  There are several ways we can approach this, one is from what we say and one from what we do. 
It starts in the very first session.  I am often quoted as saying;

"I am simply an educator and a coach.  I will educate you about your injury, what the process is, what you should expect and how we will progress you for return to play.  I will coach you along the process, telling you what to do, how to do it and push you hard.  BUT at the end of the day it is up to you to make it happen.  This is not easy.  There will be challenges which we will overcome.  You have to want it.  It will define you as an athlete.  But you can do it.  You will do it and we will do it together.  You will come out of this faster, stronger and a better and more rounded athlete.  Are you ready and willing to make that happen?"

In that short 2 1/2 minute discussion, I have passed the sport locus of control to the athlete.  Psychologically, what was also done?  Two things:

1. I gave the athlete confidence in me as the clinician.  Gaining the athlete's confidence in you as a provider is critical to their success.
2. I gave the athlete confidence in themselves.  Confidence that they can do this, that they are in control and will determine their own destiny.

This immediate first step is critical to setting the pace for the entire rehab process and critical to building the patient's confidence.  The next thing we need to do early in the rehab process is start to build confidence in their ability to return to play.  Part of this is the conversation we just had and the other part is actually performing activities that provide you confidence that you can go the the next level.

As common knowledge as we might think this is, what we find is that it is not as common as we might think.  A recent case highlights this.

19 y/o female division I soccer player who is 5 months post op R ACLR.  She has been receiving "accelerated" rehab in an aggressive sport specific training center in Florida.  She is being assessed for return to sport specific training.  We are engaged by the team to do our movement assessments which is an aggressive movement assessment (ViPerform AMI) using 3D wearable sensors.  This test consist of:

1. 1 minute Plank test
2. Squat test
3. 1 minute side plank right then left
4. Single Limb tests all on right first then the left
1. Single leg squat
2. Single leg hop
3. Single leg hop plant (multidirectional hop)
4. Ankle lunge test

At the 5 month mark, most s/p ACLR should be able to perform the test.  Part of the pre-requisites for the test is that the athlete must have performed each of the movements safely in the clinic prior to testing.  When asked to do a single leg squat, you could visibly the athlete was hesitant to perform but did and safely.  When asked to perform a single leg hop, the athlete's hesitancy increased, she started sweating profusely and began to feel light headed.  This is an extreme case of kinesiophobia!  But why did she have this kind of response?  

We are going to dive into this case in some detail next week and specifically how we can avoid it with our athletes.  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 and ACL injury prevention.  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.