Perceived personal importance of exercise and fears of re-injury: a longitudinal study of psychological factors related to activity after anterior cruciate ligament reconstruction
Gignac MA, Cao X, White LM, Hurtig M, Kunz M, & Marks PH. BMC Sports Science, Medicine and Rehabilitation. 2015, 7:4.
Take Home Message: Fear of re-injury, exercise importance, and age are associated with return to activities after an anterior cruciate ligament reconstruction.
A patient’s perceived importance of exercise and fear of re-injury are very important when recovering from anterior cruciate ligament (ACL) surgery. Short- and long-term outcomes of successful return to activity and previous levels of activity may be affected by these perceptions. The authors of this study investigated perceptions of exercise and re-injury fears pre-surgery and annually up to three years post-surgery in 95 participants. Over half of the injuries were reported from soccer, skiing, and basketball and largely in recreational athletes. At baseline and each annual visit the participants answered questionnaires about physical activity (Minnesota Leisure-time Physical Activity Questionnaire), perceived importance of exercise (Exercise Identity Scale), pain (Knee Injury and Osteoarthritis Outcome Score, KOOS), fear of re-injury (ACL-Quality of Life Questionnaire), as well as sports and recreation activity limitations (ACL-Quality of Life Questionnaire). Exercise importance perceptions remained constant at all time points. Pain, activity limitations, and re-injury fears decreased over time, achieving relatively low levels by 2 years post-surgery (see chart). On average, while participants reported high function and minimal pain their time spent in sports and recreational activities was diminished and never returned to pre-injury levels three years post-surgery, regardless of fear of re-injury. A decrease in fear was associated with time spent in activities, specifically activities with a higher risk of knee injury. Age was also associated with time spent in activities, with younger participants reporting more time spent in activities with lower and higher risk of knee injury while older participants reported more time spent in household activities. Greater exercise importance at any time point was associated with more time spent in activities with lower and higher risk of knee injury.
Fear of re-injury decreases over time and is associated with greater time spent in activities with a higher risk of knee injury while exercise importance remained relatively constant over all time points. Furthermore, a greater perception of exercise importance is associated with time spent in physical activity. Intervention efforts should be targeted towards decreasing fear of re-injury as well as emphasizing exercise importance, even after completion of ACL rehabilitation. Clinicians could implement high-risk activities in a supervised and controlled environment as a strategy to help participants gain confidence. The authors also found that age was related to different types of activities a patient engaged in. As individuals age, they typically have more responsibilities (e.g., employment, family lives) which may naturally result in changes from activities with higher risk of injury to activities with lower risk of knee injury. Further research regarding normal role changes as people age may be beneficial in determining if a knee injury prematurely coerces individuals to make these role changes earlier. However, exercise importance is critical to long-term joint health and these individuals need to be reminded that they should find time to exercise. This study highlights that fear of re-injury may not be the only limiting factor when attempting to return to pre-injury activity levels. Clinicians should focus on reinjury fears as well as educate our patients about the importance of exercise for maintaining long-term health.
Questions for Discussion: Do you currently do anything during your ACL rehabilitations to address psychological perceptions? What are some common tasks that you see that cause fear within the patients that you have returning from ACL injury, and what activities do you do to try to mitigate that fear?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
Return to Sport Following ACL Reconstruction Surgery – How Many Athletes Return to Preinjury Levels?