Sports Medicine Research: In the Lab & In the Field: Fear and Exercise Importance in Returning from ACL Injury (Sports Med Res)
Wednesday, February 18, 2015

Fear and Exercise Importance in Returning from ACL Injury

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

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Gignac MA, Cao X, White LM, Hurtig M, Kunz M, & Marks PH (2015). Perceived personal importance of exercise and fears of re-injury: a longitudinal study of psychological factors related to activity after anterior cruciate ligament reconstruction BMC Sports Science, Medicine and Rehabilitation, 7:4.

5 comments:

Stacy Schurr said...

I've never been in a situation where we have directly targeted psychological aspects of ACL rehab, but it's definitely something we should consider more often. I definitely see more apprehension when in comes to transitioning to weight-bearing activity and then onto more sport-specific tasks. I was definitely on the same page as far as your comments. It definitely could fall in the Athletic Trainer's responsibility to help the athlete gain confidence in those higher risk activities, as well as educating them about the importance of of exercise in terms of long term health. I also think it would have been interesting to use other outcome measurement tools, like the Fear Avoidance Belief Questionnaire or the Tampa Scale of Kinesiophobisa which also target the patient's thoughts on exercise and re-injury.

Nicole Cattano said...

Thanks for your comments Stacy. What types of activities do you (or others) try to integrate when transitioning to weight bearing activities or when transitioning into sport-specific tasks to ease the athlete's fears?

Anonymous said...

It's unclear whether the ACL-Quality of Life Questionnaire has been validated for post-surgical patients as it was created to measure QOL in patients with chronic ACL deficiency. Does anyone know?

Kyle Murray said...

I have definitely seen patients struggle with fear of activity when it comes to rehabilitation for ACL injuries. Most commonly I have seen it when progressing flexion immediately post-op and progressing to eccentric quadriceps focused exercise. To address these concerns in our patients I think we have to make sure we are encouraging our athletes to progress and building trust within the relationship to ensure them that we would not be placing them in harms way with our prescribed exercises. I also have seen good results, especially in athletes, with added goal oriented tasks as rehabilitation or incorporating that idea into our rehabilitative exercises. By including a goal (time, repetitions, etc.) in a task, many athletes respond well to the challenge and it serves as a good way to monitor and track progress in a way that they can see and feel.

Jeffrey Driban said...

Hi Kyle, thanks for the tips. They all sound like great ideas that people should try to use in their rehab program. Having them meet goals is a great motivator and a great way for them to see for themselves that they are advancing, which is probably important to helping them see that their body is returning to normal.

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