Sports Medicine Research: In the Lab & In the Field: To Properly Motivate Patients, We May Need to Manage Expectations (Sports Med Res)

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Wednesday, March 13, 2019

To Properly Motivate Patients, We May Need to Manage Expectations

Expectations for return to preinjury sport before and after anterior cruciate ligament reconstruction.

Webster KE, and Feller JA. Am J Sports Med 2019. [Epub Ahead of Print].

Take Home Message: While 84% of people expected to return to preinjury levels of activity after an anterior cruciate ligament reconstruction, only 24% of them actually did within 12 months of surgery.

A patient’s expectation to return to activity after an anterior cruciate ligament reconstruction (ACLR) may predict the patient’s motivation during the rehabilitation process. While most patients expect to return to preinjury levels of activity, understanding what these expectations are and how they change after surgery is important to help clinicians develop strategies to properly manage patient expectations. Therefore, Webster and Feller completed a prospective cohort study to investigate return-to-activity expectations before and after an ACLR and decipher which factors related to a change in expectation. The authors included 675 patients (437 males, 238 females, average age 26 years) who reported pre-injury participation as highly or frequently competitive and who had less than prior 2 ACLR. All participants had the ACLR surgery (514 primary, 81 primary with a history of contralateral ACLR, 80 revision) followed by identical rehabilitation protocols and return-to-sport criteria. Prior to ACLR, all participants completed an original return-to-activity expectation survey generated by the researchers, and the Marx activity scale. Twelve months after ACLR, all participants reported their current level of activity compared to preinjury levels (no return, return to training, return to lower level, return to the same level). If the person did not plan to return to pre-injury level of activity, then they explained why. Overall, 91% (613 participants) of patients expected to return to activity with 84% (566 participants) expecting to return to a preinjury level of activity. A patient who was undergoing their first ACLR, male, or younger had higher expectations than their peers. At follow-up, 24% (138 participants) of participants who expected to return to preinjury levels of activity reported achieving this goal while 9% (49 participants) gave up sports participation. Overall, more than 1 in 7 participants (15%) gave up sport participation after an ACLR (including those who expected to return or not). The most common reasons for giving up sports were “fearful of reinjury” (71%) and “did not feel their knee was ready” (18%). Females and participants with a history of a prior ACLR were more likely to give up sport than their peers.

Overall, the current study provides some interesting data regarding the difference between patients’ expectations and the reality of returning to pre-injury levels of activity following ACLR. The authors demonstrate that only a quarter of patients who undergo ACLR meet their expectations of returning to a preinjury level of activity. A strength of this study is that these participants expected to return to preinjury levels of activity. Hence, it is unlikely that other life events (e.g., graduating from high school or college) influenced their return to play. These are important results to consider when discussing realistic expectations for a return to activity with patients who will undergo ACLR. Furthermore, it may be beneficial to talk to patients about their fear of reinjury and refer patients as needed to help address these concerns. There are two points of concern which may help clinicians interpret the results. First, the study included patients undergoing a revision ACLR. While it was 11% (n = 80) of the cohort, these patients already had experience with what to expect after an ACLR and could potentially have a negative outlook given that they had a failed ACLR. The authors showed this by noting that 88% of participants undergoing a primary ACLR expected to return to preinjury levels of activity versus only 63% who underwent a revision. Secondly, while participants reported expectations prior to surgery, no reference to time was made. Future research would benefit from asking patients not only about their expected level of activity but also in what time they expected to return. Potentially a patient could anticipate returning to a preinjury level of activity after 12 months. Until more research is done to address this concern, clinicians should be honest with patients about return-to-activity rates and address patients’ concerns (e.g., fear of re-injury).

Questions for Discussion: How do you deal with a patient with unrealistic expectations of injury? Did these authors present results that either support your current approach or help you better communicate with your athletes?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

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