BEAR: A Bridge to Better Psychological Readiness After an ACL Injury

Psychological Readiness to Return to Sport at 6 Months Is Higher After Bridge-Enhanced ACL Restoration Than Autograft ACL Reconstruction: Results of a Prospective Randomized Clinical Trial

Sanborn RM, Badger GJ; BEAR Trial Team, Yen YM, Murray MM, Christino MA, Proffen B, Sant N, Barnett S, Fleming BC, Kramer DE, Micheli LJ. Orthop J Sports Med. 2022 Feb 9;10(2):23259671211070542. PMID: 35155707

Full Text Freely Available

Take-Home Message

Participants that received the bridge-enhanced anterior cruciate ligament (ACL) restoration (BEAR) reported higher levels of psychological readiness to return to activity than people that underwent ACL reconstruction (ACLR).

Background

Return to pre-injury activity is considered a primary goal of an anterior cruciate ligament reconstruction (ACLR). Unfortunately, many patients never meet their expectations about returning to pre-injury activity levels. Psychological factors such as lack of confidence and fear of re-injury play a role in a patient’s ability to feel prepared to return to play. Additionally, a traditional ACLR requires a graft harvest, adversely affecting strength, range of motion, and pain. BEAR is a new technique that uses a collagen scaffold instead of a graft to repair the ACL. A patient may recover strength faster after a BEAR than traditional ACLR. However, whether patients experience a faster psychological recovery after BEAR than traditional ACLR is unknown.

Study Goal

Sanborn and colleagues performed a secondary analysis of a randomized clinical trial to evaluate if participants who received the BEAR procedure had better psychological readiness to return to sport than participants who underwent an ACLR. They also explored what factors relate to psychological readiness to return to sport.

Methods

The authors recruited 100 patients with a complete midsubstance ACL injury. They then randomized 65 participants to receive the BEAR procedure (37% female, ~17 years old) and 35 participants to an autograft ACLR (26% female; 17years old; >90% had a quadrupled hamstring tendon autograft). Participants were assessed at 6, 12, and 24 months postoperatively with several outcome measures, including the ACL-Return to Sport after Injury (ACL-RSI) scale to measure psychological readiness.

Results

Participants who received the BEAR procedure reported better psychological readiness scores at 6 months than those who received an ACLR (scores: 71 vs. 58), regardless of sex. After 6-months, the groups had similar psychological readiness scores. A participant who suffered a contact ACL injury, was younger, and participated in a sport at the time of injury involving jumping, pivoting, and hard cutting (e.g., soccer, basketball) tended to have higher psychological readiness at 6-months.

Viewpoints

At 6-months after surgery, previous investigators suggested that a psychological readiness score greater than 60 or 65 points relates to an eventual return to pre-injury levels of sports. On average, participants who received the BEAR procedure had scores above this cut-point, while the average for those with an ACLR did not. It would have been helpful to know how many people in each group had scores above this cut-point. However, the BEAR group likely had more people above this threshold. It will be interesting to see how these participants do after being cleared to return to sport. The authors also found that younger participants and those who competed in sports with jumping and pivoting tended to have higher psychological readiness scores, which suggests these athletes may be more driven to return.

Clinical Implications

Medical professionals should be aware of the growing evidence supporting BEAR and that psychological readiness to return to play can be influenced by many factors. Medical professionals should monitor psychological readiness, especially among older athletes, those with a non-contact injury, and athletes in sports that don’t regularly require jumping or pivoting.

Questions for Discussion

What do you do to determine psychological readiness for return to play? Have you had any patients that received the BEAR procedure?

Written by: Jane McDevitt
Reviewed by: Jeffrey Driban

3 Comments

Jasmin DeBerry on June 1, 2022 at 12:52 pm

My name is Jasmin DeBerry and I am a second-year athletic training student in JMU’s Athletic Training Program. From my experience with patients who have had an ACLR, psychological readiness is a huge factor in returning to play. What my preceptors and I have done to determine psychological readiness is when we approach the return to play phase, we have them perform our functional testing and ask how they feel. We tend to have a good rapport with our patients and can tell when something is bothering them or they’re heistitent. One thing that we need to improve on is having more patient-rated outcomes for our ACLR patients aside from just verbal communications. As far as the BEAR procedure, none of our patients have received that procedure. Our team doctor does patellar tendon grafts on our ACLR patients.

Krista Clark on June 9, 2022 at 12:21 pm

As a second year masters student, I have only seen a few post operative patients. From what I have seen at the clinical sites I was placed at is that functional testing plays the biggest role of returning a player to sports. During functional assessment and after skill based training, the player was asked how they feel about what they are doing. This gives us an idea of how comfortable they are. I have not had any of my patients receive the BEAR procedure. Our team physical prefers to take a patellar tendon graft. I have also worked with a few high schoolers with a hamstring graph or a quadriceps tendon graph. I do think that giving a patient an outcome measure to determine psychological readiness would be beneficial for their return and to allow the clinician to monitor how they are feeling objectively.

Bryonna Woofter on June 14, 2022 at 4:16 pm

As a current student athletic trainer who is transitioning into my second year of my master of athletic training program I have not had the opportunity to exposure to patients who have received the BEAR procedure but I have had the opportunity to see quite a few patients post ACL reconstruction. Most of my interactions with psychological readiness to return to play occurred at my undergrad institution. Psychological readiness for return to play was determined through patient-rated outcomes, clinician-rated outcomes, functional testing, as well as face to face conversations with the patient on how and where they are in their recovery. Ultimately return to play did not occur until each of these aspects was on the positive side of the patient “passed” their testing. As a master’s student, I have only had the opportunity to encounter one patient in this scenario. In this case, my preceptor focused more on clinician-rated outcomes, protocols, and functional testing. With less of an emphasis on patient-rated outcomes and communication with the athlete. Thus, I believe it is important to verbally communicate with the patient in this scenario so that psychological readiness can truly be determined.

Jasmin DeBerry on June 1, 2022 at 12:52 pm

My name is Jasmin DeBerry and I am a second-year athletic training student in JMU’s Athletic Training Program. From my experience with patients who have had an ACLR, psychological readiness is a huge factor in returning to play. What my preceptors and I have done to determine psychological readiness is when we approach the return to play phase, we have them perform our functional testing and ask how they feel. We tend to have a good rapport with our patients and can tell when something is bothering them or they’re heistitent. One thing that we need to improve on is having more patient-rated outcomes for our ACLR patients aside from just verbal communications. As far as the BEAR procedure, none of our patients have received that procedure. Our team doctor does patellar tendon grafts on our ACLR patients.
Krista Clark on June 9, 2022 at 12:21 pm

As a second year masters student, I have only seen a few post operative patients. From what I have seen at the clinical sites I was placed at is that functional testing plays the biggest role of returning a player to sports. During functional assessment and after skill based training, the player was asked how they feel about what they are doing. This gives us an idea of how comfortable they are. I have not had any of my patients receive the BEAR procedure. Our team physical prefers to take a patellar tendon graft. I have also worked with a few high schoolers with a hamstring graph or a quadriceps tendon graph. I do think that giving a patient an outcome measure to determine psychological readiness would be beneficial for their return and to allow the clinician to monitor how they are feeling objectively.
Bryonna Woofter on June 14, 2022 at 4:16 pm

As a current student athletic trainer who is transitioning into my second year of my master of athletic training program I have not had the opportunity to exposure to patients who have received the BEAR procedure but I have had the opportunity to see quite a few patients post ACL reconstruction. Most of my interactions with psychological readiness to return to play occurred at my undergrad institution. Psychological readiness for return to play was determined through patient-rated outcomes, clinician-rated outcomes, functional testing, as well as face to face conversations with the patient on how and where they are in their recovery. Ultimately return to play did not occur until each of these aspects was on the positive side of the patient “passed” their testing. As a master’s student, I have only had the opportunity to encounter one patient in this scenario. In this case, my preceptor focused more on clinician-rated outcomes, protocols, and functional testing. With less of an emphasis on patient-rated outcomes and communication with the athlete. Thus, I believe it is important to verbally communicate with the patient in this scenario so that psychological readiness can truly be determined.