Return to Play Following ACL Reconstruction: Nothing to Fear but Fear Itself

Transcription

1 Return to Play Following ACL Reconstruction: Nothing to Fear but Fear Itself Terese L. Chmielewski, PT, PhD, SCS Adam Meierbachtol, PT, DPT, SCS, ATC MNPTA Annual Conference 2018 not be reproduced without permission. 1

2 Disclosures There are no financial relationships to disclose not be reproduced without permission. 2

3 Objectives Describe fear of re-injury following ACL reconstruction and its effect on the return to sport rate and other rehabilitation outcomes Describe ways to measure fear of re-injury after ACL reconstruction Identify interventions that may be used to decrease fear of re-injury for the purpose of facilitating the return to sport and improving other rehabilitation outcomes not be reproduced without permission. 3

4 Point of Clarification We are not psychologists Our goal is to improve rehabilitation outcomes after ACL reconstruction not be reproduced without permission. 4

5 Psychological Response to Sports Injury Initial During Rehabilitation Return to Sport Emotions Negative Anger, depression Severity is based on appraisal Improves Frustration Mixed Excitement Fear of re-injury, low confidence Morrey MA et al. Clin J Sport Med 1999 Tracey J. J Appl Sports Psych 2003 Clement D et al. J Athl Train 2015 not be reproduced without permission. 5

6 Kinesiophobia: Fear of movement not be reproduced without permission. 6

7 Fear-Avoidance Model of Musculoskeletal Pain High Threat Low Threat Vlaeyen and Linton, Pain 2012 not be reproduced without permission. 7

8 What s the Distinction? Kinesiophobia fear of re-injury Athletes that report fear of re-injury are likely to exhibit elevated kinesiophobia Kinesiophobia fear of re-injury Athletes may be afraid of something other than pain during movement Hsu CJ et al. Sports Health 2017 not be reproduced without permission. 8

9 How to Measure Kinesiophobia Patient interview Yes/no or open-ended questioning Questionnaires Tampa Scale for Kinesiophobia (TSK) ACL Return to Sport after Injury (ACL-RSI) Fear Avoidance Beliefs Questionnaire (FABQ) Athlete Fear Avoidance Questionnaire (AFAQ) Photographic Series of Sports Activities for ACL Reconstruction (PHOSA-ACLR) not be reproduced without permission. 9

10 Weighing the Options Patient Interview Less administrative burden Potentially more specific Questionnaires Quantifiable Easier to document initial level and track progress not be reproduced without permission. 10

11 Tampa Scale for Kinesiophobia (TSK) 17 item (TSK) and 11 item (TSK-11) versions Woby SR et al. Pain 2005 Fear of re-injury subscale (items 1, 2 and 10) George SZ et al. Clin J Pain 2012 Higher scores = higher kinesiophobia not be reproduced without permission. 11

12 ACL-Return to Sport after Injury (ACL-RSI) 12 items, 100 points Domains Emotions Confidence in performance Risk appraisal Lower scores = poorer psychological readiness for sport Webster K et al. Phys Ther Sport 2008 not be reproduced without permission. 12

13 Kinesiophobia and Return to Sport Fear of re-injury is the primary reason for not returning to sport after ACL reconstruction Return to Sports Fear of Re-injury Other Kvist J et al. KSSTA 2005 Lee DY et al. Ann Acad Med Singapore 2008 Devgan A et al. ISN Orthop 2011 Lentz TA et al. J Orthop Sports Phys Ther 2012 McCullough KA et al. Am J Sports Med 2012 Ardern CL et al AJSM 2013 Ardern C et al. Br J Sports Med 2014 Lentz TA et al. Am J Sports Med 2015 not be reproduced without permission. 13

14 Kinesiophobia & Knee Function kinesiophobia is associated with selfreported knee function Kvist J et al. Knee Surg Sports Traumatol Arthrosc 2005 Chmielewski TL et al. J Orthop Sports Phys Ther 2008 Lentz TA et al. Sports Health 2009 Ross M. J Orthop Traumatol 2010 Chmielewski TL et al. Phys Ther 2011 Hartigan E et al. J Orthop Sports Phys Ther 2013 Cozzi AL et al. J Sport Rehabil 2015 Tichonova A et al. Medicina (Kaunas) 2016 (meniscectomy) not be reproduced without permission. 14

15 Kinesiophobia & Performance Kinesiophobia might not be associated with hop performance Lentz TA et al. Sports Health 2009 Hartigan EH et al. J Orthop Sports Phy Ther 2013 Hsu CJ et al. Orthop J Sports Med 2016 (meniscectomy) not be reproduced without permission. 15

16 Kinesiophobia & Knee Impairments No association with quadriceps strength Hartigan EH et al. J Orthop Sports Phy Ther 2013 Possible association with knee impairment resolution TSK-11 scores at 4 weeks postsurgery odds for not meeting advanced rehab criteria at 12 weeks post-surgery TSK-11: odds ratio= 1.10 TSK-11 fear of re-injury : odds ratio = 1.31 Chmielewski TL and George SZ. In review not be reproduced without permission. 16

17 TSK-11 Scores When to Test for Kinesiophobia? Baseline Months Post-op Chmielewski TL et al. Phys Ther 2011 Lentz TA et al. Sports Health 2009 not be reproduced without permission. 17

18 Identifying Who Needs Intervention Scores that distinguish who does or does not return to sport at 1 year post-surgery Measure Score Time point Study TSK RTS 21.9 NRTS 6 mo post-op Lentz TA et al. Am J Sports Med 2016 ACL-RSI 57.3 RTS 40.4 NRTS 63.2 RTS 51.8 NRTS 4 mo post-op 6 mo post-op Ardern CL et al. Am J Sports Med 2013 Langford JL et al. Br J Sports Med 2009 not be reproduced without permission. 18

19 Interventions for Kinesiophobia Activity-based intervention Plyometric exercise: thought to bridge rehabilitation and sport participation because it mimics sports tasks Chmielewski TL et al. J Orthop Sports Phys Ther 2006 Psychosocial intervention Studied extensively in patients with low back pain, but less in patients with ACL reconstruction Hsu CJ et al. Sports Health 2017 not be reproduced without permission. 19

20 TSK-11 Scores Plyometric Exercise 8 week program Mean time from surgery ~ 14 weeks Pre-treatment TSKTot_V1 Post-treatment TSKTot_V (6.9) 17.5 (5.2) Chmielewski TL et al. Am J Sports Med 2016 not be reproduced without permission. 20

21 Plyometric Exercise 5 week advanced plyometric training program Mean time from surgery = 8 months ACL-RSI scores Pre-training: 60.1 (19.3) points Post-training: 77.9 (14.7) points Meierbachtol A et al. In Review not be reproduced without permission. 21

22 Plyometric Exercise Post-training readiness for return to sport 38% psychologically + functionally ready 24% psychologically ready 16% functionally ready 22% neither psychologically or functionally ready Meierbachtol A et al. In review not be reproduced without permission. 22

23 Biomedical Model of Healthcare Psychological Sociological Health Biological Engel GL. Science 1977 not be reproduced without permission. 23

24 Biomedical Model of Healthcare Psychologically informed practice Main C & George SZ. Phys Ther 2011 not be reproduced without permission. 24

25 Recommendations for Return to Sport Discussion of prospective return dates so athletes can begin to anticipate their return Approval from the sports medicine team that the athlete is physically ready to meet the demands of competition Assessment of athlete s confidence levels as well as discussions about any fears or thoughts related to the return to sport Discussion regarding who will make the final decision regarding when the athlete will return Podlog L and Eklund RC. Psychology of Sport and Exercise 2007 not be reproduced without permission. 25

26 Return to Sport Guidelines Br J Sports Med 2016 A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. not be reproduced without permission. 26

27 Interventions to Address Fear of Re-injury not be reproduced without permission. 27

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30 Patients randomized to receive (1) rehab or (2) rehab + guided imagery/relaxation (9 sessions) Intervention Focus on specific physiological processes occurring during recovery stage Suggestions to promote positive coping responses Outcomes: neurobiological factors, knee strength, self efficacy at 2, 6, and 12 weeks post op not be reproduced without permission. 30

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32 Neurobiological Factors not be reproduced without permission. 32

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34 Results 13M/8F; avg 34.8 years old No differences in knee extension strength Significant reduction in neurobiological factors (ie stress) in intervention groups at each time point Both groups showed reduction in self efficacy, however experimental group had smaller reduction which was maintained at 6 and 12 weeks not be reproduced without permission. 34

35 Outcomes: Re-injury anxiety, isokinetic knee strength Treatment group received standard rehab + 10 individual sessions of relaxation and guided imagery every 2 weeks x 6 months Placebo group received attention and encouragement; did 10 mins of peaceful visualization daily Control group received standard post op rehab not be reproduced without permission. 35

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37 Results 16M/14F; avg 28.2 years old (18-50 years) Treatment group showed significantly greater knee strength at 24 weeks then placebo or control Greater reduction in perceived pain at 6 months in treatment group vs placebo or control All three groups showed reductions in re-injury anxiety; treatment group showed significantly less re-injury anxiety at 24 months then placebo or control not be reproduced without permission. 37

38 Systematic review identified 4 RCT trials that met inclusion criteria Inconsistent findings for the additive benefit of psychosocial interventions for improving postoperative function, pain or self-efficacy Limited evidence for improving quality of life, anxiety, or fear of re-injury No study examined the effects of psychcosocial interventions on return to sport not be reproduced without permission. 38

39 Involves exposing patients to specific situations of which they are fearful Hierarchical; small LARGE amounts of fear Treatment strategies based on fear avoidance model have common goal of confrontational response not be reproduced without permission. 39

40 GivE vs GA Graded in-vivo Exposure (GivE): Educating patient about cognitive-behavioral perspective on fear-avoidance Discuss patients problems Establish individual hierarchy of fear eliciting movements (PHODA) Exposure to activity Graded activity (GA): Shaping of healthy behaviors through positive reinforcement of predefined activity quotes Individualized not be reproduced without permission. 40

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43 Goal: systematically review and meta-analyze effectiveness of graded activity (GA) or graded exposure (GEXP) 9 RCTs were included not be reproduced without permission. 43

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49 Conclusions GA significantly > control for improvements in disability in short term GA was significantly < graded exposure for improvement of disability in short term GA significantly < graded exposure at improving catastrophizing in short term Conclusion: Moderate evidence that graded exposure more effectively decreases catastrophizing then graded activity in short term not be reproduced without permission. 49

50 100 patients who exhibited kinesiophobia after TKA were randomly assigned to participate in CBT (n = 50) or standard care (n = 50) Outcomes: TSK, PCS, NPRS, HSS Outcomes at pre intervention and 4 weeks post intervention and 6 months not be reproduced without permission. 50

51 Intervention Individual 30 minute sessions via PT and psychologist Session 1: person-centered analysis of kinesiophobia Analyze factors causing kinesiophobia, list goals Session 2: kinesiophobia education Modifying kinesiophobia beliefs and pain catastrophizing Session 3: progressive muscular relaxation Teach patients how to apply relaxation and improve self efficacy Session 4: graded knee functional exercise Help transfer attention from kinesiophobia to knee rehab via graded exposure to situations previously identified as dangerous not be reproduced without permission. 51

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53 Conclusions CBT program had significant group and time effects on kinesiophobia, pain catastrophizing and knee function Effects lasted for at least 6 months after end of intervention CBT program was superior to standard of care in reducing kinesiophobia, pain catastrophizing and knee pain and enhancing knee function in patients who have high level of kinesiophobia post TKA not be reproduced without permission. 53

54 Graded Exercise Graded Exposure not be reproduced without permission. 54

55 Graded Exercise (n = 15); continually improving exercise and activity tolerance utilizing a quota system instead of pain abatement Graded Exposure (n = 18); hierarchically exposing patients to specific situations of which they are fearful not be reproduced without permission. 55

56 VAS not be reproduced without permission. 56

57 OSW not be reproduced without permission. 57

58 not be reproduced without permission. 58

59 Patients randomized to low (n = 12) or high (n =12 ) intensity plyometric exercise Mean time from surgery to training intervention was 14.3 weeks Higher intensity group increased perceived effort at a faster rate and performed higher intensity activities Exercise volume was matched between groups not be reproduced without permission. 59

60 not be reproduced without permission. 60

61 Fear and Confidence in Low and High Plyo Groups not be reproduced without permission. 61

62 Conclusions No significant differences detected between the low and high intensity plyometric exercise groups Improved confidence, but not fear of re-injury Both groups showed positive changes in knee function, knee impairments and psychosocial status not be reproduced without permission. 62

63 Does Graded Exercise = Graded Exposure? Only if specific exercise = feared activity Published ACL prevention programs use progressively challenging jumping exercises to improve biomechanics Fear of re-injury is major limitation graded exposure can decrease fear of re-injury does a progressive jumping program improve psychosocial status s/p ACLR?? not be reproduced without permission. 63

64 Psychological and Functional Readiness for Sport Following Advanced Group Training in Patients with Anterior Cruciate Ligament Reconstruction Meierbachtol A, Yungtum W, Paur E, Bottoms J, Chmielewski TL Objective: To examine changes in psychological and functional measures, and readiness for sport based on these measures, in patients with ACLR following advanced group training Methods: Patients with primary ACLR enrolled in a 5- week (10 session) progressive group training program after completing traditional physical therapy Outcomes: ACL-RSI questionnaire and single leg hop testing (single, triple, crossover triple, and timed hops) not be reproduced without permission. 64

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67 Study Enrollment not be reproduced without permission. 67

68 Demographics Variable Measure Age (time of surgery, years) 21.2 (7.77) Sex 37F/21M Autograft source 44 patellar tendon/14 Hamstring Number of pre-training PT visits 23.5 (7.0) Surgery to start of Training 8.1 (1.8) Time from pre to post training 40.5 (1.6) Number of training sessions 9.4 attended not be reproduced without permission. 68

69 Outcomes Outcome Pre- Training Post-Training Effect Size ACL-RSI* (points) 60.1 (19.3) 77.9 (14.7) d = Single Hop LSI* (%) 89.7 (8.7) 94.2 (6.6) d =.5837 Triple Hop LSI* (%) 88.3 (8.1) 92.6 (6.5) d =.5852 Crossover Triple Hop 89.6 (9.4) 93.0 (9.2) d =.3614 LSI* (%) Timed Hop LSI* (%) 91.2 (8.8) 94.7 (7.6) d =.4266 not be reproduced without permission. 69

70 Correlations Single Hop Triple Hop Crossover Triple Hop Timed Hop ACL-RSI Score Post-training Change Post-training r =.269* Change r = Post-training r =.275* Change r =.067 Post-training r =.144 Change r =.175 Post-training r =.233 Change r = not be reproduced without permission. 70

71 Proportion of Patients Categorized as READY/NOT READY on ACL-RSI Post Pre Pre Post Using 56 points p <.001 Using 75 points not be reproduced without permission. 71

72 Proportion of Patients Categorized as READY/NOT READY on LSI Pre Post p <.01 not be reproduced without permission. 72

73 Readiness to Return to Sport Categorization based on ACL-RSI (56 pts) and LSI Pre-Training p <.05 Post-Training not be reproduced without permission. 73

74 Readiness to Return to Sport Categorization based on ACL- RSI (75 pts) and LSI Pre-Training p <.05 Post-Training not be reproduced without permission. 74

75 Proportion of Patients that Changed from NOT READY to READY Categorization from Pre- to Post-Training Based on ACL-RSI and Hop Test Limb Symmetry Index (LSI) Return to Sport Criteria ACL-RSI of 56 points ACL-RSI of 75 points not be reproduced without permission. 75

76 Conclusions On group level, progressive advanced group training can improve functional and psychological measures Improvements not tightly linked and many individuals fail to meet either functional, psychological, or both criteria following advanced group based training For some individuals, graded exercise = graded exposure Failing group therapy may necessitate individually based interventions not be reproduced without permission. 76

77 ACL-RSI Subscale ACL-RSI has three subscales Emotions Confidence in performance Risk appraisal Are there particular subscales which show lower/higher scores? More variability? Does advanced group training address specific subscales? not be reproduced without permission. 77

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79 Conclusions Fear of re-injury questions continue to show lowest observed scores post-raining Advanced group training may improve confidence more than decreasing fear of re-injury not be reproduced without permission. 79

80 Future directions Screening for psychologically at risk individuals at group training? Adding specific psychological component to advanced group training? Individualizing graded exposure activities? not be reproduced without permission. 80

81 Clinical Pearls Elevated kinesiophobia after sports injury can impede the return to sport Kinesiophobia can be assessed through interview or questionnaires Activity-based and psychosocial intervention may be used to reduce kinesiophobia not be reproduced without permission. 81

82 Take Home Messages Cognitive behavioral interventions utilized in isolation have small short term benefits Progressive group training may have graded exposure type benefits Functional and psychological states do not necessarily correlate Asking patients what activity is specifically feared and then individually exposing them to progressive challenges may show improved outcomes Supplemental psychological interventions may be individually required if ongoing psychological deficits persist not be reproduced without permission. 82

83 References Maddison R et al. Guided imagery to improve functional outcomes post-anterior cruciate ligament repair: randomized-controlled pilot trial. Scand J Med Sci Sports. 2012;22: Cupal DD, Brewer, B.W. Effects of relaxation and guided imagery on knee strength, reinjury anxiety and pain following anterior cruciate ligament reconstruction. Rehabil Psychol. 2001;46: Coronado RA et al. Do psychosocial interventions improve rehabilitation outcomes after anterior cruciate ligament reconstruction? A systematic review. Clin Rehabil Woods MP, Asmundson GJ. Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: a randomized controlled clinical trial. Pain. 2008;136: George SZ et al. Comparison of Graded exercise and graded exposure clinical outcomes for patients with chronic low back pain. JOSPT. 2010; 40(11): Lopez-de-uralde-Villanueva, I et al. A systematic review and metaanalysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pin Medicine (2016); 17: not be reproduced without permission. 83

84 References Chmielewski TL et al. Low- Versus High-Intensity Plyometric Exercise During Rehabilitation After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016;44: Cascio BM, Culp L, Cosgarea AJ. Return to play after anterior cruciate ligament reconstruction. Clin Sports Med 2004: 23: Gobi A, Francisco R. Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation. Knee Surg Sports Traumatol Arthrosc 2006: 14: Shah VM, Andrews JR, Fleisig GS, McMichael CS, Lemak LJ. Return to play after anterior cruciate ligament reconstruction in National Football League athletes. Am J Sports Med 2010; 38 (11): Myer, GD et al. Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clinics in Sports Med 27; (2008). George SZ, Zeppieri G. Physical therapy utilization of graded exposure for patients with low back pain. J Orthop Sports Phys Ther. 2009;39: not be reproduced without permission. 84

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