As anyone who has had an ACL reconstruction will tell you… it is a big deal. The recovery from ACL surgery is not simple.
Not only is an ACL reconstruction a painful surgery to endure, the recovery is long and the goal of returning to sports seems so far off for some.
Recent studies show that athletes who suffer an ACL injury tend to experience:
- more depression
- have a fear of re-injury
- have decreased sport satisfaction
- have a higher academic test failure rate and lower GPA.
This would suggest that there is a psychological impact their injury may have on them as well as the physical impact. But for some the recovery portion seems easier then it is for others. Why is that?
The recovery from ACL surgery is not purely a physical process. There is a significant emotional or psychological component associated with the ACL recovery process as a whole. If your treatment team does not focus on the whole person, and include in that a plan to deal with the psychological impact of the injury and subsequent surgery then the likelihood of a successful return to sports diminishes significantly.
“My body could stand the crutches, but my mind couldn’t stand the sideline.”
This is the latest post in our Expert Series. In this post our experts will discuss how they help you manage the emotional and psychological aspects of the recovery process to improve your chance of a successful return to the playing field.
The most commonly reported reason that patients choose not return to their pre-injury level of activity is a fear of re-injury. Recent studies and reviews have reported that those with a greater fear of re-injury are also less likely to achieve pre-injury level of activity. There is growing awareness of just how huge the psychological component is to a successful recovery and how important it is for medical professionals to address this with patients post-surgery. As a PT, I view my role as the person who needs to gradually expose patients to potentially “scary” tasks and allow them to be successful in overcoming these tasks. A skilled PT will know how to challenge a patient just enough to allow them to succeed, thus building confidence. Additionally, I empathize with my patients early. I have the (mis)fortune of being able to relate my own recoveries post-ACLR with them and I do not hesitate to let them know of my own history. I have had numerous patients tell me that they trusted me even more after I shared my experiences with them, because they felt I knew what they were going through. This allows me to be frank when their fears are misguided but also when they are well founded. A sports psychologist could be helpful for some athletes and may be often underutilized.
My coaching background is really valuable with this aspect of rehab. HOW you communicate is essential along with PLANNING. I always tell patients that I provide the road map but they have to drive the car and we may have to change the route along the way depending on what we encounter but we will always be in communication about it…along with the destination. Confidence is HUGE in terms of this rehab; it only grows when a patient knows you are prepared, confident in the your plan, and they know what is expected of them during each stage while working together. In addition, Fear Avoidance is also a big factor in rehab. HOW you frame pain and function will go a long way in whether they view their body as “broken” or not. The more you can do to reduce fear – the smoother the rehab. All of this is best managed with excellent interpersonal communication with the patient. I also use of an outcome measure to gauge how they rate their knee and function over the course of the rehab to better track this. Finally, the more you integrate their sport/activity demands into the rehab the better…in the mid to later of stages of rehab, activities will tend to look a lot more like their sport than “physical therapy” in all possible ways – sport specific activities, unpredictable environments, reaction to outside cues (opponents), sport specific metabolic demands. When done well, this reduces the mental “jump” to return to sport/competition.
Anja Goebel : @ACL_not_again
Michael Jordan once said: “My body could stand the crutches, but my mind couldn’t stand the sideline. “
Sure, an ACL tear is physically painful, the rehab is long and gruesome and extremely frustrating at times. But the physical pain is nothing compared to the emotional one. Athletes identify themselves by the capabilities of their bodies, and when they tear an ACL their body fails them.
When guiding a student athlete through an ACL rehab I keep in mind that sweating is therapeutic and that physical exhaustion from a hard workout provides a great feeling of accomplishment to him/her. Obviously it cannot replace the love of the game they’re missing but it provides at least some sense of athletic identity. With that in mind I incorporate core and upper body strength training into the daily rehabilitation from day 1. My goal is to keep the athlete’s mind occupied while the knee heals and I accomplish that by focusing on what they CAN do as opposed to what they CAN’T.
Many times non-injured athletes come in and ask if they can work out with us. We laugh a lot, build in many little competitions involving non-injured athletes and from warm-up to cool-down I am by their side, cueing, motivating, and many times participating. I also use hands-on time with the athlete (soft tissue mobilization, modalities) to spend some quiet time with them. This is where I get to know the person inside the athlete’s body and how THEY feel as opposed to their knee. I listen to their dreams and their fears, I let them vent and I give advice when asked. Having gone through multiple ACL reconstructions myself gives me a good amount of credibility in this department.
I try to make the rehab as fun as possible for my athletes. I tell them they only have a couple weeks of downtime before I will have them sweating again. Athletes tend to focus on the long term goals like when they can run and jump again, so I try to shift their attention by setting short term goals that can be reached quickly. This allows the athlete to focus on the next step and gives them small “victories” each week. I let them know this is a time that they are able to focus on all weaknesses that will elevate their game when they return.
Data from both the NCAA and the NATA indicates that athletes who suffer an ACL injury tend to experience more depression, have a fear of re-injury, have decreased sport satisfaction, have a higher academic test failure rate and lower GPA as a result of their injury. This would suggest that there is a psychological impact their injury may have on them as well as the physical impact. All too often, it is the one component that clinician’s often miss, the psychological component. For many, it is an uncomfortable aspect of care to address. It is too touchy feely. Yet, how can you possibly address the “whole” athlete if you don’t address?
How do you deal with? According to the studies, the most significant psychological factors contributing to inability to return to pre-injury levels were: psychological readiness, fear of re-injury, sport locus control (sense their outcome determined by internal or external factors) and the athlete’s pre-operative estimate of the number of months it would take to return to sport. This highlights some very key take aways which we can address.
- The psychological state of the provider has a direct and profound impact on the patient. Do you smile, do you engage the patient, do you project positivity? YOUR projection influences the patient.
- As a provider, our role is as an educator and coach, with emphasis in this case on coach. Coaching is not passive. It is methodical in approach, motivational, inspirational and purposefully driven to the end goal all while also being empathetic to the athlete. If done right, it also gives the athlete the sport locus control.
- Make sure they know they have an active role in the process and it takes hard work, but at the end of the day, they can and will control their destiny.
- Build the patient’s confidence during the course of rehabilitation. Most fear full body weight support on the involved limb, single limb landing and cutting on the involved side. There are a lot of ways to minimize this fear, one of which is getting them to do single leg activities early (as mentioned in previous post) and often. Building the confidence in the limb as soon as possible so that they can see putting weight on the leg will not result in re-injury.
- Make them work it. Making an athlete work hard and pushing them physically will build mental toughness and confidence. All too often, we are afraid to push patients. If done within the parameters of the healing process and within protocol, it can and will result in huge physiological and psychological improvements. But it must be based on sound principles.
- Consult with the referring physician and provide the athlete with realistic estimate of time it takes to return to sport. Obviously the greatest influence on pre-operative belief and estimate is the orthopedic surgeon. Most will set that expectation for the athlete pre-operatively. Unfortunately and all too often, the rehab provider may report something different to the patient. This can result in a significant and negative impact on the patient’s psychological status. Two conflicting estimates of return to sport can create an instant internal conflict for the patient. Who do I trust? Who do I believe? This can seriously impact their motivation and sport locus control. As a rehab provider, this should be avoided at all costs.
My thoughts: The recovery from an ACL reconstruction is a long road. The ACL injured athlete requires attention to not only their physical needs during the recovery process, but their emotional and psychological needs as well.
Once again… thank you very much to our experts for their thoughts.