Psychological outcomes during rehabilitation after ACL reconstruction - and implications for second ACL injury

Abstract

An anterior cruciate ligament (ACL) injury is a common knee joint injury. An ACL injury is typically managed through surgical reconstruction of the ligament, followed by rehabilitation. For patients treated with ACL reconstruction and rehabilitation, during rehabilitation there is an ongoing interplay between the body and the mind, that is, physical and psychological factors. The purpose of this thesis was to investigate and better understand the psychological outcomes of patients after ACL reconstruction, and possible associations with a subsequent second ACL injury. This thesis comprised six studies which covered the three pillars of evidencebased medicine (EBM): clinical expertise, best available evidence and patients’ preferences. Study I, for the clinical expertise pillar aimed to qualitatively explore sports physiotherapists’ experiences of working with psychological impairments. Findings reveal that sport physiotherapists primarily rely on a blend of clinical experience, intuition, and peer discussions to navigate the psychological dimensions of rehabilitation and acknowledge a significant gap in formal training and knowledge. Studies II, III, IV, and V focused on the best evidence pillar of EBM. Study II was a systematic review, while Study III, IV and V used data from a rehabilitation specific registry. Study II summarized the prevalence and severity of self-reported depression and anxiety symptoms. Study III examined differences in physical and psychological outcomes between patients who would and would not suffer a second ipsilateral ACL injury. Study IV aimed to incorporate results from psychological patient reported outcome measures (PROs) into assessment batteries, evaluating the risk of subsequent ACL injuries. Finally, Study V calculated cutoff scores on PROs to differentiate between patients likely and not likely to experience a second ACL injury. Results showed a large heterogeneity in how self-reported depression and anxiety symptoms are reported, and that the severity of symptoms peaked in the period around ACL reconstruction. Patients who would go on and suffer a second ipsilateral ACL injury scored higher on PROs. However, implementing PROs in test batteries did not affect the second ACL injury risk and the best scores to differentiate between patients likely and not likely to experience a second ACL injury were never better than the flip of a coin. Study VI, for the patients’ preference pillar, through interviews and qualitative content analysis addressed experiences of young active females who suffered two ACL injuries. In the young females’ experiences, Abstract Abstract 7 the initial injury catalyzed a profound sense of loss, challenged their athletic identity and induced feelings of loneliness and despair. However, the journey from second ACL injury to the present day painted a picture of determination, support, hard work, and personal growth.