Thank you for joining us. I am Christine Watt, Publishing Coordinator for AJSN, and I will be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio or switching the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, use the Q&A feature at the bottom of the screen to type your question. When finished, click the send button. Questions you submit are seen by today's presenters and will be addressed throughout the presentation, so please send those questions as you watch rather than at the end. There is CME available for this online activity. Here are the learning objectives and the disclosures for our faculty and organizers. At the conclusion of today's program, we ask that you complete a brief evaluation to collect CME for this activity. Details will be given at the end of the program and in an email to attendees. At this time, I would like to introduce our moderator, Dr. Kate Webster. Dr. Webster is a Professor of Allied Health and Head of Department for Sports, Exercise, and Nutrition Sciences at La Trobe University, Melbourne, Australia. She is also a member of the AJSM Electronic Media Editorial Board and will be moderating our webinar. And with that, I'll turn the program over to Dr. Webster. Thank you, Christine. I'm absolutely thrilled that we've got colleagues joining us worldwide. So either good morning, good afternoon, and good evening. I'm really excited for today's topic on psychological aspects of ACL injury and return to play because it's a topic that I'm passionate about. And we've got an exceptional panel joining us today. I'd first like to introduce Dr. Britton Brewer, Professor Emeritus of Psychology at Springfield College. Professor Brewer has certainly been a leader in this field. And today we'll talk about how psychological factors might influence ACL rehab outcomes. I'd also like to welcome Dr. Shelby Bize, Psychiatric Trainer and Assistant Professor at the University of North Carolina at Chapel Hill. Dr. Bize is going to talk about some of her recent and really exciting work on psychological interventions for return to play. It's also my pleasure to introduce Dr. Melissa Cristino, who is an orthopedic surgeon in Boston Children's Hospital. She's also Director of Sport and Mental Skills Research for the Division of Sports Medicine. So I've therefore asked Dr. Cristino to talk about psychological considerations for the younger athlete. I'd also like to welcome Dr. Julian Feller, Professor and Orthopedic Surgeon at OrthoSport Victoria, who's listened to me talk about this topic a lot over many years. So today I've asked him to talk about when he doesn't clear a patient for return to play due to psychological concerns. So the format for today is that we're purposely keeping these initial talks short so that we have plenty of opportunity for panel discussion. And thank you to those who have already been submitting questions to us. We're going to try to get through as many of these as we can. So now I'm going to hand over to Professor Brewer. Thank you, Dr. Webster, for the kind introduction and for the invitation to be a part of this panel. It's indeed an honor to join this esteemed group of colleagues. As Dr. Webster mentioned, I'm going to be talking about how do or how might psychological factors affect ACL injury rehabilitation outcomes. So, a lot has been written over the last couple of decades on how psychological factors matter, about how they make a difference in ACL rehabilitation outcomes. But relatively little is known, that's this question mark here, about how this process occurs. How do psychological factors affect ACL rehabilitation outcomes? Just to make sure we're all on the same page, when we're talking about psychological factors, we're talking broadly about cognition, which is what people think, their thoughts, appraisals, attributions, and so forth. Emotions, what people feel, anxiety, depression, and so on. Behavior, what people do. And finally, personality, which are stable, consistent patterns of thought, feeling, and behavior over time. So, those are the psychological factors on one side of the equation. And on the other side of the equation, we have ACL injury rehabilitation outcomes. And I'm going to distinguish between three different types here. First, cognitive and affective outcomes, which are how patients think and feel about their ACL, about their rehabilitation, about their recovery. Behavioral outcomes, these are functional outcomes, what patients can do. And then finally, physical outcomes, which are anatomical or structural changes that have occurred. And even though these are all outcomes, and they are related to each other, the relationships are much, much weaker than you might expect. I'm going to spend most of my time this evening on this figure here, which is a roadmap, if you will, from how you get from psychological factors to the three different types of rehabilitation outcomes. The express lane is pathway A, over to the far left over here, which is from psychological factors to cognitive and affective outcomes. It's no surprise that, for example, what patients are thinking and feeling influences how they think and feel about their rehabilitation, about their recovery. There's also an interior pathway here, pathway B, which is through rehabilitation behavior. Psychological factors, of course, not surprisingly, influence what patients do, what they do with their rehabilitation. We're specifically talking here about compliance, adherence, and whatnot. And what people do in rehabilitation, as is frequently stressed, can affect all the different types of outcomes. The third pathway is a little bit less well understood, but it goes from psychological factors, pathway C, to biological factors. And again, it's well known that stress, for example, and how people cope with it is related to hormonal changes, tissue healing, and related factors. So it's not a surprise that that might also influence physical outcomes and behavior outcomes, what people can do as a result of those biological changes. Again, this pathway is a little bit of a black box. We don't tend to know very much about this one. We also know relatively little about the fourth pathway, the pathway over here to the far right, pathway D, which goes from psychological factors through social and contextual factors all the way around the horn to cognitive and affective outcomes, and then trickling over to the other types of outcomes as well. This is what a patient is thinking, what they're feeling, what they're doing, how it influences responses from other people in their environment, and how that then transfers to their cognitive and affect how they think and feel about their need. And again, this pathway is less well understood than some of the others. To summarize, the relationship between psychological factors and injury rehabilitation outcomes is complex. A lot of arrows, a lot of circles there, a lot of parties involved, a lot of variables involved. The relationships that have been documented provide an empirical foundation, a theoretical rationale, and a roadmap for intervention. And I believe it is to intervention that we will now turn with Dr. Baez. Here's some references that are available if you're interested, and you can contact me by email. And I thank you for your time and attention. Thank you. All right, Dr. Brewer, thank you so much for teeing me up to talk a little bit about psychologically-informed practice and psychological interventions. As Dr. Webster said, good morning, good afternoon, good evening, and thank you so much for joining us. So my background, I'm an athletic trainer, but I'm also trained as a sport and exercise psychology professional. So my interest really is at this intersection of how we can intervene from a psychosocial standpoint in rehabilitation. So as mentioned previously, we see that psychological responses are associated with poor health outcomes, from failure to return to sport, failure to engage with physical activities, secondary injury risk, poor self-reported outcomes, abhorrent jump landing biomechanics, and the list goes on. So at this point, when we're thinking about psychological responses, I'm sure a lot of us are like, what do we do about it? And how can we start to address this? And that's where this concept of psychologically-informed practice, will really come into play. I had an opportunity to work with my colleague, Dr. Kate Jockamson, to develop a current clinical concepts paper, where we've applied this idea of psychologically-informed practice for sport-related injuries. And what this is essentially suggesting is that we should incorporate the patient's beliefs, the attitudes, and their emotional responses into patient management based on biopsychosocial models. So this is not suggesting that rehab specialists or physicians should become psychologists or vice versa, but this is a consideration of both the physical factors, as well as the psychological factors that may influence outcomes. And again, our goals with psychologically-informed practice look very similar. We want to improve physical activity, we want to improve return to sport, and we want to improve our clinical outcomes. But we may start to use things like psychological screening, as well as referral to appropriate mental health professionals in order for us to optimize our care. So a couple of ways that we have done this in my group, I'm gonna present just some pilot work that has helped to inform some of our larger clinical trials that we're currently doing. Specifically, we've looked at this idea of called graded exposure therapy. So unlike Professor Gallagher, who's trying to address this fear of heights and snakes in the dark all at the same time, the key thing here is to have a gradual exposure to a fearful stimuli. So with psychologically-informed practice and thinking about tools and techniques that rehab specialists can use, graded exposure therapy is great because we are great at already progressing people through movement. But instead of using pain or soreness as the progressive factor, here we can use fear. So you work with your patient to develop a hierarchy of fearful situations. So I'm afraid of pivoting, I'm afraid of jumping, I'm afraid of cutting. And you progress that patient through that hierarchy, starting with the least fearful task first and working your way up to the most fearful task. So we've done this as a proof of concept study in six patients who had high fear after ACL reconstruction, where over the course of five weeks, we addressed three specific tasks. So the take-home point from this is that we've saw that graded exposure was really good at addressing specific functional tasks, but not so great at getting at some of those general phobic fear responses. So to orient you to this figure here, blue would represent the pre-exposure therapy fear scores, the green would represent the post-exposure therapy fear scores, and higher scores represent higher levels of fear. And the three boxes we have here represent the three tasks we addressed. So landing after a jump, lateral lunging, as well as pivoting. And as you can see, we saw a significant change that met the minimal technical change for this instrument for those specific tasks that were addressed. But again, not the general phobic responses, which got us thinking about integrating a different psychological technique such as mindfulness meditation. And mindfulness is this basic human ability to be fully present, aware of what's going on, but not overly reactive or overwhelmed by our thoughts or our feelings or our emotions. It can be a quieting of our thoughts and cultivated through meditation. And what's nice about mindfulness is that there is some literature out there suggesting that this can be very advantageous to help decrease fear and anxiety in patients with traumatic knee injuries. And in some of our proof of concept studies in our work, we've integrated to test out how four weeks of mindfulness meditation, so 12 sessions using the Headspace mobile application, could be used to help to address fear. Now, I'm gonna preface this is that when we did the study, we didn't enroll patients based off whether they had high fear or low fear. We just had patients after ACL reconstruction and we wanted to see how that helped patients. So to orient you to this figure here, blue would represent who would be considered to have high fear at baseline. Orange would represent who would be considered to be low fear at baseline. The darker colors represent the pre-mobile mindfulness meditation and the lighter colors represent the post-mindfulness meditation. And when you look at the high fear group, you can see some nice changes and decreases as it relates to their TSK-11 score or their kinesiophobia specifically. But when we look at our low fear group, we're potentially seeing some increases which can be measurement error or simply you don't give someone who maybe doesn't need a psychological intervention a psychological intervention. So take home point from this study is make sure you're measuring and using patient reported outcomes like the TSK-11, like the ACL-RSI to your advantage before you start to implement some of these different techniques. So in our current ongoing clinical trial, we're using a different technique, virtual reality mindfulness meditation to implement the meditation. And our use of VR is twofold. One, for novice meditators, sometimes it's really hard to engage in meditation and providing that auditory and visual feedback can potentially be advantageous. And then two, from a provider standpoint, having another plug and play solution that can be easily implemented into practice. So our hope is to see if we can decrease fear, improve reaction time and alter brain activity in patients after ACL reconstruction. And specifically in one patient who was a case study who had high fear, who completed the eight week protocol, we saw that improvements in TSK-11, improvements in psychological readiness, as well as improvements in self-reported function. So our goal is to hopefully be able to replicate this a couple more times. So some final thoughts here, graded exposure and mindfulness are just a few of the many psychologically informed strategies. It's important to be patient because the techniques take time in practice for you and the patient. And when in doubt, if you're ever unsure what to do, refer out. And then thank you so much and thank you to my team. Assuming you guys can all see my screen, I'm Melissa Christina. I'm from Boston Children's again. Thanks for putting together this panel. Dr. Webster. This is a great topic and really excited to be included to talk about some of our what our young patients experience. These are my disclosures. And then, you know, I think when we talk about this population it's important to put some things into context and number one, what do we see with ACL injuries in these patients. We know that children and adolescents are among the fastest rising demographic for ACL tears. We also see really high return to sport rates in this population so the middle school or tears their ACL they're going to come back and they're going to go on to play high school sports. We also know from extensive prospective studies that young patients under 20 years of age are most at risk for graft free injury so this is certainly a high risk population from an ACL injury standpoint. We also need to take into consideration what is happening in these patients lives at the time that they're experiencing this injury. So adolescents in particular is a time of identity formation these kids are trying to decide who they're going to become what they're interested in what they value. There's also a really high societal value based on sport excellence, and most of the patients that I see in the office have both either collegiate or professional sport aspirations whether or not that's realistic or not that is the culture that we are in with these patients. Another important thing to consider is that many young people have not yet experienced a significant setback in their life and an ACL injury can be a really big deal. I'm going to talk about the three psychological concerns you see here athletic identity coping skills and psychological readiness. This list is not exhaustive, but I think it gives us a good sense of what we're dealing with with these athletes. So I think identity is the degree to which one identifies as an athlete, and it can be a really important part of somebody's overall self concept. So, an athlete with a very high athletic identity sports are everything to them. And for these athletes injuries can be particularly devastating. Hopefully you can still see my screen. Dr Brewer has done some amazing work in this area and this was a study looking at that athletic identity, following ACL reconstruction and they found a significant decrease in athletic identity over time, with the most substantial decrease occurring between six and 12 months which is really interesting because as a surgeon that's when I'm sending my patients back to sports, and they propose maybe this is a self protective effect maybe the athlete is distancing themselves from actually being an athlete because they're worried about whether they're going to be able to go back and perform at the same level. Not many studies have been done on the athletic identity and a young population. This was a systematic review of just 10 studies and young patients and one of the main findings was that patients with higher athletic identity did seem to have an increased depression risk after injury. So the best way to try to understand this concept is, is from what our patients experience and what their families tell us and so this was an email from a patient's mom 14 year old boy that went through ACL recovery, and she said his physical injury was easy to see on the x ray and MRI. What was not easy to see was the injury to his identity his self confidence and his overall mental health, not being able to play sports he loves even for a little while changed how he saw himself and the safety of our home by the kind of pride that no parent wants to hear. He lost his confidence he couldn't do what he was good at and he was unsure where he fit in so very powerful words there, but I think this is very representative of what many of my patients experience with this injury coping skills is a really important thing to consider as well. did this study and they found that baseline low scores on the athletic coping skills inventory correlated with delayed recovering clearance for sport after ACL reconstruction, and they found that patients have scored less than a 58 on this scale that goes up to 84 took actually too much longer, two months longer to recover than participants in sport higher. This is something I've been interested in looking at this is unpublished study, looking at adolescent athletes and how coping strategies and athletic identity might relate in this population we found an average coping skills for 50 so way less than the slide that I showed previously, we found that patients that have the highest coping skills scores actually had high athletic identity, or were highly specialized, but these two groups also scored universally lower and the freedom from worry domain on the coping skills scale and what that suggests to me is that athletes with high athletic identity or greater sports specialization and may worry more and be at greater psychological risk after injury. I found this study really interesting to read this is a qualitative study of 18 patients that injured their ACL 20 to 30 years ago, they're all living normal well adjusted lives but it was interesting to see how much the physical and mental challenges that were residual from this injury continues to play into their life over time and so the conclusion of the study is that ACL rehab really should support coping strategies. Psychological readiness is a really important term, and Dr Webster and Dr Feller have done a tremendous amount of work in this area I believe Dr Feller is going to talk about some of this in a bit, but psychological readiness has been found to be one of the most significant predictors of return to sport that we have an ACL literature. We've done a number of these previously done studies at Boston Children's and so we wanted to look at psychological readiness and a prospective plan our young patients, and we found that our pre adolescent age group actually tended to report better on all patient reported outcomes but including psychological readiness which you see in that first column on the left hand side of the screen are pre adolescence under 14 or blue adolescents in red and adult patients in green. And then we've had a couple subsequent studies these are unpublished to date, but we found psychological readiness associated with better functional test performance with six month hop testing, and we also looked at our revision patients and age, age match them with primary reconstructions and found revision patients had much lower psychological readiness at the six month time point which is intuitive but really important when you're counseling these patients. And I think the big question of this webinar in general and the discussion about this topic is like Dr bias mentioned how do we help our patients, what do we do. And you know my job as a surgeon is to take care of the knee and control the physical health aspects but it's really important for us to also pay attention to the emotional health of the athlete, particularly with the young athletes. So I think it's pretty clear the young athletes are number one at risk for ACL injury but also at high risk for psychological consequences after the injury. I think we all have to acknowledge that abrupt cessation of sport can be extremely mentally challenging this is a really big deal. And we try to normalize this experience for young patients. It's also important to screen athletes for emotional symptoms, I think the best way of doing this is honestly to just ask them spend two minutes in your evaluation. If you ask the question you'll be very surprised at the answers that you get have a low threshold to refer to a mental health specialist, and then you want to keep athletes engaged with their teams and their friends during their recovery that can really provide a lot of benefits for them going through a hard time. So thank you so much I look forward to the discussion and my contact info is listed above. Thank you. Thank you, Kate, for the invitation to participate in this symposium. I think it's going to lead to a lot of really interesting discussion. So by way of background, I'm an orthopedic surgeon here in Melbourne, Australia. I do about 300 ACL reconstructions a year, including revisions, and I've been doing that for the best part of 30 years. By local standards, I probably follow my patients up in person a bit more than most surgeons. So I see them at three weeks, three months, six months, nine months, and often at 12 months. And the reason I mentioned that is from that, I tend to have a reasonably good idea of how they're progressing because I'll be seeing physical therapists all around the state and the country and not necessarily associated with me. And I have to therefore make decisions on average once a day about when patients are ready to return to sport and give them advice around that. And so the basic parameters I use are my experience of their progress through all those consultations, the basic examination findings, they need to have no effusion and essentially full range of motion, good stability and good strength, both as measured just in the clinic, but also in formal testing. And most of these patients will have had some testing during their sort of nine months of recovery. And we do test them at the nine month mark ourselves with strength testing and hop testing amongst other things. So I've got all that sort of information available to me. And typically this conversation is happening around the nine month mark. And assuming that they've satisfied all the previous criteria and I might say, I think a little bit too much is made of limb symmetry, particularly when it comes to strength, because often we're then comparing the operated knee to a contralateral knee that is much, much stronger than it was pre-injury. So it seems a bit unfair sometimes. But that aside, if the patient's looking good, my advice to them is to undertake four weeks of completely unrestricted training before playing. Now by unrestricted, I mean full contact, full match simulation, and it may take them two, three, four weeks to build up to that. Usually they've been doing two months or so non-contact training or modified training. And provided they can do that four weeks of unrestricted training, I say they can play, but I emphasise that they must be confident in their knee. And probably this morning, it's lunchtime here, but this morning I would have spoken to at least six patients about their return to sport and kept coming back to the issue of confidence. And the words I typically use are that it's quite normal to be a bit anxious about going back to sport. People hear about the risk of re-injury, they're not sure how they're going to perform. So a bit of anxiety I think is normal, but even with that, it's really important that they're confident in their knee. And I generally use words like the brain's a big computer and it's taking all this information and expressing it, if it thinks you're ready to go back as confidence in your knee. It's probably worth mentioning is a difference between patients who had an acute injury, went on to surgery after some prehabilitation and never really experienced giving way compared to those with chronic ACL insufficiency who know exactly what it feels like when the knee gives way due to ACL insufficiency. And it often takes them longer to regain their confidence than the patient who didn't know any different apart from the specific injury. The ACL RSI has been mentioned and I'd like to highlight that this is something that Kate was working on from very early on in our research relationship, which must go back, I think almost 30 years, Kate. I think we might've had that interview in December 30 years ago, but Kate was always interested in the psychology of it. And I have to admit as a surgeon and coming from a very surgical background for a while, I couldn't quite see where she was going with this. And whilst Kate developed the ACL RSI score, wasn't quite clear to me how that would be useful. But as has been mentioned, it's turned out to be very useful. And in 2019 in AJSM, we published a set of three papers and I'd like to acknowledge the work that April McPherson did on all of these. And they looked at different aspects of how the ACL RSI can be associated with firstly performance and those patients who had a greater psychological readiness to return to sport during their rehabilitation period, also were more likely to achieve a performance level comparable to their status pre-injury. And in fact, when you look at all the standard sort of factors, which are a bit hard to see in that table, but the usual measures of outcome, the ACL RSI was in fact the most significant predictor of returning to their pre-injury performance. But on the other side of the coin, it's also important in predicting who's at risk of further injury, either an ACL graft rupture or a contralateral ACL tear. And this is particularly true in the group of patients who are 20 and under. And as has been mentioned, these are probably the patients who present the greatest challenge to us for a whole lot of reasons that we can go into in the discussion, but they certainly have a higher risk of re-injury. So getting back to the question that Kate asked me to address, if I've got a patient and everything seems to be okay, they've done their four months of unrestricted, sorry, four weeks of unrestricted training, but they tell me they lack confidence in returning to sport. What do I do? And that's where I actually go back and check their ACL RSI score from nine months. I don't routinely do this. We largely record it for research purposes. And I don't want to be influencing my advice to that patient initially by knowing their score, but it seems like 77 is the magic number that has a 90% sensitivity of identifying a second ACL injury when we look back on patients with longer follow-up. So if their score is below 77, my view is that that patient probably just isn't ready to go back to sport. And I'd get them to hold off returning to competition and just keep on training and see them again in four to eight weeks and see how things have progressed, maybe get them to do the score again. But if they're still struggling and the score is still low, that's when I'd get a sports psychologist involved. On the other hand, if the patient lacks confidence, but scores well on the ACL RSI, I think that's a challenge. And that's where I probably would have a lower threshold to involve a sports psychologist early. Now that's probably up for debate. That's the way I'm thinking we can use the score. But I certainly think that the issue of confidence is the absolute key from my perspective of clearing patients to return to sport. And I'll always say to them, if on the day that you're going back to play, you're not quite confident, just don't play. It's much better not to do that. And I've seen patients who do suffer a graft rupture, who when I asked them, were you actually confident to go back? They'll go, no, I wasn't and I shouldn't have. So that would be my message. Thank you. Thank you to all the speakers and thank you for keeping on time. We have questions pouring in. So I'm just gonna make a start. And the first one that's coming is actually really talking to this topic, which is how, and Shelby, I might get you to do the first answer of this one. How can psychological factors in ACL surgery and rehabilitation be addressed routinely and proactively in a preventative manner? I think what Dr. Feller was just mentioning is using these patient reported outcomes to our advantage to help us make sense of the patient's recovery. But not only using it for return to sport, but using it at major clinical time points and screening to see how the patient's progressing from a psychological standpoint. I think also, in addition to using the total score and looking at the score, you can also use the questions to help facilitate conversations with the patient. I think I saw something in the chat, like how do you ask the question? And I think using these patient reported outcomes can open the door to say, hey, like you scored a 77 or a 76 on this. Can you talk me through the answer for X, Y, and Z? So that's probably my first recommendation on how to start to routinely integrate some of these psychological responses or assessment of psychological responses in the clinical practice. Thank you for that. I'm gonna move on to the next one. And Melissa, you mentioned about coping in your presentation. Certainly some athletes do seem to cope better. What do you think these athletes, if anything, are doing different during rehab? And Britt, I'm gonna get you to jump in on this too. I loved your model. Where does coping potentially fit into that as well? So if I can get both of you to answer that, that'd be great. Yeah, I think it's hard because every person is different and they have different personalities and different skillsets. And so somebody might be really good at coping. Somebody that's done a lot of sports, like in that survey that I mentioned, people that spend a high amount of time in sports, you learn something from sports. You learn something about coping, which can be very beneficial. But there's some kids that are just so terrified with the injury and everything goes out the window. So I think it's hard to know where you're starting from with people, which is why it's important to, as Shelby mentioned, if you have the ability to do some patient report outcomes, figure out where people are starting from, that's great. But also just asking these very routine questions, trying to feel out the patients, how hard is this gonna be for them and trying to get them through? And I would add only that coping is something that can influence all four of the pathways that I outlined all along the way. And my admittedly biased opinion is that probably psychological involvement, because the challenges that Dr. Cristino mentioned occur from not only day one after surgery, but even before surgery, that if you can get a person working on those, some of those coping skills earlier, you're more likely to have a smooth process throughout rather than waiting till the other end where factors like stigma may come into play. Absolutely. This next one I'm gonna direct is for both Melissa and Julian, but anyone can pipe in. Melissa, you pointed out, we're seeing an increase in young patients with ACL injuries. So what information do you give parents about psychological recovery? What are you telling the parents? What's their role? What should they be looking out for? That's a really good question. Parents are living with the kids, so they often see things that the kids won't report. And so asking the parents sometimes, ask the patient how they're doing and then ask the parents, how are they doing at home? How are they doing in school? That can give you some valuable information. I tell the parents, I have like a little handout that I give them. Some of the things they can do is make their athlete feel like this is a normal thing and what they're experiencing is not unusual, that it is okay to be sad about having this and being out of sports. Trying to keep them involved with their team as much as possible and supporting them in whatever way that they can to make sure that they know that their parents are behind them and with them on the journey. I think there's two sides to it. One is the kids who are so confident and don't have any fear at all. And that's where I try to enlist the parents' help to sort of just damp things down a little bit. And I'll say to the patient in front of, usually two parents nowadays, they're both there, adding pressure to the consultation, but you'll be keen, you'll feel like you can do everything, but we're really concerned about your risk of re-injury. And I'll spell out the numbers to them, particularly if there's a family history. And often if there is a family history and one of the parents has suffered an ACL injury, that's a really useful thing to latch onto because you can get that parent to be the one who's modifying expectations, trying to keep them in check. So I think for the over-exuberant younger patient, the parents can be really useful as a modifier. But I think the difficulty is really in the patient who is not coping. And sometimes it's, you just, a patient misses an appointment and you wonder whether that's for any specific reason or the appointment just didn't suit. But the most horrendous example I've seen of where that missed appointment was really significant was of a 16-year-old boy whose life was sport. He unfortunately tore his ACL at the start of the football season and became completely withdrawn from society and ended up committing suicide. And with the help of online friends telling him how to do it. But it was really interesting talking to the father afterwards about it, he rang me and even he didn't necessarily see what was happening. So I think that discussion about, it is okay to be upset, it is frustrating. I know it's hard, you're not really part of the team if you're not training with them and you're stuck in the gym. I think it's really important to be open and bring these things up at the consultations on a regular basis. So patients and their parents feel like there's an open channel for communication and this isn't some kind of taboo topic, it's all pretty normal. Which is one of the questions that has come in. So how universal are psychological issues with ACL injury? So I'll open this up to the panel. What are your thoughts? Lisa. Great. I mean, I would say it's, I think it's universal. I think it's normal to have a emotional reaction to something in your life that didn't go as planned, right? So whether that emotional reaction is small or big, it's gonna depend on the person. But I think it's very universal, but I think it's something particularly, an orthopedic surgery that maybe we don't consider as much and it's not part of our routine. And so I think having webinars like this, getting the word out is very important. Britt, I'll ask for your opinion too, but also you mentioned about personality factors. Another question that we've got that's coming is, well, what specific personality factors matter most? I would first say that just because it's universal doesn't make it pathological or, it's a challenging situation regardless of how you slice it. And even under the best of circumstances, it's still a disruption of the person's life. And that can be normalized and across the board. And as far as personality goes, because personality is people's general tendencies toward thoughts, actions, and emotions, it's personality factors like self-motivation critically important, but more important is how the person is thinking, feeling, and acting in this particular situation. That is sort of what do they think, feel, and do with respect to their rehabilitation, regardless of what their general tendency is, because even in trying circumstances like this, some of those general tendencies may be abandoned or set aside because of the magnitude of the situation. Could I add to that? I think it's a really important point. I mean, everyone's going to have a response and as Brett says, just because it's universal doesn't mean it's bad. But I think the patient presenting with an ACL graft rupture represents a real challenge, particularly if it's happened early. And that's what we tend to see in these younger patients. And that's where I think there is going to be a real challenge, particularly if it's happened early. And that's where I think there is going to be a big emotional response, completely understandable, sometimes even bigger on the parents' part, whose dreams of their child being a star appear to be sort of smashed on the rocks. But I think the ACL graft rupture is a very difficult situation to deal with. And I must say, I always do dread the start of the football season a bit because that's when they tend to come back in that first month or so. That's when we need to really be sort of, have our antennae alert to the potential problems. Absolutely, good point. And we're really still growing in our understanding about the first time ACL injured patients versus the second and multiple ACL injured patient and just what an impact psychologically that has. Which is a little bit in line with that. Shelby, I might put this to you. Do you think athletes worry more about being re-injured or worry more about being able to perform well after they have ACL reconstruction surgery? That's a great question. You know, when thinking about what patients are actually fearful of, I think are worrying about, it gets pretty complex. Because when we think about what's influencing someone's ability to say, do I have the capabilities and resources to overcome this stressful situation? It's gonna be personal factors as well as situational factors at play. When we're thinking about whether patients are more afraid of like, going and performing well or going back to sport, honestly, I think there may be some gender differences that are present there. So Dr. Caroline Lizet did a great qualitative paper a couple of years ago that identified that men seem to be a bit more afraid of fear of movement compared to women being afraid of more fear of activities of daily living. But there's still this intersection of fear of movement that's present. So I think it really goes into this interplay of psychological as well as social factors that are embedded that may influence whether someone's more afraid of re-injury or may be more afraid of their ability to perform. But what we've seen in the literature right now, it may be some differences between men and women. So the answer kind of, it depends. Absolutely. I wanna put to a question that's come through. Melissa, I'm gonna direct this at you because it brings up some gender issues. Have you found any correlation between increased psychological distress and or RIDS impacting ACL recovery in either gender, but specifically females who are using exercise pre-injury for coping and weight control? Yes, that is a very good question. I think in a broad stroke, anybody that has a history of a mental health concern, whether it's an eating disorder or anxiety, depression, those patients are more aggressive about getting some interventions on in the beginning. And particularly when you're talking about RIDS and under fueling and perhaps some pathologic eating practices, those things can be exacerbated by the injury and the recovery. They can't work out anymore, they're eating less. It can go down a bad path. And so I think in a patient like that, it is important to say, we're treating the whole patient here, we're treating you. We wanna make sure you're healthy physically. We wanna make sure you're healthy emotionally and that you're fueling your body appropriately for recovery because we also see issues with that when they're not taking in enough calories, that does put them at risk for not recovering their strength as much and not being able to perform at the levels that they want to. I think we need all of us to be aware of that. I think we need a lot more research in that area, but that's a great question. So for all the panel, what are some simple mental recovery strategies that all athletes should be doing? And what can we do for an athlete who has no resources or limited resources? I think I'll take a stab at the first part. I think when I've worked with clients who've had ACL reconstructions and one of the things they kind of do is try and reframe their recovery to be their sport. So when thinking about their approach to the rehabilitation, the effort and their drive that they put towards their sport, I try and always reframe as saying that recovery is now your sport and the effort and the motivation that you have towards training for X, Y, and Z sport, we're gonna reframe it and say your rehabilitation and we're gonna put that same effort there. So that's one of the just overall mentality shift that I try and do when I work with clients specifically after ACL reconstruction because of the lengthy rehabilitation process attached to it. The other thing is, is that there are a lot of just different miscellaneous applications you can use that are free. You can use free versions of Headspace and Calm and Virtual Hope Box to your advantage. And then the last thing I'll also say is that we often forget about how impactful social factors and social support can be on someone's outcomes. And I think channeling and really utilizing and leaning into those social support networks that are already established are some really low cost ways that can help someone recover from an ACL reconstruction mentally. As a surgeon, I don't claim to have any knowledge of psychological interventions, but I think the point that Shelby's made is sort of probably mirrors my approach and that's to focus on the next steps of their recovery from a real or functional point of view and give them specific targets that they want them to make, be it a strength target or a running target or that sort of thing and make sure they're getting their ball skills back and just picking out little things that they can specifically focus on. But while Shelby was talking to me, it did remind me of the effect of COVID here in Australia. Melbourne, Australia, unfortunately, has the sort of gold medal for some of the longest periods of lockdown across the world for no really good reason as far as I can tell, but we spent most of two years in lockdown and the effect on patients was enormous and the change in the rehabilitation was quite noticeable in the second year versus the first year. There was this sort of loss of hope, this general helplessness in society that no one could say when they were gonna be playing sport again and it had started and then it would stop and we'd be locked down again and I think that was a really powerful example of how taking away the ultimate goal of getting back to sport really affected people's mindset. Kate, I would add one more thing in terms of limited resources. At my institution, we have a lot of psychological support and interventions, which is great, but in the community, you might not have that and just thinking about who's on the patient's team, the parents, you can enlist them to help, the physical therapist, they're seeing them a couple of times a week and so an athlete's really struggling talking to the physical therapist or the athletic trainer and saying, we really need to get this person through, can you give them a little more encouragement and those people are already aware of those issues, but they can be really helpful at helping advance the athlete and like Dr. Baez was saying, psychologically informed practice, having people be aware of it is the biggest step. So questions that's come in, would you ever consider using psychological readiness to determine if someone is a suitable candidate or good or bad candidate for surgery or surgical repair versus non-surgical treatment? It's a really interesting question. Sort of, I guess, would be my answer. I haven't looked at scores preoperatively as part of my management, but I'm certainly very conscious of making my own subjective assessment of that person's appropriateness and readiness for surgery. I'm never in a rush to operate. People want to go elsewhere and get it done earlier, that's fine by me, but there are definitely patients who I think, no, I just think you're going to struggle a bit with this and let's just stick with rehab and let them progress and come. They need to be convinced they need surgery, I think, and they need to be ready and they're sort of intertwined. I think that we talked about very early on, I think it was Brett who mentioned how psychological factors can influence sort of physical function, swelling, stiffness, that sort of thing. And so I guess I do make subjective judgments about whether it's appropriate and when it's appropriate to proceed with surgery. And it would be interesting to try and put a number to that. Rick? I would just add that the psychological readiness that's been dealt with in the literature from your initial paper onward has been readiness to return to sport. And of course, a person's not going to be ready before surgery. And Dr. Feller mentioned readiness for surgery, and that's a different thing altogether than readiness to return to sport. And it depends on when you assess readiness. There've been some articles where readiness has been assessed at three months post-surgery. It's like, why would the person be ready then? So why would we expect them? It might be predictive, maybe because rehabilitation isn't going so well to that point, but not because it has anything to do with readiness. Readiness is going to be much more relevant as you get closer to the projected return date. We're all furiously nodding in agreement. Absolutely. I've had a couple of questions coming about the overconfident athlete. We've talked about confidence as well. What about the overconfident athlete? So to try to summarize them into one question, how do we handle an athlete who has extremely high confidence early in the recovery process, especially when you know that physiologically or physically they might not be ready? Let's jump in on this one. I just read the RIOT Act to them. I tell them in no uncertain terms, what are the risks? There's no point in going through the surgery and just going back early and we'll be starting all over again in a few months time if you go back too early. I mean, I don't know that. It's really hard to know when it is safe for someone to go back, but I guess I've been doing it for a while and I'm prepared to be a bit more forceful and not be the nice guy if I need to be. I think that's right on. Oh, sorry. I think that you're right. You have to tell them what's at risk and also what that means. If you re-tear it, you're out again, you're having a revision, the outcomes are worse and you're going to be out for longer. Those things are important. And also, I try to stay very clear with them about the restrictions at every visit and tell them, especially with the adolescents, that they have to learn to be in charge of their own body and take care of it. And so it's a little easier to put it in perspective for a younger patient like that than a grownup, but I found those things to be helpful. I think one thing I would also add in addition to just patient education is showing the patient potentially some of those functional outcomes. We collect them and oftentimes we put them in our own folder and then we put them away, but actually showing that potentially overconfident patient, this is how you're hopping, this is what your biomechanics looks like, this is what your scores, your strength looks like. And so not to scare them necessarily, but to have them have a full picture of the scope of their current health status. And I think once you can give them the tools and the techniques and the knowledge to have a better idea, in addition to knowing the risk factors of potentially going back to sport with being too overconfident, that can potentially start to help to transition that patient to have a bit more realistic view of their injury status. Also, this hints at the limitations of some of the patient reported outcomes that there's the underlining of the word reported. This is what they're telling you and sport culture kind of pulls for people to display themselves as confident and people know it's not always non-transparent where the person knows that how they respond to some of these surveys and whatnot may influence their ability to return to sport. And there may be, at least in a small portion of people, some of that overconfidence may result from a desire to return as soon as possible. So another question related to that is, well, what about sex differences with some of these schools? Do sex differences in our psych schools relate to differences in either primary or re-injury risk? Lisa, you've done a little bit of work on this. Yeah, I think we need more research in that area. And the one thing I'm always very skeptical about is many studies say there's a sex difference between males and females, but is it actually a true difference between males and females, or is it the way that males and females report? And so, I think that that's a really critical thing to think about beyond just what the studies are telling us in our statistics. Just to echo- You guys, you guys, shall we? I was gonna say, just to echo that, I know Dr. Chris Coons completed a study looking at sex differences and some psychological readiness in the TSK-11 and didn't see anything on the patient-reported outcomes, not seeing any sex differences present there. But in the qualitative interview and following up, there seemed to be some differences from athletic identity, psychological distress, fear of movements, and how that may present. So even though the quantitative scores may look similar, there could be some differences qualitatively. But I think it gets back to the complexity of the issues, and you have to communicate and talk to your patients to identify how they're responding to their recovery. I was going to say, if you look just at re-injury rates, so just straight out graft rupture rate, I don't think it's clear whether there's a sex difference or not, and it depends on where the study was done. For instance, our work, Kate, suggested males were more at risk, but at that time, we probably had a male-to-female ratio of three to one having surgery, whereas data out of the US would suggest that maybe females are at a higher risk of graft rupture. And I think that may reflect more recent data, and the ratios are different. It may reflect the sports that are being played. I think if we don't even know that, it's going to be really hard to tease out the impact of psychological issues, or the impact that has on both their performance and their risk of re-injury. Thank you. And I'm aware of time, and we're running low, so at this point, I would absolutely thank the panel for their input today on a really important topic. And I'm going to leave the audience with the questions. This is thanks to Professor Brewer for all of you listening to have a little bit of a think about. So who in your rehabilitation setting or healthcare system can intervene psychologically with patients and receive compensation for doing so? In the absence of a psychiatric diagnosis. So in elite sports rehab settings might be easy to answer, but in regular settings, this may be a much more difficult question to answer. So I'm going to leave you all with that thought, and then I'm going to hand back over to the AJSM team for the final wrap up of today's webinar. So thank you all for joining us today. I'd like to give a big thanks to our panelists and presenters for their work on tonight's webinar. On behalf of AJSM and AOSSM, we hope you enjoyed this webinar and that you are able to attend other educational programs coming up. And thank you attendees for your participation. If you're interested in CME or would like to view the recording of this webinar, please go to education.sportsmed.org and click on the link to the webinar. Thank you. Log in, click my resources, and then click the course title. You can then complete the evaluation for CME or view the recording, which will be available by Friday. This information will be emailed to you in 24 hours. So please don't worry about remembering it all. We thank you again for your participation and have a great rest of your night or your morning or your afternoon. Thank you.

psychological aspects

ACL injury

return to play

rehabilitation outcomes

graded exposure therapy

mindfulness meditation

younger athletes

athletic identity

psychological readiness