We're going to start with the psychology of return to play. What are the factors that really influence our athletes successful road back to sports by Dr. Webster. Thank you. So I'm going to talk about the psychology of return to play and in order to do so it's important to put this topic into context with the sports psychology literature. There's a vast amount of literature that looks at psychological factors that predict injury and this is largely based on injury stress models and looks at things like personality. Now this is not what I'm going to be talking about today. Instead I'm going to be talking about the psychological factors associated with the recovery from sport injury and this is also a growing literature body but interesting a lot of the athletes that are included in this research may only be injured for a couple of weeks out of sport. So I'm going to use anterior cruciate ligament injuries to illustrate the psychological factors associated with recovery from sport because this injury is typically associated with a long period in absence from sport and it's also what we've done the most research about. So it's fair to say that athletic injury does have a significant psychological impact. Athletes commonly experience mood disturbance, decreased self-worth and have heightened negative emotions and all this can threaten the athlete's athletic identity. But what's important to note is that the psychological response to injury continues long after the injury has occurred and this has an impact and effect on rehab and return to sport outcomes. So it's first of all important to look at psychological aspects related to the recovery itself because this could then in turn effect return to sport and if we look at behaviours most of the researchers looked at how athletes use coping strategies and adhere to rehab and in terms of rehab adherence personal factors tend to have a positive association whereas mood disturbances and fear tend to have a negative association. And there is some evidence that higher adherence to rehab leads to better clinical outcomes including knee stability, range of motion etc but the literature is not entirely convincing in this regard. Other important aspects include self-efficacy and this is the belief in one's ability to succeed in a particular situation. There's evidence that this improves as athletes recover from injury and higher levels of being related to post-operative physical activity as well as return to sport. Second factor is locus of control and this is a belief that there's a relationship between one's actions and outcomes. Again there's some evidence that having a high internal locus of control leads to better subjective outcomes, better knee function and has also been shown to be a predictor of returning to sport at 12 months. Now if we look specifically at psychological factors influencing returning to sport, fear of rear injury is pretty much the most common reason cited by athletes who don't return to sport or who restrict their sporting activities. However what actually constitutes this fear is kind of unclear. Is it fear of pain of the injury itself, implications for time off work or not being able to return to the prior level of function or a combination of any of these three. I do want to point out that I use the term fear of re-injury but maybe fear isn't the correct terminology. Maybe re-injury anxiety better describes the emotional response of the athlete because fear is a biological mechanism that is usually stimulus specific and designates definite danger whereas anxiety is more about uncertainty and anticipation. I'm now coming to what I consider to be perhaps the most important factor, that of psychological readiness. So what is it and why does it matter? There are a number of definitions but there's some consensus that it's influenced by emotions as well as confidence. Confidence is confidence in the rehab program. The athlete needs to be certain that their injury is completely healed and therefore they're no longer at risk of being injured as well as performing at the same level. There's some evidence if you have confidence in both these elements the athlete is considered in a psychological ready state to return to sport. We can measure psychological readiness using the anterior cruciate ligament return to sport after injury scale which looks at the athlete's emotional response, the confidence in their knee as well as their ability to perform and how they appraise the risk of returning to sport. I would also like to note that this scale has now been modified to include a number of other injuries and is particularly being used quite extensively for shoulder injuries today. We've looked at some of the factors that constitute psychological readiness so being male of younger age, shorter interval between injury and surgery, high levels of pre-injury sport participation, better functional performance and high ratings of knee function all contribute to a higher psychological readiness. And interestingly these are similar to the factors that influence return to sport. So I've told you what it is but why does it actually matter? Well it matters because it can be used to predict return to sport, return to pre-injury level of performance as well as further ASAL injury and I'm going to give you some evidence to support this from some of our research. In terms of predicting return to sport one of our earliest studies looked at this. We had a whole battery of psychological measures and found that psychological readiness was the only measure predictive of returning to sport at both pre-operatively and at four months after. The pre-operative finding was really interesting to us and it really indicated that we should consider psychological responses throughout the recovery period and these findings have now been replicated in a number of studies. More recently people keep on asking me well what about our younger and adolescent athletes? Can we use the same sort of measures? So we recently looked into this and found that well the answer is yes. Psychological readiness scores at six months were highly predictive of returning to sport at 12 months in young adolescent athletes. One other thing we noted was that our young athletes tended to be really have high levels of frustration during the rehab period. So what about sport performance? Our athlete doesn't just want to stand on the field they want to be able to perform well so we asked the question do patients who have higher psychological readiness to return to sport perform better when they return? This was a cohort study and we only included athletes who had returned to sport at two years and we asked them whether they thought that they could play or perform as well as before their injury with just a simple yes no answer. Factors that were related to returning to sport performance were psychological readiness as well as hop-limb symmetry, marks activity and IKDC subjective scores whereas sex, age, laxity and range of motion were not. But by far psychological readiness had the strongest association with returning to sport performance. Higher scores both pre-op and 12-month were associated with returning to performance at two years and the scores also correctly identified 87% of patients who returned to their pre-injury level of performance. What we're also we want our athletes not just to return but to return safely so we're clearly interested in any associations with second injury and this was a large prospective study where athletes compared measures of psychological readiness pre-op and at 12 months and we followed the cohort to see who got re-injured and all of this cohort had returned to sport. And what we found was that at 12 month ACL scores were lower in those that went on to have a second injury and in fact we were 90% certain that a patient who had a second injury score below our cutoff of 77 points. We also noted in a subsequent study in the same cohort that those that injured had little improvement from pre-operative to post-op and in fact there was 50% of those who injured had a decrease in score. So in summary psychological factors do play a significant role in the sequence of injury recovery and return to sport and there is some evidence that they also play a role in return to sport performance and re-injury. I'm often asked you know well what do I care the most about and acknowledging that there are individual differences. Generally speaking I care about an athlete who has a decrease in psychological readiness at the point of being cleared to return to sport because for me this indicates perhaps a lack of confidence and I think confidence is key. I want my athletes to have the mindset I'm excited to be back rather than thinking oh I hope I don't get injured. And finally I think we need to recognise that some level of anxiety is okay and is perhaps probably normal. Many thanks.

psychology

return to play

sports injuries

psychological factors

recovery process