Physio Network

[Physio Explained] Psychological readiness: a risk factor for secondary ACL injuries? with Dr. Ryan Zarzycki

Share episode

In this episode we explore a recent paper which showed that female athletes' with greater psychological readiness had a higher risk of second ACL injury after primary ACL reconstruction, in which Ryan was the lead author. We discuss: 

  • How and when to use questionnaires in ACL rehab
  • The interesting finding from this paper of higher ACL re-injury rates in those who scored higher in the ACL-RSI questionnaires
  • Return to sport readiness and which athletes we might want to hold back for longer to prevent second ACL injury
  • The importance of communication and discussions in ACL rehab

Dr. Zarzycki received his PT degree from the University of Delaware in 2003 and his PhD in Biomechanics and Movement Science from the University of Delaware in 2018.  Between degrees, Dr. Zarzycki practiced for 10 years in sports and orthopedic physical therapy. His research interests lie in athletes after traumatic knee injury with an emphasis on ACL injuries.  

Reference to the paper that Ryan discusses here - 

Zarzycki R, Cummer K, Arhos E, Failla M, Capin JJ, Smith AH, Snyder-Mackler L (2024) Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction. Sports Health, 16(1): 149-154.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio

SPEAKER_00:

Perhaps there's this sweet spot for psychological readiness. It depends on where you're at in your rehab. But when you're getting to that return to sport phase, from a clinical perspective, what I think of is... If you're really, really low on there, well, you probably are moving differently. And we know that if you move differently and you favor your surgical leg, you're at risk of re-injuring. And obviously not just tearing your graft, but a contralateral injury as well.

SPEAKER_02:

Today we have the privilege of being joined by Ryan Zazeky to discuss a recent paper he has had published looking at psychological readiness and risk of second ACL injury after ACL reconstruction with some very interesting and surprising findings. Ryan is Associate Professor at Arcadia University Philadelphia in the US and currently teaches and focuses his research around ACL reconstruction and the changes which occur in the nervous system after surgery as well as the associated psychological I'm James Armstrong and this is Physio Explained. Ryan, thank you so much for coming on to the PhysioExplained podcast. I'm really, really excited by this. As I said off air, I instigated this because I read the paper we're going to be discussing and wanted to get you on as soon as possible. So thanks so much for joining us. Yes, thanks for having me. So I'm going to hand over to you in a second, Ryan, because this paper that has not long been published and it's talking about the psychological readiness of for ACL and the relationship that might have to injury, which I thought when I saw this was quite surprising. And reading the paper, I think that's probably where the base of research was at that time. So this is really interesting, particularly looking at second events. So give us a summary, Ryan, of the paper, if you will.

SPEAKER_00:

Yeah, so we were a little bit surprised by the findings as well. So we know psychological factors are previous to this paper and this analysis. We knew psychological factors were important in our athletes after ACL reconstruction. We knew they related to maybe movement alterations that we see, and we definitely know that they're related to outcomes and their ability to return sport and also just self-reported outcomes. So what we wanted to do is really explore the relationship between psychological factors measured in a couple of different ways and their relationship to second ACL injury within two years of surgery. In short, we looked at three main psychological factors, one being psychological readiness measured via the ACL return to sport after injury scale. The second was the TSK 11, the Tampa scale kinesiophobia, 11 questions with that. And the final measure was looking at Coos self-report measure, and specifically one question on the quality of life measure, which is question three, which asks a specific question about knee confidence. In this study, we had 39 female athletes. This was a secondary analysis of clinical trial that I completed with my dissertation at the University of Delaware with Lynch, Schneider, Mackler. We only included females because in the group, we only had one or two males out of 40 have a second injury. And we ended up having, obviously, nine in this out of the 39 re-tear. We dichotomized the groups based off of whether they had a second injury within two years of surgery or not. And then we just ran simple comparisons between all the dependent variables that I mentioned before, all the psychological factors. What we hypothesized was that there would be a relationship between psych and second injury. However, we hypothesized that lower psychological readiness and more failure to re-injury measured by those questionnaires are less than the confidence. So more negative psychological factors would be associated with second injury. We, however, found the exact opposite is that actually the ACL RSI, which is measured on scale from 0 to 100, 100 being more positive psychological outlook, those who had higher overall ADCL RSI scores ended up having a higher rate of second ACL injuries versus those who had lower scores. We did not find a difference in TSK between the groups. So we did not find a difference between that. And we did not find a difference between groups in terms of that one question on the Qoops quality of life, the decomp and questionnaire. One thing that we did, which is, I think, a little bit innovative, wasn't done in previous analysis using the ACM RSI is we broke it down into its three individual constructs. So the ACL RSI measures three main constructs, one being emotions, two being confidence, and three being risk appraisal. And there was a difference, a very drastic difference in the risk appraisal subscale, which involves two specific questions on the RSI. And what we found kind of goes along with the overall RSI findings is that people had higher scores on those risk appraisal questions or, you know, more positive scores. outlook in terms of re-injuring ended up going on in re-injuring versus the lower scores on those two questions did not have a re-injury.

SPEAKER_02:

It's really interesting, isn't it? Because as you said, your hypothesis speaks a thousand words for what we probably all would think. And we spend so much time, don't we, in ACL rehabilitation to bring those kinesiophobia- down and increase confidence to improve movement patterning and all those things. And actually we're finding here that too much confidence, too little fear means that they're more likely to re-rupture. So where's our takeaway from this, Ryan? Where's this kind of clinically leads us as physiotherapists?

SPEAKER_00:

Yeah. So one of the things I did mention too, is we looked at how long from surgery to then meeting return to sport criteria between the two groups was as well. And what we noticed was the group that re-injured met their return to sport criteria about seven months. And that was through self-reported function, hop testing, and quadriceps strength measures. And we were using symmetry measures. The group that didn't re-injure met those criteria at about nine months. So about two months later than the group that did re-injure. So It's hard to completely say this, but it may be psychological readiness is actually a surrogate for who was doing better at those times when we tested them throughout the timeframe. So one of our big clinical takeaways was, all right, if you have higher psychological readiness, perhaps you're meeting these return to sport criteria sooner, which makes sense. If you're doing better, you're probably going to have a better psychological outlook. So is this really... just purely in a psychological relationship? Or is this a timeframe relationship that's sort of being mediated by psychological readiness? So, I mean, it fits with a lot of the data that we know that's already out there. Nine months has been now sort of that one timeframe that every week or month above nine months you go, we know you're at decreased risk of having a second ACL injury. So, you know, the big clinical takeaways for me is that once you get your athlete's to the point of going through that return to sport regression, we should be measuring these psychological factors. And then the ones that are really scoring high on the overall score and the ones that are really scoring high specifically on that risk appraisal construct, maybe we need to do extra counseling and really pull them back and hold them back from going to sports shutter.

SPEAKER_01:

Are you struggling to keep up to date with new research? That's key, isn't it? From my practice, when I see...

SPEAKER_02:

So particularly, I mean, actually losing more of the Tampa scale of kinesiophobia. But when you see that starting to drop down, so less kinesiophobia, you think that's great pushing on. But actually, that might be a point whereby we say, where are we? Where are we in our physical readiness? And do we need to, as you say, counsel and just monitor and keep back to that nine-month mark and make sure we're not jumping ahead too quickly with the athletes? Completely

SPEAKER_00:

agree. Yeah. One other clinical aspect that I see too is not to just blindly administer the ACL RSI. I think maybe as clinicians we get kind of that, but like, I just fill this out real quick and then we'll look at the final score of it. But really dive into those questions and see if there is a pattern based off of construct. Is this a confidence problem? Is it more of an emotion problem? More of a risk appraisal problem? And let that guide further discussion with your athletes rather than, you know, obviously we still have a lot of time with them during the rehab process. Let's have discussions. If it's a confidence issue, what are you not confident about? I find that, you know, in having those conversations with athletes, it's eye-opening. It's like, well, a quarterback, as an example, who tore while doing the option in American football. And we got to do an agility training and he was looking good, but then we went back to really specific. That play or that maneuver that he was doing. And he was like, that just draws up memories of where I was. So yeah, looking at the individual aspects of the question and having them drive, continue conversations to guide that, you know, return to sport, I think is very, very helpful. Definitely.

SPEAKER_02:

And I, for one, think these outcome measures are great for driving that conversation. And I think that's a really good point there as well. Out of interest as well, Ryan, you mentioned you didn't see the same correlation with the tampus galliculisophobia. Any ideas as to why that might be?

SPEAKER_00:

That's a great question. And there has been work done out of Cincinnati Hospital in Ohio State by Mark Paterno and colleagues that have looked at TSK as opposed to RSI and has found some significant differences there with people who have gone on to a second ACL injury. Comparing our data to other data, it's hard to draw conclusions because some people have found that lower psychological readiness or the opposite, or lower kinesiophobia actually leads to second ACL injury. So it gets a little confusing. We still don't know all the answers, but a lot of it has to do with differences in patient population, age matters. So we know that younger people are going to go back to return to sport and they're going to be the ones that tear. Our cohort was only females. Some cohorts have done males and females. It's just important to sort of consider when you're reading the evidence to take into account the differences in patient populations. But from a TSK specific perspective, if you really look at the questions, a lot of them are related to pain and a bunch of them are related more to pain. They are originally developed with low back pain patients and then adopted to the ACL population. So perhaps maybe we're not seeing differences because we're farther out. I mean, the two groups, I think the re-injured group was about seven months, the re-injured the non-injured group was tested or methods were described right here around nine months. And, you know, typically we're not seeing patients in a lot of pain and maybe RSI is a better measure, at least in my mind, at looking at some of these specific for our patient population at the return to sport phase when the TSK maybe is a little bit more eye-opening and more enlightening to you early on in the rehab process. Just kind of my opinion,

SPEAKER_02:

my thoughts on that. Yeah, and I think if you look at the questions, that does ring true, definitely. And I think as well, listening to this, Ryan, I think it's about that. Either way, you could look at this in terms of if we've got lower psychological readiness, then we know that we see changes in movement and that can have an impact. But then when we see greater psychological readiness, we're potentially going to see athletes taking more risks, pushing forward and going too quickly. So you could see why both might happen. have an impact on reinjury rates, actually, couldn't you?

SPEAKER_00:

Yeah, absolutely. And so one of my other dissertation papers, I think published in 2018 in JOSPT, looked at that, what you just mentioned, the relationship between psychological readiness and biomechanics. And we just did it during walking, which was kind of eye-opening as well. But at that same time frame, we still had a lot of our athletes with asymmetrical keep, which is kind of crazy because they're running, they're hopping, they're doing sports-specific stuff. We know from previous literature, too, that some of these gait alterations last for years, which is crazy. But in that paper, we found that athletes with the lower scores on the RSI had more of that stiff knee gait pattern that we see stereotypical with our patients after knee surgery. So one of the big takeaways from when you look at all the evidence is that perhaps there's this sweet spot for psychological readiness. And it's going to depend on where you're at in your rehab. But when you're getting to that return to sport phase, from a clinical perspective, what I think of is if you're really, really low on there, well, you probably are moving differently. And we know that if you move differently and you favor your surgical leg, you're at risk of re-injuring. And obviously not just tearing your graft, but a contralateral injury as well. And then the other side of it, right, is if you're really high on the ACLSR side, then what we've just talked about from you're not taking into account the risk of retiring again. So maybe, you know, between, I don't know if I have exact number, I don't have exact numbers, but you know, once you get up into eighties and they haven't returned to sport or eighties or higher, I'm thinking, Ooh, that may be something that I need to look at. And then if you're getting down into, you know, the low fifties or below that, then I'm thinking, all right, that might be something really driving movement alterations in your rehab. And then we might need to get into some other aspects of, psychologically informed practice, like graded motor injury, graded exposure, graded exercise and things like that.

SPEAKER_02:

Yeah, definitely. And as you hit the nail on the head in terms of from my point of view and experiences, it can change at what point you are in the rehab. And as soon as you start exposing these athletes to movements that replicate mechanism of injury or close to that can massively affect their psychological readiness. So that's something else to keep an eye on. And it just goes to show the importance of monitoring, monitoring this and having dialogue. Yeah, 300%. Wonderful. Ryan, it's been brilliant to have you on. I could probably go on for another two to three hours talking to you just about this paper, let alone ACL reconstruction and rehab. So I really appreciate your time and doing the study and sharing the results. Where might you go next, do you think, with this? Where do you think the research needs to take us?

SPEAKER_00:

Yeah, I think there are groups doing this and we've talked about doing this, but it's going to more qualitative approaches to research. Looking at psychological factors, I'm kind of like I mentioned is, you know, from a research perspective, really, really getting into having discussions and interviews with participants after ACL to really dive into these psychological factors. I mean, these questionnaires are great. They were really well developed by people that are a lot smarter than I am. But I'm really getting into the qualitative part of it and understanding where these athletes are coming from and having discussions, not only from a clinical perspective, but from a research perspective, I think is where groups should be going.

SPEAKER_02:

Yeah, that'd be really interesting hearing it from the athletes. And I just say that qualitative research people Really interesting and potentially very eye-opening. Quite often patients surprise us with what they're thinking and what we think they're thinking. Absolutely. Brilliant, Ryan. Right, Arsh, we'll leave you today. I'm sure we need to get you back on, to be fair, to talk more ACL and certainly around the psychological readiness and how we're looking at that and what we can do to improve our practice. But today I think we've taken away some really good clinical pearls that I'm sure the listeners will be able to put into their practice. So thank you very much, Ryan. Yeah, thanks for having me. Take care.