Degree project, 30 ECTS [12-01-21]
Progression of psychological readiness to return to
sport and the influence of covid-19 on
rehabilitation after anterior cruciate ligament
reconstruction
Version 2
Author: Ylva Zelleroth, MB School of Medical Sciences Örebro University Örebro Sweden
Supervisor: Joanna Kvist, Professor in Physiotherapy, PhD, Division of Physiotherapy, Linköping University, Linköping, Sweden Co-supervisor: Daniel Castellanos, MD/Orthopedic specialist, PhD Student Dept. of Orthopedics, Institution for Medical Sciences, Örebro University, Örebro, Sweden Word count
Abstract: 248 Manuscript: 3490
Abstract
Introduction: A successful return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R) demands optimal physical and psychological rehabilitation.
Aim: Study the change in psychological readiness to RTS between three- and six-months post ACL-R, to associate psychological readiness to patient-reported knee function and identify factors associated to greater psychological readiness to RTS. The secondary aim was to examine how the Covid-19 pandemic has affected the patients’ rehabilitation.
Methods: Prospective cohort study including patients with primary ACL-R recruited from the Swedish Knee Ligament register, age 16-40 and physically active on Tegner>3.
Demographics including pre-injury sport participation, psychological readiness reported with the Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale, knee function reported with the subjective International Knee Documentation Committee (IKDC) and the impact on rehabilitation by Covid-19 were analyzed at three- and six-months post-surgery. ACL-RSI scores were compared, correlated to IKDC and univariate analysis was used to determine the association between factors and the psychological readiness to RTS.
Results: 141 patients were analyzed (56 men, 85 women; median age 24 years), all were recreational or competitive athletes (median Tegner level 8). The psychological readiness progressed through rehabilitation, was correlated to subjective IKDC. No differences could be detected between ACL-RSI scores and included factors at six months post ACL-R. Covid-19 had an impact on 36% (40/112) of the patients’ rehabilitation.
Conclusions: Psychological readiness improved after ACL-R and was significantly associated to self-reported knee function at six months post ACL-R. Covid-19 restrictions affected rehabilitation for one in every three participants.
Abbreviations
ACL – Anterior cruciate ligament
ACL-R – Anterior cruciate ligament reconstruction RTS – Return to sport
RSI – Return to Sport after Injury
IKDC – International Knee Documentation Covid-19 – Corona Virus Disease 2019
Introduction
Anterior cruciate ligament (ACL) rupture is a serious knee injury commonly sustained by athletes in pivoting sports, with an incidence of 80 per 100 000 people per year in Sweden [1]. Most athletes are motivated and have the intention to return to their pre-injury level of sport after an ACL injury [2] and are typically advised to undergo ACL-reconstruction (ACL-R). The goal of ACL-R is to maximize stability and restore knee function, without pain or degenerative changes related to the operation [3]. In Sweden, hamstring graft is most
frequently used for primary reconstruction, using semitendinosus with or without gracilis [1].
A relatively long period of physical rehabilitation of at least 9 months is required after ACL-R in order to return to sport (RTS) and the time to RTS is assumed to be 9 to 12 months [4]. Rehabilitation should start directly after surgery and strict time- and functional-based criteria should be fulfilled before letting patients RTS [4,5]. Many athletes fail to RTS, despite achieving good physical function [6] and it is clear that physical recovery alone is not
sufficient to ensure RTS [7]. This reveals that a range of factors affect RTS after ACL-R like sex, age, preinjury level of sports, but also modifiable psychological factors, such as fear of re-injury, fear of pain and lack of confidence [6,8,9], that may partly explain the discordance between physical function and RTS [10,11]. A review shows that there is lack of evidence supporting some RTS criteria following ACL-R and it may be important to integrate psychological criteria in RTS guidelines [11,12]. A psychological factor commonly used in terms of RTS is “psychological readiness”, which often is an important determinant when it comes to RTS decision-making [2].
Among previously mentioned factors that underpin RTS, psychological factors have received growing interest due to its clinically modifiable nature. Most athletes will experience negative psychological responses after a physical trauma like an ACL injury, that may have negative effects on recovery and even result in a premature end for their career in sports [2,13]. Greater psychological readiness is associated with a greater likelihood to RTS after an injury
[6,7,10,14]. The ACL-Return to Sport after Injury (RSI) scale evaluates psychological readiness and ACL-RSI score is a strong predictive factor for RTS. It can be useful during early stages of rehabilitation in order to identify patients that find RTS difficult and might need psychological interventions [14–17]. Differences in psychological responses may occur as early as six months post ACL-R between athletes who RTS and those who do not [17]. There are likely many factors contributing to the psychological readiness to RTS, since
sociodemographic (sex, age), pre-injury sport participation and self-reported knee function and symptoms all are factors that influence the psychological response [18,19].
Complete adherence to a rehabilitation program after ACL-R is one fundamental part in the journey from injured to returning to sports again [20]. During the Coronavirus Disease 2019 (Covid-19) pandemic in 2020, restrictions and recommendations have been introduced in Sweden to control the spread of the virus [21] and the possibilities to consistent rehabilitation may have been disrupted. Some patients still have access to equipment and facilities, while others are severely limited in their training practices due to closed gyms, cancelled team trainings or unwillingness to attend direct rehabilitation sessions. This may have an impact on post-surgical athletes’ recovery both physically and psychologically [22]. Covid-19 will likely be a new contributing factor to psychological readiness to RTS to take into account.
This study is part of a greater study that longitudinally observe the continuum of participation in sports and physical activity during three years after undergoing ACL-R in order to analyze why the RTS rate differ between athletes. This would seem important, especially considering the fact that one of the main indications for going through ACL-R is to RTS and only 65% finally return to their preinjury sport level [10]. Both physical and psychological factors affect RTS, but it is not clear how psychological readiness progress in the early period after ACL-R, from three to six months. This may be correlated to participation in physical activity and/or sports in a longer perspective. A better understanding of the psychological changes of an athlete through the initial phase of rehabilitation and factors that contribute to greater psychological readiness, may help clinicians to provide a more individualized rehabilitation phase. Depending on how much Covid-19 disrupt normal rehabilitation routines, this will be even more important.
Aim
The primary aim was to study the change in psychological readiness to RTS (measured with ACL-RSI) between three- and six-months post ACL-R, to associate ACL-RSI to patient-reported knee function and to identify factors associated to greater psychological readiness to RTS. The secondary aim was to examine how the Covid-19 pandemic has affected the patients’ rehabilitation.
We hypothesized that (1) athletes’ psychological readiness to RTS would gradually improve during follow-up, (2) ACL-RSI score would be associated with patient-reported knee function
at six months (3) younger age, male gender and high pre-injury level in sports would favor a greater psychological readiness to RTS. Finally, we hypothesized that Covid-19 would affect patients’ possibilities for rehabilitation negatively.
Material and Methods
Study design, participants and inclusion criteria
This is a prospective cohort study where the patients were recruited consecutively through the Swedish ACL register, with surgery dates between November 2019 to April 2020. For the current analyses, we used data from surveys collected at three- and six-months post ACL-R.
Inclusion criteria were patients who had undergone primary ACL-R, age 16-40, had
completed surveys at six months post ACL-R and were physically active on a Tegner [23,24] level 3, which correspond to light work and ability to walk on uneven ground. Patients reported their pre-injury sport participation level and frequency in the first survey. Exclusion criteria were patients with revision ACL-R, complex multiligamentary injury, new injury after ACL-R, protected ID, included in another study run by our research team, not speaking
Swedish and missing contact information.
From November 2019 to April 2020, 1075 patients were identified in the ACL register and 42 patients were excluded directly (18 patients were included in another study, 22 had no contact information, one did not speak Swedish and two had protected ID); 1033 were initially
contacted and informed about the study via mail within three months post ACL-R. During the study, the PhD student in the research team started contacting patients by sms and/or by telephone, in cases where telephone numbers were registered in the ACL register, to increase the participation rate. Patients gave their informed consent digitally and thereafter received an electronic link by sms to access and respond to a web-based survey at three- and six-months post ACL-R.
Questionnaires
The first survey (three months post ACL-R) included baseline questions about demographics (weight, height), the knee injury and injury history, tobacco use, if any new injuries had occurred after ACL-R and sport participation. All patients completed the ACL-RSI scale and the International Knee documentation Committee (IKDC) subjective knee evaluation form at three- and six-months post ACL-R. A separate survey was sent at six months post ACL-R which considered the impact of Covid-19 in rehabilitation.
An updated Tegner activity scale [24] was used to grade pre-injury sport participation level. This was noted in the first survey. The scale rates activity level with regard to functional demands on the knee from 0 to 10. It covers activities of daily living, work, recreation and competitive sports [23]. Level 10 refers to the load such as in national or international
competitive soccer; level 7 indicates competitive basketball or recreational ice hockey; level 4 indicates recreational cycling and moderately heavy labor and level 4 indicates recreational swimming or walking and light labor to sedentary work [24]. Tegner score is valuable to use as a complement to knee functional score [23], for comparison between patients’ pre-injury- and postoperative activity level. The scale has been validated for use following ACL injury [25].
The ACL-RSI scale [26] measures psychological readiness to RTS after ACL injury or reconstruction surgery. It assesses three psychological responses: confidence in performance, emotions and risk appraisal. It includes 12 items with scores ranging from 0 to 10 [16]. Five items measure emotions experienced by the athletes during rehabilitation and their
commencement to sport. Five items cover sport confidence - both confidence in overall ability to perform their specific sport and confidence in their knee function. Two items include risk appraisal. Higher scores reflect a more positive psychological response. All answers are summed and averaged on a total score 0 to 100. When comparing two groups, the minimal clinical detectable change in ACL-RSI score is 3, indicating that changes in group mean score more than three points can be detected [26]. The scale has high reliability and validity [16,26] and has shown to discriminate between athletes who return and do not RTS [16]. ACL-RSI scores were the dependent variable for this study.
The subjective IKDC [27] is a knee-specific, reliable and valid patient-report measure of function, symptoms (pain, swelling, locking or giving way at activity) and physical activity [27]. It consists of 19 item and the total score ranges from 0 to 100 (calculated on 18 item since item 19 refers to knee function before injury), where 100 means no limitation with activities of sports or daily living and absence of symptom [28].
The survey regarding covid-19 consisted of one open-end question: “Have restrictions
regarding the corona virus (COVID-19) caused any problems to your knee rehabilitation, e.g. availability to physiotherapist or closed gyms?” and “If yes, describe”.
Data Analysis
Analyses were performed with the Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp). Mean and standards deviation (SD) or median and range/interquartile range (IQR) were calculated for descriptive statistics. The normal distribution was analyzed by the Shapiro-Wilk test. Change in the subjective IKDC score and the ACL-RSI score between three and six months, was analyzed with the Wilcoxon Signed Ranks tests. The correlation between subjective IKDC and ACL-RSI at six months was calculated using Spearman’s correlation coefficient. The strength of the correlation was classified as “strong (r > 0.5), “moderate” (0.5 < r > 0.3) and “weak” (r < 0.3 < 0.1). Difference in age and sex between responders and non-responders were assessed with the Mann Whitney U test (ratio data with non-normal distributions) and chi-Square test (nominal data) as appropriate. Significance was set at P value <0.05.
Univariate regression was used to evaluate the relationship between the potential predictive factors and ACL-RSI score at six months as the outcome (dependent) variable. The ACL-RSI score was compared between groups: patient sex (men/women), tobacco (yes/no),
contralateral injury (yes/no), affected by Covid-19 (yes/no), with the unpaired student’s t-test. Linear regression analyses were done for continuous variables (age, BMI) and ACL-RSI score. Analysis of variance was performed for multiple comparisons of means (pre-injury Tegner score). Significance was set at P value <0.1 to reduce the number of variables in eventual multiple logistic regression.
The responses of the separate survey regarding the impact on rehabilitation by Covid-19 was divided in two whether the reply was yes/no. The affected patient groups’ free text answers were processed where sentences or phrases relevant for the question were selected and then reduced in order to shorten the text. These were then coded and grouped into categories that reflect the central message in each answer.
Ethical approval/consideration
Ethical approval was obtained from the Ethics Committee (Dnr 2019-04546) and all patients provided written informed consent prior to participation. All data was coded and stored in a pseudo-anonymized database where a keycode was needed for access.
Results
Of the 1033 patients who were contacted for study participation, 141 (14%) patients
completed the last survey regarding psychological factors (Figure 1). The cohort included 56 men (40%) and 85 women (60%), with a median age of 24 (range 16.1-40.0) years old at the time of ACL-R (table 1). The mean time from surgery to participation in the study was three months (range 2.5-4.1). The cohort group and non-responders were comparable in age (P<0.237) but differed in sex (P=0<0.001), where 19% of contacted women participated and 9% of the men, respectively.
Table 1. Cohort Baseline Characteristicsa Men/Women, n (%) 56 (40%) / 85 (60%) Age, y 24 (16-40) BMI, kg/m2 24 (17-68) Tobacco use, n (%) 22 (16) Contralateral injury, n (%) 12 (9)
Pre-injury Tegner score 8 (3-10)
Sport practiced before injury, n (%) Soccer Floorball Handball Running Martial arts Tennis/squash Basketball Alpine skiing Gymnastics, competitive Aerobic Other 54 (38%) 19 (14%) 13 (9%) 8 (6%) 6 (4%) 6 (4%) 5 (4%) 5 (4%) 4 (3%) 3 (2%) 18 (13%)
aValues are presented as median and range unless noted otherwise.
Change in the ACL-RSI score
The median score of ACL-RSI increased significantly (P <0.001) from 43 (range 10-91 points, IQR 26) to 50 (range 13-100 points, IQR 27) between three to six months post ACL-R (figure 2). IKDC score also increased significantly from a median of 53 (range 22-85) to 67 (range 33-94) points.
Figure 2. ACL-RSI score at three and six months after anterior cruciate ligament
reconstruction. Higher score indicates more positive feelings associated to returning to sport. Values are presented as median and range, box shows IQR. N=139, 2 patients excluded due to internal missing data. *P=<0.001. ACL-RSI, Anterior Cruciate Ligament-Return to Sport after Injury.
Association between ACL-RSI and subjective IKDC score
Significant correlation was found between ACL-RSI and subjective IKDC score at six months follow-up (r = 0.379, r2 = 0.153, P<0.001).
Figure 3. Correlation between ACL-RSIand subjective IKDC score at six months after anterior cruciate ligament reconstruction, r = 0.379, r2 = 0.153, P<0.001. IKDC, International Knee Documentation Committee; ACL-RSI, Anterior Cruciate Ligament-Return to Sport after Injury.
Factors associated with ACL-RSI at six months post ACL-R
Univariate analysis indicated no statistically significant difference in ACL-RSI score related to age, BMI, pre-injury Tegner level, contralateral knee injury, tobacco, sex and if affected by Covid-19. No multiple regression was therefore introduced.
Table 2. Univariate analysis to identify factors associated with psychological readiness (ACL-RSI score) at six months after anterior cruciate ligament reconstruction.a
Independent Variable ACL-RSI scoreb B Coefficient P value
Age -0.027 (95% CI, -0.07-0.02) ns
BMIc
Preinjury Tegner level: Tegner level 3 Tegner level 4 Tegner level 5 Tegner level 6 Tegner level 7 Tegner level 8 Tegner level 9 Tegner level 10 48(20) 50(17) 53(34) 43(21) 50(17) 54(19) 51(20) 73d 0.075 (95% CI, -.0.06-0.17) ns ns
Contralateral knee injury, yes/no 54(20) / 50(19) ns
Tobacco, yes/no 51(20) / 51(19) ns
Sex, men/women 52(20) / 50(19) ns
Affected by Covid-19, yes/no 50(21) / 50(18) ns
aLinear regression is used for continuous factors, analysis of variance is used for ordinal
factors (Pre-injury Tegner) and unpaired t-test for dichotomous factors.
bValues are presented as mean and SD. Abbreviation as in figure 3.
cOne outlier value excluded in analysis.
dThere was just one athlete graded as Tegner level 10, therefore, there was no mean score in
this group.
Secondary outcome: Impact of covid-19 on patients’ rehabilitation
A total of 112 (79%) patients responded to the survey regarding the impact of Covid-19 on rehabilitation. The survey was collected at a mean of 6.4 months post ACL-R, which
correspond to the end of June until October 2020, depending on when the patient had his/her surgery. Covid-19 restrictions had an impact on rehabilitation in 40 out of 112 (36%) of the patients, whereas for 72 of 112 (64%), rehabilitation was not affected. Thirty-eight of 40 patients responded in free text in what way they had been affected and answers could be
categorized into five categories: “The gym closed/cancelled trainings” (N = 17), “Have not wanted to go to rehabilitation or training hall due to risk spread of infection” (N = 16) , “Less time with my physiotherapist” (N = 7), “I have been in quarantine due to infection”(N =1) and “psychosocial impact” (N=1). Answers from four patients was categorized into more than one category.
Discussion
We found that the psychological readiness to return to sport progressed through early phase of rehabilitation, between three to six months post ACL-R. The athletes experienced fewer negative emotions related to their injury and felt more positive and confident about returning to sport as rehabilitation progressed. This supports our first hypothesis that psychological readiness to RTS would gradually improve over time. The mean score change was more than three points, with an increase of eight points, indicating a clinically relevant improvement [26]. It has previously been shown that the ACL-RSI scores increase regularly after ACL-R [14,17], where in one study the score progressed from 56 at three months to 58 at six months, and another study showed scores from a mean of 41 preoperatively to 58 at six months follow-up. Additionally, these studies showed that the ACL-RSI score at six months was significantly higher in patients who had returned to sport at 12 months [17] and two years [14] after surgery, respectively. It is yet to see if our findings of ACL-RSI scores at six months will correlate or predict these athlete’s return to participation in sport in the future of the greater study.
It was also of interest to see whether any factors were associated with psychological readiness six months after surgery. Our second hypothesis was that ACL-RSI score at six months would be associated with subjective knee function and that younger age, male gender and higher pre-injury level in sports would favor a greater psychological readiness to RTS. This was just partially supported. Subjective IKDC score was positively correlated with psychological readiness to RTS at six months. This association is similar to previous research showing a moderate correlation between subjective IKDC score and ACL-RSI scores [14,20,29]. Subjective IKDC score has also been showed to be more in line with RTS outcomes than clinical measures [6,30], which underline the importance of the patient’s own perception of his or hers knee symptoms. This correlation demonstrates an interrelationship between
perception of one’s physical function and psychological readiness. Competitive athletes report that progress in rehabilitation and confidence in one’s formerly injured body part are
important basic factors for building confidence to return to sport [31]. This has clinical implications in terms of that the clinical follow-ups should be observant to both physical and psychological readiness to optimize and individualize an athlete’s return to sport after ACL-R. However, high psychological readiness does not consequently mean that it is safe to return to sport. Instead, a degree of anxiety may be protective if it means that the athlete does not recklessly resume sports participation with risk for further injury [19].
The findings of non-significant associations between ACL-RSI score and patient sex, age and pre-injury Tegner level were not expected and contradict a similar study which showed positive effects by mentioned factors on ACL-RSI score in univariate analysis [19]. This mentioned study was performed 12 months post ACL-R, showing that there may be a difference in the associations between ACL-RSI and other factors in earlier phases of rehabilitation. On the other hand, younger age was the only factor of the mentioned that remained significant in their multivariate model. Moreover, our cohort cannot be fully compared to the previous study’s regarding the span of age (16-40 vs 14-55 years) and pre-injury level in sport, which may partly explain the discrepancy for some of our results. However, it is of interest that neither male sex or higher pre-injury Tegner level were associated with higher ACL-RSI scores, since these factors, together with a positive
psychological response, are associated with a greater likelihood to return to sports [10]. One explanation to this difference could be that high level athletes have greater athletic
identification [31], and struggle more in the beginning of the rehabilitation, before allowance to do more sport-specific drills, and are more psychologically affected by not being able to do sport and train with their team like usual. On the other hand, these athletes have greater investment in their sport [32] and likely better access to structured support from rehabilitation professionals which could explain why they have twice the odds of returning to sport [7]. It is unclear why the current study did not show any differences in ACL-RSI score regarding sex. There may be several background factors, like previous injury-experience or simultaneous severe cartilage lesions that we did not consider, that could partly explain this contractionary result.
Finally, only 36% of the responders stated that their rehabilitation had been affected by Covid-19. This low rate was not expected. This could be explained by several reasons: the design of the question in the survey with examples (e.g. closed gyms and availability to physiotherapist) may have limited patient’s answers to mainly focus on these and not widen
their answers. It could be for this reason, e.g. only one athlete stated “psychosocial impact” as a result to Covid-19 which in turn may affect the rehabilitation training. Given the fact that the participants are recruited from the ACL register and live all over Sweden, another reason may be that the regions of the participants simply had not been severely affected by Covid-19 at the date of response to our survey. In contrast to other countries, Sweden has not had a complete lockdown. In June 2020, The Public Health Agency published regulations about implementing trainings and other sport activities outdoors and to reduce the numbers of spectators or in other ways avoid crowding [33] and during October up until December 2020, The Public Health Agency in Sweden could decide on “general guidelines in the event of local outbreaks of Covid-19” that apply in addition to guidelines already issued for the whole country [21]. Responses to this survey were collected during June-October, meaning that athletes in Sweden were limited differently depending on what restrictions their region had and that stricter restrictions have been implemented since the completion of the study.
The main limitation of this study is the participation rate. Only 141 patients of the 1033 of contacted for the study agreed to participate and returned completed surveys. Therefore, findings may be limited in terms of generalizability. To increase the response-rate, reminder mail-outs could be sent and insertion of quick response (QR) codes in the information mail to enable faster access to the web-based surveys. We cannot know what proportion of the responders meets the inclusion criteria. The included cohort was not comparable to the non-responders in terms of sex, since women were over-represented. This is in line with research providing strong evidence that voluntary recruitment may lead to a non-response bias in terms of women over-representing voluntary sample [34]. There may also be an additional non-response bias, if more satisfied athletes were more likely to participate in the study. Also, factors associated with psychological readiness may differ from study samples.
Conclusions
In conclusion, psychological readiness (ACL-RSI score) increased during follow-up and was moderately correlated to knee function (subjective IKDC score) at six months after ACL-R. Future research should include additional factors, like motivation and social support, to examine the relationship to psychological readiness to RTS. The restrictions due to Covid-19 affected rehabilitation for one in every three participants.
Acknowledgment
Thanks to Joanna Kvist from Linköping University and Daniel Castellanos from Örebro University for valuable help during this project.
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Även psykologisk förberedelse viktigt under korsbandsrehabilitering
- och hur påverkar coronapandemin den enskilde idrottarens rehab?
För att lyckas återgå till idrott efter en
främre korsbandsrekonstruktion krävs optimal fysisk och psykologisk
rehabilitering. ”Psykologisk beredskap för återgång till idrott” är en viktig term beträffande återgång till idrott och psykologiska faktorer har erhållit ökat intresse utifrån dess kliniskt modifierbara natur. Bl.a. ålder, kön, tidigare idrottsnivå och upplevd knäfunktion kan troligen påverka den psykologiska beredskapen. Under 2020 har Coronapandemin och restriktioner till följd av denna också blivit en faktor att ta hänsyn till och som kan påverka idrottares rehabilitering inför återgång till idrott.
En nyligen genomförd enkätstudie från Örebro Universitet tillsammans med Karolinska Institutet har observerat 141 patienters psykologiska beredskap för återgång till idrott efter tre- och sex månader efter ACL-rekonstruktion och undersökt hur bl.a. själv-rapporterad knäfunktion associerar till detta.
Hundratolv patienter uppgav även om och hur Covid-19 påverkat deras
rehabilitering.
Den psykologiska beredskapen för återgång till idrott ökade efter
ACL-rekonstruktion och korrelerade med själv-rapporterad knäfunktion. 36% av
patienterna uppgav ha påverkats av covid-19 under rehabiliteringen på olika sätt: stängt gym och inställda träningar, minskad tid med fysioterapeut, psykosocial påverkan och
karantänisolering pga. infektion.
Som slutsats kan sägas att kliniska
uppföljningar bör observera både fysisk och psykologisk preparation under rehabiliteringen för att kunna optimera och individualisera en idrottares återgång till idrott efter en främre
korsbandsrekonstruktion.
Coronapandemin har förödande konsekvenser på idrottsvärlden och
individuella träningsmöjligheter begränsas på alla idrottsnivåer. Dokumentation av idrottares erfarenheter är viktigt för framtida forskning. Åtgärder bör vidtas för att öka patienters chanser till fullgod och säker rehabilitering under smittsäkra former.
Bilder från titthålsoperation på knä med ett avslitet korsband respektive ett rekonstruerat korsband. Foto av: Daniel Castellanos.
Etisk reflektion
Detta var en prospektiv kohortstudie som en uppföljningsdel i en större studie. Patienterna rekryterades via svenska korsbandsregistret. Patienterna kontaktades först via skriftlig information per brev och därefter personligen via mejl, sms och/eller telefon. Skriftligt informerat samtycke var obligatoriskt för deltagande i studien.
Data för projektet baserades på patienternas svar på frågeformulär. All data som använts var kodad och förvarades i en pseudo-anonymiserad databas där en kodnyckel krävs för tillgång till detta. Endast huvudansvarig forskare och doktorand hade tillgång till kodnyckeln. All data har hanterats i enlighet med sekretesslagen och GDPR. Studieresultat presenteras på
gruppnivå, inga data på individnivå presenteras. Personuppgiftsansvarig är Karolinska Institutet.
Risker för studiepopulationen bedöms som ringa. Endast individer som tackat ja till deltagande i studien har följts. Studien påverkar inte kliniska rutiner eller behandling.
Studiedeltagarna har dock månadsvis lagt ner tid för att besvara enkäter, för att möjliggöra en mer detaljerad uppföljning efter främre korsbandsrekonstruktion än vid sedvanlig klinisk praxis. Den största risken skulle vara integritetsintrång varvid vi satt stor vikt vid hantering av persondata enligt gällande regelverk. Nyttan av projektet är att resultatet kommer att kartlägga en del av det postoperativa förloppet för idrottare efter en främre korsbandsrekonstruktion samt faktorer som kan ha betydelse för detta. Detta kan senare associeras till deltagande i idrott efter en 3-årsuppföljning i den större studien.
Inga jävsförhållanden föreligger avseende studieupplägg för studieansvariga eller övriga medverkande. Projektet finansieras av forskningsmedel på Karolinska Institutet, Linköpings Universitet och Örebro Universitet.
Cover letter
Örebro, December 21, 2020
Acta Orthopaedica
Department of Orthopaedics Lund University Hospital 221 85, Lund, Sweden
Dear Editor,
Please consider our manuscript titled “Progression of psychological readiness to return to sport and the influence of covid-19 on rehabilitation after anterior cruciate ligament reconstruction” for publication in Acta Orthopaedica. This is a prospective cohort study recruiting participants from the Swedish Knee Ligament Register for recruitment. A negative psychological state is common after anterior cruciate ligament (ACL) reconstruction and is often cited as a reason for a reduction in sports participation after ACL reconstruction. We have examined the changes in psychological readiness to sport between 3 and 6 months after ACL reconstruction, measured with ACL-Return to Sport after Injury scale (ACL-RSI) and correlated this to subjective knee function. We also investigated if and how patients have been affected by covid-19. We found that ACL-RSI progressed through early rehabilitation and was correlated to subjective knee function score, but not to any other included contextual factor. Approximately a third of patients were affected by Covid-19 in their rehabilitation.
Our results highlight the importance to observe both physical and psychological preparation during rehabilitation in order to optimize the athlete’s return to sport, and the corona
pandemics’ impact on the individual athlete’s rehabilitation.
We confirm this manuscript has not been published elsewhere and is not reviewed by any other journal. All authors have accepted the final manuscript.
Kind regards,
Ylva Zelleroth, MB. Örebro University
School of Medical Sciences, Faculty of Science and Health Södra Grev Rosengatan 30, 70362, Örebro, Sweden Ylva.zelleroth@hotmail.com
