Original researchDevelopment and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery
Introduction
Anterior cruciate ligament (ACL) rupture is an incapacitating knee injury that occurs frequently in athletes. It is typically treated with surgical reconstruction and it is estimated that in the United States more than 100,000 ACL reconstructions are performed annually (Owings & Kozak, 1998). Although an abundance of research has examined how knee function is affected by this surgery, less attention has been paid to psychological factors that may influence an athlete's return to sport (Podlog & Eklund, 2004). This is significant as it has been demonstrated that up to 50% of athletes do not return to their pre-injury level of sport participation following ACL reconstruction despite being physically rehabilitated (Feller & Webster, 2003; Kvist, Ek, Sporrstedt, & Good, 2005). Unfortunately, most authors do not report the reasons why athletes in their study do not return to sport. One exception is a recent study by Kvist et al. (2005) who surveyed 62 athletes following ACL reconstruction and found that of the 47% that had not returned to their pre-injury activity 3–4 years after surgery, 24% reported fear of re-injury as the reason.
Two further studies have also provided insight into the psychological consequences of ACL reconstruction surgery. Both LaMott (1994) and Morrey, Stuart, Smith, and Wiese-Bjornstal (1999) examined athletes’ emotional response throughout rehabilitation using the Emotional Response of Athletes to Injury Questionnaire (ERAIQ). Both studies showed that athletes not only experience negative emotions following injury, but also have a second increase in negative emotions in the latter part of rehabilitation. They referred to this as an emotional “U” pattern. In the Morrey et al. study, this second increase in negative emotions occurred 6 months following surgery and was associated with clearance by the orthopaedic surgeon to return to sport. Based on these findings the authors suggested that returning to sport had a significant psychological impact on the athletes. No attempt was however made to document whether or not the athletes actually returned to sport participation.
In other sporting contexts, other factors such as athletic confidence have also been raised (Johnston & Carroll, 1998; Quinn & Fallon, 1999). In a qualitative study, Johnston and Carroll (1998) asked 16 athletes with a variety of injuries to recall their experiences from the acute injury stage until return to sport. Using grounded theory to describe the athletes’ responses, they found that fear of re-injury was the predominant emotional factor that was associated with returning to sport. However, confidence in the ability to perform well and appraisal of the risk of returning to sport were also identified as key psychological responses in the model. As the model proposed by Johnston and Carroll describes both the situational and temporal context of athletic injury it may be particularly useful for understanding psychological aspects of recovery from ACL injury.
In regard to athletic confidence, the literature suggests that confidence is vital among athletes returning to competitive sport (Evans, Hardy, & Fleming, 2000; Grove & Gordon, 1995; Quinn & Fallon, 1999) and that physical and psychological readiness to return to sport do not necessarily coincide (Podlog & Eklund, 2007). Athletes with injuries have lower levels of sport confidence than athletes without injury (LaMott, 1994) and an athlete's confidence in their ability to perform well is lower when they are returning to sport after injury (Johnston & Carroll, 1998). Athletic confidence has not been considered in the context of ACL reconstruction but based on the above research findings it is reasonable to hypothesise that it may play a role in the poor rate of return to sport after this surgery.
In regard to the way in which an athlete appraises the risk of returning to sport, a key theme identified in Johnston and Carroll's model is whether to risk returning prematurely to sport. Their work has shown that clear differences exist between athletes who return early and those who choose to wait. Specifically, athletes who risk premature return tend to underestimate injury severity and focus on short-term goals whilst ignoring any possible long-term consequences of early participation. Whereas athletes who do not risk a premature return are more likely to have undergone surgery, long rehabilitation and have previous injuries. There have been no empirical studies to evaluate how athletes recovering from ACL surgery appraise the risk of returning to their pre-injury sport.
In reviewing the literature we were unable to find a scale that specifically looked at returning to sport after athletic injury. Scales such as the ERAIQ are excellent at documenting athletes’ emotions after injury but do not include emotions, which are important in the context of sport resumption, such as fear of re-injury. The recently published Knee Self Efficacy scale (Thomee, Wahrborg, Borjesson, Thomee, Eriksson, & Karlsson, 2006), which was not available at the time this study commenced, asks athletes who have suffered a knee injury about their degree of certainty at being able to return to the same activity level as before their injury and about future knee function. Sport confidence typically refers to the amount of confidence the athlete has in their ability to perform well at their sport. However, in the case of ACL reconstruction, it may also relate to the amount of confidence the athlete has in their knee function. It would be useful to identify athletes as who might find returning to sport difficult and measuring such responses might help to understand the low rate of return to pre-injury levels of sport participation following this type of surgery. Therefore, the purpose of this study was to develop a scale which measured athletes’ emotions, confidence and risk appraisal when returning to sport after ACL reconstruction surgery.
Section snippets
Participants
Two hundred and twenty athletes who had undergone ACL reconstruction participated. There were 124 males and 96 females aged between 16 and 54 years (mean=29.2 years, SD=9.7). Athletes were eligible if they had been participating in sport on a weekly basis prior to injury. In addition, only athletes who planned to return to sport after their surgery were included. The average amount of time spent in sport participation prior to injury was 6.5 h per week (range 2–26). Athletes were excluded if
Psychometric properties
The mean and standard deviation of scores for each item of the scale are listed in Table 1. The means ranged between 50.93 and 73.1 (Table 1). All items scored relatively close to the centre of the response range (i.e. 50), and had large standard deviations, both features considered preferable properties of scale items (DeVellis, 1991). The range for each item was 0–100. The four items scoring lowest on the scale were those measuring frustration, fear, and nervousness. These items were all
Discussion
In this study, a theoretical approach to scale construction was used to develop a 12-item scale to measure psychological factors associated with returning to sport following ACL reconstruction surgery. Scale items were created around three specific psychological responses hypothesised to be related to sport resumption; emotions, confidence and risk appraisal. This is the first attempt that we are aware of to specifically develop a scale that incorporates these three responses, which were found
Conflict of Interest Statement
No conflict of interest.
Ethical Approval
All procedures were approved by the Faculty of Health Sciences Ethics Committee at La Trobe University prior to data collection.
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