A systematic review of the psychological factors associated with returning to sport following injury
TL;DR: There is preliminary evidence that positive psychological responses are associated with a higher rate of returning to sport following athletic injury, and should be taken into account by clinicians during rehabilitation.
Abstract: Background Psychological factors have been shown to be associated with the recovery and rehabilitation period following sports injury, but less is known about the psychological response associated with returning to sport after injury. The aim of this review was to identify psychological factors associated with returning to sport following sports injury evaluated with the self-determination theory framework. Study design Systematic review. Method Electronic databases were searched from the earliest possible entry to March 2012. Quantitative studies were reviewed that included athletes who had sustained an athletic injury, reported the return to sport rate and measured at least one psychological variable. The risk of bias in each study was appraised with a quality checklist. Results Eleven studies that evaluated 983 athletes and 15 psychological factors were included for review. The three central elements of self-determination theory—autonomy, competence and relatedness were found to be related to returning to sport following injury. Positive psychological responses including motivation, confidence and low fear were associated with a greater likelihood of returning to the preinjury level of participation and returning to sport more quickly. Fear was a prominent emotional response at the time of returning to sport despite the fact that overall emotions became more positive as recovery and rehabilitation progressed. Conclusions There is preliminary evidence that positive psychological responses are associated with a higher rate of returning to sport following athletic injury, and should be taken into account by clinicians during rehabilitation.
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TL;DR: Return to sport varied according to different physical functioning and contextual factors, which could warrant additional emphasis in postoperative rehabilitation programmes to maximise participation.
Abstract: Background The aim of this study was to update our original systematic review of return to sport rates following anterior cruciate ligament (ACL) reconstruction surgery.
Method Electronic databases were searched from April 2010 to November 2013 for articles reporting the number of patients returning to sport following ACL reconstruction surgery. Return to sport rates, physical functioning and contextual data were extracted and combined using random-effects meta-analyses. Data from the original review (articles published up to April 2010) were combined with data from the updated search.
Results Sixty-nine articles, reporting on 7556 participants, were reviewed. On average, 81% of people returned to any sport, 65% returned to their preinjury level of sport and 55% returned to competitive level sport after surgery. Symmetrical hopping performance (d=0.3) and the contextual factors of younger age (d=−0.3), male gender (OR=1.4), playing elite sport (OR=2.5) and having a positive psychological response (d=0.3) favoured returning to the preinjury level sport. Receiving a hamstring tendon autograft favoured returning to competitive level sport (OR=2.4), whereas receiving a patellar tendon autograft favoured returning to the preinjury level sport (OR=1.2).
Conclusions Returning to sport varied according to different physical functioning and contextual factors, which could warrant additional emphasis in postoperative rehabilitation programmes to maximise participation.
854 citations
University of Wisconsin-Madison1, Philippines National Collegiate Athletic Association2, Western University of Health Sciences3, George Washington University4, International Olympic Committee5, University of São Paulo6, McGill University7, Stanford University8, University of Portsmouth9, University of Amsterdam10, University of Arizona11, Chung-Ang University12, University of Maryland, Baltimore13, McMaster University14, Kocaeli University15, Rutgers University16, Princeton University17, Vanderbilt University Medical Center18, University of Nebraska–Lincoln19, Stellenbosch University20
TL;DR: To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.
Abstract: Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.
513 citations
TL;DR: This consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport.
Abstract: Deciding when to return to sport after injury is complex and multifactorial-an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups-each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athlete's return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.
477 citations
TL;DR: Psychological responses before surgery and in early recovery were associated with returning to preinjury level of sport at 12 months, suggesting that attention to psychological recovery in addition to physical recovery after ACL injury and reconstruction surgery may be warranted.
Abstract: Background:Up to two-thirds of athletes may not return to their preinjury level of sport by 12 months after anterior cruciate ligament (ACL) reconstruction surgery, despite being physically recovered. This has led to questions about what other factors may influence return to sport.Purpose:To determine whether psychological factors predicted return to preinjury level of sport by 12 months after ACL reconstruction surgery.Study Design:Case control study; Level of evidence, 3.Methods:Recreational and competitive-level athletes seen at a private orthopaedic clinic with an ACL injury were consecutively recruited. The primary outcome was return to the preinjury level of sports participation. The psychological factors evaluated were psychological readiness to return to sport, fear of reinjury, mood, emotions, sport locus of control, and recovery expectations. Participants were followed up preoperatively and at 4 and 12 months postoperatively.Results:In total, 187 athletes participated. At 12 months, 56 athletes ...
416 citations
Cites background or result from "A systematic review of the psycholo..."
...This is important as it addresses some of the bias present in previous crosssectional research that has compared the psychological responses of injured athletes who did and did not return to sport.(5) Sample sizes used in previous studies of the psychological factors associated with returning to sport after injury generally numbered 100 athletes at most, and only one study of athletes returning to sport after ACL reconstruction(51) followed a larger population (N = 220) than the current study....
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...sport after surgery.(5,6,28,29,51) In cross-sectional studies comparing athletes who did and did not return to their preinjury level of sport after ACL reconstruction, there is evidence that low fear of reinjury, motivation to return, and psychological readiness to return to sport are associated with returning to the preinjury level of sport....
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TL;DR: In this article, a cross-sectional study aimed to examine whether appraisal of knee function, psychological and demographic factors were related to returning to the preinjury sport and recreational activity following anterior cruciate ligament (ACL) reconstruction.
Abstract: Background This cross-sectional study aimed to examine whether appraisal of knee function, psychological and demographic factors were related to returning to the preinjury sport and recreational activity following anterior cruciate ligament (ACL) reconstruction. Method 164 participants completed a questionnaire battery at 1–7 years after primary ACL reconstruction. The battery included questionnaires evaluating knee selfefficacy, health locus of control, psychological readiness to return to sport and recreational activity, and fear of reinjury; and self-reported knee function in sport-specific tasks, knee-related quality of life and satisfaction with knee function. The primary outcome was returning to the preinjury sport or recreational activity. Results At follow-up, 40% (66/164) had returned to their preinjury activity. Those who returned had more positive psychological responses, reported better knee function in sport and recreational activities, perceived a higher knee-related quality of life and were more satisfied with their current knee function. The main reasons for not returning were not trusting the knee (28%), fear of a new injury (24%) and poor knee function (22%). Psychological readiness to return to sport and recreational activity, measured with the ACL-Return to Sport after Injury scale (was most strongly associated with returning to the preinjury activity). Age, sex and preinjury activity level were not related. Conclusions Less than 50% returned to their preinjury sport or recreational activity after ACL reconstruction. Psychological readiness to return to sport and recreation was the factor most strongly associated with returning to the preinjury activity. Including interventions aimed at improving this in postoperative rehabilitation programmes could be warranted to improve the rate of return to sport and recreational activities.
309 citations
Cites background or methods from "A systematic review of the psycholo..."
...A systematic review of psychological factors associated with returning to sport following athletic injury [8] was used to guide the selection of psychological factors, based on the theoretical constructs of competence, autonomy and relatedness....
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...Recent research has suggested that psychological factors may be important influences on returning to sport and recreation after athletic injury,[8, 9] but cautioned that because there are few studies examining the relationship between psychological factors and returning to sport and recreation, more research is needed to facilitate more definitive conclusions....
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Journal Article•
TL;DR: The QUOROM Statement (QUality Of Reporting Of Meta-analyses) as mentioned in this paper was developed to address the suboptimal reporting of systematic reviews and meta-analysis of randomized controlled trials.
Abstract: Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.
Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7
In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).
Box 1
Conceptual issues in the evolution from QUOROM to PRISMA
46,935 citations
TL;DR: A structured summary is provided including, as applicable, background, objectives, data sources, study eligibility criteria, participants, interventions, study appraisal and synthesis methods, results, limitations, conclusions and implications of key findings.
31,379 citations
TL;DR: Research guided by self-determination theory has focused on the social-contextual conditions that facilitate versus forestall the natural processes of self-motivation and healthy psychological development, leading to the postulate of three innate psychological needs--competence, autonomy, and relatedness.
Abstract: Human beings can be proactive and engaged or, alternatively, passive and alienated, largely as a function of the social conditions in which they develop and function. Accordingly, research guided by self-determination theo~ has focused on the social-contextual conditions that facilitate versus forestall the natural processes of self-motivation and healthy psychological development. Specifically, factors have been examined that enhance versus undermine intrinsic motivation, self-regulation, and well-being. The findings have led to the postulate of three innate psychological needs--competence, autonomy, and relatednesswhich when satisfied yield enhanced self-motivation and mental health and when thwarted lead to diminished motivation and well-being. Also considered is the significance of these psychological needs and processes within domains such as health care, education, work, sport, religion, and psychotherapy. T he fullest representations of humanity show people to be curious, vital, and self-motivated. At their best, they are agentic and inspired, striving to learn; extend themselves; master new skills; and apply their talents responsibly. That most people show considerable effort, agency, and commitment in their lives appears, in fact, to be more normative than exceptional, suggesting some very positive and persistent features of human nature. Yet, it is also clear that the human spirit can be diminished or crushed and that individuals sometimes reject growth and responsibility. Regardless of social strata or cultural origin, examples of both children and adults who are apathetic, alienated, and irresponsible are abundant. Such non-optimal human functioning can be observed not only in our psychological clinics but also among the millions who, for hours a day, sit passively before their televisions, stare blankly from the back of their classrooms, or wait listlessly for the weekend as they go about their jobs. The persistent, proactive, and positive tendencies of human nature are clearly not invariantly apparent. The fact that human nature, phenotypically expressed, can be either active or passive, constructive or indolent, suggests more than mere dispositional differences and is a function of more than just biological endowments. It also bespeaks a wide range of reactions to social environments that is worthy of our most intense scientific investigation. Specifically, social contexts catalyze both within- and between-person differences in motivation and personal growth, resulting in people being more self-motivated, energized, and integrated in some situations, domains, and cultures than in others. Research on the conditions that foster versus undermine positive human potentials has both theoretical import and practical significance because it can contribute not only to formal knowledge of the causes of human behavior but also to the design of social environments that optimize people's development, performance, and well-being. Research guided by self-determination theory (SDT) has had an ongoing concern with precisely these
29,115 citations
Journal Article•
TL;DR: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) as discussed by the authors is an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses.
4,567 citations
TL;DR: This is the last in a series of four articles about prognostic studies, which include clinical studies of variables predictive of future events as well as epidemiological studies of aetiological risk factors.
Abstract: This is the last in a series of four articles
Prognostic studies include clinical studies of variables predictive of future events as well as epidemiological studies of aetiological risk factors. As multiple similar studies accumulate it becomes increasingly important to identify and evaluate all of the relevant studies to develop a more reliable overall assessment. For prognostic studies this is not straightforward.
Box 1 summarises the clinical importance of information on prognostic factors. Many of the issues discussed are also relevant to aetiological studies, especially cohort ones. Some features of prognostic studies lead to particular difficulties for the systematic reviewer. Firstly, in most clinical prognostic studies the outcome of primary interest is the time to an event, often death. Meta-analysis of such studies is rather more difficult than that for binary data or continuous measurements. Secondly, in many contexts the prognostic variable of interest is often one of several prognostic variables. When examining a variable of interest researchers should consider other prognostic variables with which it might be correlated. Thirdly, many prognostic factors are continuous variables, for which researchers use a wide variety of methods of analysis.
#### Summary points
Systematic reviews are applicable to all types of research design, and studies of prognostic variables are an important additional area where appropriate methodology should be applied
Prognostic variables should be evaluated in a representative sample of patients assembled at a common point in the course of their disease—ideally they should all have received the same medical treatment or been in a randomised trial
When examined critically, a high proportion of prognostic studies are found to be methodologically poor
Meta-analysis of published data is hampered by difficulties in extraction of data and variation in the characteristics of the study and patients
The poor quality of the published literature is a strong argument in favour …
801 citations