Impact of Preoperative Expectations and Fear of Movement on Return to Sport and KOOS Scores at 6 Months following ACL Reconstruction

OBJECTIVES: Limited research has examined the independent relationship between psychosocial factors and patient-reported outcomes during the early postoperative period following ACL reconstruction (ACLR). The purpose of this study was to examine the association between preoperative psychosocial characteristics and return to sport and sports function at 6 months after ACLR. A secondary objective was to examine the importance of psychosocial characteristics to knee-specific quality of life (QOL). METHODS: Fifty-four patients, 18 to 33 years of age, undergoing a primary, unilateral ACLR were enrolled between November 2012 and December 2013. Demographic characteristics and a series of validated psychosocial and outcome measures were collected preoperatively. Patient expectations for having a successful surgery were assessed with a 10-item numeric rating scale. Fear of movement was measured with the activity avoidance and somatic focus subscales from the 13-item Tampa Scale for Kinesiophobia, pain catastrophizing with the Pain Catastrophizing Scale, depressive symptoms with the Patient Health Questionnaire-9, and general and knee-specific self-efficacy with the Generalized Self-Efficacy Scale and Knee Self-Efficacy Scale. Return to sport was assessed with the Subjective Patient Outcome for Return to Sport (SPORTS) and sports function and knee-specific QOL were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales. Patients completed an identical set of outcome instruments at 6 months after surgery. Separate multivariable linear regression analyses were used to examine the association between preoperative psychosocial variables and patient-reported outcomes at 6 months after ACLR, controlling for age, education, and preoperative outcome score. RESULTS: The follow-up rate at 6 months was 93%. Ninety-six percent of patients (48/50) reported returning to sport at 6 months after ACLR, with 46% returning at the same pre-injury level of effort and performance (Table 1). Higher preoperative activity avoidance scores was significantly associated with not returning to sport at same level of effort and performance as before onset of impairment (OR = .73, p = .02), and worse scores on the KOOS QOL subscale (β = -1.4, p = .05) at 6-month follow-up. Higher preoperative expectations was a significant risk factor for worse outcomes on the KOOS subscales, with a 1-point increase in expectations associated with a 5.6-point decrease in KOOS sports/rec (p = .03) and 4.7-point decrease in KOOS QOL (p = .05) scores. Preoperative pain catastrophizing, depression, and self-efficacy were not statistically associated with patient-reported outcomes (p > .05). CONCLUSION: Screening patients for fear of movement and unrealistic expectations prior to ALCR may help identify patients at-risk for poorer outcomes. Targeted psychosocial rehabilitation strategies that address activity avoidance related to fear and expectations have the potential to improve return to sport at same level of effort and performance and knee-specific health outcomes during the early recovery period.