Ep 272: Moving on from "fear of reinjury", with Cobie Starcevich

[00:00:00] I think clinicians struggle to do that because they are fearful that they're going to bring out something in a patient that they don't necessarily feel confident dealing with. Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:32] Is fear truly at the epicenter of reinjury concerns for athletes following an anterior cruciate ligament injury, or is there more than fear of reinjury? Today we are joined by Cobie Starcevich to help us dissect and understand the multidimensional aspect of athletes' behaviors, mindsets, and

[00:00:59] actions following ACL injury. Cobie Starcevich is a PhD candidate in the School of Allied Health at Curtin University in Western Australia. She's a musculoskeletal physiotherapist with nearly two decades of clinical experience across private practice, emergency care, and elite performance settings, including work with Cirque du Soleil. Her PhD research explores reinjury fear, anxiety,

[00:01:25] and perceptions of threat in athletes recovering from ACL injury. I'm Marquise Santa Bryce. I'm a doctor of physical therapy in Baltimore, Maryland at Summit Physical Therapy and Performance. And I'm Chelsea Kuman, a physical therapist and athletic trainer at Stanford University Athletics. Cobie Starcevich, thank you so much for joining us. As a bit of like background of where this all started, what originally sparked your interest in studying reinjury concerns after ACL? And then what

[00:01:54] made you feel like that traditional kind of fear of reinjury concept might not fully capture athletes' experiences? We didn't really start off investigating reinjury concerns per se. So this was a term that developed later after the research was performed. Yeah, I suppose like how I came down the path of doing this PhD was from my clinical background, working as a physio, working with athletes who had athletic

[00:02:21] injuries like ACL injuries and obviously got back to their full physical function, you know, ticking off all the return to sport milestones and progressing really well objectively, but were being held back in some way by something. So what I found in the literature was obviously fear of reinjury is a big problem for athletes with ACL injuries. The number one psychological reason why they don't return to sport, even though they're having successful surgical outcomes and physical outcomes and ticking off

[00:02:50] those return to sport milestones. I suppose what I was finding clinically was they weren't appearing to present in a way that I would consider fearful. Their experience seemed to be more nuanced and maybe a little bit more subtle for some and looking at that fear of reinjury literature. So a lot of that is based on a conceptual understanding of the construct kinesiophobia, which is borrowed from the chronic back pain research, where they're looking at people with chronic non-specific low back pain who were

[00:03:19] experiencing pain, fear around that pain, fear around movement that's painful, avoiding those movements and becoming more disabled and fearful. A lot of those tools that they used to measure those sorts of, that construct didn't really fit with this ACL injured population where it's not a pain dominant experience. So yeah, I suppose it came from this mismatch of the literature and what I was saying clinically. So rather than imposing existing psychological labels onto their

[00:03:47] experience, we were looking to investigate that from their experience onwards. And so our team started using the term reinjury concerns as an umbrella term for the spectrum of responses to the threat of reinjury. In this population for ACL, we've just done such a great job and we're coming a long way. We had our timelines. Now we're starting to really dive deep into some of the more like even biopsychosocial, the multi-dimensional approach for this. Of course, our reinjury rates remain high.

[00:04:17] So I think the deeper that we dive into this, I think the better that we're going to get as far as outcomes. What were you actually trying to understand in this review? And how do you even begin to study such a complex experience? So our main goal was to understand how athletes with ACL injuries experience, interpret and respond to the threat of reinjury. So rather than look at questionnaire scores, we synthesize qualitative studies where athletes describe their experiences in their own

[00:04:46] words. And we included studies across different stages of recovery, different sporting backgrounds. And we used a qualitative synthesis method to look for patterns across studies and develop a deeper conceptual understanding of athletes' experiences. So the goal wasn't to simply identify whether they're experiencing fear or anxiety and put labels to this. It was to understand the underlying processes

[00:05:09] shaping athletes' experiences. So, you know, how do athletes form a sense of threat of reinjury? What sorts of things trigger this sense of threat? And how are they forming these appraisals? What contextual factors shape these perceptions? Mechanism of injury, for example, or how their injury might be managed or their level of sport that they're in? How are they being affected? So what emotions, cognitions, or physiological sensations do they experience? And how do athletes cope when they're experiencing

[00:05:39] what we call reinjury concerns? So this sense of threat around reinjury? And what behaviors and thoughts do they exhibit to cope with this? And how does this change over recovery periods? So as the injury moves from the injury to the injury to the injury, we're trying to be able to take a look at the injury, we're trying to try to find quotes to match our predetermined ideas of things. We were looking at what athletes had to say to

[00:06:07] understand the phenomenon. So in qualitative research speak, that's taking an inductive approach to the data analysis and we let the quotes and the data guide the development of the findings. That's what you were looking at and that's how you approach such a complex experience. So now let's get into what you actually found. So one of the biggest takeaways from this paper is that athletes' experiences were far more varied and dynamic than just fear. So maybe that we need to like

[00:06:34] consider some other wordage and language and just take into consideration some more things. What did you ultimately find athletes were actually experiencing during recovery? I can break the findings down into three main themes and I'll go into detail around what those themes are. So the first theme was around how athletes appraise threat of re-injury, how they form those appraisals. The second theme was around how they're experiencing feeling threatened for re-injury.

[00:07:00] And the third theme was around how they're responding to feeling threatened for re-injury. If you look at the paper, you'll see in figure two, we have a thematic diagram that walks you through this. First theme was really around the sorts of triggers that athletes find threatening for re-injury. So they found a range of triggers threatening for re-injury from things like movement, different sporting environments, certain rehab tasks, knee sensations, or even visual cues like watching

[00:07:27] someone do something that they found threatening. And these specific triggers were shaped by their personal context and the beliefs that they hold around things like the cause of their injury, their ability to control their injury, their perception of what symptoms mean, like knee symptoms, and the consequences for their injuries. So these sorts of things shaped how they appraised threat. This appraisal process is individual, so the sorts of triggers that they perceive to be threatening

[00:07:54] are also individual. So to sort of give you a bit of context around that, two athletes can have the same mechanism of injury. Let's say it's a contact mechanism and one athlete can maybe perceive that as, in terms of the cause, oh, that was just a fluke accident. It's just one of those things that happens in sport and no big deal sort of thing. And another athlete might interpret that as, oh, I've got some kind of weakness in my body or a fragility that's caused me to have this injury

[00:08:23] when someone's tackled me in that way, when I've been tackled a thousand times before in that way. The first person might not have much concern around other contact sorts of triggers, whereas the other one, other person, other athlete might feel that contact from all kinds of sources can be threatening. So for example, a dog running at them early rehab or being in a crowded social environment,

[00:08:48] like at a concert or something like that, or most commonly returning to sport and starting to enter those contact environments. So you could see how that individual appraisal process can impact how they are interpreting those sorts of triggers. The second theme was describing how athletes experience a wide range of emotions, thoughts, and physiological sensations when faced with the threat of re-injury. And that's what we mean by re-injury concerns are a multidimensional experience. In the emotional

[00:09:18] spectrum, athletes described various emotions from fearful to terrified to more milder emotions like concerned, apprehensive, or cautious when feeling this sense of threat around re-injury. And in the cognitive spectrum, these were thought processes that we identified that ranged in intensity as well from things like feeling hyper-awareness of their knee. So rather than describing their experience as fear of re-injury or whatnot, it might be, I'm just very aware of my knee. I'm really focused on it.

[00:09:47] I can't stop thinking about it. Or it might be a sense of over-analyzing movements or even intrusive thoughts around injury or re-injury. And then in terms of that physiological spectrum, again, a range of sensations there from things like muscle tension and guarding in their knee to feeling like they're frozen when they're triggered by something that they're finding threatening. The third theme described how athletes responded to re-injury concerns. So in general, we found that they

[00:10:16] adopted a range of behaviours or mental processes to move them from feeling threatened to feeling safe, whether it was behaviourally or mentally. So behaviourally, you know, our classic avoidance of, you know, maybe it's avoiding returning to sport or avoiding specific movements, or it might be modifying a task to a level that they feel comfortable with, like turning slower or changing positions on a team or whatnot. And when it came to, you know, cognitive coping processes that they

[00:10:45] were using, it might look like avoiding things that might trigger thoughts around re-injury. So avoiding watching sport or going to a certain oval that they used to play at that caused, that they had their injury on or other things that they might do cognitively might be around trying to gain control. So the sense of planning out all their movements and overthinking about how they might control

[00:11:09] risks, those re-injury concerns were dynamic and changed across the recovery period rather than being a fixed trait. So when you ask what are people with ACL injuries experiencing, it's a complex phenomenon with lots of facets. Is that how I'd describe it? As a clinician, we see these things and we hear the patients talk about them and we can see it in their movements sometimes. But you guys just like

[00:11:33] actually pulling it all together and almost just like organising it into a, this is a thing that a lot of people experience it in a lot of different ways and putting some language to it was just super helpful. The last thing you talked about was what they believe or, and what they're like thinking about it and the behaviours, but like at the end of like what they're actually doing about it. So like maybe they don't say they're afraid, but like they're moving differently. So based on this, is there anything

[00:11:58] that you guys found that clinicians should be watching for, like beyond self-reported questionnaires? So we developed a three case clinical vignettes in the paper. Those three cases describe a range of different presentations of re-injury concerns and there were some explicit action points that people or clinicians can take for each person depending on how those situations present. And one of those

[00:12:25] cases was a vignette called Jordan and they, this athlete sort of embodies what you just described where they, they're saying that they're not fearful, but they're behaving in a way that kind of suggests that they are. So, and it's really interesting because we found so many quotes within the research that were from athletes saying, I'm not afraid. I'm just, I don't want to use my leg to kick. It's not that I can't do it. It's just that I'm not comfortable doing it. I could, if I wanted to,

[00:12:53] but I'm not afraid or I'm not worried. I just think about it all the time. It's like, kind of sounds like you are worried. Some of the behaviors that we might see that they demonstrate would be things like they're, they're holding themselves back or hesitating in certain situations. And it typically presents for some people during the later stages of rehab, when you're starting to add in things like popping and, and like change of direction drills and things like that.

[00:13:17] Or if you're bringing them onto a sporting ground from onto a field from the clinic where they suddenly sort of stop using their leg in the same way that they would normally in the clinic. So it might be taking more steps to turn on the side of the injured leg, backing out of, of contact or contest with a ball, kicking a ball, but they're not really putting much force into it. It looks like they're kind of like not really giving it everything that they could give

[00:13:46] for some reason. You know, there could be a lot of other reasons as to why they're doing this, but what we found in the data is that re-injury concerns are some reasons why people behave in this way. If they're, they're seeking a lot of information from you, for example, they might be asking a lot of questions from you about the exercises. Like they might be hypervigilant about their form or their technique, or they're constantly drilling you for, are they doing this right? Or should I be doing something else that's different? Or is there anything extra I can do? Or

[00:14:14] they might be hypervigilant about meeting their timeframes or like their, you know, the timeline for return to sport or whatnot. So that hypervigilance around their program might be a sign that they're, they're concerned or they're trying to seek some control over their situation. Kobe, I think you did a really good job at kind of summarizing what are the things that we should be looking for? Because before I remember coming out of PT school, I just gave this one paper,

[00:14:39] this Tampa scale for kinesiophobia. Oh, they're, they're definitely fearful. But now we're starting to kind of dive a little bit deeper into, hey, what are some of these beliefs cues, some of the words that they may even use around some of their injury? I think we're really starting to challenge some of that traditional model that we had before that came from that fear avoidance model. Now that we kind of dissected what we're looking for, how do we begin to have that conversation?

[00:15:06] These athletes, whether we're in the clinic, we're in practice, what should we be talking about? What kind of language shouldn't we be using? Yeah, this is a really good point that we've got to. I suppose just taking a step back to where we were thinking about this traditionally, like we were essentially borrowing constructs from a chronic non-specific back pain population and trying to fit it to a specific condition, an ACL athletic population that's not traditionally a

[00:15:34] pain dominant condition. If you put yourself in the mindset of a person who's injured their ACL and we're constantly reliant on clinicians and surgeons to, I suppose, in a way dictate to us how much we're able to do, it makes sense logically that we're going to be concerned and have fear and have some apprehension around re-injury. Going back to what I talked about with chronic back pain where we're trying to encourage people to be moving despite, we're trying to eliminate fear so that they

[00:16:03] can move more and become less disabled. With someone with an ACL injury, I think what we want to reframe is that this is not a pathological process that's happened to them. This is a common sense experience that is happening to them. It makes sense. I would say in terms of how we communicate to our patients, it would be about normalising this experience. So yeah, it makes sense that you have

[00:16:28] concerns or you're fearful around re-injury or you're worried or you're focused on your knee. That's a totally normal experience. I would be surprised if you didn't, to be honest. So firstly, normalising the experience, using some neutral language to maybe engage the patient a bit more. So like, hey, do you have any concerns for re-injury? Just as we would if we were asking someone how an exercise felt to them. Like, oh, do you have any knee pain when you're doing that?

[00:16:54] How does it feel? How much effort does that require? Do you have any concerns for re-injury? This is just a normal conversation that we're having in rehab early and often so that we can hopefully open up that channel of communication with your patient. The other aspect of that would be shifting the focus away from fear itself and towards the underlying beliefs that are and the appraisals that shape how threat is interpreted, experienced and managed. So not just

[00:17:22] are you experiencing some fear or concerns or anxiety, but what's behind that? Like, what are you thinking about that's caused that appraisal that this particular activity or context is a concern for you? One big takeaway that I really like there's put yourself in their shoes and this injury has taken them a long time. It's maybe even taken them away from social, financial, other obligations, but

[00:17:50] just normalising this. And I think it is very normal to be feeling these different experiences. Do you think we sometimes unintentionally increase their re-injury concerns to the way we sometimes communicate re-injury risk, timelines that they're supposed to be on, our return to sport decision making, limb symmetry index, testing? I think that we definitely have a role as clinicians in shaping

[00:18:17] their perception around, I suppose, risk, threat and their knee for the good or bad. And that came up in our study where in the clinical case vignette of Ruth, the female athlete who had developed some concerns around re-injury. And that was informed by, you know, some of the things that her, the surgeon was talking to her about. So, you know, when you talk about risk of re-injury with your patients,

[00:18:44] and we need to be talking about risk of re-injury with an ACL injury, because it is high, like it's not, it's not all rosy, yet sticking to their rehab and not returning to sport too early, we can potentially overplay the risks. So that might look like sharing stories of other athletes who've had similar injuries to them, that they've returned too early and had a catastrophic second injury. So I suppose being mindful of the stories that we share with our athletes around catastrophic

[00:19:14] outcomes of other athletes or how we communicate to them around whether their knee is strong and stable or whether we're giving them messages around, oh, you should be careful or, you know, just be mindful of this or be careful of that. Whether we're saying, okay, yep, we know your knee has a really, has good capacity. You've got good, you can use some of those leg symmetry index assessments to help build their confidence in pointing out like, oh, you've done a great job with

[00:19:43] your rehab so far. This is what we're seeing in your leg symmetry index. We're a really important source of information for our patients. They rely on us to guide them on like how they're doing. So is my knee okay? Like where am I at in the scheme of things? Am I ahead of schedule? Am I on schedule? Am I lagging behind? And like those timelines are great if you are doing well, but if you're not doing well, they can be really detrimental to athletes' sense of their confidence in their knee.

[00:20:10] If we were to kind of take all of this together, I think the, for me, like the biggest takeaways are surveys might not capture it because the language is so varied and everyone experience, everyone's experience is so different. What they believe, what they feel, what they actually do about it. And so I think this is very validating because it really, it really lets me do my favorite thing in therapy, which is just chitty chat with the patients. Being able to bring it up regularly and kind of like normalize like the fear and the, like the, what they believe about it. So they're

[00:20:40] not just like, just kind of thinking that in their head and, you know, we're just focused on the objective things and they get to just sort the fear out themselves or their apprehension out themselves. So bringing it up regularly, getting to like the core of that and, and just chatting about like what they believe and why they're believing it so we can address it. And that will help also guide, you know, are they really super confident and we need to scare them a little bit to back down or are they super apprehensive and we don't need to lean in to like, Hey, you're,

[00:21:10] you're damaged and you're injured and you know, you can't cut yet. Don't, don't go play sand volleyball with your friend, whatever. Maybe we don't need to lean into it as much because they already have enough of that fear themselves, but that's just me because I like to chat with my patients. And so this is very validating. Is there anything else that you really want clinicians to be able to take from this? I suppose the biggest things would just be to ask the question. I do have any concerns. And I think clinicians struggle to do that because they are fearful that they're going to bring out

[00:21:38] something in a patient that they don't necessarily feel confident dealing with. Ask the question, ask it often and trying to understand, because we know that these concerns change throughout rehab. So if you think you've addressed, you know, one concern, there's going to be 20 others as they progress and you start to load them more and, you know, their context change and, and everything like that. I interviewed a patient who'd injured their ACL 20 years earlier. They were a high level

[00:22:05] rugby player. I was asking them to describe the sorts of things that they were, you know, had concerns about throughout different stages of their rehab. And they were describing this exercise of standing on a wobble board or like a BOSU ball. During him describing this, he started getting really red in his neck and like pulling at his collar sort of thing. And he was looking really uncomfortable. And he's describing that this was just a really awful, he hated this exercise. He, he found it

[00:22:33] really, he didn't like to use the word fear, really didn't like it. He was really worried for lack of a better word, I suppose that he was going to injure his, his knee. Asking him, what were you thinking about with that exercise? Like, what was it about the exercise that was concerning for you? And he was saying, I was just, when I would stand on it, I would just imagine my knee is just wobbling, you know, completely out of place and it's just going to completely give way. And, and all of that

[00:22:58] wobbling was causing strain on the ACL and he just absolutely hated it. And he vividly remembered it 20 years later. I just remember thinking like, that's not an exercise that I would think that would cause that response in a, in a, an athlete, like let alone stereotypical hyper-masculine rugby, elite rugby player. I wouldn't as a clinician just automatically go and reassure someone that this

[00:23:24] is a safe exercise. Cause I never thought that they would have those beliefs. Cause I didn't have those beliefs, but that's what I'm trying to say is don't assume what someone's believing about a certain exercise or, or how they get to that place. He didn't want that experience to get out to any members of his team, coach, or any oppositions that he might play in case they viewed that as a weakness. He said that he would really value his clinician taking the time to reassure him that

[00:23:51] those exercises were completely safe for the ACL. Before we wrap up really quick, just like plug the paper for the, it's filled with a bunch of like quotes from all of the research of direct quotes from patients and how they word things and how they're thinking about things. It was just really helpful. And I was like, Oh my gosh, I've seen and heard so many of these. It can be just a, a good resource for clinicians to kind of get used to and be able to just keep an eye out for. And then,

[00:24:18] you know, you hear that language, you see these things happen, and then that's your in on the question of, of bringing this up. And then also really those case studies in it were really helpful as well. Just really just like practical things for clinicians to consider, cue us to then open up that conversation. It's really great to be able to speak to you guys about it. Yeah. We put a lot of work into those clinical vignettes. So hopefully people, like you said, can, can draw a lot from

[00:24:44] them. More than fear of re-injury. Kobe, thank you so much for your time today. And thank you to you and your team for all the efforts that you put in to helping clinicians be able to understand this and apply it into clinical practice. No problem. Thank you for having me. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, you can subscribe to JOSPT Insights

[00:25:14] on Apple Podcasts, Spotify, TuneIn, Stitcher, Google, or your favourite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and rate and review us. To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter, we're at JOSPT, and Facebook, we're JOSPTOfficial. Talk with you next time.