Original research
The roles of acceptance and catastrophizing in rehabilitation following anterior cruciate ligament reconstruction

https://doi.org/10.1016/j.jsams.2014.04.002Get rights and content

Abstract

Objectives

The purpose of this study was to determine if pain catastrophizing and experiential acceptance predicted depression, pain intensity, and maladaptive behaviour following anterior cruciate ligament reconstruction.

Design

Patients who had undergone anterior cruciate ligament surgery completed assessment within 2 weeks of surgery (N = 44) and again 6 months post-surgery (N = 26).

Methods

Predictor measures were the Pain Catastrophizing Scale and the Acceptance and Action Questionnaire. Outcome measures included the depression scale of the Depression Anxiety and Stress Scale, numerical rating scale of pain intensity, and the alcohol and substance misuse subscale of the Brief Coping Orientations to the Problem Experience inventory. Demographic variables and athletic identity were also measured.

Results

Higher pain catastrophizing scores were associated with greater pain intensity and depressive symptoms in the 2-week post-operative period. Lower acceptance scores in the 2-week post-operative period were predictive of more severe depression scores at 6 months, even after controlling for early post-operative depression and athletic identity. Lower acceptance was also associated with greater use of alcohol and other substances, reportedly to cope with the stress of being injured.

Conclusions

This study highlights the importance of acceptance in an athletic population undergoing rehabilitation after ACL reconstruction.

Introduction

Anterior cruciate ligament (ACL) rupture is a common and debilitating injury among athletes,1 and rehabilitation following surgical reconstruction involves a relatively prescribed process of physical therapy that typically improves function and decreases pain.2 Although return to competitive sport usually commences between 6 and 9 months following surgery,2 approximately two-thirds of athletes who undergo ACL reconstruction (ACLR) rehabilitation do not return to pre-injury level of competitive sport by 12 months.3 Investigation of the psychological aspects of ACLR rehabilitation may provide further information about barriers to return to function.4

Pain intensity following ACLR has been shown to have a negative effect on rehabilitation outcomes.5 A large number of chronic pain studies have demonstrated strong positive associations between catastrophizing, pain intensity, and measures of depression, anxiety, and disability.6 Catastrophizing is characterised by negative thoughts associated with the anticipation of threat,7 and has been investigated in a small number of studies focused on ACLR rehabilitation.8, 9, 10 A higher level of catastrophic thinking is associated with greater pain intensity and poorer knee function during the post-operative phase,8, 9 and with poorer knee function and greater pain intensity at 6–12 months.8

Pain acceptance is a construct of increasing interest in chronic pain research,11 and has been associated with adjustment difficulties and reduced function in the context of chronic pain.12 There are now over 100 studies examining pain acceptance in chronic pain. Given that pain typically improves over the course of ACLR rehabilitation, a more general conceptualisation of acceptance may have greater relevance to ACLR rehabilitation than the narrower domain of chronic pain acceptance.

Acceptance, as defined in acceptance and commitment therapy, involves a willingness to embrace uncomfortable private experiences such as thoughts, emotions, and bodily sensations in the pursuit of important goals and actions.13 Hayes et al.14 have described in detail the theoretical and empirical underpinnings of the experiential acceptance construct. There is evidence that experiential acceptance correlates with measures of psychopathology.15 Low scores on experiential acceptance are associated with greater avoidant coping behaviours and, in turn, are related to higher anxiety in student populations.16 Higher levels of acceptance, as measured by the Acceptance and Action Questionnaire, also correlate with higher levels of hope, positive affect, and spiritual wellbeing in patients undergoing medical rehabilitation following spinal cord injury, stroke, amputation, and orthopaedic surgery.17 By contrast, lower acceptance has been associated with more severe depression and negative affect.17

The role of experiential acceptance has not been investigated in the sport injury rehabilitation context. Specifically, the relationships between acceptance and depressed mood and maladaptive behaviours in sport injury rehabilitation require investigation. Depression and pain intensity may impede progress in rehabilitation and, therefore, are dependent variables relevant to the rehabilitation context.5 In addition, alcohol and other substances are sometimes used to numb emotions and block unwanted thoughts during physical rehabilitation.18 Alcohol use has been associated with coping in athletic populations,19 and several studies have shown that acceptance may relate to alcohol use in veteran populations.20 However, no studies have explored the relationship between acceptance and the use of alcohol and other substances to cope with injury in an athletic sample.

A strong and exclusive athletic identity has been consistently associated with higher levels of depression and distress during sport injury rehabilitation.21 Therefore, examining the predictive capacity of a measure of acceptance after accounting for the effects of athletic identity represents a strong test of the utility of the acceptance construct in sport injury rehabilitation.

The aim of the current study was to assess the roles of catastrophizing and acceptance in relation to depression, pain intensity, and substance use to cope with injury within 2 weeks post-surgery and after 6 months of ACLR rehabilitation. The primary hypothesis was that higher pain catastrophizing scores would be associated with greater pain intensity and depression in the 2 weeks after surgery. By contrast, lower acceptance was hypothesised to be associated with greater pain intensity and depression in the 2 weeks after surgery; further, lower acceptance was hypothesised to predict higher depression and pain intensity at 6 months after accounting for depression, pain intensity, and athletic identity at 2 weeks post-surgery. A secondary hypothesis was that lower acceptance would be associated with greater alcohol and substance use, as this is a way of disengaging from the stress of being injured.

Section snippets

Methods

Individuals who had undergone ACL surgical reconstruction completed assessment within the first 2 weeks following surgery (mean = 7.4 days; N = 44; 27 male) and a subset of the questionnaires again at 6 months post-surgery (mean = 6.4 months; N = 26; 12 male). Participants also completed a consent form and provided demographic and sport participation information. The mean age of participants was 27 years (SD = 9.4 years) and the mean time between injury and surgery was 7 weeks 6 days (SD = 9 weeks 4 days;

Results

At Time 1, there were no statistically significant differences between participants who responded at both time points and those who participated at Time 1 only in terms of age, gender, time between injury and surgery, acceptance, catastrophizing, depression, pain intensity, alcohol and substance use as coping, and athletic identity; all ts(42) < 1.0, all ps > 0.3.

Table 1 contains the mean scores and standard deviations for variables at Times 1 and 2. Paired t-tests and Cohen's d effect sizes are

Discussion

Higher pain catastrophizing was significantly correlated with higher pain intensity and depressive symptoms in the 2 weeks after surgery, but not 6 months later. This finding in the immediate post-operative phase parallels the pain literature where pain catastrophizing and pain intensity have shown a strong positive association in numerous studies of chronic pain7 and post-operative pain.9 The non-significant result at 6 months may have been due to the way in which the measure of

Conclusion

This study demonstrated that general experiential acceptance is a potentially important construct in ACLR rehabilitation. A large body of research supports the utility of measures of chronic pain acceptance11 and acceptance-based interventions15 in chronic pain rehabilitation. Future research is warranted to assess the role of acceptance-focused treatment in sport injury rehabilitation and to develop measures of acceptance that are specific to the sport injury context.

Practical implications

  • Assessment of the tendency for pain catastrophizing may identify individuals who will experience higher pain intensity and mood disturbance in the early post-operative phase.

  • Assessment of acceptance may identify individuals who will have difficulty with depressive symptoms at 6 months after surgery.

  • Assessment of acceptance may identify individuals who use maladaptive coping strategies such as using alcohol and other substances as a way of disengaging from the stress of being injured.

Acknowledgements

J.P.C. is supported by a National Health and Medical Research Council (NHMRC) of Australia Career Development Fellowship (1031909).

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      Fear of movement/reinjury appears as a common preoperative emotion, while elevated pain catastrophizing is less prevalent and, perhaps, a unique state or trait characteristic among a subset of patients (George, Lentz, Zeppieri, Lee, & Chmielewski, 2012). Conflicting evidence exists for the relationship of pain catastrophizing to post-ACLR outcomes (Baranoff, Hanrahan, & Connor, 2015; Chmielewski & George, 2019; Chmielewski et al., 2011; Jochimsen et al., 2020; Pavlin, Sullivan, Freund, & Roesen, 2005; Tichonova, Rimdeikiene, Petruseviciene, & Lendraitiene, 2016; Tripp et al., 2007). Some studies have shown early postoperative pain catastrophizing (i.e., at 2–4 weeks after ACLR) predicted subsequent knee impairment resolution (e.g. 12 weeks) (Chmielewski & George, 2019) and post-rehabilitation pain, function, and quality of life (Tichonova et al., 2016), while other studies did not show significant relationships (Baranoff et al., 2015; Chmielewski et al., 2011).

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