A Psychological Support Intervention to Help Injured Athletes “Get Back in the Game”: Design and Development Study

Background After a serious knee injury, up to half of athletes do not return to competitive sport, despite recovering sufficient physical function. Athletes often desire psychological support for the return to sport, but rehabilitation clinicians feel ill-equipped to deliver adequate support. Objective We aimed to design and develop an internet-delivered psychological support program for athletes recovering from knee ligament surgery. Methods Our work for developing and designing the Back in the Game intervention was guided by a blend of theory-, evidence-, and target population–based strategies for developing complex interventions. We systematically searched for qualitative evidence related to athletes’ experiences with, perspectives on, and needs for recovery and return to sport after anterior cruciate ligament (ACL) injury. Two reviewers coded and synthesized the results via thematic meta-synthesis. We systematically searched for randomized controlled trials reporting on psychological support interventions for improving ACL rehabilitation outcomes in athletes. One reviewer extracted the data, including effect estimates; a second reviewer checked the data for accuracy. The results were synthesized descriptively. We conducted feasibility testing in two phases—(1) technical assessment and (2) feasibility and usability testing. For phase 1, we recruited clinicians and people with lived experience of ACL injury. For phase 2, we recruited patients aged between 15 and 30 years who were within 8 weeks of ACL reconstruction surgery. Participants completed a 10-week version of the intervention and semistructured interviews for evaluating acceptability, demand, practicality, and integration. This project was approved by the Swedish Ethical Review Authority (approval number: 2018/45-31). Results The following three analytic themes emerged from the meta-synthesis (studies: n=16; participants: n=164): (1) tools or strategies for supporting rehabilitation progress, (2) barriers and facilitators for the physical readiness to return to sport, and (3) barriers and facilitators for the psychological readiness to return to sport. Coping strategies, relaxation, and goal setting may have a positive effect on rehabilitation outcomes after ACL reconstruction (randomized controlled trials: n=7; participants: n=430). There were no trials of psychological support interventions for improving the return to sport. Eleven people completed phase 1 of feasibility testing (technical assessment) and identified 4 types of software errors, which we fixed. Six participants completed the feasibility and usability testing phase. Their feedback suggested that the intervention was easy to access and addressed the needs of athletes who want to return to sport after ACL reconstruction. We refined the intervention to include more multimedia content and support access to and the use of the intervention features. Conclusions The Back in the Game intervention is a 24-week, internet-delivered, self-guided program that comprises 7 modules that complement usual rehabilitation, changes focus as rehabilitation progresses, is easy to access and use, and includes different psychological support strategies.


Summary Box 1. Search strategy as applied to PubMed for literature search to address the question "What is the efficacy of psychological interventions for improving ACL injury rehabilitation outcomes in athletes?"
((((((Psychological Intervention OR ((Cognitive-behavioral therapy) OR (Cognitive) OR (Relaxation) OR (Imagery) OR (Guided Imagery) OR (Acceptance and Commitment Therapy)) OR Psychological Therapy OR (Behavioral Intervention AND (Physical Therapy)) OR (Therapeutics AND ((Mind-Body Therapies [MeSH]) OR (Acupuncture) OR (Message) OR (Goal setting) OR (Psychological Skills) OR (Meditation) OR (Videoinsight) OR (Psychotherapeutic)))))) AND ((rehabilitation outcome [MeSH] OR patient relevant outcomes OR (functional improvement) OR (strength) OR (anxiety) OR (return to sport) OR (functional outcome) OR clinical effectiveness OR Knee Outcomes))) AND (Anterior Cruciate Ligament Reconstruction [MeSH] OR ACL Reconstruction OR ACL OR ACL Surgery OR Anterior Cruciate Ligament Surgery)))

Trial Selection
We selected randomised controlled trials of psychological interventions administered before or after ACL reconstruction. To be included, trials had to fulfil the following criteria: Population. At least 50% of participants who completed final follow-up were skeletally mature athletes (any level) with ACL reconstruction Intervention. Any treatment aimed at addressing a psychological response/factor (eg cognition or emotion) Comparison. Any reasonable comparison (eg usual rehabilitation care) Outcome. Measured at least 1 rehabilitation-related outcome (eg self-reported knee function, muscle strength, return to sport rate, psychological response during treatment) One reviewer conducted the database search and selected the articles for inclusion. First, the reviewer screened the titles and abstracts of all records. Where it was unclear from the title and abstract whether an article should be included, we obtained and screened the article full text. We contacted authors to clarify information related to eligibility screening, as required.

Data Extraction
One reviewer extracted the following data elements from each included article: population (including number of participants), details of the psychological intervention, comparison, primary outcome(s) and primary trial end point. A second reviewer checked the data extraction for accuracy.
For an estimate of the effect of each intervention, one reviewer extracted the effect estimate, or sufficient data (eg mean, standard deviation, sample size) to calculate an effect estimate for the primary outcome(s) at the primary time point in each trial. Where multiple follow-ups were reported, we prioritised the longest follow-up from baseline. Where multiple primary outcomes were reported at the same time point, we extracted data for each outcome.
For an overview of trial quality, we extracted the Physiotherapy Evidence Database (PEDro) score, where available, from the PEDro website (www.pedro.org.au). If the trial was not indexed in the PEDro database, one reviewer assigned a PEDro score. [3] Data Summary Approach We identified 529 records. After deleting duplicate records, and screening, there were 7 trials to summarise ( Figure S1). We summarised the trial data elements, PEDro scores and effect estimates (Table S1), then produced descriptive summaries of the treatment approaches that had been studied. We used RevMan  The effect of sports psychology interventions on improving rehabilitation outcomes after ACL reconstruction have been studied for at least two decades. The most extensively studied psychological support interventions in sports rehabilitation were imagery, relaxation and goal setting.

Imagery or Visualisation
Athletes completed up to 10 sessions where they mentally rehearsed the specific skills or movements they were executing in physiotherapy rehabilitation, and imagined their body moving through stages of physiological healing. [4,5] There was conflicting evidence regarding the effects of imagery training on quadriceps strength, reinjury anxiety and selfefficacy.

Relaxation
Combining breath-assisted relaxation with guided imagery was effective for reducing pain and reinjury anxiety, and improving quadriceps strength in athletes at 6 months after ACL reconstruction compared to placebo or control. [4] Because it was a combined intervention, it was unclear whether relaxation alone might have yielded similar results.

Goal Setting
In a five-week goal setting intervention conducted by a sport psychologist in parallel with physiotherapy rehabilitation, athletes spent 60 to 105 minutes per week setting rehabilitation goals. [6] Athletes also completed a daily diary to document their progress and emotions during recovery. Goal setting might improve rehabilitation adherence and selfefficacy compared to social support or control. [6] Coping Modelling Participants watched a video of people with ACL injury demonstrating (modelling) coping strategies including rehabilitation exercises and sharing their thoughts, feelings and rehabilitation progress. Participants who watched the videos had superior self-reported knee function and early rehabilitation self-efficacy compared to control. [7] Therapeutic Insights After watching a contemporary art video for 2 months in combination with usual postoperative rehabilitation, participants who received the video designed to elicit positive therapeutic insights had superior self-reported knee function compared to participants who watched the video designed to elicit unfavourable insights. [8]