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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: Int J Sport Exerc Psychol. 2021 Jun 1;20(4):1133–1155. doi: 10.1080/1612197x.2021.1934712

An Interactive Cognitive-Behavioural Multimedia Program Favourably Affects Pain and Kinesiophobia During Rehabilitation After Anterior Cruciate Ligament Surgery: An Effectiveness Trial

Britton W Brewer 1, Judy L Van Raalte 2, Allen E Cornelius 3
PMCID: PMC9365250  NIHMSID: NIHMS1710246  PMID: 35968222

Abstract

Psychological interventions have been found effective in helping athletes cope with the challenges associated with knee surgery. In this investigation, an interactive cognitive-behavioural multimedia program was evaluated as a means of delivering psychological interventions to individuals experiencing anterior cruciate ligament (ACL) surgery in a field trial with 69 ACL surgery patients (30 women and 39 men; 24 competitive athletes, 41 recreational athletes, and 4 nonathletes; Mage = 35.01, SD = 11.98 years). Results indicated that compared to participants who received standard care, participants who received the multimedia program reported greater preoperative confidence in ability to cope, lower postoperative pain and kinesiophobia, and greater use and perceived utility of patient education materials. The findings suggest that the multimedia program has promise as an economical and effective means of educating and delivering psychological interventions to people experiencing ACL surgery and rehabilitation.

Keywords: ACL, knee, sport injury, patient education, pain, kinesiophobia

Injury is commonplace in association with involvement in sport and exercise. In the United States alone, an estimated 8.6 million sport- and recreation-related injuries are sustained each year (Sheu et al., 2016). Across the lifespan and the range of sport and recreational activities, knee injuries are among the most common and costly of orthopedic injuries (de Loes et al., 2000; Lyman et al., 2009). In particular, approximately 130,000 Americans sustain an acute tear of the anterior cruciate ligament (ACL) of the knee each year (Mall et al., 2014), with an estimated economic burden of 10 to 18 billion dollars annually (Mather et al., 2013). The ACL is important for providing stability to the knee (Muller, 1983). There is evidence that the incidence of ACL tears may be increasing (Lyman et al., 2009; Mall et al., 2014), especially among children and adolescents (Beck et al., 2017) and adults over the age of 40 (Mall et al., 2014). The treatment of choice to facilitate a return to sport and exercise among individuals who have torn their ACL is reconstructive surgery (Mather et al., 2013). Successful postsurgical rehabilitation is critical given that ACL tears are related to decreased sport career longevity in elite athletes (Kester et al., 2017) and that knee injuries in adolescence and early adulthood are associated with an elevated risk for osteoarthritis in later adulthood (Lohmander et al., 2004; Olestad et al., 2009).

Although the effectiveness of ACL reconstruction is well-documented (Mascarenhas et al., 2012; Osti et al., 2010; Stewart et al., 2016), several psychological challenges accompany ACL surgery. Some athletes have reported experiencing anxiety before ACL surgery (Brewer, Cornelius, Van Raalte et al., 2002; Otzekin et al., 2008), and research has shown that preoperative psychological distress is associated with less favorable rehabilitation outcomes following ACL reconstruction and other forms of knee surgery (Brewer et al., 2000; Wise et al., 1979). During the extended and rigorous period of rehabilitation that typically follows ACL surgery, athletes may experience pain and negative emotions (Baranoff et al., 2015; Brewer, Cornelius, Sklar et al., 2007; Garcia et al., 2015; Mainwaring et al., 2010; Morrey et al., 1999; Tripp et al., 2004).

As posited in the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998) and the biopsychosocial model of sport injury rehabilitation (Brewer, Andersen et al., 2002), athletes’ cognitive, emotional, and behavioural responses to sport injury can play an important role in sport injury rehabilitation outcomes. In particular, it has been proposed that psychological factors can influence three interrelated types of outcomes (i.e., cognitive-affective, functional, and physical) through both direct and indirect pathways. Cognitive-affective outcomes (e.g., subjective ratings of physical symptoms and functioning, pain, self-efficacy, anxiety) can be directly affected by psychological factors, whereas all three types of outcomes can be mediated through rehabilitation behaviour, biological factors, and social/contextual factors (Brewer, 2010; Brewer & Redmond, 2017). Accordingly, there are multiple ways that interventions targeting athletes’ postinjury cognition, emotion, and/or behaviour could have an impact on sport injury rehabilitation outcomes.

Outside the realm of sport injury rehabilitation, psychological interventions (e.g., providing sensory and procedural information about the surgery, modeling successful coping with surgery, training patients in coping strategies) have long been found useful in reducing preoperative psychological distress for a variety of surgical procedures (Johnston & Vogele, 1993; O’Halloran & Altmaier, 1995; Powell et al.,2016; Suls & Wan, 1989; Tsimopoulou et al., 2015). Cognitive-behavioural interventions, in which observable behaviours and covert mental processes are targeted for modification in an attempt to effect outcomes of interest (Plante, 2010), have also been found useful in reducing postoperative pain and enhancing cognitive-affective and functional rehabilitation outcomes for ACL reconstruction and other forms of knee surgery. For example, Ross and Berger (1996) demonstrated the efficacy of stress inoculation training (an intervention featuring training in self-monitoring, relaxation, imagery, and positive coping self-statements) for reducing pain, anxiety, and the number of days required to reach criterion physical functioning relative to a control condition following knee surgery. Similarly, in studies with ACL reconstruction patients, a relaxation and guided imagery intervention has produced significantly greater knee strength and significantly less pain and reinjury anxiety than control and placebo conditions at six months postsurgery (Cupal & Brewer, 2001) and significantly lower reductions in self-efficacy at 6- and 12-months postsurgery (Maddison et al., 2012). Experimental evidence of the beneficial effects of psychological intervention on knee rehabilitation outcomes has also been obtained for biofeedback (Draper, 1990; Draper & Ballard, 1991; Krebs, 1981; Levitt et al., 1995), goal setting (Theodorakis, Beneca, Malliou, & Goudas, 1997; Theodorakis et al., 1996), modeling (Maddison et al., 2006), and positive self-talk (Theodorakis, Beneca, Malliou, Antoniou, et al., 1997).

Despite the potential utility of psychological interventions in helping athletes cope with the challenges of ACL surgery and rehabilitation, there are several barriers to widespread implementation of such interventions. First, sports health care professionals may perceive themselves as having limited access to sport psychology consultants to whom they can refer athletes (Clement et al., 2013; Gervis et al., 2019). Second, athletes tend not to use psychological interventions of their own accord during injury rehabilitation (Arvinen-Barrow et al., 2015) and some athletes have expressed ambivalence toward psychological interventions, particularly if those interventions are “extra” or “additional” to their standard care (Brewer et al., 1994; Myers et al., 2004). Third, even if they are interested in psychological interventions, athletes undergoing ACL surgery and rehabilitation may not be able to afford the fees of a sport psychology consultant because such treatment may not be covered by health insurance (Gervis et al., 2019).

Interactive multimedia technology offers a means of overcoming potential accessibility, motivational, and financial barriers to implementing psychological interventions with ACL surgery patients, as it can provide interventions economically, engagingly, efficiently, and effectively. In particular, multimedia technology has shown promise as an easily disseminated, low-cost means of facilitating patient education and delivering cognitive-behavioural interventions prior to surgery for a variety of medical conditions (Budman, 2000; Fernandes et al., 2015; Sun et al., 2017). Multimedia technology may also be useful for delivering postoperative psychological interventions. Theodorakis, Beneca, Malliou, Antoniou, et al. (1997) used multimedia to implement a self-talk intervention with athletes after knee surgery and Levinger et al. (2017) developed an Internet-based intervention to assist individuals with self-management of their rehabilitation after ACL reconstruction. Of particular relevance to the current study, although the Levinger et al. intervention did not produce statistically significant effects on rehabilitation outcomes relative to a control condition, large and medium effect sizes were documented for quality of life and pain, respectively, and qualitative data suggested that the intervention was perceived as acceptable and favorable by participants.

The Current Study

Building on the work of Theodorakis, Beneca, Malliou, Antoniou, et al. (1997) and Levinger et al. (2017), the primary purpose of this investigation was to evaluate an interactive cognitive-behavioural multimedia program tailored to the preoperative, perioperative, and postoperative needs of individuals undergoing ACL reconstruction and postsurgical rehabilitation. In line with the models of instructional evaluation proposed by Dick and Carey (1990) and Gagne et al. (1992), the final prototype of the interactive multimedia program was subjected to the third level of formative evaluation—a field trial—in the current study. In particular, a randomized controlled trial was conducted to evaluate the effects of the multimedia program on preoperative and postoperative process and outcome variables that have been affected favorably by psychological interventions or associated with favorable rehabilitation outcomes in previous research. Given that the benefits of various components of the multimedia program (e.g., Brewer & Cupal, 2001; Maddison et al., 2006; Ross & Berger, 1996; Theodorakis et al., 1996) were demonstrated in efficacy trials—investigations in which extraneous, real-world influences were minimized and intervention dosages were carefully standardized (Finch, 2006)—an effectiveness trial was conducted. In effectiveness trials, interventions are applied as they would be in naturalistic, real-world settings (Gledhill et al., 2018). Consequently, the effects of the multimedia intervention were gauged against those of standard care, and measures of intervention uptake were administered.

It was hypothesized that relative to ACL reconstruction patients who receive standard patient education prior to their surgery, ACL reconstruction patients who received patient education through the multimedia program would experience: (a) less preoperative anxiety; (b) less pain over the first six months of postoperative rehabilitation; (c) less kinesiophobia (fear of movement) over the first six months of postoperative rehabilitation; (d) greater range of motion six months after surgery; (e) less knee laxity six months after surgery; and (f) fewer knee symptoms six months after surgery.

Method

Participants

Participants were 69 patients (30 females and 39 males) who were scheduled to have ACL reconstructive surgery between May 2007 and January 2009 with one of the three orthopedic surgeons affiliated with the project. Participants were selected on a consecutive patient basis from among prospective ACL reconstruction patients who expressed interest in participating in the study, had access to a personal computer (PC), and whose date of surgery was more than one week after the date on which the decision to have surgery was made. The mean age of participants was 35.01 (SD = 11.98, range = 15 to 67) years. Based on the self-reports of participants, the sample: (a) was predominantly White (93%) and not Hispanic or Latino (90%); and (b) consisted primarily of self-identified competitive athletes (n = 24, 35%) and recreational athletes (n = 41, 59%). The vast majority of participants (n = 53, 77%) reported that their injury occurred during sport participation. Participants had surgery a median of 46 days after their ACL injury.

Measures

Demographic, injury-related, surgery/rehabilitation process, and rehabilitation outcome variables were measured in the study.

Demographic and injury-related variables.

A questionnaire was used to obtain demographic and injury-related information from participants. The questionnaire included items requesting information on participants’ age, gender, race/ethnicity, date of ACL injury, source of ACL injury (i.e., sport-related activity or nonsport-related activity), and level of sport involvement (i.e., nonathlete, recreational athlete, or competitive athlete).

Surgery/rehabilitation process variables.

Measures of variables reflecting the process of going through ACL surgery and rehabilitation were administered. In particular, assessments of presurgical anxiety, pain, and kinesiophobia (fear of movement) were made. To gain an initial check on the potency of the experimental manipulation, items assessing perceived preparedness for ACL surgery, confidence about coping with ACL surgery and rehabilitation, perceived knowledge of ACL surgery and rehabilitation, treatment acceptability, and preparedness for surgery and rehabilitation were also administered. The state anxiety scale of the State-Trait Anxiety Inventory (STAI; Spielberger et al., 1970) was used to measure presurgical anxiety. Support has been obtained for the reliability and validity of the state anxiety scale of the STAI as a measure of current anxiety (Smith et al., 1998; Spielberger et al., 1980). The internal consistency of the STAI in the current study was acceptable (∝ = .93).

Knee pain was measured with a numerical rating scale (NRS) from 0 (no pain) to 10 (pain as bad as it can be). Strong support for the reliability and validity of the NRS has been obtained (Jensen & Karoly, 2001). In a study of ACL patients, 30-day retrospective NRS scores were highly correlated (r = .75) with daily NRS scores aggregated over the same 30-day period (Brewer et al., 2004). Kinesiophobia was assessed with the Tampa Scale for Kinesophobia (TSK; Kori et al., 1990), which consists of 17 items pertaining to the fear of reinjury (e.g., “I’m afraid that I might injure myself if I exercise”). Responses are given on a scale from 1 (strongly disagree) to 4 (strongly agree). The internal consistency of the TSK in the current study was satisfactory (∝ = .75).

In the initial check on the experimental manipulation, perceived preparedness for ACL surgery (“How prepared are you for ACL surgery and rehabilitation?”), confidence about coping with ACL surgery and rehabilitation (“How confident are you about your ability to cope with your ACL surgery and rehabilitation?”), and perceived knowledge of ACL surgery and rehabilitation (“How knowledgeable are you about your ACL surgery and rehabilitation?) were assessed with a series of single-item scales from 0 (Not at all prepared, Not at all confident, and Not at all knowledgeable, respectively) to 10 (Very prepared, Very confident, and Very knowledgeable, respectively).

Rehabilitation outcome variables.

Consistent with current standards for assessing ACL rehabilitation outcomes (Shaw et al., 2004), objective and subjective measures of ACL rehabilitation outcome were taken. Specifically, range of motion, laxity, and subjective symptoms were assessed. Range of motion (ROM) for flexion and extension in the involved and uninvolved knees was measured with a 12” plastic, hand-held 360° goniometer. Measurements were recorded with participants in the supine position (Cole & Tobis, 1982). Summary scores for range of motion were calculated by determining the degrees of difference between the involved and uninvolved knees for both flexion and extension (Engebretsen et al., 1990; Marder et al., 1991).

Instrumented evaluations of anterior-posterior laxity of the knee joint were conducted a KT1000 knee arthrometer (MEDmetric Corporation, San Diego, CA). Three trials were conducted for both the involved and uninvolved knees, and values were recorded at 30 pounds of force. A mean difference in KT1000 scores across the three trials was calculated for each participant. In vitro and in vivo data support the reliability and validity of the KT1000 as a measure of knee laxity (Daniel, Malcom et al., 1985; Daniel, Stone et al., 1985; Malcom et al., 1985).

Subjective, sport-related, knee-specific symptoms and functional disability were assessed with the Knee Outcomes Survey—Sports Activities Scale (KOS-SAS; Borsa et al., 1998), a questionnaire with 6 items measuring the extent to which various knee symptoms (i.e., pain, grinding or grating, stiffness, swelling, partial giving way or slipping, complete giving way or slipping) affect respondents’ sports activity level and 4 items measuring the extent to which respondents’ knee affects their ability to perform various sport tasks (i.e., running straight ahead, jumping and landing on the involved leg, stopping and starting quickly, cutting and pivoting on the involved leg). Item responses are given on 6-point Likert type scales scored from 0 to 5 and are summed and multiplied by two to create a 100-point (maximum) scale. Scores on the KOS-SAS are highly correlated (rs ranging from .67 to .87) with those on other major knee scoring systems (Borsa et al., 1998). In the current study, the KOS-SAS demonstrated acceptable internal consistency (∝ = .91).

Interactive Multimedia Program

The interactive multimedia program implemented in this study was developed over the course of five phases of research that are detailed in supplemental material. The program was designed to: (a) increase knowledge of the sensory and procedural aspects of ACL reconstructive surgery; (b) reduce preoperative psychological distress for ACL reconstruction patients; (c) decrease pain and reinjury anxiety following ACL reconstruction; and (d) enhance rehabilitation outcomes following ACL reconstruction. Consistent with the modified star life cycle approach to software development (Turner et al., 1997), user feedback was incorporated throughout the process of developing the program.

In keeping with the cognitive-behavioural intervention approach adopted in this study, content designed to provide ACL reconstruction patients with information on surgery- and rehabilitation-related matters and instruction in presurgical and postsurgical coping strategies was developed in the first of the five phases of program development. Such content was intended to facilitate cognitions and behaviours adaptive in dealing with challenges associated with ACL surgery and rehabilitation. Content development was guided by: (a) theory and research indicating that providing patients with both procedural and sensory information prior to surgery is preferred by patients (Wallace, 1985) and is optimal for reducing pain and distress (Suls & Wan, 1989); (b) research demonstrating the favorable effects of selected cognitive-behavioural interventions (i.e., goal setting, imagery, modeling, and positive self-talk) on postsurgical knee rehabilitation outcomes (e.g., Cupal & Brewer, 2001; Maddison et al., 2006, 2012; Ross & Berger, 1996; Theodorakis, Beneca, Malliou, Antoniou, et al., 1997; Theodorakis, Beneca, Malliou, & Goudas, 1997; Theodorakis et al., 1996); and (c) results of focus groups with 20 individuals who previously had undergone ACL reconstruction. In the second phase, the content was vetted for accuracy and usability by an orthopedic surgeon, a health psychologist, and a physical therapist. In the third phase, an initial prototype of the program was produced. In the fourth phase, three studies were conducted with the target population (i.e., current ACL reconstruction patients in two studies and former ACL reconstruction patients in one study) to assess the acceptability and usability of the program. In the fifth phase, the initial prototype of the program was modified in accordance with user feedback and a final prototype of the program was produced. The final prototype of the interactive multimedia program was used in the experimental condition of the current study. Program content is summarized in Table 1. Following a screen with introductory information and instructions for use of the program, the main menu of the program consisted of three subdivisions: (a) General Information; (b) Surgery; and (c) Rehabilitation. The Surgery section was further divided into three subsections: (a) Before Surgery; (b) Day of Surgery; and (c) After Surgery. Within the General Information section, the Rehabilitation section, and each of the three Surgery subsections, there were three further subdivisions: (a) Overview; (b) A Closer Look; and (c) Get Practical.

Table 1.

Data Collection Protocol

Timing of Data Collection Data Collected
Preoperative office visit Demographic and injury-related information, STAI state anxiety, pain (NRS), kinesiophobia (TSK), subjective knee symptoms (KOS-SAS), range of motion, knee laxity (KT1000)
24 hours before surgery STAI state anxiety, perceived preparedness, confidence about coping, perceived knowledge
1-month postsurgery pain (NRS), kinesiophobia (TSK), subjective knee symptoms (KOS-SAS)
2-months postsurgery pain (NRS), kinesiophobia (TSK), subjective knee symptoms (KOS-SAS)
3-months postsurgery pain (NRS), kinesiophobia (TSK), subjective knee symptoms (KOS-SAS)
4-months postsurgery pain (NRS), kinesiophobia (TSK), subjective knee symptoms (KOS-SAS)
5-months postsurgery pain (NRS), kinesiophobia (TSK), subjective knee symptoms (KOS-SAS)
6-months postsurgery pain (NRS), kinesiophobia (TSK), subjective knee symptoms (KOS-SAS), range of motion, knee laxity (KT1000), postexperimental questionnaire
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The five Overview sections featured video clips in which an orthopedic surgeon discussed in plain language the sensory and procedural aspects associated with the corresponding section of the program. The video clip of the orthopedic surgeon in the Day of Surgery overview included footage of an actual patient entering a surgery center, completing preoperative paperwork, meeting with the anesthesiologist, being prepared for surgery by the surgeon and the surgical staff, entering surgery, undergoing surgery, recovering from surgery, receiving instructions from the nursing staff prior to discharge, and exiting the surgery center. Other settings for the video clips with the orthopedic surgeon included a doctor’s office, an examination room, and a rehabilitation facility.

The five A Closer Look sections expanded upon the issues identified by the orthopedic surgeon in the Overview Sections. Anatomical and surgical animations, video and still images of preoperative and postoperative rehabilitation exercises, video clips of former ACL reconstruction patients describing their experiences with ACL surgery and rehabilitation, a graph of pain over the rehabilitation process, and written text were among the means by which procedural and sensory information and modeling of adaptive coping responses were presented in the A Closer Look sections.

The five Get Practical sections were designed specifically to help users apply what they learned in the other sections of the program and acquire strategies for coping with the challenges of ACL surgery and rehabilitation. Features of the Get Practical sections included links to online resources, personal accounts of and recommendations for dealing with ACL surgery and rehabilitation from former patients (varying in age, gender, and race/ethnicity) in video and text formats, a printable checklist of questions to ask the orthopedic surgeon prior to ACL surgery, a printable list of tips to prepare (one’s body, mind, and home) before surgery, a list of tips for what to do on day of surgery, tips for what to do after surgery (e.g., driving, bathing, eating, taking pain medication, obtaining support from others), tips for adhering to rehabilitation, a printable rehabilitation journal that was the primary vehicle for conveying goal setting and positive self-talk interventions to users, and instructions on how to use the preoperative and postoperative guided imagery program. The content of an empirically validated relaxation and guided imagery intervention was adapted for use in a series of one preoperative and eight postoperative audio segments that were produced in a professional recording studio. The intervention had been found effective in accelerating recovery and reducing pain and reinjury anxiety following ACL reconstruction (Cupal & Brewer, 2001). Each audio recording began with several minutes of breath-assisted relaxation and focused on (a) the specific physiological process(es) at work during each stage of recovery (e.g., edema, pain, inflammation); (b) the provision of suggestions to promote positive emotional coping responses; and (c) using various imagery modalities (e.g., internal, external, visual, kinesthetic) to facilitate vivid mental experiencing of the imagery content. Appropriate royalty-free music accompanied each of the audio segments.

Procedure

A power analysis was conducted to determine the intended sample size. Based on previous research (Cupal & Brewer, 2001; Maddison et al., 2006; Ross & Berger, 1996), we expected effect sizes of d > .45 for pain, reinjury anxiety, and subjective symptoms. Results of a power analysis (with power set at 0.80) indicated that we should have a final sample size of 99 participants. Allowing for 25% participant attrition (which actually ended up being 31%), we had hoped to recruit 132 participants into the study. After obtaining institutional review board (IRB) approval, patients who satisfied participation criteria were recruited from the office practices of the orthopedic surgeons who were affiliated with this research. At the conclusion of the appointment at which prospective participants first decided to have surgery, a research associate described the purpose and procedures of the study to patients who expressed interest in participating in the study. Participants were offered $150.00 as compensation for full participation in the study. Patients who agreed to participate were asked to read and complete an informed consent form. After completing the informed consent document, participants were instructed to fill out the questionnaire requesting demographic and injury-related information, the STAI state anxiety scale, the NRS (pain scale), the TSK (kinesiophobia), and the KOS-SAS (subjective knee symptoms). Range of motion and laxity assessments were also performed at this time by a physician assistant.

Participants were then randomly assigned to either the experimental group (n = 34) or the control group (n = 35). Randomisation was conducted in blocks of 10, with group assignment determined by drawing a slip of paper with the name of the respective condition from a manila envelope. Participants in the experimental group were introduced to the final prototype of the interactive multimedia program on a computer in the office setting. Consistent with the status of the study as an effectiveness trial, implementation of the experimental and control conditions reflected the standard patient education practices of the orthopedic surgeons involved in the research. Participants in the control group were asked to read a standardized set of printed educational materials (i.e., an informational booklet published by Krames [www.krames.com] titled Knee Ligament Injuries: Diagnosis and Treatment). Participants in the control group were asked to take their booklet home with them; participants in the experimental group were given a CD-ROM containing the multimedia program and asked to take it home with them. Before departing from the office, participants in both groups were given a set of questionnaires and postage-paid envelopes to return at designated times specified below, including the state anxiety scale of the STAI, which participants were instructed to complete and return to the researchers in a postage-paid envelope in the final 24 hours before surgery. The orthopedic surgeons were not informed of participants’ group assignment status.

Participants received arthroscopically-assisted ACL reconstructive surgery from one of the two orthopedic surgeons on the project. Most participants had either a patellar tendon autograft procedure or a combined semitendinosis-gracilis tendon autograft procedure, neither of which has a clear advantage over the other and both have been found effective (Jansson et al., 2004).

Participants were asked to complete a packet of questionnaires including the NRS, TSK, and KOS-SAS, and to return the completed packet of questionnaires in a postage-paid envelope on a monthly basis for the first five months of postoperative rehabilitation. Participants in both groups were reminded by telephone and/or electronic mail at the end of each month to return their questionnaires to the research team. Six months after surgery, participants returned to the office for an assessment battery that included the NRS, TSK, KOS-SAS, ROM, and KT1000. As a final check on the experimental manipulation, participants also completed postexperimental questionnaires assessing their perceptions of the patient education materials. Specifically, participants were asked to indicate how many times they had used the CD-ROM or booklet and how useful the CD-ROM or booklet was in helping them (on scales from 0 [not at all] to 10 [very]): (a) feel comfortable going into their surgery; (b) cope with their surgery; (c) deal with pain; (d) adhere to the rehabilitation protocol; (e) cope with rehabilitation; and (f) return to vigorous physical activity. Participants in the experimental group were also asked to indicate how many of the 5 surgeon videos they had watched, how many of the 9 patient videos they had watched, how many days per month they had used the guided imagery portion of the program, and how many days per month they had used the electronic rehabilitation journal. Upon completion of the assessment battery, participants were fully debriefed. Research participation incentives were provided following all data collection episodes to reinforce and maximize participants’ involvement in each phase of the study. A summary of the data collection protocol is provided in Table 2. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Table 2.

Summary of the Interactive Program

Major Subdivisions Features
General information
  Overview surgeon video
  A closer look knee anatomy and ACL tear animations and text
  Get practical online resources, patient stories (video and text)
Surgery
  Before surgery
    Overview surgeon video
    A closer look physical therapy images and text, patient video and text
    Get practical checklists, tips, patient video, guided imagery (audio and text)
  Day of surgery
    Overview surgeon video
    A closer look surgery animation/information, patient video and text
    Get practical surgery checklist, patient video and text
  After surgery
    Overview surgeon video
    A closer look patient video and text
    Get practical reactions to surgery, postsurgery tips (text and video)
Rehabilitation
  Overview surgeon video
  A closer look rehabilitation information (video, text, graphics)
  Get practical tips (text), guided imagery (audio, video, text), patient video and text, rehabilitation journal (goal setting, self-talk)
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Data Analysis

Preoperative assessment.

A series of independent groups t-tests and chi-square tests was conducted to compare the scores of participants in the experimental group with those of participants in the control group on all variables measured at the preoperative assessment. Independent groups t-tests were used to compare the STAI state anxiety, perceived preparedness for ACL surgery, confidence about coping with ACL surgery and rehabilitation, and perceived knowledge of ACL surgery and rehabilitation scores of experimental group and control group participants. Effect sizes were assessed with Cohen’s d (Cohen, 1988).

Attrition analysis.

Independent groups t-tests were also used to compare the scores of participants who remained in the study through the 6-month assessment with those of participants who dropped out of the study prior to the 6-month assessment on all variables measured at the preoperative assessment. Effect sizes were assessed with Cohen’s d (Cohen, 1988).

Main analyses.

Separate 2 × 6 (group x time) mixed repeated-measures analyses of covariance (ANCOVAs) were used to compare the NRS, TSK, and KOS-SAS scores of experimental group and control group participants across the six monthly assessments while statistically controlling for the preoperative scores on those variables. Separate ANCOVAs were used to compare the postoperative ROM and KT1000 scores of experimental group and control group participants while statistically controlling for the preintervention scores on those variables. Effect sizes were assessed with partial η2.

Postexperimental questionnaire.

An independent groups t-test was conducted to compare the number of times the experimental group participants reported using their CD-ROM with the number of times the control group participants reported using their booklet over the course of the study. Independent groups t-tests were used to compare experimental group participants and control group participants in terms of their ratings of how useful their form of participant education (i.e., CD-ROM or booklet) was for helping them to feel comfortable going into their surgery, cope with their surgery, deal with pain, adhere to the rehabilitation protocol, cope with rehabilitation, and return to vigorous physical activity. Effect sizes were assessed with Cohen’s d (Cohen, 1988).

Results

Data on the recruitment of prospective participants and the retention of recruited participants through the study are displayed in Figure 1. Although the sample fell short of the targeted 99 participants suggested by power analysis, we followed the suggestion of Vacha-Haase and Thompson (2004) to focus on effect sizes (in addition to statistical significance testing) to provide meaningful interpretation of the data. In the series of independent groups t-tests and chi-square tests comparing the experimental group and the control group for variables measured at the preoperative assessment, the effect sizes were all small or trivial (all ds < .40) and none of the differences were statistically significant. Thus, it appears that the randomization was successful, and the groups were equivalent prior to surgery.

Figure 1.

Figure 1.

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Flow chart of participant recruitment, enrollment, assignment, and completion of assessments.

Preoperative Assessment

Of the 69 participants, 61 (88%; nexperimental = 31, ncontrol = 30) completed the assessment 24 hours prior to surgery. The differences between the experimental group and the control group on the STAI and perceived preparedness item corresponded to small effect sizes (d = .31 and d = .26, respectively) and were not statistically significant. In terms of confidence in the ability to cope with ACL surgery and rehabilitation, the difference between participants in the experimental group (M = 9.20, SD = 1.06) and those in the control group (M = 8.32, SD = 2.10) corresponded to a medium effect size, d = 0.52, 95% CI [0.01, 1.03], t(59) = 2.04, p = .04. The difference between the perceived knowledge of ACL surgery and rehabilitation scores of participants in the experimental group (M = 8.47, SD = 1.79) and those in the control group (M = 7.65, SD = 1.64) corresponded to a small effect size, d = 0.48, 95% CI [−0.03, 0.98], t(59) = 1.86, p = .07.

Attrition Analysis

Results of the independent groups t-tests comparing the scores of participants who remained in the study through the 6-month assessment with those of participants who dropped out of the study prior to the 6-month assessment on all variables measured at the preoperative assessment revealed only a single effect of note. A medium effect size was obtained for the difference in KT1000 scores between participants who remained in the study through the 6-month assessment and participants who dropped out of the study prior to the 6-month assessment, d = 0.52, 95% CI [0.03, 1.00], t(65) = 2.12, p = .04, with the former group displaying higher KT1000 scores (i.e., greater knee laxity). The differences between the participants who remained the study and those who dropped out of the study for age, the STAI state anxiety scale, the NRS (pain), the TSK (kinesiophobia), the KOS-SAS (subjective knee symptoms), and the items assessing the extent to which participants perceived themselves as prepared for, confident in their ability to cope with, and knowledgeable regarding their surgery and rehabilitation were small (all ds < .45) and none of the differences were statistically significant.

Main Analyses

Means and standard deviations for NRS (pain), TSK (kinesiophobia), and KOS-SAS (subjective knee symptoms) scores over the course of the study are presented in Table 3. In the ANCOVA comparing the NRS (pain) scores of experimental group participants and control group participants, Mauchly’s test of sphericity was statistically significant (p = .02), so the Greenhouse-Geisser correction was applied to the tests involving the repeated-measure time effect. The effect size for time was medium, partial η2 = .20, 95% CI [.06, .31], F(3.87, 119.89) = 7.52, p < .001, with pain scores decreasing steadily over the 6-month assessment period. The effect size for group was also medium, partial η2 = .10, 95% CI [0.00, 0.34], F(1, 31) = 3.29, p = .08, with lower pain scores for the experimental group than the control group across the six monthly assessments. Superseding the time and group effects, however, was the medium effect size for the group X time interaction, partial η2 = .12, 95% CI [.02, .22], F(3.87, 119.89) = 4.28, p = .01. Examination of the simple effects revealed that the NRS (pain) scores of both groups decreased over time, but the effect size for the decrease over time was large for the experimental group, partial η2 = .25, 95% CI [.03, .44], F(2.76, 41.42) = 4.90, p = .006, and small for the control group, partial η2 = .19, 95% CI [.00, .39], F(2.55,38.35) = 3.51, p = .03. The effect size for the covariate was large, partial η2 = .39, 95% CI [.12, .62], F(1, 31) = 19.52, p < .001.

Table 3.

Means and Standard Deviations of Pain, Reinjury Anxiety, and Subjective Symptoms Before Surgery and at 1-, 2-, 3-, 4-, 5-, and 6-Months After Surgery

Variable Before surgery M (SD) 1-month M (SD) 2-months M (SD) 3-months M (SD) 4-months M (SD) 5-months M (SD) 6-months M (SD)
Pain (NRS)
  Experimental group 2.24 (1.99) 2.41 (0.66) 1.29 (1.65) 1.06 (1.44) 0.88 (0.99) 0.29 (0.47) 0.18 (0.39)
  Control group 2.59 (2.72) 2.53 (2.29) 2.06 (2.63) 2.76 (2.99) 1.88 (2.67) 1.94 (2.41) 1.47 (2.39)
Kinesiophobia (TSK)
  Experimental group 25.67 (5.18) 21.42 (5.40) 20.42 (5.50) 21.00 (4.90) 19.00 (3.86) 18.00 (5.44) 17.92 (5.14)
  Control group 25.60 (7.35) 23.33 (5.77) 24.40 (6.30) 24.87 (7.57) 23.73 (6.93) 22.80 (6.14) 21.47 (6.03)
Subjective symptoms (KOS-SAS)
  Experimental group 25.38 (19.42) 22.92 (20.11) 36.92 (19.50) 42.77 (17.73) 63.08 (18.75) 67.23 (18.52) 75.24 (24.69)
  Control group 25.25 (24.46) 19.00 (25.04) 34.00 (23.66) 32.50 (25.76) 47.25 (23.90) 51.88 (29.62) 65.38 (28.88)
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Note. Means and standard deviations are for participants who had complete responses at all seven data collection points for each variable. The “Before surgery” data were collected at the preoperative office visit.

In the ANCOVA comparing the TSK (kinesiophobia) scores of experimental group participants and control group participants, Mauchly’s test of sphericity was not statistically significant (p = .77). The effect sizes for time, partial η2 = .01, 95% CI [.00, .02], F(5, 120) = 0.25, p = .94, and the group X time interaction, partial η2 = .03, partial η2 = .03, 95% CI [.00, .07], F(5, 120) = 0.78, p = .57, were both small. The effect size for group, however, was medium, partial η2 = .17, 95% CI [.00, .47], F(1, 24) = 5.03, p = .03, indicating that the TSK (kinesiophobia) scores of the experimental group were significantly lower than those of the control group across the six-month assessment period. The effect size for the covariate was large, partial η2 = .31, 95% CI [.04, .59], F(1, 31) = 10.61, p = .003.

In the ANCOVA comparing the KOS-SAS (subjective knee symptoms) scores of experimental group participants and control group participants, Mauchly’s test of sphericity was statistically significant (p = .002), so the Greenhouse-Geisser correction was applied to the tests involving the repeated-measure time effect. The effect size for time was large, partial η2 = .38, 95% CI [.20, .52], F(3.15, 81.85) = 16.25, p < .001, with KOS-SAS (subjective knee symptoms) scores increasing steadily over the 6-month assessment period. Although the means for the experimental group were higher than those for the control group for all six monthly assessments, the effect size for group was small, partial η2 = .08, 95% CI [.00, .34], F(1, 26) = 2.19, p = .15. The effect size for the group X time interaction was also small, partial η2 = .03, 95% CI [.00, .11], F(3.15, 81.85) = 0.85, p = .48. The effect size for the covariate was medium, partial η2 = .17, 95% CI [.00, .45], F(1, 26) = 5.34, p = .03.

Means and standard deviations for ROM and KT1000 (knee laxity) scores before and after surgery are displayed in Table 4. In the ANCOVAs comparing the postoperative ROM and KT1000 (knee laxity) scores of the experimental group and the control group while statistically controlling for preintervention scores on those variables, the effect sizes for group were all trivial or small for ROM flexion, partial η2 = .00, 95% CI [.00, .99], F(1, 41) = 0.00, p = .99, ROM extension, partial η2 = .04, 95% CI [.00, .22], F(1, 41) = 1.86, p = .18, and KT1000 (knee laxity), partial η2 = .07, 95% CI [.00, .27], F(1, 41) = 3.04, p = .09, scores. The effect size for the covariate was trivial for ROM flexion, partial η2 = .01, 95% CI [.00, .13], F(1, 41) = 0.26, p = .61, and ROM extension, partial η2 = .003, 95% CI [.00, .11], F(1, 41) = 0.10, p = .75, but was medium in the KT1000 (knee laxity) analysis, partial η2 = .18, 95% CI [.02, .40], F(1, 41) = 8.73, p = .09, indicating that preoperative knee laxity is moderately predictive of postoperative knee laxity despite the implementation of reconstructive surgical procedures.

Table 4.

Means and Standard Deviations for KT1000 and Range of Motion Flexion and Extension Scores Before Surgery and at 6-Months After Surgery

Presurgery Postsurgery
Variable M SD M SD
KT1000a
  Experimental group 2.01 0.86 0.95 0.39
  Control group 2.12 0.89 1.08 0.57
Range of motion – flexionb
  Experimental group −15.55 18.64 −4.18 8.97
  Control group −20.68 30.32 −4.27 5.05
Range of motion – extensionb
  Experimental group −2.86 5.47 −0.43 1.43
  Control group 1.93 21.93 −1.09 1.80
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a

Ratio of KT1000 values for involved knee/uninvolved knee.

b

Values for involved leg-uninvolved leg.

Postexperimental Questionnaire

The effect size for the difference between participants in the experimental group and participants in the control group in terms of use of their respective patient education materials was medium, d = 0.63, 95% CI [0.04, 1.20] , t(22.95) = 2.15, p = .04, with patients in the experimental group (M = 11.91, SD = 18.65) reporting that they used the CD-ROM more times than participants in the control group (M = 3.46, SD = 2.98) reported using the booklet. Means and standard deviations of the ratings of the utility of the experimental and control materials are shown in Table 5. The effect sizes for the mean differences in utility ratings (with all means favoring the experimental group) were: (a) trivial for feeling comfortable going into surgery, d = 0.03, 95% CI [−0.53, 0.60], t(46) = 0.12, p = .90; (b) small for feeling comfortable or coping with surgery, d = 0.36, 95% CI [−0.21, 0.93], t(46) = 1.24, p = .22; (c) medium for dealing with pain, d = 0.74, 95% CI [0.15, 1.31], t(46) = 2.55, p = .01, adhering to the rehabilitation protocol, d = 0.60, 95% CI [0.02, 1.17], t(46) = 2.08, p = .04, and coping with rehabilitation, d = 0.61, 95% CI [0.03, 1.19], t(46) = 2.11, p = .04; and large for returning to vigorous physical activity, d = 0.81, 95% CI [0.2, 1.39], t(46) = 2.79, p = .008.

Table 5.

Means and Standard Deviations for Postexperimental Ratings of Utility of Patient Education Materials

Experimental Group Control Group
Variable M SD M SD
Comfort going into surgery 6.65 2.67 6.56 2.62
Cope with surgery 6.61 2.84 5.60 2.81
Deal with pain 5.52 2.98 3.40 2.78
Adhere to rehabilitation protocol 5.87 2.30 4.28 2.92
Cope with rehabilitation 6.39 2.71 4.72 2.76
Return to vigorous physical activity 6.04 3.92 2.60 2.66
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On the postexperimental questionnaire, participants in the experimental group (n = 23) reported that they watched an average of 3.87 (SD = 2.52, median = 5, mode = 5) of the 5 surgeon videos and an average of 5.48 (SD = 3.19, median = 6, modes = 6 and 9) of the 9 patient videos in the cognitive-behavioural multimedia program. They also indicated that they had used a guided imagery recording 2.61 (SD = 3.79, median = 1, mode = 0) times per week and used the electronic rehabilitation journal an average of 4.74 (SD = 8.86, median = 0, mode = 0) times per week.

Discussion

In this investigation, the effectiveness of an interactive cognitive-behavioural multimedia program for ACL surgery and rehabilitation was examined in a randomized controlled field trial. Medium effect sizes were obtained for several variables in comparisons between the experimental group and the control group. Specifically, relative to participants who received standard care in terms of patient education, those who were given access to the multimedia program reported (a) higher levels of confidence in their ability to cope with ACL surgery and rehabilitation; (b) lower levels of pain and kinesiophobia during the first 6-months after ACL surgery; (c) more frequent use of their patient education materials; and (d) higher levels of perceived utility of their patient education materials for dealing with pain, adhering to the rehabilitation protocol, coping with rehabilitation, and returning to vigorous physical activity.

Although the hypothesis that the intervention would reduce preoperative anxiety relative to the control condition was not supported, the finding for confidence in the ability to cope with ACL surgery and rehabilitation is the first documented beneficial effect of an intervention on a psychological variable assessed just prior to ACL surgery of which we are aware. The medium effect size for the confidence in coping ability manipulation check variable suggests that a patient information intervention delivered via interactive multimedia can have a tangible and favorable impact on the psychological state of individuals prior to ACL surgery.

Support was obtained for the hypotheses that the interactive multimedia program would be associated with less pain and less kinesiophobia over the first six months of postoperative rehabilitation. Previous research has demonstrated the utility of multifaceted psychological interventions for reducing pain and anxiety after sport-related knee injuries (Cupal & Brewer, 2001; Ross & Berger, 1996; Zaffagnini et al., 2013). The lack of significant effects and corresponding effect sizes of the interactive multimedia program on range of motion are consistent with those of Maddison et al. (2006). Knee laxity had not previously been investigated as an outcome in studies of the effects of psychological interventions in the context of ACL surgery and rehabilitation. Nevertheless, the nontrivial effect size (partial η2 = .07) and an inverse correlation between psychological distress and knee laxity in a previous study (Brewer et al., 2000) suggest that knee laxity may be susceptible to the influence of psychological factors. Similarly, the magnitude of the intervention effect in the current study (partial η2 = .08) and previous experimental investigations (Maddison et al., 2006; Zaffagnini et al., 2013) suggest that subjective knee symptoms are also a viable target for psychological intervention.

Because the current study was an effectiveness trial rather than an efficacy trial, the magnitude of the effects of the interactive multimedia program may have been diminished. Given that participants were free to choose the extent to which they engaged with the intervention, it is likely that they had less exposure to the intervention than they would have had in an efficacy trial. In the Cupal and Brewer (2001) study, for example, participants received the relaxation and guided imagery intervention in ten 30 to 40 min in-person sessions with a clinician and a recommended daily 10 to 15 min of out-of-clinic rehearsal of scripted activity (participants reported engaging with the intervention an average of 4.40 times per week) over the first 6 months after ACL surgery. In contrast, participants in the current study reported that they used the version of the Cupal and Brewer intervention that was adapted to the multimedia format an average of 2.61 times per week over the same period of time. Thus, the reduced “dose” of the intervention that participants received in the current study may have accounted for the reduced “response” of participants to the intervention, as evidenced by the lower partial η2 values for pain and kinesiophobia obtained in the current study (partial η2 = .10 and .17, respectively) versus those obtained in the Cupal and Brewer study (η2 = .76 and .62, respectively).

Mirroring the positive impressions expressed by participants who experienced the online intervention developed by Levinger et al. (2017), the postexperimental questionnaire results attest to the acceptability of the interactive multimedia program to participants. The multimedia program was rated as more useful than standard care for an array of tasks pertaining to coping with the rigors of postoperative rehabilitation and the return to sport. These findings attest to the social validity of the intervention and offer the most plausible explanation for the effects of the intervention obtained in the main analyses. Even with the relatively modest uptake of the multimedia program in the current study, the apparent utility of the program for coping purposes may have translated into lower levels (as indicated by effect sizes) of kinesiophobia, pain, subjective knee symptoms, and knee laxity for the experimental group than for the control group. To verify this mediational explanation, research is needed in which the effects of the intervention on coping parameters are assessed prospectively in relation to the outcomes of interest.

Several important limitations should be taken into account when interpreting the findings. First, although well-validated scales, instruments, and procedures were used to measure variables examined in the main analyses, results obtained from the checks on the experimental manipulation in the preoperative assessment and the postexperimental questionnaire are based primarily on data obtained with unvalidated, single-item scales. Although replication of the current findings with better validated instruments would enhance confidence in the results, it should be noted that use of unvalidated (or face-valid), single-item scales for manipulation checks is common practice (Chester & Lasko, 2020). Further, single-item scales can achieve validity values comparable to those of multiple-item measures of the same constructs (Bergkvist & Rossiter, 2007; Gardner et al., 1998), with the added advantages of enhanced ease of administration (Tenenbaum et al., 2007), minimized respondent burden, reduced criterion contamination, and increased face validity (Fisher, Matthews, & Gibbons, 2016). Second, retrospective self-report was used to assess participants’ use of the experimental or control materials. This approach was necessitated by the use of a CD-ROM and a booklet to deliver the experimental content and control content, respectively. Although the CD-ROM facilitated a degree of equivalence with the booklet in terms of how it was administered (i.e., handed) to participants and was an appropriate means of delivering digital content at the time the study was conducted, concurrent and objective assessment of use of the materials could readily be accomplished in future research if the materials were delivered online or via mobile (i.e., smartphone) application, which have been used to deliver content specific to the prevention (Verhagen, 2015) and rehabilitation (Lambert et al., 2015; Svingen et al., 2020) of sport injuries. Toward that end, the content for the experimental condition in the current study has been converted into a website for further evaluation and application. Third, although the smaller-than-intended sample size reduced the statistical power of the study and made statistical significance less likely to occur, it may also have had an inflationary effect on the magnitude of the effect sizes (Vacha-Haase & Thompson, 2004). It is important to note that the sample size was comparable to those of the studies used in the power analysis that provided the basis for the intended sample size of the current study (Cupal & Brewer, 2001; Maddison et al., 2006; Ross & Berger, 1996). Nevertheless, larger samples should be recruited in future studies.

Future Research Directions and Applied Implications

Avenues for future research on the multimedia program that was evaluated in the current investigation include: (a) recruiting a larger sample to increase statistical power; (b) promoting better intervention uptake to enhance the potency of the program; (c) validating (or adopting validated) measures of processes presumed to underlie the effects of the experimental manipulation (e.g., coping); (d) considering a Bayesian perspective for the design and analysis of randomized trials (Bautista et al., 2018); and (d) implementing the intervention online or via mobile application, which would allow for a more objective, real-time assessment of participant engagement with the intervention and potentially increase the accessibility of the intervention to participants. Along with examining additional outcomes of interest and importance (e.g., leg strength, return to sport), adopting such research foci would permit mediational analyses that could shed light not only which outcomes are influenced by the multimedia program and to what degree, but also on how the intervention works.

From a practical standpoint, the results of this investigation suggest that an interactive cognitive-behavioural multimedia program has potential utility as a preoperative and postoperative psychoeducational tool for people undergoing ACL surgery and rehabilitation. Based on the intervention effect sizes obtained across the preoperative, postoperative, and postexperimental assessments, the program appears to be particularly promising in terms of (a) enhancing patient confidence in their ability to cope with the challenges of surgery and rehabilitation, and (b) reducing postoperative pain and kinesiophobia. Although the program was evaluated in the current study using CD-ROM as the mode of content delivery, it is now accessible online in its entirety (at www.supportforsport.org/ACL/index.html) and is freely available for athletes, practitioners, and researchers to use as they see fit, in part or in toto. Online accessibility of the program could improve athlete uptake and, ultimately, enhance program outcomes. Program content could also be formatted for mobile application, potentially further expanding the reach and accessibility of the program. With continued empirical support, the multimedia program can be used as a cost- and time-effective adjunct to sports health care provided before and after ACL surgery and rehabilitation.

Supplementary Material

Supp 1

Acknowledgments

This research was supported in part by grants R41 AR48460 and R42 AR48460 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Its contents are solely the responsibility of the authors and do not represent the official views of the National Institute of Arthritis and Musculoskeletal and Skin Diseases. We gratefully acknowledge the cooperation of Joseph Sklar, Mark Pohlman, John Corsetti, Thomas Dugdale, Christopher Lena, Gordon Zimmermann, and Courtland Lewis in conducting this research. We thank Mark Archer, Derick Cummings, and Janel Shurrocks for their efforts in multimedia development and production; Deborah Cupal, Paul Roud, Kathleen Grady, Lyle Micheli, Daniel O’Neill, Carrie Silver-Bernstein, and Lynn Snyder-Mackler for sharing their expertise in content development and evaluation; and Josie Scibelli, Stephanie Caminiti, Janel Shurrocks, Ianita Zlateva, Laura Jensen, Albert Petitpas, John Brickner, James Alvarez, Susan Barksdale, and Michael Zande for their assistance in data collection.

Contributor Information

Britton W. Brewer, Department of Psychology, Springfield College, 263 Alden Street, Springfield, MA 01109 USA

Judy L. Van Raalte, Department of Psychology, Springfield College, and College of Health Sciences, Wuhan Sports University

Allen E. Cornelius, School of Psychology, Fielding Graduate University

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