The Short, 5-Item Shoulder Instability-Return to Sport After Injury (SIRSI) Score Performs as Well as the Longer Version in Predicting Psychological Readiness to Return to Sport

What Psychological Factors Affect Return to Sports After Shoulder Stabilization Surgery? A Scoping Review

OBJECTIVE

Despite excellent functional outcomes after shoulder stabilization surgery, a substantial number of patients fail to return to sports (RTS) at the preinjury level. The psychological factors affecting RTS postsurgery have been underexplored. This scoping review aimed to identify and analyze potential psychological factors influencing the decision to RTS after shoulder stabilization surgery.

DATA SOURCES

We reviewed the EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE, and Cochrane Library databases for studies on patients with anterior glenohumeral instability who underwent stabilization surgery. We included studies that reported on RTS and considered the psychological factors influencing the decision to return.

MAIN RESULTS

Our analysis comprised 21 articles involving 2073 patients. Psychological factors influencing RTS after surgery were categorized within the framework of transactional stress and coping model. Primary appraisal factors, such as fear of reinjury, kinesiophobia, and anxiety, emerged as significant influencers. In addition, we explored factors related to social support, self-determination, motivation, competing interests, and advanced age. Assessment tools were used to evaluate the psychological readiness for RTS.

CONCLUSIONS

This scoping review identified fear of reinjury and kinesiophobia as important psychological barriers to returning to sports after shoulder stabilization surgery. The limited use of psychological assessment tools and lack of comparative studies have restricted robust conclusions.

LEVEL OF EVIDENCE

Level IV, Scoping review.

The short version of the ALR-RSI scale is a valid and reproducible scale to evaluate psychological readiness to return to sport after ankle lateral reconstruction

Purpose

To develop and validate a short and mini version of the ALR-RSI (Ankle Ligament Reconstruction-Return to Sport after Injury) scale.

Methods

The ALR-RSI scale contains 12 items and was administered to 109 patients following arthroscopic anatomical lateral ankle reconstruction. The short (6-item) and mini (3-item) versions were developed using a systematic selection process to eliminate items based on their category, mean, standard deviation and pertinence. A second group of 75 patients participated in an analysis to validate the predictive value of these scores. These patients filled out all three ALR-RSI versions 6 months after arthroscopic anatomical reconstruction of the lateral ankle to determine the predictive value for the return to sport (RTS) at 12 months. The predictive value was evaluated with receiver operating characteristic curves (area under the curve [AUC]).

Results

The long version of the ALR-RSI had a high internal consistency (Cronbach's α = 0.97), suggesting redundancy of certain items. A short version of 6 items was developed (Cronbach's α = 0.94). A mini version of 3 items was also developed which retained one key item from each category. Factorial analysis confirmed that only one factor explained 76% of the total variance in the mini version (Cronbach's α = 0.89). The scores of the three versions were higher in patients who returned to sport at the same pre-injury level of play or better (p < 0.0001). Both versions were found to have a good predictive value for the RTS at 12 months, with comparable AUC values (full version AUC 0.70 [95% confidence interval; CI, 0.57-0.83]; short version AUC 0.72 [95% CI, 0.59-0.84]); mini version, AUC 0.73 [95% CI, 0.61-0.85].

Conclusion

The shorter versions (6 and 3 items) of the ALR-RSI may be used to predict the RTS at the pre-injury level without affecting the psychometric characteristics of the long score.

Level of Evidence

Level II prospective cohort study.

Most Athletes Who Fail to Return to Sport After Latarjet Procedure Cite Psychological Factors: A Systematic Review

PURPOSE

To identify the return-to-sport (RTS) rate in athletes undergoing a Latarjet procedure while outlining the specific reasons for failure to RTS.

METHODS

An electronic literature search was conducted (PubMed/MEDLINE, Scopus, Web of Science). Studies in peer-reviewed journals with Latarjet procedures performed on athletes that reported rates and reasons for failure to RTS were included. Excluded studies were those that reported solely on nonathletes, non-Latarjet surgery, and missing rates of and reasons for failure to RTS. Study heterogeneity was assessed using the I2 statistic, and quality assessment was performed using the Methodological Index for Non-Randomized Studies criteria.

RESULTS

After review of 3,617 articles, a total of 18 studies with 1,066 patients met the inclusion criteria. The level of evidence for included studies ranged from II to IV. Rates of not returning to sports (NRTS) ranged from 3.4% to 35.3%. More studies cited shoulder-unrelated reasons than shoulder-related reasons for why athletes failed to RTS. Ten (55.5%) studies, making up 656 (61.5%) patients, reported that shoulder-unrelated reasons were accountable for more than 50% of NRTS. Only 3 (16.7%) studies reported 100% NRTS because of shoulder-related reasons, which include fear of reinjury and psychological factors. Study heterogeneity was found to be moderate (I2 = 73.4%; 95% confidence interval 57.5-83.3; P < .001) and study quality was found to be satisfactory (mean Methodological Index for Non-Randomized Studies score 12.1 for noncomparative and 20.5 for comparative studies).

CONCLUSIONS

According to this systematic review, the rate of NRTS after Latarjet ranged from 3.4% to 35.3% across 18 studies, with the majority of studies citing nonshoulder-related reasons such as fear or reinjury or psychological factors as the major deterrent for returning to sports.

LEVEL OF EVIDENCE

Level IV, systematic review of case series.

Validation of the Short Form Shoulder Instability Return to Sport After Injury (SIRSI-5) and Its Association With Return to Sports

Background

Psychosocial readiness is thought to be important in establishing whether athletes are ready to return to sports (RTS). The 5-item Shoulder Instability-Return to Sport After Injury (SIRSI-5) is a short-form version of the 12-item questionnaire (SIRSI-12), which was validated in a postoperative Argentinian population and associated with psychological readiness to RTS. It is unknown if the SIRSI-5 is valid in surgical and nonsurgical populations in other geographic locations.

Purpose

To establish whether the SIRSI-5 is valid in another population and if it is associated with RTS.

Study Design

Cross-sectional study (diagnosis); Level of evidence, 3.

Methods

A total of 79 participants with anterior shoulder instability managed operatively and nonoperatively were included. The SIRSI-5 and SIRSI-12 total scores were calculated. Intraclass correlation coefficients (ICCs) and Pearson correlations assessed convergent validity between SIRSI-5 and SIRSI-12. Logistic regression was used to assess the discrimination ability (leave-one-out cross-validation [LOOCV]) of a preexisting SIRSI-5 cut point score (≥59/100) to determine participants who had returned to their preinjury level of sport. In addition, the discrimination ability (LOOCV) of multivariable machine learning models including age, sex, time since injury (months), SIRSI-5 (continuous score), surgery, and contact/noncontact sport to predict return to preinjury level sport was also assessed. The Youden index was calculated to assess the models' performance.

Results

Of the 79 participants, 62 (78.5%) were male and 27 (34%) had been treated surgically. Only 32% (n = 25) of participants had returned to preinjury level sport. The SIRSI-5 and SIRSI-12 were highly correlated (r > 0.9) with high levels of agreement (ICC, 0.90; 95% CI, 0.76-0.95). The prediction accuracy of the SIRSI-5 cut point score model was 66% (Youden index, 0; sensitivity, 4%; specificity, 94%). The best prediction accuracy obtained through a machine learning model (multilayer perceptron) was 72% (Youden index, 0.4; sensitivity, 64%; specificity, 76%).

Conclusion

The SIRSI-5 has excellent convergent validity with the SIRSI-12 to measure psychological readiness to RTS and can be used clinically with less patient burden than the SIRSI-12. However, in a population of surgically and nonsurgically treated contact athletes, the SIRSI-5 with a cut point of ≥59/100 had low levels of prediction accuracy for RTS at preinjury level. The SIRSI-5 should not be utilized in isolation to determine readiness to RTS, and clinicians should consider other factors such as age, type of sport, and time since injury to underpin their clinical reasoning when deciding for RTS.

Rehabilitation and Return to Sport following Operative and Nonoperative Treatment of Anterior Shoulder Instability

There has been growing interest in the rehabilitation process and timing of returning an athlete to sport following the management options for anterior shoulder instability. The purpose of this article is to review the current rehabilitation and return to sport (RTS) protocols for various nonoperative and operative management strategies following anterior shoulder instability events. When appropriate in the rehabilitation protocol, RTS testing should be criteria based, rather than time based, with a special focus given to psychological readiness in order to promote successful return to athletics and prevention of recurrent instability episodes in the future.

A qualitative investigation to identify return to sports criteria after shoulder stabilization surgery used by professional team physicians

Purpose: Purpose of this study is to explore currently utilized readiness to return to sports (RTS) criteria after shoulder stabilization surgery used in elite athletes to gain novel insights into the RTS decision making process of professional team physicians.Methods: 19 qualitative semi-structured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after shoulder stabilization surgery. General inductive analysis and a coding process were used to identify themes and sub-themes arising from the data. A hierarchical approach in coding helped to link themes.Results: We were able to identify five key themes that participating physicians focused on to determine RTS decision making: external influence, objective and subjective criteria, time elapsed since surgery and type of sport. The most important RTS criteria included: range of motion and muscle strength followed by clinical joint stability, time since surgery, ability of sporting movement, psychological readiness, functional testing, absence of pain and allied team support.Conclusion: This study identified several main themes and subordinate minor themes as having the most influence on RTS decision after shoulder surgery. We showed that even among specialized professional team physicians, the main criteria to RTS in these categories were inconsistent necessitating the future development of specific RTS guidelines.

Return to play following operative management of anterior shoulder instability in overhead athletes-A systematic review

Background

The purpose of this study was to systematically review the rate and timing of return to play in overhead athletes following operative management of anterior shoulder instability.

Methods

A systematic literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to play among overhead athletes following arthroscopic Bankart repair, open Latarjet procedure or Remplissage procedure.

Results

There are 23 studies included with 961 patients. Among those undergoing arthroscopic Bankart repair, the rate of return to play was 86.2%, with 70.6% returning to the same level of play and the mean time to return to play was 7.1 months. Among those undergoing an open Latarjet procedure, the rate of return to play was 80.9%, with 77.7% returning to the same level of play and the mean time to return to play was 5.1 months. Among those undergoing a Remplissage procedure, the rate of return to play was 70.6%, with 70.0% returning to the same level of play or mean time to return to play.

Discussion

Overall, there were high rates of return to play following operative management of anterior shoulder instability in overhead athletes.

Substantial influence of psychological factors on return to sports after anterior shoulder instability surgery: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports.

METHODS

The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals.

RESULTS

The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score (P < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95-35.53; I2 = 0%; n.s.).

CONCLUSIONS

Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes' readiness to return to sports.

LEVEL OF EVIDENCE

Level IV.

A modified Delphi study to identify which items should be evaluated in shoulder instability research: a first step in developing a core outcome set

Background

The aim of this study was to identify items that healthcare providers and/or patients consider important to include in a questionnaire for clinical trials and cohort studies in shoulder instability research. This could serve as a basis to develop a core outcome set for shoulder instability research.

Methods

Healthcare providers and patients were included in a panel for a modified Delphi consensus study. The study consisted of three rounds, comprising (1) identifying items, (2) rating the importance of the items, and (3) rating the importance again after seeing a summary of the results of round two. Importance was rated on a 9-point Likert scale. Consensus was defined as ≥ 80% of the panel giving a score of 7 or higher.

Results

In total, 44 healthcare providers and 30 patients completed all three rounds. Round one identified 54 items. After round three, the panel reached a consensus on 11 items that should be included in a questionnaire, comprising re-dislocation (99%), instable feeling of the shoulder (96%), limitations during sport (93%), patient satisfaction with the shoulder (93%), fear/anxiety for re-dislocation (91%), range of motion (88%), return to old level of functioning (85%), performing daily activities (85%), return to sport (82%), return to work (82%), and trusting the shoulder (81%).

Conclusion

Healthcare providers and patients reached a consensus on 11 items that should be included in a questionnaire for shoulder instability research. These items can facilitate design and development of future clinical trials and form the basis for the development of a core outcome set.

Qualitative Research in Return to Sport: a Current Review of the Literature

PURPOSE OF REVIEW

Return to sport (RTS) is an important metric tied to patient satisfaction after receiving treatment for a sports-related injury. Recently, there has been an explosion of literature on RTS; yet a comprehensive review encompassing multiple injuries does not exist. Furthermore, RTS has historically been defined by quantitative measures that assess strength, function, and pain but little consideration has been given to psychologic factors nor has there been an open-ended forum for athletes to share with health care providers which factors they feel are most influential for RTS. This review also serves to heighten surgeons' awareness of underlying psychologic/psychosocial factors affecting RTS.

RECENT FINDINGS

Qualitative studies which employ open-ended questioning of athletes who have undergone surgical management of superior labral anterior-posterior (SLAP) tears, shoulder instability, ulnar collateral ligament (UCL) rupture, femoral acetabular impingement (FAI), and anterior cruciate ligament (ACL) tear demonstrate that fear of reinjury, lack of social support, and unrealistic expectations are all barriers to RTS. Qualitative studies give health care providers unique insight into the perspectives of their patients so that unmet postoperative needs can be addressed to facilitate RTS. Sports psychologists, coaches, athletic trainers, and physical therapists should create a positive environment to address these needs and provide optimal, holistic care to return athletes to the field safely. Though time consuming, further qualitative research is necessary to understand the unique factors affecting RTS in athletes.

Psychological Readiness to Return to Sport: Fear of Reinjury Is the Leading Reason for Failure to Return to Competitive Sport and Is Modifiable

Many of our patients are athletes, and an ultimate goal is to help these athletes return to their preinjury level of activity or sport. Generally, we focus on patients' injuries and treatments, but there are modifiable factors that can improve patient outcomes independent of surgical technique. A factor frequently ignored is psychological readiness to return to sport. In patients including athletes, particularly teenagers, chronic, clinical depression is a prevalent and pathologic condition. In addition, in nondepressed patients (or in patients who are situationally depressed because of injury), the ability to deal with stressors may still govern clinical outcomes. Specific psychological traits of significance have been identified and defined, including self-efficacy; locus of control; resilience; catastrophizing; kinesiophobia; and fear of reinjury. (Fear of reinjury is the leading reason for failure to return to competitive sport, reduced activity levels after sports injury, and greater reinjury rates.) The traits may overlap and may be modifiable. Thus, like strength and functional testing, we should evaluate for signs or symptoms of depression, and we should measure psychological readiness to return to sport. With awareness, we can intervene or refer as indicated. Psychological readiness to return to sport represents an underexamined domain in which we can help our patients achieve best outcomes.

Editorial Commentary: Designing Patient-Reported Outcome Measures That Have High Clinical Utility and Minimum Responder Burden: When Less Is More

Patient-reported outcome measures provide important information regarding the subjective status of a patient's health. Preference is often given to the use of condition-specific measures for symptoms, pain, and function, although it is also recognized that measures pertaining to quality of life and psychological status are highly relevant. The challenge is to develop a comprehensive set of outcome measures that do not overly burden the patient. The development of short-form versions of commonly used scales plays an important part in this endeavor. Of note, such short forms show a remarkable degree of data consilience for different injury types and patient samples. This suggests that there are a core set of responses, specifically psychological responses, that are relevant to patients who desire to return to sport, irrespective of the type of injury or condition. Moreover, patient-reported outcomes are highly useful when they inform other relevant outcomes. Recent research shows that relevant patient-reported outcome scores in the shorter term predict return to sport in the longer term, which is of high clinical utility. Finally, psychological factors are potentially modifiable, and scores allowing early identification of patients who may find the resumption of sport challenging allow intervention with a goal of improving the final outcome.