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

Abstract

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.

Keywords: eHealth; feasibility; medicine; mental health; mobile phone; postoperative medicine; psychological support; rehabilitation; sports; sports injury.

Figure 1

The eight building blocks that underpin our work for developing the Back in the Game intervention.

Figure 2

Back in the Game is grounded in cognitive theory and self-determination theory and aims to facilitate return to sport behavior change. Topics that are listed in grey ovals (adjacent to "Thoughts," "Emotions, and "Behaviors") are the key contents of the intervention modules. MI: motivational interviewing.

Figure 3

Summary of the seven self-directed modules (covering psychological skills, psychoeducation, and principles of motivational interviewing) of the Back in the Game intervention. Each dot represents how often the user is prompted to complete a task in each module.

Figure 4

Overview of the "Recovery," "Return to sport," "Return to performance," and "Staying injury-free" modules plus linked cognitive behavioral therapy tasks (strategies). This screenshot is presented in the content overview video that accompanies the app introduction, which users receive when they register.

Figure 5

Overview of the "Handling thoughts & emotions" and "Injury education" modules. This screenshot is presented in the content overview video that accompanies the app introduction, which users receive when they register.