Professional Documents
Culture Documents
DOI 10.1007/s00167-013-2392-4
KNEE
Received: 22 November 2012 / Accepted: 7 January 2013 / Published online: 30 January 2013
Ó Springer-Verlag Berlin Heidelberg 2013
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852 Knee Surg Sports Traumatol Arthrosc (2013) 21:851–858
unit. The improvement of psychological status influences Committee (IKDC) [12] score (principal outcome) com-
the somatic one. The role that psychology has to play in pared to the non-intervention group. It was also hypothe-
understanding and improving the recovery after injury or sized that participants in the intervention group would
surgical intervention is really interesting and needs more show greater improvements in functional milestones [range
attention in order to treat the patient as a global unit and not of motion (ROM) and crutch use] than those in the non-
only from the single aspect of joint recovery from kine- intervention group.
matic and functional point of view.
Psychological-based interventions have been shown to
be valuable at enhancing rehabilitation outcomes post- Materials and methods
sporting injury [3, 8, 13].
The use of imagery [6, 17, 18] and goal setting [20] has A single blinded parallel arm randomized controlled pilot
been shown to enhance and speed up, post-operative per- trial was conducted between February 2012 and October
formance. Another technique that has been used in reha- 2012.
bilitation is the observational learning or modelling: this More specifically, inclusion criteria were identified as:
technique has been shown to be a powerful tool to acquire (1) patients aged 16 years or more; (2) undergoing first-
motor skill and to improve physical activity and psycho- time ACL arthroscopic reconstruction on the injured knee
logical responses [5, 8]. These two methodologies highlight within the next month; (3) no other acute lower extremity
how images are powerful and have a tremendous impact on trauma; (4) expected to engage in 6 months of post-surgi-
the personality. cal rehabilitation and in 12 months follow-up controls and
Specific images can be very powerful and are able to (5) able to give written consent to undergo study proce-
produce ‘‘insight’’. Insight in psychoanalysis means the dures. Exclusion criteria included: (1) concomitant pos-
capacity to understand the interior psychic pathway and terior cruciate ligament (PCL) insufficiency of the involved
consequently to be able to therapeutic transformation. knee; (2) diagnosis of an Outerbridge grade IV untreated
The VideoinsightÒ [14, 15] is a psychological enhancing cartilage disease in the affected joint noted at the time of
method that involves the vision of contemporary art video, the surgery; (3) meniscus loss greater than 50 %; (4)
selected according to their content and transformative osteoarthritis (OA) degree greater than Kellgren–Lawrence
potential, with the intent to catalyze the ‘‘insight’’ psy- grade II; (5) uncorrected malformations or axial mala-
chological experience and facilitate the process that allows lignment in the lower extremity; (6) systemic or local
the persons to stimulate sensations, emotions, learning, infection; (7) history of anaphylactoid reaction; (8) sys-
psycho-actitudinal orientation, actions and changes. These temic administration of any type of corticosteroid or
artistic videos that contain a significant psychodiagnostic immunosuppressive agents within 30 days of surgery; (9)
and psychotherapeutic meanings can help to treat the evidence of osteonecrosis in the involved knee; (10) history
psychological and psychosomatic disability that are fre- of rheumatoid arthritis, inflammatory arthritis or autoim-
quently observed after surgery, increasing the resistance mune diseases; (11) neurological abnormalities or condi-
capacity and improving cognitive and behaviour power tions that would preclude the patient’s requirements for the
during the rehabilitation process after surgery. rehabilitation programme and (12) pregnancy.
ACL reconstruction is associated with an extensive Approval was obtained from the Internal Review Board
rehabilitation period (4–8 months) involving different (IRB) of Istituto Ortopedico Rizzoli, Bologna, Italy
rehabilitation phases that include restore of normal joint according to the official guidelines of the Declaration of
motion and gait pattern as well as strength and flexibility Helsinki, 1996. All subjects were informed about the study
exercises [4]. procedure, the purpose of the study and any known risks;
The evaluation of any new psychological method that is all of them provided their informed consent on the day they
capable to enhance the recovery process of the long reha- were enrolled.
bilitation period that the patients must follow after an ACL Eligible participants were randomized using computer-
reconstruction surgery is fundamental and should be used in ized random number generation into two groups: Group A
the clinical settings to improve the patient return to normal and Group B. Allocation concealment up to the point of
activity from the somatic and psychological point of view. randomization was maintained.
The purpose of this study was to investigate the effec- Standard surgical equipment was used to perform the
tiveness of the VideoinsightÒ method in promoting early ACL surgical reconstructions. In particular, over-the-top
recovery during rehabilitation following ACL reconstruc- single bundle with the additional extra-articular tenodesis
tion. It was hypothesized that subjects who received the on the lateral compartment, as reported by Marcacci et al.
VideoinsightÒ enhancing treatment would report a higher [9, 10], was performed in all patients using autologous
mean subjective International Knee Documentation semitendinosus and gracilis tendons.
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Knee Surg Sports Traumatol Arthrosc (2013) 21:851–858 853
All patients of this trial underwent the same standard their performance level. The criteria to allow sport
post-operative rehabilitation protocol. No brace was used. resumption were isokinetic tests with less than 10 %
ROM, quadriceps muscle active exercises and straight leg difference between healthy and operated knee, muscle
raises were started on the first post-operative day with atrophy of operated leg equal or less than 1 cm inferior
isometric quadriceps contractions and progressed to active compared to contralateral leg, one leg hop more than
closed chain exercise. Functional muscle stimulation was 90 % and good firm anterior tibial stop at objective
used 2 h three times a day for the first 4 weeks after clinical evaluation. The decision regarding sport resump-
surgery. Patients were allowed to partial weight bearing tion timing was always taken in combination by the
with no braces during the first 2 weeks. Full passive surgeon, physical therapist and patient [21].
extension and active flexion over a range of 0°–120° was According to the VideoinsightÒ method, Group A (study
started from the third post-operative day in both isometric group) received one art video that was established to pro-
and isotonic fashion. Full weight bearing was allowed duce positive and therapeutic ‘‘insight’’, while Group B
from the third week. Stationary biking, active knee (control group) received one art video with an ‘‘insight’’
extensions with weights applied, one quarter squatting and unfavourable to the psychological recovery.
proprioceptive exercises were introduced at 4 weeks after The art videos for Group A were selected according to
intervention. After 1 month, isotonic and closed chain the principles reported in Table 1.
exercises were started. All exercises were done under The art videos for (control) Group B were selected in
continuous direction of a physical therapist, to control the contrast to the principles reported in Table 1. The lists of
individual compliance to the standard protocol. Running art videos used for Group A and for Group B are reported
was recommended after 2 months, and cutting and lateral in Table 2. Examples of the two different types of videos
sports were allowed 4 months after surgery depending on are given in Figs. 1 and 2.
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854 Knee Surg Sports Traumatol Arthrosc (2013) 21:851–858
Fig. 1 Examples of art videos used for the Treatment Group (A): video still (2010); d Kazma, A. Dance company, video still (2009);
a Whettnall S. Over the sea, video still (2007) (a part of this video is e Gilmore, K. My love is an anchor, video still (2007); f Sissi, Daniela
given as online resource N.1); b Migliora M. Forever overhead, video ha perso il treno, video still (2003). Courtesy of VideoinsightÒ
still (2010); c Zeleny D. Someone says the moon is easy to touch, Center, Turin, Italy
Fig. 2 Examples of art videos used for the control Group (B): Singspiel, video still (2009); e Mona Chisa A, Tkacova L. The
a Goldiechiari 1969, video still (2010) (a part of this video is given as descend of man and selection in relation to sex, video still (2010).
online resource N.2); b Provoust L. It, heat, it, video still (2010); Courtesy of VideoinsightÒ Center, Turin, Italy
c Mari Sue. Made in box, video still (2008); d Von Brandenburg U.
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Knee Surg Sports Traumatol Arthrosc (2013) 21:851–858 855
All patients were instructed to watch the video 3 times a expressed in terms of mean value ± SD for continuous
week for the first 2 months during the execution of the data and median ± interquartile range for non-continuous
same rehabilitative protocol. data.
Patients were evaluated pre-operatively and 3 months
after surgery with Tegner [19], subjective IKDC [12],
physical and mental SF-36 scores [1] and Tampa Scale of Results
Kinesiophobia (TSK) [11]. Time to crutches discharge was
collected at final follow-up as well. Five patients were lost to follow-up and 101 patients (80
males, 21 females; mean age at surgery 33.0 ± 17.0 years)
Statistical analysis were available at mean 3.0 ± 0.2 months follow-up
(Fig. 3).
The study sample size was based on a power calculation The two groups were homogeneous regarding pre-
assessing a 0.05 significance and 0.95 power, with a clin- operative age, gender, weight and height, interval from
ically relevant difference of 10 points on the IKDC sub- injury to surgical treatment, subjective IKDC, Tegner, SF-
jective knee form and SD of 15. The sample size requested 36 and TSK scores. Demographic data are summarized in
was 50 patients for each group. Expecting a 10 % lost to Table 3. Pre-operative data are summarized in Table 4.
follow-up, we decided to enrol 110 patients. There were no significant statistical differences in the
Differences between pre-operative and post-operative incidence of associated meniscus and chondral injuries
status and between the two groups for subjective IKDC, between the two groups.
SF-36, TSK and days before crutches discharge were All scores significantly improved (p \ 0.05) from pre-
evaluated using Student’s t test. For differences in Tegner operative status to final follow-up in both groups.
level, the non-parametric Mann–Whitney test was used. Significant improvements were observed in Group A
For differences in objective IKDC form, the Chi-square test compared to Group B at final follow-up for subjective
was used. Correlation analysis between the different clin- IKDC (p = 0.047), TKS (p = 0.0141) and time to crutches
ical outcomes was performed using Pearson’s correlation discharge (p = 0.0012) (Table 4).
test. Comparison of groups showed no significant difference
The level of significance was set at p \ 0.05. Statisti- between Group A and Group B regarding Tegner score,
cal analysis was performed using Analyse-it-2.00 (Ana- SF-36 physical and mental status, although a positive trend
lyse-it Software, Ltd, Leeds, UK). Reported results are for Group A was detected (Table 4).
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Age at surgery (years) 33.8 ±11.1 (18–41) 32.9 ±12.5 (18–40) n.s.
Final follow-up (months) 3.0 ±0.2 (2.8–3.1) 3.0 ±0.2 (2.8–3.2) n.s.
BMI at surgery (kg/cm2) 24.1 ±2.2 (22–29) 23.8 ±2.2 (22–29) n.s.
BMI at final follow-up (kg/cm2) 24.0 ±2.7 (23–29) 23.7 ±2.7 (23–29) n.s.
Time from injury to surgery (months) 5.8 ±2.1 (1–9) 6.1 ±2.9 (1–8) n.s.
Sex (male/female) 40 (78 %)/11 (22 %) 40 (80 %)/10 (20 %) n.s.
Knee involved (right/left) 24 (47 %)/25 (53 %) 21 (42 %)/29 (58 %) n.s.
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between imagery and action, motor imagery has been a rehabilitation. It is not a coincidence that the Rorschach
used strategy to improve motor performance in rehabilita- test [16], the world-class excellence tool adapted for the
tion and variety of sport [6, 17, 18]. diagnosis of profile and personality functioning, consists of
Another technique that has received limited attentions the administration, qualitative and quantitative analysis,
during rehabilitation is the observational learning or mod- and interpretation of projective answers provided by can-
elling [2]. Only two studies have analysed the efficacy of didates in response to ten ink-stain images.
such strategy during ACL rehabilitation. Artistic images with therapeutic content proposed in a
Flint [5] examined the role of coping models compared psychodiagnostic and psychotherapeutic setting can affect
to no models on psychological factors and functional out- mental, emotional and intellectual functioning positively.
come following a rehabilitation programme for ACL Interpretative answers on art reveal subconscious
reconstruction among 10 basketball players. The study impulses, wishes, fantasies, deep motivations, and hidden
showed increased self-efficacy at 3 weeks after surgery in skills, sometimes unknown and unpredictable. When
patients watching a modelling videotape. observing art, you feel sensation and emotions in a privi-
Maddison et al. [8] evaluated the efficacy of modelling leged condition of spontaneous infant regression; you
video to reduce pre-operative perception of anxiety and activate defence mechanisms which influence emotional
pain as well as post-operative self-efficacy and functional distancing which may vary from attraction to refusal. Art is
outcome after anterior cruciate ligament reconstruction. symbolic. It is the archetypal possibility to have primordial
They reported significantly lower perceptions of expected images which echo the voices of all of humanity; it con-
pain pre-operatively and significantly greater self-efficacy tains subconscious and innate ideas, which are repeated
at pre-discharge to perform rehabilitation tasks, confirming throughout history, whenever the creative imagination of
that watching a modelling videotape is effective in the individual is practiced freely [14, 15].
increasing rehabilitation self-efficacy and early function. The VideoinsightÒ method is original and different
Although effective in reducing pain and increasing self- compared to the modelling techniques [5, 8] because it
efficacy, Maddison et al. [8] reported that the self-efficacy relies on the capacity of the art video images to promote a
was more related to the enactive master experience gained intrinsic elaboration at the psychological level. It was
during exercise. Moreover, the analysis failed to show that capable not only to speed up the rehabilitation period (as
modelling interventions could enhance psychological fac- described by Maddison et al. [8] and Flint et al. [5]), but
tors capable to enhance functional variables. also to enhance patient’s motivation and self-esteem as
In the present study, on the contrary, it was demon- shown by the low mean TSK reported for Group A. TSK
strated that the use of the VideoinsightÒ method in the and the time while the patients need to walk with crutches
early rehabilitation phase after ACL reconstruction through are directly correlated, demonstrating not only a psycho-
a psychological insight can promote a subjective and logical, but also a somatic effect of the method.
mental improvement. The VideoinsightÒ method original- The present study has some limitations.
ity is to combine the effect already observed by using The main limitation of this study was the absence of a
images, with the emotional one achieved by using con- patient psychological profiling. Unfortunately, the IRB
temporary artwork. These specific images permit higher refused to apply to each patient a psychological profile
self-consideration, increasing the intrinsic motivation to according to Rorschach tables [16] because it was argued
work and problem solving. Moreover, improve autoplastic that this will be out from the main goal of the study. In this
adaptation to reality, the stress reaction flexibility to way, we could have also analysed the different efficacy of
adverse event and increase the resistance capacity to the VideoinsightÒ method according to the psychological
exercise and fatigue. In clinical practice, the result can be patients profile and probably could have been capable to
obtained faster by integrating words and pictures. The detect which patients could have had better benefit from the
integration between images and verbal communications view of artwork, and secondly we could have been more
produces outstanding diagnostic and therapeutic effects. selective in which type of artwork showing to the patients
The impact of images may be greater than that of words. according to his psychological profile.
The latter have a sense; images instead have multiple This approach, with its intrinsic capacity to promote
meanings, because they are more enigmatic. Words change changement, could have other interesting application in the
depending on the languages; pictures are universal. Images treatment of other orthopaedic pathologies where the psy-
with high psychodiagnostic and psychotherapeutic poten- chological support and the psychological patient profile are
tial can treat the symptoms of psychological and psycho- important. This methodology could become a universal
somatic discomfort that accompany the disease and can method to support the patients not only from the somatic,
enhance the cognitive, emotional and behavioural resour- but also from the psychological point of view, considering
ces needed to tackle the path of evolution, care and the patient as a global unit that includes body and mind.
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