The effect of cognitive behavioral therapy and virtual reality use in supporting physical rehabilitation after anterior cruciate ligament (ACL) operation

In this study, which aimed to develop a Cognitive Behavioral Therapy (CBT) protocol enriched with Virtual Reality (VR) to address the psychological responses that arise after ACL surgery, and to examine the effectiveness of this protocol, the protocol was developed in 5 stages, and a randomized controlled trial was conducted with 36 athletes to test its effectiveness. The study consisted of 1 experimental and 2 control groups. The effectiveness of the protocol was assessed using pre-test, post-test, and follow-up measurements with the Re-Injury Anxiety Inventory (RIAI), the Sport Injury Rehabilitation Adherence Scale (SIRAS), the Tampa Scale for Kinesiophobia (TSK), the Athletic Injury Self-Efficacy Questionnaire (AISEQ), the Return to Sport After Serious Injury Questionnaire (RSSIQ), and the Anterior Cruciate Ligament Return to Sport Scale (ACL-RSI). Anxiety levels during VR exposure sessions were measured through biofeedback and the Subjective Units of Distress Scale (SUDS). Two-way repeated measures mixed ANOVA, one-way ANOVA, and Wilcoxon Signed-Rank Test were used to test the study's hypotheses. The results of the study showed a significant group × time interaction for reinjury anxiety and adherence to rehabilitation during the rehabilitation process (RIA-R: p=0,013;η_2^p=0,220; Adherence: p=0,008;η_2^p=0,233). Statistically significant differences were observed in the scores between the groups for the RIA-RE subscale and the ACL-RSI scale (RIA-RE: F (2,29)=3,437;p=0,046; ACL-RSI: F (2,29)=9,624;p<0,001). No significant interactions or differences were found for the other variables (p>0,05). The exposure sessions produced the expected results in terms of anxiety induction (p<0,05). In conclusion, the CBT+VR protocol shows high potential for addressing psychological issues during rehabilitation and enhancing readiness to return to sport