The Videoinsight method: improving rehabilitation following anterior cruciate ligament reconstruction—a preliminary

The Videoinsight® method: improving
rehabilitation following anterior cruciate
ligament reconstruction—a preliminary
study
Stefano Zaffagnini, Rebecca Luciana
Russo, Giulio Maria Marcheggiani
Muccioli & Maurilio Marcacci
Knee Surgery, Sports Traumatology,
Arthroscopy
ISSN 0942-2056
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-013-2392-4
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Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-013-2392-4
KNEE
The VideoinsightÒ method: improving rehabilitation following
anterior cruciate ligament reconstruction—a preliminary study
Stefano Zaffagnini • Rebecca Luciana Russo
Giulio Maria Marcheggiani Muccioli •
Maurilio Marcacci
•
Received: 22 November 2012 / Accepted: 7 January 2013
Ó Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose The purpose of this randomized double blind
controlled study was to investigate if the vision of contemporary art video according to the VideoinsightÒ method
could produce better short-term clinical and subjective outcomes after anterior cruciate ligament (ACL) reconstruction.
Methods One-hundred and six patients treated with single-bundle ACL reconstruction plus extra-articular tenodesis were enrolled in this study and randomly assigned to
Group A (53 patients) and Group B (53 patients). Group A
received one art video that was established to produce
positive and therapeutic ‘‘insight’’, while Group B received
one art video with an ‘‘insight’’ unfavourable to the psychological recovery. All patients were instructed to watch
the video 3 times a week for the first 2 months during the
execution of the same rehabilitative protocol. Patients were
evaluated pre-operatively and 3 months after surgery with
Tegner, subjective International Knee Documentation
Committee (IKDC), physical and mental SF-36 scores and
Electronic supplementary material The online version of this
article (doi:10.1007/s00167-013-2392-4) contains supplementary
material, which is available to authorized users.
S. Zaffagnini G. M. Marcheggiani Muccioli M. Marcacci
2nd Orthopaedic and Traumatology Clinic, Istituto Ortopedico
Rizzoli, University of Bologna, Bologna, Italy
S. Zaffagnini (&)
Laboratorio di Biomeccanica, Codivilla-Putti Research Center,
Istituto Ortopedico Rizzoli, University of Bologna, via di
Barbiano, 1/10, 40100 Bologna, Italy
e-mail: [email protected]
R. L. Russo
VideoinsightÒ Center, via Bonsignore, 7, 10131 Turin, Italy
Tampa Scale of Kinesiophobia (TSK). Time to crutches
discharge was collected at final follow-up as well.
Results Five patients were lost to follow-up and 101
patients (Group A: 51 patients; Group B: 50 patients) were
available at mean 3.0 ± 0.2 months follow-up. Age at
surgery was 33.0 ± 17.0 years. The two groups were
homogeneous regarding pre-operative demographic data,
meniscal lesions and clinical outcomes. Significant
improvements were observed in Group A compared to
Group B at final follow-up for subjective IKDC (82.0 ±
13.8 vs. 71.0 ± 19.7, p = 0.0470), TKS (28.1 ± 6.0 vs.
32.0 ± 5.8, p = 0.0141) and time to crutches discharge
(20.9 ± 5.0 vs. 26.5 ± 8.2 days, p = 0.0012). A positive
significant correlation between TSK and time to crutches
discharge (r = 0.35, p = 0.0121) was observed.
Conclusions The VideoinsightÒ method combined to
adequate rehabilitation could be an effective tool in order
to improve short-term clinical and functional outcomes in
patients who underwent ACL reconstruction.
Level of evidence I.
Keywords Knee Rehabilitation Anterior cruciate
ligament reconstruction Contemporary art video VideoinsightÒ method
Introduction
The success of anterior cruciate ligament (ACL) reconstruction is deeply influenced by rehabilitation. Rehabilitative protocols often focus the attention on physical
recovery, without taking into account the patient’s psychological aspect.
However, the corporal and psychic dimensions are
deeply combined and reciprocally conditioned in the body
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unit. The improvement of psychological status influences
the somatic one. The role that psychology has to play in
understanding and improving the recovery after injury or
surgical intervention is really interesting and needs more
attention in order to treat the patient as a global unit and not
only from the single aspect of joint recovery from kinematic and functional point of view.
Psychological-based interventions have been shown to
be valuable at enhancing rehabilitation outcomes postsporting injury [3, 8, 13].
The use of imagery [6, 17, 18] and goal setting [20] has
been shown to enhance and speed up, post-operative performance. Another technique that has been used in rehabilitation is the observational learning or modelling: this
technique has been shown to be a powerful tool to acquire
motor skill and to improve physical activity and psychological responses [5, 8]. These two methodologies highlight
how images are powerful and have a tremendous impact on
the personality.
Specific images can be very powerful and are able to
produce ‘‘insight’’. Insight in psychoanalysis means the
capacity to understand the interior psychic pathway and
consequently to be able to therapeutic transformation.
The VideoinsightÒ [14, 15] is a psychological enhancing
method that involves the vision of contemporary art video,
selected according to their content and transformative
potential, with the intent to catalyze the ‘‘insight’’ psychological experience and facilitate the process that allows
the persons to stimulate sensations, emotions, learning,
psycho-actitudinal orientation, actions and changes. These
artistic videos that contain a significant psychodiagnostic
and psychotherapeutic meanings can help to treat the
psychological and psychosomatic disability that are frequently observed after surgery, increasing the resistance
capacity and improving cognitive and behaviour power
during the rehabilitation process after surgery.
ACL reconstruction is associated with an extensive
rehabilitation period (4–8 months) involving different
rehabilitation phases that include restore of normal joint
motion and gait pattern as well as strength and flexibility
exercises [4].
The evaluation of any new psychological method that is
capable to enhance the recovery process of the long rehabilitation period that the patients must follow after an ACL
reconstruction surgery is fundamental and should be used in
the clinical settings to improve the patient return to normal
activity from the somatic and psychological point of view.
The purpose of this study was to investigate the effectiveness of the VideoinsightÒ method in promoting early
recovery during rehabilitation following ACL reconstruction. It was hypothesized that subjects who received the
VideoinsightÒ enhancing treatment would report a higher
mean subjective International Knee Documentation
123
Committee (IKDC) [12] score (principal outcome) compared to the non-intervention group. It was also hypothesized that participants in the intervention group would
show greater improvements in functional milestones [range
of motion (ROM) and crutch use] than those in the nonintervention group.
Materials and methods
A single blinded parallel arm randomized controlled pilot
trial was conducted between February 2012 and October
2012.
More specifically, inclusion criteria were identified as:
(1) patients aged 16 years or more; (2) undergoing firsttime ACL arthroscopic reconstruction on the injured knee
within the next month; (3) no other acute lower extremity
trauma; (4) expected to engage in 6 months of post-surgical rehabilitation and in 12 months follow-up controls and
(5) able to give written consent to undergo study procedures. Exclusion criteria included: (1) concomitant posterior cruciate ligament (PCL) insufficiency of the involved
knee; (2) diagnosis of an Outerbridge grade IV untreated
cartilage disease in the affected joint noted at the time of
the surgery; (3) meniscus loss greater than 50 %; (4)
osteoarthritis (OA) degree greater than Kellgren–Lawrence
grade II; (5) uncorrected malformations or axial malalignment in the lower extremity; (6) systemic or local
infection; (7) history of anaphylactoid reaction; (8) systemic administration of any type of corticosteroid or
immunosuppressive agents within 30 days of surgery; (9)
evidence of osteonecrosis in the involved knee; (10) history
of rheumatoid arthritis, inflammatory arthritis or autoimmune diseases; (11) neurological abnormalities or conditions that would preclude the patient’s requirements for the
rehabilitation programme and (12) pregnancy.
Approval was obtained from the Internal Review Board
(IRB) of Istituto Ortopedico Rizzoli, Bologna, Italy
according to the official guidelines of the Declaration of
Helsinki, 1996. All subjects were informed about the study
procedure, the purpose of the study and any known risks;
all of them provided their informed consent on the day they
were enrolled.
Eligible participants were randomized using computerized random number generation into two groups: Group A
and Group B. Allocation concealment up to the point of
randomization was maintained.
Standard surgical equipment was used to perform the
ACL surgical reconstructions. In particular, over-the-top
single bundle with the additional extra-articular tenodesis
on the lateral compartment, as reported by Marcacci et al.
[9, 10], was performed in all patients using autologous
semitendinosus and gracilis tendons.
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All patients of this trial underwent the same standard
post-operative rehabilitation protocol. No brace was used.
ROM, quadriceps muscle active exercises and straight leg
raises were started on the first post-operative day with
isometric quadriceps contractions and progressed to active
closed chain exercise. Functional muscle stimulation was
used 2 h three times a day for the first 4 weeks after
surgery. Patients were allowed to partial weight bearing
with no braces during the first 2 weeks. Full passive
extension and active flexion over a range of 0°–120° was
started from the third post-operative day in both isometric
and isotonic fashion. Full weight bearing was allowed
from the third week. Stationary biking, active knee
extensions with weights applied, one quarter squatting and
proprioceptive exercises were introduced at 4 weeks after
intervention. After 1 month, isotonic and closed chain
exercises were started. All exercises were done under
continuous direction of a physical therapist, to control the
individual compliance to the standard protocol. Running
was recommended after 2 months, and cutting and lateral
sports were allowed 4 months after surgery depending on
their performance level. The criteria to allow sport
resumption were isokinetic tests with less than 10 %
difference between healthy and operated knee, muscle
atrophy of operated leg equal or less than 1 cm inferior
compared to contralateral leg, one leg hop more than
90 % and good firm anterior tibial stop at objective
clinical evaluation. The decision regarding sport resumption timing was always taken in combination by the
surgeon, physical therapist and patient [21].
According to the VideoinsightÒ method, Group A (study
group) received one art video that was established to produce positive and therapeutic ‘‘insight’’, while Group B
(control group) received one art video with an ‘‘insight’’
unfavourable to the psychological recovery.
The art videos for Group A were selected according to
the principles reported in Table 1.
The art videos for (control) Group B were selected in
contrast to the principles reported in Table 1. The lists of
art videos used for Group A and for Group B are reported
in Table 2. Examples of the two different types of videos
are given in Figs. 1 and 2.
Table 1 Characteristics of video art work with VideoinsightÒ impact
1
The video shows powerful images, with or without sounds, that quickly and deeply penetrate the unconscious of the patient
2
Expresses universal messages related to the primary needs of life
3
Stimulates the mind at a conscious level (intellectual comprehension) and the affectivity at an unconscious level (emotive resonance)
4
Contains metaphors with therapeutic potential
5
Stimulates narrative processes: story telling, interpretation and trauma elaboration
6
Promotes identification, reflection, projection and transfer process
7
Activates insight that means interior intuition, consciousness raising, psychological transformation
8
Reduces the evolutive resistance
9
Increases creativity
10
Catalyzes the changement
Table 2 Selected art works
Treatment group (A)
Control group (B)
Title
Author
Years
Title
Over the sea
Forever overhead
Author
Years
Sophie Whettnall
2007
1969
Goldiechiari
2010
Marzia Migliora
2010
To Ann Marie
Petra Lindholm
2010
Someone says the moon is
easy to touch
Driant Zenely
2010
Made in box
Mari Sue
2008
Dance company
My love is an anchor
Ali Kazma
Kate Gilmore
2009
2007
It, heat, it
The artist
Laure Provoust
Laure Provoust
2010
2010
Daniela ha perso il treno
Sissi
1999
Singspiel
Ulla Von Brandenburg
2009
Dying swans
Elena Kovylina
2007
The descend of man and
selection in relation to sex
Anetta Mona Chisa and
Lucia Tkacova
2010
Piel
Regina Iosè Galindo
2001
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Fig. 1 Examples of art videos used for the Treatment Group (A):
a Whettnall S. Over the sea, video still (2007) (a part of this video is
given as online resource N.1); b Migliora M. Forever overhead, video
still (2010); c Zeleny D. Someone says the moon is easy to touch,
video still (2010); d Kazma, A. Dance company, video still (2009);
e Gilmore, K. My love is an anchor, video still (2007); f Sissi, Daniela
ha perso il treno, video still (2003). Courtesy of VideoinsightÒ
Center, Turin, Italy
Fig. 2 Examples of art videos used for the control Group (B):
a Goldiechiari 1969, video still (2010) (a part of this video is given as
online resource N.2); b Provoust L. It, heat, it, video still (2010);
c Mari Sue. Made in box, video still (2008); d Von Brandenburg U.
Singspiel, video still (2009); e Mona Chisa A, Tkacova L. The
descend of man and selection in relation to sex, video still (2010).
Courtesy of VideoinsightÒ Center, Turin, Italy
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Fig. 3 Flow chart illustrating
the enrolment, allocation,
follow-up and analysis process
of the present study
All patients were instructed to watch the video 3 times a
week for the first 2 months during the execution of the
same rehabilitative protocol.
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
Kinesiophobia (TSK) [11]. Time to crutches discharge was
collected at final follow-up as well.
Statistical analysis
The study sample size was based on a power calculation
assessing a 0.05 significance and 0.95 power, with a clinically relevant difference of 10 points on the IKDC subjective knee form and SD of 15. The sample size requested
was 50 patients for each group. Expecting a 10 % lost to
follow-up, we decided to enrol 110 patients.
Differences between pre-operative and post-operative
status and between the two groups for subjective IKDC,
SF-36, TSK and days before crutches discharge were
evaluated using Student’s t test. For differences in Tegner
level, the non-parametric Mann–Whitney test was used.
For differences in objective IKDC form, the Chi-square test
was used. Correlation analysis between the different clinical outcomes was performed using Pearson’s correlation
test.
The level of significance was set at p \ 0.05. Statistical analysis was performed using Analyse-it-2.00 (Analyse-it Software, Ltd, Leeds, UK). Reported results are
expressed in terms of mean value ± SD for continuous
data and median ± interquartile range for non-continuous
data.
Results
Five patients were lost to follow-up and 101 patients (80
males, 21 females; mean age at surgery 33.0 ± 17.0 years)
were available at mean 3.0 ± 0.2 months follow-up
(Fig. 3).
The two groups were homogeneous regarding preoperative age, gender, weight and height, interval from
injury to surgical treatment, subjective IKDC, Tegner, SF36 and TSK scores. Demographic data are summarized in
Table 3. Pre-operative data are summarized in Table 4.
There were no significant statistical differences in the
incidence of associated meniscus and chondral injuries
between the two groups.
All scores significantly improved (p \ 0.05) from preoperative status to final follow-up in both groups.
Significant improvements were observed in Group A
compared to Group B at final follow-up for subjective
IKDC (p = 0.047), TKS (p = 0.0141) and time to crutches
discharge (p = 0.0012) (Table 4).
Comparison of groups showed no significant difference
between Group A and Group B regarding Tegner score,
SF-36 physical and mental status, although a positive trend
for Group A was detected (Table 4).
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Table 3 Demographic details
Treatment group
Control group
p value
Mean
SD
Range
Mean
SD
Range
Age at surgery (years)
33.8
±11.1
(18–41)
32.9
±12.5
(18–40)
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.
n.s.
Table 4 Clinical outcomes scores
Score
Evaluation
Treatment group
p value
Control group
Clinical outcomes scores at baseline
Subjective
IKDC
52.9
±13.6 (SD)
52.0
±16.2 (SD)
n.s.
SF-36 mental
SF-36 physical
44.9
50.9
±6.7 (SD)
±8.7 (SD)
44.2
50.9
±6.7 (SD)
±7.3 (SD)
n.s.
n.s.
Tegner activity
level
3
2–4 (IQR)
3
2–3 (IQR)
n.s.
TSK
33.8
±4.5 (SD)
34.0
±5.1 (SD)
Objective IKDC
0A, 0B, 34C, 17D
0A, 0B, 31C, 19D
n.s.
n.s.
Clinical outcomes scores at 3 months FU
Subjective
IKDC
82.0
±13.8 (SD)
71.0
±19.7 (SD)
0.0470*
SF-36 mental
SF-36 physical
50.9
55.6
±8.7 (SD)
±8.2 (SD)
50.9
52.6
±7.3 (SD)
±8.4 (SD)
n.s.
n.s.
Tegner activity
level
5
4–6 (IQR)
4
3–6 (IQR)
n.s.
TSK
28.1
±6.0 (SD)
32.0
±5.8 (SD)
0.0141*
Crutches (days)
20.9
±5.0 (SD)
26.5
±8.2 (SD)
0.0012*
Objective IKDC
33A, 18B, 0C, 0D
33A, 17B, 0C, 0D
n.s.
* Statistically significant differences between the two groups
(p \ 0.05). Results are expressed in terms of mean value ± SD for
continuous data and median ± interquartile range (IQR) for noncontinuous data (where applicable)
A positive significant correlation between TSK and time
to crutches discharge (r = 0.35, p = 0.0121) was observed
(Fig. 4).
Discussion
The most important finding of this prospective randomized
study was that the use of the VideoinsightÒ method during
the early rehabilitation phase after an ACL reconstruction
permits to increase the subjective outcomes at 3 months
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Fig. 4 Linear regression graphic illustrating the significant positive
correlation between TSK and time to crutches discharge (r = 0.35,
p = 0.0121)
evaluated with IKDC form, to reduce the kinesiophobia of
the patients in this important phase (when the patients need
to regain the normal gait pattern) and to reduce the time
while the patients need to walk with crutches.
This is the first study where the VideoinsightÒ method
has been applied in orthopaedics to improve the global
functional and psychosomatic results after surgery, while it
has already been applied with highly satisfactory results in
psychodiagnosis and psychotherapy [14, 15]. This method
is unique because it does not utilize simple image or
modelling video but it combines the power of images itself
with the emotional one given by the artistic world.
Various psychological interventions have been proposed
or utilized in the injury recovery setting. These include
imagery [6, 17, 18], goal setting [20], electromyographic
biofeedback [7] and stress inoculating training [13].
Motor imagery is a technique that is overlapping with
physical execution, since it activates the same brain regions
used during motor performance. For the equivalence
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between imagery and action, motor imagery has been a
used strategy to improve motor performance in rehabilitation and variety of sport [6, 17, 18].
Another technique that has received limited attentions
during rehabilitation is the observational learning or modelling [2]. Only two studies have analysed the efficacy of
such strategy during ACL rehabilitation.
Flint [5] examined the role of coping models compared
to no models on psychological factors and functional outcome following a rehabilitation programme for ACL
reconstruction among 10 basketball players. The study
showed increased self-efficacy at 3 weeks after surgery in
patients watching a modelling videotape.
Maddison et al. [8] evaluated the efficacy of modelling
video to reduce pre-operative perception of anxiety and
pain as well as post-operative self-efficacy and functional
outcome after anterior cruciate ligament reconstruction.
They reported significantly lower perceptions of expected
pain pre-operatively and significantly greater self-efficacy
at pre-discharge to perform rehabilitation tasks, confirming
that watching a modelling videotape is effective in
increasing rehabilitation self-efficacy and early function.
Although effective in reducing pain and increasing selfefficacy, Maddison et al. [8] reported that the self-efficacy
was more related to the enactive master experience gained
during exercise. Moreover, the analysis failed to show that
modelling interventions could enhance psychological factors capable to enhance functional variables.
In the present study, on the contrary, it was demonstrated that the use of the VideoinsightÒ method in the
early rehabilitation phase after ACL reconstruction through
a psychological insight can promote a subjective and
mental improvement. The VideoinsightÒ method originality is to combine the effect already observed by using
images, with the emotional one achieved by using contemporary artwork. These specific images permit higher
self-consideration, increasing the intrinsic motivation to
work and problem solving. Moreover, improve autoplastic
adaptation to reality, the stress reaction flexibility to
adverse event and increase the resistance capacity to
exercise and fatigue. In clinical practice, the result can be
obtained faster by integrating words and pictures. The
integration between images and verbal communications
produces outstanding diagnostic and therapeutic effects.
The impact of images may be greater than that of words.
The latter have a sense; images instead have multiple
meanings, because they are more enigmatic. Words change
depending on the languages; pictures are universal. Images
with high psychodiagnostic and psychotherapeutic potential can treat the symptoms of psychological and psychosomatic discomfort that accompany the disease and can
enhance the cognitive, emotional and behavioural resources needed to tackle the path of evolution, care and
rehabilitation. It is not a coincidence that the Rorschach
test [16], the world-class excellence tool adapted for the
diagnosis of profile and personality functioning, consists of
the administration, qualitative and quantitative analysis,
and interpretation of projective answers provided by candidates in response to ten ink-stain images.
Artistic images with therapeutic content proposed in a
psychodiagnostic and psychotherapeutic setting can affect
mental, emotional and intellectual functioning positively.
Interpretative answers on art reveal subconscious
impulses, wishes, fantasies, deep motivations, and hidden
skills, sometimes unknown and unpredictable. When
observing art, you feel sensation and emotions in a privileged condition of spontaneous infant regression; you
activate defence mechanisms which influence emotional
distancing which may vary from attraction to refusal. Art is
symbolic. It is the archetypal possibility to have primordial
images which echo the voices of all of humanity; it contains subconscious and innate ideas, which are repeated
throughout history, whenever the creative imagination of
the individual is practiced freely [14, 15].
The VideoinsightÒ method is original and different
compared to the modelling techniques [5, 8] because it
relies on the capacity of the art video images to promote a
intrinsic elaboration at the psychological level. It was
capable not only to speed up the rehabilitation period (as
described by Maddison et al. [8] and Flint et al. [5]), but
also to enhance patient’s motivation and self-esteem as
shown by the low mean TSK reported for Group A. TSK
and the time while the patients need to walk with crutches
are directly correlated, demonstrating not only a psychological, but also a somatic effect of the method.
The present study has some limitations.
The main limitation of this study was the absence of a
patient psychological profiling. Unfortunately, the IRB
refused to apply to each patient a psychological profile
according to Rorschach tables [16] because it was argued
that this will be out from the main goal of the study. In this
way, we could have also analysed the different efficacy of
the VideoinsightÒ method according to the psychological
patients profile and probably could have been capable to
detect which patients could have had better benefit from the
view of artwork, and secondly we could have been more
selective in which type of artwork showing to the patients
according to his psychological profile.
This approach, with its intrinsic capacity to promote
changement, could have other interesting application in the
treatment of other orthopaedic pathologies where the psychological support and the psychological patient profile are
important. This methodology could become a universal
method to support the patients not only from the somatic,
but also from the psychological point of view, considering
the patient as a global unit that includes body and mind.
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Conclusions
This is the first time that not only video technology, but
also the power of art are used in conjunction to enhance the
recovery after surgery in order to treat the patients as a
global unit including all aspects: anatomical, functional,
psychological.
The VideoinsightÒ method combined to adequate rehabilitation could be an effective tool in the day-by-day
clinical practice in order to improve short-term functional
outcomes in patients who underwent ACL reconstruction.
Conflict of interest The authors certify that the above-named
manuscript describes their own original work on properly conducted
and documented research and that all authors contributed to the
conception and design of the study or acquisition of data, analysis and
interpretation of data, and revising the final version of the article. All
authors believe that the manuscript represents honest work. This
paper has not been submitted to, or published by, any other journal,
nor will it be submitted to any other journal without prior written
notification to the Editor-in-Chief that the manuscript is to be withdrawn. The authors declare that there was neither financial nor personal relationship including employment, consultancies, stock
ownership, honoraria, paid expert testimony, patent applications/
registration and grants with other people or organization that could
inappropriately influence (bias) their work.
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