Motor imagery (MI) after anterior cruciate ligement

Motor imagery (MI)

Motor imagery (MI) is a cognitive process during which the representation of an action is mentally reproduced without any overt motor output. Different types of MI can be described and easily combined such as visual imagery and auditory imagery (for example, the rate and pace at which the movement is executed), kinaesthetic imagery which is the set of sensations that match those generated during the execution of the movement, such as muscle tension, range of motion and more generally, it is built on proprioceptive cues. Lebon et al. 2011.



Cupal et al. (2001) included 30 post ACL Reconstruction into three groups. An experimental group (EG) who received relaxation and motor Imagine (visual, kinesthetic, and motivational imagery) and standard physiotherapy, control group (CG) standard physiotherapy alone and a placebo group (PG) who received attention, encouragement, and support. The experimental group received 10 sessions of relaxation and imagery every 2 weeks with a duration of 10–15 min each session over 6 month. The outcome measures was (1) Reinjury Anxiety on a 11-point Scale— ranging 0 (absence of concern) to 10 (extreme concern) (2) Perception of Pain on a 11-point Scale— ranging 0 (no pain) to 10 (extreme pain) and (3) Cybex 6000 isokinetic dynamometer—knee strength. The main findings showed significant improvement after 24 weeks in knee strength in the EG (0.83) compared to the PG (0.63) and CG (0.66). Re-injury anxiety was significantly less in the EG (1.10) compared to both PG (4.00) and CG (3.40) groups. Pain also decreased in the EG (0.70) compared to both PG (2.70) and CG (2.70) groups (p < 0.05). The authors concluded that relaxation and imagery sessions can potentially facilitate motor recovery after ACL reconstructive surgery.


However, measurements were recorded 24 weeks after the surgery. So, Lebon et al. 2011, followed up on this study to assess muscle activation during the first weeks post-surgery.


Lebon et al. 2011 included 12 competitive or recreational athletes (10 men and 2 women) ages 18–40 with right ACL reconstruction and no other no other lower extremity traumas. The athletes were divided into two groups. A control and an experimental group. The intervention consisted of motor imagery training over 5 week (12 sessions), with 15-min sessions for every second day in combination with standard physical therapy.

For the motor imagery intervention the participants were instructed to perceive muscle activation and joint tension while imagining maximal 10 second isometric contraction of a full extended knee without movement. The outcome measures in this study was 1) The Visual Analog Scale (pain perception), 2) Maximal isometric electromyogram activity of vastus medalis at full knee extension (ACLR vs noninjured limb), (3) Lower-Extremity Functional Scale (ability to perform daily activities with the injured limb), (4) Measures to assess magnitude of effusion from surgery and atrophy ○ Knee circumference—measured just above the patella ○ Thigh circumference—15 cm from superior edge of patella and ○ ROM—assessed with goniometer. The results showed that pain perception, effusion, atrophy, and the Lower-Extremity Functional Scale scores were not different between patients receiving MI training to those who did not. However, vastus medialis electromyogram was significantly greater muscle activation during the last session in the MI group compared with the group without MI (85.36% vs 51.56% compared with the healthy limb). Thereby, the authors concluded motor imagine showed to be effective at facilitating greater muscle activation and limitation of force loss after immobilization when compared with just standard physical therapy alone. Motor imagine should be considered a reliable and cost-effective complement to improve the process of functional rehabilitation as its potential can reduce the degree of impairment when administered in combination with physical activity.


Madisson et al. (2012)  included 21 post ACL reconstruction patients (mean= 34.86y, male 62% and first-time ACLR). Main aim of the study was to evaluate the effectiveness of guided imagery and relaxation (visual and kinesthetic modalities) delivered over 9 individual sessions in addition to 6 month of standard physical therapy. The patients were divided into two groups 13 to in EG consist of MI (visual and kinesthesia) + relaxation + standard physiotherapy and 8 in the CG consist of standard physiotherapy alone. They outcome measure was 1) Cybex 6000 isokinetic dynamometer (knee strength), 2) KT1000 arthrometer (knee laxity), 3) 24-h urine sample (neurobiological factors, 4) Athletic Injury Self-Efficacy Questionnaire (self-efficacy), 5) Athletic Injury Imagery Questionnaire-2 knee strength (rehabilitation imagery). No significant difference was found in knee strength. Knee laxity was significantly lower in the intervention group (5.25–0.15 mm) compared with control (3.73–0.50 mm) after 6 months. Urine samples reflected significantly lower levels of noradrenaline and dopamine at week 2, 6, and 12 in the intervention group. Thereby, the authors concluded that motor imagery is associated with a reduction in stress levels (measured by levels of noradrenaline and dopamine) as well as improved healing (KT100 scores). Guided imagery may have a positive effect on the autonomic system by reducing stress hormones that potentially can delay the healing process. Although the self-efficacy scale did not reach significance, the intervention group showed a more stable score when rating their perceived level of knee function.


Maddison et al. (2006) included 58 post ACLR patients and divided them into two groups. EG: 30 and CG 28. The EG received the standard physiotherapy + video display (edited interviews + real examples of functional tasks) in the preoperative, before discharge, two and six weeks postoperative. The CG received standard physiotherapy. For both groups, no significant effect was found for actual pain and for anxiety. Greater self-efficacy for crutches, walking, and exercise was observed in the EG compared to the CG only at the time before loading without crutches. The objective IKDC score improved in favor of the EG (p < 0.05). There was no difference for ROM.


Wilczynska et al, 2016, included 10 outpatient clinic patients with a mix of surgeries, 3 meniscus repair, 5 ACL, 2 patellar luxation. The participants were divided into 2 groups. A control group (CG) performed traditional rehabilitation activities and an experimental group (EG) who received additional activities pertaining to visualization techniques (functional recovery and full efficiency) in addition to traditional exercises. The outcomes were evaluated over 15 sessions. The outcome measures were 1) postoperative and nonoperated limb circumference (6 and 10 cm from patella base) 2) Laitinen Pain Scale (4 = unbearable pain, and 0 = no pain), 3) postoperative and nonoperated limb flexion. Both groups showed significant pain reduction from day 1 (3.6 vs 2.8) to day 15 (0.8 vs 0.6). Further, regardless of time after surgery the EG reported less pain compared with the CG. Similar results were found for flexion ROM and limb circumference of postoperative limb where ROM day 1 (79 vs 83) to day 15 (118 vs 119). Limb circumference day 1 (417.5 vs 419.9) and day 15 (417.2 vs 425.5).

Therefore, the study concluded that adding a visualization aspect to therapy during the initial stages of rehabilitation can help increase pain control, lower effusion, swelling, and inflammation. Although their sample size is small and the study was only applied during the initial stage of rehabilitation, it showed improvement in all 3 outcome measures.


Zaffagnini et al., 2013, included 106 patient with ACLR and were randomly assigned to two groups. 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 Tampa Scale of Kinesiophobia (TSK). The results showed 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. The authors concluded that the videoinsight 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.


Rodriguez, R. M., Marroquin, A., & Cosby, N. (2019) sum up above studies in a critically  appraised The evidence supports that motor imagery can potentially reduce the fear of reinjury and pain among the ACLR population. Addressing the psychological component during the early stages of recovery has shown to be effective in reducing pain and increasing range of motion, while suggesting that the use of motor imagery is also important during the final stages of rehabilitation were motor imagery in combination with physical therapy, can potentially promote greater activation of the quadriceps muscles and reduce ligamentous laxity, which can promote greater knee function. Also the studies showed a reduction of neurobiological factors (noradrenaline and dopamine) which is associated with anxiety and stress which can delay the healing process. Finally, motor imagine may also have beneficial effects on reinjury, pain questionnaires, and rating scales; ie, Athletic Injury Self-Efficacy Questionnaire, 11-point pain/reinjury scale) to evaluate their patients during rehabilitation to identify those who would benefit from addressing psychological factors.

Although the results support that imagery is an effective intervention, there are a couple of limitations to the selected studies. All 4 studies had a sample size of 30 or less, which is not necessarily a limitation, but there should be a focus on reproducing larger scale randomized controlled trials with a larger sample size to minimize the likelihood of reproducing false positive results. Therefore, ongoing research efforts are needed to examine the benefits of addressing psychological factors affecting injured athletes.


Pastora-Bernal et al. 2021, performed a systematic review based on 6 RCT with 228 ACLR participants receiving motor imagine intervention. The sample ranged from 10 to 101. Five studies included only ACLRs and one RCT by Wilczynska et al. (2015) included a mix of knee pathologies (3 meniscus repair, 5 ACL, 2 patellar luxation). This systematic review showed no clear evidence that motor imagine added to physiotherapy was an effective intervention in ACL after surgery. The included studies showed unequal results (positive and negative) regarding pain, anxiety, fear of re-injury, function, and activities of daily living. In terms of the range of motion, anthropometric measurements, and quality of life, the results were not conclusive. Muscle activation, strength, knee laxity, time to remove external support, and neurobiological factors showed some favorable results. Nevertheless, these results were based on several issues like no sample size calculation, inability to recruit participants, no effect size, publication in no JCR journal, absence of blinding or low number of subjects in both groups, experimental or control group. The quality of the evidence was judged to be a moderate-weak recommendation. In addition, the included studies offered different motor imaging interventions (Two RCTs focused their intervention on visual MI through the visualization of therapeutic videos, 1 RCT mainly focused on kinesthetic MI, favoring the imagination of different actions on the part of the subjects, and three RCT focused on both types of MI, both visual and kinesthetic), which were used individually and simultaneously, providing unequal results on different outcomes. Due to this lack of homogeneity in outcomes and instructions, it was not possible to perform a meta-analyse. More adequately powered long-term randomized controlled trials are necessary.


Coronado et al. 2018

Coronado et al. 2018, conducted a systematic review on psychosocial factors that can influence physical function and return to sport/activity after ACLR. Psychosocial factors are individual attributes that encompass affective, cognitive, behavioral, and social/cultural domains. Examples of psychosocial factors include fear of reinjury, self-efficacy, and coping skills. Fear of reinjury has been reported as a primary reason for not returning to high-level physical functioning such as sports participation. The purpose of this review was to examine the efficacy of psychosocial interventions in improving patient reported clinical and intermediary psychosocial outcomes, including return to sport/ activity, after anterior cruciate ligament reconstruction. The results of this review can inform clinicians and researchers on postoperative strategies that are in line with the current shift in physical rehabilitation toward “psychologically-informed” practice.


A total four RCTs met the inclusion criteria for this review. A total of 210 patients after ACLR were examined. The patient’s age ranged from 15 to 53 years. There were 148 males and 63 females in total. All patients


Influence of psychosocial intervention on physical function or health-related quality of life

Zaffagnini et al. found a significant treatment effect on physical function, but not health-related quality of life (p > 0.05), with the visual imagery group having higher function scores at three months after anterior cruciate ligament reconstruction compared to the control group (mean (SD) three-month International Knee Documentation Committee Score = 82.0 (13.8) vs. 71.0 (19.7), P = 0.047). Maddison et al. reported similar physical function scores at six weeks in the coping modeling group compared to the control group (mean (SD) six week International Knee Documentation Committee Score = 61.2 (8.0) vs. 57.0 (9.6), P = 0.08).


Influence of psychosocial intervention on pain

Cupal and Brewer found significantly lower pain intensity scores at six months in the guided imagery and relaxation group (mean (SD) six month 11-point Numeric Rating Scale=0.7 (0.7) vs. 2.7 (1.0) in placebo vs. 2.7 (1.3) in standard rehabilitation group, F(2,26)=41.22, η2=0.76, P<0.001). Maddison et al. did not show lower pain intensity scores at two weeks after ACLR in the coping modeling group compared to the standard rehabilitation group (mean (SD) two-week 101-point Numeric Rating Scale = 28.0 (18.5) vs. 27.8 (18.7), P = 0.52).


Influence of psychosocial intervention on intermediary psychosocial outcomes

Cupal and Brewer found a postoperative difference in six month reinjury anxiety, which favored the guided imagery and relaxation group (mean (SD) six-month 11-point Numeric Rating Scale = 1.1 (0.7) vs. 4.0 (1.1) in placebo and vs. 3.4 (1.3) in standard rehabilitation group, F(2,26) = 21.13, η2 = 0.62, P < 0.001). Similarly, Zaffagnini et al. reported a greater effect on three-month fear of reinjury in the visual imagery group compared to the placebo group (mean (SD) three month Tampa Scale of Kinesiophobia score = 28.1 (6.0) vs. 32.0 (5.8), P < 0.05). Maddison et al. reported an increase in rehabilitation self-efficacy following guided imagery and relaxation, where these patients showed smaller reductions in 6 and 12-week self-efficacy compared to the standard rehabilitation group (F(3,17) = 4.56, η2 = 0.46, P = 0.01). In a separate study by Maddison et al., the coping modeling intervention did not demonstrate a greater effect on preoperative anxiety or postoperative walking or exercise self-efficacy compared to standard rehabilitation (P > 0.05). The coping modeling intervention had a greater effect on predischarge crutches self-efficacy compared to standard rehabilitation (F(1,56) = 6.38, d = 0.53, P < 0.01)).


Gennarelli 2020

Self-determination theory has been proposed as being important for RTP after a serious injury. This theory states that self-motivation and healthy psychological development are related to three psychological needs being fulfilled: autonomy, competence and confidence relating to one’s athletic abilities, and relatedness (perception of belonging in a social context). Research has supported the important connection between psychological factors and readiness to RTP after injury. Kinesiophobia and fear of re-injury are reported to be two of the most important psychological factors that impact an athlete’s ability to return to pre-injury activity level. Studies have also found that negative psychological responses to injury such as anxiety, low self-esteem, and depression negatively affect RTP. Conversely, psychological predictors of optimism, including high self-efficacy, self-motivation, and strong athletic identity are positively associated with improved post-operative outcomes and RTP. Positive psychological response after injury, as measured by motivation, confidence, and low fear has also been associated with a higher likelihood of returning to sport following injury. In this systematic review by Gennarelli et al, 2020, they included 8 studies where the interventions described relaxation / guided imagery, positive self-talk, goal setting, counseling, emotional/written disclosure, and modeling videos. All of these were found to be effective in promoting recovery by elevating mood, reducing anxiety, improving joint function, or improving effort and rehabilitation exercise completion after musculoskeletal sports injury.

Although all of the papers included in this systematic review evaluated whether the intervention tested was beneficial to recovery after injury (or post-operatively), none specifically examined RTP as an outcome measure. Instead, they examined the efficacy of the intervention in promoting recovery by increasing positive mood changes and rehabilitation adherence.

The studies also evaluated the efficacy of the interventions with regards to reducing negative emotional states (e.g. stress and anxiety), improving pain management, and increasing exercise compliance in the post-injury recovery period. The primary finding of this systematic review was that psychosocial interventions are effective at promoting the recovery process when used during rehabilitation after musculoskeletal sports injuries.


  • Relaxation and guided imagery were found to improve pain management, increase self-efficacy, manage stress, and reduce re-injury anxiety in athletes with knee, foot/ankle, and shoulder injuries.
  • Positive self-talk and cognitive restructuring were helpful in dealing with post-injury negative mood disturbances and lead to increased rehabilitation adherence and feelings of positive rehabilitation self-efficacy in patients recovering from ACLR.
  • Goal setting was also associated with increased motivation, exercise compliance, and rehabilitation awareness along with increasing positive feelings of self-efficacy in athletes that participated in a wide variety of sports and had injuries to the knee, foot/ankle, or the shoulder.
  • Counseling provided a source of emotional and social support, thereby positively influencing rehabilitation program adherence in athletes recovering from ACL reconstruction.
  • Emotional/written disclosure improved acceptance of injury, reduced grief-related responses, increased motivation, and perceived sense of control in the recovery process and was found to be effective for reducing stress and negative mood disturbances in athletes recovering from ACL reconstruction, PCL reconstruction, or a neck injury.
  • Modeling videos were shown to reduce pain and anxiety along with increasing athletic confidence and feelings of self-efficacy in a group following ACLR.


There are several limitations to this study. First, all of the interventions described in the studies were only performed at a single time point. No follow up study was done to see results over time. Many of the studies used surveys or questionnaires to assess the efficacy of the intervention; however, a detailed analysis (including evaluating for clinical significance) was rarely performed. This information is necessary to determine the therapeutic value of the interventions. Finally, none of the studies measured the effect on return to play. Further studies are necessary to address this question.







Slimani M, et al. (2016) .


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Andreas Bjerregaard
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