Virtual Rehabilitation

Fear of reinjury can greatly increase an athlete’s chances of getting hurt again – but VR techniques developed by Shelby Baez can get them back in the game.

March 21st, 2024

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U.S. high school athletes experienced more than 5.2 million injuries between 2015 and 2019.

Madison Davis was one of them.

In the spring of 2019, during her junior year of high school, Davis charged toward a soccer ball on her team’s side of the field. The opposing striker tried to beat her to it, and just as Davis planted her foot to send the ball flying, the striker kicked her knee out from under her.

“This was the beginning of the spring season,” shares Davis, now a senior at UNC-Chapel Hill. “I was starting and really excited. And then that kick took me out. It was disheartening, to say the least.”

That kick tore Davis’ anterior cruciate ligament (ACL) — the primary stabilizing ligament in the knee — and she underwent reconstructive surgery that summer. In the next three years, she’d have two more surgeries.

“When we’re thinking about highly functioning, physically active people, not having their ACL can be problematic because they don’t have the stability to do things like running and jumping and cutting,” Shelby Baez says.

An exercise and sport scientist at Carolina, Baez runs the Psychology of Sport Injury Laboratory. She and her team use psychological methods to help athletes return to sports, reduce the risk of secondary injury, and improve knee joint health.

More specifically, Baez focuses on athletes recovering from ACL reconstruction. Her most recent study is assessing how guided mindfulness meditation using a virtual reality (VR) headset can improve physical healing.

“There’s a lot of apprehension when you come back from an injury like this,” Davis says. “There’s a lot of rehabilitation. I had nine months’ worth, and then I had to go back to my sport. You’re very timid because you’re scared you’re going to tear it again.”

VR therapy for ACL recovery

Fear of reinjury can plague recovering athletes. Those who return to their sport within two years of surgery are 13 times more likely to have a second ACL reconstruction, according to Baez. She first noticed these psychological responses while working as an athletic trainer at Midway University in Kentucky.

“I had a lot of patients who exhibited fear and decreased confidence after their injury, and I wanted to figure out how to help them,” she says. “Sport psychology allowed me to learn how to do that.”

Sport psychology uses psychological skills to improve performance, health, and wellbeing in athletes. Baez began conducting research in this field during her master’s and PhD programs at the University of Kentucky.

For her latest project at Carolina, Baez is leading an eight-week clinical trial funded by the National Institutes of Health on how virtual reality mindfulness meditation can help people recover from ACL reconstruction. She wants to decrease fear and improve jump-landing biomechanics in female athletes, who are at higher risk of sustaining a second injury.

On average, women exhibit different movement patterns than men, such as tilting their knees inward while landing from a jump, which make them more susceptible to these kinds of muscle tears.

In Fall 2023, study participants completed a baseline assessment to test their jumping, walking, and mobility. They also participated in an MRI exercise, where Baez monitored their brain activity as they looked at images of people engaging in sports and other scenes like hanging out with friends and grocery shopping.

“We measure their fear, their confidence, their self-reported function, and how they’re moving,” Baez says.

Participants in the experimental group visited the lab three days a week to participate in VR-guided mindfulness meditation, followed by a rehabilitation workout that included exercises like lunges, squats, and glute bridges, the intensity of which increased over time. They also wore an Oura Ring, which monitors sleep quality and heart rate variability.

“The VR meditation was cool,” Davis, a participant in the study, shares. “After doing it, I felt very relaxed. I really enjoyed it, especially as I progressed with the breathing. That is something I’ve continued to do outside of the study when I’m feeling super stressed.”Baez believes that VR influences buy-in from athletes and doctors alike.

For athletes, VR makes mindfulness meditation practices more engaging. The program Baez uses lets participants choose a variety of backgrounds to complete their breathing exercises, from a beach with crashing wave sounds to a forest filled with birdsong.

“Athletes like tech,” she says. “Plus, this provides a plug-and-play solution for doctors to treat patients psychologically in clinical practice.”

Athletic trainers and physical therapists can use the VR program to supplement their physical treatment plans without specializing in mental health or mindfulness meditation practices. It’s an easy add-on for them to include in their care.

While this study still has a long way to go — from data analysis to sharing the results in a scientific paper — Baez enjoys the more immediate gratification of working with student athletes like Davis.

“I’m from North Carolina, and I did my undergrad at UNC,” Baez shares. “It’s extremely meaningful to be able to help student athletes here in a place that’s been near and dear to my heart as long as I can remember.”

Madison Davis is a senior majoring in exercise and sport science and minoring in women’s and gender studies within the UNC College of Arts and Sciences.

Shelby Baez is an assistant professor in the Department of Exercise and Sport Science within the UNC College of Arts and Sciences.