Copyright: ©Author(s) 2026.
World J Orthop. Apr 18, 2026; 17(4): 116521
Published online Apr 18, 2026. doi: 10.5312/wjo.v17.i4.116521
Published online Apr 18, 2026. doi: 10.5312/wjo.v17.i4.116521
Table 1 Study and patient characteristics
| Ref. | Study design | Trait of participants | Number of participants | Intervention | Type of imagery | Pre-op session | Duration | Frequency | Age (year) | Sex (male/total) | Mean follow-up |
| Almuhaya et al[12], 2023 | RCT | Cases: 13 ACLR only, 4 ACLR + MMR, 1 ACLR + both (MMR and LMR) | Cases: 16 | Cases: Structured education + standard physiotherapy | Virtual interactive structured educational session via Zoom platform including a series of topics related to the surgery and the rehabilitation process prepared with pictures and graphs | No | 1 week | 8 five days in a week, 2 four days, 8 three or less days | 26 (6) | 35/35 | 1 week |
| Controls: 12 ACLR only, 2 ACLR + MMR, 1 ACLR + LMR, 2 ACLR + both | Controls: 14 | Controls: Standard physiotherapy | |||||||||
| Lee et al[14], 2023 | RCT | ACL reconstruction | Cases: 55 | Cases: Smartphone app-based behavioral intervention + standard physiotherapy | A smartphone app delivering the intervention through text, pictorials, and videos on how post-surgery home-based exercises and rehabilitations will be done, behavior change techniques | No | 16 weeks | NR | 27.82 (8.73) | NR | 16 weeks |
| Controls: 41 | Controls: Standard physiotherapy | ||||||||||
| Brewer et al[6], 2022 | RCT | ACL reconstruction | Cases: 34 | Cases: Interactive cognitive-behavioral multimedia program + standard physiotherapy | Introductory information and instructions on: (1) General information; (2) Surgery; and (3) Rehabilitation. Videos in which an orthopedic surgeon discussed the sensory and procedural aspects associated with the corresponding section of the program. Anatomical and surgical animations, video and still images of preoperative and postoperative rehabilitation exercises, video clips of former ACL reconstruction patients describing their experiences with ACL surgery and rehabilitation, a graph of pain over the rehabilitation process, and written text were among the means by which procedural and sensory information and modeling of adaptive coping responses. Links to online resources, personal accounts of and recommendations for dealing with ACL surgery and rehabilitation from former patients | Yes | 24 weeks | Weekly | 35.01 (11.98) | 39/69 | 24 weeks |
| Placebos: 35 | Placebo: Printed educational materials + standard physiotherapy | ||||||||||
| D’Isanto et al[13], 2022 | RCT | ACL reconstruction | Cases: 15 | Cases: VRGI and MT + standard physiotherapy | Suggestions for imagining internal images related to the use of the affected limb in one or more functional tasks and also through the mirror box, working with the vision of a video in which, through a background voice, the subject was asked to visualize specific sports movements and gestures | No | 20 weeks | 3 times per week (training frequency was 5/week with a session length of 60 minutes, with MT added 3 times/week for 20-25 minutes after the end of the conventional physical therapy) | Cases: 33 (1.8) | NR | 20 weeks |
| Controls: 15 | Controls: Physiotherapy | Controls: 32 (1.6) | |||||||||
| Lyles et al[17], 2014 | RCT | ACL reconstruction | Cases: 15 | Cases: Mirror therapy + standard physiotherapy | Affected leg was placed behind a self-made mirror (non-reflecting side) and non-affected leg was placed in front of the mirror (reflecting side). Patients were instructed to observe the reflected leg into the mirror while performing the exercises and then attempt the same exercises with the involved leg | No | 6 days | Once a day | Cases: 33.13 (6.99) | Cases: 10/15 | 6 days |
| Controls: 15 | Controls: Standard physiotherapy | Controls: 32.4 (5.66) | Controls: 9/15 | ||||||||
| Rhim et al[8], 2020 | RCT | ACL reconstruction | Cases: 10 | Cases: Modeling intervention + standard physiotherapy | Cases: Six modeling videos of semi-structured interviews and models who discussed their injury experience, expectations, and recovery and performed postoperative time-matched | Yes | 24 weeks | NR | Cases: 27.1 (9.5), placebos: 32.2 (12.2), controls: 26.8 (7.9) | Cases: 9/10, placebos: 8/11, controls: 10/11 | 24 weeks |
| Placebos: 11 | Placebos: Placebo videos + standard physiotherapy | Tasks and rehabilitation exercises. Six videos were similar in length (5 minutes) | |||||||||
| Controls: 11 | Controls: Standard physiotherapy | Reflected 6 different time points: Preoperative period, from hospitalization to 2 weeks, 2 weeks to 6 weeks, 6 weeks to 3 months, 3 months to 6 months, and 6 months and beyond following ACLR; placebos: Videos of PowerPoint slides including epidemiology of ACL injuries, anatomy of ACL, and mechanisms of ACL injury, and describing rehabilitation exercises with words | |||||||||
| Levinger et al[7], 2017 | RCT | ACL reconstruction | Cases: 10 | Cases: Internet-based resource + usual rehabilitation | Video and images on ACL reconstruction, expected milestones during the recovery process, strategies to overcome distress associated with the injury, and recommended physiotherapy exercises | No | 12 weeks | On a daily basis for the first week following the surgery | Cases: 32.2 (10.2) | Cases: 6/10, placebos: 4/7 | 12 weeks |
| Placebos: 7 | Placebos: Restricted access to internet-based resource + usual rehabilitation | Three times per week for weeks 2-3 following the surgery | Placebos: 28.5 (9.1) | ||||||||
| Once a week for weeks 4-12 following the surgery | |||||||||||
| Zaffagnini et al[9], 2013 | RCT | ACL reconstruction | Cases: 51 | Cases: Therapeutic vision videos + standard physiotherapy | Cases: Art video producing therapeutic insight | No | 8 weeks | 3 times per week | 33 (17) | 80/101 | 12 weeks |
| Placebos: 50 | Placebos: Videos of unfavorable information + standard physiotherapy | Placebos: Art video with an insight unfavorable to the psychological recovery | |||||||||
| Maddison et al[16], 2012 | RCT | ACL reconstruction | Cases: 13 | Cases: Mental rehearsal of rehabilitation goals + standard physiotherapy | Nine individual sessions of mental rehearsal of activities to achieve physical rehabilitation goals including cognitive, motivational, and healing imagery; cognitive imagery was used to rehearse rehabilitation exercises, using both visual and kinaesthetic modalities. Motivational imagery was used to set goals, control arousal levels, and increase self-confidence. Healing imagery was used to imagine the physiological processes taking place during rehabilitation | No | 24 weeks | NR | 34.86 (8.84) | 13/21 | 24 weeks |
| Controls: 8 | Controls: Standard physiotherapy | ||||||||||
| Lebon et al[4], 2012 | RCT | ACL reconstruction | Cases: 7 | Cases: Imagining muscle contractions + standard physiotherapy | 3 blocks of 10 imagined contractions, with a 10-second rest period between rehearsals and 2-minute rest period between blocks | No | 5 weeks | Every 2 days | 28.5 (5) | NR | 5 weeks |
| Placebos: 5 | Placebos: Neutral mental task (crossword or calculation) + standard physiotherapy | ||||||||||
| Maddison et al[15], 2006 | RCT | ACL reconstruction | Cases: 30 | Cases: Coping-model video + standard physiotherapy | Two coping model videos of edited interviews and models performing rehabilitation exercises; first video pre-op to 2 weeks post-op (9-minute) and second video 2 weeks to 6 weeks post-op (7-minute) | Yes | 6 weeks | NR | 30 | NR | 6 weeks |
| Controls: 28 | Controls: Standard physiotherapy | ||||||||||
| Cupal and Brewer[3], 2001 | RCT | ACL reconstruction | Cases: 10 | Cases: Mental rehearsal of rehabilitation goals + standard physiotherapy | Videos of patient’s arthroscopic procedure, facilitating knee flexibility and ROM, edema reduction, knee strength, position sense, anxiety reduction, anatomical and neurological mental comparison | No | 24 weeks | Every 2 weeks | 28.2 (8.2) | 16/30 | 24 weeks |
| Placebos: 10 | Placebos: Peaceful scene imagery + attention, encouragement, and support + standard physiotherapy | ||||||||||
| Controls: 10 | Controls: Standard physiotherapy |
Table 2 Outcome evaluations between intervention and control groups
| Ref. | Measured outcomes | Results |
| Almuhaya et al[12], 2023 | Kinesiophobia (TSK) | Improved TSK (P = 0.026) and ACL-RSI (P = 0.009) in cases than controls, no significant difference in IKDC (P = 0.42) between groups |
| Return to sport (ACL-RSI) | ||
| Functional status (IKDC) | ||
| Lee et al[14], 2023 | Knee strength (biodex isokinetic dynamometer) | No significant difference in muscle strength (P = 0.25 to 0.96), knee laxity (P = 0.96), and subjective knee evaluation (P = 0.99) between groups |
| Knee laxity (KT1000) | ||
| Functional status (IKDC) | ||
| D’Isanto et al[13], 2022 | Pain (VAS score) | Greater psychological readiness (P < 0.01) and lower postoperative pain in cases than controls |
| Psychological readiness (ACL-RSI) | ||
| Lyles et al[17], 2014 | Pain (VAS score) | Improved postoperative pain (P = 0.0018), AROM (P = 0.0004), PROM (P = 0.0011), and Lysholm score (P = 0.044) |
| ROM (AROM and PROM in flexion) | ||
| Functional status (Lysholm) | ||
| Rhim et al[8], 2020 | Kinesiophobia (TSK) | No significant difference in self-efficacy (P = 0.808), return to sport (P = 0.574), kinesiophobia (P = 0.888), and KOOS subscales (P = 0.236 to 0.916) between groups |
| Return to sport (ACL-RSI) | ||
| Self-efficacy (K-SES) | ||
| Functional status (KOOS) | ||
| Maddison et al[16], 2012 | Self-efficacy (AISEQ) | Improved postoperative knee laxity (P < 0.05) favoring the intervention |
| Knee strength (180/second, 60/second) | No significant difference for knee strength for extension at 180/second (P = 0.67) or 60/second (P = 0.48) | |
| Knee laxity (KT1000) | Fairly stable self-efficacy between weeks 6 to weeks 12 in cases than controls | |
| Lebon et al[4], 2012 | Preoperative perception of pain (0-100 scale) | Improved crutches (P < 0.01), walking (P = 0.01), and exercise (P < 0.05) SE in cases than controls only at predischarge, better IKDC 6 weeks postop, less crutches use time in cases than controls (P < 0.01) |
| Preoperative anxiety (STAI) | ||
| Self-efficacy (CSE, WSE, ESE) | ||
| Functional status (IKDC subjective and objective) | No significant difference in preoperative anxiety reduction, preoperative perception of pain reduction (P = 0.52), and postoperative ROM (P = 0.36) between groups | |
| ROM by goniometry | ||
| Crutches use time | ||
| Maddison et al[15], 2006 | Pain (0-10 scale) | Improved pain in cases than controls (P < 0.05). Greater post-op knee strength in cases than controls (P < 0.02). Reduced re-injury anxiety in cases than controls (P < 0.05) |
| Reinjury anxiety (0-10 scale) | ||
| Knee strength (cybex 6000) | ||
| Isokinetic dynamometer) |
Table 3 Outcome evaluations between intervention and placebo groups
| Ref. | Measured outcomes | Results |
| Brewer et al[6], 2022 | Pain (NRS) | Lower postoperative pain (P = 0.02), lower kinesiophobia (P = 0.77), improved postoperative symptoms (P = 0.002) in cases than controls |
| Kinesiophobia (TSK) | No significant difference in flexion ROM (P = 0.99), extension ROM (P = 0.18), and knee laxity (P = 0.09) between groups | |
| Subjective symptoms (KOS-SAS) | ||
| Knee laxity (KT1000) | ||
| ROM (flex and ext) | ||
| Rhim et al[8], 2020 | Kinesiophobia (TSK) | No significant difference in self-efficacy (P = 0.808), return to sport (P = 0.574), kinesiophobia (P = 0.888), and KOOS subscales (P = 0.236 to 0.916) between groups |
| Return to sport (ACL-RSI) | ||
| Self-efficacy (K-SES) | ||
| Functional status (KOOS) | ||
| Levinger et al[7], 2017 | Self-efficacy (K-SES) | No significant difference in KOOS subscales (P = 0.07-0.76), self-efficacy subscales (P = 0.42 and 0.71), kinesiophobia (P = 0.46), fear of activity (P = 0.96) between groups |
| Functional status (KOOS) | ||
| Kinesiophobia (TSK) | ||
| FABQ | ||
| Zaffagnini et al[9], 2013 | QOL (mental and physical SF-36) | Improved subjective IKDC (P = 0.047), TKS (P = 0.0141) and time to crutches discharge (P = 0.0012). No significant difference in Tegner score, and SF-36 mental and physical status between groups |
| Kinesiophobia (TSK) | ||
| Functional (subjective and objective IKDC, Tegner) | ||
| Crutches use time | ||
| Lebon et al[4], 2012 | Isometric activation of the medial musculature (EMG during maximum knee extension) | Greater postoperative musculature activity in cases than controls (P = 0.02). No significant difference in postoperative pain, ROM, effusion reduction, thigh circumference, LEFS score (P > 0.05) between groups |
| Pain (VAS score) | ||
| Ability to perform daily activities with lower extremity injury using the LEFS | ||
| Magnitude of surgical effusion and atrophy by the circumference of the knee above the kneecap and circumference of the thigh 15 cm above the kneecap | ||
| Knee ROM (goniometry) | ||
| Cupal and Brewer[3], 2001 | Pain (0-10 scale) | Improved pain in cases than placebos (P < 0.05). Reduced re-injury anxiety in cases than placebos (P < 0.05). Greater post-op knee strength in cases than placebos (P < 0.003) |
| Reinjury anxiety (0-10 scale) | ||
| Knee strength (cybex 6000) | ||
| Isokinetic dynamometer |
- Citation: Salimi M, Mafhoumi A, Mosalamiaghili S, Arvin A, Keshtkar A, Lowe W, Akbari H. Effectiveness of motor imagery in postoperative outcomes after anterior cruciate ligament reconstruction. World J Orthop 2026; 17(4): 116521
- URL: https://www.wjgnet.com/2218-5836/full/v17/i4/116521.htm
- DOI: https://dx.doi.org/10.5312/wjo.v17.i4.116521