The Differential Effects of First-Person and Third-Person Motor Imagery on Anxiety and Psychological Readiness in Athletes Recovering from ACL Reconstruction: A Longitudinal Study

The Differential Effects of First-Person and Third-Person Motor Imagery on Anxiety and Psychological Readiness in Athletes Recovering from ACL Reconstruction: A Longitudinal Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Differential Effects of First-Person and Third-Person Motor Imagery on Anxiety and Psychological Readiness in Athletes Recovering from ACL Reconstruction: A Longitudinal Study Nobuchika Yamaki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7751825/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Psychological factors such as anxiety and fear of reinjury are critical barriers to successful recovery after anterior cruciate ligament (ACL) reconstruction. Motor imagery (MI) has been proposed as a promising psychological tool, with first-person and third-person perspectives potentially offering distinct benefits. In this study, 100 athletes aged 18 to 25 years who returned to sport after ACL reconstruction were followed for nine months to examine how imagery perspectives influence psychological recovery. Imagery ability was assessed using the Vividness of Movement Imagery Questionnaire-2, psychological readiness with the ACL-Return to Sport after Injury scale, and anxiety with the State-Trait Anxiety Inventory. Repeated assessments demonstrated that first-person imagery consistently enhanced psychological readiness and reduced anxiety across all time points, emerging as the strongest predictor of positive outcomes. Third-person imagery was particularly effective in lowering situational anxiety around the six-month mark, when athletes faced critical challenges in their return-to-sport process. Together, these findings highlight the complementary roles of first-person and third-person imagery in rehabilitation. Incorporating both perspectives into psychological training programs may optimize athletes’ readiness, alleviate anxiety, and foster a smoother and more confident transition back to competitive sport. Figures Figure 1 Figure 2 1. Introduction Anterior cruciate ligament (ACL) injuries are among the most common and debilitating injuries in athletes, often requiring reconstructive surgery followed by extensive rehabilitation. While physical recovery is essential, psychological factors such as anxiety, fear of reinjury, and motivation play an equally important role in determining an athlete's ability to successfully return to sport (RTS)( 1 )( 2 ). Elevated anxiety levels during rehabilitation can delay RTS, impair performance, and increase the risk of reinjury( 3 )( 4 ). Therefore, addressing these psychological barriers alongside physical rehabilitation is crucial for optimizing recovery outcomes. One emerging psychological intervention is motor imagery (MI), which involves mentally rehearsing movements without physical execution. MI allows athletes to practice sport-specific skills and regain confidence in a controlled mental environment, thereby alleviating psychological barriers such as fear of reinjury( 5 )( 6 ). Research has demonstrated that MI enhances motor control, proprioception, and psychological resilience during rehabilitation( 7 )( 8 ). By allowing athletes to mentally rehearse complex movements without placing stress on the recovering joint, MI can improve technical performance while simultaneously reducing anxiety( 9 ). Motor imagery, however, is not a singular process; it can take different forms, notably first-person and third-person perspectives. First-person imagery involves visualizing movements as though performing the action oneself, engaging internal sensory feedback and motor control. This form of MI has been associated with improvements in motor precision, technical execution, and increased confidence in performing specific movements( 10 )( 11 ). In contrast, third-person imagery involves visualizing oneself from an external observer’s perspective, which is thought to enhance spatial awareness, decision-making, and tactical readiness, particularly in game-specific scenarios( 12 )( 13 ). Although MI has been extensively studied, most research treats it as a general intervention without distinguishing between first-person and third-person imagery. Few studies have directly compared these two imagery perspectives in the context of rehabilitation. Recent findings suggest that first-person imagery may be particularly effective in reducing anxiety related to technical performance, while third-person imagery may help alleviate situational anxiety related to tactical scenarios( 14 ). These results highlight the need to investigate how these imagery styles impact psychological readiness and anxiety across different stages of ACL rehabilitation. Furthermore, psychological readiness and anxiety may evolve over time during recovery. In the early stages of rehabilitation (0–3 months post-surgery), athletes often focus on regaining confidence in their physical abilities, where first-person imagery may play a more prominent role. Conversely, as athletes approach "pre-return" (around 6–8 months post-surgery, when they begin advanced sport-specific training but have not yet competed), third-person imagery may become more relevant for managing situational anxiety and preparing for competition( 15 ). This study, therefore, aims to address these gaps by investigating the differential effects of first-person and third-person imagery on psychological readiness and anxiety in athletes recovering from ACL reconstruction. Specifically, we hypothesize that: First-person imagery will be more strongly associated with psychological readiness (measured by ACL-RSI) and reductions in overall anxiety (measured by STAI), particularly in the early stages of recovery. Third-person imagery will be more effective at reducing situational anxiety during the later stages of rehabilitation, particularly around 6 months post-return to sport. The effects of first-person and third-person imagery will vary over time depending on the stage of recovery, with first-person imagery being dominant in early recovery and third-person imagery becoming more prominent in the later stages. To ensure robustness, this study will include a clearly defined cohort of athletes aged 18–25 years who have undergone ACL reconstruction and completed physical rehabilitation. This age range was chosen because younger athletes often experience a higher psychological burden due to competitive expectations and reinjury risk( 16 ). Participants will include individuals engaged in competitive sports at either amateur or professional levels, with details such as the affected limb and history of previous injuries recorded during screening. To ensure consistency, individuals with concurrent injuries (e.g., meniscus tears) or undergoing other psychological treatments will be excluded. Instruments such as the ACL-RSI and VMIQ-2, both validated for this population, will be used to assess psychological readiness and imagery vividness, respectively( 17 ). By systematically evaluating first-person and third-person imagery, this study seeks to provide insights into how MI can be integrated into rehabilitation programs to optimize psychological recovery, reduce anxiety, and support athletes’ overall well-being during their recovery journey. 2. Methods 2.1 Study Design This longitudinal study investigated the effects of first-person and third-person motor imagery on psychological readiness and anxiety in athletes recovering from ACL reconstruction. Assessments were conducted at four time points: baseline (pre-return to sport), 3 months post-return to sport (RTS), 6 months post-RTS, and 9 months post-RTS. The independent variables were first-person and third-person motor imagery abilities, measured by the Vividness of Movement Imagery Questionnaire-2 (VMIQ-2). The dependent variables were psychological readiness to return to sport, measured by the ACL-Return to Sport after Injury scale (ACL-RSI), and anxiety levels, measured by the State-Trait Anxiety Inventory (STAI). Participants provided written informed consent. All the methods of this study were carried out in accordance with the Declaration of Helsinki, and the study received approval from Institutional Review Board of eightis Co. (No. 0404) ensuring adherence to ethical guidelines for confidentiality and participant rights. Recruitment of participants was conducted from 12/01/2023 to 01/04/2024. 2.2 Participants A total of 100 athletes (50 male, 50 female), aged 18 to 25 years (M = 21.0, SD = 2.5), were recruited from university sports teams and rehabilitation centers. Participants provided written informed consent. All the methods of this study were carried out in accordance with the Declaration of Helsinki, and the study received approval from the Institutional Review Board of eightis Co. (No. 0404) ensuring adherence to ethical guidelines for confidentiality and participant rights. Recruitment of participants was conducted from 12/01/2023 to 01/04/2024. 2.3 Inclusion criteria : Athletes aged 18 to 25 years who had undergone ACL reconstruction surgery. Active participation in competitive sports prior to injury. Currently undergoing structured rehabilitation and planning to return to sport within 9 months. 2.4 Exclusion criteria : Significant lower limb injuries other than ACL reconstruction. Combined ACL and meniscus injuries. Ongoing psychological treatment unrelated to ACL rehabilitation. Neurological or psychiatric conditions affecting motor imagery abilities. Prior formal training or experience with motor imagery techniques. 2.5 Sample size calculation: The required sample size was determined using a priori power analysis (G*Power 3.1). Assuming an effect size of 0.3, alpha = 0.05, and power = 0.80, a minimum of 88 participants were required. To account for potential attrition, 100 participants were recruited. 2.6 Procedures Motor Imagery Assessment (VMIQ-2) : Motor imagery abilities were assessed using the Vividness of Movement Imagery Questionnaire-2 (VMIQ-2), which evaluates first-person (internal) and third-person (external) imagery abilities. The VMIQ-2 includes 12 items for each imagery perspective, divided into visual, kinesthetic, and motor imagery subcategories. Participants rated their vividness on a 5-point Likert scale (1 = perfectly clear and vivid as normal vision/movement, 5 = no image at all). Lower scores indicated more vivid imagery. The VMIQ-2 has demonstrated strong reliability and validity in athletic populations recovering from injury( 7 )( 18 ). 2.7 Psychological Readiness Assessment (ACL-RSI): The ACL-Return to Sport after Injury scale (ACL-RSI) was used to measure psychological readiness, including confidence in performance, fear of reinjury, and emotional readiness. Participants rated each of the 12 items on a scale from 0 (extremely negative response) to 100 (extremely positive response). Higher scores indicated greater psychological readiness. The ACL-RSI is validated for use in ACL-injured populations【Webster et al., 2018】. 2.8 Anxiety Assessment (STAI): Anxiety levels were measured using the State-Trait Anxiety Inventory (STAI), comprising two subscales: state anxiety (STAI-S, 20 items) and trait anxiety (STAI-T, 20 items). Participants rated their responses on a 4-point Likert scale (1 = not at all, 4 = very much so). Higher scores indicated greater anxiety. 2.9 Testing Environment All assessments were conducted in a quiet, controlled environment to minimize distractions. Questionnaires were completed independently, with research staff available to clarify items if necessary. The single-leg hop test for functional recovery was conducted in a well-lit gymnasium with standardized measurement protocols. 2.10 Statistical Analyses Data Normality and Homogeneity : Prior to analysis, normality of the data was tested using the Shapiro-Wilk test, and homogeneity of variance was assessed using Levene's test. Repeated Measures ANOVA : Changes in VMIQ-2 (first-person and third-person imagery), ACL-RSI, and STAI scores across four time points (baseline, 3 months, 6 months, and 9 months) were analyzed using repeated measures ANOVA. Mauchly's test of sphericity was conducted, and Greenhouse-Geisser corrections were applied when sphericity assumptions were violated. Post-hoc comparisons were performed with Bonferroni correction. Correlation Analyses : Pearson or Spearman correlations were calculated (based on data distribution) to examine relationships between motor imagery abilities (VMIQ-2), psychological readiness (ACL-RSI), and anxiety (STAI) at each time point. Multiple Regression Analysis : Multiple regression was conducted to determine whether first-person and third-person imagery abilities predicted psychological readiness (ACL-RSI) and anxiety (STAI). Regression models controlled for sex and time since surgery, and assumptions such as multicollinearity, homoscedasticity, and normality of residuals were verified. Subgroup Analyses : To explore potential sex-based differences, subgroup analyses were performed to stratify results by sex. Significance Level Statistical significance was set at p < 0.05, and all analyses were conducted using SPSS version 27. 3. Results 3.1 Descriptive Statistics Participants consistently reported lower first-person imagery scores (indicating more vivid imagery) compared to third-person imagery across all four time points. Over the course of the study, ACL-RSI scores increased, reflecting improved psychological readiness to return to sport, while STAI scores decreased, reflecting reductions in anxiety as rehabilitation progressed (see Fig. 1 ). Participant Demographics : Participants (N = 100; 50 male, 50 female) had a mean age of 21.0 years (SD = 2.5). No significant differences in baseline psychological measures (ACL-RSI, STAI) were observed between male and female participants (p > 0.05). First-person imagery (VMIQ-2) : Baseline (M = 22.8, SD = 6.4), 3 months (M = 18.4, SD = 5.9), 6 months (M = 15.6, SD = 5.2), 9 months (M = 13.8, SD = 5.0). Third-person imagery (VMIQ-2) : Baseline (M = 29.6, SD = 7.1), 3 months (M = 25.3, SD = 6.8), 6 months (M = 22.7, SD = 6.3), 9 months (M = 20.5, SD = 5.8). ACL-RSI : Baseline (M = 55.2, SD = 12.7), 3 months (M = 64.1, SD = 11.4), 6 months (M = 71.5, SD = 10.2), 9 months (M = 76.8, SD = 9.3). STAI : Baseline (M = 42.3, SD = 9.5), 3 months (M = 38.4, SD = 8.7), 6 months (M = 34.1, SD = 8.1), 9 months (M = 30.5, SD = 7.8). 3.2 Group Comparisons Data were tested for normality using the Shapiro-Wilk test and for homogeneity of variance using the Levene's test. Results indicated that all variables met the assumptions of normality (p > 0.05) and homogeneity of variance (p > 0.05) across the four time points. Repeated measures ANOVA revealed significant main effects for both first-person and third-person imagery on psychological readiness (ACL-RSI) and anxiety levels (STAI), with key findings highlighted below (see Figs. 2 and 3). First-person imagery and ACL-RSI : F(3, 297) = 18.34, p < 0.001. Post-hoc comparisons revealed significant improvements in psychological readiness between: Baseline vs. 3 months (p < 0.01), Baseline vs. 6 months (p < 0.001), Baseline vs. 9 months (p < 0.001). Athletes with stronger first-person imagery abilities (lower VMIQ-2 scores) demonstrated higher psychological readiness at all time points. First-person imagery and STAI : F(3, 297) = 12.67, p < 0.01. Post-hoc comparisons showed significant reductions in anxiety levels between: Baseline vs. 3 months (p < 0.01), Baseline vs. 6 months (p < 0.01), Baseline vs. 9 months (p < 0.01). Third-person imagery and ACL-RSI : F(3, 297) = 15.42, p < 0.001. Post-hoc comparisons revealed significant improvements in psychological readiness between: Baseline vs. 6 months (p < 0.001), Baseline vs. 9 months (p < 0.001). Third-person imagery and STAI (situational anxiety) : F(3, 297) = 10.21, p < 0.05. Significant reductions were observed between: Baseline vs. 6 months (p < 0.05), Baseline vs. 9 months (p < 0.05). This suggests that third-person imagery became more effective in reducing situational anxiety during the later stages of rehabilitation. 3.3 Subgroup Analysis by Sex Sex-based analyses revealed no significant interactions between sex and imagery type for ACL-RSI or STAI scores. However, males reported marginally lower STAI scores at 6 months compared to females (p = 0.06), suggesting potential trends that warrant further investigation (see Table 1). Although no significant interactions were found between sex and imagery type, the marginally lower STAI scores observed in males at 6 months suggest potential sex-based differences in anxiety reduction. Future studies should explore whether sex influences the effectiveness of motor imagery techniques in specific psychological domains. 3.4 Correlation and Regression Analysis First-person imagery was significantly correlated with ACL-RSI scores at all time points, indicating that better imagery abilities were associated with higher psychological readiness: Baseline: r = 0.50, p < 0.001 3 months: r = 0.55, p < 0.001 6 months: r = 0.60, p < 0.001 9 months: r = 0.63, p < 0.001 First-person imagery was also negatively correlated with state anxiety (STAI-S): Baseline: r = -0.40, p < 0.01 3 months: r = -0.43, p < 0.01 6 months: r = -0.48, p < 0.001 9 months: r = -0.52, p < 0.001 Regression analysis showed: First-person imagery significantly predicted psychological readiness (ACL-RSI): β = 0.46, p < 0.001. Third-person imagery significantly predicted reductions in situational anxiety at 6 months post-RTS: β = 0.28, p < 0.05. 4. Discussion 4.1 Study Objectives and Hypotheses This study investigated the differential effects of first-person and third-person motor imagery on psychological readiness and anxiety in athletes recovering from ACL reconstruction. The findings confirmed the first hypothesis, showing that first-person imagery enhances psychological readiness and reduces fear of reinjury during the early stages of rehabilitation. The second hypothesis was partially supported, demonstrating that third-person imagery effectively reduces situational anxiety at 6 months post-return to sport (RTS). These results highlight the complementary roles of both imagery types in addressing the evolving psychological needs of athletes during recovery. 4.2 First-Person Imagery and Psychological Readiness First-person motor imagery plays a critical role in fostering psychological readiness to RTS. Athletes with stronger first-person imagery abilities reported higher ACL-RSI scores and lower state anxiety (STAI-S) across all recovery stages. This aligns with previous studies suggesting that first-person imagery engages internal sensory feedback and motor control, enabling athletes to mentally rehearse movements from their own perspective. This process reduces fear of reinjury and bolsters technical confidence( 5 )( 6 ). Neuroimaging evidence supports these findings, showing that first-person imagery activates motor-related brain regions such as the motor cortex and basal ganglia, which are essential for rebuilding motor confidence( 7 )( 8 ). The PETTLEP model further explains that first-person imagery closely mirrors physical movement execution, enhancing self-efficacy and reducing anxiety during the early stages of rehabilitation( 9 ). Our results indicate that first-person imagery is particularly effective during early rehabilitation, when athletes focus on regaining motor control and technical confidence. By mentally rehearsing complex movements, athletes alleviate fear of reinjury and develop a sense of mastery over their physical capabilities, enabling a smoother transition to subsequent recovery stages. 4.3 Third-Person Imagery and Situational Anxiety Reduction Third-person motor imagery significantly contributes to reducing situational anxiety, particularly as athletes approach competitive scenarios. At 6 months post-RTS, athletes with stronger third-person imagery abilities reported lower situational anxiety, suggesting that this imagery style becomes increasingly effective during later recovery stages. These findings align with research highlighting third-person imagery’s role in enhancing spatial awareness and decision-making, which are critical for advanced rehabilitation( 10 )( 11 ). The Motor Imagery Integrative Model supports these observations, emphasizing that third-person imagery facilitates mental rehearsal in complex environments involving external factors such as team dynamics and strategic decisions( 5 ). As athletes prepare for competition, third-person imagery enables them to visualize movements in a broader context, reducing situational anxiety by fostering a sense of preparedness for tactical and strategic challenges. 4.4 The Interaction of Time and Imagery Styles A unique contribution of this study is its exploration of the temporal dynamics of imagery effectiveness. The results demonstrate that first-person imagery is most impactful during early recovery, while third-person imagery gains importance as athletes progress toward full RTS. This temporal shift reflects the evolving psychological demands faced by athletes throughout rehabilitation. Initially, athletes prioritize regaining physical confidence and motor control, explaining the dominance of first-person imagery during early recovery stages. As they approach competitive readiness, external demands such as team coordination and tactical preparation become critical, highlighting the utility of third-person imagery. These findings support theoretical frameworks proposed by Smith et al. and Lang et al., advocating for a stage-specific approach to motor imagery interventions( 12 )( 13 ). 4.5 The Role of Motivation in Motor Imagery Motivation likely moderates the effectiveness of motor imagery interventions. Athletes with high intrinsic motivation may engage more consistently with imagery practices, amplifying their benefits. For instance, motivated athletes may experience enhanced outcomes from first-person imagery due to more vivid and detailed mental rehearsals. Similarly, in later recovery stages, high motivation may lead to greater utilization of third-person imagery for preparing tactical scenarios. Future studies should quantify motivation levels and examine how intrinsic and extrinsic motivation interact with imagery styles to influence psychological outcomes. This could inform tailored interventions that account for individual differences in motivation and adherence to imagery training. 4. 6 Clinical Implications The results of this study offer practical guidance for designing stage-specific motor imagery interventions: Early Stages : Emphasize first-person imagery to rebuild motor confidence, reduce fear of reinjury, and enhance technical performance. Later Stages : Introduce third-person imagery to improve spatial awareness, tactical preparation, and reduce situational anxiety. By aligning motor imagery practices with the athlete’s recovery stage, clinicians can address their evolving psychological needs, optimize outcomes, and facilitate a confident RTS. This approach aligns with the PETTLEP model and the Motor Imagery Integrative Model, which stress task-specific and recovery stage-specific imagery interventions( 9 )( 5 ). 4.7 Limitations and Future Research Several limitations should be considered: Sample Bias : The sample consisted of university athletes, limiting generalizability to professional or recreational athletes. Future studies should include diverse populations to validate these findings across different competition levels. Subjective Measures : Reliance on self-reported data (VMIQ-2, ACL-RSI, STAI) may introduce bias. Incorporating objective measures, such as neuroimaging or biomechanical analyses, could provide deeper insights into motor imagery’s neural and physiological effects. Sex-Based Differences : While no significant sex differences were observed, trends suggest potential differences in anxiety reduction and imagery effectiveness. Larger, stratified samples are needed to explore these differences further. Motivation : The role of motivation was not directly assessed. Future research should examine how motivation interacts with imagery styles to influence psychological readiness and anxiety. 5. Conclusion This study provides robust evidence that first-person and third-person motor imagery play distinct yet complementary roles in the psychological recovery of athletes following ACL reconstruction: First-Person Imagery : Enhances psychological readiness and reduces fear of reinjury during early recovery stages. Third-Person Imagery : Reduces situational anxiety and improves spatial awareness as athletes approach competition. By tailoring motor imagery interventions to the athlete’s recovery stage and incorporating motivational factors, clinicians can optimize rehabilitation outcomes, addressing both psychological and tactical needs, and supporting a successful return to sport. Declarations Author Contributions: Nobuchika Yamaki was responsible for all aspects of this study, including conceiving the research idea, designing the study, collecting and analyzing the data, interpreting the results, and writing the manuscript. Data Availability Statement: The data supporting the findings of this study are available as supplementary material attached to this submission. Consent to publish: Not applicable. Conflict of Interest( s ): The authors declare no conflicts of interest related to this study. Funding: This research received no external funding. References Ardern CL, Taylor NF, Feller JA, Webster KE. 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Cogn Therapy Res. 2015;39(4):391–400. https://doi.org/10.1007/s10608-015-9694-5 . Guillot A, Collet C. The effectiveness of third-person motor imagery in high-pressure scenarios. Psychol Sport Exerc. 2021;55:102072. https://doi.org/10.1016/j.psychsport.2020.102072 . Holmes PS, Collins DJ. Practical considerations for imagery use in rehabilitation: Revisiting the PETTLEP model. Phys Ther Sport. 2001;9(3):112–21. https://doi.org/10.1016/j.ptsp.2008.01.001 . Guillot A, Collet C. A new approach to motor imagery for ACL rehabilitation. J Sports Sci. 2021;39(8):921–9. https://doi.org/10.1080/02640414.2021.1898832 . Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. 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08:21:49","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79228,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7751825/v1/fb665d9f7d0453058bd500fe.html"},{"id":96244943,"identity":"b36f8c1e-2678-4b04-881f-21b11f5b7d98","added_by":"auto","created_at":"2025-11-19 07:19:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":113557,"visible":true,"origin":"","legend":"\u003cp\u003e・First-person Imagery( VMIQ-2 ) Scores Over Time\u003c/p\u003e\n\u003cp\u003eMean first-person imagery scores at baseline, 3 months, 6 months, and 9 months post-return to sport, with standard deviation bars.\u003c/p\u003e\n\u003cp\u003e・Third-person Imagery( VMIQ-2 ) Scores Over Time\u003c/p\u003e\n\u003cp\u003eMean third-person imagery scores at baseline, 3 months, 6 months, and 9 months post-return to sport.\u003c/p\u003e\n\u003cp\u003e・ACL-RSI Scores Over Time\u003c/p\u003e\n\u003cp\u003eMean ACL-Return to Sport after Injury scale ( ACL-RSI ) scores at baseline, 3 months, 6 months, and 9 months post-return to sport.\u003c/p\u003e\n\u003cp\u003e・STAI Scores Over Time\u003c/p\u003e\n\u003cp\u003eMean State-Trait Anxiety Inventory ( STAI ) scores at baseline, 3 months, 6 months, and 9 months post-return to sport.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7751825/v1/d3efa0d5a3c034afdd4a7431.png"},{"id":95973529,"identity":"9c3516a7-82b4-48c0-8020-1ff15039ff60","added_by":"auto","created_at":"2025-11-15 08:21:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":145786,"visible":true,"origin":"","legend":"\u003cp\u003e・First-person Imagery and ACL-RSI\u003c/p\u003e\n\u003cp\u003eMean ACL-RSI scores for first-person imagery at baseline, 3 months, 6 months, and 9 months.\u003c/p\u003e\n\u003cp\u003e・Third-person Imagery and ACL-RSI\u003c/p\u003e\n\u003cp\u003eMean ACL-RSI scores for third-person imagery at baseline, 3 months, 6 months, and 9 months.\u003c/p\u003e\n\u003cp\u003e・First-person Imagery and STAI\u003c/p\u003e\n\u003cp\u003eMean STAI scores for first-person imagery at baseline, 3 months, 6 months, and 9 months.\u003c/p\u003e\n\u003cp\u003e・Third-person Imagery and STAI\u003c/p\u003e\n\u003cp\u003eMean STAI scores for third-person imagery at baseline, 3 months, 6 months, and 9 months.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7751825/v1/3bbae90dab4bdca997d5235e.png"},{"id":103803891,"identity":"b23d78f7-ca8a-4c67-a332-a5b8daad3a4b","added_by":"auto","created_at":"2026-03-03 06:41:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1171962,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7751825/v1/f4f1e066-e02b-4c4e-8a29-7730782fc416.pdf"},{"id":95973526,"identity":"47e6e024-255f-4883-9e1d-6e8c1a5a8a4e","added_by":"auto","created_at":"2025-11-15 08:21:48","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14067,"visible":true,"origin":"","legend":"","description":"","filename":"recoveryvalue.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7751825/v1/97040c79c3154a7eb29493f8.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Differential Effects of First-Person and Third-Person Motor Imagery on Anxiety and Psychological Readiness in Athletes Recovering from ACL Reconstruction: A Longitudinal Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAnterior cruciate ligament (ACL) injuries are among the most common and debilitating injuries in athletes, often requiring reconstructive surgery followed by extensive rehabilitation. While physical recovery is essential, psychological factors such as anxiety, fear of reinjury, and motivation play an equally important role in determining an athlete's ability to successfully return to sport (RTS)(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Elevated anxiety levels during rehabilitation can delay RTS, impair performance, and increase the risk of reinjury(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Therefore, addressing these psychological barriers alongside physical rehabilitation is crucial for optimizing recovery outcomes.\u003c/p\u003e\u003cp\u003eOne emerging psychological intervention is motor imagery (MI), which involves mentally rehearsing movements without physical execution. MI allows athletes to practice sport-specific skills and regain confidence in a controlled mental environment, thereby alleviating psychological barriers such as fear of reinjury(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Research has demonstrated that MI enhances motor control, proprioception, and psychological resilience during rehabilitation(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). By allowing athletes to mentally rehearse complex movements without placing stress on the recovering joint, MI can improve technical performance while simultaneously reducing anxiety(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMotor imagery, however, is not a singular process; it can take different forms, notably first-person and third-person perspectives. First-person imagery involves visualizing movements as though performing the action oneself, engaging internal sensory feedback and motor control. This form of MI has been associated with improvements in motor precision, technical execution, and increased confidence in performing specific movements(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In contrast, third-person imagery involves visualizing oneself from an external observer\u0026rsquo;s perspective, which is thought to enhance spatial awareness, decision-making, and tactical readiness, particularly in game-specific scenarios(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough MI has been extensively studied, most research treats it as a general intervention without distinguishing between first-person and third-person imagery. Few studies have directly compared these two imagery perspectives in the context of rehabilitation. Recent findings suggest that first-person imagery may be particularly effective in reducing anxiety related to technical performance, while third-person imagery may help alleviate situational anxiety related to tactical scenarios(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These results highlight the need to investigate how these imagery styles impact psychological readiness and anxiety across different stages of ACL rehabilitation.\u003c/p\u003e\u003cp\u003eFurthermore, psychological readiness and anxiety may evolve over time during recovery. In the early stages of rehabilitation (0\u0026ndash;3 months post-surgery), athletes often focus on regaining confidence in their physical abilities, where first-person imagery may play a more prominent role. Conversely, as athletes approach \"pre-return\" (around 6\u0026ndash;8 months post-surgery, when they begin advanced sport-specific training but have not yet competed), third-person imagery may become more relevant for managing situational anxiety and preparing for competition(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study, therefore, aims to address these gaps by investigating the differential effects of first-person and third-person imagery on psychological readiness and anxiety in athletes recovering from ACL reconstruction. Specifically, we hypothesize that:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFirst-person imagery will be more strongly associated with psychological readiness (measured by ACL-RSI) and reductions in overall anxiety (measured by STAI), particularly in the early stages of recovery.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThird-person imagery will be more effective at reducing situational anxiety during the later stages of rehabilitation, particularly around 6 months post-return to sport.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe effects of first-person and third-person imagery will vary over time depending on the stage of recovery, with first-person imagery being dominant in early recovery and third-person imagery becoming more prominent in the later stages.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eTo ensure robustness, this study will include a clearly defined cohort of athletes aged 18\u0026ndash;25 years who have undergone ACL reconstruction and completed physical rehabilitation. This age range was chosen because younger athletes often experience a higher psychological burden due to competitive expectations and reinjury risk(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Participants will include individuals engaged in competitive sports at either amateur or professional levels, with details such as the affected limb and history of previous injuries recorded during screening. To ensure consistency, individuals with concurrent injuries (e.g., meniscus tears) or undergoing other psychological treatments will be excluded. Instruments such as the ACL-RSI and VMIQ-2, both validated for this population, will be used to assess psychological readiness and imagery vividness, respectively(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBy systematically evaluating first-person and third-person imagery, this study seeks to provide insights into how MI can be integrated into rehabilitation programs to optimize psychological recovery, reduce anxiety, and support athletes\u0026rsquo; overall well-being during their recovery journey.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design\u003c/h2\u003e\u003cp\u003eThis longitudinal study investigated the effects of first-person and third-person motor imagery on psychological readiness and anxiety in athletes recovering from ACL reconstruction. Assessments were conducted at four time points: baseline (pre-return to sport), 3 months post-return to sport (RTS), 6 months post-RTS, and 9 months post-RTS. The independent variables were first-person and third-person motor imagery abilities, measured by the Vividness of Movement Imagery Questionnaire-2 (VMIQ-2). The dependent variables were psychological readiness to return to sport, measured by the ACL-Return to Sport after Injury scale (ACL-RSI), and anxiety levels, measured by the State-Trait Anxiety Inventory (STAI). Participants provided written informed consent. All the methods of this study were carried out in accordance with the Declaration of Helsinki, and the study received approval from Institutional Review Board of eightis Co. (No. 0404) ensuring adherence to ethical guidelines for confidentiality and participant rights. Recruitment of participants was conducted from 12/01/2023 to 01/04/2024.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Participants\u003c/h2\u003e\u003cp\u003eA total of 100 athletes (50 male, 50 female), aged 18 to 25 years (M\u0026thinsp;=\u0026thinsp;21.0, SD\u0026thinsp;=\u0026thinsp;2.5), were recruited from university sports teams and rehabilitation centers. Participants provided written informed consent. All the methods of this study were carried out in accordance with the Declaration of Helsinki, and the study received approval from the Institutional Review Board of eightis Co. (No. 0404) ensuring adherence to ethical guidelines for confidentiality and participant rights. Recruitment of participants was conducted from 12/01/2023 to 01/04/2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.3 Inclusion criteria\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAthletes aged 18 to 25 years who had undergone ACL reconstruction surgery.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eActive participation in competitive sports prior to injury.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCurrently undergoing structured rehabilitation and planning to return to sport within 9 months.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.4 Exclusion criteria\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSignificant lower limb injuries other than ACL reconstruction.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCombined ACL and meniscus injuries.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOngoing psychological treatment unrelated to ACL rehabilitation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNeurological or psychiatric conditions affecting motor imagery abilities.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePrior formal training or experience with motor imagery techniques.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Sample size calculation:\u003c/h2\u003e\u003cp\u003eThe required sample size was determined using a priori power analysis (G*Power 3.1). Assuming an effect size of 0.3, alpha\u0026thinsp;=\u0026thinsp;0.05, and power\u0026thinsp;=\u0026thinsp;0.80, a minimum of 88 participants were required. To account for potential attrition, 100 participants were recruited.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Procedures\u003c/h2\u003e\u003cp\u003e\u003cb\u003eMotor Imagery Assessment (VMIQ-2)\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eMotor imagery abilities were assessed using the Vividness of Movement Imagery Questionnaire-2 (VMIQ-2), which evaluates first-person (internal) and third-person (external) imagery abilities. The VMIQ-2 includes 12 items for each imagery perspective, divided into visual, kinesthetic, and motor imagery subcategories. Participants rated their vividness on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;perfectly clear and vivid as normal vision/movement, 5\u0026thinsp;=\u0026thinsp;no image at all). Lower scores indicated more vivid imagery. The VMIQ-2 has demonstrated strong reliability and validity in athletic populations recovering from injury(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Psychological Readiness Assessment (ACL-RSI):\u003c/h2\u003e\u003cp\u003eThe ACL-Return to Sport after Injury scale (ACL-RSI) was used to measure psychological readiness, including confidence in performance, fear of reinjury, and emotional readiness. Participants rated each of the 12 items on a scale from 0 (extremely negative response) to 100 (extremely positive response). Higher scores indicated greater psychological readiness. The ACL-RSI is validated for use in ACL-injured populations【Webster et al., 2018】.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.8 Anxiety Assessment (STAI):\u003c/h2\u003e\u003cp\u003eAnxiety levels were measured using the State-Trait Anxiety Inventory (STAI), comprising two subscales: state anxiety (STAI-S, 20 items) and trait anxiety (STAI-T, 20 items). Participants rated their responses on a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;not at all, 4\u0026thinsp;=\u0026thinsp;very much so). Higher scores indicated greater anxiety.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.9 Testing Environment\u003c/h2\u003e\u003cp\u003eAll assessments were conducted in a quiet, controlled environment to minimize distractions. Questionnaires were completed independently, with research staff available to clarify items if necessary. The single-leg hop test for functional recovery was conducted in a well-lit gymnasium with standardized measurement protocols.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.10 Statistical Analyses\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eData Normality and Homogeneity\u003c/b\u003e: Prior to analysis, normality of the data was tested using the Shapiro-Wilk test, and homogeneity of variance was assessed using Levene's test.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eRepeated Measures ANOVA\u003c/b\u003e: Changes in VMIQ-2 (first-person and third-person imagery), ACL-RSI, and STAI scores across four time points (baseline, 3 months, 6 months, and 9 months) were analyzed using repeated measures ANOVA. Mauchly's test of sphericity was conducted, and Greenhouse-Geisser corrections were applied when sphericity assumptions were violated. Post-hoc comparisons were performed with Bonferroni correction.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCorrelation Analyses\u003c/b\u003e: Pearson or Spearman correlations were calculated (based on data distribution) to examine relationships between motor imagery abilities (VMIQ-2), psychological readiness (ACL-RSI), and anxiety (STAI) at each time point.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMultiple Regression Analysis\u003c/b\u003e: Multiple regression was conducted to determine whether first-person and third-person imagery abilities predicted psychological readiness (ACL-RSI) and anxiety (STAI). Regression models controlled for sex and time since surgery, and assumptions such as multicollinearity, homoscedasticity, and normality of residuals were verified.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSubgroup Analyses\u003c/b\u003e: To explore potential sex-based differences, subgroup analyses were performed to stratify results by sex.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSignificance Level\u003c/strong\u003e\u003cp\u003eStatistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and all analyses were conducted using SPSS version 27.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Descriptive Statistics\u003c/h2\u003e\u003cp\u003eParticipants consistently reported lower first-person imagery scores (indicating more vivid imagery) compared to third-person imagery across all four time points. Over the course of the study, ACL-RSI scores increased, reflecting improved psychological readiness to return to sport, while STAI scores decreased, reflecting reductions in anxiety as rehabilitation progressed (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eParticipant Demographics\u003c/b\u003e:\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eParticipants (N\u0026thinsp;=\u0026thinsp;100; 50 male, 50 female) had a mean age of 21.0 years (SD\u0026thinsp;=\u0026thinsp;2.5).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNo significant differences in baseline psychological measures (ACL-RSI, STAI) were observed between male and female participants (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFirst-person imagery (VMIQ-2)\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline (M\u0026thinsp;=\u0026thinsp;22.8, SD\u0026thinsp;=\u0026thinsp;6.4), 3 months (M\u0026thinsp;=\u0026thinsp;18.4, SD\u0026thinsp;=\u0026thinsp;5.9), 6 months (M\u0026thinsp;=\u0026thinsp;15.6, SD\u0026thinsp;=\u0026thinsp;5.2), 9 months (M\u0026thinsp;=\u0026thinsp;13.8, SD\u0026thinsp;=\u0026thinsp;5.0).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eThird-person imagery (VMIQ-2)\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline (M\u0026thinsp;=\u0026thinsp;29.6, SD\u0026thinsp;=\u0026thinsp;7.1), 3 months (M\u0026thinsp;=\u0026thinsp;25.3, SD\u0026thinsp;=\u0026thinsp;6.8), 6 months (M\u0026thinsp;=\u0026thinsp;22.7, SD\u0026thinsp;=\u0026thinsp;6.3), 9 months (M\u0026thinsp;=\u0026thinsp;20.5, SD\u0026thinsp;=\u0026thinsp;5.8).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eACL-RSI\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline (M\u0026thinsp;=\u0026thinsp;55.2, SD\u0026thinsp;=\u0026thinsp;12.7), 3 months (M\u0026thinsp;=\u0026thinsp;64.1, SD\u0026thinsp;=\u0026thinsp;11.4), 6 months (M\u0026thinsp;=\u0026thinsp;71.5, SD\u0026thinsp;=\u0026thinsp;10.2), 9 months (M\u0026thinsp;=\u0026thinsp;76.8, SD\u0026thinsp;=\u0026thinsp;9.3).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSTAI\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline (M\u0026thinsp;=\u0026thinsp;42.3, SD\u0026thinsp;=\u0026thinsp;9.5), 3 months (M\u0026thinsp;=\u0026thinsp;38.4, SD\u0026thinsp;=\u0026thinsp;8.7), 6 months (M\u0026thinsp;=\u0026thinsp;34.1, SD\u0026thinsp;=\u0026thinsp;8.1), 9 months (M\u0026thinsp;=\u0026thinsp;30.5, SD\u0026thinsp;=\u0026thinsp;7.8).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Group Comparisons\u003c/h2\u003e\u003cp\u003eData were tested for normality using the Shapiro-Wilk test and for homogeneity of variance using the Levene's test. Results indicated that all variables met the assumptions of normality (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and homogeneity of variance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) across the four time points.\u003c/p\u003e\u003cp\u003eRepeated measures ANOVA revealed significant main effects for both first-person and third-person imagery on psychological readiness (ACL-RSI) and anxiety levels (STAI), with key findings highlighted below (see Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and 3).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFirst-person imagery and ACL-RSI\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eF(3, 297)\u0026thinsp;=\u0026thinsp;18.34, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Post-hoc comparisons revealed significant improvements in psychological readiness between:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 3 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 6 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 9 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAthletes with stronger first-person imagery abilities (lower VMIQ-2 scores) demonstrated higher psychological readiness at all time points.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFirst-person imagery and STAI\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eF(3, 297)\u0026thinsp;=\u0026thinsp;12.67, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. Post-hoc comparisons showed significant reductions in anxiety levels between:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 3 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 6 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 9 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eThird-person imagery and ACL-RSI\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eF(3, 297)\u0026thinsp;=\u0026thinsp;15.42, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Post-hoc comparisons revealed significant improvements in psychological readiness between:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 6 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 9 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eThird-person imagery and STAI (situational anxiety)\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eF(3, 297)\u0026thinsp;=\u0026thinsp;10.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Significant reductions were observed between:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 6 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBaseline vs. 9 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThis suggests that third-person imagery became more effective in reducing situational anxiety during the later stages of rehabilitation.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Subgroup Analysis by Sex\u003c/h2\u003e\u003cp\u003eSex-based analyses revealed no significant interactions between sex and imagery type for ACL-RSI or STAI scores. However, males reported marginally lower STAI scores at 6 months compared to females (p\u0026thinsp;=\u0026thinsp;0.06), suggesting potential trends that warrant further investigation (see Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eAlthough no significant interactions were found between sex and imagery type, the marginally lower STAI scores observed in males at 6 months suggest potential sex-based differences in anxiety reduction. Future studies should explore whether sex influences the effectiveness of motor imagery techniques in specific psychological domains.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Correlation and Regression Analysis\u003c/h2\u003e\u003cp\u003eFirst-person imagery was significantly correlated with ACL-RSI scores at all time points, indicating that better imagery abilities were associated with higher psychological readiness:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline: r\u0026thinsp;=\u0026thinsp;0.50, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e3 months: r\u0026thinsp;=\u0026thinsp;0.55, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e6 months: r\u0026thinsp;=\u0026thinsp;0.60, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e9 months: r\u0026thinsp;=\u0026thinsp;0.63, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eFirst-person imagery was also negatively correlated with state anxiety (STAI-S):\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBaseline: r = -0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e3 months: r = -0.43, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e6 months: r = -0.48, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e9 months: r = -0.52, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eRegression analysis showed:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eFirst-person imagery significantly predicted psychological readiness (ACL-RSI): β\u0026thinsp;=\u0026thinsp;0.46, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThird-person imagery significantly predicted reductions in situational anxiety at 6 months post-RTS: β\u0026thinsp;=\u0026thinsp;0.28, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Study Objectives and Hypotheses\u003c/h2\u003e\u003cp\u003eThis study investigated the differential effects of first-person and third-person motor imagery on psychological readiness and anxiety in athletes recovering from ACL reconstruction. The findings confirmed the first hypothesis, showing that first-person imagery enhances psychological readiness and reduces fear of reinjury during the early stages of rehabilitation. The second hypothesis was partially supported, demonstrating that third-person imagery effectively reduces situational anxiety at 6 months post-return to sport (RTS). These results highlight the complementary roles of both imagery types in addressing the evolving psychological needs of athletes during recovery.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.2 First-Person Imagery and Psychological Readiness\u003c/h2\u003e\u003cp\u003eFirst-person motor imagery plays a critical role in fostering psychological readiness to RTS. Athletes with stronger first-person imagery abilities reported higher ACL-RSI scores and lower state anxiety (STAI-S) across all recovery stages. This aligns with previous studies suggesting that first-person imagery engages internal sensory feedback and motor control, enabling athletes to mentally rehearse movements from their own perspective. This process reduces fear of reinjury and bolsters technical confidence(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNeuroimaging evidence supports these findings, showing that first-person imagery activates motor-related brain regions such as the motor cortex and basal ganglia, which are essential for rebuilding motor confidence(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The PETTLEP model further explains that first-person imagery closely mirrors physical movement execution, enhancing self-efficacy and reducing anxiety during the early stages of rehabilitation(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur results indicate that first-person imagery is particularly effective during early rehabilitation, when athletes focus on regaining motor control and technical confidence. By mentally rehearsing complex movements, athletes alleviate fear of reinjury and develop a sense of mastery over their physical capabilities, enabling a smoother transition to subsequent recovery stages.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Third-Person Imagery and Situational Anxiety Reduction\u003c/h2\u003e\u003cp\u003eThird-person motor imagery significantly contributes to reducing situational anxiety, particularly as athletes approach competitive scenarios. At 6 months post-RTS, athletes with stronger third-person imagery abilities reported lower situational anxiety, suggesting that this imagery style becomes increasingly effective during later recovery stages. These findings align with research highlighting third-person imagery\u0026rsquo;s role in enhancing spatial awareness and decision-making, which are critical for advanced rehabilitation(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Motor Imagery Integrative Model supports these observations, emphasizing that third-person imagery facilitates mental rehearsal in complex environments involving external factors such as team dynamics and strategic decisions(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). As athletes prepare for competition, third-person imagery enables them to visualize movements in a broader context, reducing situational anxiety by fostering a sense of preparedness for tactical and strategic challenges.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.4 The Interaction of Time and Imagery Styles\u003c/h2\u003e\u003cp\u003eA unique contribution of this study is its exploration of the temporal dynamics of imagery effectiveness. The results demonstrate that first-person imagery is most impactful during early recovery, while third-person imagery gains importance as athletes progress toward full RTS. This temporal shift reflects the evolving psychological demands faced by athletes throughout rehabilitation.\u003c/p\u003e\u003cp\u003eInitially, athletes prioritize regaining physical confidence and motor control, explaining the dominance of first-person imagery during early recovery stages. As they approach competitive readiness, external demands such as team coordination and tactical preparation become critical, highlighting the utility of third-person imagery. These findings support theoretical frameworks proposed by Smith et al. and Lang et al., advocating for a stage-specific approach to motor imagery interventions(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.5 The Role of Motivation in Motor Imagery\u003c/h2\u003e\u003cp\u003eMotivation likely moderates the effectiveness of motor imagery interventions. Athletes with high intrinsic motivation may engage more consistently with imagery practices, amplifying their benefits. For instance, motivated athletes may experience enhanced outcomes from first-person imagery due to more vivid and detailed mental rehearsals. Similarly, in later recovery stages, high motivation may lead to greater utilization of third-person imagery for preparing tactical scenarios.\u003c/p\u003e\u003cp\u003eFuture studies should quantify motivation levels and examine how intrinsic and extrinsic motivation interact with imagery styles to influence psychological outcomes. This could inform tailored interventions that account for individual differences in motivation and adherence to imagery training.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e4. 6 Clinical Implications\u003c/h3\u003e\n\u003cp\u003eThe results of this study offer practical guidance for designing stage-specific motor imagery interventions:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEarly Stages\u003c/b\u003e: Emphasize first-person imagery to rebuild motor confidence, reduce fear of reinjury, and enhance technical performance.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eLater Stages\u003c/b\u003e: Introduce third-person imagery to improve spatial awareness, tactical preparation, and reduce situational anxiety.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eBy aligning motor imagery practices with the athlete\u0026rsquo;s recovery stage, clinicians can address their evolving psychological needs, optimize outcomes, and facilitate a confident RTS. This approach aligns with the PETTLEP model and the Motor Imagery Integrative Model, which stress task-specific and recovery stage-specific imagery interventions(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.7 Limitations and Future Research\u003c/h2\u003e\u003cp\u003eSeveral limitations should be considered:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSample Bias\u003c/b\u003e: The sample consisted of university athletes, limiting generalizability to professional or recreational athletes. Future studies should include diverse populations to validate these findings across different competition levels.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSubjective Measures\u003c/b\u003e: Reliance on self-reported data (VMIQ-2, ACL-RSI, STAI) may introduce bias. Incorporating objective measures, such as neuroimaging or biomechanical analyses, could provide deeper insights into motor imagery\u0026rsquo;s neural and physiological effects.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSex-Based Differences\u003c/b\u003e: While no significant sex differences were observed, trends suggest potential differences in anxiety reduction and imagery effectiveness. Larger, stratified samples are needed to explore these differences further.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMotivation\u003c/b\u003e: The role of motivation was not directly assessed. Future research should examine how motivation interacts with imagery styles to influence psychological readiness and anxiety.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study provides robust evidence that first-person and third-person motor imagery play distinct yet complementary roles in the psychological recovery of athletes following ACL reconstruction:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFirst-Person Imagery\u003c/b\u003e: Enhances psychological readiness and reduces fear of reinjury during early recovery stages.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eThird-Person Imagery\u003c/b\u003e: Reduces situational anxiety and improves spatial awareness as athletes approach competition.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eBy tailoring motor imagery interventions to the athlete\u0026rsquo;s recovery stage and incorporating motivational factors, clinicians can optimize rehabilitation outcomes, addressing both psychological and tactical needs, and supporting a successful return to sport.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNobuchika Yamaki was responsible for all aspects of this study, including conceiving the research idea, designing the study, collecting and analyzing the data, interpreting the results, and writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available as supplementary material attached to this submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest( s ):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArdern CL, Taylor NF, Feller JA, Webster KE. 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A new approach to motor imagery for ACL rehabilitation. J Sports Sci. 2021;39(8):921\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/02640414.2021.1898832\u003c/span\u003e\u003cspan address=\"10.1080/02640414.2021.1898832\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7751825/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7751825/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePsychological factors such as anxiety and fear of reinjury are critical barriers to successful recovery after anterior cruciate ligament (ACL) reconstruction. Motor imagery (MI) has been proposed as a promising psychological tool, with first-person and third-person perspectives potentially offering distinct benefits. In this study, 100 athletes aged 18 to 25 years who returned to sport after ACL reconstruction were followed for nine months to examine how imagery perspectives influence psychological recovery. Imagery ability was assessed using the Vividness of Movement Imagery Questionnaire-2, psychological readiness with the ACL-Return to Sport after Injury scale, and anxiety with the State-Trait Anxiety Inventory. Repeated assessments demonstrated that first-person imagery consistently enhanced psychological readiness and reduced anxiety across all time points, emerging as the strongest predictor of positive outcomes. Third-person imagery was particularly effective in lowering situational anxiety around the six-month mark, when athletes faced critical challenges in their return-to-sport process. Together, these findings highlight the complementary roles of first-person and third-person imagery in rehabilitation. Incorporating both perspectives into psychological training programs may optimize athletes\u0026rsquo; readiness, alleviate anxiety, and foster a smoother and more confident transition back to competitive sport.\u003c/p\u003e","manuscriptTitle":"The Differential Effects of First-Person and Third-Person Motor Imagery on Anxiety and Psychological Readiness in Athletes Recovering from ACL Reconstruction: A Longitudinal Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-15 08:21:44","doi":"10.21203/rs.3.rs-7751825/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2560d24-bea3-469b-b1dd-46a98185154d","owner":[],"postedDate":"November 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-03T06:40:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-15 08:21:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7751825","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7751825","identity":"rs-7751825","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}