The Return to Play Conundrum Part 1 - Griffin Waller



Introduction

Ever since I can remember, baseball was my world. My passion. Unfortunately, I’ve had my fair share of injuries. Having played since childhood, and specialising as I disregarded other sports (for which I do not advise, but that’s a whole other topic in itself), I ran the gamut of elbow and shoulder issues. There were times I felt as though I spent as much time in the doctor’s office and training room as I did on the field. On the flip side, as a Sports Performance Coach over the past 8 years, I’ve been exposed to nearly every injury on the spectrum. Having worked at almost all levels of collegiate athletics, I keep finding a common thread; inconsistency and disconnect within the “Return to Play” process. I continue to ask myself the same questions: What is the plan? Why is there no standardized operating procedure? Why are we not communicating? Why are coaches and staff not involved? Why are athletes completely taken out of activity? Why is “rehab” isolated to the area of injury? How are we addressing all athletic qualities? How are we progressing the athlete back to competition? Are we using outcome measures and criteria-based progressions? Are we addressing barriers to successful return? How are we monitoring training load and adaptation? What are the criteria for clearance? Is the athlete mentally ready to return? How do we keep the athlete mentally engaged with the team and team culture? To sum it up with one question, WTF are we doing?? (There were some other questions, but I don’t want to pollute your virgin ears).

Objective

Through a series of posts, I will answer these questions to provide some clarity on the Return to Play (RTP) process. Namely, is that even an appropriate designation? The objective of these posts will be to outline a standardised, performance-based, and shared- decision making model to prepare athletes for a return to competition. Within my first post, I will cover the importance of relationships, effective communication, and outlining roles and responsibilities for the integrated multidisciplinary team. These posts are not intended to convince you that my process solves the RTP conundrum. Nor is this system applicable across all disciplines and situations. However, these posts will offer ways to consider structuring, planning, and executing the RTP process, while questioning contemporary practice in order to make quality decisions. Everything outlined is based on review of literature, discussions with industry professionals, and my own experience. I’m not a Doctor. I’m not a licensed Physical Therapist. I’m not a certified Athletic Trainer. I’m a former student-athlete and current Sports Performance Coach who wants to challenge the status quo and improve the reconditioning model for enhanced and sustainable long-term athletic development.

So, where do we start?

Before we get into creating, planning, and executing a system, we first need to address the human factor: the individuals involved. This starts by fostering quality relationships, establishing effective lines of communication, and outlining roles and responsibilities for the integrated multidisciplinary team. Granted there will be overlap, without this foundation, creating and executing a system becomes blurred.


Relationships

“Life begins at the end of your comfort zone.”—Neal Donald Walsch. For many, investing time into relationships at work may be difficult, but it’s essential to create a foundation for a system to thrive. Team member relationships at work have been shown to be directly associated with organizational commitment and job performance (1). Therefore, success can only be achieved if everyone believes in the process, is committed to their role, and puts the athlete’s well-being above all. Just like a sports team, the performance team needs high levels of trust, collaboration, and communication, while checking egos at the door. And it starts with you. Get to know yourself first to better leverage and amplify your traits to create buy-in with both your athletes and team members (2). Understanding your own strengths and weaknesses can help you create strategies to improve interactions with everyone involved. Then comes the hard part; investing time. Easier said than done, right? We’ve all worked with athletes who don’t make training a priority or staff members who don’t pull their weight and want to work in a silo for fear of being “found out” they can’t effectively do their jobs (3). All I can say is, be patient and stay the course. It takes time to foster effective relationships and create enough trust throughout the RTP process. I’m not saying completely throw your integrity out the window, but there may be times when you bite your tongue or yield to someone else even if it goes against every fiber of your being. To quote Brett Bartholomew, “There’s a reason why the best tasting foods cook the longest; it allows all the ingredients to blend together in order to bring out the true essence of the dish” (2). So, allow your relationships to marinate. Get to know your athletes and team members on a personal level. Ask questions, be a good listener, and foster trust through positive interactions. Being mindful of your athletes and team member’s personality types, attitudes, and behaviors can help you learn more about them to create strategies for individualizing interactions (2). Being able to consider the individual’s preference with respect to the relationship formed is vital to improving intrinsic motivation, autonomy, and adherence with everyone involved (4). At their best, relationships can be extremely rewarding. At their worst, they can be toxic, corrosive, and dysfunctional (1). If the ultimate goal is to improve the long-term welfare of the athlete, it can only happen by improving the relationships with everyone involved.

Communication

Effective communication is a vital factor in determining the efficiency with how an organization performs as a whole.(5). This is essential in a RTP process that not only involves athletes, but a multidisciplinary team with varying degrees of understanding and education, who also may interpret information differently. The complexity of this dynamic, coupled with the inherent limitations of human performance, make it vital to have a common language and standardised communication tools in order to improve efficiency and minimise risk. (6). Numerous studies have indicated internal communication as an important risk factor within the RTP process. (7, 8, 9). Specifically, in a study of 36 elite- level football teams across 17 European countries from 2012-2016, injury burden and incidence of severe injuries were significantly higher in teams with low quality communication between medical personnel, fitness coaches, and sport coaches (9). Athlete adherence in injury prevention strategies and coach compliance have also been found to suffer due to poor communication (10). So how do we mitigate these findings? Start by speaking the same language. Common language creates a clearly agreed upon communication model, that helps avoidthe natural tendency to speak indirectly and deferentially (6). Creating understanding of what is being communicated isalso vital. Using the same language and terminology allows information to be disseminated consistently. This can effectively bridge the gap between all members to minimise communication failures and improve teamwork. This also keeps engagement high, sends a consistent message, and increases accountability (11). Once a common language has been established, the next step is to standardise lines of communication, which can occur in person or electronically. In person, we must simplify language, control emotions, listen ardently, and use feedback (5). Secondly, we must beconsistent. Humans are creatures of habit so the more consistent we can be the better. Particularly with the multidisciplinary team, this involves setting meetings (weekly in my opinion) where all members are present,

prepared, and actively involved. This way information can be communicated and

understood more effectively. This also allows for opportunities to collaborate, ask questions, and use feedback to improve outcomes within the RTP process. In conjunction with in-person meetings, I suggest mandating meeting breakdowns via email. This is vital. Not only do meeting break downs maintain lines of communication with those not directly involved, it’s also a form of documentation that holds the multidisciplinary team accountable for their roles and responsibilities, an important element within the RTP decision-making process (12). Without this component, execution becomes an issue. Individualised care requires well-developed communication pathways between everyone involved. So, in order to avoid breakdowns and improve the RTP process, we need to create a common language and standardise lines of communication.


Integrated Multidisciplinary Team


The RTP process involves multiple disciplines. From Medical Doctors, Physical Therapists, Athletic Trainers (AT),and Chiropractors, to Sport Scientists, Strength & Conditioning Coaches (S&C), Nutritionists, and Sport Coaches (SC), there can be a lot of specialists

involved (which is why we need to improve relationships and optimise communication first!).Although every situation is different, every discipline is valuable. Therefore, avoiding exclusivity and elitism of our role is imperative when it comes to athlete care (3).ATs, S&Cs, and SCs (for simplicity sake, I will reduce the members involved to these three) all bring a unique skill set tothe table. So in order to optimise the RTP process, each member involved needs to understand and respect what each specialty brings to the table (trust me, I know this can be difficult). Since the RTP decision should be a decision shared between all members (I’ll dive into the shared-decision making model in a future post), we need to clearly define roles, responsibilities, and actions of each member. This was echoed in the 2016 consensus statement on return to sport from the first world congress in sport physical therapy, where they indicated that defining and outlining roles and responsibilities of the multidisciplinary team as an important part of progressing the athlete back to sport (12). So, without further ado:



Athletic Trainer

Definition: multi-skilled health care professional who collaborates with physicians to provide preventative services, emergency care, clinical diagnoses, therapeutic intervention, and rehabilitation of injuries and medical conditions (3).


Role within RTP:

  • Collaborate and communicate with physicians, physical therapists, and all members of the multi-disciplinary team to administer rehabilitation guidelines for injured athletes.

  • Provide appropriate parameters in a progressive manner that prepares athlete for increased function through the RTP process (8).


Strength and Conditioning Coach

Definition: certified coach who applies scientific knowledge to train athletes for the primary goal of improving athletic performance through the use of safe and effective strength training and conditioning programs (13).


Role within RTP:

  • Collaborate and communicate with all members of the multi-disciplinary team to assist in rehabilitation.

  • Maintain and/or restore long term athletic development qualities in a progressive manner that prepares athlete for a return to sport- specific participation, while reducing the potential for re-injury (8).


Sport Coach

Definition: SCs provide the direction, instruction, and training of sport specific qualities, while providing the direction of a team or individual athlete (14).


Role within RTP:

  • Collaborate and communicate with all members of the multi-disciplinary team within the rehabilitation process to safely return injured athlete back to full participation.

  • Maintain and/or restore technical and tactical competitive performance functions (8).


Clearly defining roles and responsibilities of the multidisciplinary team creates an integrated model that allows each discipline to focus on what they’re good at, while allowing the athlete to benefit from everyone’s strengths (3). Other components to consider when building your multidisciplinary team includes having a shared vision and purpose. Success is highly dependent upon teamwork and having a consensus on goals and objectives (15). Creating a shared vision has also been shown to increase commitment, accountability, and transparency among health care professionals (16). Goal setting has also been indicated as an important element in guiding the RTP decision-making process (12). Therefore, creating a combined performance team that understands and respects everyone’s role, maximises each members’ strengths, and works under a shared vision is important in advancing the athlete back to high function.


Closing


“Coming together is a beginning; keeping together is progress; working together is success”- Henry Ford. If we can’t work together effectively, we can’t instil a system that succeeds. The human factor is paramount and should be the first priority when establishing RTP guidelines. As you can see, returning an athlete back to high function has a lot of

moving parts, and we haven’t even scratched the surface yet! In order to optimize this

system for the welfare of the athlete, its starts with fostering quality relationships, establishing effective lines of communication, and outlining roles and responsibilities for the integrated multidisciplinary team. Stay tuned for Part 2 of the Return to Play Conundrum, where I will create a framework for success through adopting model to guide the RTP process.


Resources

  1. An examination of the mediating role of psychological empowerment on the relations between the job,interpersonal relationships, and work outcomes

  2. Conscious Coaching: The Art and Science of Building Buy-In

  3. Bridging the Gap From Rehab to Performance

  4. Prediction of sport adherence through the influence of autonomy-supportive coaching among spanishadolescent athletes

  5. Interpersonal Communication: Lifeblood of an Organization

  6. The human factor: The critical importance of effective teamwork and communication inproviding safe care

  7. A systematic review of the psychological factors associated with returning to sport following injury

  8. Recovery from injury in sport: Considerations in the transition from medical care to performance care

  9. Communication quality between the medical team and the head coach/manager is associated with injuryburden and player availability in elite football clubs

  10. Injury prevention strategies, coach compliance and player adherence of 33 of the UEFA Elite Club Injury Study teams: a survey of teams’ head medical officers

  11. http://training-conditioning.com/content/better-together

  12. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy,Bern

  13. National Strength and Conditioning Association

  14. https://en.wikipedia.org/wiki/Coach_(sport)

  15. Principles of effective team building interventions in sport: A direct services approach at Penn StateUniversity

  16. https://nic24thnationalconf.pathable.com/static/attachments/106805/1412353682.pdf



About the Author:


Griffin Waller is a Certified Strength and Conditioning Specialist by the NSCA. Griffin has a Bachelor of Science in Exercise and Sport Science, and a Master of Arts in Kinesiology, Concentration in Exercise Physiology. Griffin has close to a decade of experience working in a university based environment including; Starting at the University of Portland as an athletic performance intern, followed by various roles at the University of Florida, the University of Stanford and Missouri State, before Griffin return to the University of Portland as the Director of Athletic Performance in 2017. Griffin is also an IUSCA Advisory Board member.

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