Updated: May 4, 2020
It’s time to nail down this definition before I outline how to create a program. Currently, there is no universal definition or gold standard (1), which can lead to an athlete’s status being interpreted differently by different members of the performance team (2). To use basketball as a reference, spot shooting, playing half court 5 on 0, or playing a full court scrimmage are all variations of “play”, but greatly differ in their levels of physical and cognitive load.
Therefore, defining the process is paramount. But what is the right designation? Where does rehab end and performance training begin? How can we define something that may change based on the situation and variables at stake? Within this post I will define the process, providing an objective and goals to support this definition, while outlining how to plan the process. Establishing a Purpose
“Just because biological healing has occurred, it does not mean the athlete is prepared for performance”—Bill Knowles (3). As I outlined in my first post, there can be disagreement, disconnect, and pressure that can influence the RTP process. Some members of the multidisciplinary team may push an athlete back to competition after the injured tissue has healed, but are they physically prepared? This demonstrates the need to have clear definitions that create a shared vision for all members of the multidisciplinary team. Objective & Goals Now that we have adopted and understand the models that will guide the RTP process, we can funnel this into a definition. But how can we have a definition if we don’t agree on what the objective is? Using the work of both Knowles and Sue Falsone, as well as numerous articles (2, 3, 4, 5, 6, 7). I have come up with the following:
Objective: Return the athlete back to competition that at least reaches or exceeds their pre-injury level.
This objective is clear, concise, and creates an outcome-focus relative to the athlete’s status pre-injury. However, we can’t ignore differing contextual considerations. There are a number of elements that can influence decision making, such as medical factors, individual factors, and sport related factors. Therefore, in order to optimize the decision-making process, we need to agree on common goals that ultimately support this objective. Based on the aims outlined in Current Concepts in Sports Injury Rehabilitation (7), I have come up with the following overarching goals:
Protection of athlete long-term health
This keeps an athlete-centered focus that ensures we maintain the best interest of the athlete when making decisions.
Prepare and sustain athlete for a return to competition
This ensures we take a reconditioning focus that addresses all qualities to prepare for long-term performance.
Reduce potential of reinjury
This ensures we appropriately progress, prepare, and monitor the athlete. If we can understand and agree on what the ultimate objective is, while creating common goals that support it, the decision-making process becomes easier. Ultimately, it’s about making collaborative decisions that are in the best interest of the athlete.
Defining the Process
In a 2016 Consensus Statement on Return to Sport from the First World Congress in Sports Physical Therapy (4), it was determined that a return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. In this continuum, three phases were outlined: return to participation, return to sport, and return to performance (shown in the figure below).
As we know, there are a number of factors that can influence how an athlete progresses along this continuum, so we must avoid absolutes, instead, allowing the athlete to move along this continuum dependent on their current status and response to training. This is echoed in Falsone’s book, Bridging the Gap from Rehab to Performance (2), in which she refers to the process as the performance-training continuum. She goes on to state how the process from injury to return to competition is not a linear one. Concepts overlap, professions overlap, and restoration can fluctuate. This culminates in a return to performance in which the athlete at least reaches or exceeds their pre-injury level with potential for growth related to performance. This finally leads us to my definition:
Return to Performance: an athlete-centered, criterion-based, and shared-decision making model to prepare and sustain athletes for a return to competition.
This definition uses the models outlined in my previous post, as well as the objective and goals stated above, as drivers of the process. I have also replaced the word “play,” which I indicated leaves too much up for interpretation, with the word “performance”. This puts an emphasis on returning the athlete back to high function as it relates to their sport.
Creating a Plan
At this point, we should have improved relationships with the multidisciplinary team, standardized lines of communication, and outlined roles and responsibilities for all contributing members. We also should have agreed upon the models that will guide our decision-making process, as well as a shared vision through clear objective and goals. This makes the planning process that much easier when we have a system to operate from, since establishing a formal RTP structure to help guide interactions has been shown to improve outcomes (6). Expanding on the continuum outlined in the 2016 Consensus Statement, I will outline how to create a RTP plan through testing, using a Performance Model, monitoring the process, and addressing psychological readiness.
In order to create a plan, we must have a way to measure progress. Ultimately, we can’t measure what we don’t test. And if testing drives our programming, then we need to establish baseline measures and performance metrics that create a roadmap for a return to competition. In order to create objective criteria (as I stated in my previous post), we first need an understanding of the sport and what biomechanical and physiological demands this has on the athlete. With this information we can execute functional tests that will guide the progression of interventions throughout each phase of the reconditioning model, and ultimately a return to competition. There are an infinite number of tests, but I have included some below:
Lower Body: Squat, Deadlift
Upper Body: Bench Press, Military Press, Chin up
Strength Endurance Testing
Lower Body: Rear Foot Elevated Split Squat with % of BW for Reps
Upper Body: <80% Bench Press, Pushup, Chinup
Lower Body: Vertical & Horizontal Jump Variations (bilateral/unilateral, static/dynamic/rebound), Olympic lifting variations
Upper Body: Medicine Ball Throw variations
Speed & Agility Testing
Sprints: 10yd, ¾ Court, 60yd Dash
Agility: Box Drill, L-Drill, Illinois Drill
1 Mile Run, Beep Test, YoYo IL1 or IL2
Performance testing is not limited to these tests by any means. Nor is it practical or suggested to do all these at every stage of the RTP process. Its highly dependent on the current status of the athlete and where they fall within the continuum. As mentioned above, it’s up to you to choose the tests that provide the most information about the athlete as it relates to their given sport. Using technology is also a great way to create more repeatability, precision, and validity. However, they can bequite costly. I suggest designing an environment that is repeatable, with specific protocols to diminish interference. Performance testing are not the only metrics we should be evaluating. Documentation of baseline measures is also paramount to compare performance and functional status to a preinjury level. Baseline measures may include various assessments and evaluations, such as body composition, joint range of motion, and functional mobility and stability tests. One of the most popular and heavily researched screens, the Functional Movement Screen (FMS), has been shown to provide actionable information in a time efficient manner. In a study evaluating injury prediction in professional football players, it was determined that players with dysfunctional fundamental movement patterns (FMS score of 14 or less) are more likely to suffer an injury than those scoring higher on the FMS (8). Although the FMS has its drawbacks, it does provide an objective measure to evaluate progress, which can be used to guide the decision-making process. The importance of testing has been indicated as a vital element of the RTP process in the 2016 Consensus Statement, in which they suggest that tests should be performed at four key times after an injury has occurred (4):
Immediately after injury (ie, diagnostic tests)
Through the course of reconditioning (to monitor progression)
At the time of clearance for a full return to sport
After return to sport to measure performance and reinjury risk
At each of these stages, the type of testing administered matches the current status of the athlete. These tests also create objectivity to advance the athlete to the next stage of the process. Therefore, we must not be fixated on a timeline, rather on the achievement of functional criteria. There must be an emphasis on graded, criterion-based progressions, that are applicable for any sport and aligned with RTP goals (4).
The multidisciplinary team strategically develops a plan, working backwards from where the athlete needs to be physically as it pertains to the demands of the sport and position played. A RTP plan needs to be both tissue specific and functional, with an emphasis on motor learning, reorganization, and sport relevance (5). As an athlete recovers from injury, the emphasis progresses from protecting the injured tissue, to guiding the healing process, and finally restoring the capacity of strength and energy systems (9). This involves creating
a detailed athlete-centered reconditioning plan that includes performance outcomes based on baseline measures and prior performance metrics (using the models outlined in my previous post). This creates objective criteria to progress the athlete through each stage of the process. As stated in my first post, this is not owned by one particular specialist, but developed and agreed upon by all members of the performance team. Using
Knowles’ Performance Model outlined in Sports Injury Prevention and Rehabilitation (figure
shown above), all members need to work together to ensure the athlete is kept safe and healing structures are protected, while the athlete is progressively trained in all aspects of athletic development. This is where baseline and sport-specific functional testing can create specificity not only to the sport, but to the individual athlete throughout the RTP process. As the athlete undergoes reconditioning, all elements of performance must be addressed, such as movement quality, coordination, strength, power, speed, and fitness.
Competency-based reconditioning ensures that there is a logical progression to tissue loading, which involves advancement of movements from simple to complex, general to specific, slow to fast, and controlled to uncontrolled. Using the SAID principle (specific adaptation to imposed demands), we know consistent adaptation requires optimal stimulus and recovery. This involves the performance team managing the athlete’s exposure to volume, intensity, density, and collision/contact to prompt consistent adaptation. As the athlete progresses towards sport-related skills, this also involves balancing technical and tactical factors that can systematically progress that athlete from sport-related skills, practice, and ultimately competition. Lastly, the performance team should also apply the acute:chronic (A/C) ratio (which I outline in the next section) to monitor the entire process to manage that training is progressed at an optimal pace. With this in mind, the multidisciplinary team creates a periodized program that strategically works backward through the continuum, using clearance criteria to ensure the athlete is physically prepared for a sustained return to sport. This involves creating a plan into phases of escalating demand.
Monitoring the Process
Due to the physical demands of sport, graded load progression plays a vital role in a successful RTP. It is paramount to consistently monitor the athlete throughout the performance model to ensure optimal loading of the injured tissues. Load progression and monitoring has also been outlined as a key part of rehabilitation and the return to sport decision by multiple publications (4, 5, 7, 9). Daily training loads can provide a way to quantify how much training the athlete has performed, while also ensuring the athlete has trained enough to withstand practice and competition loads. In a recent study examining if athletes have trained enough to RTP safely (10), a significant relationship between excessive training loads and risk of reinjury was found. However, when optimal loading was employed it exhibited a protective effect against injury. This demonstrates the importance in monitoring training load to safely progress the athlete. This also allows the multidisciplinary team to manipulate training variables for consistent improvement without exposing the athlete to loads they are not prepared for. Using Session Rating of Perceived Exertion (sRPE), the athlete rates the intensity of the training as outlined in the figure to the right. Monitoring the training load during the current training week (acute) against the average of preceding four training weeks (chronic) provides an A/C workload ratio (14). This ultimately provides objective way to plan load progressions and advancement throughout the RTP continuum. Blanch and Gabbett recommend an A/C workload ratio between 1.0 and 1.5 with a higher ratio associated with higher reinjury risk (10). Using these guidelines, the multidisciplinary team can ensure the athlete has been exposed to and able to sustain sufficient training loads over time. The nature of monitoring is likely to be different depending on the sport, but it is vital to create objectivity to the individual physiological response to training. Therefore, the usage of sRPE and the A/C can provide the multidisciplinary team with objective data to allow for a smooth transition from injury to a return to competition, while ensuring that the athlete has performed an appropriate amount of chronic loading to tolerate these progressions. Psychological Readiness
I hope we can agree that creating a plan is paramount for a successful return to competition. Thus far we have heavily focused on physical parameters within the RTP plan. However, injury is more than physical. The psychology of the athlete is crucial in rehabilitation, as their emotions, beliefs, and thoughts all affect how their bodies respond to injury (3). Athletes also cope with injury differently and may have anxieties concerning a return to sport. Common concerns may include fear of reinjury, regaining status on a team, and failing to perform at preinjury levels, which can affect the rate of recovery through overuse, avoidance, and other compliance issues (11). Furthermore, the parameter most associated with a successful RTP is the perception of whether or not the athlete feels they will be able to return as before (12). Therefore, being able to address cognitive and emotional factors is just as important as physical performance qualities. To combat potential negative psychological responses to injury, athletes need graduated opportunities to perform and experience success in physical tasks in order to build confidence in performance. This is engrained within the graded progression of the performance model outlined above. This also involves adopting a way to evaluate an athlete’s psychological status. Using the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale, which was validated as an assessment of an athlete’s psychological readiness to return to sport (13), the multidisciplinary team can provide the six-question scale to confirm progression through each phase of the return to performance continuum. Motivation also plays a big role in a successful RTP. Carson and Polman found that positive psychological responses including motivation, confidence and low fear were associated with a greater likelihood of returning to the preinjury level of participation and returning to sport more quickly (14). Using the Self-Determination Theory (15) outlined below, it was determined athletes can produce more adaptive coping strategies and increase adherence to the RTP process.
Autonomy: self-initiation and self-regulation of one’s own behavior
Provide athletes with an in-depth understanding of the injury and plan to increase self-regulation and provide some control throughout the process.
Competence: ability to interact proficiently or effectively with the environment
Competence is developed by increasing physical and performance proficiency as athletes progress through each phase.
Relatedness: feelings of closeness and belonging to a social group
It is vital to keep the athlete involved with the team after an injury to create social support and belonging.
It is clear positive psychological responses are associated with a higher rate of returning to sport following injury. This highlights the importance of including psychological interventions in conjunction with the performance model above. Psychological interventions can be used in combination with reconditioning to aid effective healing via the biological interaction between the mind and body. Ultimately, the athlete must be psychologically ready for the demands of his or her sport. Closing
“Failing to plan is planning to fail.” Benjamin Franklin. In order create a plan, we must first establish a purpose to provide a shared vision for all members of the multidisciplinary team, as well as the athlete. Having a clear objective and goals ultimately help to create a roadmap for success when planning the process. Using the Performance Model, while integrating objective measures such as performance testing, A/C ratio, and I-PRRS, will ensure a strategic, graded progression that accounts for both the physical and psychological demands placed on the athlete. Stay tuned for Part 4 of the Return to Play Conundrum, the final section of this series, in which I outline each phase of the Return to Play Continuum.
Consensus Criteria for Defining ‘Successful Outcome’ after ACL Injury and Reconstruction: A Delaware-Oslo ACL Cohort Investigation
Bridging the Gap from Rehab to Performance
Sports Injury Prevention and Rehabilitation
2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern
High-Performance Training for Sports
Return to Play in Sport: A Decision-Based Model
Current Concepts in Sports Injury Rehabilitation
Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen?
Energy System Development and Load Management Through the Return to Play Process
Has the athlete trained enough to return to play safely? The acute:chronic worload ratio permits clinicians toquantify a player's risk of subsequent injury
Recovery from Injury in Sport: Considerations in the Transition from Medical Care to Performance Care
Return to Sport Injury Mitigation Performance Continuum Presentation
Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale
Self-Determined Motivation in Rehabilitating Professional Rugby Union Players
Self Determination Theory and the Facilitation of Intrinsic Motivation, Social Development, and Well-Being
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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