Blurred lines – A shift towards social
Return to Play (RTP) is gaining increasing attention in the therapeutic and medical spheres. The 2016 Consensus Statement on return to sport provides clinicians with a framework to establish best practice principles when making such decisions. If you have not had a chance to read the consensus statement, I highly recommend that you do so. The multifactorial nature of RTP assessments means no two can be the same. The return to sport decision is one that should be graded and not defined by finite outcomes. Athletes should be guided through return to participation, return to sport and finally return to performance. The biopsychosocial model of RTP is one that is widely advocated and outlined in the 2016 Consensus Statement. It is a framework that I use to guide my decision-making process throughout rehabilitation.
When considering RTP clinicians often start where we feel most comfortable, the biological components. There is a range of standardised outcome measures available to clinicians to confidently assess an athlete’s physical readiness to return to sport. The battery of hop tests is one such example following lower limb injury. Ploughing through the treasure trove of information on social media one can find a select group of clinicians and researchers providing open access to the range of possible tests and standardised norms. Increasing open access to these evaluations provides us with multiple options when evaluating athletes and thus improves our confidence in RTP decision-making.
Although there is a growing body of evidence to assess the psychological readiness of players for RTP, the availability of standardised measures is not a vast as those for biological elements. In saying this, the psychological elements are accepted as being of vital importance when assessing RTP[2,4]. A player’s mental readiness is, in my opinion, more important than his/her biological readiness.
This brings us the social elements that need to be considered in RTP. The so called “grey” area. Where the line between yes and no becomes blurred. Working in an isolated environment has posed a unique challenge for me when making RTP decisions. I work in an environment where in most circumstances, due to logistical reasons, I am the only clinician an individual will consult. The best-practice approach is to include a multi-disciplinary team when making RTP decisions. However, when this becomes difficult due to circumstance, the weight of the different elements seems shift.
At this stage, it should be said that it is the obligation of the clinical professional to override all RTP decisions when the health of the athlete is in question. The decisions I am discussing in this post are when the health of the athlete is not necessarily in question and the risk of negative long-term health consequences have been mitigated.
In the professional sporting environment, the multi-disciplinary team is often well balanced, with all stake holders having an equal contribution to the decision. However, very few clinicians have this luxury and are often the only medical professional involved in the RTP decision. This person is often the physiotherapist, biokineticist or sport scientist working with an athlete. I have used a series of pie charts to represent the shift in the RTP decision making process that often occurs in isolated environments where the treating professional is often the only medical stakeholder.
Figure 3 represents best practice RTP. The pie charts above represent the complexity of RTP decision-making. The colour diagrams represent the likely bias of each stakeholder. As can be seen there is a likely shift between stakeholders with each favouring an element in the bio-psychosocial model. Medical clinicians are likely to have a bias towards the biological elements. In the ideal situation there are multiple treating clinicians involved in the decision-making process. Non-medical staff and the athlete having a greater bias towards the social and psychological elements. Please note this is not an accurate depiction of all clinicians, athletes or non-medical staff members. Each team will have its own unique variation of this representation. Each element is equally represented and thus is likely to assist all stakeholders in making a decision that best favours the interests of the athlete. Bingo! Optimal RTP achieved…if such a thing exists.
Now what happens when there is a shift in the representation of stakeholders around the table as shown in Figure 4. This places an increasing bias to the social and psychological elements. Social considerations now place an increasing pressure on the RTP decision and place a different focus on the discussion between stakeholders. The smaller the medical professional team the fewer biological factors are introduced into the discussion and topics often shift from physical factors to social and psychological elements. Invariably, this places a different dynamic to the RTP decision and the once clear decision starts to become hazy. It takes confidence and a sense of emotional and social intelligence from the medical clinician to successfully manage this situation and ensure that the best practice RTP decision is still made.
What does all this mean for us on the front-line of RTP decision-making? Ultimately, the reality is that we are not often offered the opportunity to be involved in truly multidisciplinary teams when deciding on whether a player is ready to return to play. This requires a shift in the mindset of the professional and an increased awareness of the stakeholder interests. The awareness that such a shift has occurred will give the practitioner the power to provide a clear and confident opinion in this discussion. Understanding that the relationship between everyone involved shifts according the percentage of representation will immediately allow you to best place your voice in the discussion. The development of additional communication and social-intelligence skills will undoubtedly provide us with an increased comfort in any decision taken and ensure that the athletes best interest is truly considered when signing off on the big “Yes you can!” or “No, not yet!”
Ardern, C. L. et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical. 1–12 (2016). doi:10.1136/bjsports-2016-096278
Ardern, C. L., Taylor, N. F., Feller, J. A., Whitehead, T. S. & Webster, K. E. Sports Participation 2 Years After Anterior Cruciate Ligament Reconstruction in Athletes Who Had Not Returned to Sport at 1 Year. Am. J. Sports Med. 43, 848–856 (2015).
Hughes, M. Return To Sport Test: The Hop Test Battery. Available at: https://www.mickhughes.physio/single-post/2017/06/18/Return-To-Sport-Test-The-Hop-Test-Battery. (Accessed: 27th October 2018)
Gerometta, A., Klouche, S., Herman, S., Lefevre, N. & Bohu, Y. The Shoulder Instability-Return to Sport after Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability. Knee Surgery, Sport. Traumatol. Arthrosc. 26, 203–211 (2018).
Gliedt, J. A., Schneider, M. J., Evans, M. W., King, J. & Jr, J. E. E. The biopsychosocial model and chiropractic : a commentary with recommendations for the chiropractic profession. (2017). doi:10.1186/s12998-017-0147-x