The decision to allow an athlete to return-to-sport (RTS) after an injury is complex and multifaceted.
Clinicians must weigh various factors, such as the athlete's physical and psychological readiness, medical clearance and individual preferences. Understanding decision-making theories and sharing decisions among interdisciplinary staff of clinicians and coaches can help improve effectiveness and reproducibility of the RTS.
In sports medicine, a framework is a model that focuses on the most relevant aspects of successful and consistent health and performance outcomes. In a sense, this can be viewed as a simplification of the entire complicated scenario, encompassing all essential aspects required for recovery from a specific injury.
One of the crucial components in constructing a relevant rehabilitation protocol is a risk-based decision-making approach. This approach is designed to aid decision-makers in determining when an athlete is prepared to initiate sport and/or team training outside the clinical environment.
This kind of framework takes into account two primary components: (1) the risk assessment outcome and (2) the decision-maker's risk tolerance:
Risk assessment outcome involves evaluating the potential risks associated with the athlete's RTS, for example the re-injury rate or potential chronic weaknesses and functional disorders. This evaluation should consider the athlete's healing progress, psychological readiness and most importantly: the balance between functional abilities and disabilities.
Risk tolerance refers to the willingness to accept a certain level of risk, which could be influenced by factors, including economic, social and team conditions, athlete’s preferences and the potential consequences of returning to sport too early and/or physically unprepared.
By comparing the results of the risk assessment to the decision-maker's risk tolerance, the framework based on the aforementioned model assists in guiding the decision-making process for returning to sports in a more structured manner. This can be viewed as a straightforward equation in which practitioners of rehabilitaiton establish idealised criteria and, by employing standardised testing methods, assess whether the objective outcomes align with these criteria.
■ Visual of the risk protection equation.
□ Reduction of the prevalence of RTS risk should be based on standardised testing protocol based on available resources and information to give maximally objective reference point for clear and fast decision making within the group of collaborating doctors, physios, trainers and coaches.
□ Standardisation testing outcomes creates the baseline, which should be enhanced by the current level of protocol completion, especially in means of performance training and tolerance to sport-specific expositions of high-intensity and unpredictable movement, which are often beyond the scope of objective measurements.
Establishing a Baseline.
Revisiting the most evident truths is a valuable practice, particularly in the rapidly evolving landscape of information and the development of innovative, technology-driven solutions in sports rehabilitation. One such truth to emphasize is that the primary focus of a successful RTS is to restore the pre-injury performance levels of an injured athlete.
To achieve this, it is essential to establish a performance baseline for monitoring the progress of sports rehabilitation. However, creating an objective and replicable baseline is challenging because of the lack of precise guidelines and confusion regarding the timing, frequency and form of tests implementation. This picture can be furthermore distorted by the daily fluctuations in physiological and performance profiles.
To illustrate concerns with the baseline setting, let’s point to the limb symmetry index (LSI). Although a 90% side-to-side difference within LSI threshold is commonly used, little scientific evidence supports this parameter and even achieving full symmetry does not necessarily indicate a level of fitness sufficient for safe participation in high-performance sport. Additionally, it is questionable whether the uninvolved side can be used as a benchmark when pre-injury data is not available.
Consequently, defining a baseline measure for comparison remains a challenge.
To overcome this problem it is popular to use the batteries of diverse tests that give a more direct insight into different qualities of biomechanics and values of dynamic motoric functions and imbalances. If a particular assessment reveals performance that falls short of an established standard – conceptualised both ideal and safe – it has the potential to point at specific motor function deficit. This deficit can be then targeted through corrective exercises as integral part of integrative methods of performance training.
■ Visual of the acknowledged aspects of comprehensive assessment that underlie the typical return-to-sport rationale and is documented throughout the rehabilitation process for an athlete, using our example of an anterior cruciate ligament reconstruction (ACLR) protocol.
The optimal quantity of tests for assessing an athlete's condition may differ depending on the situation.
Utilizing an inadequate number of tests could potentially compromise the clinician's ability to obtain a full understanding of the injured athlete's profile. Conversely, conducting an excessive number of tests might introduce greater error, i.e. paralysis by analysis and decreased performance resulting from fatigue or diminished motivation and consume additional resources, i.e. personnel, time, equipment.
At present, there is no definitive guidance on the ideal combination or number of tests that would offer the most valuable insight into an athlete's preparedness for return to sport (RTS).
To understand how decisions may deviate from optimal outcomes due to limitations in information, time or processing capacity, medical and coaching staff members should be familiar with the theory of bounded rationality. It explains how humans take cognitive shortcuts and make decisions within the limitations imposed by the environment, abilities, information and the (overreaching) sporting goal. Simplification through heuristics can be helpful for clinicians to make efficient judgments without consuming too much time or processing capacity, especially when dealing with insufficient or overly complicated information. However, heuristics can also lead to deviations from rational decisions if not used carefully.
Decision-making is often limited by factors of cognitive capacity, time constraints and incomplete information. Clinicians often face time pressures to make decisions about when athletes are ready to RTS and may lack access to all the relevant information about the athlete's holistic state of health and performance.
Bounded rationality can help clinicians be more aware of their potential biases and can encourage them to seek out additional information or perspectives to make better decisions. It also highlights the importance of using evidence-based guidelines and standardised tests to help mitigate the impact of cognitive biases on decision-making.
To address the challenges mentioned above, it is recommended to implement the ‘best practice of medicine’, which is shared decision-making. This approach involves partnership that should be settled between the athlete, clinicians, trainers and other stakeholders in the sports organisation and/or team.
In this outlook, each stakeholder brings unique perspectives and concerns, making it essential to consider different viewpoints for a comprehensive decision of RTS. Shared decision-making ensures that decisions are well-informed, consider individual preferences and minimise discrepancies due to conflicting interests.
Imagination of an athlete in action transcending limitations imposed by past injuries.
Current research on RTS decision-making is limited and primarily focuses on biological and medical factors. Future research should explore decision-making theories, heuristics and biases in sports medicine practice.
Additionally, as sports technology advances and provides an increasing amount of data, there is a need to develop tools, such as statistical models and artificial intelligence algorithms, to aid clinicians in processing information and making better decisions.
The proposed risk-based framework aims to provide a systematic and objective approach for clinicians to improve the decision-making process in return to sport. By selecting appropriate tests, understanding decision-making theories, and employing shared decision-making, clinicians can enhance the quality of their decisions.
Yung KK. A Framework for Clinicians to Improve the Decision-Making Process in Return to Sport. Sports Medicine OPEN (2022).
King E at al. Biomechanical but Not Strength or Performance Measures Differentiate Male Athletes Who Experience ACL Reinjury on Return to Level 1 Sports. American Journal of Sports Medicine (2021).
Wiggins AJ et al. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. American Journal of Sports Medicine (2016).
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