It is time for consensus on return to play after injury: five key questions.

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The overall question “When will I be able to play again?”

When making return-to-play decisions, ‘physio’s’ and athletes might engage in a risk–benefit analysis weighing up the risks associated with participation and the extent to which those risks can be tolerated.

But

  1. when does the physio’s determine the athlete is ready to return to play?
  2. Is physical recovery alone enough for return to play?
  3. What is successful return to play?
  4. What are the sports medicine clinician’s responsibilities within the team, and to the athlete?
  5. Should athletes even return to play?

This article should answer these questions and highlight some of the complexities in making the return-to-play decision.

1)ASkærmbillede 2016-04-13 kl. 00.58.16NSWERS?

In the traditional evidence-based practice model, the clinician integrates the best available evidence from research with individual clinical experience and the patient’s preferences when making decisions.

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Return-to-play criteria must depend on the type of injury, demands of sports and the affected body region. Ideally, a battery of accepted clinical criteria are used to guide safe return-to-play decisions.Skærmbillede 2016-04-13 kl. 00.57.54

2)Skærmbillede 2016-04-13 kl. 01.03.21Is physical recovery alone enough for return to play?
Recovery of physical capabilities to cope with the demands necessary to maximise performance and avoid reinjury.

However, after serious injury, returning to play is not simply a matter of ‘getting back up on the horse’. Psychological readiness to return to play is also important in making the return-to-play transition. Many athletes say fear of reinjury hinders their return to the preinjury level.
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Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: a consensus statement, Scand J Med Sci Sports 2010: 20 (Suppl. 2): 103–111 doi: 10.1111/j.1600-0838.2010.01195.

3) What is successful return to play?

The definition of success might depend on whether you ask the athlete or the physio. From the athlete’s perspective, performing at the desired level in the desired sport is important. From the physio’s perspective, a safe return without re-injury or long-term complications is important. Another question is if we Can consider the return to play a success on the basis of one match? What is the minimum time duration the athlete needs to participate before the return can be labelled ‘successful’? Is it a success if the athlete returns to play at the desired level but still experiences symptoms for months after returning to play or suffers a reinjury a week later.

4) What are the sports medicine clinician’s responsibilities within the team, and to the athlete?

Does the physio recognise that working for a sports team he may represent an inherent conflict of interest. In many situations, what is in the athlete’s best interests is also best for the team.

5) Should the athlete even return to play?

Role transparency is crucial to return-to-play decisions. Pressure from the athlete, coaches or family members, financial implications of scholarships or endorsements, may influence the athlete’s and physio’s decisions.

The next step

Skærmbillede 2016-04-13 kl. 01.16.37Return to play is complex and influenced by a range of factors. Research is necessary to answer many of these questions. However, in the absence of research evidence, consensus can help provide guidance for clinical practice and identify research gaps.

Being a slave to external evidence, waiting without tempering it with the best individual clinical experience and accounting for the patient’s preferences may not be an effective approach to return to play. This does not mean evidence should be ignored, rather that its use must be judicious. Creighton et al’s three-step model (figure 1) is a biopsychosocial framework that captures and discusses key elements to be considered in the return-to-play decision; although the decision itself is not solved within this model. For optimal return-to-play decisions the clinician and athlete share decision-making. We propose that Creighton et al’s model sits perfectly at the intersection of the three evidence based practice pillars.

 

 

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