Return-to-Play in Sport: A Decision-based Model

Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine (Impact Factor: 2.27). 09/2010; 20(5):379-85. DOI: 10.1097/JSM.0b013e3181f3c0fe
Source: PubMed


Return-to-play (RTP) decisions are fundamental to the practice of sports medicine but vary greatly for the same medical condition and circumstance. Although there are published articles that identify individual components that go into these decisions, there exists neither quantitative criteria nor a model for the sequence or weighting of these components within the medical decision-making process. Our objective was to develop a decision-based model for clinical use by sports medicine practitioners.
English literature related to RTP decision making.
We developed a 3-step decision-based RTP model for an injury or illness that is specific to the individual practitioner making the RTP decision: health status, participation risk, and decision modification. In Step 1, the Health Status of the athlete is assessed through the evaluation of Medical Factors related to how much healing has occurred. In Step 2, the clinician evaluates the Participation Risk associated with participation, which is informed by not only the current health status but also by the Sport Risk Modifiers (eg, ability to protect the injury with padding, athlete position). Different individuals are expected to have different thresholds for "acceptable level of risk," and these thresholds will change based on context. In Step 3, Decision Modifiers are considered and the decision to RTP or not is made.
Our model helps clarify the processes that clinicians use consciously and subconsciously when making RTP decisions. Providing such a structure should decrease controversy, assist physicians, and identify important gaps in practice areas where research evidence is lacking.

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    • "Together, these factors determine the risk of injury with activity and the third step involving decision modifiers reflects health factors unrelated to biomechanical injury risk. The three-step model was developed based on a literature review and knowledge from experienced clinicians (Creighton et al., 2010). In addition to face validity, each of the 19 different factors (Shultz et al., 2013) in the three-step RTP decision-making model was considered relevant by at least 40% of experienced team clinicians making RTP decisions, albeit with a high degree of variability in how they weight the different factors (Shultz et al., 2013). "
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    ABSTRACT: The purpose of this study was to validate a recently proposed return-to-play (RTP) decision model that simplifies the complex process into three underlying constructs: injury type and severity, sport injury risk, and factors unrelated to injury risk (decision modifiers). We used a cross-over design and provided clinical vignettes to clinicians involved in RTP decision making through an online survey. Each vignette included examples changing injury severity, sport risk (e.g. different positions), and non-injury risk factors (e.g. financial considerations). As the three-step model suggests, clinicians increased restrictions as injury severity increased, and also changed RTP decisions when factors related to sport risk and factors unrelated to sport risk were changed. The effect was different for different injury severities and clinical cases, suggesting context dependency. The model was also consistent with recommendations made by subgroups of clinicians: sport medicine physicians, non-sport medicine physicians, and allied health care workers.
    Full-text · Article · Sep 2014 · Scandinavian Journal of Medicine and Science in Sports
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    • "con la intención de garantizar un RTP seguro del lesionado, Creighton et al., (2010) presentan un modelo de decisión global, donde se interrelacionan criterios de tipo médico (síntomas y signos, historial lesivo, tests de laboratorio y tests funcionales, estado psicológico, etc.) específicos de la modalidad deportiva (tipo de deporte, posición en el campo, nivel competitivo, etc.) y contextuales (fase de la temporada, momento semanal, presión del entorno, etc.). Atendiendo a los factores psicológicos condicionantes en el momento de esta decisión, son numerosos los autores que, basándose en el patrón emocional " U " vivenciado durante el proceso lesivo, el cual sostiene una aparición de respuestas negativas tanto al principio como al final del proceso (Morrey, Stuart, Smith y Wiese-Bjornstal, 1999) han hecho hincapié en la importancia de una buena predisposición o confianza psicológica antes del RTP (Ardern, Taylor, Feller y Webster, 2012; Bauman 2005; Glazer, 2009; Kvist, Ek, Sporrstedt y Good, 2005;Webster, Feller y Lambros, 2008). "
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    ABSTRACT: This study aims to design and validate a questionnaire that measures the perception of the injured athlete regarding their short-term RTP. For the validation of the instrument the Delphi methodology for content validity, involving a total of 16 expert judges, was applied. For the calculation of the concurrent validity, different physical (anthropometric measurements, 8x5 speed test and Barrow test), psychological (anxiety state and moods) and medical (process of functional progression and perception pain) tests were used as gold standard. The results show that the implementation of the questionnaire in a sports context invites professional to think of appropriate levels of validity and utility of the instrument as a complement to other tests and assessments.
    Full-text · Article · Jan 2014 · Revista de Psicologia del Deporte
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    • "Limitations with current consensus statements have been recognised for several years. For example, Fuller et al. [19] discussed how injury recurrences, reinjuries, and exacerbations could be recorded; Bahr [20] discussed how overuse injuries often limited athletic performance but were not recorded in injury surveillance systems if there was no time-loss; and Creighton et al. [21], discussed how injury severity was dependent on whether return-to-play decisions were based on an athlete's full return to sport without limitation or were based on limited return to training. Some injury surveillance studies have addressed the issue of continued participation or return-to-play under restricted performance conditions. "
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    ABSTRACT: . Describing the frequency, severity, and causes of sports injuries and illnesses reliably is important for quantifying the risk to athletes and providing direction for prevention initiatives. Methods . Time-loss and/or medical-attention definitions have long been used in sports injury/illness epidemiology research, but the limitations to these definitions mean that some events are incorrectly classified or omitted completely, where athletes continue to train and compete at high levels but experience restrictions in their performance. Introducing a graded definition of performance-restriction may provide a solution to this issue. Results . Results from the Great Britain injury/illness performance project (IIPP) are presented using a performance-restriction adaptation of the accepted surveillance consensus methodologies. The IIPP involved 322 Olympic athletes (males: 172; female: 150) from 10 Great Britain Olympic sports between September 2009 and August 2012. Of all injuries ( n = 565 ), 216 were classified as causing time-loss, 346 as causing performance-restriction, and 3 were unclassified. For athlete illnesses ( n = 378 ), the majority ( P < 0.01 ) resulted in time-loss (270) compared with performance-restriction (101) (7 unclassified). Conclusions . Successful implementation of prevention strategies relies on the correct characterisation of injury/illness risk factors. Including a performance-restriction classification could provide a deeper understanding of injuries/illnesses and better informed prevention initiatives.
    Full-text · Article · Nov 2013
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