Validating the three-step return-to-play decision model

What contextual factors influence pain management decision making concerning player availability in professional men's football? A qualitative analysis of practitioner perceptions

PURPOSE

Football practitioners must regularly assess the risk of participation when determining player availability. At present, there is a lack of information detailing the factors that influence risk assessments. Accordingly, the following research question was explored: what contextual factors influence pain management decision-making when determining player availability in professional men's football?

METHODS

20 semi-structured interviews were conducted with club doctors (8), physiotherapists (6), and heads of medicine and performance (8) working in professional men's football in the United Kingdom. The methodology is reported using COREQ criteria and data were analysed using thematic analysis.

RESULTS

Three themes were created that explain how decision-making concerning analgesia was influenced by: (1) access to medical resources, (2) trust between staff and players, and (3) prioritising short-term success. First, the time, resources, and medical information available to staff impacted the ability to assess players and their risk tolerance in relation to analgesia. Second, decision-making was perceived as a multi-stakeholder process and the nature of relationships with players and performance staff could increase or decrease risk tolerance. Third, player decisions are made against a performance and working environment that privileges short term success over long term wellbeing.

CONCLUSION

The data support that pain management decision-making in professional men's football is influenced by the player and staff's working context. Further, practitioners viewed potential harm to a player from a socio-economic and physical perspective. These findings support the adoption of a patient-centred care approach and can inform clear recommendations from international and national governing bodies.

Rehabilitation of the painful shoulder

Managing the painful shoulder in overhead athletes can be difficult because of a lack of time-loss injuries in overhead sports and focusing primarily on either pathoanatomic causes or movement impairments. Although managing the painful shoulder can be challenging, the combination of identifying pathoanatomic causes with movement impairments can provide a more focused rehabilitation approach directed at the causes of shoulder pain. Understanding the potential influence of scapular positioning as well as mobility and/or strength impairments on shoulder pain can help clinicians develop more directed rehabilitation programs. Furthermore, sports-specific methods such as long toss or the use of weighted balls for achieving physiological or performance-based gains have limited empirical evidence regarding their clinical and performance-based benefits, which may impede the rehabilitation process. Applying a comprehensive evaluation approach prior to and throughout the treatment process can assist clinicians with selecting the most appropriate treatment based on patient need. Reconsidering traditional treatments based on existing evidence may help refine the treatment process for overhead athletes with shoulder pain.

A Framework for Clinicians to Improve the Decision-Making Process in Return to Sport

Return-to-sport (RTS) decisions are critical to clinical sports medicine and are often characterised by uncertainties, such as re-injury risk, time pressure induced by competition schedule and social stress from coaches, families and supporters. RTS decisions have implications not only for the health and performance of an athlete, but also the sports organisation. RTS decision-making is a complex process, which relies on evaluating multiple biopsychosocial factors, and is influenced by contextual factors. In this narrative review, we outline how RTS decision-making of clinicians could be evaluated from a decision analysis perspective. To begin with, the RTS decision could be explained as a sequence of steps, with a decision basis as the core component. We first elucidate the methodological considerations in gathering information from RTS tests. Second, we identify how decision-making frameworks have evolved and adapt decision-making theories to the RTS context. Third, we discuss the preferences and perspectives of the athlete, performance coach and manager. We conclude by proposing a framework for clinicians to improve the quality of RTS decisions and make recommendations for daily practice and research.

Wearable Technology and Analytics as a Complementary Toolkit to Optimize Workload and to Reduce Injury Burden

Wearable sensors enable the real-time and non-invasive monitoring of biomechanical, physiological, or biochemical parameters pertinent to the performance of athletes. Sports medicine researchers compile datasets involving a multitude of parameters that can often be time consuming to analyze in order to create value in an expeditious and accurate manner. Machine learning and artificial intelligence models may aid in the clinical decision-making process for sports scientists, team physicians, and athletic trainers in translating the data acquired from wearable sensors to accurately and efficiently make decisions regarding the health, safety, and performance of athletes. This narrative review discusses the application of commercial sensors utilized by sports teams today and the emergence of descriptive analytics to monitor the internal and external workload, hydration status, sleep, cardiovascular health, and return-to-sport status of athletes. This review is written for those who are interested in the application of wearable sensor data and data science to enhance performance and reduce injury burden in athletes of all ages.

Unanticipated jump-landing quality in patients with anterior cruciate ligament reconstruction: How long after the surgery and return to sport does the re-injury risk factor persist?

BACKGROUND

Inadequate reactions to unforeseen external stimuli are regarded as a major cause for non-contact anterior cruciate ligament (ACL) injuries. We aimed to delineate a potential deficit in the ability to perform unanticipated jump-landing manoeuvres, its sustainability and potential as a new outcome measure after ACL-reconstruction.

METHODS

Physically active adults (n = 27, 13 females, 14 males, 29.7 standard deviation 3.1 years) with a history of unilateral ACL rupture and subsequent reconstruction (6 months to 7 years ago), cleared for return to sports, were included. All participants performed counter-movement jumps with unanticipated single leg landings. Visual information shown after jump take-off indicated the required landing leg. Jump time [s] and successfulness [yes/no], vertical peak ground reaction forces at landing [N], as well as time to stabilisation after landing [s] and path length of the centre of pressure (CoP, [mm]) were calculated. Limb symmetry ratios were determined and analysed for their association with the time since surgery.

FINDINGS

Time since ACL reconstruction was logarithmically (basis 10) associated with side symmetry improvements in peak ground reaction force (R² = 0.23, p < .01) and time to stabilisation (R² = 0.18, p < .01) during and after landing in unanticipated/unpredictable single-leg jump landing tasks. The asymmetry found persists up to 18-26 months post-surgery.

INTERPRETATION

A deficit in unanticipated jump-landing ability seems to persist far beyond surgical restoration of mechanical stability and resumption of initial physical activities levels. The assessment of the ability to suddenly adapt movements to unanticipated visual stimuli may be a relevant complementary component within current functional testing canon in monitoring therapy success and return to sport testing.

Acute effects of preventive warm-up exercises on modifiable risk factors for anterior cruciate ligament injuries: a three-arm randomized-controlled crossover trial

BACKGROUND

We aimed to compare the potential acute effects of single bouts of a classic prevention and a risk factor-focus training aiming to target modifiable anterior cruciate ligament (ACL) rupture risk factors and the impact of neuromuscular fatigue on relevant ACL rupture risk factors.

METHODS

Two preventive warm-up (standard and ACL rupture risk factor training) and one inactive arm were compared; each of these were followed by a standardized neuromuscular fatigue protocol. The assessments included two Trail making tests (TMT-A; TMT-B, time to complete), drop jump landings (knee separation distance, normalized at hip width), as well as unanticipated counter movement jump landings (time to stabilization and peak ground reaction force).

RESULTS

We included 18 participants (25±2years). No differences were found between times and conditions for TMT (P>0.05). A significant time effect occurred in time to stabilization (F=2.6; P<0.05) and a significant time*baseline-value*jumping time interaction was seen in peak ground reaction force (F=3.1; P<0.05). No time effect was found for any knee separation distance (F=.1-2.4; P>0.05); but a significant time*baseline-value*jumping time interaction was seen at initial ground contact (F=2.8; P<0.05), and lowest point (F=4.2; P<0.01).

CONCLUSIONS

Risk factor-focus and classic warm-up may not differ in their acute effects on modifiable functional ACL (re-)injury risks factors.

Modern pain neuroscience in clinical practice: applied to post-cancer, paediatric and sports-related pain

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Generalized hypersensitivity in post-cancer, sports-related and pediatric pain.

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Rationale for pain education, stress management and cognition targeted exercises.

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Need to change from a biomedical or psychosocial to an integrated approach.

In the last decade, evidence regarding chronic pain has developed exponentially. Numerous studies show that many chronic pain populations show specific neuroplastic changes in the peripheral and central nervous system. These changes are reflected in clinical manifestations, like a generalized hypersensitivity of the somatosensory system. Besides a hypersensitivity of bottom-up nociceptive transmission, there is also evidence for top-down facilitation of pain due to malfunctioning of the endogenous descending nociceptive modulatory systems. These and other aspects of modern pain neuroscience are starting to be applied within daily clinical practice. However, currently the application of this knowledge is mostly limited to the general adult population with musculoskeletal problems, while evidence is getting stronger that also in other chronic pain populations these neuroplastic processes may contribute to the occurrence and persistence of the pain problem. Therefore, this masterclass article aims at giving an overview of the current modern pain neuroscience knowledge and its potential application in post-cancer, paediatric and sports-related pain problems.

Measuring heterogeneity of reinjury risk assessments at the time of clearance to return to play: A feasibility study

OBJECTIVES

Different individuals may make different return to play (RTP) decisions due to different risk assessments or risk tolerances. Our objectives were to determine the feasibility of eliciting reinjury risk assessments with Bayesian methods, and risk tolerance with questionnaires, from clinicians and athletes in a real-world RTP setting.

DESIGN

Feasibility study with a descriptive prospective case-series.

METHODS

We recruited the athlete, sport physician and physiotherapist caring for an athlete ("triplet") within on-going groin and hamstring injury studies. We applied Bayesian methods to elicit estimates for reinjury risk over the next 2 months, based on the available clinical knowledge, and projected activity level. We used a standardized questionnaire to elicit factors affecting risk tolerance.

RESULTS

Although our methods appeared feasible in general, there were important challenges that included language, time availability of practicing clinicians, and general work-flow issues related to embedding our study within an on-going larger study. We did obtain valuable data from more than one person on 10 of the 15 eligible athletes recruited. Despite the limited number of cases, there were clinically meaningful differences in risk estimates in some cases. In one triplet, participants estimated the reinjury risk between 1-10%, 20-50% and 30-40% for the same athlete. The most common factors modifying risk tolerance were "timing and season", "pressure from athlete", and "external pressure".

CONCLUSIONS

Bayesian methods for risk elicitation in clinical sport medicine are feasible, and large differences in both risk estimation and risk tolerance sometimes occur.

A multistate framework for the analysis of subsequent injury in sport (M-FASIS)

Physical activity is beneficial for many aspects of health but is associated with a risk of injury. Studies that assess causal risk factors of injury and reinjury provide valuable information to help develop and improve injury prevention programs. However, the underlying assumptions of analytical approaches often used to estimate causal factors in injury and subsequent injury research are often violated. This means that ineffective or even harmful interventions could be proposed because the underlying analyses produced unreliable or invalid causal effect estimates. We describe an adapted version of the multistate framework [multistate framework for the analysis of subsequent injury in sport (M-FASIS)] that makes investigator choices more transparent with respect to outcome and healing time. In addition, M-FASIS incorporates all previous sport injury analytical frameworks and accounts for injuries or conditions that heal or do not heal to 100%, acute and overuse injuries, illnesses, and competing event outcomes.