Load Monitoring: quick and easy RPE

I recently spoke at the UMBC Sports Performance Seminar regarding athlete load monitoring.  I find that in all my years of coaching I rely heavily on the monitoring process to help drive decisions in the training I am prescribing, getting to know my athletes and clients better, and tracking if the programs I am writing are having the desired effect.

 So let us start out with one of the ways you can monitor yourself , your clients, or your athletes and how you can make some decisions about the training status.

 Rate of Perceived Exertion (RPE) is one of many ways in which we can monitor the loads we are prepared for and our fitness or fatigue levels.

  RPE has been around since ~ 1950’s and I believe was first used in the endurance community. RPE is an internal load metric and is calculated by taking the average level of difficulty for the entire session and multiplying it by the session duration in minutes. The most common RPE scale used is this one:

Most research suggest a 30 minute reporting window from the time you completed your session to the time you record your RPE. This allows your body time to adjust so that your not reporting on the very last thing you just completed. I have found at least 1 study that states there is no difference in a 10 minute reporting window vs a 30 min reporting.

 Before you start to implement the RPE scale for your everyday training you will want to anchor it. Typically for my athletes and clients I have them first report on their RPE after performing a maximal fitness test. For some this has been a YoYo IR1, for others it has been a 1-mile test, and for others maybe a KB snatch test and for the CrossFit community maybe it is one of the signature workouts that you value. What ever you use, you will want to be able to repeat it in the future and have a submaximal version that you can use to “re-test” as a way to track your progress. The submaximal version will come back to be incredibly helpful to get insight into a fatigue indicator or an improvement indicator. Your submaximal version should last no more than ~ 6 minutes.

 RPE is categorized as an internal load marker, and because of its versatility is considered a “Gold standard” of monitoring. It is a marker that you will never have to update, and the units will always remain the same.

 Whether you are using this for yourself, your team, or your clients, RPE is NOT a group project. It is how you felt the session was, not what you wanted it to be, what it should have been, or what your training partner thought it was. It is not to be judged, it is only to be used for information. Over time I feel that RPE can also be used as a communication tool to prescribe intensity, but I would not suggest you roll this out right away with your clients or athletes. Give it some time for the language and feelings to solidify before you add more pieces to the puzzle. Eventually it is a great way to teach, communicate, and allow for auto regulation of any session.

 One of the ways you can organize this is to set up a simple Google forms sheet where you input the type of session (ie run, practice, lift….) Have a scale of 1-10 and a place to input the duration (in minutes only). Once you have created the form, send the short URL link to the appropriate party and have it put in the calendar on their phone (or your phone if you are going to monitor yourself) with an alarm everyday. It literally takes 8 seconds to open, fill out, and be sure the results were submitted. The information that can be gained from this 8 second investment overtime can be profound. Once the results are submitted into Google forms, you will basically have an excel file being created for you that you can then add in some simple calculations to track your loads.

 As you are tracking your daily loads and accumulating this overtime you will have significant data that you can refer back to. One of the markers I mostly use for an athletes lifetime training history or an athletes training history in the current phase is the Acute to Chronic Workload Ratio (ACWR). Dr. Gabbetts research points out to a sweet spot of .8-1.3 for this ratio. That “Sweet spot” tells us that on AVERAGE we are protected from injury and are in a proper loading cycle. This is what his research has shown on average, but there are always outliers that we will get to in a later post.

 Systematically building high chronic workloads protects us from injury and allows us to improve our overall fitness. Improving our overall fitness is about preparing the body for the sympathetically driven stress of life and improving our overall health and wellbeing.  Tracking the physical loads is one way to be aware of our preparedness for upcoming loads, our fatigue and our improvement. When our ACWR is too low, what you see is an increased risk of injury just as when our ACWR is too high. So, decreasing the load may not always be the correct response.

 Below are some of the calculations to use with RPE

• sRPE Training Load = RPE X Duration in Minutes

• Acute 7 day load = SUM of the 7 days of training (including today and the 6 days prior)

• Chronic 21 day load =  Average the Acute training load

• ACWR = (Acute 7 day) / (Chronic 21 day)

One of the reasons this is important is that a spike in your Acute load can leave you at an increased risk of injury for up to 4 weeks, it is definitely not just about making it to your next off day and you are in the clear. Workload spikes can linger around leaving us more susceptible to injury for days and weeks.

Now, back to our fatigue and improvement indicators with your submaximal protocol. An increase of 2 pts or more on a submaximal protocol is an indication of fatigue, while a decrease of 1-2 points is an indication of improvement. If we are performing a submaximal protocol on a regular basis it is one more variable allowing for checks and balances.

 Unfortunately at some point we all might be injured and tracking your RPE will give you, or the sports medicine professional, or the sports performance professional detailed information of the loads you were under and how you were experiencing them. It can give an indication of how long you might need to take before you are 100%. Lets say you have been sidelined with an injury for 4 weeks, and your training has diminished significantly, if you go back to your old training loads based one tissue healing alone, you will likely be subjecting yourself to a workload spike. Just a few paragraphs before I mentioned that workload spikes can leave us at risk of an injury for up to 4 weeks, when you add on-top of that spike the fact that previous injury history increases our susceptibly to future injury, you could be dusting off the welcome mat to another injury.

In short, tracking your RPE can:

1. Give you insight into the loads you are prepared for

2. Serve as a language marker for prescribing training intensity

3. Provide markers indicating fatigue or improvement

4. Greatly improve the return to performance process and success

References:

1. BioForce Conditioning Coaches Certification Course – Joel Jamieson 2018

2. Workload Management and Injury Prevention in Team Sports – Tim Gabbett

3. Gazzano, Francois. A Practical Guide to Workload Management & Injury Prevention in Elite Sport.

4. Science and Application of High-Intensity Interval Training

5. Haddad, M., Stylianides, G., Djaoui, L., Dellal, A., & Chamari, K. (2017). Session-RPE Method for Training Load Monitoring: Validity, Ecological Usefulness, and Influencing Factors. Frontiers in neuroscience, 11, 612. doi:10.3389/fnins.2017.00612

Nutrient Timing

Misconceptions of nutrient timing abound, leading to outdated dietary practices in home kitchens, locker rooms and training tables. We’ll use the most current scientific literature to clear them up, addressing protein and carbohydrate timing issues and requirements, and sharing actual examples of meals and snacks we recommend to our athletes.

(Note: We omitted discussion of dietary fat since timing its intake is rarely discussed for athletic performance.)

Protein

Many of us believe that if we don’t eat within one hour after lifting weights, we’ve failed to fully tap our potential to increase strength and size. This leads us to drink shakes and eat bars that we would otherwise find unappealing, trading the taste and nutrition of real food for the convenience of supplements. While early research hinted at the possibility of a narrow post-training anabolic window, the totality of evidence points towards a different conclusion.

 We’ve reviewed the research on short-term muscle protein synthesis and long-term exercise-induced hypertrophy, and support the recommendation to consume pre- and post-training meals within about four to six hours of each other. If training on an empty stomach, eat as soon as possible. The anabolic effects of a typical meal last up to six hours, and muscles remain sensitized to protein intake for at least one day following training. Our bodies are therefore much more flexible than we might assume (1).

 How much protein do we require after training? The collective body of evidence indicates that we should consume 1.6-2.2 g/kg/day to maximize training-induced strength and growth, which we can divide across four meals to deliver 0.4-0.5 g/kg/meal (2). Doing the math, we find that even a plant-based Chipotle burrito (e.g. brown rice, black and pinto beans, sofritas, lettuce, fajita vegetables, and salsa) achieves protein needs for a 180-pound athlete (3), making extra efforts to “get enough protein” generally unnecessary. This liberates us from trading taste and nutrition for immediate protein supplement hits.

Bottom line: Sandwich weight training within a four- to six-hour window of real, whole-food meals.

Carbohydrate

The topic of carbohydrate timing is also often misunderstood, particularly in the context of weight training. Those seeking strength and size often consume sizeable amounts of post-training sugar in order to spike insulin and grow muscle. Importantly however, the amount of insulin required to maximize muscle protein synthesis is just three to four times resting levels and easily attained by eating a normal meal (1). Megadosing sugar to augment insulin is therefore wasted effort, contributing empty calories without an upside.

Carbohydrate timing for endurance training is of greater importance for endurance athletes and those with less than eight hours of recovery between two fuel-demanding sessions.

Pre-event fueling:

• Consume 1-4g/kg 1-4 hours before exercise. A bowl of oatmeal with fruit would easily hit the mark.

During training:

• During brief exercise lasting less than 45 minutes, carbohydrate consumption is unnecessary.

• Sustained high-intensity exercise lasting 45-75 minutes benefits from small amounts of carbohydrate, including mouth rinse. In these cases, the carbohydrates confer benefits by stimulating the central nervous system to increase work outputs.

• Endurance exercise including “stop and start” sports lasting 1-2.5 hours benefit from 30-60 g/h.

• Ultra-endurance exercise lasting more than 2.5-3 hours benefit from up to 90 g/h, particularly from products containing glucose/fructose mixtures like Gatorade or Tailwind.

Post-training:

• In the event that a second training session will occur within eight hours of the last one, consume 1.0-1.2 g/kg/h for the first four hours and then resume with typical eating. A fruit smoothie is one example of how one could achieve this.

Overall carbohydrate requirements depend on the intensity of training. 5-7 g/kg/d are required when exercise lasts just one hour per day while 6-10 g/kg/d is recommended when training intensely for 1-3 hours per day (D). Importantly, athletes can meet carbohydrate needs via whole foods like fruit and whole grains. If struggling to get enough carbohydrates, opt for dehydrated gains (e.g. whole grain bread and cereal) and fruit (e.g. dried mango and raisins) instead of  hydrated grains (e.g. whole wheat pasta and oatmeal) and fruit (e.g. apples and grapes).

Bottom line: Unless two intense training sessions take place less than eight hours apart, simply eat plenty of whole foods throughout the day to meet carbohydrate needs.

References

1.     Schoenfeld BJ, Aragon AA. Is There a Postworkout Anabolic Window of Opportunity for Nutrient Consumption? Clearing up Controversies. J Orthop Sports Phys Ther. 2018 Dec;48(12):911-914.

2.     Schoenfeld BJ, Aragon AA. How much protein can the body use in a single meal for muscle-building? Implications for daily protein distribution. J Int Soc Sports Nutr. 2018 Feb 27;15:10.

3.     Chipotle Nutrition Calculator.

4.     Thomas DT, Erdman KA, Burke LM. Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance. J Acad Nutr Diet. 2016 Mar;116(3):501-528.

THE RETURN TO PLAY CONUNDRUM – PART 3

Introduction

I have spent the last two posts highlighting the importance of the multi-disciplinary team and building support for models that will help guide the Return to Play (RTP) process. But what does RTP even mean? How do we plan the process? It’s time to nail down this definition before I outline how to create a program. Currently, there is no universal definition or gold standard (1), which can lead to an athlete’s status being interpreted differently by different members of the performance team (2). To use basketball as a reference, spot shooting, playing half court 5 on 0, or playing a full court scrimmage are all variations of “play,” but greatly differ in their levels of physical and cognitive load. Therefore, defining the process is paramount. But what is the right designation? Where does rehab end and performance training begin? How can we define something that may change based on the situation and variables at stake? Within this post I will define the process, providing an objective and goals to support this definition, while outlining how to plan the process.

Establishing a Purpose

“Just because biological healing has occurred, it does not mean the athlete is prepared for performance”—Bill Knowles (3). As I outlined in my first post, there can be disagreement, disconnect, and pressure that can influence the RTP process. Some members of the multidisciplinary team may push an athlete back to competition after the injured tissue has healed, but are they physically prepared? This demonstrates the need to have clear definitions that create a shared vision for all members of the multidisciplinary team.

Objective & Goals

Now that we have adopted and understand the models that will guide the RTP process, we can funnel this into a definition. But how can we have a definition if we don’t agree on what the objective is? Using the work of both Knowles and Sue Falsone, as well as numerous articles (2, 3, 4, 5, 6, 7). I have come up with the following:

• Objective: Return the athlete back to competition that at least reaches or exceeds their pre-injury level.

This objective is clear, concise, and creates an outcome-focus relative to the athlete’s status pre-injury. However, we can’t ignore differing contextual considerations. There are a number of elements that can influence decision making, such as medical factors, individual factors, and sport related factors. Therefore, in order to optimize the decision-making process, we need to agree on common goals that ultimately support this objective. Based on the aims outlined in by Dhillon, H; Dhillon, S; and Dhillon, M in Current Concepts in Sports Injury Rehabilitation (7), I have come up with the following overarching goals:

• Protection of athlete long-term health

  • This keeps an athlete-centered focus that ensures we maintain the best interest of the athlete when making decisions.

• Prepare and sustain athlete for a return to competition

  • This ensures we take a reconditioning focus that addresses all qualities to prepare for long-term performance.

• Reduce potential of reinjury

  • This ensures we appropriately progress, prepare, and monitor the athlete.

If we can understand and agree on what the ultimate objective is, while creating common goals that support it, the decision-making process becomes easier. Ultimately, it’s about making collaborative decisions that are in the best interest of the athlete.

Defining the Process

In a 2016 Consensus Statement on Return to Sport from the First World Congress in Sports Physical Therapy (4), it was determined that a return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. In this continuum, three phases were outlined: return to participation, return to sport, and return to performance (shown in the figure below).  

As we know, there are a number of factors that can influence how an athlete progresses along this continuum, so we must avoid absolutes, instead, allowing the athlete to move along this continuum dependent on their current status and response to training. This is echoed in Falsone’s book, Bridging the Gap from Rehab to Performance (2), in which she refers to the process as the performance-training continuum. She goes on to state how the process from injury to return to competition is not a linear one. Concepts overlap, professions overlap, and restoration can fluctuate. This culminates in a return to performance in which the athlete at least reaches or exceeds their pre-injury level with potential for growth related to performance. This finally leads us to my definition:

• Return to Performance: an athlete-centered, criterion-based, and shared-decision making model to prepare and sustain athletes for a return to competition.

This definition uses the models outlined in my previous post, as well as the objective and goals stated above, as drivers of the process. I have also replaced the word “play,” which I indicated leaves too much up for interpretation, with the word “performance”. This puts an emphasis on returning the athlete back to high function as it relates to their sport.

Creating a Plan

At this point, we should have improved relationships with the multidisciplinary team, standardized lines of communication, and outlined roles and responsibilities for all contributing members. We also should have agreed upon the models that will guide our decision-making process, as well as a shared vision through clear objective and goals. This makes the planning process that much easier when we have a system to operate from, since establishing a formal RTP structure to help guide interactions has been shown to improve outcomes (6). Expanding on the continuum outlined in the 2016 Consensus Statement, I will outline how to create a RTP plan through testing, using a Performance Model, monitoring the process, and addressing psychological readiness.

Testing

In order to create a plan, we must have a way to measure progress. Ultimately, we can’t measure what we don’t test. And if testing drives our programming, then we need to establish baseline measures and performance metrics that create a roadmap for a return to competition. In order to create objective criteria (as I stated in my previous post), we first need an understanding of the sport and what biomechanical and physiological demands this has on the athlete. With this information we can execute functional tests that will guide the progression of interventions throughout each phase of the reconditioning model, and ultimately a return to competition. There are an infinite number of tests, but I have included some below:

• Strength Testing

  • Lower Body: Squat, Deadlift

  • Upper Body: Bench Press, Military Press, Chinup

• Strength Endurance Testing

  • Lower Body: Rear Foot Elevated Split Squat with % of BW for Reps

  • Upper Body: <80% Bench Press, Pushup, Chinup

• Power Testing

  • Lower Body: Vertical & Horizontal Jump Variations (bilateral/unilateral, static/dynamic/rebound), Olympic lifting variations

  • Upper Body: Medicine Ball Throw variations

• Speed & Agility Testing

  • Sprints: 10yd, ¾ Court, 60yd Dash

  • Agility: Box Drill, L-Drill, Illinois Drill

• Fitness Testing

  • 1 Mile Run, Beep Test, YoYo IR1 or IR2

Performance testing is not limited to these tests by any means. Nor is it practical or suggested to do all these at every stage of the RTP process. It is highly dependent on the current status of the athlete and where they fall within the continuum. As mentioned above, it’s up to you to choose the tests that provide the most information about the athlete as it relates to their given sport. Using technology is also a great way to create more repeatability, precision, and validity. However, they can be quite costly. I suggest designing an environment that is repeatable, with specific protocols to diminish interference. Performance testing are not the only metrics we should be evaluating. Documentation of baseline measures is also paramount to compare performance and functional status to a preinjury level. Baseline measures may include various assessments and evaluations, such as body composition, joint range of motion, and functional mobility and stability tests. One of the most popular and heavily researched screens, the Functional Movement Screen (FMS), has been shown to provide actionable information in a time efficient manner. In a study evaluating injury prediction in professional football players, it was determined that players with dysfunctional fundamental movement patterns (FMS score of 14 or less) are more likely to suffer an injury than those scoring higher on the FMS (8). Although the FMS has its drawbacks, it does provide an objective measure to evaluate progress, which can be used to guide the decision-making process. The importance of testing has been indicated as a vital element of the RTP process in the 2016 Consensus Statement, in which they suggest that tests should be performed at four key times after an injury has occurred (4):

1. Immediately after injury (ie, diagnostic tests)

2. Through the course of reconditioning (to monitor progression)

3. At the time of clearance for a full return to sport

4. After return to sport to measure performance and reinjury risk

At each of these stages, the type of testing administered matches the current status of the athlete. These tests also create objectivity to advance the athlete to the next stage of the process. Therefore, we must not be fixated on a timeline, rather on the achievement of functional criteria. There must be an emphasis on graded, criterion-based progressions, that are applicable for any sport and aligned with RTP goals (4).

Performance Model

The multidisciplinary team strategically develops a plan, working backwards from where the athlete needs to be physically as it pertains to the demands of the sport and position played. A RTP plan needs to be both tissue specific and functional, with an emphasis on motor learning, reorganization, and sport relevance (5). As an athlete recovers from injury, the emphasis progresses from protecting the injured tissue, to guiding the healing process, and finally restoring the capacity of strength and energy systems (9). This involves creating a detailed athlete-centered reconditioning plan that includes performance outcomes based on baseline measures and prior performance metrics (using the models outlined in my previous post). This creates objective criteria to progress the athlete through each stage of the process. As stated in my first post, this is not owned by one particular specialist, but developed and agreed upon by all members of the performance team. Using Knowles’ Performance Model outlined in Sports Injury Prevention and Rehabilitation (figure shown above), all members need to work together to ensure the athlete is kept safe and healing structures are protected, while the athlete is progressively trained in all aspects of athletic development. This is where baseline and sport-specific functional testing can create specificity not only to the sport, but to the individual athlete throughout the RTP process. As the athlete undergoes reconditioning, all elements of performance must be addressed, such as movement quality, coordination, strength, power, speed, and fitness. Competency-based reconditioning ensures that there is a logical progression to tissue loading, which involves advancement of movements from simple to complex, general to specific, slow to fast, and controlled to uncontrolled. Using the SAID principle (specific adaptation to imposed demands), we know consistent adaptation requires optimal stimulus and recovery. This involves the performance team managing the athlete’s exposure to volume, intensity, density, and collision/contact to prompt consistent adaptation. As the athlete progresses towards sport-related skills, this also involves balancing technical and tactical factors that can systematically progress that athlete from sport-related skills, practice, and ultimately competition. Lastly, the performance team should also apply the acute:chronic (A/C) ratio (which I outline in the next section) to monitor the entire process to manage that training is progressed at an optimal pace. With this in mind, the multidisciplinary team creates a periodized program that strategically works backward through the continuum, using clearance criteria to ensure the athlete is physically prepared for a sustained return to sport. This involves creating a plan into phases of escalating demand.

Monitoring the Process

Due to the physical demands of sport, graded load progression plays a vital role in a successful RTP. It is paramount to consistently monitor the athlete throughout the performance model to ensure optimal loading of the injured tissues. Load progression and monitoring has also been outlined as a key part of rehabilitation and the return to sport decision by multiple publications (4, 5, 7, 9). Daily training loads can provide a way to quantify how much training the athlete has performed, while also ensuring the athlete has trained enough to withstand practice and competition loads. In a recent study examining if athletes have trained enough to RTP safely (10), a significant relationship between excessive training loads and risk of reinjury was found. However, when optimal loading was employed it exhibited a protective effect against injury. This demonstrates the importance in monitoring training load to safely progress the athlete. This also allows the multidisciplinary team to manipulate training variables for consistent improvement without exposing the athlete to loads they are not prepared for. Using Session Rating of Perceived Exertion (sRPE), the athlete rates the intensity of the training as outlined in the figure to the right. Monitoring the training load during the current training week (acute) against the average of preceding four training weeks (chronic) provides an A/C workload ratio.14  This ultimately provides objective way to plan load progressions and advancement throughout the RTP continuum. Blanch and Gabbett recommend an A/C workload ratio between 1.0 and 1.5 with a higher ratio associated with higher reinjury risk (10). Using these guidelines, the multidisciplinary team can ensure the athlete has been exposed to and able to sustain sufficient training loads over time. The nature of monitoring is likely to be different depending on the sport, but it is vital to create objectivity to the individual physiological response to training. Therefore, the usage of sRPE and the A/C can provide the multidisciplinary team with objective data to allow for a smooth transition from injury to a return to competition, while ensuring that the athlete has performed an appropriate amount of chronic loading to tolerate these progressions.

Psychological Readiness

I hope we can agree that creating a plan is paramount for a successful return to competition. Thus far we have heavily focused on physical parameters within the RTP plan. However, injury is more than physical. The psychology of the athlete is crucial in rehabilitation, as their emotions, beliefs, and thoughts all affect how their bodies respond to injury (3). Athletes also cope with injury differently and may have anxieties concerning a return to sport. Common concerns may include fear of reinjury, regaining status on a team, and failing to perform at preinjury levels, which can affect the rate of recovery through overuse, avoidance, and other compliance issues (11). Furthermore, the parameter most associated with a successful RTP is the perception of whether or not the athlete feels they will be able to return as before (12). Therefore, being able to address cognitive and emotional factors is just as important as physical performance qualities. To combat potential negative psychological responses to injury, athletes need graduated opportunities to perform and experience success in physical tasks in order to build confidence in performance. This is engrained within the graded progression of the performance model outlined above. This also involves adopting a way to evaluate an athlete’s psychological status. Using the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale, which was validated as an assessment of an athlete’s psychological readiness to return to sport (13), the multidisciplinary team can provide the six-question scale to confirm progression through each phase of the return to performance continuum. Motivation also plays a big role in a successful RTP. Carson and Polman found that positive psychological responses including motivation, confidence and low fear were associated with a greater likelihood of returning to the preinjury level of participation and returning to sport more quickly (14). Using the Self-Determination Theory (15) outlined below, it was determined athletes can produce more adaptive coping strategies and increase adherence to the RTP process.

• Self-Determination Theory

  • Autonomy: self-initiation and self-regulation of one’s own behavior

    • Provide athletes with an in-depth understanding of the injury and plan to increase self-regulation and provide some control throughout the process.

  • Competence: ability to interact proficiently or effectively with the environment

    • Competence is developed by increasing physical and performance proficiency as athletes progress through each phase.

  • Relatedness: feelings of closeness and belonging to a social group

    • It is vital to keep the athlete involved with the team after an injury to create social support and belonging. 

It is clear positive psychological responses are associated with a higher rate of returning to sport following injury. This highlights the importance of including psychological interventions in conjunction with the performance model above. Psychological interventions can be used in combination with reconditioning to aid effective healing via the biological interaction between the mind and body. Ultimately, the athlete must be psychologically ready for the demands of his or her sport.

Closing

“Failing to plan is planning to fail.”—Benjamin Franklin. In order create a plan, we must first establish a purpose to provide a shared vision for all members of the multidisciplinary team, as well as the athlete. Having a clear objective and goals ultimately help to create a roadmap for success when planning the process. Using the Performance Model, while integrating objective measures such as performance testing, A/C ratio, and I-PRRS, will ensure a strategic, graded progression that accounts for both the physical and psychological demands placed on the athlete. Stay tuned for Part 4 of the Return to Play Conundrum, the final section of this series, where I will establish a purpose, define the process, and outline how each phase of the Return to Play Continuum.

Resources

(1)  Lynch, A., Logerstedt, D., Grindem, H., Eitzen, I., Hicks, G., Axe, M., Engebretsen, L., Risberg, M. and Snyder-Mackler, L. (2013). Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. British Journal of Sports Medicine, 49(5), pp.335-342.

(2)  Falsone, S. (2018). Bridging the gap from rehab to performance.

(3)  Joyce, D., & Lewindon, D. (2016). Sports injury prevention and rehabilitation integrating medicine and science for performance solutions. London: Routledge.

(4)  Ardern, C. L., Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen, B., Cools, A., . . . Bizzini, M. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine,50(14), 853-864. doi:10.1136/bjsports-2016-096278

(5)  Joyce, D. (2014). High-performance training for sports. Champaign, IL: Human Kinetics.

(6)  Creighton, D. W., Shrier, I., Shultz, R., Meeuwisse, W. H., & Matheson, G. O. (2010). Return-to-Play in Sport: A Decision-based Model. Clinical Journal of Sport Medicine,20(5), 379-385. doi:10.1097/jsm.0b013e3181f3c0fe

(7)  Erratum: Current concepts in sports injury rehabilitation. (2017). Indian Journal of Orthopaedics,51(6), 724. doi:10.4103/0019-5413.217722

(8)  Almuzara, L. L. (2018). Effectiveness of Functional Movement Screen as an injury predictive value in football players. A systematic review. doi:10.24175/sbd.2018.000051

(9)  Morrison, S., Ward, P., & duManoir, G. R. (2017). ENERGY SYSTEM DEVELOPMENT AND LOAD MANAGEMENT THROUGH THE REHABILITATION AND RETURN TO PLAY PROCESS. International journal of sports physical therapy, 12(4), 697-710.

(10) Blanch, Peter & Gabbett, Tim. (2015). Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player's risk of subsequent injury. British journal of sports medicine. 50. 10.1136/bjsports-2015-095445.

(11) Kraemer, William & Denegar, Craig & Flanagan, Shawn. (2009). Recovery From Injury in Sport: Considerations in the Transition From Medical Care to Performance Care. Sports health. 1. 392-5. 10.1177/1941738109343156.

(12) Return to Sport Injury Mitigation Performance Continuum Presentation

(13) D Glazer, Douglas. (2009). Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Journal of athletic training. 44. 185-9. 10.4085/1062-6050-44.2.185.

(14) Carson, Fraser & Polman, Remco. (2017). Self-determined motivation in rehabilitating professional rugby union players. BMC Sports Science, Medicine and Rehabilitation. 9. 10.1186/s13102-016-0065-6.

(15) Ryan, Richard & Deci, Edward. (2000). Self-Determination Theory and the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. The American psychologist. 55. 68-78. 10.1037/0003-066X.55.1.68.

THE RETURN TO PLAY CONUNDRUM - PART 2

Introduction

Welcome back! In my first post I outlined the crucial first steps when developing a Return to Play (RTP) protocol: relationships, communication, and integrating the multidisciplinary team. If the ultimate goal is to improve the long-term welfare of the athlete, it can only happen by improving the relationships with the performance team first; adopting a common language and establishing standardized lines of communication; and outlining everyone’s role to maximize each members’ strengths to work under a shared vision that advances the athlete back to high function. It is paramount to address these in order to create sustainable relationships that allow your system to flourish. This is a fluid and ever-evolving process that doesn’t happen overnight. It takes time, investment, and ultimately letting go of your ego for the higher purpose of helping the team and athlete. However, the benefits can lead to improved function and execution that further advances the organization. As Fergus Connolly stated at exhaustion in his book Game Changer, “…human beings are always the number one asset.”

Creating a Framework for Success

Once we have addressed the human factor, it’s time to adopt models that will guide the RTP process. In a 2016 Consensus Statement on Return to Sport from the First World Congress in Sports Physical Therapy (1), they indicated the importance of using models to help understand and guide the RTP process. These models will create a framework that provides a transparent, collaborative, and evidence-based approach to progress the athlete. This involves adopting Athlete-Centered, Reconditioning, Shared-Decision Making, StAART Framework, and Criterion/Performance-Based models.

Athlete-Centered Model

Traditionally, rehabilitation has placed the Surgeon, Team Physician, and/or Athletic Trainer as the focal point to direct all protocols throughout the RTP process, relegating other professionals to a subservient role, and taking the focus off the athlete. This is where ego tends to rear its ugly head, leading professionals to argue over their own territory, ultimately leaving the athlete with insufficient care. This approach fails to account for the one constant in everyone’s setting, the athlete. The athlete should always be at the center of the management process (2). This is echoed by the National Athletic Trainers Association, in which they indicate the importance of “athlete-centered care” through the delivery of healthcare services that are focused on the individual athlete’s needs (3). Therefore, an athlete-centered model places the athlete at the center of the program, with all professionals working together to ensure the athlete attains his or her goals (4). Within this model, everyone has the athlete’s best interest in mind, respects and understands everyone’s role (as I stated in my previous post), and uses evidence-based practice within the framework of the RTP process. In order to have the athlete’s best interest in mind, the athlete must also be heavily involved in the process. This leads me to the four key habits of athlete-centered return to sport as outlined by King, Roberts, Hard, and Ardern (5):

• Empower

  • Educate athlete about their injury

  • Consult athlete about management options

  • Develop short-term and long-term criteria the athlete agrees with

• Engage

  • Encourage athlete to outline their objectives

  • Educate athlete on plan for RTP

  • Encourage athlete to use this information to contribute to the process

• Feedback

  • Schedule regular meetings throughout process

  • Allow athlete to speak first to limit influence of other stakeholders

  • Summarize key action points and update progress

• Transparency

  • Communication must be frequent and honest to manage expectations

  • Transparency allows for stakeholders to openly discuss issues/expectations

As you can see, this places the athlete at the center of the process, in which they have a major influence on their own progress. This fosters athlete autonomy, which has been shown to promote personal development, improve motivation and task performance, and subsequently improve rehabilitation outcomes (5). Ultimately, the athlete-centered model moves away from the fragmented approach to traditional rehab, to a more unified reconditioning model involving the athlete and all members of the multidisciplinary team.

Reconditioning Model

So now you may be asking what the difference is between rehabilitation and reconditioning? Traditional rehabilitation has been focused on the isolated injury using a localized treatment modality, while disregarding total physical development. This process doesn’t always identify the “cause” of pain or injury, such as faulty mechanics, neurological deficits, or underlying structural issues (4). It’s not to say that traditional rehabilitation is bad. It’s not. During the acute period after an injury, it’s essential to restore tissue health, joint mobilization, and ligament integrity, while respecting homeostasis (6). However, we must take a more wholistic view in order to optimally prepare the athlete. With this in mind, a more modern approach needs to be both tissue specific and functional, with an emphasis on motor learning, reorganization, and sport relevance (2). This is the benefit of the reconditioning model, which is a performance-based and medically supported model for training athletes following injury or surgery (7). This takes a more comprehensive approach that pinpoints the root of the problem, while allowing the integrated multidisciplinary team to collaborate throughout the process. This allows the performance team to address all aspects of athletic development immediately post injury to better prepare and sustain the athlete for a return to competition. One of the biggest components of reconditioning is training around injury, with the aim of avoiding prolonged immobilization, which has been shown to have detrimental effects on muscle tone, strength, and structure (8). On the other hand, resistance training early in the rehabilitation process has been shown to be critical to the redevelopment of neuromuscular control and function, and the development of strength and endurance in injured tissues (9,10). With this in mind, emphasis is placed on what the athlete can do. This immediately integrates the medical team with the strength and conditioning coaches and coaching staff (2). Close coordination with trainers and coaches is essential, and all need to understand that the reconditioning phase is crucial to safely progressing the athlete back to competition. (11). As Bill Knowles states, “it is easy to get them back, but difficult to keep them back” (7). In an epidemiology of High School Sports-Related injuries from 2005-2014, it was concluded that of all the sporting injuries that led to medical disqualification, 60% were suffered during competition (12). This demonstrates the importance of a reconditioning model that bridges the gap between the medical team and the performance team to ultimately develop a more robust athlete who can sustain the demands of competition.

Shared-Decision Making Model

So, who’s decision is it anyway? As I mentioned above, in the past the Surgeon, Team Physician, and/or Athletic Trainer was the gatekeeper and ultimate decision maker. However, times have changed. The RTP process now involves a multidisciplinary team navigating a complex situation in which roles can overlap. This has a high potential for conflict as decisions, opinions, and goals may differ among the parties involved (highlighting the importance of the elements outlined in my first post). External information and relationships have also been shown to play a significant role, as coaches family members, teammates, and friends can influence the decision-making process (13). Ultimately, the decision to further progress the athlete through the process, and eventually full clearance for competition, should be a decision shared by all contributing members of the performance team, as well as the athlete (13). This sentiment is shared by a number of publications (4, 6, 11) that indicate there is obvious overlap between professionals within the RTP process, and we need to get comfortable understanding no single person can do everything. Therefore, adopting a model that creates structure and transparency within a complex situation, especially given the circumstances under which a decision is made will always be different, is essential. This leads us to the 3-step decision-based model for RTP provided by Creighton, Shrier, Shultz, Meeuwisse, and Matheson (13). Shown in the Venn diagram above, this model allows all contributing members to evaluate the health status and risk of participation of an athlete at any point during the process, while considering factors involved in decision modification. The best part about this model is it allows risk assessment to be applicable at any stage of the process and by any member of the multi-disciplinary team, as long as there is effective communication (13). As I outlined in my first post, understanding and providing clarity on everyone’s role is imperative.

• Athlete: main contribution is subjective-make informed preference decision

• Healthcare Professionals (including S&C Coach): main contribution is objective-evaluate health status, provide advice on management and outcome

• Sport Coach: main contribution is contextual-evaluate athlete’s current ability to perform

Ultimately, the shared-decision making model provides a formal structure and process to help guide interactions, while providing contributing members with an evidence-based rationale for decision making.

StAArt Framework

Once the athlete has cleared the functional criteria needed for each phase of the reconditioning model, a decision to return to sport approaches. As stated in the Shared-Decision Making Model, the decision of returning to sport is not one taken in isolation. It is a collaborative decision made by the entire multidisciplinary team, as well as the athlete being the final judge. This is where the strategic assessment of risk and risk tolerance (StAART) framework can guide members in making informed decisions, while gradually returning the athlete back to competition. Since the multidisciplinary team may have differing opinions on whether the athlete is sufficiently prepared to increase sport activity, the StAART framework provides a three-step framework to estimate risks associated with a return to sport. Along with being aware of the demands of the sport, this is where the achievement of carefully formulated objective criteria and monitoring load progression can provide tangible context to make better decisions. Using baseline measures, functional testing, and psychological readiness, as well as assessing both open and closed skills as it pertains to the sport, the multidisciplinary team needs to ensure the athlete can meet the physical demands of the sport without sustaining a reinjury (14). Below I have outlined each step of the StAART framework:

• Evaluation of Health Status (Step 1): Evaluate health status of the athlete through the assessment of medical factors to provide information on how much healing of the injury or illness has occurred.

• Evaluation of Participation Risk (Step 2): Evaluate risk associated with athlete participation. This is risk directly associated with athlete and sport, such as type of sport, position, and competitive level. can be risk of reinjury, use of risk modifiers, time of year (pre-season, conference play, playoffs), and social factors.

• Decision Modification (Step 3): Decision Modification is set aside from the other steps because participation risk does not contribute information about Decision Modification, and Decision Modification cannot be used to determine RTP except in the context of participation risk. This includes time of year, internal and external pressure, and conflict of interest.

This process is repeated as the healing process continues and if the status of the athlete changes as they progress through the RTP process. Therefore, to reduce potential conflict between the multidisciplinary team, as well as maintain an objective approach, the StAART framework provides a transparent process to guide RTP decisions.

Criterion/Performance-Based Method

Historically, surgeons and physicians have used time as the major criteria when determining when an athlete should return to play. However, the calendar doesn’t optimally determine individual recovery rate and functional status (11, 15). In his book, The Checklist Manifesto, Dr. Atul Gawande indicates that “under conditions of complexity, not only are checklists a help, they are required for success” (16). Although we’re not necessarily working in life and death situations as Dr. Gawande does, we are working in complex settings which involve varying degrees of injuries, occurring in different sports, and most importantly, with different athletes. Adopting a checklist method to help guide our decisions through the RTP process can help ensure that nothing gets overlooked, while also safeguarding that the athlete meets the necessary criteria to advance. In a recent study, an evidence-based checklist approach was validated to reduce the chance of reinjury for athletes following ACL reconstructions (15). Prior to a return to play, patients underwent seven objective measures, including physical exam, functional testing (hop and agility testing, movement assessment), and functional outcome score. Among the findings of the study, checklist patients had a significant decrease in both ipsilateral and contralateral knee re-injury. As this study indicates, checklists and objective measures play an integral role in clearing the athlete, while reducing the chance of reinjury. Therefore, the progression of a reconditioning program should be based on functional criteria instead of being time based, with sport-specific functional testing determining the progression to the next phase (11).

Closing

“Excellence is a continuous process and not an accident”—A. P. J. Abdul Kalam. We must be strategic about how we create our process to minimize interference and maximize progression for the athlete. This involves optimizing a framework that provides a transparent, collaborative, and evidence-based approach to progress the athlete. Integrating the Athlete-Centered, Reconditioning, Shared-Decision Making, StAART Framework, and Criterion/Performance-Based models will serve to create objectivity within our process. Stay tuned for Part 3 of the Return to Play Conundrum, where I will establish a purpose, define the process, and outline how to create a plan.

Resources

(1) Ardern, Clare & Glasgow, Philip & Schneiders, Anthony & Witvrouw, Erik & Clarsen, Benjamin & Cools, Ann & Gojanovic, Boris & Griffin, Steffan & Khan, Karim & Moksnes, Håvard & Mutch, Stephen & Phillips, Nicola & Reurink, Gustaaf & Sadler, Robin & Silbernagel, Karin & Thorborg, Kristian & Wangensteen, Arnlaug & E Wilk, Kevin & Bizzini, Mario. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British journal of sports medicine. 50. 10.1136/bjsports-2016-096278.

(2) Joyce, D. (2014). High-performance training for sports. Champaign, IL: Human Kinetics.

(3) https://www.nata.org

(4) Falsone, S.,(2018). Bridging the gap from rehab to performance.

(5) King, J., Roberts, C., Hard, S., & Ardern, C. L. (2018). Want to improve return to sport outcomes following injury? Empower, engage, provide feedback and be transparent: 4 habits! British Journal of Sports Medicine. doi:10.1136/bjsports-2018-099109

(6) Kraemer, William & Denegar, Craig & Flanagan, Shawn. (2009). Recovery From Injury in Sport: Considerations in the Transition From Medical Care to Performance Care. Sports health. 1. 392-5. 10.1177/1941738109343156.

(7) Joyce, D., & Lewindon, D. (2016). Sports injury prevention and rehabilitation integrating medicine and science for performance solutions. London: Routledge.

(8) Booth, Frank. (1987). Physiologic and Biochemical Effects of Immobilization on Muscle. Clinical orthopaedics and related research. &NA;. 15-20. 10.1097/00003086-198706000-00004.

(9) Kraemer, William & Ratamess, Nicholas & French, Duncan. (2002). Resistance Training for Health and Performance. Current sports medicine reports. 1. 165-71. 10.1249/00149619-200206000-00007.

(10) Järvinen, Tero & Järvinen, Teppo & Kääriäinen, Minna & Äärimaa, Ville & Samuli, Vaittinen & Kalimo, Hannu & Järvinen, Markku. (2007). Muscle injuries: Optimising recovery. Best practice & research. Clinical rheumatology. 21. 317-31. 10.1016/j.berh.2006.12.004.

(11) Dhillon, Himmat & Dhilllon, Sidak & Dhillon, Mandeep. (2017). Current Concepts in Sports Injury Rehabilitation. Indian Journal of Orthopaedics. 51. 529. 10.4103/ortho.IJOrtho_226_17.

(12) Tirabassi, Jill & Brou, Lina & Khodaee, Morteza & Lefort, Roxanna & K Fields, Sarah & Dawn Comstock, R. (2016). Epidemiology of High School Sports-Related Injuries Resulting in Medical Disqualification: 2005-2006 Through 2013-2014 Academic Years. The American Journal of Sports Medicine. 44. 10.1177/0363546516644604.

(13) Creighton, David & Shrier, Ian & Shultz, Rebecca & H Meeuwisse, Willem & O Matheson, Gordon. (2010). Return-to-Play in Sport: A Decision-based Model. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 20. 379-85. 10.1097/JSM.0b013e3181f3c0fe.

(14) Gabbett, Tim & Benton, Dean. (2008). Reactive agility of rugby league players. Journal of science and medicine in sport / Sports Medicine Australia. 12. 212-4. 10.1016/j.jsams.2007.08.011.

(15)  https://www.sciencedaily.com/releases/2018/03/180306101654.htm

(16) Gawande, A. (2014). The checklist manifesto: How to get things right. Gurgaon, India: Penguin Random House.

THE RETURN TO PLAY CONUNDRUM – PART 1

Introduction

Ever since I can remember, baseball was my world. My passion. Unfortunately, I’ve had my fair share of injuries. Having played since childhood, and specializing as I disregarded other sports (for which I do not advise, but that’s a whole other topic in itself), I ran the gamut of elbow and shoulder issues. There were times I felt as though I spent as much time in the doctor’s office and training room as I did on the field. On the flip side, as a Sports Performance Coach over the past 8 years, I’ve been exposed to nearly every injury on the spectrum. Having worked at almost all levels of collegiate athletics, I keep finding a common thread; inconsistency and disconnect within the “Return to Play” process. I continue to ask myself the same questions: What is the plan? Why is there no standardized operating procedure? Why are we not communicating? Why are coaches and staff not involved? Why are athletes completely taken out of activity? Why is “rehab” isolated to the area of injury? How are we addressing all athletic qualities? How are we progressing the athlete back to competition? Are we using outcome measures and criteria-based progressions? Are we addressing barriers to successful return? How are we monitoring training load and adaptation? What are the criteria for clearance? Is the athlete mentally ready to return? How do we keep the athlete mentally engaged with the team and team culture? To sum it up with one question, WTF are we doing?? (There were some other questions, but I don’t want to pollute your virgin ears).

Objective

Through a series of posts, I will answer these questions to provide some clarity on the Return to Play (RTP) process. Namely, is that even an appropriate designation? The objective of these posts will be to outline a standardized, performance-based, and shared-decision making model to prepare athletes for a return to competition. Within my first post, I will cover the importance of relationships, effective communication, and outlining roles and responsibilities for the integrated multidisciplinary team. These posts are not intended to convince you that my process solves the RTP conundrum. Nor is this system applicable across all disciplines and situations. However, these posts will offer ways to consider structuring, planning, and executing the RTP process, while questioning contemporary practice in order to make quality decisions. Everything outlined is based on review of literature, discussions with industry professionals, and my own experience. I’m not a Doctor. I’m not a licensed Physical Therapist. I’m not a certified Athletic Trainer. I’m a former student-athlete and current Sports Performance Coach who wants to challenge the status quo and improve the reconditioning model for enhanced and sustainable long-term athletic development.

So, where do we start?

Before we get into creating, planning, and executing a system, we first need to address the human factor: the individuals involved. This starts by fostering quality relationships, establishing effective lines of communication, and outlining roles and responsibilities for the integrated multidisciplinary team. Granted there will be overlap, without this foundation, creating and executing a system becomes blurred.

Relationships

“Life begins at the end of your comfort zone.”—Neal Donald Walsch. For many, investing time into relationships at work may be difficult, but it’s essential to create a foundation for a system to thrive. Team member relationships at work have been shown to be directly associated with organizational commitment and job performance (1). Therefore, success can only be achieved if everyone believes in the process, is committed to their role, and puts the athlete’s well-being above all. Just like a sports team, the performance team needs high levels of trust, collaboration, and communication, while checking egos at the door. And it starts with you. Get to know yourself first to better leverage and amplify your traits to create buy-in with both your athletes and team members (2). Understanding your own strengths and weaknesses can help you create strategies to improve interactions with everyone involved. Then comes the hard part; investing time. Easier said than done, right? We’ve all worked with athletes who don’t make training a priority or staff members who don’t pull their weight and want to work in a silo for fear of being “found out” they can’t effectively do their jobs (3). All I can say is, be patient and stay the course. It takes time to foster effective relationships and create enough trust throughout the RTP process. I’m not saying completely throw your integrity out the window, but there may be times when you bite your tongue or yield to someone else even if it goes against every fiber of your being. To quote Brett Bartholomew, “There’s a reason why the best tasting foods cook the longest; it allows all the ingredients to blend together in order to bring out the true essence of the dish” (2). So, allow your relationships to marinate. Get to know your athletes and team members on a personal level. Ask questions, be a good listener, and foster trust through positive interactions. Being mindful of your athletes and team member’s personality types, attitudes, and behaviors can help you learn more about them to create strategies for individualizing interactions (2). Being able to consider the individual’s preference with respect to the relationship formed is vital to improving intrinsic motivation, autonomy, and adherence with everyone involved (4). At their best, relationships can be extremely rewarding. At their worst, they can be toxic, corrosive, and dysfunctional (1). If the ultimate goal is to improve the long-term welfare of the athlete, it can only happen by improving the relationships with everyone involved.

Communication

Effective communication is a vital factor in determining the efficiency with how an organization performs as a whole. (5). This is essential in a RTP process that not only involves athletes, but a multidisciplinary team with varying degrees of understanding and education, who also may interpret information differently. The complexity of this dynamic, coupled with the inherent limitations of human performance, make it vital to have a common language and standardized communication tools in order to improve efficiency and minimize risk. (6). Numerous studies have indicated internal communication as an important risk factor within the RTP process. (7, 8, 9). Specifically, in a study of 36 elite-level football teams across 17 European countries from 2012-2016, injury burden and incidence of severe injuries were significantly higher in teams with low quality communication between medical personnel, fitness coaches, and sport coaches (9). Athlete adherence in injury prevention strategies and coach compliance have also been found to suffer due to poor communication (10). So how do we mitigate these findings? Start by speaking the same language. Common language creates a clearly agreed upon communication model, that helps avoid the natural tendency to speak indirectly and deferentially (6). Creating understanding of what is being communicated is also vital. Using the same language and terminology allows information to be disseminated consistently. This can effectively bridge the gap between all members to minimize communication failures and improve teamwork. This also keeps engagement high, sends a consistent message, and increases accountability (11). Once a common language has been established, the next step is to standardize lines of communication, which can occur in person or electronically. In person, we must simplify language, control emotions, listen ardently, and use feedback (5). Secondly, we must be consistent. Humans are creatures of habit so the more consistent we can be the better. Particularly with the multidisciplinary team, this involves setting meetings (weekly in my opinion) where all members are present, prepared, and actively involved. This way information can be communicated and understood more effectively. This also allows for opportunities to collaborate, ask questions, and use feedback to improve outcomes within the RTP process. In conjunction with in-person meetings, I suggest mandating meeting break downs via email. This is vital. Not only do meeting break downs maintain lines of communication with those not directly involved, it’s also a form of documentation that holds the multidisciplinary team accountable for their roles and responsibilities, an important element within the RTP decision-making process (12). Without this component, execution becomes an issue. Individualized care requires well-developed communication pathways between everyone involved. So, in order to avoid breakdowns and improve the RTP process, we need to create a common language and standardize lines of communication.

Integrated Multidisciplinary Team

The RTP process involves multiple disciplines. From Medical Doctors, Physical Therapists, Athletic Trainers (AT), and Chiropractors, to Sport Scientists, Strength & Conditioning Coaches (S&C), Nutritionists, and Sport Coaches (SC), there can be a lot of specialists involved (which is why we need to improve relationships and optimize communication first!). Although every situation is different, every discipline is valuable. Therefore, avoiding exclusivity and elitism of our role is imperative when it comes to athlete care (3). ATs, S&Cs, and SCs (for simplicity sake, I will reduce the members involved to these three) all bring a unique skill set to the table. So in order to optimize the RTP process, each member involved needs to understand and respect what each specialty brings to the table (trust me, I know this can be difficult). Since the RTP decision should be a decision shared between all members (I’ll dive into the shared-decision making model in a future post), we need to clearly define roles, responsibilities, and actions of each member. This was echoed in the 2016 consensus statement on return to sport from the first world congress in sport physical therapy, where they indicated that defining and outlining roles and responsibilities of the multidisciplinary team as an important part of progressing the athlete back to sport (12). So, without further ado:

• Athletic Trainer

  • Definition: multi-skilled health care professional who collaborates with physicians to provide preventative services, emergency care, clinical diagnoses, therapeutic intervention, and rehabilitation of injuries and medical conditions (3).

  • Role within RTP:

    • Collaborate and communicate with physicians, physical therapists, and all members of the multi-disciplinary team to administer rehabilitation guidelines for injured athletes.

    • Provide appropriate parameters in a progressive manner that prepares athlete for increased function through the RTP process (8).

• Strength & Conditioning Coach

  • Definition: certified coach who applies scientific knowledge to train athletes for the primary goal of improving athletic performance through the use of safe and effective strength training and conditioning programs (13).

  • Role within RTP:

    • Collaborate and communicate with all members of the multi-disciplinary team to assist in rehabilitation.

    • Maintain and/or restore long term athletic development qualities in a progressive manner that prepares athlete for a return to sport-specific participation, while reducing the potential for re-injury (8).

• Sport Coach

  • Definition: SCs provide the direction, instruction, and training of sport specific qualities, while providing the direction of a team or individual athlete (14).

  • Role within RTP:

    • Collaborate and communicate with all members of the multi-disciplinary team within the rehabilitation process to safely return injured athlete back to full participation.

    • Maintain and/or restore technical and tactical competitive performance functions (8).

Clearly defining roles and responsibilities of the multidisciplinary team creates an integrated model that allows each discipline to focus on what they’re good at, while allowing the athlete to benefit from everyone’s strengths (3). Other components to consider when building your multidisciplinary team includes having a shared vision and purpose. Success is highly dependent upon teamwork and having a consensus on goals and objectives (15). Creating a shared vision has also been shown to increase commitment, accountability, and transparency among healthcare professionals (16). Goal setting has also been indicated as an important element in guiding the RTP decision-making process (12). Therefore, creating a combined performance team that understands and respects everyone’s role, maximizes each members’ strengths, and works under a shared vision is important in advancing the athlete back to high function.

Closing

“Coming together is a beginning; keeping together is progress; working together is success”—Henry Ford. If we can’t work together effectively, we can’t instill a system that succeeds. The human factor is paramount and should be the first priority when establishing RTP guidelines. As you can see, returning an athlete back to high function has a lot of moving parts, and we haven’t even scratched the surface yet! In order to optimize this system for the welfare of the athlete, its starts with fostering quality relationships, establishing effective lines of communication, and outlining roles and responsibilities for the integrated multidisciplinary team. Stay tuned for Part 2 of the Return to Play Conundrum, where I will create a framework for success through adopting models to guide the RTP process.

Resources

(1) Liden, R. C., Wayne, S. J., & Sparrowe, R. T. (2000). An examination of the mediating role of psychological empowerment on the relations between the job, interpersonal relationships, and work outcomes. Journal of Applied Psychology,85(3), 407-416. doi:10.1037//0021-9010.85.3.407

(2) Bartholomew, B. (2017). Conscious Coaching: The Art and Science of Building Buy-In. Createspace Independent Publishing Platform.

(3) Falsone, S. (2018). Bridging the gap from rehab to performance.

(4) Almagro, Bartolomé & Buñuel, Pedro & Murcia, Juan. (2010). Prediction of Sport Adherence Through the Influence of Autonomy-Supportive Coaching Among Spanish Adolescent Athletes. Journal of sports science & medicine. 9. 8-14.

(5) Sethi, Deepa & Seth, Manisha. (2009). Interpersonal Communication: Lifeblood of an Organization. IUP Journal of Soft Skills. 3.

(6) Leonard, Michael & Graham, S & Bonacum, Doug. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe patient care. Quality and Safety in Health Care. 13. 185-190. 10.1136/qshc.2004.010033.

(7) Ardern, Clare & Taylor, Nicholas & Feller, Julian & Webster, Kate. (2012). A systematic review of the psychological factors associated with returning to sport following injury. British journal of sports medicine. 47. 10.1136/bjsports-2012-091203.

(8) Kraemer, William & Denegar, Craig & Flanagan, Shawn. (2009). Recovery From Injury in Sport: Considerations in the Transition From Medical Care to Performance Care. Sports health. 1. 392-5. 10.1177/1941738109343156.

(9) Ekstrand, Jan & Lundqvist, Daniel & Davison, Michael & D’Hooghe, Michel & Marte Pensgaard, Anne. (2018). Communication quality between the medical team and the head coach/manager is associated with injury burden and player availability in elite football clubs. British Journal of Sports Medicine. bjsports-2018. 10.1136/bjsports-2018-099411.

(10) Mccall, Alan & Dupont, Gregory & Ekstrand, Jan. (2016). Injury prevention strategies, coach compliance and player adherence of 33 of the UEFA Elite Club Injury Study teams: A survey of teams' head medical officers. British Journal of Sports Medicine. 50. BJSPORTS-2015. 10.1136/bjsports-2015-095259.

(11)  http://training-conditioning.com/content/better-together

(12) Ardern, Clare & Glasgow, Philip & Schneiders, Anthony & Witvrouw, Erik & Clarsen, Benjamin & Cools, Ann & Gojanovic, Boris & Griffin, Steffan & Khan, Karim & Moksnes, Håvard & Mutch, Stephen & Phillips, Nicola & Reurink, Gustaaf & Sadler, Robin & Silbernagel, Karin & Thorborg, Kristian & Wangensteen, Arnlaug & E Wilk, Kevin & Bizzini, Mario. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British journal of sports medicine. 50. 10.1136/bjsports-2016-096278.

(13) National Strength and Conditioning Association

(14) https://en.wikipedia.org/wiki/Coach_(sport)

(15) Yukelson, David. (1997). Principles of effective team building interventions in sport: A direct services approach at Penn State University. Journal of Applied Sport Psychology - J APPL SPORT PSYCHOL. 9. 73-96. 10.1080/10413209708415385.

(16)  https://nic24thnationalconf.pathable.com/static/attachments/106805/1412353682.pdf

Athlete Monitoring: Where to even begin

There are so many tools out there, so many companies, so many ways to monitor our athletes. Sometimes its hard to know where to even begin.

• First and most importantly all parties who will be involved need to be on the same page. Sport Coaches, Performance Staffs, Sports Medicine, Front Office or Administration staff. If these individuals are not bought in, the athletes never will be. This can be part of the cultural and budget piece to the puzzle as well.

• Secondly you need to know what your question is. What problem are you trying to answer?

  • How are athletes tolerating the loads being placed on them? – This is a wellness / fatigue / adaptation question

  • What are the specific demands for our style of play / our conference? – This is a training data question

• Third, who will be overseeing your monitoring processes, the data, and giving their professional advice on what the information is telling you.

• For the amount of money you have to spend, you then need to decide is the money better spent on wearable technology that you may not have or personnel that you may not have.

Our money is always on personnel.

Human Performance: Learning from Others and Breaking the Rules

One of the best professional lessons I have learned as a sports performance professional is how much we gain from those people who work outside of our chosen field. I find it sparks creativity for me and challenges me to “up my professionalism game”.

Several years ago, my boss/colleague/dear friend, Brad and I were sitting around the dinner table, sharing beers and talking shop with my relator. As the conversation continued about hopes and dreams for where Brad and I wanted to take our athletic department, we couldn’t articulate our mission and vision. So, sitting around a table together, with guidance from my relator, we sketched out the first mission statement for our department. This small act was GAME CHANGING for us.

Once we developed the department’s mission and vision, we had a roadmap to work from. Now, we were able to clearly identify what questions had “yes” answers and which had “no” answers. With a clearer mission, our growth as individuals, professionals and as a department expanded in so many directions.  All because we were open and receptive to learning from professionals outside of our field, the work happening within the walls we controlled skyrocketed. My relator had little to no experience in “my world” and I had none in his, but he was very successful in his chosen field, and I knew I needed to listen to what he had to say.

Brad recently passed this article from Harvard Business Review on to me (side note: when you find those people in your life who push you, support you, and walk next to you in your pursuit of growth – never let them go). It is a quick read about the willingness to be vulnerable and thus keeping the competitive edge. In the e-mail Brad sent me with this article attached, he wrote nothing other than a quote from the last line in the article: “When growth becomes the goal of everyone in the organization, complacency doesn't have time to take root and radical ideas can emerge time and time again.”

Take the 3 minutes to give this a read. Be willing to break tradition. In my opinion, one of the most dangerous statements is “because this is how we have always done it.” It’s a dream killer.

Trim the fat, improve your global human performance

A few months back I finished one of the best books I have read in a long time – “Peak Performance” by Brad Stulberg and Steve Magness. One of my big takeaways was how important it is to reduce the amount of decisions we have to make each day to allow for more brain space availability for the bigger, harder decisions. If I am spending little amounts of effort on small things, such as “What I am going to wear today?” “What are my kids are going to wear today?” (no they are not old enough to dress themselves yet), “What I am going to have for breakfast or lunch?”, I am wasting “decision-making capital.” There is a fair amount of research on this topic of “trimming the fat” when it comes to wasted brain power to improve your productivity and performance on the things that matter most. 

Another area I find particularly important – yet at times incredibly difficult – is to “trim the fat” when it comes to your relationships. Just as wasted decision-making capital impacts your productivity, being surrounded by negative people drains your “emotional savings account” and overall health. A recent New York Times article “The Power of Positive People” cites research that health behaviors appear to be contagious and that our social networks can influence obesity, anxiety, and overall happiness. Dan Buettner, a National Geographic fellow and author who has studied health habits of people is quoted saying “friends can exert a measurable and ongoing influence on your health and behaviors in a way that a diet never can.”  

As a coach, a parent, and a team leader, your actions speak volumes and influence those around you. As a parent and a coach myself, I know that everyday I will face decisions that need my full attention and it is my responsibility to ensure that I am in a mental space ready to make them.  By making the decision to eliminate the possibility that my cabinets are filled with junk food, I immediately “trim the fat” on wasting decision-making capital: who wants to spend precious brain energy making the decision to not eat the chips? It is much easier for me to simply NOT buy cookies and chips and instead buy fresh fruit and vegetables. As a parent and a coach, I am in a position of leadership and my actions will be contagious to those around me, my children and my athletes.

Several years ago I was working with a team on basic sports nutrition habits, and during my conversation with the sport coaching staff I suggested they themselves needed to make better decisions if they wanted their team to eat with a performance mindset. I was both shocked and not at all surprised when the response was “Oh, the team pays no attention to what we eat.” If we want our children and athletes to make good decisions and to show up to practice or the classroom prepared we ourselves need to be living this life. My 2 yr old is not going to eat roasted beets if I am eating ice cream; your 14+yr old is not going to go to employ a “training mindset” as a lifestyle if you do not. 

Trim the fat from your decisions and your negative relationships; once we gain the recognition that our actions are contagious in the lives of others, we are better positioned for to reach optimal performance, health and overall quality of life. 

Looking at the Big Picture to Improve Athletic Performance: The 24-Hour Athlete and the Human Eco-System.

Stress: we all have it. And we all know it affects us. How do we as athletes control certain areas of our lives so that we can positively impact an athlete’s performance? Exploring the 24-hour athlete and our human ecosystem will help us understand. 

Stress has really been around forever. But it was Hans Selye who discovered the fight-or-flightresponse as part of the general adaptation syndrome in 1936 (14) and defined two different types of stress, eustress (the good stress) and distress (the bad stress). 

Our body doesn’t really care if it is positivestress or negativestress, the fight-or-flight alarm is sounded and cortisol, a hormone is released. Eustress creates a positive feeling and a heightened state of arousal (think: “it’s game time, baby.) This is that moment in time where you pop out of bed and you take on the world. Everything you do comes out awesome. You can’t miss a shot. You feel like you could run a marathon or two, and then discover the cure for cancer, all before breakfast. Eustress happens after a period of training, and then restoration, where your body feels ready. 

In “distress,” quite the opposite happens. You’re tired, distracted, your heart might be racing, and you might be experiencing pain. Distress happens when we’re intensely training, not sleeping or eating properly, or dealing with emotional distress—or a combination of all of the above.  

Understanding the 24-hour athlete concept can help us learn how we can encourage eustress, discourage distress and keep cortisol levels where they should be to positively affect human performance. 

WHAT IS CORTISOL?

Cortisol is a naturally occurring steroid hormone made in the adrenal glands and secreted by the hypothalamus, the pituitary gland, and the adrenal gland. (1) Cortisol is secreted in response to physical, psychological, or physiological stressors. (13) When we experience fear (like watching a horror movie!) or experience stress (like crunching all night on a project), cortisol is released as part of the fight-or-flight mechanism. (14)

Most cells in the body have cortisol receptors, so needless to say, cortisol is kind of a big deal. 

Cortisol, typically known as “the stress hormone” does have many positive functions, despite its nickname. (2,3) Cortisol:

·     Accelerates the breakdown of proteins into amino acids. As a result, plasma glucose levels are raised, and the body is given the energy it requires to combat stress from trauma, illness, fright, infection, mental stress, and more

·     Can help maintain blood sugar levels

·     Regulates metabolism and body temperature 

·     Reduces inflammation

·     Has a controlling effect on electrolyte and water balance

·     Assists in controlling blood pressure

·     Supports the developing fetus during pregnancy

·     Impacts immune response

·     Modifies mood and behavior, as well as perception of pain

But like all things, too much of a good thing can be a bad thing. Cortisol in excess leads to catabolic reactions, which negatively affect us. Too much Cortisol can:

·     Increase blood pressure (1, 2, 4)

·     Impact metabolic disorders such as developing insulin resistance, dyslipidemis, hypertension, and obesity (2, 4)

·     Increase retention of water and sodium (4) 

·     Result in abnormal bone regeneration and collagen synthesis or calcium deficiency (4). 

·     Increase the risk for depression, mental illness, and a lower life expectancy (14) 

NUTRITIONAL IMPACT ON RECOVERY AND CORTISOL 

For the most part, our nutritional impact is 100% in our control. And we can use nutrition as one way to control the overproduction of cortisol. There are certainly times when “fed is best,” which means eat something over nothing (yes, even if it’s fast food.) But for the most part, and you have the time AND the choice, if you can catch it, grow it, or kill it you can eat it. If you have to read a food label, it is not food, you have never seen a food label on carrots have you? 

Processed foods do nothing for us except fill a hunger void in the short term, and in the long term, processed foods are stress-inducing and increase cortisol levels. 

The Western diet is characterized by whatever is “fast and easy,” which leads to an overconsumption of the bad stuff coupled with reduced variety. We over consume everything from refined sugars and salts to saturated fats. (7) Too much of all this processed crap leads to increased inflammation, a reduction in the control of infection, a weakened immune system, and an increased risk for allergic and auto-inflammatory disease. (7) On the flip side, the complex carbohydrates found in fruits and vegetables reduce inflammation. 

So how can you reduce your intake of packaged food? Shop at local farmers markets, which promotes eating what is in season. You’ll also increase your variety, increase your ability to buy grass fed meats, and limit the availability of purchased foods. If you can’t get to the farmer’s market, simply shop the edges of your grocery store, which is where you find the least processed food.

Hereis a great article that discusses nutritional sports nutrition strategies for balancing cortisol and stress.  

THE IMPORTANCE OF SLEEP ON RECOVERY AND OVERALL HEALTH AND PERFORMANCE

We have all heard the wisdom that everyone needs six to eight hours of sleep to function at their best. It’s actually true. Sleep, or the lack thereof greatly impacts cortisol levels, and ultimately athletic performance. A lack of sleep:

·     (Or less than six hours of sleep a night) is shown to put a person at greater risk for developing illness  (8, 10)

·     (Or less than six hours of sleep a night)  increases our potential for autonomic nervous system imbalance, which stimulates symptoms of overtraining syndrome (11) 

·     (Or less than eight hours of sleep a night) increases their risk of injury by up to 1.7% (11)

·     Decreases cognitive performance, alertness, reaction time, memory, and decision making (11)

·     Leads to the possible promotion of pro-inflammatory cytokines, which could promote immune system dysfunction (11) 

·     Prevents making new memories (8)

·     Increases our production of beta amyloid, a protein that is associated with Alzheimer’s (8)

·     Decreases reproductive system function (8)

·     Negatively impacts our cardiovascular system, resulting in up to a 200% increased risk of having a fatal heart attack, or stroke in your lifetime (8)  

For all of you caffeine-loving night owls, we know what you’re thinking! What about sleep excess? Relatively little work has been done on the research of sleep excess. The study by Mah et all was one of the pivotal studies emphasizing sleep as a secret and legal “performance enhancer.”  

The team followed a 2-4 week habitual sleep-wake schedule to establish a base line, and then a 5-7 week sleep extension period was implemented where the minimum goal was 10 hours in bed each night. The players were measured on sport specific measurements after every practice. Reaction time, levels of daytime sleepiness, and mood were also monitored.  Players showed faster sprint times, improved shooting accuracy, improved reaction time, and self reported ratings of physical and mental well-being during practice and games also improved. And they were able to achieve it all just by getting some more zzzz’s.

Two notable teams, the Seattle Seahawks and the Chicago Cubs winning the Super bowl in 2014 and the World Series in 2016 respectively have utilized a company Fatigue Science to better understand their players levels of fatigue for a performance edge.  

Sleep may not always be in our control. (Sometimes, no matter how hard you try, you just cannot sleep!) There are some simple things you can do to create good sleep habits, which will improve your sleeping, which will control your cortisol levels. Click hereto read more.

EXERCISE AND TRAINING IMPACT / The Importance of Appropriate Programming for Both Team Practice as well as Outside Training 

One of the main problems in sports performance as it relates to both teams and individuals is poor programming and periodization. We simply cannot have hard day after hard day nor can we have moderately hard, hard, moderately hard, hard, so on and so forth week in and week out. Can we sustain either of these patterns for any certain amount of time? Maybe. But the damage done is far more of a concern.  Cortisol increases with moderate to high intensity exercise, Hill et al defines moderate to high intensity exercise as 60% of VOs max or greater. (13) When looking to compare heart rate percentages to its equivalent in VO2 max refer to thisdocument. For now, 60% of VO2 Max is closely associated with a heart rate of 75% of your max heart rate. If your heart rate max is 195bpm for example, you can expect to have elevated levels of cortisol from completing a training session at a heart rate of 146bpm or greater. Duration is also important. Most of the research found for this article was 30 minutes or longer. One important fact to remember is that low intensity exercise (40% VO2 Max) has been shown to reduce the amount of circulating cortisol levels. (13) Low restorative days are incredibly important. 

When it comes to training, everything we do has a physiological cost—whether it’s your walk-through practices, your hard, small sided games, or 1 v 1 work, your hard sessions in the weight room or out on the field conditioning. It all has an impact. Some of it is restorative and some of it is very taxing. We need both, the really taxing work followed by the truly restorative work to see and reap benefits. 

That’s why it’s SO important to make sure you are looking at the total picture. Your weight coaches, head coaches, trainers, sports performance teams, and nutritionists should all be working together to create a plan that works for you as an athlete, or your team (if you are a coach).  

EMOTIONAL STRESS

A fight with your significant other, a terrible roommate situation, financial stress, academic stress, and other events that cause fear or other emotional stressors cause the adrenal glands to release cortisol in the name of fight-or-flight. 

Remember eustress (the good stress we talked about in the beginning) creates this positive “its game time baby!” feeling and a heightened state of arousal. Cortisol levels return to normal upon completion.  

Distress (the negative stress we talked about in the beginning and throughout the article) without the opportunity to flush cortisol levels results in a build up in the blood and wreaks havoc on our minds and our bodies (14). 

We can’t always control our emotional stress. But we can limit our exposure to things that stress us out. For example, find a good group of friends who lift you up. Avoid dramatic people and situations at all costs. Find a way to let little stuff go. And if you cannot, seek help from a professional. 

CONCLUSION

Look at the total picture: that is the essence of the 24-hour athlete/human eco system. Think about the things happening in your life that relate to your cortisol levels. Choose to control the things that you can control. Here are the things you can control, which in turn can keep your cortisol levels in check:

1.    Your nutrition. Avoid packaged, processed foods. Stick to vegetables and produce you can buy locally.

2.    Your sleep. Develop healthy sleep habits. Aim to get 6-8 hours per night or more.

3.    Training. Don’t go hard ALL the time. Work with your coaches and team to build in recovery and restorative days.

4.    Emotions. Surround yourself with people who want what’s best for you—and support you. Find outlets and ways to let go of the little things. If you can’t do that easily, seek help from a professional who can help give you the skills. 

References: 

1) https://www.hormone.org/hormones-and-health/hormones/cortisol

2) https://www.precisionnutrition.com/all-about-cortisol

3) https://www.irunfar.com/2017/12/painting-bridges-chemical-stress-in-a-running-injury.html

4) https://link.springer.com/article/10.1007/s00217-016-2772-3

5)http://main.poliquingroup.com/ArticlesMultimedia/Articles/Article/1237/Avoid_These_10_Foods_That_Increase_Cortisol_Impede.aspx

6) Stress and Eating Behaviors. Yvonne H.C. Yau and Marc N. Potenza. Minerva Endocrinol. 2013 Sep; 38(3): 255-267

7) Fast food fever: reviewing the impacts of the Western diet on immunity. Ian A Myles. Nutrition Journal 2014 13:61 

8) https://www.sleepdiplomat.com/speaker

9) The eEffects of Sleep Extension on the Athletic Performance of Collegiate Basketball Players. Cheri D. Mah et al.  July 2011

10) Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Prather et al.  September 2015 

11) Recovery for Performance in Sport, Chapter 4 Managing Active Recovery, Yann Le Meur, Christophe Hausswirth 

13) Exercise and Circulating cortisol levels: the intensity threshold effect.  Hill EE, Zack E, Battaglini C, Viru M, Viru A, Hackney AC. J Endocrinol Invest. 2008 Jul; 31 (7): 587-91 

14)https://www.psychologytoday.com/us/blog/the-athletes-way/201301/cortisol-why-the-stress-hormone-is-public-enemy-no-1