Return To Play Protocol: What an RTP Protocol Could Look Like For You

It’s easy to assume that once you’re symptom free you’re back to 100%, when really, this is a result of desensitizing the tissue irritation or stimulant. We have control of the what, the whycan still be an issue, particularly when integrating it back into a moving system. This is the same as if you replace a transmission in your vehicle, when the transmission is replaced, some important criteria should be met before using it to take your family on a trip. Same thing for your body, we have to restore function in isolation, then integrate it back into the system as a whole. We must hit milestones of movement competency, but before we do that, we must create a criteria for discharge from an active state of care that is specific to your body. Therefore, we can say for certain that we’ve not only restored function and decreased irritation to tissue, but we can say confidently that we’ve reduced your chances of acquiring the same injury or a new injury down the road. In essence, we’re treating you as a person and not as a body part. This is what makes us different. Significantly different. To understand this better, let’s dive into what the biggest predictors of an injury are, systems we use to establish our milestones, and the criteria for being discharged from active care.

Predicting an injury, which by our definition, that which is most likely to be the underlying cause of an injury. Research states that the top 4 predictors of injury are:

1. Previous injury

2. Asymmetry

3. Motor Control

4. BMI (high and low)

   What we know about an injury to the human body, is that it alters our entire

musculoskeletal system up and down the chain. An example of this is an ankle sprain. When this occurs, that entire limb is used completely different, limiting joint range of motion and, therefore, less strain on irritated tissues. In other words, you hobble. It’s inherent and it is what has protected us since the beginning of time. With this, muscle activation is lessened in prime movers, coordination of mobility is reduced, sequencing of muscle firing is altered, this in a short amount of time is used for protection; but if this is adopted as a new means of locomotion, you create dysfunction. Asymmetry is the 2nd most common cause of injury, this is left to right differences. When mobility or stability is altered on one side when compared to the other, this requires other joints/tissues to accept or handle more of a load or compensate by exploiting a range of motion that shouldn’t be used in the manner it is. The 3rd is motor control, which is the ability to stabilize segments that need to be stabilized, move regions of the body with prime movers, strength, and flexibility; integrating all of these components to perform movement. With the systems we have in place, we’re able to quantify and screen, test, and assess all of these components of movement.

How do we determine and set milestones for patients discharging from active care? There are a few biomarkers that form clinical guidelines that lead to the discharge of active care, such as, no pain with the provocative movements, outcome assessments, and orthopedic exams. The only problem associated with these set criteria is that it is subjective, it’s everything the patient is telling the doctor. It’s a great win when a patient comes in and states that they can now run for 3 miles when originally they weren’t able to without having pain. But more importantly, we need to know if regional movement and, therefore, global movement has changed, objectively. This is why we’ve established systems that quantify movement and can be looked at objectively. This also allows us to compare these numbers with what is in the literature to establish risk of injury. The first of these systems is called Functional Movement Screen (FMS), this has a 0 to 3 scoring on 7 basic movements to make a perfect score of 21; this determines movement literacy in fundamental patterns. The second system used to create a criteria to be dismissed from care is the Y-Balance Test, which tests motor control of left and right arm and leg. As you can see on figure 1, we start from the ground up approach which is if someone presents with pain we administer the Selective Functional Movement Assessment (SFMA) and progress to the FMS and Y-Balance Test.

Figure 1: Systems in a ground up perspective

There is extensive research behind the FMS and the Y-Balance test and predicting the likelihood of an injury occurring. This also establishes a baseline of your movement patterns and whether or not they have been disturbed from previous injury. Research has shown that having a low score in the FMS can be predictive of injury in football players, female collegiate athletes, military personnel and firefighters (<14/21). Research supports the Y-Balance test in allowing us a window into predicting whether an athlete is going to miss time from sport or whether a patient has not been fully rehabilitated. In a study that looked at female basketball players, those who had an asymmetry on the anterior lower quarter reach test, were 2.5x’s more likely to have an injury occur, and those who scored in the lower third of their peers were 6x’s more likely to have an injury (figure 2). Furthermore, in a study that was done on football player’s, those who have a composite score on the Y-Balance Test less than 89% (their scores in relation to their lower limb length), were much more likely to have an injury occur. What we’ve discovered is that programs that improve Y-Balance Test score actually had a reduced risk of injury.

Figure 2: Anterior lower quarter reach test

Based on these values and research presented, we have concluded that a discharge from active care can’t occur until we have met the respected criteria acquired through research (figure 4). Pain lies and is not a good biomarker for health, this is why we have created an objective measurement that relies more on what your movement tells us, rather than subjective measurements. Below you will see a detailed path of rehabilitation when discharge from active care is warranted. Criteria created from combining the FMS and Y-Balance Test will be determined on normative data acquired from generalization, sport, profession, or activity.

Figure 3: Return to Play Protocol Structure

By creating this model, we can safely say, based off of current research that we will not only reduce your musculoskeletal pain, but we will assess your risk of future injury and develop a program that decreases your chances of acquiring either the same injury or a new one. In figure 3, you will see our Return to Play Protocol track, which creates a structured timeline of testing and retesting, and exactly what test will be done.

Figure 4: Discharge criteria from active care

References:

1. Kiesel, Kyle B., et al. “Prediction of Injury by Limited and Asymmetrical Fundamental Movement Patterns in American Football Players.” Journal of Sport Rehabilitation, vol. 23, no. 2, 2014, pp. 88–94., doi:10.1123/jsr.2012-0130.

2. Hewett, T E. “A Review of Electromyographic Activation Levels, Timing Differences, and Increased Anterior Cruciate Ligament Injury Incidence in Female Athletes.” British Journal of Sports Medicine, vol. 39, no. 6, 2005, pp. 347–350., doi:10.1136/bjsm.2005.018572.

3. Lehr, M. E., et al. “Field-Expedient Screening and Injury Risk Algorithm Categories as Predictors of Noncontact Lower Extremity Injury.” Scandinavian Journal of Medicine & Science in Sports, vol. 23, no. 4, 2013, doi:10.1111/sms.12062.

4. Chorba, Rita S, et al. “Use of a Functional Movement Screening Tool to Determine Injury Risk in Female Collegiate Athletes.” North American Journal of Sports Physical Therapy, 5 June 2010, pp. 47–53.