BRINGING SCIENCE TO TREATMENT

Listen up! Athlete voices in injury rehabilitation

Sports injury research typically focuses on objective, anonymous outcomes to remove the subjectivity of human ‘error.’ However, what if the ‘error’ is removing the human element that is the athlete? Jason Tee explores listening to the athlete’s voice to improve outcomes and avoid the pitfalls of a one-size-fits-all approach.

New York Yankees center fielder Aaron Judge is interviewed during All-Star-Batting Practice at Dodger Stadium. Mandatory Credit: Jayne Kamin-Oncea-USA TODAY Sports

For too long, sports and injury rehabilitation research has focused on the clinical rather than the contextual. Scientific research searches for specific, objectively measurable outcomes to injury prevention and rehabilitation challenges. It aims to provide clear recommendations to all athletes and practitioners regarding these. But this goal is rarely fulfilled.

In his book The End of Average, Todd Rose explains the problem of applying generalized findings to any particular individual. He relates the story of how in the 1950s, the United States Air Force tried to improve their cockpit design by measuring the average dimensions of 4000 different pilots. The standardized cockpit they produced was a terrible fit for most pilots because fewer than 3% were average in all their dimensions. This demonstrates that we should always be wary of one-size-fits-all recommendations in any area of life, including injury prevention and rehabilitation.

An example from the sports injury prevention space is the problem presented by ACL reconstruction injuries. Complete ACL ruptures are relatively common injuries in team sports, where approximately 1 in every 100 athletes will suffer an ACL rupture(1). In any given year, this results in approximately 250 000 ACL ruptures across the USA. The sports medicine fraternity has established very clear clinical guidelines for rehabilitating ACL rupture injuries(2). However, despite this clear understanding of how to rehabilitate athletes following reconstructive surgery, return to sport outcomes are rather poor. The ACL rehabilitation process takes 12 months in most cases, but less than 30% of patients complete evidence-based rehabilitation beyond six months, and fewer than 5% fully complete the rehabilitation process(3). As a result, only about half of all ACL reconstruction candidates return to their pre-injury level of competition. There has been no shortage of research effort poured into establishing effective practices for ACL repair and rehabilitation, so why are rehabilitation outcomes so poor? Could it be that injury researchers have been focusing on the wrong outcomes?

Recently there has been a shift in the research approach in the sports injury prevention and rehabilitation space, where researchers have begun to embrace qualitative research methods(4). Qualitative research foregoes the traditional approach of precise, repeatable measurement of specific phenomena and instead tries to understand why these phenomena occur through the use of direct observation, interviews, and questionnaires. Part one of the Athlete Voices series described some of the recent findings from qualitative research.

Part two will focus on what qualitative research tells us about the experience of ACL rehabilitation patients and provides good lessons for where we can improve the rehabilitation process. Researchers at Bond University in Australia conducted a study to investigate the viewpoints of patients regarding the barriers and facilitators of ACL reconstruction rehabilitation(5). Here is what we can learn from their experiences.

Psychological Barriers

Expectations

The interviewed participants indicated that they understood the length of the rehabilitation process (12 months). However, the participants were not prepared for the ongoing pain and the difficulty of completing the rehabilitation plan. Most participants felt they would have benefitted from a discussion before surgery to manage these expectations.

Kinesiophobia

Most participants feared reinjury, but exposure to sport-specific movements like jumping and changing direction during rehabilitation reduced their fear.

Loss of motivation

Most participants reported a loss of motivation during the middle stages of the long rehabilitation process. However, providing athletes with milestones and achievable short and medium-term goals avoided this.

Figure 1: The five organizing themes that influence the patient’s rehabilitation journey from injury to return to sport(5)

Physiological barriers

Age
Older individuals find it slower and harder to recover from surgery but are also occasionally patronized by rehabilitation staff, who assume that retirement is the natural response for this subgroup. It would be better to ask the clients about their rehabilitation goals and support them in achieving those rather than assuming the older athlete is ready to hang up their boots.

Weight gain

Weight gain as a result of reduced activity levels can hinder rehabilitation and delay return to performance. Clinicians can support athletes through nutritional advice and information regarding alternative exercise modes.

Pain

Pain doesn’t subside after the early weeks of recovery, and patients need assistance managing pain throughout rehab.

Access to rehabilitation service

Initial service delivery

An initial misdiagnosis often delays access to rehabilitation services. In addition, although highly beneficial, few patients were offered the option of prehabilitation services before surgery.

Access

Patients find it difficult to find time to travel to and attend rehabilitation sessions, particularly when unable to drive post-op. Rehabilitation professionals should consider alternative operating hours to support working athletes and explore options such as telehealth conversations to increase the session’s convenience.

Duration of service

Rehabilitation session costs are often prohibitive leading to athletes quitting within the intimal six months. Instead, practitioners should consider providing cost-saving options such as group classes and telehealth consultations.

Exercise prescription and provision

In most cases, rehabilitation professionals prescribed exercise training for athletes to do independently/at home. A major barrier is rehabilitation professionals providing unclear or overly technical instructions. In addition, exercise prescription was often insufficient in the end stages of rehabilitation to support the return to sport. Providing clear explanations for exercises and the underpinning reasoning for the selection of those exercises were highly valued by patients. Athletes undergoing rehabilitation also highly recommended the use of training applications to support exercise prescription. Another important factor was for the rehab professional to consider individual circumstances such as training experience, access to equipment, and work and family commitments when prescribing training.

Interpersonal interactions

A good athlete-clinician relationship supports successful rehabilitation. The surgeon is key to this, with participants reporting that positive, motivating, and supporting interactions with the surgeon enable rehabilitation. In addition, family, coaching staff, and teammate support significantly improve rehabilitation outcomes. As rehabilitation professionals, it is useful to emphasize the importance of this social support to athletes and encourage them to develop active support networks.

Summary

The qualitative research highlighted in this article illuminates several areas where barriers to successfully completing a rehabilitation program can easily be addressed and overcome. Ironically, aside from issues related to access, most of the barriers discussed have little to do with practitioner skills or knowledge and are mainly relational. Clinicians can overcome most of these barriers by anticipating or discovering the athlete’s needs through conversation. Athletes are not robots that need to be programmed; they are humans with genuine wants and needs. The role of rehabilitation practitioners is more than just providing a rehabilitation plan; the role is to facilitate the plan by navigating the real-world problems that our athletes experience in a constructive partnership with them!

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Getting patients to talk

Getting athletes to talk is a predictor of rehabilitation outcomes. A clinician’s ability to harness the power of an athlete’s voice to understand better and inform the support they give athletes will determine rehabilitation outcomes. Open and honest communication may not come naturally in a rehabilitation setting. Clinicians must remember that when athletes commence rehabilitation, they have experienced injury trauma and lost their ability to participate in their sport. They are propelled into what is often an unfamiliar environment and may not have established relationships with their rehabilitation support team. Is it any wonder that rehabilitation athletes are generally closed to discussing their needs? Clinicians need to get athletes to open up about their experiences through proactive approaches that break down communication barriers.

Create space

Rehabilitation sessions are work, and when athletes arrive for these sessions, there are things that need to get done. The quality of conversation between sets and reps is low. Schedule 15 minutes before the start of the session to ensure that athletes have time to communicate with you unrushed and you have time to listen actively.

Mirror

Mirroring is when one person imitates the verbal or nonverbal behaviors of another. When being mirrored, most people begin to feel a greater sense of connection and understanding from the person mirroring them and, as a result, are more confident to open up and share. The easiest way to achieve this is to actively listen and focus on the most important words or phrases a person uses and repeat them back to them.

Rehab professional: “How have the at-home exercises been going?”

Rehab client: “I dunno; I never know if I’m doing them right.”

Rehab professional: “You say you’re uncertain whether you’re doing them right?”

Rehab client: Further, more detailed explanation…

Mirroring encourages patients to share more because they feel accepted, understood, and listened to.

Label

Labeling is a technique designed to let the other person in a conversation know that their feelings are understood. It helps to build relationships, gather information, and establish trust. In practice, clinicians try to determine the client’s emotion and name it with an accurate label. For example, “It seems like you are feeling overwhelmed by the rehabilitation program.” In response, the client will either agree with the label and elaborate or disagree and provide a more accurate label. In either case, the client feels a sense of empathy and increased comfort due to being heard and understood

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References

  1. Orthop J Sports Med.2018 Jun; 6(6): 2325967118777823.
  2. Sports Med. 2004;34(4):269-80.
  3. Knee Surg Sports Traumatol Arthrosc.2018 Aug;26(8):2353-2361.
  4. J Sci Med Sport. 2020 Oct;23(10):898-901.
  5. BMC Sports Sci Med Rehabil. 2022 Jun 15;14(1):106.
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