You’re not steering this ship alone, but you’re also not being blindly driven through this process either! Too often we hear stories of a surgeon, clinician, or coach being the sole barrier to an athlete having a say in returning to the sport or activity that they love! A true shared decision-making process can include many stakeholders, but most importantly, it should include you, the one actually going through the rehab process! Dingenen et al. proposes the picture below as a visual representation of the return to sport process as a whole! For now, we’re zooming in on the “Shared decision-making process” and emphasizing, SHARED!
According to Professor and Researcher, Ronald Howard, “A high quality decision refers to a decision that is logical and made based on the uncertainties, values, and preferences of the decision-maker. A high-quality decision doesn’t always warrant a good outcome.”
We as coaches and clinicians have to respect the idea that every person’s ACL rehab journey is unique and there’s a possibility that the rewards outweigh the possible risks for some. We understand that sometimes these return to play timelines can sound arbitrary. It’s up to us as coaches and clinicians to do our best to set expectations and use all of the information we have at hand to do our best to guide the decision for you, the athlete. Now, saying that, I still highly recommend these guidelines to optimize your return to sport process. We all just need to understand that unique situations can arise (i.e. the risk isn’t too high and you really want to take this hiking trip, or it’s your last few games as a collegiate athlete) and we need to hedge and allow the person to make that decision for themselves, assuming we have a model or models to assist in that decision making process.
Speaking of models…there are lots of models and theories out there to help guide the art of decision making. A balanced model can allow us to zoom out and decrease the chances of our biases showing through (as much as possible). One such model, mentioned in Yung et al. “A Framework for Clinicians to Improve the Decision-Making Process in Return to Sport” is pictured below as an example:
To give more context:
- Alternatives – Relates to the options that a decision maker has. In the context of return to sport after injury, this could be laying out all of the options an athlete has (return to practice, modify rehab, return to modified game minutes, or take on more risk because of special circumstances…maybe that hiking trip sounds a little early, but it’s really important to you and you understand that your knee may be a little angry afterward)
- Information – Refers to the knowledge the decision-maker has to formulate an outcome. For example, what information do these return to sport tests or your rehab process so far give us?
- The Decision – On what basis will the decision be made?
- The Preferences – The preferences of the main stakeholder (the individual going through rehab!). How important are the upcoming activities to them, what is their risk preference here? Hopefully the person going through rehab has had some autonomy leading up to these decisions, otherwise it may seem like a shock all at once.
We understand that not only can it be frustrating having to compromise and miss out on activities that are important to you, but it can also be scary having to make decisions when returning to these same activities. I’m sure it would help to start the process of feeling empowered early on in your recovery! Bedside manner isn’t just for surgeons. Whether your rehab process is being guided by a coach/clinician remotely or in-person, it doesn’t change the fact that if we want you to feel empowered to assist in decision making. We need to give you the information to feel competent, we need to communicate with each other to form a relatedness about the rehab process, and we need to provide an environment where autonomy is a constant, without feeling lost of course.
Remember, this is YOUR rehab process, and YOU get a say in how and where we steer the ship.
Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47(8):1487-1500.
Yung K, Ardern C, Serpiello F, Robertson S. A Framework for Clinicians to Improve the Decision-Making Process in Return to Sport. Sports Med Open. 2022 April 13; 8(1): 52. Doi 10.1186. PMID: 35416633