Can a return to sport checklist improve compliance and outcomes?

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I was performing an initial evaluation on a complex patient. Her history included a lateral ankle reconstruction five years ago with recurrent ankle instability and an ACL reconstruction 10 years prior.  Over the past couple of years her knee and ankle instability worsened so much that she couldn’t play basketball at home with her kids. She opted to have both her ankle and ACL reconstructed again.

Picture by Elvis Kennedy Double Rainbow in Door County

Picture by Elvis Kennedy – Double Rainbow in Door County

At the time of her evaluation, I had recently changed my approach to goal setting and discharge criteria. I was taught in PT school to be sure to get the patient’s goals (in this case, to be able to play basketball). But what I wasn’t doing was clearly describing and getting the patient to “sign off” on the goals that I had for her (for both return to sport and discharge…and those may be different). So I went through my discharge checklist with her. Since she was no stranger to rehab, most of the first part  of the checklist made sense (normal range of motion, good strength, etc).

But when I got to the Y Balance Test she asked, “What is that?”

YES! An opportunity to talk about my favorite subject! I started to describe it verbally but decided it would be best if I just stood up and showed her. As I was doing the posterolateral reach, she stopped me. “I have never been able to do that after my previous surgeries! Do you really think I will actually be able to do that?”

“Yes, you will able to that and more! I will have utterly failed you if you can’t do this by the end rehab.”

This interaction taught me 4 important lessons:

1.  Clearly articulate discharge criteria on the first day
Think of it this way, if a mother brings her teenage daughter in after ACL reconstruction, both are highly motivated to avoid a future occurrence of this type of physical and emotional pain, not to mention the financial burden. Unfortunately, much like pregnancy and childbirth (from what I have heard!), the passage of time dulls the memory of the pain encountered. Signing off on clear, objective return to play and discharge criteria at the start, minimizes the negotiating when they “feel and look ready to play.”

2.  Avoid the perception of “Bait and Switch”
If the discharge criteria is not articulated clearly up front, it can feel a bit like you just want to keep the patient around for your financial gain. The surgeon told her she would be back to sports in 4-6 months. When that time rolls around, questions naturally crop up about going back to sport. If you begin defining the criteria at this point, it feels as if you just moved the finish line on her and this is incredibly frustrating. If I talk about the return to sport criteria early, it also gives me the opportunity to discuss the 4-6 month time frame that was introduced by the surgeon. I clarify that it means no earlier than 4-6 months and discuss the importance of  passing all of the return to play criteria on the checklist.

3.  People are highly motivated if they know they are going to be tested
Do you remember when you were given reading assignments in college? Did you do the reading? Even with the best intentions and interest in completing the assignment,  more urgent tasks commonly take priority. I only did the reading if I knew that there would be a specific quiz over it. Patients are very similar. A well placed return to sport and discharge checklist can tap into a patient’s motivation.  Objective physical testing criteria encourages compliance and accountability all around.

4.  We can give hope
Patients sometimes lack perspective regarding recovery goals and we need to provide specifics regarding their realistic potential.  Can you imagine a patient not being able to perform the posterolateral reach of the Y Balance Test after an ACL reconstruction? Obviously this patient didn’t know it was possible (or that she should be able to do it). We may take our knowledge about recovery for granted. Many patients carry fears about the future or think their pain and disability is permanent.  Conveying clear expectations for the recovery of function can not only boost compliance for the effort required, but also bolsters the hope patients can have for returning to the activities that matter to them.

How do you think using a return to sport and discharge checklist early in rehabilitation could impact the people in our care?

 

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2 Comments:

  • By Scott A. Jones 03 Mar 2016

    Thanks for posting this, Phil.
    This is the very heart of the patient-clinician relationship, and has everything to do with motivation. I also see this as being very similar to organizational development, in that once the team fundamentally understands the process and why it is important, there is much greater personal buy-in and motivation to achieve the clearly defined goal. Giving someone who needs your help a goal with no map is hardly a recipe for motivation. You didn’t just show her the destination, you gave her a detailed map of how she can get there. I don’t take nearly enough time to do this on a daily basis.

  • By Kyle Matsel 17 Jul 2016

    Great post Dr. Plisky!!!!
    The rehabilitative process can sometimes feel like an endless road and patients have trouble seeing the light at the end of the tunnel. This is especially true for an ACL reconstruction. Setting clear discharge goals provides the patient with a way to monitor and gauge their functional progress throughout their rehab. I perform initial Y Balance Test and Functional Movement Screening on patients post op ACL reconstruction at 8 weeks out and every substuquent 4 weeks. It is very gratifying as a PT to see the excitement of the patient when they finally pass the test validating all of their hard work!

    This practice also helps gain creditability in rehabilitation as a profession. If my blood pressure is high, lets say 150/100 mmHg, then I know my goal is to get this number back to 120/80 mmHg. My treatment may consist of more exercise, better diet, or medication but treatment does not end until the goal of 120/80 mmHg is met. The problem in rehab is that sometimes patients don’t see the value to continuing, especially if they are symptom free. These clear discharge goals sets the bar for what is considered functionally normal and completely rehabbed which leads to a job well done.

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Phil Plisky

I want to change peoples lives through dialogue about injury prevention research and return to activity testing.

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