Clinical Reasoning Plays a Role in Return-to-Play Decisions

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    Yes, making return-to-play decisions requires solid assessment skills and a thorough understanding of the physical demands of the activity in question, but that's just the beginning. These complicated, highly contextual decisions also require physical therapists (PTs) to have the ability to question assumptions, think about how they're thinking, and decide what the decisions are—all while being sensitive to the concerns of patients, coaches, and family members.

    In a 3-part presentation titled "Return-to-Play Decision Making: Evidence-Enhanced Clinical Reasoning for Assessing Return-to-Sport Participation," presenters B. James Massey, PT, DPT, OCS, Niles Fleet, PT, DPT, ATC, and Brett Aefsky, PT, DPT, provided attendees with a framework for understanding clinical reasoning and case examples of that framework in action. Though a lot of ground was covered, the presentation might best be summed up in Fleet's advice near the end of the session: "Know what you know, know what you don't know, and apply it appropriately."

    According to Massey, PTs can make the best decisions when they have the ability to see how it is they're reasoning their way through a case, and what kinds of decision-making and evidence evaluation models they're applying. And though it's an easy enough concept to describe, Massey explained that it can be hard to know when assumptions are substituting for solid reasoning.

    Massey walked attendees through clinical, reasoning, and decision-making models, as well as approaches to assessment. He pointed out how probabilistic, causal, case-based, and narrative reasoning approaches may all be useful models, but only when the PT knows which approach she or he is using, and understands its limitations.

    The reasoning approach is informed by the context of each case, and vice versa, Massey said. It's an important consideration, but one that hasn't been thoroughly examined in research literature. "There's been lots of research on physical factors [related to return-to-play], but not so much on the contextual side of things," he explained. "Overall, there's not a lot of consistency in the way these decisions are made."

    To underscore his point on the importance of context and the risks of unexamined assumptions, Massey asked the audience to complete the sentence, "If you hear hoofbeats, think of..."

    Most responded by saying "horses."

    But, Massey asked, what if a certain context made that answer less appropriate? What if you're in the African veldt, surrounded by zebras? What if you're in the woods of North Carolina with deer nearby? No, he said, the best way to complete that sentence is, "If you hear hoofbeats … think of hooves."

    He told attendees that to make the best-informed return-to-play decisions, PTs need to ask themselves questions about how they're thinking through the issue—what's being decided, how the PT is going about making those decisions (the reasoning models used), potential outcomes and options, and the effect of known and unknown factors—all while ensuring a high level of collaboration with the patient and caregivers.

    That insight was echoed by Aefsky, who presented a case study of an elite tennis player who suffered an upper extremity injury. Aefsky used the specifics of the player's injury to underscore just how important it is for PTs to be sensitive to how tissue healing time, pain, range of motion, strength, endurance, and power should be assessed relative to both the injury itself and the patient's sport. For example, he said, appropriate range of motion can be affected by the sport a patient plays and by differing norms among different populations.

    The role of patient attitude and involvement was reinforced by Fleet, who provided a case study of a female college basketball player who had suffered an ACL injury. Both she and her coach were hopeful that she could return to play in 6 months. Fleet told attendees that PTs need to be sensitive to the expectations of players and caregivers, and understand how the PT's attitude can impact expectations.

    Like Aefsky, Fleet stressed the importance of using the right tests and using them appropriately, and on always being aware of the reasoning and decision-making models being used so that risk is minimized."

    Fleet added to Aefsky's insight on how function norms differ in different sports by saying that those differences can extend to positions within a sport. The stresses experienced by a guard in basketball, for example, might be significantly different from those experienced by a center. All of these considerations can only be fully analyzed when the PT is well-armed with evidence, self-consciousness, and an awareness of the context of the decision, he said, but, ultimately, PTs need to understand their own role in the process. "Athletes and coaches are the ones who make the return-to-sport decision," Fleet said. "The PT empowers them."

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