Monday, December 18, 2017

Anterior Cruciate Ligament Injury: Is It Just An Athletic Injury or A Major Life Lesson? – Part III

Over the course of the last couple of weeks, we have talked about psychological factors that influence rehab and return to sport.  Factors like sport locus of control, how vital that is and how we can impact this clinically in the very first visit with our athlete.  Last week we discussed fear and lack of confidence in the athlete and how this can lead to increased risk for re-injure.  We also discussed in some detail how this can be identified and addressed very early in the rehabilitation process.

This week, we will be discussing communication among providers and how imperative this is.  Ironically, this is one that is so basic and simple that we often think that is the standard of practice.  But, be assured that it is not a standard of practice.  So before we discuss too much in detail, let’s consider the following scenario.  Imagine you are the athlete in this scenario.

You are a 20 year old Division I athlete who has injured his/her ACL.  Prior to surgery your MD tells you that you should be back to play in 9 months.  During surgery, the surgeon finds that you have a meniscal tear and a chonral defect on the weight bearing portion of the medial femoral condyle.  Post surgery, the surgeon comes in and explains the surgery, tells you all the things that he did, that you will be non-weight bearing for 2-4 weeks and that you will be staring rehab tomorrow.  The next day you arrive for your first physical therapy visit and the PT sees a script for s/p ACLR without any additional information.  The therapist tells you that you will be off the crutches in a couple of days what the anticipated course of treatment will be and anticipated timeline for return to sport.

Now, in this scenario, there are some obvious and major implications from this lack of communication which can have a long term negative impact on overall outcomes if they are not addressed ASAP.  This is especially true considering the chondral defect on a weight bearing surface.  For the athlete, they are in a major conflict.  Who do they trust?   The obvious answer is there would be more confidence in the MD because he is the one that did the surgery and saw the inside of your knee.  Do you think they have confidence in the therapist?  Now that this is the initial perception of the therapist, how long do you think it will take to build that trust?

Let’s reverse this scenario.  The physical therapist has been seeing the athlete throughout the rehabilitation process and is going back to see the MD to determine return to sport.  The PT does an evaluation on the athlete and finds that range of motion and manual muscle testing scores are within functional limits.  However, when they do a movement assessment, they find that the limb symmetry index (variance in stability in single limb performance on multiple tests) is way off and that the athlete is still at a high risk.  The therapist communicates this to the athlete, sends this information to the MD and the athlete goes in for their appointment.  During the appointment the MD does not have the PT progress note and does a traditional post-operative assessment (which does not include a movement assessment).  Based on the post-operative assessment, the MD tells the athlete they are ready for return to sport.  Who do they trust?

As easy as these scenarios are to see, these happen every day.  So what can we do to prevent?  One, open up the lines of communication with the MD.  So many therapists hesitate to get on the phone or even go see an MD face to face.  In sports medicine, this is not an option but should be a standard of care.  As clinicians, we must put ourselves in the shoes of the athlete and the parent.  As a parent, what would you do differently in the communication if that was your son or daughter?  Would you change or improve your communication? If you are in sports medicine, it means that you have to do more and go several steps beyond.  Send the note with the patient and call the MD prior to the appointment.  A team huddle with the MD is an imperative part to doing what is in the best interest of the athlete and in optimizing the outcome the athlete is able to achieve.  It is also imperative for safe return to sport.

Although the two scenarios above did not talk about the communication between the physical therapist and the athletic trainer, this is also an imperative part of the team approach.  Imagine if you are the athletic trainer at Division I school and your star football player is being treated by a physical therapist who does not communicate to you on a weekly basis.  When that head football coach questions that athletic trainer about that athlete, they had better know the athlete’s status.  If they don’t, they won’t be there very long.  If you don’t communicate to the head ATC about that athlete, you won’t be seeing their athletes very long.  Why should they put themselves at risk if you can’t simply pick up a phone and communicate to them?  No matter how good we think we are, if we have a lack of communication, we can compromise the outcome and care just as much as a poor manual technique.  So although these scenarios talk specifically about PT communicating directly to the MD, in the treatment of the athlete we also need to consider the PT communicating directly to the ATC.

Finally, improved lines of communication often aids in preventing conflicting thoughts or contradicting communication from the MD to the athlete about their status and return to play.  If there is anything that will result in conflict between the PT and MD it is a PT contradicting the MD to the athlete.  This creates a huge problem not only for the MD but also the athlete.  Who are they to trust?  Even if they trust the therapist, the surgeon did their surgery.  Now what is my faith in what he/she did from a surgical perspective?  Think about when the athlete says something to the MD about this (which most often they will), what kind of situation does this put the athlete in?  Depending on the MD, the response can vary greatly.  From the MD pulling the athlete from the PT’s clinic, to berating the PT in front of the athlete to contradicting everything the PT has said.  MOST IMPORTANTLY, what does this do to the athlete’s psyche?  No matter if you are wrong or right, you have placed the athlete in a very bad situation.  So no matter who is right, not controlling that situation is wrong and will result in less than optimal outcomes. 

The simply solution is over communication.  Whether that communication is with the athletic trainer or physician, in the presence of the patient, it is imperative for them to know and feel like all their care provider team is on the same page.   It is imperative to the psychological wellbeing of your athlete that “all” the providers involved in the athlete’s care communicate.  If the MD, ATC, PT and the coach are not communicating, then the only one that suffers is the athlete.  We hope you found this series helpful and if you like what you read, the biggest compliment you can give is to share the passion.  Follow us on twitter @ACL_prevention or follow us on Facebook at Athletic Therapy Services and #MoveRight.

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

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