Overall, upon examination of the included return-to-play (RTP) protocols for ACL injuries through an ICF lens, several key trends were identified that could have significant implications on the current landscape of sports rehabilitation. These trends not only shed light on existing practices but also identify potential areas for improvement and development in the pursuit of more effective and participant-centered rehabilitation protocols.
The variability in emphasis toward contextual factors describes a potential gap in current RTP protocols for ACL injuries. A comprehensive rehabilitation protocol addresses physiological factors, while also incorporating an individual’s personal attributes, psychological well-being, and environmental influences. Integrating these approaches into future RTP protocols, would address the identified gap in most of the included studies and align with the holistic principles of the ICF framework. Acknowledging and addressing the bio-psychosocial and environmental factors involved in recovery could contribute to a more individualized and effective rehabilitation process, ultimately improving player outcomes post-ACL rehabilitation. For example, important environmental factors such as access to rehabilitation facilities, availability of skilled healthcare professionals, and social support networks may influence recovery or access to services. Additionally, psychosocial factors such as motivation, confidence, and coping strategies play a crucial role in the rehabilitation process. By considering these factors alongside the physiological aspects of injury recovery, rehabilitation plans can be tailored to better meet the needs and preferences of each individual, leading to more successful outcomes and a smoother return to play. However, it was intriguing that a few protocols recognized the significance of addressing the psychological aspects of ACL injury recovery, specifically acknowledging factors such as fear of re-injury, loss of confidence, and the mental toll associated with a prolonged recovery period. It would be interesting to see if there was an association between the inclusion of psychological factors in the recovery process and the time of recovery as it could promote further research into whether the inclusion of psychological factors significantly impacts rehabilitation time. Additionally, it would be interesting to investigate whether the recent emphasis on mental health in sports encouraged the inclusion of psychological factors in the recovery process as it could indicate a societal shift in values [27]. As psychological factors play a crucial role in an athlete’s readiness to return to play, the integration of physiological and psychological components within RTP protocols is essential for an effective recovery [28].
Although the analysed RTP protocols addressed an individual’s participation through sport, it is equally important to include an individual’s participation at work, school, within their community, and also their participation in their social environment. Given that the greatest number of ACL injuries occur in individuals aged 15 to 25, it is intriguing how the included RTP protocols fail to address an individual’s academic and work commitments as well as their social activities [29]. They simply focus on the injury rather than the individual and their life, raising questions regarding the effectiveness and individuality within these protocols. ACL recovery is inherently individualized as numerous factors can influence the speed at which one recovers – including age, fitness, pre-injury health status, social support, and personal commitments, none of which are adequately addressed in the included RTP protocols [3]. The absence of personalized components within these protocols may potentially disregard an individual’s specific needs through their rehabilitation process. A more nuanced approach, accounting for contextual factors and comprehensively capturing participation in other life domains, could enhance adherence and long-term success of RTP protocols in ACL recovery. The rigid structure of these protocols, with their predefined timelines and progression, may not align with the goals of the individual. An individual with an ACL injury may require an accelerated timeline due to work, or may require targeted exercises to strengthen specific movements relevant to their sport. Therefore, a rigid structure lacks the necessary flexibility to accommodate the diverse characteristics and priorities of the players that are meant to be designed for.
Clinical Implications
The findings suggest that upon examination using the ICF framework, there are several avenues by which these ACL RTP protocols can be improved. Primarily, the incorporation of contextual factors, including both environmental and personal factors, could contribute to the development of a more comprehensive and individualized protocol. This could be in the form of a questionnaire or through meetings with their rehabilitation team integrated throughout the rehabilitation process. Additionally, the acknowledgment and incorporation of psychological support within protocols could be further emphasized as ACL injuries can have a toll on an individual’s well-being. Recognizing the symbiotic relationship between mental and physical recovery could potentially lead to improved outcomes post-rehabilitation. Lastly, adopting a flexible method of progression could enhance adherence and overall success in ACL injury rehabilitation.
Future Research
Moving forward, further research can be performed to develop a standardized RTP protocol for ACL injury rehabilitation that aligns with the ICF. Individuals with ACL injuries should be involved in this process to better understand and capture the numerous and diverse influencers of recovery. This would permit comparative studies and longitudinal studies that could investigate the impact an ICF-aligned RTP protocol has on patient outcomes. Lastly, these findings can be applied to other RTP protocols within sports medicine such as those for shoulder injuries.
Strengths & Limitations
Given the nature of a rapid review, there are strengths in the study’s design, particularly as it was able to streamline the systematic review process and synthesize evidence promptly. This was aided by the fact that guidelines outlined by the NCCMT were followed, improving the review’s credibility [9]. Additionally, the research question examined RTP protocols for ACL injuries in all populations, thereby identifying the generalizability of our findings.
This review is also limited, specifically because there was only one reviewer. However, a rapid review was determined to be an appropriate approach to address the research question and identify areas for future research in a timely manner. The team also reviewed the primary authors’ interpretations to provide feedback, where appropriate. Additionally, there was a small sample of studies included within the review (n = 15), many others of which were excluded due to their language. Gathering more data would improve the power of any observations and trends made by the research team, such as expanding databases searched and including non-English articles. Nonetheless, the inclusion of fifteen studies was deemed to be appropriate for answering the research question and determining actionable research and clinical implications and suggestions.