The control-chaos continuum: A thinking tool for rehabilitation professionals

In 2016, leading sports injury rehabilitation experts drafted a consensus statement to define the three critical return to sport (RTS) stages following injury(1). These exist on a continuum and are designated (1) return to participation, (2) return to sport, and (3) return to performance.

The RTS continuum highlights that the role of sport rehabilitation professionals extends well beyond returning athletes to participation. The job doesn’t stop when the athlete is pain-free and functionally capable. Practitioners need to support athletes in going as far down the RTS continuum as they wish. Some individuals will be satisfied with returning to sport; however, others won’t be satisfied until they reach or beat their previous best. In either case, the practitioner’s role is to support this journey fully.

A major frustration for any athlete is re-injury following a period of rehabilitation. Sadly, this happens frequently, with one in five athletes that undergo ACL reconstruction experiencing re-injury when they RTS(2). Outcomes are worse for hamstring strains, where re-injury occurs in one out of every three athletes(3). As a result of figures like these, a previous injury is one of the main risk factors for sports injury(4). The sports medicine fraternity needs to reflect on the high re-injury rates and determine if re-injury is inevitable or a reflection of the mismatch between inadequate rehabilitation processes that fail to prepare athletes for the demands of their sport. Taking athletes further along the RTS continuum improves their chances of staying injury-free, performing well, and increasing their enjoyment.

What is performance? The first challenge in adopting the return to performance approach is understanding performance. This is an area where searching for and interpreting research is invaluable. Sports scientists regularly assess and document the physical demands of various sports to inform training and rehabilitation practices. For example, researchers at the Institute of Exercise and Sport Sciences at the University of Copenhagen summarised the physical demands of matches and training for professional footballers(5). This research reveals that elite players may run up to 13 km in a game, including 2.4 km at high intensity and 650m sprinting. In addition, players perform up to 250 brief, intense actions such as accelerating, decelerating, changing direction, tackling, and jumping within a game.

Basketball is similar, as researchers in Spain reveal that, on average, a professional basketball player runs 72m and performs three hard accelerations and decelerations per minute of match play(6). This information is highly informative regarding the sports demands and physical capacity required by athletes returning to performance. However, it is essential to remember that these demands will vary according to sex, age, and level of competition. Therefore, clinicians should use cohort norms that best represent their athletes and sport-specific demands.

Losing control The sports injury rehabilitation environment is a safe, structured, and controlled space for athletes to redevelop tissue capacity and confidence. There are generally no opponents, and clinicians typically create an environment where athletes return to participation by progressively demonstrating various physical skills and capabilities such as straight-line running, progressive accelerations, deceleration, and plyometrics. Once athletes can demonstrate a certain level of competency, a clinician may initiate the return to participation. However, although these activities are necessary steps on the rehabilitation pathway, they are different from playing or performing on a sports field.

The critical difference is that the sports field is unsafe, unstructured, and unpredictable. In rehabilitation settings, the movement challenges allow athletes to plan before executing. However, the sports performance environment offers athletes few opportunities to plan and execute. Instead, athletes have to react in response to an opponent or teammate. Sport movement patterns are a collection of hundreds of mini duels between opponents where both are continually trying to gain an advantage over the other. For example, there is a significant difference between a jump landing in rehabilitation and attempting to land after an aerial duel with an opponent.

Clinicians and athletes need to realize that the sports environment is chaotic and does not mimic safe rehabilitation settings. This will lead clinicians to understand that to progress athletes through the RTS continuum appropriately, they need to progressively expose them to the chaos of real-life sports environments. If clinicians fail to do so, they can only hope for the best when athletes RTS. Fortunately, researchers working in England’s professional football leagues have mapped out an approach for safe return to performance –’ Control -Chaos Continuum’ (CCC)

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