Authors: Michael Cole (BSc, PGC(H)E, PgDip, PFHEA, NTF), Briony Hurd, Karl Anthony and Abdulayneyn Nassir


In part one we discussed how Sports and Exercise Rehabilitation is taught in higher education in the United Kingdom and suggested an alternative approach to the traditional ‘expert-student’ paradigm. This article demonstrates the “fruits of our labours” by presenting a report produced by three BSc Sports Therapy students in partnership with their senior lecturer. The following report demonstrates this collaborative approach to co-producing Sports Medicine knowledge in higher education.

Part 2: What is Sports and Exercise Rehabilitation?

Sports and Exercise Rehabilitation (SER) is an evidence-informed, structured and progressive athletic reconditioning programme with the aims of (i) returning the athlete to optimum performance (or the non-athlete to required function) following an injury, or other trauma, including management of pain or dysfunction (Moksnes and Glasgow, 2017)); (ii) addressing associated risk factors; and (iii) reducing the risk of re-injury. To achieve these aims, SER practitioners are advised to employ a multidisciplinary approach combining aspects of clinical reasoning, physical therapy, strength and conditioning, sports psychology, and current concepts in sports science (Kraemer, Denegar and Flanagan, 2009; Crockett, 2011; Dhillon, Dhillon and Dhillon, 2017) to devise, and implement, a rehabilitation programme tailored to the athlete’s unique circumstances. In keeping with the fundamental principles underpinning athletic training programmes, an SER programme is split into several phases, each with its own primary focus, to guide and support the athlete’s optimal progression from point of trauma or pain to return to competitive performance, and beyond.

Conceptual models provide a common framework for a multidisciplinary rehabilitation team to optimise the physical and psychological outcomes of the patient. Safe and effective sports and exercise rehabilitation can be informed by a number of models. Knowles’ (2016) approach illustrates a “reconditioning” model – a criteria and performance-based process with the end goal in mind, progressing backwards to the injury date. Lorenz, Reiman and Walker (2010) suggest a periodised approach to rehabilitation and Reiman and Lorenz (2011) suggest that a rehabilitation programme should emphasise the integration of strength and conditioning principles. Furthermore, Blanchard and Glasgow’s (2014) model explicitly foregrounds the relationship between exercise prescription and clinical reasoning. As shown in figure 1 the model progresses through cycles, actively encouraging a systematic approach to optimal loading, adding new stimuli at each progression.

Blanchard and Glasgow’s theoretical model of exercise rehabilitation (Blanchard and Glasgow, 2014, p. 4, fig. 2).
Figure 1: Blanchard and Glasgow’s theoretical model of exercise rehabilitation (Blanchard and Glasgow, 2014, p. 4, fig. 2).

In comparison, Taberner, Allen and Cohen (2019) emphasise the use of the control-chaos continuum as a framework for returning to sport. Illustrated in Figure 2 this individualised model transitions from high control exercises in early injury to unpredictable and minimally controlled exercises in the later stages of rehabilitation. Progression is only accepted when risk of re injury is minimal.

Figure 2 – The control-chaos continuum framework. (Taberner, Allen and Cohen, 2019, p. 2. Fig. 4)
Figure 2 – The control-chaos continuum framework. (Taberner, Allen and Cohen, 2019, p. 2. Fig. 4)

Effective rehabilitation can be accomplished by combining multiple models and modalities (Beam, 2002). However, the exercise rehabilitation programme is structured it should always be informed by a thorough understanding of the athlete’s injury status, performance needs and goals (Reiman and Lorenz, 2011) combined with sound clinical reasoning and knowledge of the biological healing process (Moksnes and Glasgow, 2017). This will ensure the athlete is able to return to optimal function and safely return to sport and competition with minimal risk of reinjury.

It is widely accepted that return to competition comes after the athlete has reached, or superseded pre-injury performance levels (Ardern et al., 2017; Buckthorpe, Frizziero and Roi, 2019; ACPSEM Physiosinsport, 2020). Specific functional tests can act as reference throughout the phases of rehabilitation and return to play (RTP) decision-making (Hoog et al., 2016; Gomez-Piqueras et al., 2018). Spikes in acute workload occur across a variety of sporting seasons, according to individual/team performance and playing positions, this means baseline measures should be taken during low-loading periods (Black et al., 2016; ACPSEM Physiosinsport, 2020).

Load can be monitored through various means; variability has been highlighted amongst different methods and brands, thus validating methods is warranted (Beato, Devereux and Stiff, 2018; Crawford et al., 2018; Fox et al., 2018; Ferioli et al., 2021). Selected tests and load management techniques should reflect the kinematic patterns involved in sport (Bridge et al., 2014; Black et al., 2016; Da Silva Santos and Franchini, 2016; Güler and Ramazanoglu, 2018; Tayech et al., 2020).

A predetermined successive criterion based on optimal loading and progression of sport-specific qualities can strategically and safely progress an athlete from injury to preinjury performance and beyond whilst reducing re-injury risk (Moksnes and Glasgow, 2017; Dhillon, Dhillon and Dhillon, 2017; Serner et al., 2017; Buckthorpe, Frizziero and Roi, 2019; Taberner, Allen and Cohen, 2019). Rehabilitation programmes shift from general recovery and inflammation optimization in the phase immediately following the injury (summarised in the ‘PEACE’ and ‘LOVE’ acronyms (Dubois and Esculier, 2020)), to more sports-specific criteria in subsequent phases that address the increased demands of the sport on the tissues, systems and holistic personhood (Arden et al., 2017; Dhillon, Dhillon and Dhillon, 2017; Moksnes and Glasgow, 2017; Serner et al., 2017; Taberner, Allen and Cohen, 2019; Buckthorpe, Frizziero and Roi, 2019).

Incorporating psychological measures of assessment can support favourable psychosocial parameters being met, increasing rates and minimising time for RTP (Ivarsson et al., 2017; Buckthorpe, Frizziero and Roi, 2019; Nwachukwu et al., 2019; Green et al., 2020 McCrea et al., 2020). Premature RTP decisions and previous injury are risk factors for recurrent injury (Green and Pizzari, 2017; Dingenen and Gokeler, 2017; Green et al., 2020). The Strategic Assessment of Risk and Risk Tolerance (StARRT) framework was developed to consider the specific history and wider athletic context in addition to biomedical factors, the specific stresses placed on the tissue during participation, and the psychosocial variables that augment the decision process and facilitate a more robust RTP decision (Shrier, 2015; Arden et al., 2017; Blanch and Gabbett, 2017; Dingenen and Gokeler, 2017; Buckthorpe, Frizziero and Roi, 2019).

References (Part 2)

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