“4-6 weeks,” “6-12 months,” “it depends”
All phrases you wish you could un-hear… After an injury interrupts your sport performance the shortest path back to function is the best one, right?
Almost… The ultimate goal of rehabilitation is to improve overall functional and performance while minimizing risk of re-injury. A Physiotherapist's job is to find the balance between adapted participation/quick return, and the risk of re-injury (not an easy gig by the way). The ‘Control Chaos Continuum’ is an adaptable pathway progressing training from high control to high chaos²: also a good paradigm to help an athlete understand the formula for rehabilitation in return to sport.
When it comes to athlete rehabilitation, there is a general set of principles. This involves:
-Facilitating tissue healing while loading as/if tolerated
-Re-training neuromuscular control (brain to muscle connection)
-Re-strengthening isolated muscles (by stressing the tissue and progressively increasing the load)
-Strengthening and training muscle groups to work together using compound or more complex exercises
-Training with specificity for function (sport or movement specific)
This is where physiotherapy fits in! Beyond return to sport, a good physiotherapist will push for a return to performance. Performance looks different in every domain, as does the training. In order for athletes to return to a level of capability that allows them to be competitive, they need to progressively train to meet the physical, technical, and tactical loads of their activity² all while doing this well enough that the risk of re-injury is satisfactorily low.
How does it work?
The Control Chaos Continuum can be applied to short and long-term injuries, with adjustments for injury severity and return to sport requirements⁴. Rehab advancement is criteria led rather than time dependent so that an athlete must be able to perform certain tasks before they progress. They start retraining under controlled circumstances, and slowly task demands and environmental constraints are manipulated to influence how an athlete must vary their movements to deal with risk management in increasingly unpredictable situations.
An athlete begins re-training under a highly controlled environment: controlled speeds, loads, impact, and cognitive demands allow them to re-condition their muscles in a safe environment. In reference to high level soccer, designer Matt Taberner describes, “As these constraints are reduced, we gradually increase situational awareness, sensory integration, motor control, coordination and neuromuscular demands. They are also required to perceive and respond to increasingly complex, unpredictable situations including movement of other players, opponents and interaction with the ball."⁴ Under moderate control, we add new challenges and movement variability such as quick change in direction, accelerations, and decelerations⁴. Training begins to resemble the neuromuscular and physiological demands of the desired activity².
The chaos end of the continuum reflects the unpredictable nature of high-level activity; spontaneity is required to respond to external influences. There is overload of sport specific principles: increase in load, intensity, speed and endurance. Technical considerations are dialed in and demanded under fatigue. The goal is to simulate worst-case scenarios in which the athlete must maintain performance and safety⁴.
What next?
There are no tests or checks we can simulate that will match the demands of competition. The goal is to identify key considerations particular to the injury and sport, and also recognize the complexity in how a body adapts to perform it. Return to sport after an injury is an unfortunate experience shared by many, as is the desperation to do so as quickly as possible. A physiotherapist from Shift is the perfect someone to balance drive with rehab progression principles: they work with you as a team to get you back to doing what you love to do.
References
1. T. Allen, S. Wilson, D.D. Cohen, M. Taberner, Drill design using the ’control-chaos continuum’: Blending science and art during return to sport following knee injury in elite football, Physical Therapy in Sport, Volume 50, 2021, Pages 22-35, ISSN 1466-853X, https://doi.org/10.1016/j.ptsp.2021.02.011.
2. Taberner M, Allen T, Cohen DD, Progressing rehabilitation after injury: consider the ‘control-chaos continuum’British Journal of Sports Medicine 2019;53:1132-1136.
3. Taberner, Matt & Allen, Tom & Constantine, Emma & Cohen, Daniel. (2020). From Control to Chaos to Competition: Building a pathway for Return to Performance following ACL reconstruction.
4. Morales, J. S (2020, June) Mat Taberner’s “Control-Chaos Continuum” Rehabilitation After Injury Model. Barca Innovation Hub. https://barcainnovationhub.com/matt-taberners-control-chaos-continuum-rehabilitation-after-injury-model/