 Honored to have Mr. Trent Salo joining us. Trent is his second season as performance director for the Detroit Pistons. Hopefully everybody is watching the last dance, which had a great feature about the bowls and pistons rivalry. Native of Rudyard, Michigan, Salo earned his bachelor's degree in exercise science in Calvin, where he was a two-year captain and starting point guard for the Knights as a junior and senior, not playing basketball against you, Trent. So first up, Trent Salo. All right, hey everyone, thanks for tuning in. My name is Trent Salo and I'm a physical therapist and strength and conditioning coach, currently working as a director of sport performance for the Detroit Pistons. And for the next 15 minutes, I'll be discussing return to play considerations in the NBA. Before we get started though, I do wanna share a bit on where my interest in return to play came from. So I'm gonna take you back. It's 2011, my senior season at Calvin University. It's actually our first scrimmage of the year. Catch the ball and out of the pass, sprinting full speed down the court, do a step back, move into a jumper and snap my fifth metatarsal. Now, of course at the time I'm devastated, but looking back, it was this injury and having to go through the return to play process as an athlete is what sparked my interest in how these decisions are made. And so what I did is I took this interest to my next stop, which was the University of Kentucky. And while going through my graduate studies and exercise physiology, I tried to view the return to play continuum through the lens of a strength and conditioning coach, you know, what I was studying at the time. And then taking this interest to the University of St. Augustine, you're going through my graduate studies as a physical therapist and viewing the return to play continuum through the lens of a medical provider, a physical therapist. And from there, basically trying to improve my decision-making process as a clinician and then as a group at each of my stops along the way. And we continue to try to do that with our team here in Detroit. And so as you can see, I'm considering myself a generalist in nature, which of course is why I was stoked when I thought David Epstein's book range come out. But I think this is why I have an affinity for studying and refining the return to play process is because I've seen it holistically and generally from different vantage points, you know, as a player at Kelvin as a coach and now as a clinician. So I'm excited to be here today. I'm really passionate about this return to play topic. There's some excellent presentations coming up after mine as well. So let's get started. Objectives, the first one is to identify key stakeholders and terminology within the return to play process. Two is we'll talk about a bio-cycle social framework that captures some of the key elements. And then the third one is discussing the importance of shared decision-making across multiple disciplines when it comes to return to play. Quick disclaimer. So we're dealing with the human body here, which of course lends itself to some inherent uncertainty. And you'll likely leave this presentation with more questions than answers, but hopefully we'll be able to address some of them in the Q and A session afterwards. Return to play stakeholders and terminology. So everybody on this slide in some way, shape, or form is involved in the return to play process. Now some of course are more involved than others. The general manager, the head coach, the physio, the surgeon, but at the same time, fans, family, media, they're all wondering when this player is going to return. And so I put this slide on here to raise awareness of the vast plethora of individuals who are some way involved in this process. And especially at the elite level, how we have to communicate differently with each of them. From a terminology standpoint, return to play is an overarching phrase that is often used, but really what it consists of is three distinct phases, as you can see on the screen here. Return to participation essentially describes returning to practice, turning to training. Return to sport is returning to gameplay and returning to performance. This stage basically extends the returning to sport, but it's characterized by the athlete performing at levels similar or above their pre-injury. An excellent presentation coming up on specifically the return to performance aspect. So terminology, little thing, but a big thing. Let's take a look, decision-making framework. So how are return to play decisions made? Return to play has seen a surge of research in an attempt to understand this whole process of how these decisions are made, particularly in the ACL and concussions, but really in all aspects and looking holistically at the continuum, and particularly the end stage of who's making the final call when the athlete can return. Traditionally, it's been the physician. So as you can see the study in 2011, are they the team of physicians' responsibility? Surgeons, medical doctors were primarily the gatekeeper and the final decision-maker, but what we're finding is more and more studies come out and they're moving towards the shared decision-making process, which we'll touch on briefly. So let's get into the specific framework. So the framework is called the strategic assessment of risk and risk tolerance for return to play decision-making. It was created by Dr. Ian Shrier out of McGill University and it consists of three steps. The first step, individual risk assessment. Step two is activity risk assessment. And step three is tolerance to risk assessment. And so what these three steps do is it provides a bio-cycle social framework that captures and discusses key elements to be considered in the return to play decision. Important to keep in mind though that the decision itself is not solved within the model. It's not a plug and play. It's not gonna tell you what to do. It's not prescriptive. It simply organizes the information available into assessing risk for a particular outcome and assessing risk tolerance for that outcome. And in my opinion, one of the benefits of the framework is it makes a lot of the hidden assumptions more transparent for the stakeholders, particularly the key decision-makers. And so in talking to Dr. Shrier this week he's exchanging emails. He said, look, this framework is based on simple principles. But what it does is it requires synthesis of information from different sources on multiple outcomes, which is not always an easy task. So simple framework or simple principles that we'll touch on here. So let's get to it. So this is the framework in its entirety. As you can see, step one, step two, step three. Essentially what it is is step one is what the tissue can handle. Step two, what the activity demands. And step three, the contextual decision modifiers. Let's dig a bit deeper on step one. Step one looks specifically at assessing the tissue health. Looking at the patient demographics, the symptoms, past medical history, are they weak, is there some swelling in there? What does imaging say? And we do this because we wanna synthesize this information on the load the tissue can absorb before injury. And again, it's tissue specific. We're talking about just the tissue that's healing from injury. So that's step one, step two. Step two is basically the demands of the activity the athlete is returning to. The type of sport, the position, what limb dominant they are, what competitive level they play. They have the ability to protect it, wearing bracing or padding, functional tests. What is the assessment of the other tissues that could have potentially deconditions during the period of rehab. And then psychological readiness as well. So step two, what we look to do is look at the stress of the activity. And if it's greater than the capacity of the tissue, you know, that might be a problem. A quick example of this is the, you know, step two differences between return to participation, what you're looking at the demands of practice. And step two, looking at the demands of returning the sport or the demands of gameplay. Okay, so step one, looking at tissue health. Step two, what are the expected tissue stresses? And step three, so step three is the contextual considerations that need to be kept in mind. The decision modifiers, the threshold for acceptable risk. And so how I like to put this is you're looking at an athlete who sprained his ankle and it's the preseason. You know, if they're not doing very well, if they still have a little pain, you're less likely to clear them to return to play because it's the preseason. Now, compare that to game seven of the NBA finals where that athlete is still having a little bit of pain. Well, we probably would be willing to accept a little bit of risk, more risk on that. And so that's what step three deals with. You know, the pressures the athlete may be having, you know, if they're masking the injury, if there's a conflict of interest, you know, so we have to assess, you know, how much risk are we willing to tolerate? An important consideration though with the risk of re-injury is only one of several outcomes that affect overall health or well-being of the athlete. When we talk about re-injury, yes, that's important. We don't want to re-injure our ankle if we just sprained it, if we're returning to play. But at the same time, we need to keep in mind potential socioeconomic impact, potential mental health impact, because sometimes the risk of re-injury, if it's greater than socioeconomic impact than mental health, well, yeah, we don't have to return to play. But there's scenarios where a player needs to play because he needs to make money. You know, maybe he's got to play and he gets a bonus if he plays in 60 games in the NBA season, the last game of the year and he's at 59. And so these are the challenging decisions that have to be made and these are considered in step three of the framework. So here's my attempt at a schematic, you know, drawing the process from start to finish when it comes to return to play decision-making. And so an injury occurs, you go through a period of reconditioning, eventually you have the return to play evaluation, which consists of step one and step two of the framework, taking into consideration step three, the risk tolerance. And you really have two decisions here. The first one is if the risk of re-injury, step one and step two are less than how much risk you're willing to tolerate, not the easy decision, the athlete should return to play. Now, if the risk of re-injury is greater than the risk tolerance, well, that's also an easy decision, the athlete should not return to play. And so very simply, the objective of the start framework is to arrive at a decision based on whether the risk assessment exceeds one's risk tolerance. Now, let's talk about who's decision is it? You know, who, return to play, who's decision is it? This slide basically says everybody has their own bias. And so in a high-performing organizations, clinicians and decision-makers are able to set aside their bias to be as objective as possible, but not always as easy as it sounds. So keeping that in mind. An excellent commentary here, return to play in elite sport, a shared decision-making process. This is getting into this phrase shared decision-making and where return to play is currently and where it's headed. And so there's three people in the decision-making process, the athlete, the healthcare provider and the coach. And they each contribute something a little different. The athlete, main contribution obviously is subjective. Yes, I feel ready to go or no, it doesn't feel quite right. The coach main contribution contextual timing of the season. You know, the coach says, gosh, we need to win some games or I'll lose my job or it's my best player, we need them back. And so his contribution is contextual. And then also healthcare providers, our main contribution should be objective as we evaluate health status. And we make the athlete and coach aware that regional options exist, you know, what those options are and guide them to making the best decision. And really that's what shared decision-making is all about. Another commentary Marcus Walden and Claire Ardern from Sweden and talking about this decision-making process and how shared decision-making is where it's headed. And, you know, unbiased is underlined here and talking about previously because we need to bring unbiased opinions to these decisions even though we all have our own bias. And the second paragraph there, basically talks about these decision-makers need to be established as early as possible because it's, you know, especially when you're in elite sport when you get to the end stages of rehab and you're looking around saying, well, who should make this decision? You know, that needs to be established early on in the process before that environment or before that situation is reached. And so I just wanna finish here these next couple of minutes talking about our approach in Detroit. Martin Buchet put out an excellent article outside the box and we tend to follow that, you know, looking for the right people, getting the right people on the bus before you move the bus. And that's those type three personalities in an organization. And from there, we look at our athletes as people first, athlete second, you know, we focus on what they can do when they're injured, not what they can't do. You know, the return to play process is a part of one of our three pillars under the injury management pillar and a couple of hashtags, a couple of words that we would describe that pillar as the, you know, principle-based, criteria-based, athlete-centered, objective, et cetera. You know, I put objective in there twice simply because we were trying to bring as much objective data to the decision. And then this slide from Kramer, Recovery from Injury in Sport, basically just depicts the different providers that are involved throughout the entire process and then comparing that to how we do it, you know, we want our key stakeholders involved in the entire process, for coach involved as soon as possible because each of them are our key when it comes to the end decision-making. And so we feel they should be a part of the process from day one, you know, obviously some more than others early on and then versus later on, but important for those three to be, or closer to be involved the entire way. This slide here is, we try to use a team of teams approach. You know, when I say try, you know, we're in the early stages of it and it takes time for it to grow organically, but we're establishing small groups of people around each athlete. And what that means is, you know, return to play starts day one, you know, strength coaches, we're doing contralateral limb exercise, three-legged bike, you know, the sport coaches doing stationary ball handling if the athlete can't handle any impact. And so this is how we operate in these small groups of people or small pods around each athlete. And how do we make return to play decisions? Well, we use the same framework that we just discussed. I just want to finish here the last minute or so of asking, would you allow this athlete to return to play? And really I'd like to present this because it shows the challenges we face in professional sports when it comes to decision-making on return to play. So let's take a look. So would you clear this player to return? He's your best player, two-week status post grade, two lateral ankle sprain, a figure eight measurements indicated he's got some swelling, range of motion's not quite there, a little bit of pain walking, strength isn't quite there, some pain running and some good amount of pain cutting. Most of us would probably say, no, we don't want to return this athlete, he's not ready yet. But what about if it's a playoff game and the head coach and GM need to win now or else they lose their job? This is just one scenario that we face in professional sports all the time. And so it's just, it's one of many, one of many potential scenarios that we face that we have to deal with and provide objective information and make the best decision. And so the take home message here is return to play is a complex process, particularly professional sports, but it boils down to risk assessment versus risk tolerance. It requires shared decision-making and it requires a formal structure to process and process to guide the interactions between the individuals. So a lot of time appreciated everyone for tuning in. We'll look forward to hearing from you during the Q and A.