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The Role of Chartered Physiotherapists in Olympic Sports
The Role of Chartered Physiotherapists in Olympic Sports JANE HALL MCSP .Research Physiotherapist, Royal National Hospital for Rheumatic Diseases, Bath
Key words: Questionnaire, physiotherapy, Olympics, sport. SUmmary: This article describes the results of a postal questionnaire
sent to Chartered physiotherapists who work with the national teams of the Olympic sports, the aim of which was to identify their role. Results showed that team physiotherapists had a multiplicity of roles and a keen commitment to their sport in the face of poor working conditions. The implications of this are discussed and recommendationsmade for a more co-ordinated service and understanding by the governing bodies.
Biography: Jane Hall is a research physiotherapist at the Royal National
Hospital for Rheumatic Diseases, Bath, and in her spare time acts as honorary physiotherapist to the Great Britain Rhythmic Gymnastics Team. This study was prompted by a curiosity to find out if similar physiotherapists existed, and if they did, whether their .roles were comparable.
Introduction THE aim of this study was t o identify the role of Chartered physiotherapists working with the national teams, in both training and competition, of sports affiliated t o the British Olympic Association. Literature Search A literature search revealed several personal accounts of the authors' experiences at a sporting event (John, 1983; Macdonald, 1983; Anon, 1981/82; Whitney, 1983) and these principally detail the injuries treated. Historically 'spongemen' have been used in sport at all levels and a survey (Chapman, 19771, conducted on behalf of the Association of Chartered Physiotherapists in Sports Medicine (ACPSM) showed that this was still the case in 1975. The aim of the survey was to 'ascertain the staff, honorary or paid' available t o selected sports clubs. Questionnaires were posted to 3,031 clubs through the mailing lists of the governing bodies and despite the poor return rate (9.9%) the results demonstrated that unqualified physiotherapists (28%) predominated (compared t o 7 % of Chartered physiotherapists). Informal discussion with the various bodies involved suggests that the physiotherapy profession has made some, if not considerable, inroads into changing the situation of 1975. This may be due, in part, to the advent of 'amateur' professional sportsmen and women and the increasingly important role of the sponsors and media. As a consequence the demands made on the medical support staff have assumed a greater importance. Despite this Grant Smith's (1981) observation detailing 'the reluctance on the part of the individual and of sports groups in general to accept that time, skills and materials are valuable and expensive commodities' appears t o hold fast and the financial incentives t o provide a physiotherapy service remain poor.
686
Identifying the Study Population The present survey was carried out between March 1988 and January 1989 by means of a postal questionnaire, sent to those physiotherapists involved in both the training and competition environments of national squads. Before the study could begin it was necessary to identify the Olympic sports which utilise the services of Chartered physiotherapists and this was done through a number of different channels. The British Olympic Association (BOA), the ACPSM and the British Association of Sport and Medicine (BASMI were asked to supply registers of the relevant physiotherapists. Unfortunately, none of these bodies keep such a list. It was therefore decided to approach the 28 governing bodies of the Olympic sports affiliated to the BOA. Names and addresses of the Chartered physiotherapists providing a physiotherapy service to that sport were requested. In this way 71 Chartered physiotherapists were identified (see table). The BOA Physiotherapy Sub-committee indicated that a further nine individuals were involved and advised that some of their representatives had been omitted in the original governing body lists. The governing bodies were asked to identify the national team with which the physiotherapist worked. For example, it was known that the Amateur Rowing Association had six distinct squads: men's heavyweight, men's lightweight, women's heavyweight, women's lightweight, junior men and junior women. Many of the governing bodies did not give this information and if the information was given it was likely, when cross-referenced, t o be incomplete. Time and financial constraints limited the governing bodies investigation to an initial and follow-up postal contact only. Despite misgivings that the governing bodies would list all Chartered and non-Chartered physiotherapists, this in fact did not occur and governing bodies appeared t o appreciate the significance of the title 'Chartered physiotherapist'. Some sports, eg the British Amateur Athletics Association, do not have national team training as such and the services of honorary physiotherapists are used for national and international competitions only. A s the aim of the survey was to identify the physiotherapists' role in both training and competition environments it was decided that, in these cases, only the BOA representative would be the spokesperson. Therefore, while a total of 79 Chartered physiotherapists was identified, postal questionnaires were sent t o only 53 people (see table).
The Questionnaire The data were collected by means of a postal questionnaire. A covering letter and stamped addressed envelope were included and a reminder was sent to non-respondents t w o weeks after the initial reply date. The questionnaire was divided into t w o parts and consisted partly of closed and partly of open questions; space was given for comments on each question. Part I concerned the physiotherapists' personal and career details.
Physiotherapy, December 1989, vol75, no 12
Number of Chartered physiotherapists identified, questionnaires sent and responses received ~~
~
Governing body Amateur Fencing Association Amateur Rowing Association Amateur Swimming Federation British Amateur Athletics Board British Amateur Boxing Association British Amateur Gymnastics Association British Amateur Weightlifters' Association British Amateur Wrestling Association British Bobsleigh Association British and Irish Basketball Association British Canoe Union British Cycling Federation British Equestrian Federation British Handball Association British Ice Hockey Association British Judo Association British Racing Toboggan Association British Ski Federation British Volleyball Association Football Association Grand National Archery Society Great Britain Hockey Board Great Britain Target Shooting Federation Joint United Kingdom Table Tennis Committee Lawn Tennis Association Modern Pentathlon Association of Great Britain National Skating Association of Great Britain Royal Yachting Association Totals
Chartered physiotherapists Questionnaires Responses identified sent received
4 10
4 8
3
5
5
3
22
1
1
1
1
0
7
6
5
1
1
0
2 1
2 1
0
0 0 1
0
0
0 1
5
1
0 1 0
3
0 3
0 3
0 3
0
0 3 3
0 3
1
0 3 3 1
1 7
1 7
2
0
0
0
0
0 1
0 0
0
0
0
1
2
2
1
2
1 1
0
0
0
79
53
31
1
1
0
Questionnaires were sent only to BOA representatives.
Part II of the questionnaire was designed t o elicit the physiotherapists' role in respect of the following: 1. Circumstances of appointment - respondents were asked to detail the mechanism by which they were appointed ('How did you become honorary physiotherapist for this sport'?)
2. Extent of duties - details of duties other than recognisable physiotherapeutic tasks were sought. For example, a Likert-type scale was used to determine the extent of the physiotherapists' involvement in 'nonphysiotherapy conditions' (eg respiratory tract infections, menstrual, gastro-intestinal, emotional problems, etc) and the most common problems and the treatment offered were requested. The penultimate question asked physiotherapists to 'state any other duties that you carry out on behalf of your governing body'.
3. Injuries commonly encountered - physiotherapists were asked t o list the three most common injuries in their sport. 4. Facilities and treatments - respondents were asked t o list the facilities available at their usual squad training centre
Physiotherapy, December 1989, vol75, no 12
(eg private room, hoticold water, plinth, ice, first-aid equipment, etc) and the treatment modalities supplied by themselves and by the governing body. Treatment modalities commonly used in their treatment of squad athletes were requested. 5. The physiotherapists' involvement in training, team selection, education and injury prevention was detailed and the level of satisfaction w i t h these activities assessed (eg 'Are you involved in the selection of new squad members? If yes, please explain the extent of your involvement', and 'Are you satisified w i t h your level of involve m ent '? )
6. Management and administrative details - specific questions regarding the type of records kept and the liaison between governing body doctors (if available) and physiotherapists were asked. Respondents were asked to comment on the channels of communication presently operating between themselves and coaches, athletes and officials, and whether they felt the system was conducive t o the athletes' well-being. Details regarding how much time the physiotherapists gave t o their sport, the travel involved, and the type of leave taken, were elicited. information was also collected on the receipt of fees and whether the physiotherapists received travel expenses. Pilot Study A pilot study was conducted t o test the questionnaire design and nine physiotherapists, five'of whom worked w i th local sports teams and four from the study population, completed the questionnaire. As a result minor changes in wording and format were implemented and further piloting was considered unnecessary. A s only 5 3 physiotherapists w h o met the entry criteria were identified, it was decided that when piloting only four subjects meeting the criteria should be used.
Results In the main study 49 questionnaires were sent out and a response rate of 55% ( 2 7 ) achieved. However, only 2 5 questionnaires were analysed as t w o respondents felt unable to complete both parts due to recent changed circums tances in their sporting involve ment . The Physiotherapists Of the 2 5 physiotherapists, 7 6 % were female, and overall the mean age was 3 2 w i t h a range from 2 4 t o 57 years. The mean length of time since qualifying was 10 years w i th a range of 2 t o 3 3 years and the average time since qualifization to governing body appointment was six years (range: 21 months t o 18 years). The majority were employed by the National Health Service in senior I grades and 80% (22) worked full-time; 5 6 % (14) also worked part-time in a local sports injuries clinic. Only four people replied positively when asked if they possessed any other qualifications, for example, a first-aid certificate, but all stated that they had recently attended a course relevant t o their work w i t h their sport ahd t seemed that mobilisations (Maitland and Cyriax) and sports-oriented courses were favoured. Interestingly, 64% (16) respondents felt that completion of a recognised sports medicine course was an unneccessary pre-requisite 3ut all agreed that a sound clinical basis and in-depth mowledge of the sport was vital. Membership of 21 different Specific Interest Groups or similar were listed w i th the ACPSM and BASM proving most popular. Most physiotherapists appeared t o confine their sporting
687
involvement t o one governing body only, but seven replied that they had ad hoc arrangements t o cover other sports at this level on an occasional basis. Approximately half of all respondents had participated in a sport at county level or above and seven of these had participated in the sport in which they now act as physiotherapist. Of the subjects 4 8 % (12) stated that they possessed a coaching, judging, timekeeping or umpiring award in a sport and seven of these possessed such an award in the sport in which they provided a physiotherapy service. The mean length of time worked for the governing body in which the respondent was the physiotherapist was four ye'ars but it ranged from three months t o 15 years. Of the 2 5 physiotherapists 19 had been recommended, either by a professional colleague already involved in that sport or by an athlete. Five physiotherapists were invited by the governing body's director of coaching and the t w o swimming respondents had progressed, as physiotherapists, from club and county involvement t o national team physiotherapists. The British Ski Federation advertises for physiotherapists in Physiotherapy and t w o of the skiing respondents had been appointed in this way. Only four physiotherapists were former competitors; three of the five British Amateur Gymnastics physiotherapists fell into this category.
The Role of the Physiotherapist The physiotherapists' role, as identified from the data collected, covered the areas of injuries and treatment, iniury prevention, administration duties, and miscellaneous. Injuries and Treatments Soft tissue injuries appeared t o be the most common lesions seen by the physiotherapists. Ankle sprains were identified as the most frequently encountered injury. The physiotherapists working for the same governing body demonstrated a consensus with regard t o the injury most commonly seen in their sport, eg the three swimming physiotherapists all listed rotator cuff problems. Respondents were asked t o list the physiotherapeutic modalities commonly used in their management of national team athletes and results showed that ultrasound (84%), massage ( 8 0 % ) and ice ( 7 2 % ) were the most frequently applied treatments. Exercise (68%) and mobilisations (64%) were also popular and 14 different treatment modalities were listed, ranging from advice t o laser therapy. It appears that 2 3 governing bodies utilise the services of a doctor but it is rare for them t o attend national squad training sessions. Consequently 9 2 % (23) physiotherapists stated that they were the first contact for the athletes and coaches with regard t o medical matters. The most common problems appeared t o be respiratory disorders (eg colds), headaches, emotional problems and gastrointestinal complaints. In most instances the patient was referred t o the honorary doctor or hidher general practitioner. Injury Prevention Injury prevention is largely accomplished through coach and athlete education, the former receiving both formal and informal lectures on the subject, and both groups being involved in discussions on the prevention of re-injury. Education of parents and officials played a small but important part in the physiotherapists' role. The consensus of opinion was that prevention through education 'is very hard work with very little feedback'. Other methods of preventive work included prophylactic exercise regimes,
688
alteration of the conditioning programme, re-education of technique, alteration of equipment and the prescription of orthoses. It was interesting that those physiotherapists who stated that they altered the athletes' training programme or re-educated their technique were ex-participants. Of the total, 44% (11) stated that they were actively engaged in coach education. Similarly, of the ten physiotherapists who stated they were involved in the training programme, six were either excompetitors or possessed relevant coaching qualifications. The extent of involvement ranged from advice regarding the suitability of specific training regimes t o organising the warm-up, stretching and cool-down sessions. Most physiotherapists did not appear t o be directly involved in making decisions regarding selection for international events but were consulted' with regard to injury fitness. No physiotherapist in a professional capacity was involved in the selection of new members to t h e national team. Many respondents felt that communication could be improved and that an open relationship with the coaches, with time for discussion, was to be recommended. Administrative Details Most physiotherapists kept records of their consultations, either in an index card system or by notes in a loose-leaf file. A Problem Oriented Medical Record approach seemed favoured but it was interesting t o note that certain sports recorded specialised details, eg hockey and rowing noted the player's position within the team. In cases where a course of treatment was required, the majority of physiotherapists endeavoured t o arrange local physiotherapy, either by direct contact with a colleague or through the athlete's general practitioner. The facilities enjoyed by national team physiotherapists varied widely. For those sports with a permanent base, a private room with plinth and hot and cold running water was available. For those sports without a national training centre, facilities were extremely variable and often the physiotherapist's hotel bedroom doubled up as the treatment room. Ten of the physiotherapists supplied their own ultrasound machines and ten of the governing bodies also supplied similar equipment. Twenty-four respondents stated that they did not have a job description and 17 thought it would be useful, as their role could then be defined and understood by the coaches. However, a flexible approach was recommended as the questionnaire demonstrated that the physiotherapists' duties were not limited t o simply treating injuries. Miscellaneous On average, the majority of physiotherapists spent up t o a quarter of their free time engaged in national training, and considerable time was spent travelling to and from venues; often the return journey was in excess of 150 miles. Most physiotherapists took annual leave t o pursue their national squad duties, and sometimes unpaid leave was taken, for which no governing body offered reimbursement. Nineteen physiotherapists received full reimbursement for travel expenses but this varied between the different squads of a sport. The overwhelming majority (21) did not receive reimbursement for their services.
Discussion The 55% response rate was disappointing and may be partly attributable to the complexity of the questionnaire, which took a minimum of 2 0 minutes t o complete.
Physiotherapy, December 1989, vol75, no 12
The Governing Body Response Many of the problems in this study arose from the difficulty of extracting current and accurate information from the governing bodies. In some instances it was found that the addresses given by the governing bodies were out of date; also some names known t o the BOA-Physiotherapy Sub-committee had been omitted. Many of the governing bodies did not identify the team with which the physiotherapist worked and the physiotherapists' responses confirmed that many (15) worked only within a specific squad and not for the entire governing body. Not only does it seem that communication within some of the governing bodies was unreliable but also the communication between the different squads and the governing body appeared uncoordinated. One governing body (table tennis) stated that while it did not employ physiotherapists it did use the services of an osteopath, and some governing bodies used the questionnaire to gain information. For example, the British and Irish Basketball Association and British Volleyball Association intimated their interest in appointing suitable candidates. In these cases the request was passed on t o the BOA and as a result an appointment was made. Despite the difficulties associated with identifying the physiotherapists, it is considered that over 9 0 % of the eligible population received a questionnaire. At present there is no register of Chartered physiotherapists working with national teams and as one of the objectives of the BOA-Physiotherapy Sub-committee is t o improve the provision of physiotherapy services, it would be sensible for the BOA to administer this. The Physiotherapists' Role In this study the female/male ratio was 76%:24% compared with the Chartered Society of Physiotherapy's membership numbers (95%:5%). As surmised, this group has a very strong interest in sport and it is as a result of this personal contact that an appointment to a governing body is made. There does not appear t o be any systematic progression within a sport (ie most physiotherapists simply begin their professional sporting career as national physiotherapist), or governing body policy on the appointment of suitable candidates. This casual approach does little t o enhance the status of physiotherapists in sport and it is recommended that the BOA advise governing bodies on recruitment procedures and act as a peer review body to maintain professional standards. The majority of respondents agreed that completion of a recognised course was unnecessary and considered that a thorough grounding in basic physiotherapy (as evidenced by the gap of six years from qualification to sporting appointment) and hands-on practice were sufficient. This may be a reflection on the seniority of the group or the absence of suitable courses. The study highlighted the need for physiotherapists t o be competent in diagnosing and treating soft tissue injuries and it appears that specific training in first-aid and management of routine medical conditions must be included in any course on sports medicine. Knowledge of the particular sport was considered essential and perhaps this is one of the reasons (the other being time constraints) why most physiotherapists work with one sport only. The enthusiasm and commitment of the physiotherapists was in no doubt and was evidenced by the considerable time they spent engaged in their work with the national teams, including sometimes excessive travelling time, the use of
annual leave t o pursue their duties, and the lack of financial reward. This dedication was further illustrated by the physiotherapists' membership of sports organisations and by attendance at recent courses considered relevant to their work in sport. The educational role played by the physiotherapists suggests that developed interpersonal skills are required t o maintain an harmonious relationship as the following comments illustrate: 'The coach k n o w s best' and 'Considerable tact is necessary for fear of criticising'. A n article on 'the coach/physiotherapist relationship' (Campbell, 1986) advocates that a successful relationship can be established only by two-way communication, and this study strongly demonstrated that good communication between the various governing body officials and the physiotherapists is vital for the athletes' benefit. It is therefore recommended that the medical team has regular meetings w i th the governing body t o discuss policies and strategies for maintaining and improving a high standard of co-ordinated care. The rowing, fencing, hockey and gymnastics associations regularly hold such meetings, and this may help towards improving the physiotherapists' status within those sports. The fact that 17 respondents felt it would be useful to have a job description does perhaps show the uncertainty felt by the physiotherapists and others over their role. It would be useful for the BOA t o issue guide lines, bearing in mind Bob Willis' (1979) comments on the role: 'He is so much more than a physiotherapist. He is father, confessor, nurse-maid, a friend t o all w h o need him.' Indeed, the results from this study show that the physiotherapists act as chaperone, driver, mother, friend, time-keeper and public relations officer as and when the need arises.
Conclusion This survey attempted t o identify the role of Chartered physiotherapists working w i t h the national teams of governing bodies of the Olympic sports. It has demonstrated that not only do the physiotherapists treat injuries, they act in a variety of other capacities and perform these duties o n a regular basis, often in inadequate surroundings and without receiving payment. The results suggest that adequate training in professional, educational, managerial and counselling skills is essential, and a strong personal enthusiasm for sport a pre-requisite. It seems that the commitment made by physiotherapists is sometimes undervalued by the governing bodies. In view of this 'world which is notoriously inconsiderate and unreliable' physiotherapists 'must possess a certain personality in order t o tolerate a constantly fluctuating environment in terms of attitudes, behaviour and sense of values' (Wright, 1979). The demands placed upon governing bodies t o produce medalwinning performances is resulting in a more professional approach to sport, and physiotherapists must make sure that their contribution is equally professional and valued if it is t o be of maximum benefit to the athlete. One of the objectives of the BOA-Physiotherapy Sub-committee is t o improve the provision and quality of physiotherapy services offered t o its affiliated members, and this study has demonstrated the clear need for some directives. ACKNOWLEDGMENTS Grateful thanks are extended t o all respondents who took the
irouble to complete the questionnaire and to the British Olympic 4ssociation-Physiotherapy Sub-committee, and in particular to i e l e n Bristow who gave me continual encouragement.
A
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REFERENCES Anon (1981/82). 'All in a week's work', Physiotherapy in Sport, V, 1, 2 - 6 . Campbell, S (1986). 'The coachiphysiotherapist relationship', Physiotherapy in Sport, IX, 2, 9-12. Chapman, D P (1977). 'Report of a questionnaire conducted by t h e Association of Chartered Physiotherapists in Sports Medicine', Physiotherapy in Sport, 1, 2, 2 6 - 2 9 . John, M (1983). 'Physiotherapy's role in t h e marathon race fever', Physiotherapy in Sport, VI, 1, 16-17.
~
Macdonald, R P (1983). 'Report on the third European veterans games', Physiotherapy in Sport, VI, 1, 14-15. Smith, G 11981). 'An overview of physiotherapy of athletes', Physiotherapy in Sport, IV, 3, 5-6. Whitney, S (1983). 'World c u p hockey', Physiotherapy, 69, 11, 390-392. Willis, B (1979). Diary of a Cricket Season, Pelham Books. Wright, D (19791. 'Prevention of injuries in sport', fhysiotherapg 65, 4, 114-119.
Assessment and Treatment of Knee In-juries with Particular Attention to the Hamstring Muscles and Joint Swelling GUNNEL A L BERRY MCSP
Physiotherapist, Sports Injury Clinic, Alton Sports Centre, and private practitioner
Key words:
anatomy and function of the hamstring muscles are included. The posterior femoral muscles (the hamstrings) consist of the semitendinosus (ST), the semimembranosus (SM), and the biceps femoris (BF).
Knee injury, hamstrings,' joint swelling, home exercises,
rehabilitation.
Origins
Summary:
This article attempts to highlight methods of assessment and treatment of knee injuries with particular attention to the hamstring muscles and reduction of joint swelling. Methods of treatment are left as brief as possible to give room for individual choice.
ST Upper part of the tuberosity of the ischium, by a tendon common to it and the long head of the BF, from an aponerosis connecting the adjacent surfaces of the t w o muscles.
Biography: Mrs Berry trained at the Middlesex Hospital, London, from
SM: Arises by a thick tendon from the upper and lateral impression on the tuberosity of the ischium. The tendon of origin also receives t w o fibrous expansions which lie on either side of the adductor magnus.
1971 to 74, and then returned to her native Sweden for 2% years. She gained the Swedish physiotherapy qualification and worked in general hospitals and in the community in Kalmar, Uppsala and Lapland in Sweden. She returned to England in 1977 and worked at Haslemere District Hospital, then spent a year in Borneo as an accompanying wife, and worked as a volunteer in a disabled children's home. After maternity leave she worked as a part-time physiotherapist at the Lord Mayor Treloar Hospital, Alton. Mrs Berry started in private practice in 1984 doing domiciliary work, and in 1987 started at the Sports Injury Clinic in Alton. She qualified as certified reflexologist at the Bayly School of Reflexology in February 1989.
Introduction THIS paper outlines assessment procedures and gives a summary of the aims of treatment for knee injuries. It proposes that hamstring tendons are often responsible for symptoms of knee injuries where there is an absence of diagnosis. Even though the wasting of the quadriceps muscles is greater than that of the hamstrings after knee injury (Kannus, 1988), it is most important t o keep in mind that, the hamstrings are the most common of muscle tears and that they are particularly vulnerable in all short speed activities such as football and short distance running (Devereaux e t a / , 1983). The role of the quadriceps muscles in knee rehabilitation is well documented (see Smillie, 1978) but very little has been said about the hamstrings. This paper also suggests that control of joint swelling should be the first aim in knee rehabilitation. According t o Noyes et a/ (1983), swelling is an early sign of future problems and Walla e t a / (1985) suggest that degenerative changes on X-ray film are directly related t o swelling as a warning of future impairment. The case histories describe knee injuries where both hamstring tendons and joint swelling had been ignored during assessment. However, with the correct diagnosis and proper treatment a successful outcome was achieved in each case. For easy reference a brief description and diagrams of the 690
BF: Has t w o heads of origin - one, the long head, arises from the lower and medial impression on the upper part of the ischial tuberosity by a common tendon to it and the ST and from the lower part of the sacrotuberous ligament; the other, the short head, from the lateral lip of the linea aspera of the femur between adductor magnus and vastus lateralis extending up almost as high as the insertion of gluteus maximus from the lateral supracondylar line to within 5 c m of the lateral condyle and from the lateral intermuscular septum.
Insertion (see figure opposite)
ST The medial side of the upper part of the shaft of the tibia behind sartorius and inferior t o gracilis; at its insertion it is united with the tendon of gracilis. SM: Into a groove on the back of the medial condyle of the tibia, t o the back of the capsule of the knee joint and to bone inferior t o the medial ligament.
BF: The t w o heads join to form a tendon which is inserted in the lateral aspect of the head of the fibula, inferior t o the fibular collateral ligament of the knee (Joseph, 1984; Gray's Anatomy, 1969). Function The posterior femoral muscles, acting from above, flex the leg on the thigh (knee flexion). Acting from below, they support the pelvis on the head of the femur and they draw the trunk backwards when it is raised from the stooping position (hip extension). When the knee is semi-flexed, the biceps femoris can act as a lateral rotator and the semitendinosus and semimembranosus as medial rotators of the leg (Gray's Anatomy, 1969). Physiotherapy, December 1989, vol75, no 12
Key words: Questionnaire, physiotherapy, Olympics, sport. SUmmary: This article describes the results of a postal questionnaire
sent to Chartered physiotherapists who work with the national teams of the Olympic sports, the aim of which was to identify their role. Results showed that team physiotherapists had a multiplicity of roles and a keen commitment to their sport in the face of poor working conditions. The implications of this are discussed and recommendationsmade for a more co-ordinated service and understanding by the governing bodies.
Biography: Jane Hall is a research physiotherapist at the Royal National
Hospital for Rheumatic Diseases, Bath, and in her spare time acts as honorary physiotherapist to the Great Britain Rhythmic Gymnastics Team. This study was prompted by a curiosity to find out if similar physiotherapists existed, and if they did, whether their .roles were comparable.
Introduction THE aim of this study was t o identify the role of Chartered physiotherapists working with the national teams, in both training and competition, of sports affiliated t o the British Olympic Association. Literature Search A literature search revealed several personal accounts of the authors' experiences at a sporting event (John, 1983; Macdonald, 1983; Anon, 1981/82; Whitney, 1983) and these principally detail the injuries treated. Historically 'spongemen' have been used in sport at all levels and a survey (Chapman, 19771, conducted on behalf of the Association of Chartered Physiotherapists in Sports Medicine (ACPSM) showed that this was still the case in 1975. The aim of the survey was to 'ascertain the staff, honorary or paid' available t o selected sports clubs. Questionnaires were posted to 3,031 clubs through the mailing lists of the governing bodies and despite the poor return rate (9.9%) the results demonstrated that unqualified physiotherapists (28%) predominated (compared t o 7 % of Chartered physiotherapists). Informal discussion with the various bodies involved suggests that the physiotherapy profession has made some, if not considerable, inroads into changing the situation of 1975. This may be due, in part, to the advent of 'amateur' professional sportsmen and women and the increasingly important role of the sponsors and media. As a consequence the demands made on the medical support staff have assumed a greater importance. Despite this Grant Smith's (1981) observation detailing 'the reluctance on the part of the individual and of sports groups in general to accept that time, skills and materials are valuable and expensive commodities' appears t o hold fast and the financial incentives t o provide a physiotherapy service remain poor.
686
Identifying the Study Population The present survey was carried out between March 1988 and January 1989 by means of a postal questionnaire, sent to those physiotherapists involved in both the training and competition environments of national squads. Before the study could begin it was necessary to identify the Olympic sports which utilise the services of Chartered physiotherapists and this was done through a number of different channels. The British Olympic Association (BOA), the ACPSM and the British Association of Sport and Medicine (BASMI were asked to supply registers of the relevant physiotherapists. Unfortunately, none of these bodies keep such a list. It was therefore decided to approach the 28 governing bodies of the Olympic sports affiliated to the BOA. Names and addresses of the Chartered physiotherapists providing a physiotherapy service to that sport were requested. In this way 71 Chartered physiotherapists were identified (see table). The BOA Physiotherapy Sub-committee indicated that a further nine individuals were involved and advised that some of their representatives had been omitted in the original governing body lists. The governing bodies were asked to identify the national team with which the physiotherapist worked. For example, it was known that the Amateur Rowing Association had six distinct squads: men's heavyweight, men's lightweight, women's heavyweight, women's lightweight, junior men and junior women. Many of the governing bodies did not give this information and if the information was given it was likely, when cross-referenced, t o be incomplete. Time and financial constraints limited the governing bodies investigation to an initial and follow-up postal contact only. Despite misgivings that the governing bodies would list all Chartered and non-Chartered physiotherapists, this in fact did not occur and governing bodies appeared t o appreciate the significance of the title 'Chartered physiotherapist'. Some sports, eg the British Amateur Athletics Association, do not have national team training as such and the services of honorary physiotherapists are used for national and international competitions only. A s the aim of the survey was to identify the physiotherapists' role in both training and competition environments it was decided that, in these cases, only the BOA representative would be the spokesperson. Therefore, while a total of 79 Chartered physiotherapists was identified, postal questionnaires were sent t o only 53 people (see table).
The Questionnaire The data were collected by means of a postal questionnaire. A covering letter and stamped addressed envelope were included and a reminder was sent to non-respondents t w o weeks after the initial reply date. The questionnaire was divided into t w o parts and consisted partly of closed and partly of open questions; space was given for comments on each question. Part I concerned the physiotherapists' personal and career details.
Physiotherapy, December 1989, vol75, no 12
Number of Chartered physiotherapists identified, questionnaires sent and responses received ~~
~
Governing body Amateur Fencing Association Amateur Rowing Association Amateur Swimming Federation British Amateur Athletics Board British Amateur Boxing Association British Amateur Gymnastics Association British Amateur Weightlifters' Association British Amateur Wrestling Association British Bobsleigh Association British and Irish Basketball Association British Canoe Union British Cycling Federation British Equestrian Federation British Handball Association British Ice Hockey Association British Judo Association British Racing Toboggan Association British Ski Federation British Volleyball Association Football Association Grand National Archery Society Great Britain Hockey Board Great Britain Target Shooting Federation Joint United Kingdom Table Tennis Committee Lawn Tennis Association Modern Pentathlon Association of Great Britain National Skating Association of Great Britain Royal Yachting Association Totals
Chartered physiotherapists Questionnaires Responses identified sent received
4 10
4 8
3
5
5
3
22
1
1
1
1
0
7
6
5
1
1
0
2 1
2 1
0
0 0 1
0
0
0 1
5
1
0 1 0
3
0 3
0 3
0 3
0
0 3 3
0 3
1
0 3 3 1
1 7
1 7
2
0
0
0
0
0 1
0 0
0
0
0
1
2
2
1
2
1 1
0
0
0
79
53
31
1
1
0
Questionnaires were sent only to BOA representatives.
Part II of the questionnaire was designed t o elicit the physiotherapists' role in respect of the following: 1. Circumstances of appointment - respondents were asked to detail the mechanism by which they were appointed ('How did you become honorary physiotherapist for this sport'?)
2. Extent of duties - details of duties other than recognisable physiotherapeutic tasks were sought. For example, a Likert-type scale was used to determine the extent of the physiotherapists' involvement in 'nonphysiotherapy conditions' (eg respiratory tract infections, menstrual, gastro-intestinal, emotional problems, etc) and the most common problems and the treatment offered were requested. The penultimate question asked physiotherapists to 'state any other duties that you carry out on behalf of your governing body'.
3. Injuries commonly encountered - physiotherapists were asked t o list the three most common injuries in their sport. 4. Facilities and treatments - respondents were asked t o list the facilities available at their usual squad training centre
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(eg private room, hoticold water, plinth, ice, first-aid equipment, etc) and the treatment modalities supplied by themselves and by the governing body. Treatment modalities commonly used in their treatment of squad athletes were requested. 5. The physiotherapists' involvement in training, team selection, education and injury prevention was detailed and the level of satisfaction w i t h these activities assessed (eg 'Are you involved in the selection of new squad members? If yes, please explain the extent of your involvement', and 'Are you satisified w i t h your level of involve m ent '? )
6. Management and administrative details - specific questions regarding the type of records kept and the liaison between governing body doctors (if available) and physiotherapists were asked. Respondents were asked to comment on the channels of communication presently operating between themselves and coaches, athletes and officials, and whether they felt the system was conducive t o the athletes' well-being. Details regarding how much time the physiotherapists gave t o their sport, the travel involved, and the type of leave taken, were elicited. information was also collected on the receipt of fees and whether the physiotherapists received travel expenses. Pilot Study A pilot study was conducted t o test the questionnaire design and nine physiotherapists, five'of whom worked w i th local sports teams and four from the study population, completed the questionnaire. As a result minor changes in wording and format were implemented and further piloting was considered unnecessary. A s only 5 3 physiotherapists w h o met the entry criteria were identified, it was decided that when piloting only four subjects meeting the criteria should be used.
Results In the main study 49 questionnaires were sent out and a response rate of 55% ( 2 7 ) achieved. However, only 2 5 questionnaires were analysed as t w o respondents felt unable to complete both parts due to recent changed circums tances in their sporting involve ment . The Physiotherapists Of the 2 5 physiotherapists, 7 6 % were female, and overall the mean age was 3 2 w i t h a range from 2 4 t o 57 years. The mean length of time since qualifying was 10 years w i th a range of 2 t o 3 3 years and the average time since qualifization to governing body appointment was six years (range: 21 months t o 18 years). The majority were employed by the National Health Service in senior I grades and 80% (22) worked full-time; 5 6 % (14) also worked part-time in a local sports injuries clinic. Only four people replied positively when asked if they possessed any other qualifications, for example, a first-aid certificate, but all stated that they had recently attended a course relevant t o their work w i t h their sport ahd t seemed that mobilisations (Maitland and Cyriax) and sports-oriented courses were favoured. Interestingly, 64% (16) respondents felt that completion of a recognised sports medicine course was an unneccessary pre-requisite 3ut all agreed that a sound clinical basis and in-depth mowledge of the sport was vital. Membership of 21 different Specific Interest Groups or similar were listed w i th the ACPSM and BASM proving most popular. Most physiotherapists appeared t o confine their sporting
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involvement t o one governing body only, but seven replied that they had ad hoc arrangements t o cover other sports at this level on an occasional basis. Approximately half of all respondents had participated in a sport at county level or above and seven of these had participated in the sport in which they now act as physiotherapist. Of the subjects 4 8 % (12) stated that they possessed a coaching, judging, timekeeping or umpiring award in a sport and seven of these possessed such an award in the sport in which they provided a physiotherapy service. The mean length of time worked for the governing body in which the respondent was the physiotherapist was four ye'ars but it ranged from three months t o 15 years. Of the 2 5 physiotherapists 19 had been recommended, either by a professional colleague already involved in that sport or by an athlete. Five physiotherapists were invited by the governing body's director of coaching and the t w o swimming respondents had progressed, as physiotherapists, from club and county involvement t o national team physiotherapists. The British Ski Federation advertises for physiotherapists in Physiotherapy and t w o of the skiing respondents had been appointed in this way. Only four physiotherapists were former competitors; three of the five British Amateur Gymnastics physiotherapists fell into this category.
The Role of the Physiotherapist The physiotherapists' role, as identified from the data collected, covered the areas of injuries and treatment, iniury prevention, administration duties, and miscellaneous. Injuries and Treatments Soft tissue injuries appeared t o be the most common lesions seen by the physiotherapists. Ankle sprains were identified as the most frequently encountered injury. The physiotherapists working for the same governing body demonstrated a consensus with regard t o the injury most commonly seen in their sport, eg the three swimming physiotherapists all listed rotator cuff problems. Respondents were asked t o list the physiotherapeutic modalities commonly used in their management of national team athletes and results showed that ultrasound (84%), massage ( 8 0 % ) and ice ( 7 2 % ) were the most frequently applied treatments. Exercise (68%) and mobilisations (64%) were also popular and 14 different treatment modalities were listed, ranging from advice t o laser therapy. It appears that 2 3 governing bodies utilise the services of a doctor but it is rare for them t o attend national squad training sessions. Consequently 9 2 % (23) physiotherapists stated that they were the first contact for the athletes and coaches with regard t o medical matters. The most common problems appeared t o be respiratory disorders (eg colds), headaches, emotional problems and gastrointestinal complaints. In most instances the patient was referred t o the honorary doctor or hidher general practitioner. Injury Prevention Injury prevention is largely accomplished through coach and athlete education, the former receiving both formal and informal lectures on the subject, and both groups being involved in discussions on the prevention of re-injury. Education of parents and officials played a small but important part in the physiotherapists' role. The consensus of opinion was that prevention through education 'is very hard work with very little feedback'. Other methods of preventive work included prophylactic exercise regimes,
688
alteration of the conditioning programme, re-education of technique, alteration of equipment and the prescription of orthoses. It was interesting that those physiotherapists who stated that they altered the athletes' training programme or re-educated their technique were ex-participants. Of the total, 44% (11) stated that they were actively engaged in coach education. Similarly, of the ten physiotherapists who stated they were involved in the training programme, six were either excompetitors or possessed relevant coaching qualifications. The extent of involvement ranged from advice regarding the suitability of specific training regimes t o organising the warm-up, stretching and cool-down sessions. Most physiotherapists did not appear t o be directly involved in making decisions regarding selection for international events but were consulted' with regard to injury fitness. No physiotherapist in a professional capacity was involved in the selection of new members to t h e national team. Many respondents felt that communication could be improved and that an open relationship with the coaches, with time for discussion, was to be recommended. Administrative Details Most physiotherapists kept records of their consultations, either in an index card system or by notes in a loose-leaf file. A Problem Oriented Medical Record approach seemed favoured but it was interesting t o note that certain sports recorded specialised details, eg hockey and rowing noted the player's position within the team. In cases where a course of treatment was required, the majority of physiotherapists endeavoured t o arrange local physiotherapy, either by direct contact with a colleague or through the athlete's general practitioner. The facilities enjoyed by national team physiotherapists varied widely. For those sports with a permanent base, a private room with plinth and hot and cold running water was available. For those sports without a national training centre, facilities were extremely variable and often the physiotherapist's hotel bedroom doubled up as the treatment room. Ten of the physiotherapists supplied their own ultrasound machines and ten of the governing bodies also supplied similar equipment. Twenty-four respondents stated that they did not have a job description and 17 thought it would be useful, as their role could then be defined and understood by the coaches. However, a flexible approach was recommended as the questionnaire demonstrated that the physiotherapists' duties were not limited t o simply treating injuries. Miscellaneous On average, the majority of physiotherapists spent up t o a quarter of their free time engaged in national training, and considerable time was spent travelling to and from venues; often the return journey was in excess of 150 miles. Most physiotherapists took annual leave t o pursue their national squad duties, and sometimes unpaid leave was taken, for which no governing body offered reimbursement. Nineteen physiotherapists received full reimbursement for travel expenses but this varied between the different squads of a sport. The overwhelming majority (21) did not receive reimbursement for their services.
Discussion The 55% response rate was disappointing and may be partly attributable to the complexity of the questionnaire, which took a minimum of 2 0 minutes t o complete.
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The Governing Body Response Many of the problems in this study arose from the difficulty of extracting current and accurate information from the governing bodies. In some instances it was found that the addresses given by the governing bodies were out of date; also some names known t o the BOA-Physiotherapy Sub-committee had been omitted. Many of the governing bodies did not identify the team with which the physiotherapist worked and the physiotherapists' responses confirmed that many (15) worked only within a specific squad and not for the entire governing body. Not only does it seem that communication within some of the governing bodies was unreliable but also the communication between the different squads and the governing body appeared uncoordinated. One governing body (table tennis) stated that while it did not employ physiotherapists it did use the services of an osteopath, and some governing bodies used the questionnaire to gain information. For example, the British and Irish Basketball Association and British Volleyball Association intimated their interest in appointing suitable candidates. In these cases the request was passed on t o the BOA and as a result an appointment was made. Despite the difficulties associated with identifying the physiotherapists, it is considered that over 9 0 % of the eligible population received a questionnaire. At present there is no register of Chartered physiotherapists working with national teams and as one of the objectives of the BOA-Physiotherapy Sub-committee is t o improve the provision of physiotherapy services, it would be sensible for the BOA to administer this. The Physiotherapists' Role In this study the female/male ratio was 76%:24% compared with the Chartered Society of Physiotherapy's membership numbers (95%:5%). As surmised, this group has a very strong interest in sport and it is as a result of this personal contact that an appointment to a governing body is made. There does not appear t o be any systematic progression within a sport (ie most physiotherapists simply begin their professional sporting career as national physiotherapist), or governing body policy on the appointment of suitable candidates. This casual approach does little t o enhance the status of physiotherapists in sport and it is recommended that the BOA advise governing bodies on recruitment procedures and act as a peer review body to maintain professional standards. The majority of respondents agreed that completion of a recognised course was unnecessary and considered that a thorough grounding in basic physiotherapy (as evidenced by the gap of six years from qualification to sporting appointment) and hands-on practice were sufficient. This may be a reflection on the seniority of the group or the absence of suitable courses. The study highlighted the need for physiotherapists t o be competent in diagnosing and treating soft tissue injuries and it appears that specific training in first-aid and management of routine medical conditions must be included in any course on sports medicine. Knowledge of the particular sport was considered essential and perhaps this is one of the reasons (the other being time constraints) why most physiotherapists work with one sport only. The enthusiasm and commitment of the physiotherapists was in no doubt and was evidenced by the considerable time they spent engaged in their work with the national teams, including sometimes excessive travelling time, the use of
annual leave t o pursue their duties, and the lack of financial reward. This dedication was further illustrated by the physiotherapists' membership of sports organisations and by attendance at recent courses considered relevant to their work in sport. The educational role played by the physiotherapists suggests that developed interpersonal skills are required t o maintain an harmonious relationship as the following comments illustrate: 'The coach k n o w s best' and 'Considerable tact is necessary for fear of criticising'. A n article on 'the coach/physiotherapist relationship' (Campbell, 1986) advocates that a successful relationship can be established only by two-way communication, and this study strongly demonstrated that good communication between the various governing body officials and the physiotherapists is vital for the athletes' benefit. It is therefore recommended that the medical team has regular meetings w i th the governing body t o discuss policies and strategies for maintaining and improving a high standard of co-ordinated care. The rowing, fencing, hockey and gymnastics associations regularly hold such meetings, and this may help towards improving the physiotherapists' status within those sports. The fact that 17 respondents felt it would be useful to have a job description does perhaps show the uncertainty felt by the physiotherapists and others over their role. It would be useful for the BOA t o issue guide lines, bearing in mind Bob Willis' (1979) comments on the role: 'He is so much more than a physiotherapist. He is father, confessor, nurse-maid, a friend t o all w h o need him.' Indeed, the results from this study show that the physiotherapists act as chaperone, driver, mother, friend, time-keeper and public relations officer as and when the need arises.
Conclusion This survey attempted t o identify the role of Chartered physiotherapists working w i t h the national teams of governing bodies of the Olympic sports. It has demonstrated that not only do the physiotherapists treat injuries, they act in a variety of other capacities and perform these duties o n a regular basis, often in inadequate surroundings and without receiving payment. The results suggest that adequate training in professional, educational, managerial and counselling skills is essential, and a strong personal enthusiasm for sport a pre-requisite. It seems that the commitment made by physiotherapists is sometimes undervalued by the governing bodies. In view of this 'world which is notoriously inconsiderate and unreliable' physiotherapists 'must possess a certain personality in order t o tolerate a constantly fluctuating environment in terms of attitudes, behaviour and sense of values' (Wright, 1979). The demands placed upon governing bodies t o produce medalwinning performances is resulting in a more professional approach to sport, and physiotherapists must make sure that their contribution is equally professional and valued if it is t o be of maximum benefit to the athlete. One of the objectives of the BOA-Physiotherapy Sub-committee is t o improve the provision and quality of physiotherapy services offered t o its affiliated members, and this study has demonstrated the clear need for some directives. ACKNOWLEDGMENTS Grateful thanks are extended t o all respondents who took the
irouble to complete the questionnaire and to the British Olympic 4ssociation-Physiotherapy Sub-committee, and in particular to i e l e n Bristow who gave me continual encouragement.
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REFERENCES Anon (1981/82). 'All in a week's work', Physiotherapy in Sport, V, 1, 2 - 6 . Campbell, S (1986). 'The coachiphysiotherapist relationship', Physiotherapy in Sport, IX, 2, 9-12. Chapman, D P (1977). 'Report of a questionnaire conducted by t h e Association of Chartered Physiotherapists in Sports Medicine', Physiotherapy in Sport, 1, 2, 2 6 - 2 9 . John, M (1983). 'Physiotherapy's role in t h e marathon race fever', Physiotherapy in Sport, VI, 1, 16-17.
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Macdonald, R P (1983). 'Report on the third European veterans games', Physiotherapy in Sport, VI, 1, 14-15. Smith, G 11981). 'An overview of physiotherapy of athletes', Physiotherapy in Sport, IV, 3, 5-6. Whitney, S (1983). 'World c u p hockey', Physiotherapy, 69, 11, 390-392. Willis, B (1979). Diary of a Cricket Season, Pelham Books. Wright, D (19791. 'Prevention of injuries in sport', fhysiotherapg 65, 4, 114-119.
Assessment and Treatment of Knee In-juries with Particular Attention to the Hamstring Muscles and Joint Swelling GUNNEL A L BERRY MCSP
Physiotherapist, Sports Injury Clinic, Alton Sports Centre, and private practitioner
Key words:
anatomy and function of the hamstring muscles are included. The posterior femoral muscles (the hamstrings) consist of the semitendinosus (ST), the semimembranosus (SM), and the biceps femoris (BF).
Knee injury, hamstrings,' joint swelling, home exercises,
rehabilitation.
Origins
Summary:
This article attempts to highlight methods of assessment and treatment of knee injuries with particular attention to the hamstring muscles and reduction of joint swelling. Methods of treatment are left as brief as possible to give room for individual choice.
ST Upper part of the tuberosity of the ischium, by a tendon common to it and the long head of the BF, from an aponerosis connecting the adjacent surfaces of the t w o muscles.
Biography: Mrs Berry trained at the Middlesex Hospital, London, from
SM: Arises by a thick tendon from the upper and lateral impression on the tuberosity of the ischium. The tendon of origin also receives t w o fibrous expansions which lie on either side of the adductor magnus.
1971 to 74, and then returned to her native Sweden for 2% years. She gained the Swedish physiotherapy qualification and worked in general hospitals and in the community in Kalmar, Uppsala and Lapland in Sweden. She returned to England in 1977 and worked at Haslemere District Hospital, then spent a year in Borneo as an accompanying wife, and worked as a volunteer in a disabled children's home. After maternity leave she worked as a part-time physiotherapist at the Lord Mayor Treloar Hospital, Alton. Mrs Berry started in private practice in 1984 doing domiciliary work, and in 1987 started at the Sports Injury Clinic in Alton. She qualified as certified reflexologist at the Bayly School of Reflexology in February 1989.
Introduction THIS paper outlines assessment procedures and gives a summary of the aims of treatment for knee injuries. It proposes that hamstring tendons are often responsible for symptoms of knee injuries where there is an absence of diagnosis. Even though the wasting of the quadriceps muscles is greater than that of the hamstrings after knee injury (Kannus, 1988), it is most important t o keep in mind that, the hamstrings are the most common of muscle tears and that they are particularly vulnerable in all short speed activities such as football and short distance running (Devereaux e t a / , 1983). The role of the quadriceps muscles in knee rehabilitation is well documented (see Smillie, 1978) but very little has been said about the hamstrings. This paper also suggests that control of joint swelling should be the first aim in knee rehabilitation. According t o Noyes et a/ (1983), swelling is an early sign of future problems and Walla e t a / (1985) suggest that degenerative changes on X-ray film are directly related t o swelling as a warning of future impairment. The case histories describe knee injuries where both hamstring tendons and joint swelling had been ignored during assessment. However, with the correct diagnosis and proper treatment a successful outcome was achieved in each case. For easy reference a brief description and diagrams of the 690
BF: Has t w o heads of origin - one, the long head, arises from the lower and medial impression on the upper part of the ischial tuberosity by a common tendon to it and the ST and from the lower part of the sacrotuberous ligament; the other, the short head, from the lateral lip of the linea aspera of the femur between adductor magnus and vastus lateralis extending up almost as high as the insertion of gluteus maximus from the lateral supracondylar line to within 5 c m of the lateral condyle and from the lateral intermuscular septum.
Insertion (see figure opposite)
ST The medial side of the upper part of the shaft of the tibia behind sartorius and inferior t o gracilis; at its insertion it is united with the tendon of gracilis. SM: Into a groove on the back of the medial condyle of the tibia, t o the back of the capsule of the knee joint and to bone inferior t o the medial ligament.
BF: The t w o heads join to form a tendon which is inserted in the lateral aspect of the head of the fibula, inferior t o the fibular collateral ligament of the knee (Joseph, 1984; Gray's Anatomy, 1969). Function The posterior femoral muscles, acting from above, flex the leg on the thigh (knee flexion). Acting from below, they support the pelvis on the head of the femur and they draw the trunk backwards when it is raised from the stooping position (hip extension). When the knee is semi-flexed, the biceps femoris can act as a lateral rotator and the semitendinosus and semimembranosus as medial rotators of the leg (Gray's Anatomy, 1969). Physiotherapy, December 1989, vol75, no 12