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Working in high performance and professional sport
Physical Therapy in Sport 13 (2012) 1–2
Contents lists available at SciVerse ScienceDirect
Physical Therapy in Sport journal homepage: www.elsevier.com/ptsp
Editorial
Working in high performance and professional sport
Welcome to the first issue of 2012, and as this heralds the start of an Olympic year, this is a special issue dedicated to research in high performance and professional sport. Working at the top level in sport is often the pinnacle of a clinician’s career and it can be one of the most rewarding experiences. However, working at this level can also raise many additional challenges to clinicians including working long hours under intense conditions, pressure from management and coaches in making decisions about players ability to train and play, responsibilities to the athlete and athlete confidentiality, working within your scope of practice, working in isolated situations in different locations both nationally and internationally, to name but a few. Sport has also become increasingly litigious and clinicians need to be aware of the rules and codes of the sport they are working with. Contraventions of professional or sporting rules of conduct could have serious implications for those concerned. One such example is the incident that has become known as ‘Bloodgate’. For those of you not familiar with this episode, it was during a quarter final game of the 2009 Heineken cup between Harlequins and Leinster. The important thing to note here is that in rugby union if a player is bleeding they are temporarily substituted whilst the blood injury is dealt with off the pitch. It was a very tight game and at a critical moment when a kick had been awarded, Harlequins faked a blood injury on a player in order to bring on a specialist kicker. The physiotherapist responsible for bringing on and giving the blood capsule to the player was suspended and subsequently struck off the professional register and had to go to the high court to appeal the ban. Eventually the physiotherapist was re-instated but only after a long legal battle. Ironically the doctor involved who, after the opposition suspected of faking the injury actually cut the players lip to try and disguise the fact and later denied doing so, was not struck off their respective professional register and only given a warning. The case raises many ethical and moral issues for all of us working in sport and the sometimes blurred lines between right and wrong. The commercial and personal pressures to succeed in sport can wrongly influence the surrounding team. One of the competencies for sports physiotherapists defined by the IFSP is the promotion of fair play and anti-doping practices. However in a piece of research looking at the perceptions of elite rowers in this issue, the athletes did not identify this as a role for sports physiotherapists. Is it time to revisit the list of competencies for sports physiotherapists or do we need to more clearly define what these roles are? One of the ongoing issues for those working in professional sport is that the results of research in healthy individuals are not 1466-853X/$ – see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ptsp.2011.12.002
necessarily representative of highly trained athletes. For those of you working with an elite group know how difficult it can be to carry out any research on these athletes. Apart from the barriers of time, ‘traditional research methods’ normally demand large sample sizes, however, clinicians are often working with a sample size of 1. This is not a barrier to researching methods that enhance recovery or improve performance in an individual; it just doesn’t and cannot fit classical research methodology. However, this doesn’t mean that it doesn’t have ecological validity, far from it. There are often the pressures of secrecy working at this level, which can lead to anecdotal reporting. All these elements are not very conducive to producing an evidence-based approach for managing these athletes. This combination of factors helps to perpetuate the myths of treatments such as extract of monkey hypothalamus. The articles in this issue are testament to the fact that research can be conducted at this level. A broad variety of sports is covered in this issue and includes weightlifting, rugby union, rowing, tennis, cricket, golf and Australian Rules. The subject for the masterclass of this special issue is very apt and whilst the topic has been written on at length, the management of the painful tendon in athletes continues to be a clinical challenge. The masterclass is presented by Mark Reinking from Saint Louis University and covers the conundrums and clinical decision making for the non-invasive management of this condition. In the first piece of original research, Patraporn Sitilertpisan and colleagues from Chiang Mai University examine the cross sectional area and symmetry of the lumbar multifidus (LM) at multiple levels in elite level weight lifters. The sample studied represented the entire population, male and female, available for national selection. The group was separated into those with and without LBP, and the resting cross sectional area of LM was measured using ultrasound. Perhaps not surprisingly, the cross sectional area was significantly larger in males compared to females, and the values obtained were greater than for normal healthy controls reported in the literature. However, there was no difference between those suffering current symptoms of LBP and those that were symptom free. The growing body of evidence suggests that highly trained individuals with LBP do not experience the same atrophy in LM seen in the non-athletic population. This does warrant some further thought about pain inhibition and atrophy and what is different in these highly trained athletes. The International Federation of Sports Physiotherapists (IFSP) has been instrumental in establishing the core competencies for sports physiotherapists. Aiden Woods and Catherine Woods from
2
Editorial / Physical Therapy in Sport 13 (2012) 1–2
Dublin City University present a piece of qualitative research exploring the perception of the role of the sports physiotherapist (SP) amongst a group of elite rowers. The combined experience of the rowers involved represented a total of 76 years competing at International level. The results were then mapped against the IFSP competencies. Interestingly of the 11 competencies defined by the IFSP, 9 were identified by this group of rowers. The ones that were not identified were the role of the SP in the promotion of a safe and active lifestyle, and the role the SP could play in promotion of fair play and anti-doping practices. The authors discuss the possible reasons for these omissions. Two of the over riding messages that came out from the athletes regarding SP’s were the importance of good communication and having an open mind with the respect of the athletes' opinions and the use of other practitioners. The prevention of shoulder injuries is an attractive proposition in overhead athletes. Peak torques and pure strength measures have limited application in endurance sports such as swimming or tennis where fatigue resistance may be more relevant. Roland Julienne and colleagues from the University of Caen BasseNormandie investigated the shoulder internal rotators using isokinetics and EMG, and compared the dominant and non-dominant arms in elite male tennis players during an isokinetic fatigue protocol. Interestingly, there was no fatigue resistance on the dominant side compared to the non-dominant side as one might have predicted. The authors discuss the possible reasons for these findings and the implications for conditioning programs for these athletes. Evaluation of performance is a fascinating area for research, especially in team sports where individual contributions are more difficult to quantify. There are many objective measures that can be employed, but there are just as many subjective elements such as psychological, skill and tactical factors that are less easily evaluated. Michael Kinchington and colleagues from Victoria University and the Australian Catholic University present a prospective study following 79 professional footballers (Australian rules and rugby union) for one season in order to examine associations between comfort and performance. The authors present the comfort index which is a validated outcome measure and has been shown to be a responsive instrument to assess rated performance criteria in football. Additionally, 2 useful case studies are included showing how players can be tracked over the season. ACL injury can be one of the most frustrating and psychologically challenging injuries from an athlete’s perspective with respect to the length of time to return to sport and the often protracted absence from the team environment during rehabilitation. In the second piece of qualitative research, Fraser Carlson and Remco Polman from the Australian College of Applied Psychology and the
University of Central Lancashire, respectively, present the experiences of 5 professional rugby union players who had spent between 6 and 12 months in rehabilitation. What is probably no surprise to clinicians working in this area was that confidence in the knee was a key influence psychologically, and the increase in confidence came from the ability to complete both clinical tests and performance tasks. Confidence building, anticipation and anxiety formed the general dimension ‘Influential Emotions’, while the ‘Coping Strategies’ general dimension comprised of the themes physical preparation, psychological preparation and social support. The authors discuss the different components within these individual themes which provide an insight to the psychological as well as physical progress and how these are achieved through the rehabilitation process. Injury evaluation in professional athletes can be difficult to collate for many reasons. For those sports such as tennis, track and field, golf and swimming, athletes will frequently be competing and training in different cities and often countries, and managing these athletes if they are not travelling with a medical team can be challenging. Mark Smith and Rob Hillman from the University of Lincoln and the European Golf Tour present an audit from the mobile physiotherapy unit following the Professional Golfers Association European tour at selected events over 2 seasons. The data provides some interesting insight into this unique group of players. Finally, Murray Johnson and colleagues from the University of Sydney present the literature review on the prevalence and risk factors of lumbar stress injury in fast bowlers. It is well established that the mixed bowling action has been strongly associated with the development of lumbar stress injury in these athletes. Current evidence suggests that for adult bowlers, excessive contralateral lumbar side-flexion during the delivery stride, rather than shoulder counter-rotation, is the key variable in the mixed action that increases the risk of lumbar spine injury. Whilst potential risk factors are identified, the areas of research required for the future (and this holds true for many areas of injury prevention) are the need for well conducted, prospective studies to test these theories. If you are a clinician working in the field and struggle to find time and/or support to do any research, don’t worry you have a wealth of information at your fingertips from your athletes. Why not start with a case study? You have all had interesting cases, so go on, write one up and make it your mission for the year. The thought is often worse than the action, and the feedback I get from clinicians who undertake the process is overwhelmingly positive. I hope you enjoy this special issue of Physical Therapy in Sport. Zoe Hudson Editor
Contents lists available at SciVerse ScienceDirect
Physical Therapy in Sport journal homepage: www.elsevier.com/ptsp
Editorial
Working in high performance and professional sport
Welcome to the first issue of 2012, and as this heralds the start of an Olympic year, this is a special issue dedicated to research in high performance and professional sport. Working at the top level in sport is often the pinnacle of a clinician’s career and it can be one of the most rewarding experiences. However, working at this level can also raise many additional challenges to clinicians including working long hours under intense conditions, pressure from management and coaches in making decisions about players ability to train and play, responsibilities to the athlete and athlete confidentiality, working within your scope of practice, working in isolated situations in different locations both nationally and internationally, to name but a few. Sport has also become increasingly litigious and clinicians need to be aware of the rules and codes of the sport they are working with. Contraventions of professional or sporting rules of conduct could have serious implications for those concerned. One such example is the incident that has become known as ‘Bloodgate’. For those of you not familiar with this episode, it was during a quarter final game of the 2009 Heineken cup between Harlequins and Leinster. The important thing to note here is that in rugby union if a player is bleeding they are temporarily substituted whilst the blood injury is dealt with off the pitch. It was a very tight game and at a critical moment when a kick had been awarded, Harlequins faked a blood injury on a player in order to bring on a specialist kicker. The physiotherapist responsible for bringing on and giving the blood capsule to the player was suspended and subsequently struck off the professional register and had to go to the high court to appeal the ban. Eventually the physiotherapist was re-instated but only after a long legal battle. Ironically the doctor involved who, after the opposition suspected of faking the injury actually cut the players lip to try and disguise the fact and later denied doing so, was not struck off their respective professional register and only given a warning. The case raises many ethical and moral issues for all of us working in sport and the sometimes blurred lines between right and wrong. The commercial and personal pressures to succeed in sport can wrongly influence the surrounding team. One of the competencies for sports physiotherapists defined by the IFSP is the promotion of fair play and anti-doping practices. However in a piece of research looking at the perceptions of elite rowers in this issue, the athletes did not identify this as a role for sports physiotherapists. Is it time to revisit the list of competencies for sports physiotherapists or do we need to more clearly define what these roles are? One of the ongoing issues for those working in professional sport is that the results of research in healthy individuals are not 1466-853X/$ – see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ptsp.2011.12.002
necessarily representative of highly trained athletes. For those of you working with an elite group know how difficult it can be to carry out any research on these athletes. Apart from the barriers of time, ‘traditional research methods’ normally demand large sample sizes, however, clinicians are often working with a sample size of 1. This is not a barrier to researching methods that enhance recovery or improve performance in an individual; it just doesn’t and cannot fit classical research methodology. However, this doesn’t mean that it doesn’t have ecological validity, far from it. There are often the pressures of secrecy working at this level, which can lead to anecdotal reporting. All these elements are not very conducive to producing an evidence-based approach for managing these athletes. This combination of factors helps to perpetuate the myths of treatments such as extract of monkey hypothalamus. The articles in this issue are testament to the fact that research can be conducted at this level. A broad variety of sports is covered in this issue and includes weightlifting, rugby union, rowing, tennis, cricket, golf and Australian Rules. The subject for the masterclass of this special issue is very apt and whilst the topic has been written on at length, the management of the painful tendon in athletes continues to be a clinical challenge. The masterclass is presented by Mark Reinking from Saint Louis University and covers the conundrums and clinical decision making for the non-invasive management of this condition. In the first piece of original research, Patraporn Sitilertpisan and colleagues from Chiang Mai University examine the cross sectional area and symmetry of the lumbar multifidus (LM) at multiple levels in elite level weight lifters. The sample studied represented the entire population, male and female, available for national selection. The group was separated into those with and without LBP, and the resting cross sectional area of LM was measured using ultrasound. Perhaps not surprisingly, the cross sectional area was significantly larger in males compared to females, and the values obtained were greater than for normal healthy controls reported in the literature. However, there was no difference between those suffering current symptoms of LBP and those that were symptom free. The growing body of evidence suggests that highly trained individuals with LBP do not experience the same atrophy in LM seen in the non-athletic population. This does warrant some further thought about pain inhibition and atrophy and what is different in these highly trained athletes. The International Federation of Sports Physiotherapists (IFSP) has been instrumental in establishing the core competencies for sports physiotherapists. Aiden Woods and Catherine Woods from
2
Editorial / Physical Therapy in Sport 13 (2012) 1–2
Dublin City University present a piece of qualitative research exploring the perception of the role of the sports physiotherapist (SP) amongst a group of elite rowers. The combined experience of the rowers involved represented a total of 76 years competing at International level. The results were then mapped against the IFSP competencies. Interestingly of the 11 competencies defined by the IFSP, 9 were identified by this group of rowers. The ones that were not identified were the role of the SP in the promotion of a safe and active lifestyle, and the role the SP could play in promotion of fair play and anti-doping practices. The authors discuss the possible reasons for these omissions. Two of the over riding messages that came out from the athletes regarding SP’s were the importance of good communication and having an open mind with the respect of the athletes' opinions and the use of other practitioners. The prevention of shoulder injuries is an attractive proposition in overhead athletes. Peak torques and pure strength measures have limited application in endurance sports such as swimming or tennis where fatigue resistance may be more relevant. Roland Julienne and colleagues from the University of Caen BasseNormandie investigated the shoulder internal rotators using isokinetics and EMG, and compared the dominant and non-dominant arms in elite male tennis players during an isokinetic fatigue protocol. Interestingly, there was no fatigue resistance on the dominant side compared to the non-dominant side as one might have predicted. The authors discuss the possible reasons for these findings and the implications for conditioning programs for these athletes. Evaluation of performance is a fascinating area for research, especially in team sports where individual contributions are more difficult to quantify. There are many objective measures that can be employed, but there are just as many subjective elements such as psychological, skill and tactical factors that are less easily evaluated. Michael Kinchington and colleagues from Victoria University and the Australian Catholic University present a prospective study following 79 professional footballers (Australian rules and rugby union) for one season in order to examine associations between comfort and performance. The authors present the comfort index which is a validated outcome measure and has been shown to be a responsive instrument to assess rated performance criteria in football. Additionally, 2 useful case studies are included showing how players can be tracked over the season. ACL injury can be one of the most frustrating and psychologically challenging injuries from an athlete’s perspective with respect to the length of time to return to sport and the often protracted absence from the team environment during rehabilitation. In the second piece of qualitative research, Fraser Carlson and Remco Polman from the Australian College of Applied Psychology and the
University of Central Lancashire, respectively, present the experiences of 5 professional rugby union players who had spent between 6 and 12 months in rehabilitation. What is probably no surprise to clinicians working in this area was that confidence in the knee was a key influence psychologically, and the increase in confidence came from the ability to complete both clinical tests and performance tasks. Confidence building, anticipation and anxiety formed the general dimension ‘Influential Emotions’, while the ‘Coping Strategies’ general dimension comprised of the themes physical preparation, psychological preparation and social support. The authors discuss the different components within these individual themes which provide an insight to the psychological as well as physical progress and how these are achieved through the rehabilitation process. Injury evaluation in professional athletes can be difficult to collate for many reasons. For those sports such as tennis, track and field, golf and swimming, athletes will frequently be competing and training in different cities and often countries, and managing these athletes if they are not travelling with a medical team can be challenging. Mark Smith and Rob Hillman from the University of Lincoln and the European Golf Tour present an audit from the mobile physiotherapy unit following the Professional Golfers Association European tour at selected events over 2 seasons. The data provides some interesting insight into this unique group of players. Finally, Murray Johnson and colleagues from the University of Sydney present the literature review on the prevalence and risk factors of lumbar stress injury in fast bowlers. It is well established that the mixed bowling action has been strongly associated with the development of lumbar stress injury in these athletes. Current evidence suggests that for adult bowlers, excessive contralateral lumbar side-flexion during the delivery stride, rather than shoulder counter-rotation, is the key variable in the mixed action that increases the risk of lumbar spine injury. Whilst potential risk factors are identified, the areas of research required for the future (and this holds true for many areas of injury prevention) are the need for well conducted, prospective studies to test these theories. If you are a clinician working in the field and struggle to find time and/or support to do any research, don’t worry you have a wealth of information at your fingertips from your athletes. Why not start with a case study? You have all had interesting cases, so go on, write one up and make it your mission for the year. The thought is often worse than the action, and the feedback I get from clinicians who undertake the process is overwhelmingly positive. I hope you enjoy this special issue of Physical Therapy in Sport. Zoe Hudson Editor