The Wonder Physio… A guest blog by Paul Westwood

So today I am really excited to give you a fantastic blog by Paul Westwood, a specialist sports physio working (and training) with elite triathletes. Paul works for JFT Racing which is Joel Filliol's international professional training squad. Paul has kindly done a blog on some of his experiences of working in elite sport. He wanted to share this after reading my controversial rant on Sports Physios a few months ago. So with out further ado, its over to Paul… A word of warning thou he starts off by singing…

The Wonder Physio…

We're off to see the Physio,

The Wonderful Physio of Oz,

We hear he is a whiz of a phiz, if ever a phiz there was,

If ever, oh ever a phiz there was, the Physio of Oz is one because

Because, because, because, because, because

Because of the wonderful things he does…”


As you may have read in Adam’s blog here: athletes put their faith in a variety of therapists to help them with their injuries and sometimes to help them improve performance. But why do they do this, and what do we need to do as therapists in order to help athletes perform at their best?

Here are my own thoughts and some experiences of the wonderful world of sports physiotherapy. Thanks to Adam for allowing me the opportunity. I know coaches and athletes who follow Adam’s work, that provides valuable knowledge and advice to help athletes at all levels improve and get more out of their sport. Of course as I am writing on Adams blog I have tried to make it as controversial thought provoking as possible.

All athletes need help and support in order to achieve their best.

However, athletes can often behave like the scarecrow, the tinman, the lion, or even Dorothy from the film Wizard of Oz. In case you didn't know, the scarecrow didn’t have a brain, the tinman had no heart, the lion had no courage and Dorothy was just lost (aren’t we all??). But what they all had in common was they put too much faith in someone else to sort out their problem.

Wizard of Oz

They believed they needed the help of a powerful wizard to sort out thier problems, and in our world that wizard is usually the wonder physio, chiro, osteo, sports therapist, healer, doctor or any other practitioner who purports to have the answers.

This search for help is normal human behaviour and many do it. However, injured athletes tend to be more vulnerable due to emotion and panic setting in, and a belief that anything and everything has to be done in a quest to find a solution to their problem. Unfortunately they are often sold, both physically and psychologically, plenty of things that actually aren’t that helpful at all, usually by those in positions of trust and respect such as team doctors and wonder physios!

In their quest for a solution, atheltes are often willing to try anything, even if it gives just a 1% improvement. In the new world of marginal gains we have so many 1% improvements we should actually start going back in time!

How do you spot a Wonder Physio?

Here are my top ten tips to spot a wonder physio …

  1. They come up with convoluted, complicated and ridiculous rehab/exercise plans that no one could ever actually do. If the athlete gets better you say it was down to the ‘magic plan’. If they don’t you blame them for not sticking to the plan.
  2. They make your rehab as complex as possible. Instead of saying “go for a 10-20 minute steady run and include a walk break if you need to”, you say: “run for 02:30 @Z1+2 pace, then walk 00:30, then run 02:45 @A1+Z2 pace, then walk 00:15, then run 02:30 @Z1+3 pace, then walk 00:30…”
  3. They make their assessments ridiculously complicated and written in a language no one can understand. Who ever reads it will be suitably impressed. If they don’t understand it then they are obviously not worthy of knowing such things.
  4. They try to impress elite athletes by trying too hard. Spend ridiculous amounts of time with them and use all the treatment techniques you know. If you think you don’t have enough techniques go on that course this weekend and make sure you throw that at them too first thing on a Monday morning. Remember you’ll have to go in early to put your new certificate in a frame above the treatment couch.
  5. They keep talking AT them. This gives them no chance to reflect, get a word in edge ways and question your knowledge. They will be impressed with all your anatomical know-how and how “everything is connected speech”, and they will be really impressed that you are doing the Swindon 10K so tell them about all the training you’ve been doing for that as well.
  6. With non-elite athletes they make them feel even more special by treating them like elite athletes. Tell them that they should be doing yoga, foam rolling and filling the bath with ice everyday because that’s what elite athletes do.
  7. They ensure that all rehab plans are ‘Individual Plans’ made up of exercises that no one else is doing… or has ever done before. In fact just make up some exercises to help create this illusion.
  8. They use space age machines that go ‘ping’ to impress an athlete. Make sure you wear surgical greens, a white gown or something like that. This seems to make interferential / muscle stimulation machines work even better.
  9. They charge a high price for your services. Just as with with art, no one thinks cheap paintings are any good.
  10. They get as many celebrity athletes’ endorsements as they can. Note: most pro athletes don’t care what or who they endorse… as long as they don’t have to pay for it.

I once saw a runner with a ‘calf strain’ who was raving about how good his Wonder Physio was in getting him running again.

His treatment included 4 months of no running, acupuncture and soft tissue work to get rid of the 'knots' plus lots of stretching and foam rolling. After 4 months his pain went away -great work! However a year down the line he was still only running on the treadmill, and was still concerned that his calf would go again, and now had developed an unhealthy obsession with stretching and foam rolling, talk about operant conditioning? Yet he still thought his Wonder Physio was awesome!!!

Excuse my bias but hang out with a bunch of elite triathletes for any length of time and you will see a lot of anxiety, insecurity, poor confidence and mal-adaptive behavior. High performance sport creates a lot of pressure. As a physio in elite sport I have found the 'Going-for-Coffee Rx Technique' (patent pending) highly successful in fully assessing and treating athletes by simply diffusing pressure and stress. Guess what, chatting works*

*The massage table is also good place for this.

Are all elite sports physios bad?

Many athletes put their faith in these wonder physios and elite therapists and swear by their ability to make them better and improve their performance. But they are often creating the chronic pain sufferers of the future. That elite runner who comes to see you with a new Achilles injury will get better with time and the right guidance, yet many wonder physios are inadvertently giving athletes emotional and psychological baggage to potentially carry around with them for the rest of their life.

This is what many elite sport therapists (me included) are guilty of. The NZ sport academy used to send me athletes to have their biomechanics screened. They’d come in with no problems but I’d send them away with plenty – I almost felt like I wasn’t doing the job expected of me unless I found something wrong with them. Even the lawn bowlers (a high performance sport in NZ) who had been doing their sport for decades with no issues didn’t escape.

I’ve subsequently learnt not to tell athletes that whatever pain/injury they have or are going to have is because they have flat feet, winging scapula, can’t do clams, their spine is not in neutral, they don’t stretch/foam role every day, they can’t disassociate their pelvis or they can’t balance on one leg with their eyes closed without moving! Who the freak can?! Joel Filliol told me that he liked the fact that I didn’t “rip his athletes apart“. Lessons learnt.

Don't Be That Guy At The Gym

If an athlete hasn’t got any pain don’t be ‘that guy in the gym’ telling people that whatever they are doing they are doing wrong… that because they can’t do an ass to ground squat they haven’t reached their full athletic potential! When I watch someone running for the first time, the first thing I tell them is ‘you’re running well’, no matter what I actually think.

It is my belief that there is a danger of athletes becoming over sensitised. What were once considered normal physiological changes to training are now perceived by the athlete (the organism) as threats and therefore as pain. Scans are sent for and the athlete begins to fall into the ‘Rehabilitation Pit of Doom’

In my experience there is general lack of understanding about pain science in the world of sport. This leaves athletes prone to developing unhelpful pain responses and beliefs. Pain is always associated to a damaged structure or if not damaged then bio-mechanically disadvantaged. We know from some of the best coaches in sport that performance is a lot more than just physicality; muscles and blood, it is the person, the organism which determines how fast they go. Yet for many elite sports therapists (apart from the Twitter crowd) it still seems its all about the Bio.

What should sports physiotherapists be doing?

A sports therapist’s job is to make sure the athlete keeps training according to their coach’s instructions. But almost every day an athlete will complain of an ache, pain or niggle. This is where it can get stressful for the therapist.

However, for the most part the therapist should be normalising these pains…

A therapist needs to reassure an athlete that what they are feeling is a normal response to training and that they will only improve from it. If necessary therapists could also suggest that athletes reduce their load and progress with appropriate training and graded exposure. However therapists must work with the coach and athlete to adjust training load. One of the biggest beefs I hear from coaches is physios advising athletes on what training they should be doing despite what the coach has planned, this isn’t helpful.

Stay on Target

“Stay on target, Stay on target!” A lot of shit comes in too fast for an athlete. A therapist needs to help keep them on target / training / competing.

The therapist should always simply and honestly answer any questions from the athlete such as ‘Should I be concerned?’ ’Am I coming to harm?’ ‘What will happen if I continue?’ ‘When will I not be in pain?’

You could use the good old laying on of hands to show them that it actually doesn’t hurt that much after all and things are OK. I use adjuncts very little these days I have found I am more effective without needles, electro, ice or tape for me it often just distracts from getting stuck into actually helping the athlete.

Pandering to athletes… Pandering to pain.

We tend to try that extra bit harder with high performance athletes. We want to impress them, they deserve more, they need to get everything they want. If they’re complaining of pain we need to do something about it and do it now! They need ‘intensive physiotherapy’. If the pain doesn't reslove they need even more intensive physiotherapy. MRI scans are done at the drop of the hat, steroid injections given instantly, arthroscopes quickly, as long as it makes them happy and gives them what they want.

As therapists we need to be resolute and stick to our clinical reasoning. If we feed a child chocolate it’ll keep them quite, until they start crying again. Tough love is sometimes needed

Pain can become a useful means to get an athlete what they want, especially if they are not performing well or injured. Once they were given flowers and loved for winning competitions, they don't get this from finishing with the ‘Also Rans’, but they will do from a hospital bed after their latest surgery. They only want attention and to feel loved, if pain becomes a means to that end, then so be it.

Injuries and changes can and do just happen, there doesn’t always need to be an identifiable change.

You may not think the run you have just finished is different to any previous runs you have done, but you are a different person to the one that started that run… Ooooh! #Philosophy

A philosophical question: “Are you the same person today as you were yesterday, last year or when you were at school?” Well you can argue for both but essentially we are constantly changing.

There are so many distractions for athletes: supplements; stretching; core work; gym work; meditation; pilates; yoga; mindfulness; magnets; k-tape; compression wear; spiky balls; muscle stimulators; ice baths; hot baths; epsom baths; coconut oil; emu oil; snake oil; bee venom; orthotics. The list is endless but on the whole they do little to enable athletes to perform better, and energy wasted on superfluous distractions is energy that could be used elsewhere. Training comes first, judicious use of S&C, maintain mobility, then eating, then sleeping. Be wary about adding any more stressors into this mix.

What ever an athlete needs to relax is always good. Whether that be sitting on a spiky ball, getting a massage or having a glass of wine it doesn't matter. I’m not going to tell an athlete who swears on having his ‘Rose tinted quartz crystals’ under his pillow that they shouldn’t bother but I’m not going to be recommending it either, I’m focusing on the things that matter.

Become a stoic!

With a supposed answer and cure for everything we are losing the ability to be stoical, and we frustrate ourselves looking for what can’t be found. If your athlete bangs their knee causing a soft tissue injury 3 weeks before an important competition… “Don’t panic Mr Mainwaring!”

Mainwing

Think about what you can actually do to make a difference. Often this is not a lot. Don’t throw everything and the kitchen sink at athletes, don’t pump them full of pain killers, perform endless manips, poke them full of needles and give relentless massages trying to release what isn’t stuck. Don’t fly them across the world to see one expert after the next. In life shit happens from time to time. Once we accept this we can quickly move on and get back on track rather than wasting energy on a fruitless searches and potentially harmful interventions. A calm and reassuring response is all that is often required.

You’re athlete relies on you to be their rock of stability when their world is turned upside down, as it can do on a daily basis sometimes.

Always check for serious harm (red flags) and explain what’s happened – swelling is normal (as is pain) it’s there to protect and allow healing. You will heal and get better. Keep moving, graduate the activity and strengthen where necessary. This equals full recovery and no baggage.

The stressful part is we should always be thinking of what it could be, do we regress, stop or continue with training. A physio should feel the ‘Sword of Damacles’ hanging above them. We should have courage in our clinical reasoning to allow an athlete to continue to train with appropriate changes where necessary. We should be the one concerned and not pass any of these ‘worries’ onto the athlete. Anyone can remove the sword dangling over their head and tell the athlete to do nothing for 3-6 months while they stick needles in them, getting them to do endless stretches and balance on a bosu-ball. Leading to the athlete’s season being over and the danger of further physical and mental de-conditioning (sorry dualism I know).

Smoke and mirrors

So back to the Wizard of Oz, and it turns out the lion was already brave, the scarecrow intelligent and the tinman had a heart after all. They discovered this through their actions, and the wizard was revealed to be a fraud.

But a downhearted Dorothy pointed out that she didn’t get what she wanted… she couldn’t get home. The White Witch told her “You don’t need help any longer, you’ve always had the power to go back to Kansas.” When the scarecrow asks why she hadn’t told Dorothy that before, the witch replied, “Because she wouldn’t have believed me.”

When you work with your athletes, show them what they are capable of rather than showing them what YOU think is wrong with them, and sometimes they just need to train and race to find their belief.

Once you look beyond the smoke and mirrors of the wonder physio there usually is a great therapist in there. They just have to trust their knowledge, humanist skills and faith in what people are actually capable of. Find this out by knowing your athletes. My most successful outcomes are usually achieved by simply listening and talking.

Westy


Paul Westwood @TriathlonPhysio

Foot Note:

A massive congratulations to Mario Mola and his coach Joel Filliol winning the Grand Finale in the World Triathlon Series in Chicago last weekend. In doing so he became the first man to run a sub 29 min (28:59) 10K in the event. I’ll leave you to guess how he achieved the fastest run ever?

tri

 

 

30 thoughts on “The Wonder Physio… A guest blog by Paul Westwood

  1. Hi French Boy this is the best Blog I’ve ever read so I would like to appoint you as the Real Chief Executive of the Chartered Society of Physiotherapy Hung Parliament with my Lead Professional Dr Ian Horsley to take our Physiotherapy profession from the Black Hole at sub zero degree Kelvin to success in my Nana Potassium-40 super conducting nuclear fusion powered boat in Nano second. This is my exercise programme for my world class athletes https://www.youtube.com/watch?v=6moxVQjnJcI Regards Bean, HCPC registered physiotherapist

    Date: Sun, 27 Sep 2015 08:30:54 +0000 To: yuimustow@hotmail.co.uk

  2. Great article! I work with a lot of triathletes and couldn’t agree more. It seems like when I get a new one they have a mental scar from the last PT that they saw. Sadly sometimes this is worse that the scar the MD left (with the wording of the diagnosis)…

  3. hey Paul. Been looking forward to seeing this for sometime! Really good insight and the direction that therapists should take in any level where individuals are pressed for deadlines and the associated stressors that accompany them! Many thx. Jim

  4. The more we TRY to help the more we complicate and erode the belief the person has in themselves. I am glad to have found this community of people who help through teaching the person to listen to themselves and be patient. Thank you Paul

    • Yes Grant! They do exist and thanks to the likes of Meakins this community is able to come together and take the profession forward in adding real value to athletes and peoples lives.

  5. I was very fortunate to work in a small team with Paul over a 6/7 month period and have seen his methods employed first hand, often described as “Gold Standard” not because they were technically difficult to deliver but because they simply worked for every single athlete.

    The experience was refreshing and enlightening, stripping away the layers of “at best ineffective Rx” and “at worst tail chasing, fragility methodology, scaremongering” that only serves to empower the (selfish) therapist, creating physically weak(er) athletes that are psychologically dependant.

    A fantastic article that sums up everything I have learned from PW and now employ to give the athlete the best chance of getting the best out of themselves……… “once the ‘fires’ have been extinguished”.

    “There are NO silver bullets” or shortcuts………. We / they just need to turn up everyday and produce the goods, worry free and with the confidence to be / become robust!!!

    Thank you and keep up the good work Westwood 🙂

    A Fan.

    • Cheers Warrior! Great to see you develop and learn how to actually help people become ‘better versions of themselves’. You’re a rough diamond mate. Everything was there, just needing polishing. Proof was in the pudding of the results you got.
      Keep up the good work.

    • Much thanks. Appreciate you spreading the word. Physiotherapy is capable of bringing so much more value to athletes / people. Just need to do the simple things well.

  6. Hey Paul. Great blog, can’t disagree with anything you said. I think there is a “right” way to do things and your blog explains that, the hard bit is the belief of the patient. It’s hard for this comment not to come across as sour grapes but I was at a function on the weekend and chatting to a stranger they said they go to an osteopath and he is “amazing”, I realised I had taught said osteopath and my memory was that this guy was ok, maybe a bit sure of himself. Anyway the stranger said the osteo is booked out for 3 months ahead, I said “wow” he must be good. Perhaps a wonder osteo? I thought to myself I probably wouldn’t wait 3 days to see someone, ok, maybe a week, let alone 3 months. I wondered about what sort of passive,reliant , no one else can fix me but you, sort of fear in his patients he must instill. Back to my idea on belief. Don’t take this the wrong way, but you are an accomplished athlete, athletes come to you with probably strong belief. Thankfully you are talking the right language. Sadly for practitioners who are hackers as athletes we struggle with belief from high performing athletes even though we speak the same language. Not sure what the answer is, just the way it is. Thanks again for the blog.

    • Hi Nigel,
      Thanks for your thoughtful reply and you raise some interesting points.
      Your case in point is a classic case of a ‘wonder therapist’. I think if healthcare is there to help people, society and humans become healthier and more prosperous than they were in previous generations we have to promote this ‘right’ approach in helping people. I’m not in the business of creating dependancy in communities and cultures where people risk being able to do less, suffering more chronic pain/debilitations, are less robust and resilient to what life throws at them. Having experience working with different nationalities and cultures I have seen this evolving but it takes time. A bit like democracy in Europe it took time but eventually people realised and worked out how to live and have freedom. I have seen people who are quite surprised when I get them better after a few sessions and tell them that they don’t need to come again they’re all good. They go and tell their friends and so forth. It’s likely there will always be a certain amount of people who want to sign up for all that wonder physio stuff and thats fair enough but the chances are these individuals aren’t making the most of their abilities, lives and are probably spending a lot of money.

      Regarding hackers :-). The main thing is that we can gain empathy with the people we are trying to help, we need to think what they would do and not ‘what I would do’. Being a running hack is good in this respect as you share a common bond with your ‘athlete’… most of us are just hackers. Many of the people I see don’t know my background and I certainly don’t talk about it in my first interactions, I’m mainly listening. Sure you are right it does often make a difference to a person’s belief when I carefully leak out I’ve done about 15 Ironman Triathlons and worked with some good athletes but I try and use this sparingly. Starting off on that angle has little substance, you need to work on the nuts and bolts of the person themselves and what they need to do to improve.
      As therapists we need to act as good coaches, leaders and teachers. Leading by example and helping people to become better versions of themselves. Rather than just scaring them into following us and doing what we think they should do like the Wizard / Physio of Oz.

      Lots of food for thought… needs another Blog 😉

      Westy

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