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.

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.

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!” 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!”

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?