Lessons From Elite Sport – the All Blacks

Long post today…

I’ve just had the great pleasure of listening and speaking with legendary All-Black rugby captain Sean Fitzpatrick. See: www.balls2business.com for Sean Fitzpatrick’s story and valuable information.

The conference was for clinicians and the theme of Sean’s talk was how to transfer the lessons of successful sports teams into clinical practise. Being a huge rugby fan it was great to meet a living legend but I was also really impressed with the message (as well as the messenger) and found it inspiring.

It got me thinking about applications to Physiotherapy and below are some thoughts based in Sean’s presentation.

What makes a global brand? What sets it apart from all other brands? How can lessons be learned from the All Black brand and applied to your own business?

The role of branding applied to physiotherapy can be considered in terms of the public perception of what physiotherapy has to offer (ie What is it?) or more specifically how it relates to the individual organisation/hospital/practice in which we conduct our business. The public perception of physiotherapy is very much based on their own interpretation or second-hand information unless they have been in a position where they have had previous care administered to them or a relative. Therefore, there frequently isn’t a yardstick by which to measure the competence of a therapist other than looking for familiar clues of ..

Professionalism

Communication skills

Personal presentation

Effectiveness of treatment.

Essentially patients are looking for solutions to problems and generally are not concerned about the clinical challenges which clinicians wrestle with in order to deliver optimum care.

I must confess it has taken me far too long to realise that the technical aspects of the job are only part of the essential core skills required.

“When the All Blacks win, I’d much rather be the All Blacks captain, and when they lose, I’d much rather be the prime minister.” Jim Bolger, ex-Prime Minister of New Zealand. How do you lead the All Blacks? How do you lead?

Again there are multiple levels to apply the analogy of strong leadership in physiotherapy practise. Those in a leadership role must communicate their vision and ensure that staff entrusted with delivering care are comfortable with the vision and it is consistent with their principals. It goes without saying that leaders should lead by example to have any credibility.

On an individual basis if we think about the qualities employed by effective leaders they would include..

Seeking advice

Collaboration

Decisive decision making

Implementation

Evaluation

Feedback

all of these concepts are equally applicable for a patient care plan delivered by a sole practioner – as Sean Fitzpatrick says “be the best you can”

The basis of sporting excellence is all about identifying, maximising, and then utilising your strengths. Find out how this is achieved in a sporting context, and how to transfer this understanding into your business.

No one can have all the answers. Recognising our skill limitations and the possibilities of better treatment options from other care providers is sometimes a humbling experience for a therapist. However, leaving aside the associated personal challenge our fundamental objective is to do what is best of the patient. If often seems these lines get blurred in daily practice. “Do what’s best for the patient” is a mission statement to start every therapist’s day.

Developing and implementing a plan to win a World Cup brought with it lessons and insights that might prove highly useful to those responsible for business planning.

As the saying goes “failing to plan means planning to fail.” As therapists we must have a clear vision and process of how we intend to pursue treatment and its delivery to a patient. We must also have a clear plan of recognising when our strategies are not being effective and need to be altered. Far too often patient’s failing to respond is transferred into blaming the patient for non-compliance rather than therapist self scrutiny.

Things to consider are..

Poor planning

Poor treatment delivery

Failure to recognise the potential limitations of the pathology

Failure to match expectations with reality

Sometimes the business requirement is to take the direct line, tackle the issue full-on, head to head. What can we learn from crash ball rugby about when – and how – this tactic can work best?

There are undoubtedly situations where clinicians have to take a chance and take risks As long as these risks are not reckless but calculated they are not negligent. The outcome may not always be positive, but if you don’t try you will never know. Fear of failure leads therapists to avoiding clinical decision making. Telling a player to return to a club training session with advice to “take it easy” instead of testing functional tolerance in a controlled environment or defining the boundaries loading parameters is an example of this. Having a patient “breakdown” during rehabilitation is not a pleasant experience but engineering this breakdown to happen away from the clinical environment is simply looking the other way! We need to take responsibility.

In 1986 a young team including thirteen debutants travelled half way round the world, and beat the reigning 5 Nations champions. How was this achieved? Succession planning…

Planning for continuity of care is the most obvious example that springs to mind. No matter what detail is recorded in clinical notes a 1 minute conversation between therapists can be more effective than hours of reading. Establishing a bond is a critical part of delivering care and drawing on the experience of face to face contact time is invaluable.

For example

Knowing there is an important upcoming competition

Knowing there are concerns about serious pathology

Wondering if things will ever get better

Conflicting information from healthcare providers

This type of detail not usually recorded in clinical notes but vital to shape the patient – therapist relationship.

Would you rather watch a team play beautiful rugby and lose, or watch a team grind out a win? And (whichever answer you give) which one would you rather play for? Is your business about process, or outcome?

Simply put as therapists we can get pre-occupied with technical aspects and new technologies but we need to constantly remind / test and re-test our interventions to ensure our work with a patient is effective. I’m old enough to remember using short wave diathermy and heat lamps for hours without any tangible measure of benefit. We have to make our contact time count!

Unfortunately, there isn’t a ready-made recipe. But this module includes a set of thoughts and insights from one of the great team leaders of one of the great teams in sporting history. What are the dynamics that you have to consider in order to get a collection of individuals to perform as a team at the very highest level?

The team can be within a department / practise or the wider application to multidisciplinary healthcare teams. Having “outsource” options for surgery, pain management, rheumatology, psychology, pharmacology are all necessary components of musculoskeletal pain management. Having confidence in the clinician is absolutely critical to deliver effective care.

I’ve lost count of how many times a treatment plan has been sabotaged by…

Dismissive comments

Trivialisation of symptoms

Flippant remarks

Superficial examination

Disinterest

Abrasive language

We need to know the team members if we are to have confidence in them. We don’t have to like them – just respect their clinical judgment. Matching the personality to the patient and be very valuable in the right circumstances. For example, an abrupt neurosurgeon dealing with an acute surgical disc prolapsed is far more acceptable than in a chronic pain management situation. A holistic pain specialist is more appropriate than an invasive pain specialist for a patient who fears needles!

I’m sure we’ll come back to this post in future and drill deeper into the points raised.

Some powerful lessons that we need to integrate into our practise.Please share your comments and opinions.

Enjoy the clinical challenge

David

Technorati Tags: chronic disease, clinical examination, detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, pain questionnaires, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, peak performance, persistent ongoing symptoms, physiotherapy, Previous response to treatment, primary care, professionalism, prognosis, psychosocial flags, quality assurance, sean fitzpatrick, subjective questioning, targeted therapy, therapist credibility, Type of interventions prescribed

Planning Rehabilitation Programs

Key points to consider planning a rehabilitation program

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1. How do we determine the relative amount of resistance for an individual?.

2. How many repetitions should be done?.

3. How much rest period is necessary?.

4. How do we determine the factors limiting exercise performance clinically?.

5.How do we determine which components of rehabilitation are appropriate targets?.

6. Where is the transition between rehabilitation and conditioning?.

7. What is the difference between physiotherapy prescribed exercise and sport rehabilation / fitness instructor?.

8. How do the principals of strength and conditioning apply to rehabilitation?.

9. What do we need to know about the structures we are rehabilitating?.

10. How do we improve exercise compliance?

Technorati Tags: Exercise, physiotherapy, prescription, rehabilitation

Manipulating Exercise Variables

Selecting variables to modify in a rehabilitation program can prove challenging. Most therapists are familiar with the obvious variables of LOAD & REPETITION but there are numerous other factors that can be manipulated.

1. Speed
2. Range of Motion
3. Base of Support
4. Plane of Motion

Combining different elements of these components allows progression or regression as required. It is essential that therapists are competent in applying these principals in a clinical setting

Click exercise variables to hear the lecture.

Technorati Tags: Exercise, rehabilitation, treatment

Functional Assessment

Many of you will be familiar with the concept of functional training in rehabilitation, so a brief review of historical aspects will suffice here.

Functional training from a rehabilitation perspective has been used for many decades with the obvious goal of returning an individual to their pre-injury functional status.

The astute reader will note that this implies a degree of individuality and specificity in rehabilitation strategies depending on the individual’s response to the injury in question and the planned functional goals to be achieved. In this discussion we are concerned with a return to playing sport, which has different functional requirements depending on the sport of choice.

Most rehabilitation specialists would agree that the fundamental measure of success is the ability to “perform at maximal function”. The issues of debate usually centre around:

1. Whether to use functional exercise as an initial priority.
2. Whether to place prerequisite criteria for progressing to functional exercise e.g. base line flexibility measures, stability measures, agility, coordination and power.
3. The use of over load / external resistance to achieve progressive increases in power output.
4. Key variables to manipulate in exercise progression e.g. load, speed, plane of motion, movement sequence.

Perhaps the biggest source of discussion in this regard is the use of fixed weights / machine systems relative to free weights. In the non-elite athlete there are some attractive aspects to using fixed weights as the machines themselves provide some degree of stability, are relatively safe, allow max or near max loads to be utilised and can be undertaken individually.

Unfortunately the artificial stability provided by machine systems dictates that a critical aspect of functional strength is not trained and therefore of debatable relevance in functional loading. On the other hand free weights use allow mass activation of stability and mobility muscle groups, more closely approximates functional movement patterns and requires higher levels of skill and coordination particularly if technical or explosive lifts are being attempted. Most serious athletes will incorporate some degree of free weights into their training.

The gap between these two approaches can be neatly filled by incorporating batteries of functional tests which explore movement control and coordination in varying combinations of body position, primarily with body weight as the external load, but progressing with small proportional increases in resistance as control allows. It can be reasonably argued that inability to control one’s body weight through a full functional repertoire of positions which are likely to be encountered in the course of the game situation may predispose to injury.

One of the current difficulties related to repeated tests / re-tests of functional measures are the measurement systems used. These tend to be somewhat “low tech”, can sometimes rely on the individuals perception of effort to perform a desired task or require an external examiner’s observation of the quality and sequencing of movement. Needless to say there maybe many hours of debate regarding differences of opinion on these issues!!!

Nonetheless a useful concept in this regard (popularised by American Physiotherapist Gary Gray), utilises the concept of threshold training in which the extreme position which an individual can control is measured relative to that of the other side. Any further change in position produces falling or loss of balance or some compensatory adaptive mechanism – indicating failure.

Components of a total body functional profile.

1. Safety.
2. Measurability.
3. Reliability and validity.
4. Simplicity.
5. Meaningful.
6. A full spectrum functional testing.

These concepts should be borne in mind when deciding what battery of functional tests to include for an individual or as part of a team training / screening protocol. The other critical point to recognise is that loading is occurring in three planes of motion simultaneously – tri-plane motion.

In clinical practice it is often by combining three planes of motion simultaneously that one can expose weaknesses, which do not appear evident when testing an isolated plane. If one analyses the movement patterns involved in most sports we can see that they can be broken into groups of core functional activities e.g. jogging, running, decelerating, excelerating, twisting, pivoting, jumping and pushing.

Each of these complex movement patterns can be broken down into components and each can be stressed using varying combinations of challenges e.g.

1. Range of motion.
2. Sequence of motion.
3. Eyes opened / closed.
4. Corporating simultaneous trunk and limb movement.
5. External resistance e.g. elastic tubing, bungee cords or dumbbells.

All allow varying degrees of difficulty to be explored in order to be determine the functional threshold of control.

Gray groups his functional tests under the following categorisations.

1. Balance tests.
2. Balance reach tests.
3. Excursion tests.
4. Lunge tests.
5. Step up tests.
6. Step down tests.
7. Jump tests.
8. Hop tests.

Functional self-test menu

Below are listed a group of self-test movements which can be administered and the degree of difficulty noted. Please note that there can be many different reasons for an inability to perform complex patterns which could include flexibility, stability, power, endurance or coordination deficits.

1. In- line lunge with body rotation.

Stand in a long stride position with front and rear legs in one line and feet pointing forwards in the same direction. Heels must stay on the ground. Bend front knee and hold leg position still. Add alternating twists of the upper torso to left and right side.

2. Single leg stance with toe touch.

Standing on one leg bend forwards to touch toes with the hand on the same side as your standing leg. Return to upright and reach arm overhead. Focus on maximising hip and knee bend in order to increase the leg stress. Ensure that standing leg does not roll inwards.

3. Kneeling lunge with trunk side bend.

In a kneeling lunge position, with both legs in line, side bend the upper torso from left to right. If toes grip floor strongly, tap floor to prevent fixing.

4. Single leg stance forward / downward leans.

Stand facing a wall, goal post or barrier about 3ft away initially and stand on one leg. Reach forward with the index finger to touch the ground as far out in front to reach the ground if possible. Return to upright and reach with opposite hand.

5. Single leg stance reverse pivot.

Stand on one leg with back to wall or post or barrier. Reach overhead with left and right hands alternately to try and touch behind without falling over. If it is too easy move a further distance from the barrier.

6. Incline lunge with trunk rotation

Lunge at 45° from straight ahead position, holding dumbbell in opposite arm (6 to 10kgs) reach down and across to the outside of the forward foot. Return to upright. Alternate sides.

PS to initially feel the coordination for this drill try work without weights.

There are infinite numbers of variations of these types of drills which can be exciting, fun, challenging and very revealing. We will come back to some of these concepts in the future.

Technorati Tags: Balance reach tests, Balance tests, Hop tests, Jump tests, Lunge test, specific strengthening, Step down tests

Physiotherapy & Exercise Prescription

No doubt many of you are aware of the competition amongst health professionals for the the mantle of key exercise prescribers.

Many therapists feel that their undergraduate training is insufficient.

Some feel that the boundaries of practise are at best “blurred” which creates confusion with the public regarding choice of therapist.

This has led to an explosion of interest in “functional training” – which is fast becomming a by-word for strength and conditioning. Understandably, physiotherapists core training does not provide these skills. This can make physiotherapists feel “inadequate” but we need to consider the type of caseload we see and whether strength & conditioning principals are the nesessary tools or whether other parameters are more relevant.

What do you think? Post your comments

David

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