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

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 2 comments | Add to del.icio.us
Post 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

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There may be something missing from your physio’s basic training that could affect you…

The facts that every athlete needs to hear – get your free copy of Sports Injury Bulletin’s most controversial issue ever

Plus, a bundle of free bonus special reports for every reader

“SIB provides a level of understanding of an injury that doctors and physios, for whatever reason, do not provide”
- Michael O’Connor, Sports Injury Bulletin member, Canada

Dear Athlete,

A recent issue of Sports Injury Bulletin sparked controversy with an article stating that there is a crucial element missing from the physio profession’s basic training.

Today, I would like to invite Sports Performance Bulletin subscribers to judge for themselves by offering you exclusive access to this restricted circulation newsletter – absolutely free.

Miss out? It could cost you your career.

Hot off the press, each issue of Sports Injury Bulletin has a cover price of $16.50. But for a limited time only you can get a copy absolutely free. Click here to learn how to claim your copy now.

What’s all the fuss about?

Our contributor’s recent experience of completing a Level 2 Strength and Conditioning course provoked him into asking publicly a question that has bothered him privately for a long time.

How can a physio practise in the sports field without a sound knowledge of strength and conditioning training?

The article, written by Sean Fyfe, argues that physiotherapy and strength and conditioning go hand in hand.

It is an integral part of the physiotherapist’s role to plan long-term rehabilitation and maintenance programs for acute and chronic injuries.

When Fyfe does this part of his job he is constantly drawing upon his knowledge of strength and conditioning. He has gained this knowledge as a result of a vast amount of independent study, a post-graduate degree and his own experience as a tennis player.

But if a physio is not taught the fundamentals of strength and conditioning in their undergraduate physiotherapy studies – how many have this ‘crucial’ knowledge now? And what effect will it have on the rehabilitation of your injuries – from back pain to achilles tendinitis – if your physio isn’t ‘in the know’?

It must be emphasised that Fyfe is in no way claiming to be unique among physios in having such knowledge; the important point is that those who have acquired it have done so through mechanisms other than their physiotherapy training. And Fyfe would hazard a guess that a large proportion of physios practice without such knowledge.

“I certainly took comfort in the fact that the physios with whom I underwent my recent strength and conditioning course, share my sentiments exactly. And all of us were at a loss to explain how it was that we were never taught the fundamentals of strength and conditioning training in our undergraduate physiotherapy studies.“

Claim your free copy of SIB and Sean Fyfe will take you through some of the principles behind program design, and as always with Sports Injury Bulletin, illustrate his argument with case studies. PLUS, act now and also claim a bundle of bonus free reports on Core Muscle Training and Back Injury Treatment and Prevention, and much more…

The flip side

Perhaps Sean has it all wrong.

Physiotherapy is not sports training.

After initial rehab it is up to the athlete to move on to the next professional with a different skill set. Isn’t it?

What all physios should know but don’t

Strength and Conditioning training covers a broad range of skills – strength, power, speed and agility, endurance and flexibility training and recovery methods – the significance of each of which varies according to the athlete being trained and their sport.

A competent trainer needs to understand the purpose of different exercises, exercise technique, correct programming for different sports, phases of training and individual circumstances, and the detail of how, when and why to vary instructions on the performance of sets, repetitions, speed of repetitions and length of rest periods.

But should a physio be expected to have the competencies of a strength and conditioning coach?

Whose job is it anyway?

It can be argued – and no doubt many physiotherapists will be thinking this – that this kind of exercise program-setting is surely the job of a professional strength and conditioning coach.

This is a fair comment – up to a point. It is the job of a physiotherapist to prescribe exercises and they therefore need to know what kinds of exercises should be done at which rehab points.

That is only possible if you understand properly how the movement and load will affect the injured structures.

Secondly, if they don’t understand these principles, how can we advise our coaching colleagues (whose primary purpose is to train healthy bodies, not injured or recovering ones)?

Thirdly, how many of you, as athletes, can afford to track down and work with a strength and conditioning coach, especially once you’ve already paid for your physiotherapy treatment?

Three key elements

Sean Fyfe states that three elements of strength training – exercise technique, progressive overload and specificity – are critical to the competent practice of physiotherapy.

“One of the lecturers on my recent course tells of how, as a tutor, he routinely encounters sports physiotherapists, many with more than 10 years’ experience, who cannot teach the performance of a basic squat. If they can’t teach a squat, it is doubtful they could teach someone to deadlift. So how, for example, have they been teaching their patients with lumbar disc injuries to brace their low backs in neutral?”

To take the point further,

“if they can’t teach a double-leg squat, they surely can’t teach a single-leg squat, so how have these physiotherapists been rehabilitating someone with patellofemoral dysfunction?”

Fyfe wasn’t taught on his undergraduate course how to squat or how to deadlift correctly, which does seem to me a pretty incredible omission.

“Here’s something else that was barely touched on in my undergraduate studies. The overload principle is the underpinning principle of all training. Put simply, the body adapts in line with the demands placed on it. To achieve a positive training response and thus gain strength improvements, you must overload the relevant muscles. Too little effort and the client will fail to make strength gains. But too much overload at any point will cause injury, so it is necessary to prescribe a program of progressive overload, manipulating the weight, repetitions, sets, rest periods and speed of movement”

The other key principle common to effective training and physiotherapy is specificity, or SAID (specific adaptations to imposed demands). Again, put simply, the body adapts in a highly specific way to increased demands: the precise input will determine the precise adaptation.

Case Study – Sprinter vs Marathon Runner

To illustrate this, let’s look at how you might use a single-leg squat in the rehab of a sprinter versus a marathon runner, both recovering from patellar tendinitis. The aim of the single leg squat is

• to improve strength and activation through gluteus maximus and gluteus medius
• to improve quadriceps strength and activate vastus medialis (VMO)
• to maintain neutral spine under load, and
• to improve proprioception of the lower limb chain.

The exercise is functional for the sporting needs of both athletes, and will be working aspects of their lower limb chain that probably need improvement to prevent further tensile overload to the patellar tendon. But the 100m sprinter needs to do all of these things fast, with maximal contraction, for 10 to 11 seconds; while the marathon runner does them all sub-maximally and slower — for more than two hours.

It is therefore no good prescribing exactly the same dose of this exercise to both athletes. The sprinter will need:

• low repetitions
• greater load to achieve maximal contraction
• fast speed of movement, and
• longer rest periods.

And the marathon runner needs quite the opposite.

The teaching of correct technique and the principles of overload and SAID should be at the forefront of a physiotherapist’s mind whenever prescribing an exercise program. Indeed, they should underpin the setting of all rehabilitation programs.

Programming in practice

In your free copy of SIB 57 you’ll find an in depth case study which outlines how strength and conditioning knowledge needs to be woven into the way a physiotherapist treats musculoskeletal problems. In this particular case, Fyfe examines a lumbar spine stress fracture which developed in this 16-year-old male tennis player as a result of serving.

A detailed 18 week strength and conditioning rehabilitation programme is given, at no cost, to further illustrate Fyfe’s argument.

Join in the debate: tell us your reactions to Sean Fyfe’s argument, your own views, experiences and proposals. Claim your free copy of Sports Injury Bulletin now

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: exercise prescription, fitness to practise, peak performance, physiotherapy, professional boundaries, strength and conditioning

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