Free access to Jarrod Wade's presentation on Rehabilitation for Match Demands
Despite the large amount of knowledge we now have regarding injury prevention of athletes, the shear amount of non-contact injuries that occur each year can be alarming. The balancing act between allowing an athlete to perform at an elite level and keeping them in a rehabilitation program for an extra couple of days can be a decision that keeps the medical team up at night. There are many factors which can contribute to a decision such as this and being pain free is not always a necessity. It has been found that an athlete’s performance will increase with volume and intensity increases, however, with these factors also comes the increased risk of injury. It has been found that an athlete is seventy times more likely to suffer injury if they exceed their individual weekly training threshold. The following article looks to answer some questions in how the medical team may deal with the manipulation and interpretation of an athlete’s load during the during pre, inter and post season.
Pre-season training for elite clubs, is the strength and conditioning programs designed to prepare athletes for an entire competitive season and not just an individual event. For amateur clubs the pre-season may be used for maintenance of fitness in the post season. The development of a well-planned pre-season training program can lead to a decrease in injury risk, increase in mental strength and condition the body for the cues and contacts of a game. The old adage of “train smarter not harder” has changed with the recent evidence produced by Tim Gabbett and Peter Blanch, with the new spin stating: “Train Smarter, Train Hard”.
The premise being that completing short hard training sessions is more beneficial to athletes than those of a longer duration which has the potential to increase injury risk. Training hard with a vehicle like High Speed Running helps to protect physical qualities of an athlete. However, a well-planned pre-season can only be as well planned as the measurement of the athletes load during that pre-season.
There are a number of different ways that load can be measured both subjectively and objectively and all with their own pros and cons.
One such way of measuring an athletes training load is through the use of the Acute: Chronic Workload Ratio. The chronic workload is measured over a four week rolling average, while an acute workload can be anything from one training session to one week, depending on the fatigue level of the athlete. The ratio known as the “sweet spot” is between 0.8 and 1.3, this is further supported by the rule of “10% volume increase” which would produce a 1.1. The “Danger Zone” in the Acute: Chronic Ratio is any workload exceeding 1.5, however, there is increased risk for any ratio above a 1.
Another way of measuring athlete load is through Rate of Perceived Exhaustion (RPE) times the duration of the session (minutes). Using this measurement tool allows for not only physical load to be recognized but the mental load being placed on an athlete. If a programmed session is expected to rate a 7 on the RPE scale but the athlete scores the session as 12 then there may be something else worth exploring within the athletes life.
It is suggested that you have 7 days to manage an injury risk for a non-contact presentation. If an athlete is seen to be in the danger zone for too long a period the use of more recovery sessions or complete rest may be required to decrease the physical and mental stressors affecting the athlete. The load variables that have potential to affect the load felt by the athlete are sport specific and can be both intrinsic and extrinsic in nature.
Contributors to Load
There are a large number of factors which can contribute to load accumulation in an athlete and how that load accumulation is attenuated by the tissues of the body. Past injuries are one of the biggest contributors to future injury whether within the same region of tissues or in a separate region as a result of detraining. What was originally an ankle injury which saw an athlete reduce training load for two weeks, can easily lead a vortex of injury in other regions due to deconditioning associated with the reduced game readiness.
Additionally, the bio-mechanics of an athlete cannot be directly correlated to an injury which has not occurred yet – in other words, you cannot predict a specific injury based on bio-mechanical factors that you may visualize. Yes, those bio-mechanical factors can be seen as risk factor for injury but not specifically tied to an individual athlete and the injury they may incur.
Moment in time injuries (ankle sprains/ACLs) and contact injuries of varying degrees will lead to weakness within those tissues and an increase of further injury in the future. This may be a result of “overloaded” tissues relative to their current ability to handle loads – therefore the question is posed again, is it an Overuse Injury, Overload Injury or Training Error which should be the primary umbrella term used to describe these conditions.
The rehabilitation process which has been used to see the athlete return to sport is also important in the contribution to athlete load.
Did the athlete stop all physical activity over the time of injury?
Did the athlete return to training before returning to sport?
Was the athlete returned to their pre-injury chronic load before returning to game play?
Was the athlete 100% ready to return?
If not is the club, player and practitioner willing to take that risk?
There are many more questions that need to be asked and many more which we have not covered here. These decisions are commonly made under pressure to get the player back to field as soon as possible.
So far we have seen what may contribute to an athlete’s load as well as how we can best measure that load in both a subjective and objective format. But how good is that information if we do not have an effective way of managing those risk factors, acute physical load spikes and psychological stressors?
Load should be considered a vehicle, an objective and subjective matter that can drive an athlete towards injury or away from injury. At the end of the day your main destination is “game day performance” or “season performance”, how you reach that destination can be done via a number of routes and selecting the best one is what must be decided upon by the medical staff, athlete and the organization.
When looking to manage load, an athlete’s activity levels should be modified but never ceased. This is to limit detraining, maintain aerobic and anaerobic fitness and continue a base level of their chronic work load. The use of increased aerobic fitness and lower limb strength has been found to reduce an athletes risk of injury. For a long term injury which requires an extensive rehabilitation program it is suggested that workload is increased by 10% per week until the patient reaches their pre-injury chronic workload and are suitable to return to full training.
In conclusion, the monitoring of an athletes load with both subjective and objective measures is essential in the preparation for the competitive season. The development of a well-structured pre-season training plan can bullet proof an athlete not only for a single event but an entire season if completed successfully. A detailed medical history, injury history and lifestyle awareness is important for understanding of how an athlete should prepare for the sporting tasks required of them; from an easy recovery run to a worst case scenario within a single game. It is important to note that an athlete should not stop activity altogether but modify their activities in a way which is most appropriate for their injury.
Blanch, P., & Gabbett, T. (2016). Has The Athlete Trained Enough to Return to Play Safely? The Acute: Chronic Workload Ratio Permits Clinicians to Quantify a Players Risk of Subsequent Injury. British Journal of Sports Medicine.
Gabett, T., Hulin, B., Blanch, P., & Whiteley. (2016). High Training Workloads Alone Do Not Cause Sports Injuries: How You Get There Is The Real Issue. British Journal of Sports Medicine.
Halson, S. (2014). Monitoring Training Load To Understand Fatigue In Athletes. SPorts Medicine, 139 - 147.
Saw, A., Main, L., & Gastin, P. (2015). Monitoring The Athlete Training Response: Subjective Self-Reported Measures Trump Commonly Used Objective Measures: A Systematic Review. British Journal Of Sports Medicine, 281 -291.
Bruce Hood (Hood 2009) in his book “Supersense: why we believe in the unbelievable” makes a couple of quite pertinent points. He outlines a simple experiment he uses in his presentations where he presents to the audience ‘the pen’ (he admits to stretching the truth here) that Albert Einstein used. The object causes a sense of awe with people wanting to touch it. Immediately after, he offers up an old cardigan which he asks if people would like to try on (maybe that was Albert’s as well). After he has a few takers, he lets it be known that it used to belong to an infamous serial killer -whereupon all of the takers tend to withdraw. As a group, we tend to apply an irrational, supernatural spirituality to objects. This is displayed economically by a painting, supposedly by a grand master being worth millions one day, and nothing the next when described as a fake. Now before all you extremely analytical people jump up and say “I would wear the cardigan” or “I think both paintings are of equal value” this supersense actually extends to the essence of what forms human relationships.
Hood (Hood 2009) further points out that whilst humans do have the capability to make judgements and to reason, there are parts of what make us human and makes our society function that rely on things that go beyond the boundaries of rational analysis. The unconditional love of a mother, the warm feeling you get when you see old friends (in fact having old friends) or being attached to an heirloom from a dead parent, are all examples of emotional based responses that we just accept as ‘normal’. Now again there maybe a few (hopefully only a few) that are still saying, “I feel indifferent about my mother/kids”, “Old friends, what have they done for me lately!” and “I only like new shiny stuff”. If this is the case, it is you that is in the extreme minority. It is argued that it is these traits that have allowed humans to be evolutionarily successful. As individuals in the grand scope of evolutionary time, we are not a particularly hardy example of a species. However as a group that can divide the labour, provide protection and co-operate towards a common goal, we become far more viable. This requires that we form social bonds and these bonds require us to have something more than cold hard reason. We need to believe in something special about the people around us. Our ancestors who were able to create these bonds would have been more successful (finding food, protecting children) and these traits would have entered and then dominated the genetic pool.
In describing the vagaries of evolution theory, in particular evolution of the human cortex, Granger and Lynch in their book “Big brain” point out that we often fall into an evolutionary fallacy (Granger 2008). We often believe we humans are carefully planned, rather than Mother Nature throwing a dice with the DNA and seeing what comes up. Granger and Lynch point out there is no specific reason for why we have 5 fingers (4 or 6 may have been equally as good), but it was a piece of genetic code that was shared about (eventually) amongst a great number of species that worked and didn’t seem to need changing. As a trait becomes more engrained in the success of a species (and then subsequent off-shoots) the less likely there continues to be variations in the code of that trait. Also, it is not only attributes that may bestow some sort of evolutionary advantage, but also those that don’t create too much disadvantage, that can be passed on. Over time these successful (or not too damaging) adaptations form modular patterns within the genetic code that tie together numerous traits and show very little variation. The characteristics of mammals of a spinal cord, head , tail, four limbs, two eyes, two ears and highly similar circulatory, digestive, reproductive and nervous systems, is quite consistent. Furthermore, many of these traits were perfected well before mammals and are borrowed from further back along the evolutionary chain.
Returning to the brain, one of the arguments regarding the evolution of brain size is that increases in brain size are as a result of need, due to changes in behaviour. As our behaviour became more sophisticated, the brain grew to cope with it. Granger and Lynch (Granger 2008) point out that this is somewhat Lamarckian (inheritance of acquired characteristics) and perhaps falling into the above fallacy that our characteristics were carefully planned. They argue that increases in brain size are largely accidental and it is then the behaviour of the species that has to adapt to the rather high biological cost of having a bigger brain. In their words, “Brains are expensive”. Brain cells use up about twice as much energy as the other cells in the body. Bigger brains require longer gestation periods and necessitate longer development to maturity. For humans to survive the genetic code that gave us our big brains had to also encode behaviours that allowed us to pay the cost.
Let’s get back to me on my icebergs and my shivering interpretation of all this. I would argue that for humans to pay the cost of the big brain, the behaviours required would be to create social units that allowed for greater protection and food gathering capabilities. As mentioned earlier, these social units require more than blind brain power to be effective. Whether we call it the “supersense” as described by Hood (Hood 2009) or another name, there appears to be an irrationality and a need to believe, integral in the formation of human emotional bonds. It is within these very traits that the origin of the placebo effect lies. It then may seem attractive to look at the placebo effect as an evolutionary redundancy (did no harm so no need to get rid of it). I think this is a little myopic. We modern humans have been around for about 200,000 years and have been getting sick and injured for most of that time. For a lot of that time, we have had all sorts of healers, shaman and medicine men to help us on our way. However, it is probably only the last seventy years or so (since the advent of evidence-based medicine) that we have any sort of proof that any of the interventions, libations and chants offered up to us has had any effect (helpful or deleterious) (Goldacre 2008).
So, now as I stand somewhat more comfortably than I have for years, with my two icebergs merging into one (those adductors were getting a little stretched). I think we believe because it is far more evolutionary viable to believe than to not believe.
I hope there are no polar bears around here.
- Goldacre, B. (2008). Bad science. London, Fourth Estate.
- Granger, G. L. a. R. (2008). Big Brain: The origins and future of human intelligence New York, Palgrave MacMillan.
- Hood, B. M. (2009). Supersense : why we believe in the unbelievable. New York, HarperOne.
Firstly, thanks to the SportsMap for asking me to wrote this blog. I hope as least a couple of you out there can take a thing or two from it!
I first enrolled in Physiotherapy with the aim of working in elite sport. Thankfully, due to a combination of having clear goals, working hard and a fair bit of luck, I have managed to work full time in professional sport since 2010. I am often asked by other Physios about how to get a foot in the door in this area. The reality is that with more students enrolling in Physiotherapy courses than ever before, the competition for jobs is only going to get worse. I by no means have all the answers, but these are a few tips that might help you get an opportunity, and then hopefully allow you to make it a success.
I love working in elite sport. However, it can involve long hours, pressure situations, weekend work, dealing with an array of personalities, constant turnover of staff (including perhaps yourself), public criticism, politics and more. In my view all these potentially negatives are far outweighed by the positives, but prior to embarking on this path make sure you understand all that it involves.
HERE ARE MY 16 KEY’s BE SUCCESSFUL WORKING IN ELITE SPORT:
- You need to immerse yourself in the job and be always evolving. In this age of social media there is no excuse for not keeping abreast of the latest in sports science and medicine. From the time you begin university start to attend conferences and courses, & use social media to follow prominent people, journals and other resources that will add to your knowledge.
- Attempt to get experience working in sport as early as possible. I do not agree with the theory that one should work in a hospital first to ‘round out’ their education. Working in a hospital and sport are miles apart. Attempt to get work in a private practice, with good mentors that will take time to educate you and also have links to sporting clubs or organizations.
- Do not be afraid to network. Be prepared to write emails and call people that you think may be able to give you an opportunity. Showing a willingness to learn and work hard is important early in your career.
- The well known book ‘legacy’ states that ‘better people makes better all blacks.’ The same thing could easily be applied to Physio’s. If I am looking to hire someone, it is the impression I get of them as a character that counts for the most.
- Be familiar with the load requirements of the sport, and ensure when rehabilitating a player that you have them prepared to meet these demands.
- Coaches, players and other staff will often ask why you have a certain opinion, or how you came to a particular decision. Be able to justify how you go about things.
- Do not be a know it all. The best Physio’s I have come across are humble, always learning and realize that they do not have all the answers. Be prepared to listen, evolve, seek assistance and do not be offended when someone else challenges your view points.
- Being ‘just’ a physio is not enough. You should have at least a moderate understanding of other areas such as strength and conditioning & nutrition. This will help you be a better Physio and should allow you to build better relationships with staff in these areas… As long as you don’t tell them how to do their job!
- Each player is different. Work closely with other relevant staff such as the doctor and S & C to provide players with an individual physical preparation program that aims to maximize performance and reduce the risk of injury.
- When a player is injured focus on what they CAN do, as opposed to what they can’t. Be creative and always work around the injury. Use the rehab time as an opportunity to not only address the specific injury, but also to work in conjunction with the S & C staff to improve the overall physical characteristics of the athlete.
- Plan well and have key objective markers from early rehab all the way up until clearing a player to return to competition.
- Have a plan, but also be flexible and ready to adapt and deal with challenges and obstacles along the way.
- Ensure the athlete receives the same message from all support staff. Don’t be the guy that undermines the rest of the group and tells the player that you would be approaching things differently or that your colleague is wrong. Debate amongst staff is healthy, but this needs to be done in the correct manner.
- Be organized, document well and prioritize things that you think will best impact performance.
- Enjoy your job. Bring positivity to the group and don’t take yourself too seriously. Maintain high standards and keep professional relationships with players but don’t be afraid to have a laugh when the time is right.
- Maintain a healthy work / life balance. Work hard but also put aside time to relax and pursue interests away from the job. This will help you be more productive when at work and also minimize the risk of burn out.
In this 9th Episode of the Sports MAP Podcast we chat for a second time with Rehabilitation Specialist from Ireland Enda King about ACL Rehabilitation. Enda touches on many aspects of Rehabilitation with some clinical gold around the following key aspects:
- Key targets/ criteria in early, mid & late stage rehabilitation
- Specific exercise selection
- Errors commonly in rehabilitation and exercise technique
- Isokinetic testing benchmarks
- Linear mechanics and when to commence running
- COD mechanics & how to translate to the field
- Rate of force development prescription and testing
- Key jumping tests
- Changing poor movement patterns in a previously injured athlete
- The influence of fatigue in rehabilitation
- Return to sport
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.
- Elite sport rehabilitation
- Gym based performance markers in rehabilitation
- How advances in technology assist in the rehabilitation process
- Working in high performance sport
- Jump testing in rehabilitation
- Working in a multidisciplinary team environment.
- Training for match demands
- Jarrod's key career influences
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via twitter & Facebook.