An exploration of the perspectives of elite Irish rowers on the role of the sports physiotherapist

Article Outline

• Abstract
• 1. Introduction
• 2. Method
  • 2.1. Participants
  • 2.2. Instrument
  • 2.3. Procedure
  • 2.4. Data analysis
• 3. Results
  • 3.1. Role of the sports physiotherapist
  • 3.2. Qualities of a sports physiotherapist
  • 3.3. Achieving sporting success
  • 3.4. Physiotherapy treatment techniques
  • 3.5. Enhancement of sports physiotherapy services to elite athletes
• 4. Discussion
• 5. Conclusion
• Conflict of interest
  • Ethical approval
• Funding
• Acknowledgement
• Appendix. Supplementary material
• References
• Copyright

Abstract 

Objective

The purpose of this study was to (i) explore the perceptions of elite Irish rowers on the role of sports physiotherapy during their sports career, (ii) to compare their information to the International Federation of Sports Physiotherapists (IFSP) competencies and standards and (iii) to use the information gathered to highlight issues regarding quality of sports physiotherapy services, and how these services could be enhanced.

Design

Participants completed a short open-ended questionnaire that evaluated the service provided by sports physiotherapists. Participant anonymity was protected and they were encouraged to be honest and critical of their experiences.

Results

Thirteen Irish rowers preparing for the 2008 world championships or the 2008 Olympic Games, with a minimum of nine years rowing experience and participation in international competitions within the 12 months prior to the study beginning participated in the study. Against the competencies and standards of the IFSP this elite group of athletes had a clear understanding of the role of the sports physiotherapist. They identified nine of the eleven competencies recommended by the IFSP for auditing a sports physiotherapist, and advocated the use of sports physiotherapists in all areas that could improve their performance. Reasons as to why the athletes missed two of the competencies are discussed.

Keywords: Physiotherapist, Rowing, Competency, Standard, Sport, Qualitative

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1. Introduction 

In the past decade, the Irish rowing team have won numerous medals at senior world championship level. In order to do this, they endured a gruelling training regime. This typically involved training two to four times per day, seven days a week; often for a full year without a break. A training session would last between one to 4 h, and in addition to regular rowing training the athletes used other activities such as cycling, weight training, running and swimming to complement their training. The physical demands that athletes of this calibre place on their bodies has been documented by Wilson, Gissane, Simms, and Gormley (2010), who found that on average elite rowers had 2.2 injuries sustained over a 12 month period. The lumbar spine was the most commonly injured area, followed by the knee and cervical spine.

The sports physiotherapist (SP) involved with these athletes, is also the first author. He worked closely with the athletes for a period of eight years, during which time they participated in the 2004 and 2008 Olympics, numerous world championship, world cup events and training camps. This provided him with a unique opportunity to observe, first-hand the training and performance requirements of the athletes. It also allowed him to assess how they dealt with their injuries, from first contact with a physiotherapist to full rehabilitation. The purpose of this study was to (i) explore the athletes’ opinions, attitudes and beliefs about the role of sports physiotherapy during their international sports career, (ii) to compare the rowers’ information to the International Federation of Sports Physiotherapists (IFSP) competencies and standards recommended for sports physiotherapists and (iii) to use the information gathered to highlight issues regarding quality of physiotherapy services and make recommendations on how the role of the physiotherapist could be enhanced.

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2. Method 

2.1. Participants 

Purposeful sampling was used to recruit international level Irish rowers. Inclusion criteria dictated selection as part of the Irish rowing squad preparing for the 2008 world championships or the 2008 Olympic Games, a minimum of nine years rowing experience and participation in international competitions within the 12 months prior to the study beginning.

Thirteen elite Irish rowers (5 female, 8 male), ranging in age from 25 to 31 years (M = 28.7 years, SD = 1.9), participated in the study. The participants had a combined total of 164 years rowing experience, 76 of which were at international level. They had a total of 60 world championship performances and had won a total of 18 medals at world championship level. Six of the athletes had competed at four different Olympic Games. The athletes were treated by numerous physiotherapists throughout their international careers.

2.2. Instrument 

Due to the exploratory nature of this study, a 10-item open-ended questionnaire was developed (see Appendix). As the purpose of this study was to explore the athlete’s opinions, attitudes and beliefs about the role of sports physiotherapy to their sports career, a brainstorming exercise was undertaken between a physiotherapist, a sports scientist and two elite rowers to determine question wording. Item generation for the questionnaire was also guided by the list of competencies and standards of the IFSP expectations of a SP. The questionnaire evaluated how the athlete perceived the role of the SP, the qualities they felt a SP should possess, how instrumental the SP was to their goal achievement in their sporting careers, their views on specific treatments received and any general advice they would give for improvement of the service. The questionnaire has face validity. Pilot testing on 3 athletes revealed no problems regarding the comprehension or layout of the questions.

2.3. Procedure 

Data were collected at two training camps between January and May 2008 as athletes prepared for the 2008 competitive season. Questionnaires were electronically completed at a time that suited each individual. All questions were open ended and there was no limit to the time an athlete could spend neither answering the question, nor to the amount of text included in their answers. To protect confidentiality, and to encourage participants to be frank and critical in their comments, no individual identifier was requested in the questionnaire, and all answers were saved in a word document under a random number, unknown to the authors, to prevent data being linked to any single individual. The study protocol was approved by the research ethics committee of Dublin City University, and all participants provided written informed consent for their involvement in the study.

2.4. Data analysis 

All data were saved to a word file. Following this, a content analysis of the responses for each question was conducted, this involved reading the data several times, identifying emerging themes and coding them. Coding is a way of indexing the text in order to establish a framework of thematic ideas about it (Flick, 1998, Moser and Kalton, 1993, O’Cathain and Thomas, 2004). Data for each theme were then grouped together, and re-analysed to ensure appropriate categorisation. Once complete, all data plus the list of themes were then passed to the colleague to assess and provide feedback on categorisation. Discussion took place to ensure that all data were linked to the appropriate theme and new themes developed where necessary. The results section presents the emerging themes, their frequency of reporting (in terms of % of all data, and number of times reported (n)) and examples of quotes given by the athletes. In order to evaluate athletes’ perceptions of the role of the SP, the themes identified in the data were then compared to the list of competencies and standards for sports physiotherapists published by the IFSP (Bulley et al., 2005) (Table 1).

Table 1. The IFSP list of competencies and standards of a sports physiotherapist.

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3. Results 

3.1. Role of the sports physiotherapist 

Question 1 asked athletes for their views on ‘what does a sports physiotherapist do?’ Analysis of the data revealed that rowers have a clear, though limited, understanding of the role of the SP. Four themes emerged; these were injury treatment, injury prevention, rehabilitation and performance enhancement (Table 2). The themes established in the data are supported by the competencies recommended by the IFSP. Injury treatment was most frequently cited, followed closely by injury prevention revealing that athletes see the role of the SP as mainly injury focused. Fewer athletes acknowledged the role of performance enhancement, suggesting a limited interpretation of the role of the SP by the athlete. No athletes mentioned the role of the SP in the promotion of a safe and active lifestyle, also an IFSP competency. This raises concern, as if SP’s are not adhering to this competency in their service provision, or if athletes are not picking up on the cues to a healthy and active lifestyle given by an SP, then athletes who are sacrificing their long term health to achieve sporting success may not be receiving the help they need. Results suggest that there may be a requirement by the profession to raise awareness as to the full potential of an SP, particularly in relation to performance enhancement and also as to how to achieve sporting success without long term negative health implications.

Table 2. What does a sports physiotherapist do?

Values are percentage of all data (%) and number of individuals making a comment (n).

Question 2 assessed athletes’ views on ‘what a sports physiotherapist should not do?’ Four themes emerged from the data (Table 3). The theme “break medical confidentiality” was cited most often by athletes revealing the importance of a high level of trust between them and the SP. Essentially, the athletes were referring to a code of conduct. The theme “become complacent” reveals that the athletes expect their SP to practice continual professional development; this was contextualised due to the fact that the SP was working with a “high level team”, indicating work is required from all parties in order to deliver on an elite performance.

Table 3. What things should a sports physiotherapist involved with a team of athletes not do?

Values are percentage of all data (%) and number of individuals making a comment (n).

Both of these requirements are identified by the IFSP as necessary competencies. The IFSP state that SP’s should manage time, resources and personnel in a professional, legal and ethical manner, and facilitate professional development and excellence (competency number 7). In their sixth competency they state the need for SP’s to maintain and improve clinical standards by their critical, reflective and evidence-based approach to practice, and through a continual process of learning and teaching in collaboration with other professionals.

The IFSP have identified that SP should not practice treatments that they are not properly qualified in administering. This was not specifically mentioned by the participants. In fact the comments “There is nothing a physiotherapist should not do” would appear to indicate that some athletes are happy for the SP to be involved in all aspects of their performance. It also indicates a level of trust, that when needed they expect the SP to consult with other more suitably qualified personnel, or refer if necessary.

3.2. Qualities of a sports physiotherapist 

This section of the questionnaire was designed to gain an insight into the qualities that athletes feel are important for SPs to possess. The question ‘What qualities do you feel are important in a sports physiotherapist?’ produced four themes. “Being professional” was the most frequently cited and the most highly valued quality required of an SP by the athletes. This was followed by having good personal qualities, being accessible and having an interest in the athlete you were working with. The following quote provides a good summary of all answers to this question, “[a SP should be] patient, persistent, [have a] high level of competency, know when to refer, understand the emotional and psychological demands of the sport, [be a] good communicator with athletes and coaching staff”. Good personal qualities were seen by most as an essential skill of the SP for working with elite athletes. “Communication, so that they can explain the type of treatment they are giving you and that they understand your way of explaining how it [injury] happened”. The athletes’ opinions were all supported by the IFSP their seventh competency, one of professionalism and management.

The question ‘What qualities do you not like to see in a SP?’ was added to identify any negative qualities that a SP could bring to a team of athletes. Bad personal qualities, being unapproachable and not being a team player were common themes, followed by an inability to diagnose injuries.

The rowers identified the need for the SP to have an open mind especially when it came to athletes’ ideas regarding their management, and to the use of other practitioners.

The IFSP have identified dissemination of best practice and extending practice through innovation as two of their competencies. SPs disseminate new information and innovations to other professionals and decision-makers through different media. SPs promote the appropriate application of new knowledge and innovations in multidisciplinary practice and decision-making processes, and influence the directions of further research and innovation. If the number of support personnel available is limited, then the athletes may expect the SP to have a more extended role in all aspects of their performance for example; driving cars, help with equipment, advice on diet, social support, psychological support, help with coaching etc. This is echoed in some of the rowers’ comments. It was seen as a negative if there was an “unwillingness to do the extras that are sometimes needed in particular with small teams” or if the SP was “just getting through the days without really participating in the team”. While it is important for the SP to fully participate in team activities, they should not be expected, nor should they provide services they are not qualified to do.

One rower volunteered information on how an athlete should behave when dealing with a SP. “All problems probably carry some degree of uncertainty as to a diagnosis and cause, but sports specific injuries or problems may be remedied by close observation of the athletes’ technique or habits such as posture while walking or sitting etc. While this may seem to be overly intrusive to some athletes, my opinion is that a good athlete should be prepared to listen and take advice from all professionals that could have a direct impact on injury prevention or in a best case – improve technique and performance”.

3.3. Achieving sporting success 

The next section deals with how SPs can help or hinder athletes in their achievement of sporting success. Answers to the question ‘How does Sports Physiotherapy help you achieve your sporting goals?’ are shown on Table 4. The main themes found reflect an injury focus, similar to those on Table 2; however a change in perspective was recorded here. Athletes acknowledged the role of the SP, not only in preventing and managing injury, but more importantly in helping them to train for increased duration and intensity without becoming injured. “Helps maintain training volume, treatment of injuries very quickly keeps me on the water when I might have to miss training in other circumstances” and “keeping me able to train by keeping my body at its fittest and without injury”. The athletes were able to identify the limitations in their own bodies “physio work can allow you push the body that bit further by pre-empting injuries” this reflects the need for professionalism from the SP in terms of health versus performance. One rower answered the question very simply by saying that sport physiotherapy was “essential” in helping them achieve their sporting success. Finally, the SP needs to be confident in their abilities so that this can filter through to the athlete and in turn give the athlete “peace of mind” or the confidence to train and compete safely and to the best of their abilities.

Table 4. How does Sports Physiotherapy help you achieve your sporting goals?

Values are percentage of all data (%) and number of individuals making a comment (n).

Answers to the question ‘How could sports physiotherapy stop you achieving your sporting goals?’ revolved around the importance of a SP being highly competent in injury diagnosis and management (Table 5). This competency is also identified by the IFSP. In addition, the athletes identified the need for the SP to be familiar with the athlete’s history and personality; they recommended that this could be achieved by engaging with them and the rest of the team. “[A SP] Could aggravate an injury if not familiar with the patients’ history. Going forward though, I would say that physiotherapists may, in a non negative way, hinder an athlete’s development by not actively engaging with athletes enough”.

Table 5. How could sports physiotherapy stop you achieving your sporting goals? Give examples if necessary.

Values are percentage of all data (%) and number of individuals making a comment (n).

3.4. Physiotherapy treatment techniques 

The treatment techniques used by SPs that rowers felt were beneficial were mobilisation, massage, manipulation and exercise prescription. Acupuncture and taping were also mentioned, though not as frequently or with the same amount of emphasis. It is important to note that the treatment techniques athletes find beneficial will be influenced by their exposure to the range of treatments, as different physiotherapists favour different treatment techniques. The athletes in this study worked with numerous sports physiotherapists throughout their careers.

When asked what physiotherapy techniques they found not beneficial, very few techniques were identified by the athletes “I feel that the physio is the expert and have trust in them to remedy any issues I may bring to them” and “none that I know as, sometimes though I feel that physiotherapists can be overly cautious with treatment where a more aggressive approach with certain problems could bring quicker results”. Two treatments that athletes reported as non-beneficial were ultrasound and traction. “Traction, I don’t see why my back should be stretched by hanging weights off the end of the bed”. What is of note in these comments is the level of trust in the professionalism of the SP employed by the athletes, especially during this crucial phase in their sporting career. Also, the notion that SPs can be overly cautious emphasises the need for the SP to be familiar with the athletes, so they know what techniques work for that particular athlete. In essence if the SP is not familiar with the athlete then it is better to be “overly cautious” than “more aggressive”.

3.5. Enhancement of sports physiotherapy services to elite athletes 

The last section of this study dealt with understanding the athlete’s needs and identifying ways of improving sport physiotherapy services. Table 6 shows themes and examples of quotes that explain what an athlete would do if they felt unhappy with the physiotherapy treatment they were receiving. The majority indicated that they would find another physiotherapist, and only a fraction of these said that they would discuss their lack of satisfaction with the treatment they were receiving with their physiotherapist. This result highlights the need for open communication between the rower and their SP. The rowers feel that is important that they should be able to give opinions on how they are being managed and the SP should be receptive to these opinions. Several athletes indicated that they would seek advice from another professional, other than a physiotherapist, this highlights the need for athletes to be educated as to what services are available to them to help them achieve excellence in their sporting careers. It is important that athletes can make an educated decision on how they manage their health, their training and their performance. This will give the athlete the self confidence to evaluate what is on offer from a number of different professionals and select the most appropriate service provider for their situation.

Table 6. If you were receiving Sports Physiotherapy treatment you were not happy with what would you do?

Values are percentage of all data (%) and number of individuals making a comment (n).

The IFSP have identified that sports physiotherapists should maintain and improve clinical standards by their critical, reflective and evidence-based approach to practice and through a continual process of learning and teaching in collaboration with other professionals (competency 6). Table 7 shows what recommendations the athletes suggest to improve sports physiotherapy services. The rowers felt that a SP must be accurate in diagnosing and treating injuries, and importantly they must believe that their treatment is correct, they must use evidence-based techniques and be up-to-date. The rowers felt that in order for a SP to be able to do this, they must gain experience and learn about rowing through their involvement in training on and off the water. They also recommended participation by the SP in rowing, as they felt that this would give the SP a greater understanding of the technique and the demands of this specific sport. The IFSP recommends that sports physiotherapists critically evaluate their practice in relation to new information, identifying questions for further study, and be involved in research that addresses these questions at different levels. The rowers identified the need for SPs to be involved in continual professional development and emphasised the need for this to involve research and continual assessment.

Table 7. What suggestions would you have to improve the standard of Sports Physiotherapy you have received over the course of your career?

Values are percentage of all data (%) and number of individuals making a comment (n).

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4. Discussion 

The elite Irish rowers involved in this study identified nine of the eleven competencies and standards for sports physiotherapists recommended by the IFSP. These rowers expected the SP to be highly competent in their own field. From my experience (AW), I feel it is important for athletes to be able to approach their SP with any issues, and be confident that their SP will be professional, adhere to their code of conduct and not break medical confidentiality. The rowers expect the SP to be informed, and potentially involved, in all aspects of their athletic performance. This broadening of the role of the SP supports the earlier work of Hemmings and Povey (2002) who commented “that future physiotherapy education may need more emphasis on the psychological aspect of injury, and seek to increase knowledge on the potential of using psychological interventions within a physiotherapy rehabilitation programme”. The athletes in this study indicated that the involvement of the SP in all aspects of the athletes performance was particularly relevant to them when they have limited support services from other professionals available to them, for example when abroad at training camps or competitions. Further research is now needed to determine what different aspects of athletic performance the SP should be involved in, how to integrate this new knowledge and skill level into physiotherapy education, to establish if a specialism in sports physiotherapy should be provided at undergraduate or postgraduate level, and to determine how to get professionals from other fields involved when appropriate.

Irish rowers competing at an elite level identified the need for rapid and easy access to SP services. Further research is required to determine whether SP services are being used unnecessarily by athletes, and whether athletes are in danger of becoming over dependant on these services. The rowers also identified the need for continuity of care with SPs particularly in having a lead physiotherapist who would oversee the athlete’s management, drawing up a treatment plan and continually monitoring and evaluating the progress of this plan. Several times it became evident that the rowers would be willing to use practitioners other than SPs. From my experience (AW), I would emphasise the importance of a SP listening to athletes’ opinions on their management. It is important for the SP to be aware of what contributions other professionals can make, and to educate athletes as to what role other professionals can play in helping or hindering them achieving their sporting goals. I have found that it is only when the athlete is properly educated and confident in what they know, that they will be comfortable in the decisions their physiotherapist makes. It also identifies the need for open communication between the athletes and the SP, particularly the lead physiotherapist.

There were two competencies that the rowers missed. The rowers missed IFSP’s fifth competency: Promotion of a Safe, Active Lifestyle. The IFSP recommend that a SP provides evidence-based advice regarding the optimal activity or sport for specific individuals and the ways in which they can minimise risk of injury and promote health. Lopes, Barreto, Aguiar, Gondo, and Neto (2009) showed that 65.7% of Brazilian athletes attending the 2007 Pan American Games needed physiotherapy treatment as 22.1% of the Brazilian athletes attended the games with an injury. Hannay, English, Usherwood, and Platts (1993) showed that 40% of physiotherapy treatments at the 1991 World Student Games in Sheffield were for recurrent conditions that had started before arrival at the games. Research is required to determine the incidence of chronic injuries in Irish athletes, and the long term implications of these injuries on their health. Frequently, I (AW) have seen Irish athletes willing to sacrifice their long term health for potential short-term sporting gains. Further research is required to determine how best the SP can implement the IFSP’s fifth competency and what impact the Promotion of a Safe and Active Lifestyle by a SP may have. A recommendation to all SPs working with elite athletes would be to promote safe and healthy participation in sport as a way of also achieving sporting excellence.

The Irish athletes interviewed also missed the role the SP could play in promotion of fair play and anti-doping practices (competency 11). There are several potential reasons for this. The most obvious one being that elite athletes generally tend to avoid all association, even through conversation, of anything to do with doping. Another reason would be that athletes don’t see it as the SP role to be involved in anti-doping practices. Cruz (1999) and Sheedy (1990) proposed that sports sciences in general need to communicate their aims, worth and availability more clearly to the sporting community in order to make them a viable alternative to drugs for enhancing performance. Another reason could be a lack of understanding of the SP on their role on promoting fair play and anti-doping practices. Moran, Guerin, Kirby, and MacIntyre (2008, p. 16) identified that “the environment in which an athlete trains and competes may shape decisions regarding doping practices. If this is the case, then anti-doping interventions and sanctions cannot be confined to athletes alone. Coaches, managers, sports scientists and other support staff need to be educated on the importance of creating an appropriate motivational climate if their athletes are to remain drug free.” Either way it needs to be clearer to Irish rowers what the role of the SP is in anti-doping and fair play.

The results of this study are limited as the data were collected from athletes involved in one sport. No attempt was made to establish how many physiotherapists the athletes had come in contact with, nor the full extent of treatment techniques that they had been exposed to. At the time of this research being conducted the athletes were being treated by a team of four sports physiotherapists who exposed them to a wide variety of treatment techniques; however their answers may have been influenced by the care they were receiving at that time. Overall, the athletes have used numerous SPs worldwide throughout their international careers (some of which spanned 15 years) and the authors are confident that they were well informed on all aspects of SP management. Due to the small number of participants the results are not generalisable; however the open-ended qualitative nature of the data allowed for an in-depth analysis of the role of the SP in elite sport. This was the purpose of the study.

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5. Conclusion 

In conclusion, this study showed the extended role that the SP is expected to participate in while being involved with elite rowers. Future research should evaluate if Irish athletes involved in other sports have similar opinions. It would also be useful to extend this research to determine what other service providers feel the role of the Irish SP is, particularly when athletes are training or competing abroad.

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Conflict of interest 

None declared.

Ethical approval 

The study protocol was approved by the research ethics committee of Dublin City University. All participants provided written informed consent for their involvement in the study.

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Funding 

None declared.

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Acknowledgement 

We would like to thank Dr. Marie-Elaine Grant, Ms. Tara O’Meara and Professor Moira O’Brien, for their support during this research. We would also like to acknowledge the participants for providing constructive and critical comment when asked.

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Appendix. Supplementary material 

The following are the Supplementary data related to this article:

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