A Team Within a Team

If your job is mentioned in the title and you haven't read this article, written by a physio, and featured in the BJSM (linked in their bio), it's worth a read. 

My immediate thought was, what a click-baity title, and click away I did, but not after being put off by its us vs them nature as if the two professions are in a dogfight for the use of exercise. The author opens by noting he will keep the conversation about athletes but decides to group recreational and professional together, which I found to be a very broad generalization. 

Before I dive further into my thoughts, here is the author’s conclusion: "Rehabilitation of athletes (recreational and professional) must be recognized as an advanced practice skill requiring specialist training. Without this recognition, physiotherapists can only ever be considered technicians in the functional restoration of the patient/athlete." S&C coaches were declared the ‘winner.’ 

There's so much to unpack from this article that I'm sure I won't be able to do it all justice, but I wanted to explore some ideas and hopefully the general concepts comes across. If I miss the mark I'd love to hear where and why. 

My working definition for the role of a physiotherapist in this setting is to assess and treat (rehab) an musculoskeletal injury through a variety of methods including, but not limited to, exercise. Exercise is a very important part of our story but not the whole story. 

After looking at various resources online for the definition of a S&C coach there seems to be a consensus that involves improving athletic performance (the specific traits necessary for the athletes sport), specific programming of in-and-out of season training, and the reduction of athletic injuries. For S&C coaches, exercise is the story. 

So, if we are talking about exercise broadly, then I think a very competent S&C coach should and will have a better understanding of exercise for the development of specific athletic characteristics, skill-acquisition, skill transfer to sport, and specific programming than a very competent physical therapist. To me there’s not really a discussion here, nor a competition. 

Where I become confused is why the author suggests a physiotherapist shouldn’t work with athletes in any instance unless they have specific advanced training. 

The nuance of where the athlete is in the injury-recovery continuum strikes me as being heavily overlooked in this discussion. Personally, I would be extremely surprised if a healthy athlete ever walked into my office looking for off-season programming, as an example, because that’s not something that is necessarily in my scope of practice (it may be for some physios). In the acute stages of the injury there are a number of exercise-based interventions that depending on the assessed injury will be critical to getting things back on track and restoring a normalcy of day to day function. Simply, if an athlete can’t bend, twist, squat, walk, lift, or move whatever limb is in question, they probably will have a tough time with their S&C coach. However, once things are progressing along it makes all the sense in the world to get them back in the gym with their coach to continue on with the process as they would be best suited to build back up the sport-specific qualities the athlete needs to return to play. Moreover, they would have all the data on where the athlete was and is currently at. 

To this point, the author writes “In practice, we see the athlete either handed over to their strength and conditioning team as they near return to sport or the athlete discharged and left to manage their own return to sport.” 

The return of the athlete to their S&C team sounds like the correct play.

At this point I believe the differences between a youth athlete, weekend warrior/recreational athlete, and a professional athlete becomes important. The team and resources surrounding these different populations of athletes are going to heavily dictate the personal available to assess, manage, and rehab these injuries. 

For the average weekend warrior and youth athlete I would argue that most PT's should have enough of an exercise arsenal to make that happen if that athlete doesn’t have a dedicated S&C contact. We come out of school with a decent exercise knowledge which should only grow with experience and observation of more senior therapists. Perhaps the schooling is the difference as I believe the author is from the UK and makes note that “this would be true if our undergraduate training prepared fledging physiotherapists with a basic grounding in exercise prescription and training science. However, we know that in the vast majority of cases this is not so!” 

At a certain age and skill level the team will likely have one direct contact, whether it be a S&C coach, athletic therapist, or physiotherapist. This person may wear a few hats and it will be on them to decide based on their experience, confidence, and skill-set how best to manage the athlete. Whether it can be done in-house or if a referral is needed. This scenario would be quite common in Junior A hockey where I know a number of extremely competent individuals in this position.

However, the story will change for a professional athlete. There is a reason all major sports teams have a host of different professionals and don’t rely on only one person to do the job. They want the best people in the various positions to work together and get the athlete healthy to return to play as quickly and safely as possible. It's likely that all invested groups will be in communication the entire time and the athlete will certainly spend time with multiple people before returning to play. 

With my work in hockey I have had the opportunity to meet and observe a few of Edmonton’s top S&C coaches in this sport. I reached out to one to get his thoughts on the article regarding exercise and injury management. 

Here is what Joel Jackson, the S&C coach for the U of A Golden Bears Hockey Team, had to say: 

“Every injured athlete needs an integrated support team (IST). I don’t like the title because it suggests that the physio or S&C coach can take the athlete from injured to healthy [themselves]. The proper way to go is to have the athlete start with a therapy heavy approach and then transition to working more and more with the S&C coach…I always lean on you guys in the initial stages of the injury…It has to be a team within a team.” 

Brilliantly said. 

A team within a team… both utilizing exercise differently and at different stages of the rehab to return-to-play process, for a common goal of returning the athlete to health. 

The author is accurate to say we, as physios, don't have extensive training in school, in a lot of high level S&C facets including programming, skill acquisition, and skill transfer. I have never thought of this as a bad thing, as there is another profession that specializes in exactly that. If you are working with (semi-)professional athlete’s all you need to do is be very good at your job, not do everyone’s job. 

It would be bananas for me to think that I could do what these guys are doing and insulting to the years of experience and professional development they have done to build up their knowledge base. 

It would be also be a complete disservice to the athlete to suggest I could do as good of a job in preparing them for the upcoming season compared to a sport-specific S&C coach. Even for hockey, a sport I know very well. 

They're just different crafts. 

And to that point, I still don't fully understand why this article was written. This doesn't strike me as a scenario where there is a "winner" but more so two professions that can work together in different stages of an injury and with different roles to get the athlete back to action.

Exercise is a modality that can be delivered in countless ways for countless reasons and I’m happy to share the opportunity to utilize it with those around me. 

I'm curious what others in my profession and the S&C world think after reading this article. Perhaps there are physios, like the author, who believe we should be able to fill both roles proficiently or S&C coaches who feel physios should have no role in exercise prescription at all. 

I would take away one message from Joel…a team within a team. 

Thanks for reading!