Friday, 6 March 2015

Remote Physiotherapy Service

Kim Baxter & Associates is launching a new remote-physiotherapy service aimed at runners of all types (road, fell, ultra, orienteering). In this blog I describe how my past experiences and recent thinking have led me to believe this can be a valuable offering.

I’ve been a competitive runner since I was a child, and have had my fair share of injuries, including an ankle ligament reconstruction. My most recent injury was last year, in my foot. It put me out of the Sheffield Half Marathon, my goal for the year. As ever, I didn’t follow my own advice - I pushed too hard in training and then didn’t listen to the warning signs as things started to unravel.

After fourteen years as a GB Orienteering Squad member I joined British Orienteering as physiotherapist for the Junior Squad in 2007, under the then Performance Director Gareth Candy, and moved to lead physiotherapist in 2009. At this point we both felt that the squad physiotherapy intervention needed to change from being based on physical presence i.e. at squad weekends and competitions, to be more generally available. Athletes would tend to wait until a squad weekend to get their injury assessed. We wanted athletes to become much more proactive in their injury management.

Injuries are a time where athletes face many negative emotions - fear, doubt, worry, even depression and grief. I felt an important part of regular contact with the athletes was to support them through these difficult times.

Initially our longer term goal was to build a network of “approved” physiotherapists based around the country that were available to provide diagnosis and treatment at short notice.

What I hadn’t realised at that point was the prevalence of online training logs, the fact that many Squad athletes were using them, and, after a suitable period of building trust, might even be happy for me read them. This allowed me to be more proactive in contacting them when they started with an injury and also allowed me to more closely follow their progress.

In 2010 and then for the whole of the 2012/2013 season I collected data that included training hours and the number of days training lost due to illness or injury for most of the Squad athletes. It would be entirely inappropriate to label what I’ve been doing scientific and the results don’t stand up to that kind of scrutiny. Throw in personal bias and placebo and you’ve little more, in scientific terms, than a suggestion of an area where further research might be fruitful.

However I have to work with what information I can get and the information was revealing. Whilst athletes were in general training at a high level the average time lost through injury and illness was astonishingly high. This was evident through the winter months November to January but also showed following the stresses of major competitions.

This started me thinking more about how their training might be affecting their injury and illness levels.  

How has my thinking about injuries changed?

Much of my education has focused on the intrinsic factors for injuries - biomechanics, the structure and movement of the body, and associated theories such as core stability, functional stability and muscle imbalance. Extrinsic factors such as training load, specificity of activity, equipment and surface were only covered in passing.

The general idea is that improved biomechanics will reduce injuries and your injury, when not caused by falling on slippery ice, has been caused by imbalance in your biomechanics. Rectify that and the injury will go away.

At some point many of us will have been told we have weak gluts, tight calves, a weak core or tight hamstrings, or that we over-pronate, supinate, have poor hip control or weak inside knee muscles. It may have been me that told you these things.

And of course it’s probably true, we probably do have these things when they are diagnosed and they probably do have an effect on injury development. But are these the factors that really tip us over into injury?

I’ve seen patients with relatively good biomechanics get serious long-term injuries through overtraining, and I’ve seen patients with terrible biomechanics who have been running competitively for years and only recently come to see me with their first real injury.

The concept that load as opposed to imbalance is an important factor in injury development is gaining ground. I’m using load in a very general sense. It could mean a breaking load that causes an acute injury, load applied over a long time that causes progressive breakdown, or a variation in load e.g. suddenly running on roads when you’ve been training on the fells.

Obviously acute injuries sometimes happen - there is not necessarily a lot that can be done, but the other two types of load can be managed. For one, recovery-time between loads is important, for the other common sense is quite useful.

But, if you are anything like me, sometimes common-sense needs external input.

I believe the biomechanical analysis and approach is valid in many ways and there will always be patients where it is the most significant factor. But if I’m having to hunt to find a significant biomechanical issue then I start to question how much of a factor is it?

The difference in thinking about loads is that it is much simpler. If your body is strong enough to resist the required load it doesn’t matter if you are biomechanically unsound. Sure, all things being equal you would perform better if your biomechanics were better, but it doesn’t mean that is the best route to avoid injury.

A nice example are climbers, who tend to be have very good core strength and excellent movement patterns through the biomechanical chain. They often present with better strength and control than many seasoned runners. They also often like running, but in my experience they tend to break pretty quickly when they start running seriously, simply as their bodies aren’t used to running specific loading.

Put in simple terms, I believe many injuries can be overcome through a managed programme of activity-specific strengthening and many injuries can be prevented through appropriately managed training.

Something as simple as just being sensible.

I recently helped a 60 year-old patient who was injured after walking a 50 mile ultra-race. He told me he was “getting too old for this”. I remembered he had recently completed a 60 mile run for his 60th birthday. A few questions later he realised that the latter was in  hilly terrain, he was used to running long distances and he had trained for it, the former was walking, on the flat, and he hadn’t prepared. It didn’t seem as if age was the most significant factor.

How has this changed my approach with British Squad athletes?

I now focus far more on trying to spot training errors. For example, too many hard sessions without recovery, sudden increases in training, sudden variations in training or activities, even just athletes starting to sound tired.

Dealing with injuries has also changed. I now focus much more on helping the athlete to find the right load levels to allow the injury to heal and the supporting structures to strengthen without further aggravation. Sometimes this can mean suggesting they back off, sometimes it might mean giving them the confidence to push a little harder.

With online training diaries and free video-conferencing tools such as skype this approach to injury prevention and rehabilitation can be done almost as effectively remotely as face-to-face. It is based on developing an understanding of the athlete’s goals, training, lifestyle, activity levels and the external and internal stressors they have to overcome to reach them.

If you want to learn more take a look at the Remote Physiotherapy FAQ on

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