Pitch perfect

Rugby physiotherapy is evolving to meet the demands of play, says Graham Clews.

Graham talks with rugby union’s national physios Rehabilitation will be the physiotherapy buzzword during the six weeks of high-octane action that is the annual Six Nations Rugby Union Championship. As England, Scotland, Wales, Ireland, France and Italy go head-to-head to battle for the title of champions of Europe, the physios behind the scenes will be engaged in their own fight to keep their best players on the pitch, and off the treatment table. Today rugby physios have to be part of the team that produces strong, quick and injury-free players, rather than just treating players when they’re injured. At this elite level of competitive, professional sport, physios are increasingly becoming movement specialists who profile and develop athletes in order to prevent, as well as treat, injuries. They will use complex planning and statistical analysis to ensure their star players play the maximum number of minutes during the rigours of the six nations. Stephen Mutch, Scotland’s chief physio says after each six nations match around one third of the players involved will report to him for treatment, but thanks to the degree of planning involved, very few will miss the next game, even though it may only be one week away. ‘In a tournament like the six nations, momentum is very important,’ he says.  ‘In professional sport there’s a mantra of taking each game as it comes but in medical terms you have to have a plan. It’s not something you’re taught, but you have to look at pattern recognition, and planning and prehabilitation are the key to reducing these injury numbers.’ On the evolution of rugby physio, Mr Mutch says: ‘The link between physical conditioning and physiotherapy is becoming increasingly important, as is the liaison with other specialists, such as dieticians. ‘Sport has leapt ahead over the past 10 years or so, and we’ve seen the incredible progress made by British competitors in the Olympics, for instance. I’ve seen enormous development in the 20 years I’ve been working, and I think it’s only going to continue.’ FASTER AND FITTER Rugby union turned professional 10 years ago, and since then the players have got bigger, stronger, faster and fitter. The trauma injuries that result in a high impact collision sport like rugby can be spectacular, but Phil Pask and Mike Snelling, who run the England team’s physiotherapy department, have developed a sophisticated injury audit that allows them to monitor the types and numbers of injuries suffered by their players year on year. ‘It’s allowed us to introduce what we call prehabilitation, concentrating on injury prevention,’ says Mr Pask. ‘I like  to say my job is to get the player from plinth to pitch as safely and sensibly as possible. Although we now have more sophisticated kit we won’t necessarily get the players fit again more quickly because we’re less willing to compromise on their condition when they return to playing.’ Managing the journey from injury to becoming fully match fit was a recurring theme for all the national physios. For Mr Snelling, the key to a successful physiotherapy and fitness team in any sporting set up is the gap between rehabilitation and ‘match fitness’; that is, between getting a player fit in terms of their body working normally and fit in terms of being able to play 80 minutes of international rugby. Ireland’s national physio Cameron Steele agrees that physiotherapy at elite sport level has moved away from the treatment couch, where the focus is individual injuries, and into rehabilitation. Hands-on treatment is still vital, but not as predominant as it was. Today, close liaison with fitness coaches is key: it’s about judging the right time and method to bring players back on to the pitch. For example, do they play 10 minutes of a full match, or a reserve match? ‘Players’ athleticism and conditioning has made the job easier, if anything,’ Mr Steele says. ‘Traditionally rugby was perhaps a sport played by guys who were too big and clumsy to play soccer, but they’re athletes now. Previously players were asking too much of their bodies, which weren’t able to cope, but now the fine tuning means the players are in much better shape to cope with the demands of the sport.’ He adds: ‘Playing top-level rugby isn’t good for your body, but players from the professional era are likely to have fewer problems in middle age than those playing in the elite amateur days.’ A PASSION FOR THE SPORT Experience, education and technical knowledge are obviously paramount for these elite physios, but a love of rugby, and sport in general, is an essential ingredient for physios who will live and breathe the game for many weeks of the year. England’s Phil Pask, who played top-level amateur rugby, and initially completed a sports science degree before retraining as a physio is, he says, ‘a physio by profession, and a rugby player by inclination’. Mr Mutch played first division rugby in Scotland, and Hwyel Griffiths, the Welsh national physio, also played the game at first-class level. Mr Steele was, he admits, ‘no great shakes’, as a rugby player, but he warns that if a young physio only wants to work in elite sport to be around the big names, then it’s not for them. ‘You need to love the sport,’ he says. Not all the physios are rugby nuts, however. Mike Snelling, an Australian at the heart of the England set-up, worked with Australian rules football, American football, netball, Surrey cricket club and Fulham football club before making the switch to the oval ball game. He says the tendency to concentrate on one sport is more common in the UK, and he believes the same biomechanical principles apply across all sports. ‘Cricket and rugby are obviously very different sports, but as a physio you have to diagnose and treat what you find.’ He notes that ‘T-shape practitioners’, where the bottom of the T is deep specific knowledge and the top of the T is a broad knowledge of other aspects that are needed, is the model the England team aim for – something that has been borrowed from the business world. NON-STOP FOR 40 DAYS It’s not just the players who will be running themselves into the ground during the Six Nations Championship. The physios will be working 40 days non-stop too. For Wales’ Hywel Griffiths, a typical six nations non-match day starts at 7.30am for a meeting with the conditioning team who monitor each player as he arrives for training. They test their weight, ask how they slept, gauge how tired they are, and assess their keenness to throw themselves into that day’s two training sessions. As the players go through their paces on the training ground or in the gym, Mr Griffiths and his team will keep a watchful eye, offering advice on mobility and flexibility. The Welsh injury audit suggests one quarter of the team’s injuries come from training, a key point in negotiations where physios and strength and conditioning trainers determine the balance between pushing players to their limit, and keeping them match-fit. The long hours mean the physios rarely get to enjoy the glamorous moments such as the after-match dinner because they will be taking the injured players back to the hotel. But that doesn’t diminish the thrill of being an integral part of the national rugby squad, particularly when the team has won, and especially when players helped back to the pitch have played  their part in the victory. WHY IT’S ALL WORTH IT Phil Pask says: ‘When you achieve something like winning the European Cup with Northampton Saints, or the World Cup with England it’s special, but also humbling. ‘Even when the team’s not going so well it’s still special, and there’s still that camaraderie. I want to beat Wales more than anything, but if I’m needed I’ll be the first one to help treat any Welsh player.’ Hwyel Griffiths says the buzz makes all the long hours behind the scenes more than worth it. ‘I feel very privileged to have this job,’ he says. ‘I’d hoped to play rugby for Wales, and I suppose I’m doing the next best thing. When you’re working on the six nations and they just become another series of internationals then it’s time to pass on the baton to someone else.’ For all the home union physios the six nations are anything but ‘just another series of internationals’. They’re the chance to go head-to-head on the pitch, and in the treatment room, with their colleagues from the other five countries, and, as all sportspeople know, there’s nothing like a local derby to get the competitive blood flowing. The physios will be giving their all for six weeks to ensure their country comes out on top. They’ll also be working as hard as they possibly can to demonstrate the key role physiotherapy plays today in top-level sport. FL Tips from the top The national teams’ physios give their advice for physios wanting to work in elite sport: a) find a sports team you can offer support to. It might be for free, it might only involve massage and strapping and it might involve working two nights a week and Saturday morning but, as they say in rugby, you’ve got to make the hard yards b) join the Association of Chartered Physiotherapists in Sports Medicine and work through their bronze, silver and gold system of accreditation c) use the ACPSM mentoring system to find someone to help you out when you work with a club so that you are not completely exposed d) a good rotation in an NHS outpatient department is very helpful. It will give you diagnostic skills that are increasingly important in top-level sport e) an MSc three or four years after qualification is recommended. You can get too much education too quickly, and experience is important f)  having an extra string to your bow, such as a knowledge of Pilates, or strength and conditioning, can give you that advantage g) rugby physiotherapy will get tougher, and it can be a frustrating career path, but if you can stick it the rewards are fantastic
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Graham Clews

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