Raising the game

Whether you're a world-class athlete or a weekend enthusiast, you can boost performance with the help of physiotherapy. Jane Hobden talks to the experts

In November last year, top squash player Madeline Perry got to the quarter finals at the women's world squash championships in Belfast. Phil Glasgow, head physiotherapist at the Sports Institute Northern Ireland, was watching her game closely. Ms Perry began performance enhancement work with Dr Glasgow four years ago. Since then, her world ranking has risen from number 19 to seven. 'It's quite indicative that she was disappointed not to reach the semis - whereas a couple of years ago she would have been thrilled with reaching the quarters,' Dr Glasgow comments. The 29-year-old squash player is based, and trains, in Halifax, Yorkshire. She flies to see Dr Glasgow at the University of Ulster-based Sports Institute which, along  with the UK's other national sports institutes, was set up  to support the country's top athletes. Performance enhancement work is key in lifting her game and making her less prone to injury, says Ms Perry (she had ongoing problems with patella tendonosis in her right knee). 'The changes to my movement have not only put less stress on my knee, but I now move more economically, exerting less energy for each movement, as well as increasing my speed.' The structure of her training has also improved, with greater emphasis now on building strength and stability. 'It is very well planned, which means  I always feel prepared when entering an event. This was really necessary to get into the top 10 in the world.' Sports physiotherapy is widely perceived as focusing on treating people after injury. However, this view is changing, with physiotherapy's role in enhancing performance gaining ground over the past five years. The International Federation of Sports Physiotherapy now flags it up as one of the three main competencies of sport physios. Dr Glasgow also  feels regional sports institutes have been key in developing performance enhancement. Although often labelled specialist, performance enhancement is rooted in the basic principles of physiotherapy, he maintains. 'Physios are experts at analysing movement. So much of our work is about restoring formal form and function. Here we are also trying to improve function and are taking it to another level.' He sees a range of potential positive influences of physiotherapy. These fall into the broad categories of injury prevention and improved efficiency through enhanced muscle strength, movement control, flexibility, motor recruitment, neuromuscular control and spatial awareness. 'All of these elements then feed into an enhanced ability to train at high levels and perform sport specific skill.' Dr Glasgow's work with athletes like Ms Perry always begins with a full screening. This consists of a clinic-based musculoskeletal profile, looking at areas like posture, flexibility, balance and control, along with assessing previous injuries and their impact on performance. The second stage is a gym-based functional movement assessment, where each task is videoed from different angles. 'We're taking a key movement pattern for a specific sport, and identifying whether they can maintain good alignment, whether they can control the movement, and picking up areas of limit and restriction.'   Although there is little research into performance enhancement, due to difficulties getting together subject numbers and specific interventions,  Dr Glasgow notes there is some evidence  that functional training, such as working  on balance and control, leads to  improved performance. The focus of the final stage of screening is training in the competition environment. Here footage of the athlete warming up, competing and warming down may be analysed. Having identified any weaknesses, Dr Glasgow works with the athlete and their coaches to develop a programme. Preventing injury goes hand in hand with improving performance, he believes, by giving the person a safer, more efficient technique. 'If a person is moving more safely and efficiently, they have more control, the technique is improved and the additional power is transferred into greater distance and speed.' This has been backed up by research. A study published in the Journal of Strength and Conditioning Research showed how a neuromuscular training programme led to significant increases in single-leg hop distance, vertical jump height and sprint performance, as well as improvements in squats and bench presses. As Ms Perry had a history of knee injury, one of Dr Glasgow's top priorities when working with her was to reduce the number of strides she took during her game in order to lessen the impact on her knee joints. He encouraged her to exercise holding a lunge position so she could get used to hitting the ball taking large strides. WORKING WITH THE TEAM Exercises were also used to build her leg strength and boost her core stability: single raises, squats, and jumps off boxes on to the ground to work on landing with light feet. In addition, Dr Glasgow worked on Ms Perry's daily routines with her strength and conditioning coach - the person who oversees a top athlete's fitness programme. Close teamwork with coaches is a crucial part of the job. Dr Glasgow often involves coaches in early assessments and goes through his findings with them, giving recommendations for the athlete's gym programme. A tactful approach, which acknowledges the role of the coach, is important. 'It's up to the coach to decide how to train his or her athletes. However, it is vital we put across the key role we can play. The top priority must be keeping athletes injury free, and coaches may need our guidance to understand the risks and to respond to that.' Diplomacy is also needed when working with athletes themselves, to ensure they view the assessment process in a positive way and buy into the programme. Dr Glasgow explains, 'Athletes are very focused on their performance. If you say: “Do these rehab exercises,” they are not so interested, but if you say: “Do this and it will improve your performance,” they are much more likely to do it.' Nicki Phillips, director of postgraduate healthcare studies at Cardiff University, is an experienced sports physiotherapist working with top-level athletes at world-class events. She has assisted the Great Britain team at  the past four Olympics – providing general back up and being assigned to teams including weightlifting, diving  and gymnastics. Dr Phillips concurs that boosting the performance of top athletes involves being a team player – working with coaches, dieticians, and medical staff. It's about maintaining the optimum condition of the athletes, ensuring they exercise appropriately and preventing injury, she says. This may be as simple as taping an old exercise injury or padding a blister to provide extra protection and increase confidence.  'It's often the little things that can make the different to an athlete's performance,' she adds. FIELD SET TO DEVELOP Both Dr Phillips and Dr Glasgow believe improving performance is an area of sports physiotherapy that is set to grow. Dr Phillips, who also chairs the Association of Chartered Physios in Sports Medicine, notes that one of the aims of the ACPSM has been to highlight performance enhancement as a key role for physios. She says: 'When UK Sport came to ask us for advice on what skills are needed by those working at the national sports institutes, we were able to identify performance enhancement as a key area.' The athletes too are convinced this is the way forward. Ms Perry says her perception of physiotherapy has changed dramatically over the past four years.  Before working with Dr Glasgow, she had always thought of a physiotherapist as 'someone who fixes you up after an injury'. In contrast, she now sees physiotherapy as an intrinsic part of an athlete's training, schedule and planning. 'I will continue to use it to improve my performance and Phil will be part of that whole process. It is also essential to keep on top of rehabilitation exercises to prevent injury and lengthen my career. At the top level of sport, very little improvements made and attention to detail can make a difference to your ranking, and I think that sports physio can make that difference.'  Such high praise, from world class athletes like Ms Perry, looks set to ensure sports physiotherapists are in demand in the run up to the Olympics in 2012. FURTHER INFO Wyer et al. 'Neuromuscular training improves performances  and lower-extremity biomechanics in female athletes',  Journal of Strength and Conditioning Research (2005), 19:51 Sports Institute Northern Ireland www.sini.co.uk Scottish Institute of Sport www.sisport.com Welsh Institute of Sport www.welsh-institute-sport.co.uk  English Institute of Sport www.eis2win.co.uk  www.madelineperry.com  Helping the recreational weekend warriors It's not only elite athletes who benefit from performance enhancement. At the University of Ulster, physiotherapist  and research associate, Chris Bleakley, helps run a physiotherapy clinic treating people doing recreational sport including rugby, hockey, soccer  and gaelic football. The same principles apply for recreational sportspeople as for top athletes, says Dr Bleakley, although the resources are different. 'You are not working with a team of coaches, video analysis and other resources. It's all about you having an awareness of movement patterns within a given sport and an individual's risk factors.' The success of this type of physiotherapy, as with any form of therapy, is about having the client on board, willing to work to see improvements, he maintains. Mark Raphael agrees. A recreational hockey player, who formerly played at a higher level, he used to have problems with back pain. Dr Bleakley identified tightness in his right lumbar spine, to which hockey players are prone. 'Their right hand is lower down the stick, so they spend a lot of time in right side flexion,' he explains. Following hands on therapy, Mr Raphael now does stretching and strengthening exercises at home as part of a long-term maintenance programme. He feels his commitment to the programme has been an important part of its success. 'The physio I've received has really improved my enjoyment of the sport. I'm fitter on the pitch, and able to move about freely.' Treatment has also changed his perception of sports physiotherapy. 'Before working with Chris, I used to seek physiotherapy when I was injured. Now if I feel a niggle I go at that point in order to prevent injury.' A mixture of sportspeople - 'from elite athletes to recreational weekend warriors' - make their way to the university's clinic. 'Most of them use screening as a means of injury prevention,' says Dr Bleakley, 'and we get a lot of “injury-prone” athletes, who want a musculoskeletal screen in a bid to ascertain why they are  always injured.' A typical case is the person who wants an exercise regime that will maximise the muscle strength and efficiency of the movement patterns they must perform during their sport. 'For example,' says Dr Bleakley, 'golfers with weak core muscles frequently have to stop putting practice prematurely, due to back pain. They seek ways to strengthen their core, in a bid  to lengthen their practice time and thus perform better.' More and more coaches, he observes, are beginning to understand the importance of physiotherapy, with many having had a positive physiotherapy experience from their own playing career. In his experience, the coach can have a large role to play in directing sports people to a physiotherapist for performance enhancement work. He cites the following example: if a club has a young rugby player moving position into the front row; the coach and player often want to know if they have the necessary range of movement or not, and the strength and control to cope with the new physical demands of this position. 'If they don't, then they want to know how they can then achieve this,' he says. Another example he gives is of a young hockey player starting to flick  short corners. 'Coaches often want to know if the player is capable of performing this complex movement pattern; that is, do they have the prerequisite hip range of movement and core strength? If not, can this be improved with treatment or exercises? Or would his time be better spent developing another player?'  These are all situations sports physiotherapists can help with.

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