Healing hands and sports injuries during lock-down
Paul Brennan spoke to physiotherapist Paudie Whelan on the issues facing the profession and sports people with injuries in this time of the Coronavirus shut-down
CAST your mind back to the days leading up to the weekend of March 14/15. That Saturday the Kerry hurlers were scheduled to play Antrim in the Division 2A league final in Croke Park. Twenty-four hours later their football counterparts were down to play Monaghan in Inniskeen in the fifth round of the Allianz League. The following Tuesday - St Patrick’s Day - the Kerry Under-20 footballers were to play Galway in an All-Ireland semi-final.
These were just three games in a comprehensive schedule of fixtures - nationally and locally - that fell by the wayside on the evening of March 12 as the GAA fell into line with the Government’s earlier announcement that all schools, colleges and pre-schools would close immediately until March 29, at the earliest, as well as there being limits put on the amount of people that could attend public gatherings together, because of the Coronavirus pandemic
At the time we were struck by a thought (one of many): might the few weeks break from sport and competition allow sports people currently on the injured list to rehabilitate from their injuries without actually missing any competitive action? Might there be a silver lining on the black Coronavirus cloud, whereby sports people could use the hiatus from training and competition to rehab without the pressure of getting back fit and competing quickly?
A week or so later a conversation illuminated the situation in a different light. With the initial two-week shut-down set to extend to another fortnight, bringing with it stricter restrictions on people’s contact and movement, it became obvious that sports people wouldn’t have access to physiotherapists, and that there would be implications for those people and for their rehabilitation.
With that in mind The Kerryman spoke to a physiotherapist with years of experience working with sports people and treating sports-related injuries. Causeway native Paudie Whelan owns and runs the Listowel and Ardfert Physio Clinics, and has carried the physio bag for several GAA teams for more than a decade.
Whelan has worked as a physiotherapist with Kerry hurling teams of all greades, up to senior, and was physio to the Kerry Under-21 football team in 2008, when the Kingdom last won the Clarke Cup, and the Kerry minor footballers. Whelan has also been on the treatment bag for different Causeway, Lixnaw, Ardfert and Ballyduff hurling teams, and Dingle, Castlegregory, Ardfert, Ballyduff and Pobal Scoil Corca Dhuibhne football teams.
With input from his colleagues Caolan Scott and Niamh Enright, Whelan offers an informed insight into how physiotherapists are coping with the Coronavirus-induced lock-down, and how sports people with injuries might be affected by the absence of the healing hands of their physios.
How has the Covid-19 shutdown affected your practice / business, with regard to the day-to-day activity, employees, clients?
PHYSIOTHERAPY treatment requires close physical contact so due to the face-to-face nature of our business we had to close our clinics in Listowel and Ardfert, as has every other private practice in the country. The Covid-19 virus is so easily transmittable that it was far too risky for us to continue seeing patients in a clinical setting. We have a very varied demographic who attend the clinic so we stopped all individual appointments and all our classes including our Pilates, ante-natal and post-natal classes. This protects our patients as well as staff.
While the work is now greatly reduced for our private practitioners, there are many different areas physiotherapists are required. Many people only think of sport when they think of physiotherapy, but physiotherapists play a huge role in other areas within a hospital, such as respiratory and neurology. So despite Covid-19, physiotherapists are still very much required in an acute setting, so some employees from private clinics across the country have been able to return to work on wards where physiotherapy is essential to prevent patients from deteriorating.
With no person-to-person hands-on treatment, are there other ways a physiotherapist can continue to treat a client?
THE current situation makes it very difficult for physiotherapists. Without being able to see a patient in front of us, it can cause issues with our services. As we specialise when we are face-to-face with patients within the clinical setting, our services are now limited. We are following up patients via telephone, various apps, for example Whatsapp, and giving advice where possible. We have also issued exercise rehabilitation programs for various clients, but again, it is difficult to assess and progress accordingly in such circumstances.
Have you explored on-line help for clients, or can a client treat themselves with phone/ online guidance from a physio?
YES, some physiotherapists have tried to provide some level of treatment through options such as telehealth and phone consultations. While it’s not ideal and doesn’t replicate the outcomes of face-toface interactions with clients, it can be a temporary method of giving clients some guidance due to the difficult circumstances. However, this can be particularly difficult for a client’s initial assessment where we are unable to do an objective/ physical exam. The purpose of the objective examination is to confirm or refute hypothesis formed from the subjective examination.
For follow-up clients who have already had an initial assessment, a phone consultation can be a good way to check in with clients and how they are doing. Telehealth and video consultations can work well with clients who are good with technology and we can then e-mail on the information we went through, having already explained it. This also helps us to continue giving advice, education and reassurance to the patient, which are key components to an overall management plan for any patient
For example, we can progress on post-fracture rehab exercises and modify rehab programs depending stage of injury / response to treatment. This can prove challenging with any of our older population who may not be great with technology but is a very useful tool with those that have access.
Having worked with a lot of GAA teams, and players, what are the most common type of injuries to footballers and hurlers that a physio has to treat? What is the general recovery time for soft tissue/hamstring/ligament/ etc/ injuries?
THAT’S a very broad question but in general we would see more lower limb injuries compared to upper limb. A lot of ankle, knee and hamstring injuries as well as quadricep contusions otherwise known as ‘dead legs’. Upper limb injuries then, secondary to GAA being a contact sport, clinically we would often treat acromioclavicular (AC) joint sprains - a joint at the top of the shoulder which can get injured from a direct blow or falling on an outstretched hand.
Recovery time for injuries varies significantly and is dependent on a number of factors. In general the average soft tissue injury takes six to eight weeks to resolve.
For example, hamstring injuries are divided into three different grades. A grade 1 is a mild injury and can take a few days or up to three weeks to recovery. A grade 2 then can take four to eight weeks and a grade 3 which is severe can take anywhere up to six months and in some cases may require surgery.
Approximately one third of the hamstring injuries will recur with the highest risk for injury recurrence being within the first two weeks of return to sport. This is due to a number of reasons - the athlete’s age, previous hamstring injury, the demands of the sport they are playing, the client not completing a comprehensive rehab program, and a premature return to sport.
Therefore, physiotherapy input is recommended to ensure accurate diagnosis and determining the type of rehabilitation program that most effectively promotes muscle tissue and functional recovery, which is essential to minimise the risk of re-injury and to optimise athlete performance.
How would the absence of direct involvement of physio affect players who were in the middle of rehab, or who had just picked up a bad injury before the shut-down?
IT can possibly have a very negative effect especially in the early stages of rehab when a player is looking to someone to provide them with the reassurance and guidance that they need. Having said that, each player responds differently to injury, both physically and mentally.
It can be a worrying time for players with injuries, as the game has become very competitive and there can be a huge pressure on players to return to full fitness as quickly as possible. Many players will be anxious to get physiotherapy treatment and want the reassurance and structure a physio can provide in terms of a treatment plan to guide their return to sport. Regular physiotherapy sessions also ensure the client stays on track with their rehabilitation and we can modify it where required.
It is important to remember that injuries are not just physical for many players. Experiencing an injury can cause players to become worried, stressed and obsessed with the question of returning to play. These issues should also be addressed when providing injured athletes with comprehensive rehabilitation programmes. To do this it is important to build trust and a rapport with players, which can prove difficult without with face-toface interaction with clients.
Depending on the player and the level at which they are playing, the professionalism seen from GAA players these days can be an advantage. Many players are very disciplined in their rehab and work hard to return to full fitness. Therefore despite being unable to provide face-to-face treatment, the majority of players will be happy to utilise online and phone consultations given the current circumstances. The absence of the pressure of return to play at the moment may also be a help as players can focus solely on their rehabilitation without trying to rush it and without the added stress of wanting to get back for a particular game.
How serious could it be for a player who just had a cruciate operation not to be able to visit a physio regularly? Presumably they would still get some form of essential rehab treatment the way any post-operation patient would, but could there be long-term consequences for a sports person in the absence of rigorous and regular physio?
IF the appropriate intervention and support is not there it could possibly be quite serious and result in a poor outcome for the patient. Players post-cruciate repair have to ensure a long and tedious rehabilitation programme to return to sport. It requires huge commitment from players and regular physiotherapy is needed, especially in the first couple of months to ensure the player is progressing accordingly. A poorly managed knee and surgical sites could result in a serious infection and poor recovery. Delaying physio will only prolong the rehabilitation further down the line. We had a client a few months ago who waited about three weeks before attending physio, thinking they could self-manage, only to find out they actually had worsened in this period.
The player would receive essential in-patient physiotherapy postop and would be provided with the early stage rehab exercises. It is then up to the player to link in with their team or local physiotherapist to monitor and progress their treatment appropriately. To ensure a successful outcome post-ACL reconstruction it is important for the client to be continually assessed and progressed accordingly. While generic guidelines and rehab protocols can be provided to clients based on how many weeks post-op they are, this is not always ideal as each individual is different in their recovery. However, given the challenging circumstances, we would have to ensure we keep regular contact with them, carry out video and phone consultations to demonstrate and explain their rehab process, and to ensure they are responding appropriately to the rehab and prevent any
setbacks.
With regard to the Covoid-19 shut-down, and the cessation of training and games, could this period give certain players/ injuries a better chance to rehab fully, without the pressure of getting back playing quickly, or do ‘elite’ players always need some sort of maintenance physiotherapy even if they don’t have a specific injury?
ABSOLUTELY, there can be huge pressure on players to return to play. As I’ve said, one of the most common reasons for re-occurrence of injury is premature return to sport. Physiotherapists play a role in injury prevention and injury management. Therefore, while the players might not always need regular physiotherapy ‘treatment’, players can link in with their physiotherapist for input with regards to injury prevention. Hence, the period of shut-down could be used to players’ advantage to work on their weaknesses.
Like I said earlier, some patients and players will find a silver lining in this break from sport. Even those players that have that niggle that won’t settle, but have been on the go for months with rigorous sport and exercise, might find that their issues ‘disappear’. For some issues, for example a stress fracture, time is the healer. As regards maintenance physio for a player, even if they don’t have a specific injury, that depends on the player. If a player has a demanding schedule not just from their sport but also from work and family life, the regular contact with a physio gives them a high level of confidence and reassurance when they do play their sport.
Apart from GAA players, have you worked with other sports people from other disciplines, and, if so, what sort of issues could arise for them with regard to the absence of physiotherapy treatment at this time?
I HAVE worked with soccer players, badminton players, swimmers, triathletes, marathon runners, jockeys, cyclists to name but a few. There will be similarities across all the different disciplines. For some participants at the end of their season, the time off might be good, as their body is tired and stressed. Whereas those who are just into the swing of their training or rehab, they have now hit a wall and will have to start up again. I suppose everyone will be in a similar position fitness-wise, depending on their self-management. Hopefully when we return to normal people don’t up their exercises levels too much too soon and cause further injuries.
Physios would advise that while players, whatever their discipline, have this extended break that they ensure they maintain some level of fitness and conditioning so that when they do return to training and matches it’s not a massive spike in training load as this is a common cause of injury, which we see regularly in the clinic. The message would be to keep it simple, keep moving and training, eat well and sleep well. Do what works for you.