Monday, 25 February 2013

to treat or not to treat...

Is THIS performance therapy??
In part I of this series, I discussed performance therapy- argued for its importance, and used it as a start-off point to delve into what I think are some of the bigger issues facing elite sport right now.

Part II discussed the reductionist nature of traditional Newtonian science - how this has influenced our roles as coaches, and how I feel this ‘separatist’ nature retards creativity and expertise.  I used my own career as an example: beginning with my early apprenticeship through Dan Pfaff, I formed specific ideas on what I thought the requirements were for elite performance, and it was the holistic-integrated nature of this philosophy that led me down many a dead-end road - perpetually blocked by those that didn’t particularly share the view! That I should be offering nutritional advice.  Or doing ‘therapy‘ on athletes.  Or advising on supplementation.   It was often frustrating...and it was  often my own fault...

I was asked by a friend and colleague to share some of these frustrations, maybe some of the lessons they taught me, and how it all enabled me to come out the other side a better, more understanding, and well-rounded coach...

As I learned more... as I gained a deeper understanding of not just coaching, but of human nature itself, I began to gain an appreciation for the process of doesn’t happen requires patience, cooperation, empathy...

...three words that I only recently learned the meaning of.

Looking back, many of the road-blocks that I attempted to bash my way through existed because of the ambiguity of my role...was I a sprint coach?  A strength coach?  A therapist? 
Well - the answer was yes...I was all of them (to an extent)...

But, a lack of clarity begat confusion, which often begat frustration...
  • To my sprinters, I was unquestionably their coach.  The buck stopped with me - I wrote the sprint programs, the strength programs, the nutritional programs, the supplement programs, and did most of the ‘therapy’ essence - the Head Coach.
  • In my mind, it wasn’t too much different with the bobsled and skeleton athletes.  I fulfilled all of the previous roles, but because it was now with mostly National Team athletes, there was an additional group of folk that had a vested interest - namely the NGBs, the Olympic Committees, other coaches, and members of the support team.
  • With the football players, I wrote their speed and strength programs, and that was pretty much it...not a lot of confusion there (this is different now, as ‘performance therapy’ now predominates my time with the NFL guys I work with)  
  • With the speed-skaters, I would consult on their speed programs, their strength programs, their nutritional and supplement programs, and do quite a bit of therapy...usually hidden out of the way, as I was working primarily (at least at first) as a private consultant for the athletes.  

So you can see the where the confusion was borne out of...
shoot, just writing this up is making me confused, and I lived it! 
...for over a decade!

The overriding principle (and justification) for me during this time was I would do whatever was best for the athlete (at least in my mind, in that moment).  If the athlete was having some tightness during warm-up, and had asked me for some quick work, then I would reply “no problem” success with their current treatment plan, and had asked me (or a member of their ‘team’ had asked me) to assist/step-in/take-over - “no problem”...if they were having trouble with body comp, and wanted some assistance with their diets - “no problem!”...
problem was...this was a problem...

folks were getting upset...
but ‘screw ‘em’...I was keeping the athlete training...optimizing their sessions...getting them healthier...getting them leaner.  In short, they were doing better...and isn’t that why we are all here?

Part II of this discussion prompted quite a bit of feedback - both from Twitter and on the comments thread of the blog itself.  Canadian strength coach and therapist, Scott Livingston brought up some excellent points in regards to the confusion often experienced, and identified ‘pathology’ - and as it relates to responsibility - as a possible line in the sand:
“...the problem becomes when athletes are suffering from pathology, or the inherent dysfunctions that have been observed and treated and are not resolving.
The primary reason for the discourse often seen between treating coaches and therapists can lie in the concept of and desire to “box” out or “boxing” in, and this is often ego driven and turf oriented. But it also resides in a deeper more understandable and practical issue, the issue of
responsibility. As professional domain is defined by level of responsibility and this is why as you move further up the food chain of such responsibility the cost of your liability insurance increases. Thus the reason for the often seen discourse between therapists and physicians which at times can be as strong as the one seen between performance coaches and therapists. I spend a lot of money every year for the right to practice therapeutic techniques as well as building and delivering performance training programs, of which both policies have very clear delineations of what I can, and can’t do.

The key issue in the delivery of therapeutic skill sets is the underlying cause of the issue you wish to treat. Therapists spend a long time learning and practicing the art of history taking, differential assessment systems, and understanding how to recognize underlying pathology. I can’t tell you how many times I’ve attended courses on skill sets capacity and never once has anyone taught the attendees how to recognize or assess underlying pathology. Skills are often taught in an assess and effect approach, and this works just fine when the practitioner taking the course is a therapist because he/she has already been taught how to approach the process of “clearing” for other potential sources of the problem. When the source of the problem ends up being something far graver than musculoskeletal dysfunction, and the athlete ends up suffering grave consequences, who’s fault does it become? Thus the issue of responsibility being at the forefront of the discourse”.

Now, today - I don’t mess with ‘pathology’...Scott makes some excellent points, and I wholeheartedly agree with everything written above....a decade ago though, it was a different deal - this was trumped by the success (or lack of it) the athlete was currently having with their situation, their desire for me to help out, and my confidence that I actually could help out...pathology be damned!

(I will qualify this by stating that I never stepped outside of my ‘comfort zone’, and employed only those techniques that I was 1) extremely comfortable with and competent in - i.e pretty much only ART-type therapy ‘below the belly button’, and 2) only when I was absolutely certain that any intervention would ‘do no harm’.  Perhaps this was naive, and perhaps I was just lucky, but I don’t believe any athlete ever ‘got worse’...but this is not the point)

So what changed?  What’s the point in all of this?
Well - be patient....I’m coming to it...

how much training time would these two guys have missed without Performance Therapy?

Performance Therapy of some sort, and in some manner, is essential to optimizing the training process of the high performance athlete.  If you have a skilled ‘track-side’ therapist, then fantastic!  Working with a knowledgeable and technical coach - and perhaps even a biomechanist - this can be the perfect training situation.  Unfortunately, this rarely exists.  

If you believe in performance therapy - if you believe in integrating various treatment protocols into your physical training - and you don’t have a therapist, then what can you do?  

As I see it, there are a couple of different scenarios that require a couple of different solutions each:

1. If the S&C coach is the one that recognizes ‘dysfunction’ (e.g. being Lorne’s example in his blog last week), then he could/should intervene to the extent of his skill-set in the attempt to optimize the session.  If he is a qualified therapist (as Scott is, and as are an increasing number of other S&C coaches), then he will have a larger tool-kit to draw from than the rookie S&C coach straight out of the CSCS exam.  Scott has a wide variety of techniques at his disposal, and has the know-how and experience to do so; the rook pretty much has to rely on stretching, foam or ball rolling, and other forms of ‘self-manipulation/treatment’, as Scott refers to here (again from part II’s comments section, and alluding to my F1 analogy):

Just as the driver in the F1 car can tell the mechanics when something isn't right, and in many instances can dial this down to the actual problem. Further there is much they can do themselves with various self therapies such as forms of self-massage like foam and ball rolling, forms of active stretching, nutritional programming and supplementation, etc. that can help them personally manage their own bodies. This translates into how they warm up, cool down, and recover from each training and competition session”.

Focus here is on athlete education...helping the athlete understand how his body moves...what he can do to help it move more efficiently.  And what you - as a coach - can do to aid in this process.  As the lines between therapy and strength & conditioning continue to blur, increasing numbers of strategies are opening up to help the strength coach to do this. From short weekend massage courses, to on-line resources (such as Kelly Starrett’s excellent mobilityWOD), and everything in between, the options are varied and many...

One option that doesn’t exist, though is to STOP.  Stopping a session should only happen under fairly drastic circumstance (i.e. acute injury requiring immediate attention).  If you (or a combination of you and the athlete) cannot get the athlete moving better to at least the point where the session is not potentially  injurious, then move to Plan B.  If you don’t have at least three Plan Bs for every session in your program, then you are doing your athlete a disservice - your programming is incomplete.  If you cannot complete Plan B, then move to Plan C.  If you cannot complete Plan C, then move to Plan D, and so on down the line.  Stopping, picking up your water bottle, and heading home is not a high-performance option!

2. If it is the main (i.e Head Coach) coach who recognizes the ‘dysfunction’, then he has a little more license to ‘experiment’.  My example here is myself as a sprint coach - late 1990s, working with a group of sprinters with no opportunity for ‘qualified’ therapy support (especially on the side of the track). Like Lorne alluded to in his blog, and Lisa mentioned in her comment in part II, the main purpose of this ‘treatment’ was two-fold: 
    1. optimize movement; and 
    2. extend-finish the session.  
I would do whatever I could do to aid in these processes, and not a day went by when an athlete’s training session wasn’t either improved, or extended because of this intervention.  The key again, though, is understanding where the line exists between ‘treating an injury’ and ‘optimizing the training session’. Scott continues: 

“The existence of pathology is not so much the issue as the use of the therapy to ‘treat’ pathology, versus the use of therapy to augment or assist training effects. If your intent is to ‘treat’, then you should have some form of medical qualification. If the intent is to support training effect, then it becomes an available option for delivery by a coach. This can be a slippery slope though as what constitutes real expertise in these adjunct skill sets”. 
I slipped down this slope...many times.  To be honest, as the main coach, it was a fairly straight-forward justification.  Either I dealt with it, or we potentially wait days/weeks to get someone else to look at it, prescribe a treatment program, Plan B sessions, etc.  Best case scenario is we miss a few days of training.  Worse case was we missed much more. This was not acceptable, and again speaks to the generalist nature of coaching.  When you don’t have a team of support (which speaks to almost all athletes and coaches), then what are the options in pursuit of high performance? The S&C coach is normally part of a larger team - a team that would normally include medical support - so the options are often fairly straight-forward: if it’s not within your specific ‘scope of practice’, then pass it along.  For the main coach, this is often not the case.  But the creative coach can still find ways.  
For example, a young coach we worked a lot with in London over the last three years is Jonas Tawiah-Dodoo.  A graduate of the UK’s excellent coaching education program, Jonas worked as an Apprentice Coach for UK Athletics for the last two years.  During this time, he also became an accredited massage therapist (a program actually initiated by UKA specifically designed for coaches).  He learned as much about therapy as he could - spending as much time with the therapy team as he did with the coaching team.  Now - Jonas is a bit of a hustler, and crucially, he was also able to develop his own ‘support network’, recruiting a number of therapists to work with his development group.  Even though none of his athletes could afford therapy, none of them ever went without.  Young student therapists became track-side, performance therapists.  First or second year osteopaths would come to the Center once or twice per week to experience ‘real-world’, practical therapy; it’s always pretty easy to recruit young and eager therapists to help out in sport, as it definitely beats hanging out in a clinic all day.  I encourage all young coaches to develop their own, private support networks.  If you cannot afford part-time therapy from qualified and experienced professionals, then recruiting young volunteers is a great option, for it is usually these guys that are the most dynamic and keen...the ones who will bring the most to the group...the ones who are not afraid to work hard, to think outside the box...
Jonas now coaches the best group of young sprinters in the UK.  He has a team of therapists in support.  All work hard.  All understand the bigger picture. All are volunteers.  
Chijindu Ujah - young sprinter coached by Jonas
This post has taken a few twists and turns in the process of writing it, as a lot of what I was originally going to cover was much more eloquently expanded on by Scott Livingston in the comments of Part once again, this has ended up being far longer than anticipated.  I will expand on the options of the coach in the next post, including how I personally moved I learned patience, cooperation, and empathy... as well as expanding on  what I feel is the main key to success in high performance sport. 


  1. I love this series of post, it's getting better and better. I'm far from being a high performance coach, but I still can pick up some ideas that are most useful. I'll share my experience. I'v always been frustrated by therapist (particularly with chiro for me the most dishonnest profession after bankers, some are really good but most just try to suck your bank account). As an athlete I spend thousands of dollars in therapy, without much success. I tried chiro, physio, osteo and all things that end with o. My coach was never implicated in my rehab and didn't care about the injuries I had. Then as a coach I decided to do things by myself. I discovered a thing call trigger points therapy and tried it in myself. In one week I solve a 14 years old back issues, a 2 years old shoulder issue (I couldn't raise my right arm or do a dip for example) and a 5 years old hip issue (I couldn't squat anymore). All this with very simple massage technic and a little bit of anatomy and mechanics.

    I experiment on myself for 6 months and develop a simple system that works pretty well. Now I was reluctant to apply that on my athletes. But with this discussion and guidelines + the experience I gained I think I'll slowly introduce it not as a treatment tool but as a mobility enhancer and a preventive tool. The guideline that you and scott gave are very useful.

    I really believe that basic massage therapy works great and every coach should learn some experiment on himself and on his athlete. Even for non professional athlete I think it would prevent many injuries and save a lot of money. To me it's like knowing some nutrition and supplementation theory. You don't necessarily need a nutritionist. The only problem I see is that you must know your limits as explained.

    Thanks again for this series. This is just great.

  2. Stuart. Great words! Thanks for all the effort to put this on paper!

    In am wondering, is it an idea to get more specific on performance therapy. Maybe we can make a top-5 list of most important joints/regions where most of the time the dysfunctions occur with the athletes and what in your opinion the best tools have been to correct these.

    Just an idea to keep you busy :-)

    1. thanks Rogier...yes - a practical guide will be included at the end of the series - hopefully part V! Going to get Gerry involved in it...

  3. If you can't wait, there is a nice podcast of Gerry on athleticscoacingcanada :

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