The new paradigm in physical therapy

Proactive Physiotherapy

Many aspects of healthcare have slowly been converting from a reactive to a proactive approach⁽³⁾. As a result, research funding is redirected to focus on disease prevention rather than reacting and managing the disease as it presents. The WHO reports 50% of total healthcare spending is on chronic illness, which fuelled the advocation of the P4 approach to healthcare⁽⁴⁾. The four pillars of P4 include Predictive, Preventative, Personalised, and Participation. As Benjamin Franklin said, "An ounce of prevention is worth a pound of cure."

There is a global shift in the approach to healthcare, and physiotherapists cannot afford to get lost in passive treatments. There is still a place for passive treatments, but perhaps more as a basis to facilitate further active treatment and exercise. Optimal outcomes from any healthcare intervention require the athlete or patient buy-in, including the management of their expectations guided by current evidence and the practitioner’s experience⁽⁵⁾. Education is imperative in effectively delivering any proactive approach⁽⁶⁾. Most of the literature on preventative or proactive physiotherapy interventions hails from public health and professional sports environments, where stakeholders are vested in the results and have access to funding. The challenge lies in the delivery of this model to the general population.

The current preventative model relies heavily on education, specific regular monitoring, assessments, and known benchmarks. Practitioners are guided by evidence and established predictable patterns to emphasize active participation and athlete engagement. The evidence continues to evolve with preventative programs developed and cited for large global health issues, including falls and back pain, and common sporting injuries such as ACL, groin, hamstring, and ankle injuries^(7-10). The evidence pool for high-performance environments and non-professional sports cohorts continues to grow. For example, the proper application and follow-through of an appropriate warm-up routine (e.g., FIFA 11+) can significantly decrease the likelihood of injuries to both male and female athletes at differing levels⁽¹¹⁾. Football teams who engage in the physiotherapy-specific warm-up routine outlined in the FIFA 11+ protocol have 30% to 70% fewer injured players than the control groups. Physiotherapy applied in a preventative manner is effective at reducing injuries.

Physiotherapy interventions applied to people who work in manual labor roles decreased the incidence of injury and severity, recovery times, and time off work⁽¹²⁾. Preventative physiotherapy interventions include core and low back endurance exercises, client-specific consultations, education, and behavioral therapy. Physiotherapy assessment and treatment tools can decrease the likelihood of future injury occurrence and prevent the possibility of future physical dysfunction.

However, the proactive or preventative model recommendations are routinely developed around an average patient and not an athlete’s individual needs or dysfunctions. Therefore, programs are best-fit-for-all rather than individualized. This seems bizarre, given rehabilitation programs are best designed specifically for the individual. Therefore, an individualized and performance-driven model may improve injury rehabilitation outcomes.

Performance Physiotherapy

Performance physiotherapy is both proactive and reactive. It is a planned, individualized approach with early identification of goals and dysfunction guided by systematic, specific benchmarking and screening measures. This includes physical, emotional, historical, and psychosocial components. It is about treating the "whole athlete," not just the presenting injury.The center of performance physiotherapy is the individual, who they are, and what matters most to them. As such, it is imperative that the professional dialogue between practitioners’ changes, including the language around injury. The goal is to change the conversation from "what is the matter with you?" to "what matters to you?". Practitioners can establish the athlete’s goals over time, preventing injury and improving performance.

Team effort

Performance physiotherapy requires physiotherapists to work towards solving the performance puzzle as part of a collaborative team⁽¹³⁾. It only works with equal commitment from all stakeholders, including the athlete, coaching staff, medical professionals, and the strength and conditioning coach. This team will differ in size and diversity in different situations, but the goal is consistent, athlete-focused performance. This gives a unique opportunity to manage "load" and injury. Load refers to the athlete’s physical and emotional stressors and recovery behaviors. When the entire team sees the athlete as a whole, opportunities exist for performance enhancement.

Multi-disciplinary teams (MDT) function effectively with adequate communication, sharing of information and ideas, mutual respect, and shared goals. The individualized performance approach exists in individual sports and is gaining traction in team sports environments. Perhaps the most exciting component of this model is the potential to build robust athletes. A collaborative approach builds athletes with greater physical capacity and a greater understanding of the importance of recovery and injury prevention. Furthermore, athletes will be more emotionally and psychologically supported and aware.

An injury can be "the straw breaks the camel’s back," and education, collaboration, and knowledge sharing are fundamental to improving this narrative⁽¹⁴⁾. An MDT that includes all the stakeholders will allow a holistic approach. From a bird’s eye view, practitioners can zoom in on the components relative to them and their skill set. Collaboration is vital to ensuring optimal clinical outcomes regardless of a practitioner’s role in the MDT.

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What can every physiotherapist learn from elite sports?

• High performance is not a one-size-fits-all affair.
• Load and capacity tolerance is multifactorial.
• Many factors influence load tolerance and capacity, and management requires input from all stakeholders.
• The goal should always be to evolve, not just regain the status quo.
• The patient or athlete must drive the process.

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References

1. Physical Therapy Reviews,17(4), 207-226.
2. Scandinavian J of Med & Sci in Sports,25, 1-72.
3. Clinical pharmacology and therapeutics,105(1), 10.
4. Rambam Maimonides Medical J,4(2).
5. BMJ,312(7023), 71-72.
6. Musculoskeletal Science and Practice,28, 46-53.
7. J of Physiotherapy,61(2), 54-60.
8. Scandinavian J of Med & Sci in Sports,20(6), 814-821.
9. BJSM,39(6), 363-368.
10. J of athletic training,50(6), 589-595.
11. Australian J of Physiotherapy, 46: 259-269
12. J of Environmental Research and Public Health, 11: 11986-12000
13. J of Athletic Training,55(9), 874-884.
14. BJSM,53(7), 394-395.