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THE FUTURE OF SPORT PHYSIOTHERAPY
58 SPORTFISI@ 2022
Anna Stitelmann Loic Bel
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THE FUTURE OF SPORT PHYSIOTHERAPY: OPPORTUNITIES AND CHALLENGES.
A COMMENTARY FROM TWO NEW GRADUATES IN SPORT PHYSIOTHERAPY.
Authors: Loïc BEL and Anna STITELMANN With the participation of: Anne-Sarah DYSLI, Lolita FISCHER, Brandon N’DJOLI, Amici RÉMIÉ, Jean-Paul VASSALLI
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We are two physiotherapists who graduated less than five years ago with a Bachelor of Science (BSc) and only a few months ago with a Master of Science (MSc) in Sports Physiotherapy (SPT), and we have already experienced some big evolutions in our domain. Our field evolves fast and has lots of opportunities to explore and challenges to overcome. What we learned at school a few years ago, we don’t necessarily apply anymore. For example to measure strength, we were mainly taught to use manual muscle testing. Now the use of a handheld dynamometer is highly recommended. The goal of this commentary is to discuss how we perceive the current state of SPT in Switzerland, and to expand more on how we view the future of SPT in our country, and some of the challenges we will have to overcome to make it even greater. Along those lines, you’ll find a few quotes from other young colleagues, with different backgrounds and experiences in the field of SPT: athlete or ex-athlete, sports physiotherapist student or graduate, from different cultural backgrounds. Through the words of a small but diverse group of colleagues, we wanted to illustrate some thoughts and ideas that we perceive as key in order to make our field grow even further.
**DISCLAIMER: The goal of this commentary is to propose an opinion on what should be done. You may find some scientific literature along the document to support some of our thoughts, but some are just our own reflections regarding the field of SPT**
1. ACCREDITATION
Recently, the Swiss Sports Physiotherapy Association (SSPA) announced that an accreditation system had been created for its members. This pathway was approved by the International Federation of Sports Physical Therapy (IFSPT). Based on continuous professional development (CPD), experience, and reflective practice, an individual will get an accreditation level A, B or C, as a sports physiotherapist. The main goal is to increase the quality of care for athletes through better regulation of the title of SPT.
This accreditation system has lots of benefits and is - in our opinion - necessary for various reasons. The first is that due to the rapid evolution of our profession, we need to promote clinicians that will do their best to acquire new competencies and stay up to date with upcoming knowledge. A second reason is that we need to separate ourselves from clinicians who proclaim themselves sports physiotherapists after only a few hours of CPD, which doesn’t align with the IFSPT competencies. Lastly, using this accreditation system, we can make sure that the baseline level of development is on par with the current evidence. Some recent data show that lots of the CPD development in the field of musculoskeletal physiotherapy is not adequate for current guidelines[1,2]. Since to become an accredited SPT you need to fulfil some requirements, that could be a motivating factor for SPTs to follow high quality continuous education, based on the SSPA’s requirements. It could also lead to other benefits for our profession such as enhanced collaboration with different sports associations and more support with national sports federations, to a more established, recognised specialty in physiotherapy.
Overall, this system enhances the number of opportunities for qualified individuals, disregarding the influence of their network and connection. We are conscious that it won’t make the problem of diversity non-existent, but it could play a big role in improving it. It would put a bigger emphasis on individuals competencies, and less about their personalities.
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2. EDUCATION
When speaking about opportunities, every person should have the same chance to access education. In 2022, the only Masters of Sciences (MSc) degrees in SPT are located in the German speaking side of our country, more precisely in Winterthur (ZHAW) and Bern (BFH). Even though these schools do their best to include participants from all over Switzerland by allowing students to submit assignments and to pass exams in English, this situation discourages French and Italian speaking physiotherapists to continue their education. Notably language barriers, but also financial barriers in terms of costs and travel time. However, access to long-term continuing education is not the only challenge that needs to be addressed. In shorter CPD courses, we sometimes notice that some may prefer to participate in “sexier”, more practical, and sometimes non evidence-based courses. The difficulty of bringing concrete elements from research data into clinical practice is often highlighted. Although it is improving, the current Swiss continuous education needs to offer a wider range of short evidence-based education courses.
Brandon N’DJOLI – Sports physiotherapist (MSc)
As there is a need for education, there is a gap in opportunities to learn. We also want to emphasise the importance of mentoring, but opportunities are rare in our country. We think that we should find a way to increase the number of peer-learning opportunities and then, find a way to have them count as continuous education. It could be by the creation of a portfolio or other feed-back documents like that.
When it comes to the online format - which we began to encounter more since the COVID-19 pandemic – it may also be a great opportunity to promote the diffusion of knowledge. It is not the most developed in our country, but it is beginning to take place, especially regarding conferences. If we look at what some of our colleagues in North-America provide regarding continuous education, the online model is more developed. Some colleagues, such as Erik Meira, Michael Reiman, (and more) developed online platforms allowing everyone to learn using asynchronous learning through videos. Sometimes, it also combines online meetings to answer questions related to the content of the course. Maybe that could be a way to move forward in Switzerland - as having a family and other commitments take time in any therapist’s life. Providing high quality content accessible at any time could participate in reducing barriers to continuous education. Given the growing number of SPT achieving a Master’s Degree, or even a PhD, we should try to find a way to incorporate them in the creation of high quality education. That doesn’t mean that field experience and clinicians’ expertise should be set aside, but mixing both views of the field, promoting evidence-based information with realistic views of what is happening on the field could help in creating development with better quality. We think that to promote the highest quality of SPT, continuous education should be mandatory. We think that the SSPA should make sure that its members meet some standards, such as setting an amount of hours of continuous education which must be achieved each year, like some other countries do.
We are conscious that these propositions - which are no novelty in our field and already exist in other countries - necessitate big amounts of human resource and infrastructures to achieve the expected results (monitoring of education, creating formation…). However, we think that such a model could bring a lot of value in order to reach better evidence based SPT in our country. Furthermore, we are optimistic that setting high standard expectations and keeping the momentum going could lead to the excellence of SPT in Switzerland.
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3. SPORTS PHYSIOTHERAPY – SCOPE OF PRACTICE
Anne-Sarah DYSLI – Sports physiotherapist (MSc)
In today’s world, when we talk about SPT, it is easy to imagine a physiotherapist on the sidelines with an elite sports team, treating a player. However, this is a bit reductive. According to the IFSPT definition of a SPT, one should demonstrate “advanced competencies in the promotion of safe physical activity participation, provision of advice, and adaptation of rehabilitation and training interventions, for the purposes of preventing injury, restoring optimal function, and contributing to the enhancement of sports performance, in athletes of all ages and abilities , while ensuring a high standard of professional and ethical practice.”[3] The SPTs competencies deserve to be more developed and better known to the public. SPT is not only targeted to elite sports during acute and rehabilitation phases. It should be more inclusive and directed to all ages and abilities. The other competencies, among the 11 set out by the IFSPT, deserve to be more emphasised.
Amici RÉMIÉ – Physiotherapy student (BSc)
We argue that we should try to change this ‘elitist’ view of SPT for something that better represents our competencies and what we do on a daily basis. As SPT, our competencies are not only focussed on elite or amateur athletes, but to a much wider population. We can use our skills to work in fields sometimes considered less attractive, such as sport with the elderly, with children, or with people living with disabilities.
Let’s not forget that, first of all, we are health professionals, but we have some extra competencies in understanding movement and training. We should try to make a bigger part of the population benefit from our expertise related to movement, exercise, and training, to encourage people to be more active. That would help in preventing future diseases, that could be unrelated to the musculoskeletal system, from happening. To name a few examples, we could play a role in schools alongside teachers to promote safe physical activity in children, reach associations of workers not just to do massage but to propose sessions of physical activity (Yoga, pilates, gym sessions – a few examples, just to get people to move), or on a more individual level encourage our patients to do more movement (such as the stairs).
Let’s preach it even more: health for performance in elite sports, and movement for health for the more sedentary population.
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4. INCLUSION & OPPORTUNITIES
“In my experience, it was pretty easy for me to join the world of SPT. But I think that it also was a bit of luck as I applied at the right time (as a student). But as SPT is expanding, I think that it’s becoming easier in every kind of sport to make yourself some space in a team, even as a student.”
Jean-Paul VASSALLI – New grad physiotherapist (BSc)
We want to emphasise the fact that, in our experience, SPT doesn’t have that big and diverse population that we could expect in our field. In Switzerland, 74% of physiotherapists are women[4]. What we observed, is that these numbers are not representative of the proportion of women we see on the sidelines of competitions or, more generally, in the field of SPT. To include more women, as they account for most of the physiotherapists in our country and approximately half of the athletes in Switzerland, we should also strive to be even more inclusive. It means that we should strive to make some room for every SPT, no matter their gender identity, sexual orientation, age, ethnicity, race, or disability. We recognise it is a challenge. However as we will encounter athletes in all these categories, we cannot expect our profession not to diversify. We argue that it is mandatory to make our space safe for everyone, athletes and colleagues, in order to have a better representation of the real world in our field. All that could lead to a diversification in the field of SPT, but also give the opportunity to diversify key positions on different scale; head of medical team, president of a regional/national association, head of physiotherapists, or physiotherapist in a team.
It will also allow expression of diversity, encourage discussion, and push the field even further, bringing new point of views and background in what should be a diverse field, with cultural influences playing a role in how someone can train and compete, or access health care (think Ramadan for example). Representation matters. For young men and women, it is a big motivator to see someone looking like them being involved in a big sports team, or being at the Olympics. Even on a lower scale. We can set a standard for our profession and others, by showing that everyone can make it, and we should try to facilitate these opportunities and access to the study of SPT. All that could also play a major role with the athletes we are working with. Providing the best care for someone - athlete or not - requires connecting at a certain level, and being someone with commonalities, such as culture, ethnicity, gender and more, allows us to provide better care. It is about being fair, but it is also about providing the best support we can to the athlete we are working with.
As physiotherapists, we can also play a major role with women athletes by promoting gender equity as we know from experience that most female teams do not have the same access to infrastructure and medical staff compared to men’s teams. Our proximity with athletes could be a strength to make changes on the field. It is our role to promote access to the medical staff, to infrastructure (e.g., gym, training court) and to create a safe space to perform and prevent injuries. That applies to sport as the traditional view we have. However let’s not forget about para sport. These athletes seek specific care and we must find a way to promote continuous education regarding what we can do for them, and strive to create safe space and access to safe healthcare and infrastructures.
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5. RESEARCH, TECHNOLOGY, AND MORE
We are pretty used to reading quantitative research, with numbers, results on patient-reported outcomes scores or strength test values, but these last years have shown the big impact qualitative research has on our practice and the new perspective it can give us.
If we have one short message to pass on right now regarding research reading, it is that maybe we should all take time to read a bit more qualitative research. To give an example, a recent paper from Piussi and collaborators[5] discussed the experience of young female athletes who experienced a re-rupture of their anterior cruciate ligament. We can learn lots of insights on psychological struggle, resilience, impact on these athletes’ careers, and all the questions that can go through an athlete’s mind during a rehabilitation. That allows us, as SPT, to be better prepared to fulfil the needs that some of the athlete we are working with could have. It can also help us to prepare in case some of these issues go beyond our scope. Make us realise that a strong network with sports psychologists, doctors, nutritionists, and more can be needed in certain situation. As patient-centred care – and in this case athlete-centred care – should be the gold standard, we should try to listen to athlete’s voices more. That is what qualitative study allow us – have a glimpse of what their fears, hope, resilience, experience, and needs are.
The rapid evolution of technology will also lead to massive changes in physiotherapy assessments and treatments. This has already been the case for a few years, with the emergence of wearable connected devices, handheld dynamometry, force plates, and even inertial measurement units. It is exciting to think that it is now possible to objectify more parameters than before, even some that are not identifiable by the eyes or hands of a clinician. However as technology advances and becomes more and more sophisticated, it is important to be able to understand what is coming out of such tools. Lots of noises can perturb the clinician as tons of information can come out from the usage of these machines. It is important to find a way to educate the clinician on the interpretation of all these data and suggest the usage of sometimes easier and cheaper tools (e.g., hand-held dynamometry) instead of the most expensive one (e.g., isokinetic, force plates), as the first ones give less information but can be easier to interpret.
When it comes to telehealth, the COVID19 pandemic has enhanced its use, as it is an alternative for health care delivery. However, telehealth should not be seen as a temporary solution, but rather as a sustainable alternative modality for patients to access health care. Some systematic reviews have shown that telehealth can provide improvements that are similar to usual care for patients with musculoskeletal conditions.[6,7] It is easy to imagine this model of care being developed in the coming years and we think that SPT will find many advantages in it. We assume that this system could considerably improve the quality of care, for example to follow athletes in sports with smaller budgets that can’t afford to pay for the travel of the physiotherapist. We can imagine that in this context, when the athlete is traveling abroad, it could help the athlete self–manage a condition with professional advice being accessible. Telehealth could also help to increase the adherence to home exercises by having the possibility to perform a session with the therapist observing exercises and cueing the athlete the necessary corrections when needed.
We believe there is also an opportunity to use digital communication as a key tool to have an impact in health prevention. Although some of the benefits of telehealth are known, there are several challenges that need to be overcome before widely implementing it. Using virtual care involves upgrades in the field of competences of a SPT, such as communication skills and - that may sound bizarre - the use of the technology in an efficient way. Secondly, laws on the legal and ethical side should be adapted to protect data, those of the health care providers as well as those of the patients.
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6. CONCLUSION
Amici RÉMIÉ – Physiotherapy student (BSc)
If science is a process rather than a conclusion, so is SPT. We are right now in an era with many challenges to take on a societal level and in our specific field of SPT. We are conscious that there are many more challenges that are coming for our community than those discussed, and as you may have guessed, we selected the subjects we wanted to discuss with you, our colleagues and peers. We hope that it may give new or different perspectives to some of you, and we hope that we will hear from you, and the other challenges you think are important to overcome in the near future.
So, let’s keep it going. Let’s stay engaged, proactive, innovating, creative. Let’s be even more curious, sceptical, empathetic, listening, and caring. With those qualities, we think that we will keep on moving in the right direction.
REFERENCES
1. Peterson, S., Shepherd, M., Farrell, J., & Rhon, D. I. (2022).
The Blind Men, the Elephant, and the Continuing Education
Course : Why Higher Standards Are Needed in Physical
Therapist Professional Development. The Journal of Orthopaedic and Sports Physical Therapy, 1-14. https:// doi.org/10.2519/jospt.2022.11377
2. Peterson, S., Weible, K., Halpert, B., & Rhon, D. I. (2022).
Continuing Education Courses for Orthopedic and Sports Physical Therapists in the United States Often Lack
Supporting Evidence : A Review of Available Intervention Courses. Physical Therapy, 102(6), pzac031. https://doi. org/10.1093/ptj/pzac031
3. Bulley, C., Donaghy, M., Coppoolse, R., Bizzini, M., van Cingel, R., DeCarlo, M., Dekker, L., Grant, M., Meeusen, R., Phillips, N., & Risberg, M. (2005) Sports
Physiotherapy Competencies and Standards. Sports Physiotherapy For All Project. [online] Available at: www.SportsPhysiotherapyForAll.org/publications
4. Merçay, C., Grünig, A., & Dolder, P. (2021). Personnel de santé en Suisse- Rapport national 2021. Observatoire suisse de la santé (OBSAN). https://www.obsan.admin.ch/ sites/default/files/2021-11/Obsan_03_2021_RAPPORT.pdf 5. Piussi, R., Krupic, F., Sundemo, D., Svantesson, E., Ivarsson, A., Johnson, U., Samuelsson, K., & Hamrin Senorski, E. (2022). « I was young, I wanted to return to sport, and re-ruptured my ACL’—Young active female patients » voices on the experience of sustaining an ACL re-rupture, a qualitative study. BMC Musculoskeletal Disorders, 23(1), 760. https://doi.org/10.1186/s12891-022-05708-9
6. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and metaanalysis. Clinical Rehabilitation. 2017;31(5):625-638. doi:10.1177/0269215516645148
7. Dario, A. B., Moreti Cabral, A., Almeida, L., Ferreira, M.
L., Refshauge, K., Simic, M., Pappas, E., & Ferreira, P. H. (2017). Effectiveness of telehealth-based interventions in the management of non-specific low back pain : A systematic review with meta-analysis. The Spine Journal: Official Journal of the North American Spine Society, 17(9), 1342-1351. https://doi.org/10.1016/j.spinee.2017.04.008
