I had the pleasure of visiting the training facility of West Bromwich Albion of the English Premier League.
Like a kid in a candy store, I was exited to visit and spend the day with Stephen Wright, the Lead Rehab Physiotherapist whom I met years ago at Athletes' Performance's Rehab Mentorship.
To say that this visit was a privilege was certainly an understatement so rather than provide you with a summary, I thought it would be more appropriate to utilize a question and answer format to shed a little bit more light into their experiences and perspectives on sports science, strength & conditioning and rehabilitation. Especially given that there's only so much we can take away during spot visits.
1) Stevo, I cannot thank you enough for allowing me to spend the day with your team. Would you mind summarizing who comprises your support team, not including the coaches and scouting staff as well as the importance of the integration of all members?
Well the Science and Medicine department is headed up by Dr Mark Gillett. He has a wealth of Sports Specific experience, has previously worked for Chelsea FC and is currently head of GB Basketball Science & Medicine team. It helps me immensely to work alongside a Dr who understands Physical Therapy and the rehab process.
Then essentially we have a flat structure within the 1st Team Physical Therapy Dept each with a specialist area. The team consists of: myself – Lead Rehab Physio, Richie Rawlins - Performance Physio and Rick Carter – Part time Consultant Physio. In addition we are supported by two full time soft tissue therapists. 1st Team Sports Science is headed up by Chris Barnes, who works alongside 1st team Fitness Coach Matt Green and S&C Specialist Mark Jarvis, and who are supported by 4 sports science interns, and an IT intern. The Science and Medicine Team are further supported by part time Podiatrist, Osteopath, Nutritionist and Yoga instructor.
2) As the Lead Rehabilitation Physiotherapist, your obvious primary role is managing the care of their injuries. I was intrigued by the "Injury Progressions Board" you have posted in your rehab room. Without going into too much detail can you briefly summarize the impetus for this board as well as the importance of attaining the medical and sports sciences goals along the various phases?
Sure I developed the Injury Progression board a number of years ago with a former colleague of mine Bill Styles (Celtic FC). He was a Sports Scientist who had recently joined us from another club, and we had to develop a successful working relationship quickly. So we basically sat down and hammered out what we thought each of our roles were in the rehabilitation process, and how they fitted in to the 4 basic stages of tissue healing (Hunter, 1994), namely: Phase 1 The time of injury, Phase 2 inflammatory (lag) phase, Phase 3 fibroblastic (regeneration) phase and Phase 4 the remodeling phase, and for each stage we agreed what our aims and objectives would be. We decided to add a 5th stage Monitoring and injury prevention strategies.
Essentially whilst we both had a daily role to play in the rehabilitation of the injury, the Physical Therapist would lead the process in the earlier phases; where early goals could be accurate diagnosis, employ a PRICE strategy, review modifiable causative factors, screening data etc, leading to recovering full Range of Motion and pain free function during Activities of Daily Living, promoting a healthy injury site with optimal collagen formation, stimulate neuromuscular pathways etc. As we advance through the phases and the athlete was able to perform functional sport specific return to play drills, the role of the Sports Scientist increased, and progressed to be greatest during the latter stages at the extreme right hand end of the board where they player was required to perform all requirements of the game which their position demanded, repeatedly and in a fatigued state. The board gave us a simple checklist which ensured a safe appropriate progression based on successfully completing criteria for each phase.
The Injury Progression board which you saw is quite simplistic, and whilst the phases and objectives continue to remain wholly appropriate, the influx of additional multidisciplinary staff, in conjunction with more sophisticated monitoring processes mean that there are many more strands feeding into a players rehab at any one time. In reality today we use a more comprehensive digital version of the board, which facilitates multiple disciplines to feed into each stage of the rehab process to create a pathway of care which is joined up, planned and has appropriate monitoring and goal setting built into it. An example of this may be graphical representations of objective markers, supported by progressive GPS, Accelerometry and Heart Rate monitoring.
3) You mentioned the "Yo-Yo" test. This seems similar, yet different, to the beep test. Can you explain it's relevance to soccer/football?
Sure the standard Beep Test (Leger Test) requires the athlete to run between two cones placed 20m apart, at a steadily increasing pace, the pace is dictated by a beeping metronome which gets progressively faster, and upon reaching the mark the athlete turns around and runs back. It is a continuous run to failure. The Yo Yo Intermittent Recovery Test also requires the athlete to also complete a 20m run, turn around and run back in time to the increasing beep of a metronome, however after performing a shuttle they are allowed a 10sec recovery, before repeating the shuttle at ever increasing speeds. The intermittent nature of the Yo Yo test, together with the resulting higher speeds attained, mean that is of greater relevance in determining soccer specific fitness. A number of papers have found it to be a valid and reliable measure, and it would be an equally appropriate test for any field based sports requiring intermittent bouts of high intensity running (see paper below).
Jens Bangsbo, F. Marcello Iaia and Peter Krustrup, (2008) The Yo-Yo Intermittent Recovery Test: A Useful Tool for Evaluation of Physical Performance in Intermittent Sports, Sports Medicine 2008; 38 (1): 37-51.
4) At this level of sport, you guys certainly have no shortage of "high-tech" equipement. Would you mind providing us with your experiences using the AlterG Anti-Gravity Treadmill and the Hydroworx pool?
We have used the Alter G treadmills for 2 years now, and find them an invaluable tool for the load compromised athlete. This may be a fit player who is at a stage in their career where they cannot withstand high impact loading on their joints or tissues on a daily basis; or an athlete who is recovering from injury, where I find it removes some of the guess work associated with a graded return to full weight baring running. Amongst other things, running at lower percentages of full body weight like this clearly reduces the demand on the cardiovascular system, in situations where we want to increase the CV stimulus we have had a great deal of success in using it in conjunction with hypoxia, via a closed circuit bag and mask system and a hypoxic generator which is capable of simulating altitudes of up to 12 000ft .
The hydroworx pool is a large underwater treadmill on a variable height floor, it allows us to simulate running, and perform multidirectional twists and turns in an off-loaded underwater environment. Similarly to above we use it to offload a compromised or injured athlete, but also find it an excellent medium for recovery sessions post match. The two pieces of equipment complement each other well, the Hydroworx enables the athlete to move freely, in an environment of increased hydrostatic pressure, and the Alter G allows us to more precisely grade external load acting on the body, albeit in a linear fashion.
5) I noticed your high altitude chamber, when exactly do you use this?
This is our first season with the high altitude chamber. As you’ve seen it measures approx 100 square feet and contains a Woodway Curve treadmill, and an exercise bike. In the rehab process we may use it to increase cardiovascular stimulus in athletes who’s tolerance to load is compromised by injury, example sessions may include metabolic type circuits consisting of low load, high rep compound movements, or interval work on an ergo. Our S&C guru Mark Jarvis has coined the term hypoxing, to describe his much feared boxing sparring sessions which are brutal when performed at 10 000ft! The Sports Science team headed up by Chris Barnes have been exploring a variety of intermittent high intensity exercise protocols performed in hypoxic conditions, using amongst other things a non motorised woodway curve treadmill. Although this research is at an early stage, some of the results are impressive.
6) In speaking with Dr. Mark Gillet, your Head of Medical Services, he mentioned that your team has a "no tolerance" policy for groin pain. Can you shed some light into the importance of this?
When Dr Gillett came on board 3 years ago he felt that the incidence of groin pain and training days lost to groin injury would be a key performance indicator for an English Premier League Medical Team. We have a low tolerance for withdrawing players from training with groin pain, and when withdrawn they undergo a repeat of our bespoke hip and lumbo-pelvic evaluation tool. The tool includes measures of groin strength in various positions, but is strongly focused on determinants’ of form and force couple closure of the pelvis, segmental stabilization, range of motion and symmetry. Our experience suggests that getting on top of these issues as soon as they arise, frequently allows a quick return to pain free training, and to date we have had very few if any players absent for more than a few days due to groin pain over a 3 year period, and zero incidence of sports hernia. It may be worth mentioning that whilst groin pain is often multi-factorial, and our assessment and interventions reflect this, we have observed a strong correlation with groin pain of poor extension control of the low back in football players for a number of years now.
7) Finally, your sports scientists, hold an important role on your team, especially in the analysis of load using such technology as GPS, Heart Rate and Heart Rate Variability monitoring and others. Would you mind providing us with some of variables you measure - as well as their importance - as they pertain to internal (cardiovascular) and external (mechanical) loads?
Like many teams within the English Premier League, we use GPS, Accelerometry and Heart Rate monitoring to quantify training. Our Sports Scientists and interns crunch a vast amount of data which paint a picture of the nature and type of work done. Some of the commonly reported metrics which you will have seen us using will be:
Total distance covered, no. of accelerations and decelerations, and these are self explanatory, although within this we have the ability to set thresholds or bands for what constitutes an acceleration or deceleration, and can tailor these thresholds to an individual.
High Intensity Distance and High Intensity Time are measures of how much distance is covered or time is spent with the athlete moving above a particular speed. The software which we use to analyse these variables allows us to set this speed specifically for an individual. For example if you were one of our players Jeff, we may work out your running speed at lactate threshold, since above this velocity your blood lactate would increase and the effort or intensity would feel much harder, it may represent a useful threshold for what constitutes high intensity work for you as an individual. Alternatively you may have a good reason for selecting this threshold another way or as a percentage of you maximum speed. The main thing is that it is reflective of higher intensity bouts of work, and as such will be of greater value if the threshold is set specifically to you as an individual.
Player load can be a very valuable metric. It is calculated using data acquired by accelerometers contained within the GPS unit. It gives you a single number derived from a complex calculation, which is reflective of how much movement a player makes in each of 3 planes, vertical, lateral and linear, and the calculation assigns a higher value to movements performed over greater range or those made at higher speeds. The player load gives you a metric which is measured in arbitrary units, but is reflective of effort. Different players will achieve differing loads for an identical task, depending largely on the efficiency with which they accomplish the task.
To supplement this information we record Heart Rate data in the form of Red Zone minutes, time spent above 85% Heart Rate max, and something called a Training Impulse or TRIMP. To calculate TRIMP an exponential scale is applied to heart rate data as a percentage of Heart Rate max ie it assigns a greater value to Heart Rates which are closer to maximum than those closer to 50% on a 10 point scale. As such it creates a more complete picture of the overall cardiovascular workload than Red Zone minutes alone would.
Our experienced staff closely monitor this data, along with a host of additional data streams, to establish trends over time which may be significant, ie markers of over-reaching or over training, injury or illness, fatigue or freshness, or performance. When a player is injured we refer to this information to tell us the precise physical requirements necessary for a given individual to play a particular position. During the rehab process we work to ever increasing percentages of these until we are satisfied that he can perform all of them and is safe to return.
8 ) Thank you Steve. I really appreciated the privilege of visiting and think you have a lot of information to share to sport medicine and performance professionals. You mentioned that you will be hosting a conference sometime next year. Can you leave us with some information that we should look forward to?
Sure Jeff, building on the success of our 2012 conference, we are proud to announce that on March 20th - 21st 2013 we will be hosting a conference at the recently opened state of the art St. Georges Park, home of the National Football Centre in Burton-upon-Trent, Staffordshire, UK. The conference is titled Maximising Multidisciplinary Team Performance 2013: "The Success Factor", will host a world-renowned panel of experts, including Bill Knowles, Dr Greg Whyte, Calvin Morris, Humphrey Walters, Damian Hughes, Ian McCurdie, Nick Broad & others. We aim to explore the implementation, development and management of truly successful multi-disciplinary teams and how they can be harnessed to deliver sustainable world class sporting performance. In addition, myself, together with colleagues Dr Mark Gillett, Chris Barnes and Mark Jarvis will be taking the opportunity to further expand on some of the topics covered in this interview and share our experience with you.