BRINGING SCIENCE TO TREATMENT

Physios on the move: travelling with teams

Kay Robinson uses her extensive experience to provide an insight into the challenges and requirements of travelling with a high-performance team, and provides practical strategies to maximize performance outcomes.

Northampton Saints’ physio’s bib Credit: Action Images / Andrew Boyers Livepic

There are many demands, challenges, and amazing opportunities that come as a traveling physiotherapist, whether you are heading to the Olympics or travelling with a youth team on their first trip away from home. For a number of years I was one of the most travelled physiotherapists in the English Institute of Sport, spending 5-6 months of the year on the road, culminating in the Sochi Winter Olympics. Having also travelled with a local league hockey, national U18s athletes, invitational rugby teams and supported nations at multi games events, I developed a number of practical strategies and practices which may be helpful to those on the road.

Preparation

Planning prior to a tour is vital – whether you are travelling with a team of athletes you have known for years or it’s your first trip away with them. In particular, it’s useful to have athletes complete a pre-tour screening form (or even better a face-to-face introduction). Details such as allergies, medications and next of kin are vital as it’s often the physio who is first on the scene of an injury, and accompanies an athlete to the hospital if needed.

It’s also important to have a clear understanding of each athlete’s recent medical and injury history, initiating contact with the athlete’s regular physiotherapist if appropriate. Athletes and staff should be up to date with their vaccinations required for travel. All athletes should have adequate amounts of any prescription medications they take, along with relevant Therapeutic Use Exemption forms (TUEs).

If you aren’t travelling with a team doctor ensure a medical contact person,  should an athlete need more advanced care. Regular contact is advised to discuss any concerns, and also gives you the opportunity to discuss clinical reasoning away from the often stressful and impulsive touring environment. Establishing a relationship with the overseeing physician prior to travel is particularly useful in case athletes suffer an infectious ‘illness outbreak’ (which is frequently seen on tour); acquire travel viruses, or experience food-borne illnesses. Obviously, having a clear hand-hygiene regime from pre-travel helps minimize this, but it is always useful to have an isolation plan if needed (for athletes and staff). Another must in your travel bag should be sterilizing tablets, as water bottles can go a while without seeing a dishwasher!

Packing becomes easier the more you travel with the same team, but preparing kit bags and knowing how many roles of tape and acupuncture needles are needed can still be daunting. Try and get a plan for the week ahead from the coach so you know how many training/competition days there are and ascertain from each athlete their ‘normal’ usage, which will give you a baseline.

If you are travelling to places with good equipment supplies it can be worth pre ordering tape etc or hiring beds to minimise excess baggage. Depending on the size of the team it may also be the physio’s responsiblility to organise and carry rehab equipment, hydration supplies and additional nutrition. Always ensure this is planned with the team nutritionist and strength and conditioning coach beforehand.

Travel

Travel is a big challenge in sport due to long drives, flights, and jet lag. It is crucial, therefore, to work with the rest of the team officials to manage the effects of travel so as not to disrupt performance. Jet lag is a disorganization of the circadian rhythm and mismatch between the body clock and environment you’re in(1). In the athlete-specific population, symptoms include decreased reaction times and reduced grip, back, arm and leg strength as well as decrements in sprint times.

Jet let is experienced following rapid travel across time zones and usually persists for one day each time zone travelled. This is in contrast to general travel fatigue, which is caused by prolonged travel across one time zone and which can accumulate over a season(2). Adjustments tend to take longer following eastward travel; this is thought to be due to the body clock adjusting more easily to lengthening of the day than shortening(3). Symptoms can include fatigue, sleep disruption, decreased concentration and motivation, gastrointestinal distress, decreased appetites and headaches (see box 1 and table 1).


Box 1: Strategies to help minimize the effects of jet lag

  • Adapting to a new time zone before travel by adjusting to light exposure and timing of eating/sleeping can be difficult to implement, but is an effective way to minimise jet lag. Another option when travelling for only short periods and when competition is completed during ‘home daytime hours’ is for athletes to chose to stay on their home time zone. However this brings other challenges such as arranging meals, access to training facilities etc.
  • Prior to departure look at the possibility of changing practice/training times at home to coincide with the actual time of day when competition occurs abroad. For example, if travelling to New York (5 hours behind the UK) for a race with a 3pm start time, UK athletes would start training at 8pm.
  • During travel, consideration should be given to ensure good levels of hydration by drinking more water/electrolytes. Hydration monitoring can be used to observe hydration pre departure and on arrival. Alcohol should be avoided during as it can act as a diuretic and may promote waking during the night.
  • Risk of DVT and swelling can be reduced by wearing properly fitted compression stockings. Frequent movement should be encouraged to assist in circulation and will also reduce post travel muscle tightness(4).Examples of movements that can be utilised in the confinements of a plane are walking around the plane, carrying out isometric exercises while seated and gentle stretches at least once every 90-120mins. This can also decrease fatigue from sitting for long periods.
  • While travelling, athletes should aim to sleep with the time zone of their destination in mind. If travel occurs during the ‘home routine night’, naps of 20-30 minutes are better than longer naps, which will reinforce the natural sleep cycle based on home routines. Once at the new destination, night-time sleep should be optimised by using black out curtains/eye masks, avoiding stimulants prior to sleep, minimising noise disturbances and maintaining normal sleep routines. Athletes should also avoid screen usage (mobiles, laptops etc) prior to sleep.
  • Upon arrival, meals should be smaller, more frequent and taken at the appropriate mealtimes of the destination time zone. There is some recommendation of advocating high-protein breakfasts to increase energy and high-carbohydrate dinners to increase drowsiness, but this has to be managed alongside the athlete’s current nutritional schedule. Athletes should avoid trying new foods during training and competition and if necessary dietary staples should be pre ordered or accompany the team.
  • The use of caffeine is advocated to mitigate effects of sleep inertia and increase alertness, particularly if athletes have encountered previous problems associated with jet lag. However, this should not be a new variable in a competition week.

Table 1: Light exposure and time zone shifts

Direction of travel East West
Time zones crossedLess than 3 time zonesMore than 3 time zonesLess than 4 time zonesMore than 4 time zones
Length of implementationAs requiredInitial 2 days of arrivalAs requiredInitial 2 days of arrival
StrategiesMid morning light exposer (30-60 min)Mid morning light exposure (30-60mins)Mid morning light avoidanceMid morning light avoidance
Mid-afternoon light avoidanceMid-afternoon light avoidanceMid-afternoon light exposure (30-60 min)Mid-afternoon light exposure (30-60 min)
Light exposure should be adjusted according to direction of travel (see figure 1)(5). Engaging in outdoor activity in bright light and relaxing in dim indoor lightning can assist this according to direction of travel. Training should be altered to reduce volume, intensity and frequency, with neuromuscular training being less likely to exacerbate fatigue. Moderate activity has been shown to aid resynchronisation.

Figure 1: Light-induced manipulation of circadian rhythm

The vertical red line at 3am is considered the average transition point. Bright light in the late evening or very small hours tends to shift sleep later (as would be desired flying west). After 3am, bright light tends to shift sleep patterns early (as would be desired flying east).


During the tour

For each location on tour, you should prepare a file with key information which is gathered prior to or on arrival. Useful information to collate includes:

  • Assigned doctor (including contact details)
  • Local doctor
  • Nearest hospital
  • Emergency numbers
  • Evacuation process
  • Medical supplies available at ground/track etc (including location)

If possible, have a trial evacuation at each new venue to familiarize yourself and staff with the processes, as well as identifying obstacles. I once had to remove a player from the field after suffering a broken leg; the transition to stretcher/buggy went well and there was an ambulance on standby. However nobody could locate the key to the gate between the player and ambulance. A more thorough recce of this would have reduced the time in getting the player to the ambulance. If you are on a regular touring circuit, it’s always advantageous to have a good working relationship with your fellow medical staff. You never know when you may need to borrow that role of tape or need an additional pair of hands in a critical situation!

At the start of a tour, I would recommend outlining processes and expectations for physiotherapy and massage – whether it be sign up sheets, routine timeslots or via messaging apps. Physiotherapy is usually carried out in a separate hotel room/ rehab area or physiotherapist’s room. Regardless, this space needs to maintain athlete privacy and allow for confidential and personal conversations to be had.

It’s always a good idea to liaise with team managers and coaches to ensure treatment fits in with other scheduling for the day. With these clear plans, athletes can plan their day (as can the physiotherapist) and it will hopefully avoid ad-hoc knocks on your door. Physiotherapy should be scheduled around the athlete’s independent recovery, although it is often the role of the physio to supervise this. Experienced athletes usually have routines in place but education may be needed for more junior athletes.

Time management

As a physio, there are only a limited number of hours in a day. Athletes therefore need to be prioritised if you are dealing with a big squad. Monitoring systems should be used to aid prioritisation, with self-report questionnaires and neuromuscular testing being useful tools(6). Other monitoring can include; amount and quality of sleep, rate of perceived exertion scoring (RPE), pain scores, fatigue levels, load monitoring, weight and hydration levels.

Objective measures such as vertical jump testing, range of motion and strength measures may also be useful adjuncts to monitor athlete health while away. Many teams plan to send any athletes with longer term injuries home for rehab. Return-to-performance protocols, using baseline markers to aid decisions on returning, are a useful adjunct in return from injury. This ensures processes are transparent for athletes and the high performance team, and avoids rash decisions regarding fitness.

Match/competition days can be stressful; keeping processes in place and communication pathways clear can decrease unnecessary stress. Routines should be kept the same where possible, with physiotherapy access and the athlete’s well being remaining the priority. However, physios are often called upon to do last-tasks such as to help athlete. With this in mind, physios should remain flexible to aid in other critical race day roles when required and if available. Following travel with teams, physiotherapists (along with the rest of the travelling team) should seek feedback and reflect on the successes and challenges encountered. This is in order to be more prepared and provide optimal support when travelling again.

Summary

Travel is an exciting yet challenging part of being a physiotherapist in sport. It pushes yourprofessionaland communication skills and logistical planning to another level. To summarise, the key components of working well within a team while travelling are:

  • Thorough preparation and clear communication within the team.
  • Having knowledge of your environment, and planning individualised strategies to minimise the detrimental effects of travel.
  • Incorporating daily monitoring to identify and minimise injury and illness risk.
  • Having clear processes in place while allowing for flexibility.

References

  1. Sleep Medicine Review 2009. 13, 249-56
  2. Sports Health 2012. 4(3), 211-216
  3. Clinical Sports Medicine 2005. 24: 367-380
  4. International Emergency Medicine 2011. 6, 113-6
  5. Clinical Journal Sports Medicine 2012. 22(3) 268-273
  6. Journal of Australian Strength and Conditioning 2012. 20(1) 12-23
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