R e s e a r c h A r t i c l e P h y s i o t h e r a p y U t il is a t io n b y S p o r t s P h y s i c i a n s f o r M u s c u l o s k e l e t a l In j u r ie s in S e l e c t e d E l it e S p o r t s in N i g e r i a . A B S T R A C T : In Nigeria, the majority o f injured athletes seen in sports physiotherapy units are referred by sports physicians. The extent to which a physician utilises the services o f physiotherapy in sport depends largely on the level o f awareness or knowledge o f physiotherapy services that such physicians have. This survey evaluated the degree o f utili­ sation o f physiotherapy services f o r the treatment o f injuries during preparation f o r multi-sports events by sports physicians in selected elite sporting events in Nigeria. One hundred and twenty-eight athletes, coaches, sports administrators, scientists, medical doctors and physiothe­ rapists located at fo u r different camping sites, were sampled. The responses between different professional groups on the non-utilisation o f physiotherapy services by sports physicians during preparation f o r m ulti-sport events, was not significant. However, Nigerian professionals who were surveyed, accepted the hypothesis that sports physicians did not utilize physiotherapy services f o r the managem ent o f musculoskeletal injuries during training and pre-gam es preparation in selected elite sports in Nigeria. This retrospective study o f the actual referral records at the clinic o f the sports medicine centre revealed that 20 (91%) different types o f musculoskeletal injuries sustained by volley ball players were referred f o r physiotherapy. Nine (56.3%) injuries sustained by basketball players, 62 (87.3%) by track and fie ld athletes, and 6 (74%) by footb a ll players were referred f o r physiotherapy between 1992 and 1995. The majority o f the injuries sustained were liga­ mentous sprain and muscular strain with jo in ts o f the lower limbs and the back mostly affected. KEYWORDS: UTILISATION, ELITESPORTS, PHYSIOTHERAPY, SPO RTS PHYSICIANS. USHOTANEFE u', MBAJIOGU FE', SANYA AOJ ’ Department of Rehabilitation and Anatomy, Faculty o f Medicine, University o f Z im b ab w e ^Department of Physiotherapy, College of Medicine, University of Isaba n, N ige ria INTRODUCTION Perform ance o f sportsmen and women in their chosen sports depends on the support received from mem bers o f the training crew. This crew ensures that the state o f preparedness, well being and the physical fitness o f the athletes is optimal. In developed countries, m em ­ bership o f such a crew usually consists o f the coach or/and the trainer, sport physician, the physiotherapist, the exer­ cise physiologist and team managers. Watson (1993) expressed the opinion that for an athlete to be successful at the highest level of sport, com m itm ent to a system atic and dem anding program m e o f training and com petition extending over a protracted period of several months or years, is a requirement. Such a train­ ing program m e could be disrupted if the injuries sustained are not adequately m anaged. T he m anagem ent o f these injuries requires a team effort; the physio­ therapist being a mem ber o f such a team. In Nigeria, the majority o f injured athletes treated in sports physiotherapy units are referred by sports physicians, while in other countries, physiotherapy is a first contact profession though they also frequently depend on referrals from doctors. The extent to which physicians utilise the services o f physiotherapists in sport depends largely on the level of awareness or know ledge o f these phy­ sicians o f the available physiotherapy services (Allman, 1974). Thus physi­ cian s’ know ledge o f the role played by physiotherapists w orking with athletes influence the num ber o f referred cases for physiotherapy. Also im plicated in the extensive use o f physiotherapy services are the physio­ therapists them selves. Some physiothe­ rapists are not aware o f their possible roles in the treatm ent o f sports injuries (Sperryn, 1976). In our experience o f sport in Nigeria, it has becom e evident the list o f pro­ fessionals w orking with sportsm en and w om en is reduced at the w him and caprice o f those making the decisions on treatm ent for various reasons. Ignorance and budgeting constraints (due to lack o f funds) often affect this decision. The physiotherapist is a m em ber o f the crew who has to date been haphazardly utilised. Many different injuries occur during sporting events. The type o f injuries, causes and parts o f the body that are com m only injured, in m ulti-sport events have been reported in previous epide­ m iological studies (Jull and Cupit, 1984; A huja and Ghosh, 1985; Sadat-A li and Sankaran-Kutty, 1985; W atson, 1993; Hannay et al, 1993; Jelsm a et al, 1997 a and b; Karlsson, 1998; and Fahlstrom et al, 1998). CO RRESPONDENCE: U seh U shotanefe D epartm ent o f Rehabilitation, Faculty o f M edicine, University o f Zim babwe, P. O. Box M P 167, M ount Pleasant, Harare, Zim babwe. Tel: 263(4) 791631 Ext 175(w) SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 1. The responses o f p ro fe ssio nals an d athletes to the hypothesis th a t sports physicians do not use physiotherapy services fo r the treatm ent o f injuries during train ing fo r m ulti-sports events. Professional groups Response Options Total SA A D SD No. % No. % No. % No. % No. % Sports scientists 3 75 1 25 0 0 0 0 4 3 M edical doctors 10 67 5 33 0 0 0 0 15 12 SADM 3 20 12 80 0 0 0 0 15 12 Physiotherapists 8 100 0 0 0 0 0 0 8 6 Coaches 26 62 13 31 3 7.2 0 0 42 33 Athletes 22 50 20 45 1 2.3 1 2.3 44 34 TOTAL OVERALL % 72 56 51 40 4 3 1 0.8 128 100 SADM - Sports Administrators SD - Strong Disagree SA - Strongly Agree A - Agree D - Disasgree No. - Num ber o f Subjects % - Percentage Table 2. The degree o f agreem ent and disagreem ent o f responses b y the professional groups. Professional groups SA+A D+SD SS 4(100) 0 MD 15(100) 0 SADM 15(100) 0 Physios 8(100) 0 Coaches 39(93) 3(7.2) Athletes 42(95) 2(5) TOTAL 123 5 OVERALL % (96) (4) There was a dearth o f information and literature on injuries sustained during preparation for these m ulti-sport events. It was also observed that there was no study on physiotherapy utilisation during preparation for these games. T he aim o f this study was to evaluate the degree o f utilisation o f physiotherapy services by sports physicians for the treatm ent o f injuries during physical training and preparation for multi-sports events in Nigeria. We also attem pted to investigate the com m on m usculoskeletal injuries that were referred for physio­ therapy, and recorded the sport that was responsible for the m ost referrals within a sports medicine facility. SUBJECTS AND METHODS O ne hundred and tw enty-eight different sports professionals were included in our sample. The group consisted o f physio­ therapists, medical doctors, sports scien­ tists, sports adm inistrators, coaches and elite athletes who participated in the prepa­ ratory camp for the sixth All Africa Games. The group was selected from the sixth All African G am es (AAG) prepa­ ratory cam ps located in four different zones (Kaduna (Northern zone), Ibadan (Western zone), Bauchi (Central zone) and the Lagos zone in Nigeria. Inclusion Criteria: T he particip an ts w ere p ro fessio n als from d ifferen t parts o f the country including some athletes from abroad w ho turned up fo r the p rep arato ry camps. The professionals and athletes should have taken part in high level sports or should have been involved in preparations for events o f the standard o f the All Africa Games. This ensured adequate exposure and experience for the participants and therefore guaran­ teed accurate and unbiased responses to the questionnaire. Instrument: The instrum ent for data collection was a self-developed questionnaire, which was pre-tested (by the first author) to resolve any problem s and ambiguities around the questionnaire. The question­ naire was divided into three sections: A, B and C. Section A was concerned with the personal and dem ographic data SADM - Sports Administrators SS - Sports Scientist MT - Medical Team SADM - Sports Administrators PHYSIOS - Physiotherapists Values in bracket are percentages o f each o f the participants. Section B tested the participant’s know ledge o f the use o f physiotherapy services by sport physicians in sports, and section C dealt with the actual utilisation o f phy­ siotherapy services in participants respec­ tive clinics/or medical centres/or sport­ ing associations. The questionnaire was designed in a Likert model and scaled on a four-point scale. This enabled the respondents to indicate the extent o f agreem ent or disagreem ent for every statem ent examined. T he data obtained from the question­ naire were augm ented with the data from the retrospective exam ination o f the records o f injuries at the National Sports M edicine Centre, Lagos. This centre is located within the National SA - Strongly Agree A - Agree D - Disagree SD - Strongly Disagree N o - Num ber o f subjects sports com plex and is used for the treatm ent o f sports men and women when cam ping for national and inter­ national com petitions. All the questionnaires for the profes­ sionals were hand-delivered to them. This was done to ensure that the p arti­ cipants received them in good time and enabled the researchers to make appointm ents for the retrieval of the instrument. Individual coaches and all professionals were approached at the different cam p locations and sporting associations. T he questionnaires that were com pleted by the athletes were returned by their coaches. None o f the coaches d eclin ed to take part. The research ers also m et w ith the team doctors and p h y sio th erap ists during 20 SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 3. The use o f physiotherapy services fo r the treatm ent and re h ab ilitatio n o f muscu­ loskeletal injuries in the facilities o f the professionals. Professional groups Response Options YES N O Total No. % No. % No. % Sports scientists 2 (50) 2 (50) 4 (3) P* 0.6 2 Medical Doctors 9 (79) 6 (21) 15 (12) P* 0.8 8 Sports Administrators 9 (79) 6 (21) 15 (12) P* 0.88 Physiotherapists 5 (63) 3 (38) 8 (6) P* 0.9 6 2 6 Coaches 25 (60) 17 (41) 42 (33) P* 0 .8 7 Athletes 29 (66) 15 (34) 4 4 (34) P* 0.06 t o t a l OVERALL % 79 (62%) 4 9 (38%) 128 (100%) No. - Num ber of professionals surveyed % - Values in bracket are percentages p* - p-value computed for the Chi-square Test Table 4 . Comparison o f responses between the d iffere nt professional groups. SS MD SA Physio Coaches Athletes ss * 1.000 1.000 1.000 1.000 0.6073 MD * 1.2869 1.000 1.000 0.7589 SA * 1.000 1.000 0.7589 Physios * 1.000 1.000 Coaches * 0.6562 Athletes * Values in the tab e are p values computed o r the Chi-square Test SADM - Sports scientists M D - Medical doctors SA - Sports Administrators Physio - Physiotherapists these visits. Dates were then agreed on when the com pleted instruments would be retrieved. The im portance o f this study was h ig hlighted during these meetings. This strategy may have con­ tributed to the successful retrieval o f the adm inistered questionnaires. DATA ANALYSIS The data were grouped according to the speciality o f the participants and simple percentage evaluations etc used in the analysis. The C hi-square test was used to determ ine differences in the responses within and between the various pro­ fessional groups. The 5% level was used as the critical level in establishing statistical significance. The com puter statistical software, IN-STAT was used to analyse the data. RESULTS A total o f one hundred and twenty pro­ fessionals and athletes were surveyed. The breakdown o f the overall sampled population showed that 3.1% were sports scientists. O f the participants 23.4% were medical doctors and 11.7% sports administrators. Physiotherapists made up 6.3% o f the sample, coaches and athletes 32.8% and 34.4% respectively. W hen asked about the use o f physio­ therapy for the treatm ent o f sports inju­ ries by sports physicians 56% (72) o f the sam pled population strongly agreed while 40% (51) agreed, 3%(4) disagreed and 0 .8% (1) strongly disagreed to the use o f physiotherapy for the treatm ent of injuries by sports physicians (Table 1). The breakdown o f the result showed that 75% of the sports scientists, 66.7% o f the medical doctors, 20 % o f sports adm inistrators, all the physiotherapists, 61.9% o f the coaches, and 50% o f the athletes strongly agreed that physiothe­ rapy services were not optim ally utilized by sport physicians. W hile 25% o f the sports scientists, 33% of the medical doctors, 80% o f the sports adm inistra­ tors, none o f the physiotherapists, 31% o f the coaches and 45% o f the athletes agreed with the opinion that physio­ therapy services were also not utilised by sports physicians in the treatm ent of m usculoskeletal injuries. All the profes­ sionals surveyed indicated that physio­ therapy services were not significantly utilised by the sports physician (Table 4). Table 3 shows that there was no sig­ n ifican t u tilisatio n o f p h y siotherapy services by the sports physicians during preparations for m ulti-sport events in the facilities where the professionals and athletes were located. Table 5 reveals the com m on m uscu­ loskeletal injuries recorded at the sports medicine centre in a period o f four years (1992-1995). The most com m on injuries were sprains and strains affecting the joints o f the upper and low er limbs. Volleyball and athletics (track and field) events recorded the highest referrals o f 91% and 87% respectively. Football recorded a referral o f 74%, while basket­ ball recorded the least o f over 56%. DISCUSSION The pattern o f the q u estio n n aire allowed two degrees o f agreem ent and two o f disagreem ent for every statem ent on the use o f physiotherapy services by sports physicians for the treatm ent o f sports injuries during training and com petitions. It was then possible to evaluate the strength o f the responses o f each participating professional. The responses by the professionals surveyed, showed a high level o f aw are­ ness of the utilisation of physiotherapists in sports. Hence, 123(96%) o f them gene­ rally agreed that physiotherapy services were not utilized by sports physicians for the m anagem ent o f m usculoskeletal injuries during training for m ulti-sports SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 5. Common musculoskeletal injuries sustained in d iffere nt elite sports as recorded a t the sports medicine center between 1992 - 1995. N o o f injuries and different types o f sports Types o f Injuries VB FB BB TF Part Injured Sprain 7 3 4 25 W rist Strain 11 3 2 23 Ankle joint, hand, Shoulder and knee joints. Dislocation - - 2 4 Shoulder Trauma - - 3 - N o t specified Contusion - - 4 3 Quadriceps Partial rupture - - 1 2 Rectus femoris Shin splint - - - 1 Shin Tendinitis - - - 3 Hamstring and Spondylolysthesis - - - 1 Spine Spasm 1 - - 2 Thigh and Laceration 1 - - 3 Hand, head and Bruise - - - 1 Fore-arm Back pain 2 - - 5 Back Post athroscopy Effusion - 1 - - Knee Hyper pigmentation 1 - - - Hand TOTAL 22 8 16 73 CASES REFERRED H 2 0 6 9 6 2 PERCENTAGE 91% 74% 56% 87% VB Volley ball; BB Basket ball; FB Footbal ; TF Trac c and Field events. Only 5(4% ) o f them disagreed (see Tables 1 and 2). The high level o f awareness displayed by the athletes and the professionals must have resulted from their ex p erien ce and exposure to events o f this m agnitude in the past. These findings are in agreem ent with those of Hannay et al, (1993) and Jull and Cupits (1984). M ost probably, the low overall response for those who disagreed (disagree (D) and strongly disagree (SD)) on the non-utilisation o f physiotherapy services might have com e from the few athletes and professionals w ho were located in states where physiotherapy services are readily available and utilised by sports physicians. A high percentage o f the professio­ nals (except the sports adm inistrators), strongly agreed to the non-utilisation o f physiotherapy services by sports phy­ sicians during training and preparation for competition. Tw enty-two (50% ) o f the athletes strongly agreed and twenty (20) 45% agreed to non-utilisation o f physiotherapy services by sports physicians (Table 1). This represents a total agreement (SA+A) o f 95%. It is how ever interesting that only 2 (5% ) o f the athletes generally dis­ agreed (SD + D) to the non-utilisation o f phy sio th erap y services by sports physicians (Table 2). The athletes who disagreed w ith the non-utilisation o f physiotherapy would probably be those who were based abroad (since they were also invited to these preparatory camps) or located in states where there were estab lish ed phy sio th erap y units and therefore had access to these services. T his response should be o f great interest to physiotherapists and sports adm inistrators since the care o f these athletes is our responsibility. M ost o f the athletes are usually treated for the first time by physiotherapists when they are invited to national preparatory cam ps o f this nature. The lack o f physiotherapy utilisation most likely is one o f the factors responsible for athletes with inju­ ries com peting at the opening o f m ulti­ sports events. A high rate o f pre-existing injury has been reported in the literature (Jelsm a e ta l, 1997a and b; Hannay et al, 1993; M artin et al, 1987; A huja and Ghosh, 1985; Jull and C upit 1984). The response by the sports adm inis­ trators, might have been influenced by their perceptions that physiotherapists function as masseurs as they do not com prehend the need for physiotherapy as an essential service during sports training and preparation for competitions. Their perception o f the physiotherapist’s role agrees with the study o f Jull and C upit (1984) who reported that adm inis­ trators debated the role o f the physio­ therapist as a m asseur during the XII com m onw ealth games in Australia. The response by the sports adm inis­ trators has serious consequences to the u tilisatio n o f p h y siotherapy services since the adm inistrative decisions on the invitation o f physiotherapists to sports preparatory camps rests upon them. Since the cam ps were only selection locations for the athletes, they were given the opportunity to reveal the actual utilisatio n o f p h y siotherapy services available in their respective states or locations. About 62% o f the profession­ als, athletes and coaches indicated that physiotherapy services were used by sports physicians in their facilities for the m anagem ent o f injuries during train­ ing, while 38% o f them held a different opinion. However, the response by all the professionals and athletes was not significant. This high percentage o f the utilisatio n o f phy sio th erap y services observed, agrees with previous studies (A huja and Ghosh, 1985, Thom pson and Ratcliffe, 1991; Jelsma e ta l, 1997a and b; Hannay et al, 1993; M artin et al, 1987; Jull and C upit 1984). The 62% response by the groups, only refers to the utilisation but not the degree or extent o f such utilisation. Hence, 38% o f non-utilisation o f phy­ siotherapy services is quite high. This value may increase if the degree and quality o f utilisation o f these facilities and services w ere co n sid ered . T he absence or lack o f full tim e physiothera­ pists on the staff o f most sports esta­ blishm ents may have also contributed greatly to this high degree o f non-utili­ sation o f physiotherapy services by sports physicians during training and prepa­ ration for tournaments. There was no significant difference in response within each o f the professional groups and between them on the utili­ 22 SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) sation o f these services (Table 3 and 4). Further studies might be recom m ended to exam ine the type and quality o f phy­ siotherapy services that are available at these facilities. Also to be considered for further studies is to com pare the utilisation o f physiotherapy services during preparation for multi-events with the utilisation during competitions. The percentage referral o f m uscu­ loskeletal injuries to the physiotherapy departm ent o f the sports medicine centre was observed to be high. The high refer­ ral agrees with the studies o f Jones (1980) and A huja and Ghosh (1985), who indi­ cated that many athletes with sports injuries are referred for physiotherapy. However, the high percentage o f the referred cases did not agree with the perception o f the professionals on the use o f physiotherapy by sports physi­ cians. The difference may be attributed to the fact that the professionals were drawn from different parts o f the coun­ try and that the sporting conditions and physiotherapy services at each of the localities differ from what is obtained at the national sports medical centre. In addition, due to the inadequate referral system, and poor record keeping, the total num ber o f m usculoskeletal injuries recorded at the sports medicine centre may not be a reflection o f the total num ber o f injuries that occurred during the four-year period. Another probable reason for a decrease in the num ber o f cases recorded is that some sports like football and basketball keep a full com plem ent o f the medical team (of a doctor and physiotherapist) while in preparatory camps. And they would not need to use the services o f the physiotherapy unit at the medical centre. Som etim es treatm ent rendered is not recorded as indicated by Thom pson and Ratcliffe, (1991). This may account for the different result obtained from the professional groups and from the records at the medical centre. It would be appropriate to compare the result o f the sports medicine centre with that o f other centres within the country. This aspect o f the study will be carried out in the near future. However the survey o f the sports medicine centre helped to validate the fact that physio­ therapy facilities and services w ere utilised to some extent by sports phy­ sicians. A striking feature o f the findings o f the distribution and types o f injuries was the similarity to those published for multi purpose sports (Jelsm a et al, 1997a and b, Jull and Cupit, 1984; M artin et al, 1987). Injuries reported affected both the upper and lower limbs. This is com para­ ble with the studies by Karlsson, (1998) and Fahlstrom et al, (1998). Sprain and strain were also the com m on types o f injuries recorded. These accounted for 78(66% ) o f the cases reported. The sports that recorded the highest referrals after injuries were volleyball and track and field with 91% and over 87% respectively. This agrees with the findings o f Jelsm a et al, (1997b) and A huja and Ghosh, (1985). Basketball and football recorded very few cases o f referral because, the elite national football and basketball teams in Nigeria always had their full medical com plim ent o f a physiotherapist and a doctor attached to the team when they were in camp. The need for referral to the medical centre therefore did not arise since the injured athletes could be m anaged within the camp. It was diffi­ cult to collect data from the teams with their own physiotherapist as reported in previous studies (Jelsma et al, 1997a, Jull and Cupit, 1984). CONCLUSION This study revealed under utilisation o f physiotherapy services by sports phy­ sicians in N igeria during preparation for multi-sports events. Since sports adm in­ istrators and doctors make crucial deci­ sions on the general welfare o f sports persons and the referral o f the injured ath letes for p h y siotherapy services respectively, it may be necessary to edu­ cate them on the essential role o f the physiotherapist in the m anagem ent and prevention of injuries in sports. Injuries affecting the joints o f the lower limbs were common. Emphasis should there­ fore be laid on prevention o f lower limb injuries especially o f the muscles and ligam ents during prep arato ry cam ps before the actual events. Also observed was im proper docu­ mentation o f the records at the sports centre. We recom m end that a much more com prehensive docum entation be included for proper patient auditing. Finally, attem pts should be made towards encouraging teams to employ their own physiotherapists since it would go a long way in minimizing pre­ existing injuries. 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