IronMan 70.3 Dun Laoghaire

This year I was able to be, again, involved in the Dublin Ironman event.  The Dublin Ironman is a half Ironman and the route normally involved entering the Irish sea for the swim at DunLaoghaire. After a 1.9 km swim participants will transition over to the bike section which involves a 90 km cycle up the Wicklow mountains. The last section is a 21.1 km run back towards and around DunLaoghaire finishing close to the starting point of the race. If this is a half Ironman you can imagine how physically exhausting and mentally challenging full events are as well as something as, to be frank crazy as the Kona Ironman race in Hawaii, which is a 3.86 km swim, 180.25 km cycle and 42.2 km run in searing heat and hostile terrain.

Those in the event range from professionals, seasoned veterans, triathlon club members, endurance sport activists and then some of the most normal people who decided this was to be their new obsession for the coming year. Prior to race day I spent the 2 days beforehand dealing with various cases and individuals with issues ranging from simple checks on niggles, strapping, soft tissue work and full on consultations and real down to the wire decisions regarding if a certain person could compete in the race. The two days beforehand were long and tiring but being able to prepare so many people for such an event felt great.

On the race day myself and seven other therapists set ourselves up well before the end of the race was even in site. our first patient of the day had injured themselves in the water which was incredibly choppy on the day. The slow and steady stream of people who had injured themselves during the race and those professionals who had finished the race in an inhuman time suddenly became droves of being being accessed, looking for soft tissue work and even a few being stretch out because the could no longer do it themselves as a result of exhaustion. From 8:00 am in he morning until nearly 5:30 pm we provided care to a large number of the participants.

The Ironman event is such an endurance event that even the therapists are exhausted after it all. The event makes you feel like you can really do any kind of event. For all the people who loved and hated the training process you were hard pressed to find a single participant who wasn’t happy that they choose to compete, maybe only a few disgruntled partners and family members not as enthralled in the sport having to wait an entire day for the event. Yet the comradery expressed in the event and the dedication needed and shown by so many people, you can only appreciate and admire all those who decided to undertake the event.

This was my second year involved with the Ironman, in different roles between both roles and I definitely hope to involved again in the future especially with events such as the first full Ironman event being held in Cork in 2019 and the Hell of the West triathlon which I have been persuaded to train and enter next year.

 

 

 

 

Faculty of Sports & Exercise Medicine Conference 2018

Last week I attended the Faculty of Sports & Exercise Medicine (FSEM) conference at the Royal College of Surgeons Ireland. This year the Conference had a focus point in the return to play post shoulder injury. For those of you that don’t know what FSEM is – it’s an annual gathering of doctors,  surgeons, researchers, physiotherapists, and of course athletic therapists, presenting findings from studies as well as new methods of rehabilitation and surgical interventions to conditions and injuries. We basically come together to discuss the latest developments in the field of physical health. This allows for a body of knowledge, that would normally never be dispersed to be tangible for all.

There was some savage speakers this year. With the likes of Eanna Falvy, the Irish rugby team doctor who spoke about on field management and the occurrence of shoulder injuries in rugby. He interestingly   spoke about how rugby has evolved from its beginnings to something barely comparable to what it once was pre professional era. Body size, strength, play style and aggression have all lead to an increase in injuries especially those in the shoulder where the ideal of aggressive rugby in the breakdown via the poaching of a ball and active clear out has lead to an increase in shoulder injuries. He also spoke of the need to prepare athletes for the season ahead of them as you cannot prepare the athlete mid season, when training load and type are dictated by schedules and physical conditions there and then.

Edel Fanning described the return to play for contact athletes after shoulder stabilisation surgery. She described how the loading of the uninjured side and reductions in strength from one side to another or from internal to external rotators can make it difficult for athletes to return to a position where equilibrium is achieved once more. She also showed how rather than basing rehab plans off pre described time frames and rather base it off objective and measurable improvements from the athlete.

Nick Grantham described a very different int of view coming from a strength and conditioning background but showing how no one field within health and fitness is isolated. He described the strength, power and honestly versatility of an athletes shoulder using downhill biking as an example and showing how specialised a certain activity can make an athlete. He described rehab in a far less rose tinted light than it is often portrayed with the focus being placed on the avilable resoucrces and pjysical attributes being available to each and every specific athlete. We often to much on the on the structures that have become injured rather than the reason why they have become injured sometimes trapping ourselves in a loop of repeated returns and failures of tissues.

Probably my favorite piece of information from the entire conference which states that essentially just following information previously recorded and not catering rehab as an individual experience will not produce outcomes where rehabilitation’s effectiveness is maximised. Essentially, everything is situational and so you cannot paint every injury or condition with the same paint brush. Sean O’ Brien also spoke on his professional career and often as therapists we can forget but the athlete or patients point of view regarding their injury and rehab.

In all i really thought the conference was great and a huge amount of knowledge and opinions were expressed. Not all pieces were directly relatable to every field of expertise but something to better your skills as a practitioner  was present in nearly every talk, workshop or conversation on the day.

Wellfest 2018

So this year I was able to make my way to Wellfest. For anyone who doesn’t know what Wellfest is, it is essentially a two day festival where fitness and health in most of its forms gets a chance to show what its made of and allow people to experience it. Im a little late talking about it as it was nearly 4 months ago now, but I still think it is an event worth talking about and how it reflects Ireland right now. Wellfest has only been running fora couple of years now but has already become an event where thousands of people attend over two days. The event had a large number of successful and big name fitness and health enthusiasts such as Joe Wicks, Davina McCall, Simone de la Rue, Hazel Wallace and other home grown talents such as Movement 101 and Gerry Hussey. These individuals represent all very different aspects to modern health, from yoga, classes, diets, mobility and even psychology. The event represents perfectly how health and fitness has become the fasting growing industry in Ireland. Be it food, clothing, supplements or health related ideals, Wellfest acts as both a showcase to well established and start up health and fitness related businesses. Wellfest is a very unique event in the sense that fitness and its importance is given a very large and obvious spotlight.

Fitness in Ireland is going through its renaissance period where more gyms, clubs and fitness related businesses are springing up constantly. As time has gone on individual gyms within large urban areas have moved away from the old style of old school, super functional gym that may not have been what anyone could be called pretty. The new model of gym are style functional but they have now needed to be become apart of a larger industry where the best are the best for a reason. The model is perfectly shown in Flyfit and Raw gyms where near 356 day memberships, in several places and functional machinery and equipment with a pleasing aesthetic controlled by people normally with a background normally rooted in a far greater understanding of human physiology and anatomy has gained them some of the greatest success in the Irish fitness scene. Other people then such as the Happy Pear who have turned lifestyle into a successful business have shown that the fitness industry is not solely about gyms and sports clubs anymore.

This is then showcased in really only one event altogether in Ireland. You have yoga classes being held beside mindfulness talks, across from cooking tutorials and mobility classes while a HIT class it booming out across the field and various entrepreneurs passionately push their products and visions. You have people who do not share the same points of view and would rarely get a chance to speak with anyone who holds a different opinion literally sharing the space beside one another discussing their points of view and where they hope they take their own ideals in the future. It is definitely a unique event and it still also shows the growing and somewhat childish side of Ireland where we haven’t yet come to terms with the fitness industry and our knowledge of it. You have a fairly young demographic at the event but it does also show how it is continuously changing and trying to encourage a greater mixture of people to feel comfortable in the industry. This could be seen in the people who brought their start ups tho the event and the addition of a kids section for parents at the event.

Welfest does definitely show the best parts of what the health and fitness industry has to over as well as the growth of this industry in Ireland. The main question is how the event will grow, what direction they’ll try and take it and how health and fitness will mature and grow in Ireland after such an intense period of success and growth best described in an event such as Wellfest who has gone from strength to strength.

Practice What You Preach!

Should you always be able to practice what you preach? Being in a profession within the healthcare system many people have asked me am I capable of doing everything that I normally ask of my clients, be in strength, mobility or balance related. The simple answer is no, I cannot do everything that I often expect and seek from others. This can present some what like an irony that I would not consider myself to me injured or currently harboring a condition but I cannot do some of the things I ask from those that do. The honest answer is that regardless of what you may try and teach someone and expect them to be able to replicate each person has different body structures and capabilities. Each person has also developed differently including their health history regarding the injuries they have sustained and they way in which thy have recovered from these injuries. So very rarely do you find someone who is perfectly functional by the standards we test people. To the extent that when I access someone who is perfectly functional I’m almost shocked.

I have gone through my fair share of injuries so If I was to be tested for things such as ankle or shoulder stability someone may think that I may currently be carrying an injury but as of right this second I’m good. We are not always capable of doing the tests and assessments that we use to grade individuals musculoskeletal health. At times we can hold the testing methods we use a little to strongly. As those who are testing these people and trying to push them forward it can at times create goals that can be excessively difficult for people to cross. People are sometimes not capable of reaching what is perceived to be perfect functionality but most are still capable of doing the sports or events that they wish to undertake. There are always ways around certain functional shortcomings. This may mean doing things in an unconventional manner or simply by breaking activities down to their base elements.

At the same time most people involved in health and sports related activities need to be able to do the basic requirements of that activity. Be it simple skills or some of the functional movements that are heavily demanded in the sport, it is essential purely because to understand the sport and what is demanded of those involved, the best way to help them and make their plan applicable to them and their sports is to be able to understand the sport at a basic level and recreate it. Not to be able to understand every fine nuance of a game but to see the way an individual moves and the way this interacts with surrounding players or athletes can at times be one of the most valuable assets you can have. To understand how an athlete should move in their position and how they normally move themselves can lead you down a path where you realise that they may be carrying an injury or weakness. Seeing a player act differently or out of character can lead you to help them to overcome what may be effecting their game. Behind games, and this is especially true for athletes, lies the core of an individual. So if you cant put yourself in their shoes you may miss the signs behind certain problems. You are not a mind reader although many expect us to be. But at the same time make sure you can practice what you preach, to a certain degree, even to understand where your clients and athletes are coming from to better help them and to allow yourself to keep up with the hectic demands of a physical and demanding job.

Recovery

Road to Recovery

In my profession I help a lot of people to return from injury, be it chronic or acute, it is my job and my drive to get people back to a position where they can return to a healthy and functional condition, if not get them to a position where they can become even better than they were before injury. I have done this and regularly guide, and at times convince people, to give their best efforts towards this end goal. Although I get great satisfaction from helping people to return from injury I have always found it difficult to produce the same level of intensity in my own rehab and return from injury. I myself have until recently been injured or returning from injury for a little over 5 years. My life definitely dramatically changed after injury and lead to a domino effect of injury, rehab followed by complications, rehab and what seemed like an up hill struggle to return to a point where I could confidently under take the activities I wanted to without having to worry about what may happen.

My uphill struggle began in my first few weeks of college when I ended up getting a Talor dome fracture to my ankle damaging all of my lateral ligaments in the process. It occurred in the final three minutes of a rugby game in which a fluke fall and tackle interacted to cause the injury. I had began my Athletic Rehabilitation course and so I had my ankle accessed and was quickly sent to a clinic to get the ankle scanned. Before I made my way to the hospital I went to where I was staying and ended up hitting my ankle off the steps of the stairs attempting to climb them and due to the shock and pain I ended up fainting and collapsing at the top of the stairs. I went to the hospital the following morning but was told there was no fracture, merely ligament damage so I was to just rest it and it would be fine. I proceeded to attend 3 days of college before one of my lecturers told me I was being foolish and was to go home and rest as I was so tired walking around with crutches from one lecture to another that I kept falling asleep in classes.

I attended the hospital several times over the following 2 months where the assessment of my injury changed per visit. This aggravated me and I couldn’t understand where I stood with it all so I decided I would rest it and do my bit of rehab I had gotten and make a return to rugby and normal life. I spent a year getting back to walking normally but something wasn’t right. My entire leg appeared to have rotated inwards and I was unable to walk more than 5 minutes before pain would make me stop and take a break before I could walk again. In this time I had thrown my efforts into gym work and it was a saving grace but there was a very large gap left by rugby and not because I was a skilled athlete but merely because I had played rugby every year up to this point since I was 6 years old. It was a constant in my life at that point and it was where I had made most of my friends through out as well.

I had decided after a year of this that I had finally had enough and went about getting an appointment with a consultant as rehab, no matter how much effort or dedication I applied to it, was no longer helping and I had changed a number of aspects in my life that I would never have even had to give a second thought about previously. Upon meeting the specialist and getting an MRI I had found out that i had a piece of cartilage that had calcified in the center of the joint as well as a piece of cartilage on the medial edge of the joint that had torn away from the joint line. This was not the worst case scenario and key hole surgery was possible so I agreed to a date there and then. I decided to get it done the summer before third year as that was when my placement began and I needed to be able to walk and stand and just move to do it. So i gave up Summer to be alright for the coming college year. I entered the day of surgery and wasn’t nervous. I had learned a lot already and knew what they were going to do to my ankle. I was more impatient if anything. They rolled me in to the anesthetists and nearly as soon as I remember being wheeled in I was awake back in my corner of the ward post surgery. I began to come to and the pain hit me like a truck at first. Each pulse seemed like agony and it felt like someone raised the temperature in that one ward by about 20 degrees.

My doctor soon came over to me and told me the physiotherapist would be with me soon to talk everything out. I honestly only picked up every second word because I had finally noticed the massive full length leg boot I had on. He only stayed a short time but he told me it was a success and that he would see me in a week. I waited around for my dad to show up and take me away so I fiddled around on my phone and let everyone I knew know that that I was out and in a lot of pain. The physiotherapist came to show me how to use my crutches, little did she know I was a seasoned expert at them by now. I feel bad for her now looking back as I was standing and straight over to the bathroom before she even got a chance to fully explain it all. I got my tea and toast and eventually my dad arrived. I was still feeling the effects of the pain and drugs so I didn’t even realise how long I had been under for. I arrived home and went to sleep or at least what sleep was with a massive boot on your leg. My first real day began with me slipping down the stairs as I fell trying to get myself to the bathroom and me having to go to Shannon Doc to get stronger pain medication. Three days later my letter describing the surgery arrived and I read exactly what had occurred. My key hole surgery of one hour had turned into a four and a half hour surgery involving the removal of cartilage, removal of a bone growth, reconstruction of my Deltoid ligament complex and removal of excess tissue from around my Achilles. I had yet to open my boot so after reading my letter I did to notice I had more than just two dots as scars of my surgery.

My plan slightly backfired so I did rehab and work throughout the Summer but it took 6 months before I was back walking again. Thankfully at this point I was deep into the rehab phase and almost back to normal. Normal sadly did not mean I was able to return to the gym or rugby yet with another 6 months of mobility, balance and strength work needed before I was at the point where I could comfortably enjoy a gym session or a long walk again. I finished out my last year of college and just recently started to play rugby again. My body still remembers what to do but its a few steps behind what my brain demands from it. I still have difficulty and am sore to some degree but in comparison to where I was, where walking was near impossible for long periods, its like a whole different world. Looking back as a qualified health practitioner now I can barely believe the way I went about things. I refused to take proper care of myself and even held onto the belief that because of what my course was, that I knew how to sort my problems. Present me can scarcely believe my naivety but it also gave me a perspective on what pain and injury was and how people view their injuries and themselves while injured. Sort of like a person who has never been to a certain location can never truely describe it, long term and chronic injury is very much a unique journey for everyone. Im glad that my road to recovery has come to its end but now the road to performance has only started.

What does Pain mean to you

What does pain mean to you?

Pain is always a very difficult topic to discuss. So many people describe pain in different ways and pain itself and the idea of what it truly is, how its perceived and what we should do when we experience, especially in terms of injuries or activity, seems to change on a regular basis. For a long time therapists use to chase the pain finding the symptoms of pain, leading to initial short term improvements but never caused the pain to fully leave or the true cause to be chased down and dealt with. We as humans became heavily dependent on getting rid of pain so we could function long enough to compete or just get through the day. this lead to many people suffering in the long term, with tissues being damaged and movement patterns leading to injuries merely being ignored instead of changed.  The international association for the study of pain describe pain as “An unpleasant sensory and emotional experience associated or as a result of actual or potential tissue damage”.

In certain sports they have become dependent on the idea of deal with the pain to allow an individual to compete for a long enough period and then to essentially come off injured. American Football is the worst culprit for this and still continues to chase the symptoms instead of the cause.  Sadly leading to the abuse of NSAIDS, painkillers normally injected into an affected area but the overuse of which can cause tissue degeneration. Other sports have already moved away from such methods but often we find ourselves stuck in a situation where we have an athlete asking to play and willing to push through an injury, coaches balancing their want for player safety and need to produce results and therapists stuck between the want of their patient and the knowledge of what is truly occurring to them and what will occur with further stress.

People often want a quick solution and don’t want the hassle of consistent or prolonged rehab or activity when a quick solution of masking the pain will allow them to do the same. America alone spends $323 billion dollar in 2015 on pain medication with it likely to increase to $450 billion by 2021. Obviously this includes individuals taking pain medication for conditions that cannot be cured through rehabilitation and activity but a huge sum of this money is towards people suffering chronic but curable pain as well acute pain due to musculoskeletal injuries or tension.  Looking then to the entire world the money spent on short term relief of pain is astronomical in comparison to the price of what rehabilitation or increased levels of activity cost in the long run. 

The issue with always masking or reducing pain is that pain is not always a bad thing. Pain normally allows for us to find the cause or the issue or the reason behind injuries. It also allows us to prevent ourselves from returning to a position where our tissues cannot, at that time, deal with the loading asked of them.  Pain is a way for your body to protect itself by trying to force us out of positions or activities that is causing damage or this sensation to be produced. Pain not only causes physical changes but mental as both are interlinked to a level where we often cannot control it. Pain will lead to physical change which will lead to mental changes in the form of a change in movement patterns and the reaction to fear. This is often an unconscious factor but often leads to prolonged changes in the way we function. We can also become over saturated with pain meaning we can become hypersensitive to it or almost numb to its presence, both as bad as the other in functional terms.

Pain can illicit a response from several systems including the motor, endocrine, sympathetic nervous and immune system.  Pain also does not always mean tissue damage in the sense of an injury.  For muscle and tissue to correctly develop it has to be broken down and built up, with the correct loading for more avascular tissues. Pain is also exceedingly selective with pain producing a different  response or level of pain depending on its cause or placement of injury depending on the activities of each person e.g. knee pain in an Olympic weight lifter vs a musician. Our body has specific healing phases with each tissue type having a different time-frame of healing. Masking the pain or introducing exterior stimuli to reduce pain before these stages are complete to an excessive level can cause issues where a premature return to activity occurs several times causing chronic problems.

Our biggest issue stems from a mixture of refusing to spend the time needed on correct rehab to produce long standing results and our lives revolving around excessively sedentary lifestyles. We only need to be active in the correct manor for short periods each day but we find it difficult to entertain the idea of it. Time seems to be the real killer with us normally not having the patience or willingness to give time over to what seems hard to make things easy in the long run, instead doing what is easy and maintaining what is wrong for the long run.

New Therapies from Old Ideas

In our modern world the old and the new seem to inter mingle and over take one another as we see them with fads and waves of interest, fashion and ideas. This is very much true when it comes to the way in which we view how to treat patients. What is currently in fashion, what are the therapies currently used or being studied. We often see these first hand from professional athletes or at major events like the Olympics or World games. What are the athletes currently receiving for their rehab or their pre-event work. This can be clearly shown when we see therapies like cupping or kinesio tape which were around for many years especially cupping, originally an Asian treatment, making their big world showing at the Olympics and suddenly becoming the new “It” therapy.

As such, are the therapies used or wanted, implemented like a popularity contest, with the fashionable and cool person winning even without knowing for sure what it is they do. This can often lead to therapies evolving and becoming more stream lined and specific such as the therapy dry needling, coming from the Asian medical practice of acupuncture. It seemed to work for centuries but not exactly for the reasons described. Does that mean that all therapies possibly have a sell by date before they are either updated and brought forward or left to the way side.

We often see this being heavily influenced by where our school of thought lies. Western medicine for nearly a century has implemented the R.I.C.E method of Rest, Ice, Compress and Elevate to treat initial injuries and for early stage rehab. Whereas Eastern medicine often implements the use of stimuli to injured or affected areas to hopefully cause increased levels of healing. So who is right? Well neither can 100% claim that their way is without a doubt the best, it is purely based off where a therapist received their training. Many therapists will learn new methods, ideas and therapies to keep themselves up to date and relevant. So no therapist who has practiced for a long enough period is the exact same as they were when they first entered the industry.

An article I recently read put it somewhat into perspective that fad therapies often come and go due to initial popularity and exposure but they mainly end up being contained by the school of thought they come from. Which is why when therapies such as cupping, dry needling and the many different forms of soft tissue therapies that become long term and major therapies within both bodies of medicine, it is a pretty major thing,

https://newsstand.google.com/articles/CAIiEGOf56AyetebYcZ4FsuiE5wqGAgEKg8IACoHCAowy-2kCjCw_3cwjs7sAQ

The reason behind many therapies ability to reduce pain have yet to be scientifically shown, such as the term “trigger points”. A trigger point has never been shown to actually occur in enough pieces of literature to be a definitive reason behind pain or reduced mobility, but I can find them and release them somehow in patients. Sometimes we practice things that are not fully backed or that we don’t quite know why they are helpful and yet we use them regularly and we can see that they are beneficial. So unless its somehow a placebo effect present in most people or sometimes we implement different methods of treatment without needing to know why they are effective as long as they don’t cause harm. Maybe this means the way we view rehab needs to slightly change from everything being rock solid truths. Yet maybe we also need to better educate those who come to us in what exactly the methods we use do so that rehab becomes less of a popularity contest where we case what people want and provide a wide enough spectrum of treatments from several schools of thought.

I believe that my ideas were first challenged when on placement when the fully qualified Athletic Therapist in charge of me asked me as question.  We had spent a little while assessing patients with him asking me anatomy questions, which had me sweating to like good in front of this person. Eventually we went out to cover the game and he asked me what I thought about different therapies I was learning about, especially modalities and if they were any use at all. I then said that I thought R.I.C.E was the “most effective rehab”. He laughed and then asked me “So should you put ice onto an effected area straight away even though ice will reduce pain but slow the repair phases possibly causing issues later if its over used like it normally is”. After hearing this I was quit for a solid half an hour because I couldn’t answer him and my 2nd year college mind couldn’t yet comprehend the idea that “wait that cant be right”.

So after years I’ve come to the conclusion that I still do not have a conclusion and that each and every individual must be taken as an independent case and that any therapy be they strange, tried and tested, old, revamped or the simple thing you skipped because it was simple I believe that having predetermined methods and schools of thoughts cant really work anymore.

The Importance of Communication with Patients

Recently I attended the Coaching Masterclass event held in Dublin City University. Coaching itself is not something I wish to do as a profession but the premise behind good quality coaching can help with dealing with patients and receiving the best quality effort from them.

Often coaches, therapists and others, who would be perceived to be in a position of authority and care, can fail to communicate to the people that come to them.  As professionals in our fields we often talk to athletes or patients and tell them what to do. Not always necessarily listening to their own views and difficulties on the matter. We often lose ourselves in the idea that we know best and that doggedly persevering through any form of set back or failure without making changes will work.

This is of course is a selfish ideal that we can all fall in to. Thinking we know best and that if others just listen to you and do as you say, well then of course they will improve. Sadly this is not true for most. We have seen now for years that not every form of learning will suit each person, “One size fits all” does not always apply.  Within the event better ways to communicate and understand athletes as well as people in general were presented by coaches, sports scientists, sports psychologists and experts of human behavior.

We sometimes act like most people will improve at a steady and homogeneous rate. This is often a trap that health care providers fall in to with set backs and slow progress stumping many of us purely because “Well why wouldn’t it be working”.  Its the exact same way in which we look at performance. We often look at the potential in individuals and we can see where they could end up, but just as many of the people speaking at the event made reference to, you can have the greatest car in the world but it will only drive as well as the person behind the wheel.  Simple example but it holds true to anyone trying to come back from injury or improve their performance. Your body has all the capability in the world, but the effort you put into it and the decisions you make are what determines the outcome.

We normally see this in private when a person can perform to a high standard with ques and a presence to guide them step by step. Adversely we see them falter and become unsure in an open environment with unknowns and the fear of return to play. As such we need to be able to communicate with our athletes/patients in a manner that allows them to grow as an individual with the necessary skills to not only return to general activity but excel in it. These individuals must not be afraid of stumbles and failures as they will be what allows them to grow.

We all want those we aid to grow more and more but each individual is different and cannot always fall under broad methods of training or learning. We cannot merely tell them what to do at every given period. We need to instill in them to ability to return from injury and know the way to prevent re-injury. This can be difficult as most people are in a rush and want to be told what they need to do, step by step. Challenging them while aiding their physical return to play may be what is truly necessary in the long run for player health and longevity within a sport. Knowing the ques for the best result and describe where an individual truly both mentally and physically are also necessary.

Performance as well as the rate a person progresses in their rehab is seen as 90% preparation. If we do not adequately challenge people with factors relatable to their sports or general activities and merely cater to their ability to complete abitrary tasks away from a true to life scenario then we are merely setting them up for a fall. Rehab must become something where the patient, those involved with them and ourselves all share a common goal in mind that we all strive to achieve, a “shared mental model”. This system where we strengthen not just a person physically but also mentally is where we make people return and become even better than they were as staying the same in their position means they aren’t getting better. This responsibility given to the individual will hopefully make them try harder and make them more open to try methods on their return to full health and continuous improvement in their performance, be it on the field of in every day life.