Ep 275: Shaping the leadership path in sports medicine teams, with Agnes Makowski

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[00:00:56] Clare Ardern We're getting to know our athletes better, and it's strengthened our relationship. It's worked out very well for us, and it's also empowered the athletes that they feel that we're being accountable and that they've got a group of support around them. Clare Ardern Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice.

[00:01:22] Clare Ardern I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. We talk a lot on this podcast about what well-functioning teams look like and how they function. Why? Well, there's at least two important reasons. Number one, effective athlete-centred care depends on the sports medicine, rehabilitation and performance teams all coordinating to help the athlete get the best out of themselves.

[00:01:52] The second reason is that working in teams and leading those teams well is not about telling people what to do. It's about shaping the path and working together to achieve goals. Effective leaders shape the path and bring people along with them. They don't make it all about themselves. Today's guest embodies those qualities. Agnes Mikowski is a registered international sport physiotherapist and has served as Chief Physiotherapy Advisor for Skate Canada since 2014.

[00:02:21] Agnes has extensive experience working in interdisciplinary teams and supporting athletes from the recreational level all the way up to the pinnacle of Olympic performance. On today's episode, Agnes shares her experiences and approaches to working in those interdisciplinary teams. Agnes Mikowski, welcome to JOSPT Insights. Thank you so much, Claire. It's a pleasure to be here. As you know, there's much more to working as a team clinician than bringing the skills alone.

[00:02:50] And as a sports physiotherapist, you've worked in many different interdisciplinary teams across many different sports. I'd love to start by hearing from you, Agnes, what do you see makes interdisciplinary teams work well? Well, I've been very fortunate throughout my career to be part of some very inspiring teams in terms of able-bodied sport and para-sport as well.

[00:03:14] And when I've reflected on my experiences so far, and if we think of recreational level or even the highest level, even looking at the Olympic movement, their motto is faster, higher, stronger. And in 2021, they added together, which I think is something that really attracts sports physiotherapists, that we're very team-oriented, and that it truly takes a village.

[00:03:39] The successful teams that I've been a part of have a few key ingredients. I've been fortunate to work with sport medicine physicians, with other physios, with exercise physiologists, mental health, strength and conditioning, athletic therapists, sport dieticians.

[00:03:58] Everyone, including the coaches and support team, I find that a lot of the key ingredients to success include strong communication, collaboration, a sense of respect and inspiration to work together, to be very open-minded and to be appreciative of diverse perspectives. The teams I've worked with have been very engaging and athlete-focused.

[00:04:26] They've been curious, very evidence-based. I've been fortunate that a lot of the groups I've been involved in have been very motivated to try to take athlete care to a higher standard. And we've all kind of inspired each other to have a growth mindset, to be open-minded and open to others' perspectives in terms of problem-solving. We don't all come with the answers all the time. There's a lot of expertise around us.

[00:04:54] And it's okay to say, I don't know something, but to reach out to other mentors. One of the other very important things is that in sport, there can be a lot of highs and there can be lows. So it's important to be part of a group where you can support each other in the good times and sometimes the more challenging time. Those I've been involved with, they really want to create a sense of community.

[00:05:21] I've been mentored by many other sports clinicians, but I've also been very proud to be able to create and grow a community of practitioners across Canada and also meet amazing colleagues from around the globe. That sports medicine community. I love the word community and it really comes through in the connections you've made in the different teams you work with. And as you say, the many people who have mentored you and who have benefited from your mentorship.

[00:05:50] Agnes, I'm interested in how you think about your role as a sports physio in that team and what you're contributing and how you make that contribution. I've noticed myself how much sports physio has evolved. One of the main areas I'm involved in is creating a safe sport environment. I have training as a first or professional first responder instructor with the Canadian Red Cross.

[00:06:17] Earlier in my career, I didn't feel as confident in my emergency care skills. And not every sport is a contact sport, but there are high-risk sports. So, for example, I'm doing a lot of work in figure skating right now. And believe it or not, it is considered a higher-risk sport. Getting certification as a first responder is really great because it just helps with your confidence and lays down some foundations for your skills.

[00:06:46] I do think it is important to make sure you're comfortable with those emergency care skills because, unfortunately, accidents can happen at any time. I also try to create an environment where the athletes feel safe. We've done a lot of education, not only with our senior-level athletes, but the next generation. Next Gen is a term that we're using a lot in the national sports organizations for kind of the junior-level or developing athletes.

[00:07:14] I try to create a safe environment so that they know what the role of physiotherapy is, how they utilize us pre-season, during the season, throughout the season. And also so that they feel comfortable approaching us. A lot of times, they're just learning about their bodies and they're not quite sure, you know, what other pains they should be experiencing or how to manage training loads and that type of thing.

[00:07:40] So we do a lot of education and we try to make sure that the athletes feel comfortable approaching us if there is a problem. Aside from educating the athletes, we do a lot of education for the coaches as well as to how to reach out to us and perhaps look at kind of training throughout the season, off-season, during the season, injury prevention.

[00:08:06] With most of the teams I've been involved in, because they're looking at training over pretty much almost an entire year, whether it's winter or summer sport, I find a lot of sports, the training periods have really extended in terms of the amount of off time. It seems like it's kind of gotten smaller and smaller.

[00:08:26] With my integrated support team, which includes sport medicine physician, exercise physiologist, strength and conditioning, nutrition and mental health, one of the main areas I contribute is doing functional testing and musculoskeletal screens. The main sport I'm involved in now with skating is decentralized. So meaning we have athletes training across the country. So there's pros of that, that we have an amazing country in Canada.

[00:08:56] Skating in particular is a very popular sport. Whether you're a figure skater or a hockey player, you need to have strong skating skills. It is a big country. So there is some functional testing that occurs at the provincial level. We've actually been able to do a little bit of research on this. And what we have found is by doing an MSK screen, we actually involve the local therapists that are closely working with those athletes.

[00:09:25] And we do that MSK screen at the beginning of the season. So everything from like a head to toe screen. Also, each year update our MSK screens by looking at the best evidence type of types of tests that are being used. That MSK screen takes about an hour, hour and a half max. We then review that information and get almost like a bit of a report card for that athlete.

[00:09:52] It's allowed us to see the unique individual athlete, how they're moving. And also to make sure that they're safe for training that season. So we kind of have a red light, green light kind of system. We also look at their mobility, their strength, any ways that we can improve their overall health and movement so that they're better prepared for the season.

[00:10:15] Also, last season, interesting development we did is that we managed to squeeze in a second MSK screen halfway through the season. Sometimes there's concerns of athletes getting kind of deconditioned partway through the season or, you know, they're traveling a lot and perhaps losing out on certain elements of their fitness or strength and mobility. So we've been able to squeeze in another kind of reevaluation kind of at the halfway mark.

[00:10:44] This has helped us to see are the action plans for those athletes being carried through. And hopefully if there's any concerns, we can red flag them sooner versus later. We've learned a lot through that. We're getting to know our athletes better. And it's strengthened our relationship. It's worked out very well for us. And it's also empowered the athletes that they feel that we're being accountable and that they've got a group of support around them.

[00:11:11] It sounds like the screening is much more in the sense of picking up where the athlete is, picking up things to work on, picking up things that might become a problem, as opposed to how we used to think of screening, I think, which was we can pick up a red flag that's going to mean you're going to get injured later. It sounds like you've really flipped the way that you're thinking about screening, Agnes, in line with how the research is directing us to. Definitely. We've learned a lot from that.

[00:11:38] And we know from some of the amazing research that's been done in Norway that we can't predict the injuries, but we're using the tool to get to know these individuals better. And anything we can do to empower the athletes and get them stronger or more mobile to meet the demands of their sport. Yeah.

[00:12:00] And that sense of getting to know the team around them, I think, too, getting to know the athlete and also getting to know the team is so important, as our Norwegian colleagues and Aspatar colleagues and many groups around the world who have been working on this. You mentioned you work with Skate Canada, Agnes. I want to talk a bit about figure skating in particular, because that combines athletic skills and performance with artistic skills and performance. What does that mean for you as a sports physiotherapist?

[00:12:27] What are the specific things that you are paying attention to in figure skating that you might not have thought you needed or that you didn't need in other sports? So I've been fortunate to be involved with figure skating for over 20 years now. And again, I continue to learn each year from the athletes, coaches, the people around me. Some of the unique features is that rather than just one sport, we actually have four different disciplines.

[00:12:56] So we have single skaters. The unique feature for them is that they have to be able to jump. We have pair skaters. So it's a male-female partner. They do very intricate lifts. The male partner is lifting the partner and they have to carry that partner pretty much across the ice. Do very intricate throwing type of maneuvers as well. And like I said, they do jump. We have ice dance, which is pretty much dancing on ice.

[00:13:26] They do not jump. But the challenging maneuvers they do is very, very intricate footwork and very elaborate lifts. And then the final discipline where some people are not as familiar is called synchronized skating. And it's kind of like synchronized swimming, but on ice, where you get a large group of skaters can be male and female. And they're doing quite elaborate configurations and patterns on the ice.

[00:13:53] They now also do things like lifts as well. As well as the physical aspects of the sport, we look at the energy systems used. So for all of those disciplines, there is a short program, which tends to be a little under two and a half minutes. And then there is a long or free program. And that tends to be a little over kind of three and a half to four minutes. We're looking at kind of cardiovascular health.

[00:14:20] We're looking at stroking and footwork in terms of the, you know, elaborate elements that have to be done. And within those short programs, each of those disciplines have those required elements. So whether it's the jumps, the lifts, the throws, spins. And in ice dance, there is a really fun maneuver that they do called twizzles. They make it look really easy, but they have to do multiple rotations, etc.

[00:14:47] So in terms of the physical demands, they make it look easy. But on the artistic side, they're trying to tell a story. And a lot of these athletes, you know, they love the artistic side. They do a lot of choreography training. The off-ice includes things like pilates, a lot of ballet work or ballroom work, etc. As a younger clinician, you may not be an expert in ballet or in choreography.

[00:15:15] And no one would expect you to be. But it is important as a physio, if you were concerned about maybe an athlete having a problem with a certain element, perhaps to reach out to the coach. We might not necessarily reach out to the choreographer, but we might reach out to the coach and express, you know, perhaps there's a certain maneuver that's causing some difficulty for that athlete.

[00:15:40] With the evolution of any sport, and in particular with skating, we have found that these elements keep getting harder and harder. So, you know, let's say 10 years ago, a triple jump would have been considered a major feat. And now you're hearing, like from the past Olympics, the quad jump. And not only are there two quad jumps, but now there are six different quad jumps. And some people are able to do all of them. And some people, you know, perhaps they can do one or two of them.

[00:16:10] So we just find that demand has kind of skyrocketed on that level. Wow, that's amazing. I can imagine when you're doing things like throws and lifts and jumping, things can go wrong and you end up with traumatic injuries. There's also, of course, like all sports, you've got overuse or chronic injuries too. Give us a bit of a flavor, Agnes. What are the types of injuries you're expecting that's in your toolkit to say,

[00:16:38] yeah, I feel really confident at managing X, Y, Z? And what are some of the things that you need to have in the back of your mind that are not unusual to see in figure skating? With Skate Canada, we're fortunate that we have a safe sport department. And a few years back, we actually took a look at injury surveillance data. The top six injuries came out to be near misses where perhaps there was a near collision, somebody had a strain or a sprain.

[00:17:07] The second on that list was concussion. Fractures was number three. Lacerations was number four. And that's very high, especially in the ice dance or the synchronized skating because the athletes are so close together. And that's a laceration, Agnes, from the skate, I presume? Yes, from the skate itself. And then we've had head injury and just contusion or bruises. And that's been kind of across all developmental groups.

[00:17:37] We've also done some work with our senior skaters. With that injury surveillance, our senior team athletes, on a weekly basis, at the end of their training week, they complete a Oslo-type questionnaire. And they tell us a little bit about how their health has been during the week. We've also been gathering how much time they're on ice, how much time they're off ice. And we've also been able to gather data from about the last three to five seasons.

[00:18:06] In terms of our competitive athletes, lower extremity injuries were the highest. So knee, ankle, hip, the low back in particular, C-spine and shoulders. We have had incidents of dislocation, subluxation of shoulders, in particular in the pair skating. There's a lot of maneuvers where the girls are being maneuvered with their arms extended in a kind of apprehension types of positions.

[00:18:36] So we also have noticed things like endopathy, overuse in shoulder and wrist as well, shoulder, elbow, wrist. Lots going on, lots to consider. And again, that's why, as you alluded to earlier, understanding the sport and the demands is so crucial here. So you can anticipate at least some of the things that you're likely to see and then have the team support around you for the things that are less common or that are a bit more outside

[00:19:05] of your comfort zone as a sports physio. And I'm thinking concussion is a good example of that, where you as the sports physio play a really important role in concussion. There's also an element of medical care that's required for concussion too. With concussion, we certainly have noticed a high incidence of that across all the different levels of skating. We continue to update our concussion protocol pretty much with every concussion consortium.

[00:19:33] We've also tried to use the opportunity to really educate coaches, athletes and the various clubs across Canada. We've been fortunate that as soon as there is a concussion, we've been able to get very strong communication across the country. And we do find that the protocol for that, especially that first 24 hours, remove the athlete from training and contact someone for help, that that's been working quite well

[00:20:02] for us. Oh, that's really good to hear. You mentioned the NextGen and I think that's a lovely place for us to finish our conversation because you do work a lot with youth athletes in skating, with the NextGen as you called them. They've got bodies and skills that are still developing into their sport. What do you see as your most important role as a sports physio in helping keep young athletes healthy and performing well, particularly given, as we know, they're still studying, they're

[00:20:32] still developing in all aspects of their life. There's a lot going on for youth athletes. We're very fortunate within Skate Canada in particular and a lot of the groups I've been involved with where their philosophy is sincerely sport for life or skate for life. So we really want these athletes to come into the sport and have a positive experience and

[00:20:59] be healthy enough to skate through their career and be healthy enough and enjoy it and have positive reflections of that. We are very fortunate to have a very strong relationship with our coaches. I will be participating in a NextGen camp this month. What we try to do there again is educate that local group what is involved in terms of training.

[00:21:25] We try to make them aware that their bodies are often going to be undergoing changes. We often see a lot of athletes that go through growth spurts and that can affect their proprioception and their tissue tolerance for loading and that type of thing. Some of the ways we also try to make a difference is looking at that load management and educating

[00:21:51] that every younger athlete is different. At the provincial level, we're fortunate that some type of MSK screening can still occur, but it tends to be once those individuals are kind of identified. We also try to educate about what would be a reasonable training week. What would that look like? Some young skaters are on the ice once a day.

[00:22:19] As some individuals get more competitive, they might be on the ice twice a day, similar to like swimmers, for example. And to have a well-balanced program, we do try to advocate for more off-ice time. So strength and conditioning perhaps twice a week, three times max. We also encourage them to have interests outside of skating. We have one of our senior athletes. He's a fantastic frisbee golf, disc golf player.

[00:22:48] And then we have some other individuals that are very passionate dancers. Even amongst the coaches, we do encourage all of the skaters to pursue those other interests. We also encourage them to look at education because, as we know, sometimes a sport career can be very short. So in terms of the developing athletes, some of them are still in elementary school.

[00:23:12] Sometimes coaches will reach out to me if they're having a young skater perhaps not recovering properly. Sometimes we will do a special appointment to problem solve with the athlete, the parent, and maybe look at kind of the bigger picture. Are they getting enough sleep? Are they going through the growth spurt? Are they perhaps not prepared for the demands of that sport?

[00:23:38] We can communicate back to the coach and perhaps focus on what the training is looking like. And perhaps saying, no, maybe this skater isn't ready for a double jump at this point. But we're going to work towards it. They really appreciate us providing that feedback. We want the kids to have experiences aside from skating. Most of our kids are still in school.

[00:24:01] A lot of kids are pursuing college programs, stage up programs in Quebec, university programs. With the high performance team, there certainly is an openness and support for education, including things like with concussion, not only return to sport, but the return to learn aspects as well. So important, Agnes. We started our conversation with the idea of skate for life.

[00:24:31] I feel like you've given so much to sport physio over your working life as a sports physio. And I want to say thank you. And I know there are so many people internationally who have benefited from your mentorship, your wisdom. So I'm going to extend that idea of skate for life to sport for life to say thank you, Agnes Mikowski, for joining us on JOSPT Insights to share that wisdom and to share with us your passion and the expertise you bring to skate Canada every day.

[00:25:00] Thank you so much. And again, I'm also very grateful for the community in Canada and internationally as well. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights on Apple Podcasts, Spotify, TuneIn, Stitcher, Google or your favourite podcast app.

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