Every Art Requires (and Should Consider) the Whole Person: The Developing Role of Physiotherapy in Supporting the Whole Person

In our previous blog we explore the importance of autonomy supportive behaviours in the physical development of youth athletes. We proposed that the S&C coach should be encouraged to share planning and programme rationale and use language that internalises physical capabilities and enhances internal motivation. In this blog we continue to explore the diverse role of sport science practitioners in youth sport by considering the potential of the physiotherapist to recognise and respond to signs and symptoms of relative energy deficient disorder.

The role of the physiotherapists has changed over time to be more focussed on, not just the physiological factors of the human body, but a more holistic looking at the whole person. With this more holistic approach comes a greater emphasis on providing appropriately positioned education and advice. One key area of physiotherapy that is significantly gaining momentum recently is relative energy deficiency syndrome (RED-S). RED-S is particularly important within youth sports due to the fact that optimum bone density is laid down from around 15-24 years of age and peak bone mass is found at 18 in females and 20 in males (Bones.nih.gov, 2020).

The concept of RED-S is that energy input (food) vs. energy output (exercise and basal metabolic rate) is imbalanced and therefore the body does not react well and begins to suffer in a number of ways. RED-S is something that has previously been mainly linked to female athletes in weight dependent sports (light weight rowing, swimming and athletics for example), but more recently there has been a shift in an awareness for all athletes and coaches to be able to recognise and respond with appropriate support.

Some of the key indicators that an athlete is suffering from RED-S are recurrent injury, in particular stress fractures, chronic fatigue, decreased metabolism and menstrual dysfunction. The image below highlights the range of possible indicators.

The biggest hurdle in this battle is reducing the stigma around conversations with youth athletes about diet and health and in females in particular, symptoms such as menstrual dysfunction. A recent conversation with a young female athlete allowed me to understand what her thoughts were on the topic of being asked about these aspects. She, much like many other athletes and coaches, had never heard of the concept of RED-S, or even elements of it. We discussed the best method she felt of displaying this information in a non-invasive way and allowing for conversations to be had. It was clear that certain coaches would be ok to talk to and others would be more uncomfortable. She noted that she would trust a physiotherapist to discuss this topic if the opportunity were provided to her. It was also clear that if the topic of RED-S was not pushed upon the athletes (a questionnaire where the results were taken, and then automatic meetings were made if multiple symptoms were ticked for example) then they would not seek help if they were just given other sources of guidance, for example an advice sheet.

This major take-home from this experience was the lack of awareness. It is a well-established fact that awareness is poor of this topic, but how can we feel empowered to approach RED-S and put steps in place to overcome it? Does the conversation start with diet and bone density with regard to exercise and loading bones during these optimal ages? Our role as physiotherapy is ever-changing but having the awareness of topics such as this means we can have another checklist to consider when treating and supporting the development of young athletes. Within our environment we may be the first person to notice that someone has had recurrent injuries or illness, so it is essential our knowledge is sufficient to highlight any symptoms or risks. Having the confidence and knowledge to ask within a physiotherapy appointment about the symptoms stated above should be part of our remit and we must feel empowered and capable to do this. The challenge is ensuring you prioritise this topic when a symptom arises. With limited appointment times and a specific rehab and exercise role, it is easy to push it aside altogether. The long-term effect of ignoring something like this can be significant and impact the rest of these young athletes’ lives.

My top 3 pieces of practical advice would be:
1- It is our remit and we need the confidence to ask the questions.
2- Brush up on your knowledge of the symptoms of RED-S and have a plan of what to do when faced with someone who is displaying them.
3- Use your knowledge to educate those around you; coaches, athletes, teachers, parents and so on. The more people that know about it the better and one of those people will be approachable for that pupil to talk to, so make sure we are all equipped.

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