First Do No Harm: Iatrogenics in Coaching and Practice

Iatrogenics is a term most commonly used in medicine. As attested by the Hippocratic oath (and the premise ‘First Do No Harm’), the medical profession is familiar with the concept that an intervention may pose potential risks and unforeseen consequences. In contrast, the idea that we may either not be helping or through our involvement inadvertently making the athlete worse off does not necessarily occur to coaches and practitioners. In this post we explore how iatrogenics applies in the context of coaching and practice, and make the case for considering potential risks as well as benefits before we intervene.

IATROGENICS DEFINED…

@@Practice two things in your dealings with disease: either help or do not harm the patient@@
— Hippocratic corpus, “Of the Epidemics”

The central theme of iatrogenics is that when we intervene there is the potential that we could cause harm. In the realm of medicine it is easy to see how invasive surgical procedures or prescribing medication involves some level of risk of an adverse outcome. It is clear how there might be the potential for ‘complications’ or ‘side effects’ caused by the intervention itself, and unrelated to the condition it originally sought to treat. There can also be unanticipated consequences of intervention, or knock on effects. This might include disruption to natural processes and normal function, or secondary conditions elicited by the intervention.

Beyond medicine, @@it is important to recognise that essentially any intervention involving humans carries some potential for unforeseen consequences@@. The consequences might include direct negative impact akin to the complications or side effects in the medical example, or secondary issues due to our intervention. Ultimately, there is a possibility that we may cause unintended harm as a direct or indirect result of our intervention.

The concept of iatrogenics has important implications for our practice, and what deliberations we engage in when deciding on a course of action. The most important corollary of the concept of iatrogenics is that we need to consider this potential for unforeseen risks and unintended consequences before we proceed with any intervention.

IMPLICATIONS FOR COACHING AND PRACTICE…

Once again I would contend that as coaches and practitioners we do not routinely consider the scope for iatrogenic risks or adverse outcomes in relation to our input and intervention with the humans we work with. More often we simply proceed without hesitation, and without giving any real thought to the consequences, or weighing the potential risks versus probable benefits.

Perhaps more worrying is that @@we often do not consider iatrogenics as a explanation when the outcome is not what was intended@@. We have a tendency to look elsewhere for the reasons why the athlete’s performance or condition either failed to improve or became worse following our intervention.

IATROGENICS IN SPORT…

In general iatrogenics is discussed in relation to medicine, and we are referring to harmful effects on health (i.e. morbidity and mortality). In the realm of sport, the application of iatrogenics goes beyond the conventional and relatively narrow medical definition. When discussing iatrogenics in relation to our work with athletes we should consider not just physical health (for instance injury status), but also performance. Furthermore, it merits considering these aspects from both mental and physical perspectives.

An illustrative example of iatrogenics in sport is the well-publicised case of a biochemist who held the role of sport scientist with one of the premier Australian football league (Aussie rules) teams. As sport scientist he administered a supplement program to the players containing prohibited substances, and led to the 38 players who consented to receiving the supplements via injections, intravenous fluids, and in tablet form being sanctioned for anti-doping rule violations. Thirty-four players from the squad were subsequently banned from playing for two years. The sport scientist in question was given a lifetime ban. The club and coaching staff were also sanctioned with fines and bans for failing in their duty of care to the players.

IATROGENICS IN COACHING…

As coaches we often wield a great deal of power over the athletes we are responsible for. In team sports, the powers of the coach might include selecting which athletes get to compete, and even influencing decisions on who gets a professional contract. At elite levels of sport, our actions impact not only the athlete’s athletic career, but also potentially their livelihood.

Our decisions and actions have consequences for the athletes in our care, and as such there are iatrogenic risks involved. In view of the position of authority and associated level of influence, our conduct also inevitably has some effect on the athletes as individuals and as a group. In part this is mediated through the environment we create both during practice and in competition. Our interactions with others, not least how we engage with each athlete directly, also impacts not only athletes’ performance, but also their general wellbeing. Examples of iatrogenic effects in this context include reports of the major role of coaches’ conduct in relation to negative team dynamics and even athlete burnout.

Beyond the decisions we make, the actions we take, and how we conduct ourselves, there is also the potential for the instruction and input we provide as coaches to have adverse effects on performance and even health. The technical instruction we provide can conceivably lead to mechanically disadvantageous execution of athletic movements and sport skills, which will clearly not be optimal for performance, and may also predipose the athlete to potential acute injury or overuse injuries over time. A potential iatrogenic ‘coach effect’ that is more insidious concerns the excessive provision of feedback and ‘over-coaching’ with respect to instruction and input, which may ultimately impair performance and the athlete’s ability to execute under competition conditions.

IATROGENIC EFFECTS OF TRAINING ADMINISTERED…

It is easy to conceive how inappropriate provision or excessive exposure to training might have harmful effects on the athlete, rather than preparing them to perform as intended. Over-training or unexplained under-performance syndrome is one such phenomenon, whereby performance and health are adversely affected for an extended period as a result of the training performed by the athlete.

Improperly administered or inappropriate training prescription equally poses iatrogenic risks to the athlete. Injuries sustained as a result of the training provided would clearly fit the definition of iatrogenics. One example I recall from my time in Scotland was a head strength coach’s experimentation with German volume training practices (10 sets of 10 reps), and high repetition olympic lifting for ‘conditioning’, which led to players in the professional rugby union squad to suffer an epidemic of sports hernias. As in many such instances, the practitioner involved received no sanction, despite the harm done to the athletes and the negative consequences for their professional playing careers.

Conversely, with insufficient or ineffectual physical preparation we can also place athletes at risk when they come to compete by failing to adequately prepare them for the expected rigours involved.

IATROGENICS IN ‘LOAD MANAGEMENT’…

Interventions that impose arbitrary limits on athletes’ workloads or artificially restrict the degree the variation in workload within narrow bounds can similarly confer an iatrogenic effect by rendering athletes more susceptible to injury when they perform in competition.

These practices are most widespread in team sports, largely driven by marketing to promote the use of the technology employed to quantify workload, and facile reasoning on the part of authorities in the area. Whilst these practices became hugely popular and prevalent by speaking to the particular bias and desires of different practitioner groups, there has recently been a backlash, as the flaws in the original data presented to justify the approach and the rationale employed have been exposed.

As we have spoken about elsewhere, presuming to know the limits of tolerance for a group of individuals by definition ignores epigenetics and the very nature of the complex adaptive biological systems we are dealing with. Tolerance is not universal between individuals, but varies widely. Tolerance is also not uniform within a given individual but fluctuates according to a host of factors. What we do know is that imposing restrictions on overall load and fluctuations in load is likely to lead to maladaptive outcomes by depriving the system of the stressors and variability it requires to become resilient to these elements.

IATROGENIC RISKS OF RECOVERY MODALITIES…

Another example of routine interventions that seek to counter or attenuate the body’s natural adaptive processes is the use of passive recovery modalities designed to reduce inflammation. Examples of these modalities include cryotherapy and non steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. These modalities have become routinely employed in all sports during competitions and regular training. I was working in professional rugby during the era when ice baths became popularised and quickly adopted for customary use not only after games but also daily training sessions.

As in the previous example of restrictive workload management practices, as empirical study has caught up to these trends, the data have begun to demonstrate a lack of benefit in many instances, and paradoxical negative effects in some cases.

We might argue that if the effect is neutral (i.e. no apparent harm) then we could conceivably continue with these practices. As long as we feel it is worth the time and effort invested, it could be argued that if the athletes concerned believe it helps there might be some benefit due to placebo effects. The use of ice baths and related modalities following matches or competition is such an example where the perceived benefit versus neutral or minimal risk might make it worthwhile.

Conversely, the instances where these interventions have demonstrated harm in terms of adverse effects on function and blunted adaptation to training raise major questions about their routine use during training. Given that our objective is to support the athlete’s preparation and ultimately make them better able to perform, knowingly employing interventions that have the potential to compromise training adaptations and attenuate performance changes over time is clearly not obeying the ‘either help or do not harm’ principle.

ROUTINE USE OF ANALGESICS…

A range of analgesics including paracetamol, aspirin, and the aforementioned NSAIDs such as ibuprofen are routinely administered to athletes during competition particularly.

This routine use of different analgesics is intended to serve a variety of purposes. One is the prophylactic use to guard against inflammation triggered by muscle damage that will likely be sustained when competing. These pharmaceuticals are also used for their proposed ergogenic (performance supporting) effects, on the basis that reducing symptoms of soreness that might occur during the competition might facilitate greater levels of output. Finally, as in the above example, analgesics may be routinely administered following competition with the intention of reducing soreness and inflammation, and thereby accelerating recovery.

As with any medication, there needs to be a clear understanding of side effects and health risks associated with their use, both in the immediate term and over time. The potential for serious health risks should make us very reluctant to adopt these practices, whatever the supposed benefit. Clearly athletes must be informed of all potential risks before they provide their consent, but from a duty of care viewpoint the degree of risk tolerance should also reflect the population we are dealing with. For instance, there is no reasonable case to be made for the use of pharmaceuticals for such purposes with young athletes. Accordingly it is highly concerning that reports from major competitions in sports such as (soccer) football suggest the use of medication at elite youth level is almost as prevalent as reported in senior professional football.

IATROGENICS IN SPORTS INJURY MANAGEMENT…

Whatever treatment is provided following injury can conceivably have a negative, neutral, or positive effect on the healing process and recovery of function that would otherwise occur without outside intervention. In terms of the ultimate outcome, obviously the aim is a positive effect, but we might also tolerate a neutral effect, albeit we would need to consider the financial cost given than many athletes are paying for treatment out of pocket. Clearly we cannot tolerate a negative effect.

Such considerations should prompt questions over the routine application of certain treatments as often occurs presently. An illustrative example that is still being examined in the literature involves the routine use of corticosteroid injections to treat tendinopathy. The available data have led some authors to suggest that any short term benefit in terms of symptoms appears to be transient. Conversely there is some indication that the effects of the treatment may harm the structural integrity of the tissues involved, at least in certain cases. Once again the likely benefit versus potential iatrogenic risk should be taken into account before proceeding, and this should be a judgement on a case by case basis rather than routine use.

Other elements of injury management and rehabilitation concern what therapeutic exercises are prescribed and how they are executed, and how the reintroduction of activity is managed. Once again, each of these aspects can have a negative, neutral, or positive effect on healing, symptoms, and recovery of function. A positive effect means that the exercises have interacted with the body’s natural processes in a positive way, facilitating a more rapid resolution of symptoms, recovery of function, and/or directing healing more optimally.

In this case, a neutral effect means that we have been somewhat ineffectual, given that the athlete would have recovered the same without our intervention, and what we have prescribed has thus served no benefit. Whether we should tolerate this arguably depends on the professional standards of the practitioner. An overall negative effect is ultimately a failure. However, we do need to acknowledge and accept the inherent uncertainty of operating in this realm.

REHABILITATION AND RETURN TO SPORT PRACTICES…

The way the treating practitioner not only manages the athlete’s rehabilitation but also conducts themselves in general can have a major bearing on the outcome, particularly with more significant injuries such as ACL rupture. Recent data point to an apparent ‘practitioner effect’ that helps to determine whether the individual ultimately makes a successful return to sport.

Given the uncertainty, it is somewhat inevitable that there will be errors when we are seeking to push the envelope and accelerate the process in a time-pressured scenario as is commonly the case in elite sport. It is a trial and error process to establish present tolerance, and ongoing trial and error is similarly required to probe the boundaries of what the athlete is able to tolerate over time. Equally, being attentive to symptoms and responsive to adverse reactions is central to successfully navigating this process. It is crucial that we heed the warning when minor set backs occur, so that we mitigate the inherent iatrogenic risk and avoid causing any significant damage or adverse impact on the overall outcome.

Similar pressures can lead to the athlete returning to practices or competition prematurely. We should however take steps to mitigate these risks as far as possible. For instance, reports that a high proportion of athletes have not met minimum standards on return to sport assessment measures are inexcusable. Achieving these standards is certainly far from a guarantee that the athlete will make a successful return; however, failing to achieve minimum standards means we have entirely failed to mitigate known and foreseeable risks.

Conversely, and arguably more commonly, a negative practitioner effect in this context may constitute being too conservative or protective. In this case practitioner intervention can effectively deprive the athlete of the stimulus they require to support and direct healing, sustain a level of conditioning, rebuild capacity, reacquire capability, and recover the confidence to return.

A notable finding in the ACL injury literature is that the recovery of function at three months is indicative of the outcome at two years. Too often the treating practitioner does not allow injured athletes to engage in the necessary remedial work during critical periods in the weeks and months following the injury. As a result of these restrictive practices the athlete becomes entirely de-trained, so that their capacity and tolerance to load is severely impaired. At best this serves to delay their recovery and return, and at worst is can put them in a hole that they never climb out of, so that they fail to return to their previous level or cease participating in the sport entirely.

Returning to practitioner conduct, beyond what treatment is undertaken and what exercise is prescribed, a critical part of managing the rehabilitation and return to sport process is accounting for the athlete’s psychological needs. For instance, we need to recognise the athlete is in a vulnerable place in the early phases of their recovery, and it is easy for them to form an attachment with the treating practitioner during this time. Acknowledging this, part of the duty of care of the practitioner responsible for initial treatment is to reduce this attachment and avoid the iatrogenic risk of fostering dependency, particularly as the athlete progresses in their rehabilitation and starts to look towards returning to performing. A practical solution is to hand over the reins to another practitioner or coach to manage the more advanced rehabilitation and preparations to return to performing. Making a successful return means the athlete becoming autonomous once more; it is imperative that the practitioner’s ongoing involvement does not become a barrier to that.

Finally, how we behave and what we communicate, in terms of both instruction and general tone, are critical factors when dealing with athletes who are returning from injury. We need to appreciate that injured athletes will be prone to getting ‘in their heads’, both in terms of hyper awareness of the injured area during activity and a tendency to try to consciously control athletic and skill movements, which should be relatively automated. Therapists and coaches who work with injured athletes can inadvertently compound these issues with excessive instruction, particularly as movement training becomes more context specific in preparation for their eventual return to the practice environment (i.e. activities on the field or on court, depending on the sport).

Similarly, what is communicated and the general demeanour of the therapist, coach, and indeed any support staff member involved can exacerbate the doubt and anxiety that injured athletes will naturally experience. For instance, ‘kinesiophobia’ (fear or apprehension of movement, due to the possibility of pain or discomfort) is a common issue following serious injury, and with recurrent and chronic overuse injuries. As I have noted before, kinesiophobia is also contagious; too often athletes catch it from their therapy provider, and this represents an iatrogenic effect.

IN SUMMARY…

This may have been a confronting topic for some readers. However, on a fundamental level we must reckon with the fact that we work in service of the athlete, which engenders certain responsibilities. Part of our duty of care is to understand these obligations and the potential consequences when we exercise our prerogative to intervene. This necessarily involves considering the possibility of adverse outcomes or unanticipated knock on effects.

As coaches and practitioners how we conduct ourselves affects others, through the environment we create, and via the direct and indirect effects of our interactions for each of the individuals concerned. The coaching intervention or input we provide similarly has the potential to have a negative effects on the athlete’s performance, both in the short term and over time.

The purpose of introducing the concept of iatrogenics to practice in sport is not to instill anxiety, or to inhibit coaches and practitioners in how they deal with athletes. It is merely important that we engage in some deliberation before we proceed to act, and make the necessary allowances.

By definition in sport the outcome is always uncertain. Successfully operating in sport thus requires that we acknowledge and embrace the uncertainty. We must bear some degree of risk, and we need to give consideration to all sources of risk when deciding how to tackle the problem at hand.

Inevitably we are dealing with incomplete information. Besides this, given the circumstances and the fact we are dealing with humans, not everything is knowable. Given the constraints we are effectively dealing in best guesses. Equally, we do have an obligation to mitigate the risks as far as possible; and @@we should consider our own actions and conduct as part of the iatrogenic risks we are seeking to mitigate@@.

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