The power of collaboration in clinical research
After seeing a prevalence of a certain injury in cricket players, Andrew Nealon decided to embark on a research journey. Here, he talks about his experience and the ups and downs of doing transformative clinical research.
In 2007 I realised my dream: working full time in first class professional cricket, succeeding Patrick Farhart as physiotherapist at Hampshire County Cricket Club in England. Despite 10 years of private practice including six years part time with the New South Wales cricket squad,
I had only once managed a patient with an acute trunk side-strain injury. Soon an epidemic of side strains struck. Why? What had I done wrong? One day, at the Old Trafford dressing room door, I had to answer questions from journalists when a very famous bowler suffered a side strain. People expected me to have the answers, and yet, I didn’t even know the questions we needed to ask.
So began my research journey, one that spanned two countries and 10 years. More than any study I have read, my project was a product of collaboration. Despite its incidence, there are simply not enough injuries of this kind to study in one state, county or country. I sensed an opportunity to embark on a project combining data from both Australia and England. Only within the game of cricket could its two greatest national concurrent adversaries and friends provide all the people to make this happen, with data coming to me from both sides of Ashes battles at the same time. Such is the quandary that this injury provides.
I needed a lot of people to share ideas, data, time and energy; the physiotherapy community can be very powerful when it works together. Dr Alex Kountouris, put me in touch with Professor Jill Cook, who took me on as her PhD student. My confirmation presentation followed Dr Ebonie Rio’s mid-term report and I heard about isometrics for tendon pain for the first time. Ebonie set the bar very high that day and it hit me hard what the standard was for research in our field—it was the big dose of academic reality that I needed. A PhD is not really about being a clinician, but clinicians do ask good research questions. You need to also become a writer, speaker, self-starter, self-finisher, complex thinker, data analyst, computer program wizard, time manager and more. I started out as a battler in many of these fields.
For three years we received data from over 30 team physiotherapists from every Australian state, English county and both of the national teams. This included returning surveys that helped shape the studies, completing injury histories, ensuring their players signed consent forms, taking 1700 range of motion measurements on 238 fast bowlers, providing 80 MRI scans of side-strain injuries to 57 bowlers, and recording pages of standardised clinical assessment data throughout the recoveries of 56 injured bowlers. Two radiologists reported 25 MRI scans each and one radiologist reported 65 scans. We also recruited three radiologists, two of whom reported 25 MRI scans each, and one who reported 65 MRI scans, gratis (there was no funding sought nor offered). It is not surprising that this took a lot of emails, phone calls, coercion, conferences and years of work.
During this time all this work just seemed like what had to be done to get the data we needed. On reflection, it is a message about what can be achieved when good people commit to a common goal, and I thank every one of them. I then felt a deep sense of obligation to turn the data into findings that would help the clinicians that so generously donated their time to create it.
To make consistent and high-quality decisions, one must have consistent and high-quality information. So it was time to crunch the numbers to make sense of it all, and write some papers and a thesis. As a clinician with minimal recollection of undergraduate statistics and no prior research experience, I needed a lot of help. I was very fortunate to have Jill and Dr Sean Docking in my corner; brilliant minds, and even better people.
Meanwhile, I saw my PhD journey as a part-time hobby, something to fit into life alongside my work in four different settings over 10 years, including professional cricket and football clubs and then starting my own practice. More importantly, it had to fit into family life. My thesis went from partly done to completed within six months once my wife and I learned of the impending arrival of our third child—now that’s a real deadline. Being self-employed, I did not take any time out of work to write. The reality is that it was written when the house was asleep every night for many months, and I got much more sleep even after my daughter was born than when finishing my PhD. Watching it upload when submitting just before Christmas 2017 was hugely relieving, but I do admit that I was completely exhausted by then.
In the end our findings are far from perfect. So far we have published three papers, with much more data still to analyse and write in scarce spare time. Infinitely greater quantities of research have been conducted into other sports injuries of far greater incidence without even coming close to satisfactory conclusions. We are realistic that we are making a small contribution to the literature; however, given the highly specific nature of our subject injury, I am confident that our findings will be of great clinical value and use to the group of people who need them. And that is the real personal reward for my work: the knowledge that the people who now see this injury in practice have somewhere to find a few answers to a few of the questions that I was asking 10 years ago.
Our profession is blessed to have people like Jill and Sean in our field, as mentors, leaders, supervisors, as clinicians driving the research that shapes the clinical practice that secures our future as the most evidence-guided allied health practitioners in our crowded marketplace.
Those of us that have graduated with a PhD share a bond of understanding and respect for the necessary and gruelling process that research involves. We also share the incredibly special feeling of accomplishment that only those that have lived this truly know. For me, it opened doors to the minds of very generous and clever people who influence my clinical practice, and hopefully yours, every day. It opened my mind to just how much we really don’t know, to hundreds of research papers on my computer that taught me so much about all sorts of injuries completely unrelated to my specific thesis subject but make me a much better and more humble practitioner. It built friendships that will stand the test of time and it gives me the feeling that I have made a little bit of a contribution to the evolution of knowledge available to our profession to provide better help to our patients.
I am not advocating for anyone to embark on this process unless your eyes are honestly open to the work involved. But if you are so inclined, if you have a burning clinical interest that you wish to deeply explore (and definitely don’t do it if you don’t), if you really want to challenge yourself and find out what you can do, if you are stubborn enough to ensure that the process won’t beat you, then I encourage you to ask the questions to which you want answers, enlist great quality support, forge your own path and go on your own journey
Dr Andrew Nealon, APAM graduated from University of Sydney in 1997 and his work with professional athletes spanned 19 years, with the New South Wales Cricket Team, Hampshire County Cricket Club, Liverpool Football Club and Central Coast Mariners Football Club. Andrew founded Aspire Physiotherapy Centre on the New South Wales Central Coast in 2013.
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