Stop Crying Your Heart Out…

“One trip or fall, one heavy blow to the head and it could leave you in a chair, or even worse, not with us anymore”. Those words will stay with me forever.

Booking in for surgery the clerk turned to me and said “You are too young for this”. I didn’t have time to take that in, but it was profound.

The 19th February 2021 is a day I wont forget. 6am, 6,000 miles from home and ready for emergency surgery. That’s when things hit me. Into a surgical gown, stripped of all my possessions and surrounded by medical staff. “Let us check your mouth, you will have a breathing tube…. let me just mark the spot for the incision”.

Let’s rewind a month earlier. Waking up with a pain along my left arm, that I can only describe as an intense burning. Throwing ice onto my arm to relive the heat, the pain. No feeling in my left hand. I knew something was up, this pain can’t be possible. Is it a trapped nerve? Yeah, probably. It will pass.

I saw the doctor as soon as I could and he gave me some strong prescription painkillers. Everything will be fine in a few hours I thought. Those hours turned into a day or two, then a week. Still the excruciating pain. Icing my arm every morning, mid-winter and joking I could heat a small city. The thing was, and little did I know, this was no laughing matter.

At the beginning of February I visited the doctor again still in extreme pain and discomfort. Aside from changing my medication, he ordered an X-ray. I had my blood pressure taken, which was 150/100. I knew this was concerning. The X-ray results were back quickly and were showing some damage to my cervical spine, degenerative disc disease. “Ok, so a slipped disc” I thought.

I went to see the doctor to discuss the results, my blood pressure was still significantly high. The doctor said he would order an MRI immediately. Two days later I was in the tunnel having my scan.

The results came around quickly and I had access to them. “Severe spinal canal stenosis with subtle abnormal cord signal in keeping with focal myelomalacia”.

Ok. What’s this then? Myelomalacia? That’s new to me. So I did the worst thing – and googled it…

Myelomalacia is a pathological term referring to the softening of the spinal cord…There is no known treatment to reverse nerve damage due to myelomalacia. In some cases, surgery to allieviate the injury to the area may slow or stop further damage. As motor function degenerates, muscle spasticity and atrophy may occur”

Wow. I don’t trust googling medical conditions, but this hit me hard. So I called the doctor. “Come in Wednesday and we will take a look”.

I went in to see the doctor again and my blood pressure was highly elevated, 159/109. Immediately I was prescribed some blood pressure drugs. It was concerning both myself and the doctor, I’m 44 years old, I don’t carry much weight and exercise regularly (aside of my working practice!). How can this be?

A few days later the pain had become worse and worse. What was more evident though was my forgetfulness, clumsiness and dropping everything I tried to pick up. I remember trying to put the keys in my apartment door and dropping them on the floor. I couldn’t even feel them to pick them up. Opening the door and stumbling into my apartment. Surely this can’t be right? What is happening to me? I’ve just turned 44 years old, surely this can’t be happening. But it was, at an alarming rate and deteriorating rapidly.

A day or so later the doctor called me to tell me I needed to see a consultant neurosurgeon in Seattle immediately. On Wednesday 17th February I visited the consultant. At first I saw a nurse who took my vitals. My blood pressure was still high, very high indeed. The nurse did a few manual muscle tests and then opened my MRI. “Oh God” where her words. I won’t forget that. Ever.

“Let me get the Dr.” she said. Within a few minutes the consultant came in and started some testing. “Stand over there and close your eyes” he said “now walk towards me”.

Then he sat me down. “We have to operate immediately, as a matter of emergency” he said. “Why? What’s up?” I said. Then there was a silence that seemed and eternity, but was probably a matter of seconds.

“This is an emergency procedure for a cervical myelopathy. The rate you are declining is of huge concern. We need to operate to take the pressure off your spinal cord”. Right there in that moment, I had no idea what to think. I asked when they needed to operate. “Friday morning, 6am”. Wow. “What next?” I asked tentatively. “Tomorrow you will need to come back here, we will do some tests and talk you through the procedure”.

Myelopathy describes any neurologic symptoms related to the spinal cord and is a serious condition. It occurs from spinal stenosis that causes pressure on the spinal cord. If untreated, this can lead to significant and permanent nerve damage including paralysis and death.

I left the hospital in some form of shock, but didn’t really feel any emotion. The first thing I did was call my parents back in the UK. Both of them were silent when I explained I needed an operation in less than 48 hours. I then called my club to let them know what was happening. They were just as shocked as my parents.

The next day I went back to the hospital in Seattle. It still hadn’t sunk in what was happening. The nurses took my blood pressure, which was still high, and then did some COVID testing. Pretty standard in 2021. Then the nurse who had been with the Dr. the day before came in. I don’t really remember too much of the conversation, as she outlined the potential risks of the surgery. “Spinal cord fluid leak, paralysis and unfortunately, death”. Wow. I though the operations was going to help was my thoughts.

I left the hospital and went to see the team in a friendly match. I started to hit me what was going to happen the next morning. The staff and players wished me luck. And that was it, I didn’t know when I would see them again.

That night I hardly slept. Every thought in the world went through my mind. ‘who’s going to let my parents know?’, “will everything be ok at work?’, ‘what about the players and staff?’. I would be lucky if I slept at all that night.

5am the next morning I was collected by our Director of Rehab, Nicole. I probably spoke absolute rubbish the whole way, but the nerves were pretty evident. Nicole dropped me outside and that was it. I walked into the hospital entrance, past a man and a metal detector and walked towards the lift.

I arrived at the admissions desk, which somehow felt like a basement. There were probably 20 other patients next too me. At that point I decided to reveal on my social media that I was having emergency surgery. My phone was red hot, so many lovely messages, but not much time to reply.

A nurse appeared and called out my name. I remember walking along a corridor and into a cubicle. That was it. Clothes off, gown on, X marks the spot on my throat. I remember a few nurses coming in and a couple of neurosurgeons, they explained the operation. “We are going to remove two cervical discs, add in a cadaver bone graft and then fuse your spine with a plate & screws”. Now it was getting real. There were tubes coming from my arms, both sides. All my clothes and possessions were put in a bag, labelled and taken away. The last thing I remember is being wheeled out the cubicle.

“Andrew, Andrew, can you hear me?”. Who the hell is that was my first thought. “Andrew, it’s the nurse. You are out of surgery now”. The whole operation, from what I know, took a few hours. There were no complications.

I was taken for a scan to check the surgeons work. All I remember was being cold and sleepy. Then I was taken to my ward.

Once I was comfortable on the ward, I managed to FaceTime a few friends and my family. I couldn’t talk much (I actually didn’t know I had a drain tube coming out my throat!). However, I didn’t sleep at all that night. I sat up until 6am, there was no chance of sleeping with the nurses in every hour, and the amount of medication I was on.

The next morning the Neurosurgeon visited me. “The operation was very successful”. I was relieved and grateful. The pain had gone, but I still couldn’t feel my hands. He had already told me there was no guarantee this will ever return. 6 weeks later and I still don’t have that feeling back.

The medical staff informed me that would keep me in for another night. If I was well enough, I could go home after two days in hospital. I live on my own which concerned them, but one of my colleagues was coming to check on me daily to change my dressing and observe. This was pleasing enough for the hospital staff and I was discharged the next day.

For the next week or so I was so heavily medicated that I really had no idea what day it was. I just wanted to sleep and recover. Even six weeks on, there is still some fatigue (afternoons seem worse) and my sleep was literally ruined for four weeks or so.

A couple of weeks ago, and after my first check up, I began my rehab programme. Slow and steady is the key. Gradually build myself back up. I lost 2kgs, mainly of muscle mass, during my time in pain. I can’t lift, and my left scapula is severely winged due to the lack of innervation on that side. I have to be very careful with sharp, sudden movements to my head.

I managed to get back to my job eventually, although for such a physically demanding job, I’m very much restricted (making it difficult to demo anything at all!). I’m lucky to have such great colleagues and players at my club. Everyone has been so supportive & willing to help out, both personally and professionally.

Despite being six weeks post surgery I’m still not out the woods. The doctors warned that while they have alleviated the immediate (and pain causing) issue, there is a chance that the bone fusion won’t occur. There is also the prospect of further surgery if things don’t hold up in there.

The doctors told me I am reasonably lucky that we managed to spot the condition early. The majority of patients they see are so far gone their loss of motor control means they cannot control their bladder and bowels. The doctor was complimentary that I recognised something was wrong. It wasn’t just me though, my colleagues had realised something wasn’t right, the clumsiness, the forgetfulness, the blood pressure – things didn’t add up, and they were onto it immediately. Trying to demonstrate a skipping motion during a warm up I fell to the floor. This was before the condition was diagnosed, but made sense. I couldn’t control a simple movement like that.

Of course, everything has come at a cost. The appointments and surgery has left me with a six figure medical bill. Even with insurance (thankfully!), I still need to find a five figure sum to pay the bills. Insurance covered the majority, but I am still liable for some of the costs, and thats after the excess had been paid. Somehow, I’ll figure a way to settle the medical bill. My collector’s item Jordan 4s and some of my signed shirts may need to be traded, but they are material things, I cant trade my health.

Throughout this experience though I have learn’t many lessons. Life is so precious. There are people in far worse positions in this world than me. Some have poor health and no roof over their heads. The pandemic has cost people their livelihoods, while I am blessed to work with incredible staff and players and continued to work throughout the pandemic.

I guess as they say, what doesn’t kill you makes you stronger. However, the last few months have taught me so much. I haven’t seen my family since Dec 2019, but I have good people around who have gone above and beyond to help and comfort me.

I am still human though. There are good days and bad days, I can’t deny that. Some days are comfortable, some are uncomfortable. It can be a easy to ignore these feelings and emotions, its all part of a process. The body is still healing, the mind is trying to make sense of it all. I try not to get overwhelmed or frustrated. I’ve always been a hands on person. Some might think I’m just a data guy, and thats an easy assumption, but I love problem-solving, finding solutions, getting creative with drill design and getting the best out of players physically whilst having fun ( a few players may disagree haha!)

I’m still recovering, although I have spent lots of time being deeply reflective and with introspection. I can’t control a lot of things and it’s pointless trying, but what I can control is how I face the challenges in this moment, and that will inevitably arise. Without challenge there is no progress, in life or sport.

Despite these challenges, I am still here to tell the tale and still doing my best to keep smiling.

99 Healthy is not 100% Injured. There is always something you can do, something you can do to get better, to improve in one area or another. Whether it’s physically, mentally, academically, it may not seem it at the time, but injury provides opportunity.

Nothing lasts forever.

There are still so many people I need to thank from everyone at OL Reign, Statsports, USSF, and all my friends and family back in the UK & Ireland. Your support has been invaluable, I won’t forget it x

A fact about an opinion – is that it’s not a fact.

2020 was one hell of a year. For many it was a very, very difficult year. The beginning of 2021 has already seen political scenes we may never witness again.

Throughout all of this turmoil we have seen mountains, upon mountains, of information. Social media becoming prominent source of information, sometimes good, sometimes not so good (as I write this Twitter has banned a Donald Trump).

From believers, non-believers, pro-vaccine, anti-vaccine, conspiracy theorists etc etc, it can become a minefield for anyone seeking facts. It can be overwhelming and somewhat confusing to separate the facts from the bullsh*t.

The aim of this blog is to explain what the difference in terms and terminology used between opinions, facts, biases.

A fact:

A fact is a truth, or statement of truth, that can be supported or verified by evidence. It is a truth about events that is not someones interpretation or opinion.

An opinion:

A statement is a point of view that is based on beliefs, values, emotions or personal perspective. Of course, everyone has an opinion and are fully entitled to it. However, a person’s opinion can be supported or dismissed when the facts are presented (generally through critical thinking).


Its key to know the difference between fact, opinion and bullsh*t. There is so much of it out there it can be harmful, dangerous and spread very, very quickly. However, bullsh*t is different from a lie, which is just that a lie. As defined by Bergstrom and West (2020).

Bullshit involves language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence.

I’d also highly recommend the authors free course “Calling Bullshit: Data Reasoning in a digital world.

The scientific method and scientific inquiry:

Broadly speaking, scientists will generate a hypothesis based on the relationship between variables. A hypothesis is essentially a proposed explanation of a phenomenon. For example: there may be a relationship (correlation) between X & Y. But does X cause Y? Or why does X cause a change in Y?

Thus, scientists will take an educated guess (research hypothesis) about the relationships of the variables within their research study.

However, a null hypothesis maybe formed and accepted when the research does not accept or refute the research hypothesis.

Types of Bias

A bias, is simply the tendency of a human to have a positive tendency or inclination for something/someone, or perhaps a negative tendency or inclination against something/someone.

The concept of cognitive bias was first introduced by researchers Amos Tversky and Daniel Kahneman in 1972. Cognitive Biases are limitations in objective thinking by seeing things through personal experiences and perceptions.

Below are some examples:

Groupthink bias: the tendency to put value on consensus, thus not thinking independently. A group will favour harmony, cohesiveness and agreement, as opposed to a lack of harmony and/or conflict.

Confirmation bias: The tendency to support new ideas or accept things that are consistent and congruent with their already held thoughts, beliefs, and opinions.

Overconfidence bias: This bias appears when someone is inherently biased towards their own perspectives and opinions. They may hold the belief that they are the only expert that ever exists and everyone else is dumb. A small bit of knowledge can be a very dangerous thing.

Dunning-Kruger Effect: This is when people who believe that they are smarter and more capable than they really are. For example, they are too stupid to realise how stupid they are.

The halo effect: when a the initial perspective of an individual (such as a first impression) tends to cloud the judgement of the individual as a whole. Therefore, it becomes difficult to re-think that perspective of an individual based on new or opposing information.

The horn effect: The opposite of the halo effect. The horn effect is when someone demonstrates a negative attitude or set of behaviours towards another based on their appearance or character.

2020: A time of uncertainty & risk. Time for the team behind the team to step up.

The last few months have seen some challenging circumstances, both in life and sport.

Periods of deep uncertainty that have, at times, shown no promise of an end in sight. Colossal life challenges, comparisons with war time, lockdowns, and not forgetting those who have tragically lost their lives.

Whatever the outcome in the future, the past few months have undoubtedly changed our worlds – forever.

Whether we see it or not, there are many parallels that can be drawn between life and sport. Teamwork, camaraderie, a fast paced and dynamic environment, where thinking fast, and slow, can help determine the outcome we strive for, whatever that may be.

As a performance scientist, the current challenges within the profession are like nothing we’ve ever experienced, and it’s likely we will never see them again. But, it has also been a time of great reflection.

The game of football (soccer) is relatively simple, and adored by billions globally. Two teams attempt to kick a spherical object into a designated area, more times than the other team to win.

Paradoxically though,  performance science is a multitude of complexities that may (or may not!) have a role in increasing the probability of winning.

In his book Behave Robert Sapolsky ,  discusses how when we are faced with multifaceted and complex phenomena such as human behaviour, we use a certain cognitive strategy to break down the individual facets into buckets of explanation. This leads us to categorical thinking. 

For example, let’s take Lionel Messi vs Xavi and their ‘work rate’ as discussed by Fergus Connolly’s in his excellent Game Changer book, and was the feature of Isaiah Cambron’s 2013 article for Barcelona Football Blog.

Whilst comparing distances covered by certain players over a few games, Cambron noted that Messi covered 44,027m in 482 minutes, scored five goals and further contributed with three assists. However Xavi, the midfield genius, contributed with 56,552m in 441 minutes. If using total distance as the only metric, then Messi would be preferred player over Xavi.  Messi appears to have played more minutes, but seemingly less ‘work’.

Dig a little deeper and contextualise these statistics, and a different picture emerges. Divide Messi’s lower distance by the higher number of goals and assists – and he is by far the more effective and efficient player. Furthermore, Messi’s m/min (91.34) was less than that of Fabregas (136.88), Jordi Alba (131.31) and many others. Over the same period of time, the only goalkeeper in the analysis by Cambron, was Celtic’s Fraser Forster who incidentally, covered 32,671m and 50 m/min respectively. Make of that what you want.

This poses a question – if we work in buckets or silos as performance staff – are we missing vital clues within the performance puzzle? Do we end up becoming victims of categorical thinking?

Sapolsky argues that it is no bad thing to put facts into these “demarcated buckets of explanation” as it can indeed help you better remember the facts. However, as he explains, it can also wreak havoc in your thinking about the facts.

As the past few months have progressed working procedures have changed exponentially, we are in the somewhat unknown as to when or how, or even if, respective seasons across the world will restart.

This has led to many challenges. We have seen so much uncertainty in our daily lives, and those of our players, you would think that uncertainty doesn’t exist. But it does. The world is uncertain, sport is uncertain. Science doesn’t give us all the answers, but it does allow us to somewhat reduce uncertainty.

It is human nature to avoid uncertainty in the best way possible, even if this leads to us being wrong. Certainty is a comfortable place to be. We want to be comfortable. We are, after all , simply human.

However, working with athletes in these times, and the potential restart of some leagues has left us with a risk factor too. Just to add to our woes!

But the world is generally full of uncertainties, and it has changed in many ways since the COVID19 outbreak began in late 2019.

When we consider risk, we assume to know all of the facts, the consequences of our actions, or maybe those of others and/or alternative ways of working to minimise risk to our players when bring them back into training/match scenarios. It’s like starting again, with maybe a higher risk because of the lack of training time in the last few months, which brings uncertainty to the table. Who knows?

As practitioners, this world of uncertainty brings a sense of many unknown unknowns. Risk we look to minimize, whatever it may be. Uncertainty, as the last few months has shown, has given us other things to think about. Things have happened unexpectedly, maybe I was naive, but personally I didn’t think it would take this long.

Maybe I have been lucky, here in Utah, and should count my blessings that I haven’t been in London or NY, where lockdown has been the norm for the last 6-8 weeks or so.

During the uncertainty, it has been nigh on impossible to calculate the exact risk to our players. There are now, more than ever, variables/risks that we would have probably never considered 6 months ago. But we still need to make decisions. Based on what we know, and what we don’t know – and that is no mean feat at all.

Screenshot 2020-05-13 at 15.25.59

Whatever uncertainties or risks we face in the coming weeks/months, it us down to us practitioners to continue to provide the our players with the best possible environment to flourish. As difficult as the past few months have been, we must understand the risk or uncertainty that is involved in the coming weeks and months. This will involve many decisions, some that we may never thought of before.

When we know the risks, we can make informed choices based on logical and statistical thinking.   When the risks are unknown, and uncertainty is paramount, then heuristics and intuition may drive the decision process.

However, if the last few months has taught me one thing,  it’s that decisions aren’t really made one or the other, but more likely to be that of both risk and uncertainty.

Thus, working outside of silos, decreasing categorical thinking and coming together to become one team, may just help with the risk and uncertainty that we have been facing, and at present continue to face.

Stay safe people!

Guest Blog from @TheAndySeraphin Four Action Steps for Healthcare Students Wanting to Work in Football

Four Action Steps for Healthcare Students Wanting to Work in Football


Hey everyone! My name is Andy Seraphin, and I am a strength coach and physical therapy student who aspires to work in professional football in the future. Although I am certainly a few years off of achieving my goal, I have put together a few actionable steps that I believe can help students gain valuable experience in sport, while still in school.


  • Get Strength and Conditioning Experience

Every member of a sport performance staff needs a solid understanding of strength and conditioning principles to succeed. There is no better time to learn the basics of strength training than as a healthcare student. I recommend taking as many courses as possible in physiology and sport performance, and earning a personal training or strength coaching certification. Afterwards, reach out to as many strength and conditioning facilities near you to see if there are any employment or internship opportunities. If none come your way, no worries- you can still gain valuable experience by training friends and family for free!

  • Get Experience in Sport Rehabilitation

If you aim to assist in the rehabilitation of athletes as an athletic trainer or physio, you need to get as much exposure to sport rehabilitation as possible. Generally speaking, practicing clinicians are happy to have students shadow or volunteer (especially if they have a strength training background). When it comes to volunteering, I recommend reaching out to facilities that have relationships with professional or youth teams. Be active while shadowing, and ask questions that reflect your current level of knowledge in sport performance. Furthermore, if your academic program has clinical internships, try to have at least one of them be within a sport performance setting.

  • Find a Club to Volunteer For

After getting exposure to both rehabilitation and strength and conditioning, I recommend finding a football club near you where you can volunteer. You can serve as an intern for the rehabilitation, performance, or sport science departments. When finding a football club, you will likely have a few options. You can reach out to your university team, local grassroots youth clubs, youth academies, or professional clubs. Most clubs have the contact info for their athletic trainers, physios, and performance coaches listed on their website. If not, I recommend reaching out to them via Twitter, Instagram, or LinkedIn. Also, try making a map or list of all clubs in your area, and reaching out to every single one of them. If you don’t hear back, don’t get discouraged. You only need one club to say yes for you to get a solid start.

  • Networking, Networking, Networking

Networking is key to advancing in any field, and the sport performance world is no different. Be sure to establish solid relationships with your peers, professors, and any practicing clinicians you encounter along your journey. In today’s age of social media, you can follow and connect with many of our field’s leaders with just a few clicks. Also, try and attend as many conferences as you can involving football and sport performance and network there as well.


That’s all for now! If you have any questions about any of the topics I discussed, feel free to reach out to me via email, Instagram, or twitter. If you’re a student, just know that we’re all in this together, and although our end goal is difficult to achieve, there’s a ton to learn on our journey J


-Andy Seraphin

Twitter: @TheAndySeraphin

Instagram: TheFutbolPhysios

Sleep disturbances and Sports Concussion- time to address the sleeping elephant in the room – Meeta Singh MD

Sleep disturbances and Sports Concussion- time to address the sleeping elephant in the room.

Meeta Singh MD (@athletesleepmd1)

A ‘sports concussion’ is a mild form of traumatic brain injury caused by a blow, a fall, a bump or a shake during play. Because our brains are essentially the consistency of gelatin and float in our skulls, any trauma that makes the brain move back and forth quickly, can lead to damage. The cells can stretch and tear, and this results in the symptoms of concussions. Usually, an athlete recovers from concussion relatively quickly (days to weeks), but some athletes have persistent symptoms that interfere with daily life. For most athletes who suffer a concussion, sleep disturbances are often an issue. In fact, the story of sleep and concussion is closely intertwined, and disturbances of sleep can occur both acutely and chronically after the concussion happens. Additionally, there is new data that shows sleep disturbances may in fact, increase an athlete’s risk of developing concussions. So, this relationship is bidirectional and it’s important for athletes, athletic trainers, coaches, to understand this better as it affects athlete performance and wellbeing.

For starters, the relationship between concussion and sleep is best understood by exploring what parts of the brain are affected by concussion. We know that sleep is produced in areas of the brain that lie deep under the surface and concussions often cause damage to those same areas, so it’s not surprising that disturbed sleep will occur in 30-80 percent of the concussion cases.

Immediately after the concussion, many athletes will complain of excessive sleepiness and will sleep longer.  Research shows that this is a protective mechanism as most of the healing processes in the brain occur during sleep and so concussed athletes require more restorative sleep. Getting proper sleep during the initial recovery stage therefore, is beneficial to the concussed athlete as it restores the electrochemical balance in the brain and decreases the likelihood of the athletes experiencing prolonged symptoms. Thus, allowing athletes to rest and easing the athlete back to their full athletic schedule becomes important. Another complaint the concussed athlete may have acutely after concussion, is of variable sleep, with nights of poor sleep mixed with nights of “catch-up’ good sleep. The problem is that variability in sleep is associated with low mood, pain and feelings of restlessness. These factors interact to reduce the quality of life of a concussed athlete. Therefore, this complaint of variable sleep should serve as a cue to the athletic trainers to refer the athlete to the sports physician for an assessment.

The one important clarification that is needed here is regarding the advice that used to be given out immediately after concussion that seems to contradict the advice of letting concussed athletes rest. The advice was that “if you have a head injury or a sports related concussion, you may be warned to stay awake for several hours or to have someone wake you up every hour’.The reason for this advice was based on the idea that if you are asleep; your family or doctors will miss indications of serious brain damage (like seizures, loss of consciousness, weakness of one side of the body, etc. which can result if there is swelling the brain due to a bleed). This recommendation however is a myth. The new recommendation is that the concussed player should be observed for 3-6 hours and if they show any worsening, they should be sent to the emergency room immediately. If there are no such signs, the player should be allowed to sleep undisturbed.

In addition to acute sleep issues, changes in sleep quality and quantity, as well as new-onset of sleep disorders can also occur chronically (>1 month) after the concussion. As mentioned above, it becomes very important to address these, as the presence of sleep problems prolongs recovery time (3- to 4-fold increase) and negatively impacts quality of life in athletes. These sleep complaints range from players complaining of difficulty falling and staying asleep as well as changes in their sleep/wake pattern. They may be excessively sleepy during the day and complain of snoring or leg kicks at night. These complaints should alert the athletic trainers and coaches to refer these players to team doctors who can address these sleep issues. Additionally, the knowledge that sleep plays a starring role in athletic performance is only growing. We are learning more about its importance for optimal accuracy, speed, muscle growth and restoration, learning, and memory consolidation; so, it’s not surprising that sleep disturbances following concussion contribute to poorer athletic performance. Secondly, athletes with continuing sleep issues after concussion, feel that they have not recovered well, and this perception itself impacts performance. Finally, impaired athletic performance may add to the stress the athlete might feel.  Thus, the bottom line is that sleep disturbances are often seen in athletes after a concussion. These should be identified and addressed as left untreated they tend to prolong the recovery time and affect athletic performance.

Now to come to the newer research findings that show that athletes who have poor and inadequate sleep may be at a higher risk for sports-related concussions. This study done in 190 NCAA Div 1 athletes found that athletes suffering moderate-to-severe insomnia saw concussion risk increased more than three times, and those suffering from excessive daytime sleepiness more than doubled their risk. Given what sleep scientists already know when it comes to the detrimental effects of poor and inadequate sleep on mental fatigue, attentional lapses, visual tracking, and reaction time, it is not surprising that the athlete’s capacity to minimize or avoid injuries is reduced. In addition, poor sleep will increase impulsivity, and risk-taking behaviors, both of which result in poorer in-the-moment decisions and may results in increased injury and concussion risk. Thus, it seems sleep disturbances may play a starring role in concussion causation, in addition to being caused by concussions.

Currently, concussions are a serious concern for athletes and a rising public health problem. For coaches and athletic trainers looking for modifiable factors that might improve athlete health and performance after concussion, identifying and addressing sleep concerns is key.  Placing an emphasis on sleep education may potentially facilitate better sleep habits in athletes. Additionally, its important to be cognizant of the bidirectional relationship of sleep and concussion. Until recently the major risk factor for sustaining a sports concussion was a history of one of more prior concussions. Poor and disturbed sleep may hold the steps to developing the first and subsequent concussion. Assessing and proactively improving sleep issues may thus reduce sports-related concussion risk.



  1. Wickwire EM, Williams SG, Roth T, et al. Sleep, Sleep Disorders, and Mild Traumatic Brain Injury. What We Know and What We Need to Know: Findings from a National Working Group. Neurotherapeutics. 2016;13(2):403–417. doi:10.1007/s13311-016-0429-3
  2. Adam C. Raikes, Sydney Y. Schaefer, Sleep Quantity and Quality during Acute Concussion: A Pilot Study, Sleep, Volume 39, Issue 12, 1 December 2016, Pages 2141–2147,
  3. Michael S. Jaffee, W. Christopher Winter, Christine C. Jones & Geoffrey Ling (2015) Sleep disturbances in athletic concussion, Brain Injury, 29:2, 221-227, DOI:
  4. Raikes, Adam & Athey, Amy & Alfonso-Miller, Pamela & Killgore, William & Grandner, Michael. (2019). Insomnia and daytime sleepiness: risk factors for sports-related concussion. Sleep Medicine. 10.1016/j.sleep.2019.03.008.



FIFA WWC: Why judge a path you haven’t walked on?

On Friday evening, before the Engand vs Argentina game, I saw this BBC interview with Carly Telford. Attending in her 3rd World Cup as part of the England squad, Friday night was her first World Cup start.

However, over the past ten days, I’ve also seen some negativity on women’s football via social media, most of which goes above and beyond acceptable. “It’s not the same game” one avid social media user tweeted me. The use of female commentators (when a male was co-commentating). The mockery of a South Korea player hitting the side netting from a corner. The memes of commentators with irons instead of microphones. Is that the society we actually live in? Or is it the work of a few individuals that would prefer the nonsensical validation achieved through social media likes? A recent twitter post by a rather vocal Dutch coach was crass and uncalled for. I’ve challenged a few of these keyboard warriors, but it seems to me that it falls on deaf ears.

Having worked in Women’s football, and throughly enjoyed every minute of it, I think the Carly Telford speaks volumes about the sacrifices made by the players to get to, and participate in a tournament, that we’ve all dreamed of playing in at some stage. The biggest footballing stage of all – the World Cup.

The majority of teams in the World Cup do not have full time professional players or leagues. With the exception of England (WSL 1), USA (NWSL), Germany and France, the majority of domestic leagues are part time. The huge dedication of the players (and staff in many cases) to commit to play for club and country opened my eyes. Most players have full time jobs, football doesn’t pay their bills. The current prize package for winning the WSL is nothing. Clubs are given money in forms of grants from the FA. However, this is set to change in the 2019/20 season with a new sponsorship deal with Barclays for the WSL, with a prize fund becoming available for distribution across the league.

The women’s game in England has been professionalised over the last couple of years and still has a long, long way to go. Even players classed as full time, may need additional income to live. Furthermore, in 2018, injury pay was reduced for women players in the WSL.

However, attendences in women’s football across Europe have increased, with over 60,000 fans attending a recent Atletico vs Barcelona Women’s game in Madrid. In England, 2.2 million people tuned in to watch the FA Cup Final at Wembley between Manchester City and West Ham – a small increase on the 2018 final between Arsenal and Chelsea. An incredible 6.1 million people viewed the recent England vs Scotland game on June 9th.

Thus the video sums a lot up for me, players who have given up so much to live their dreams. Sacrifices beyond belief. I feel incredibly lucky to have worked (Albeit on a very small scale!) with some of the players at this World Cup, I’ve seen what they have had to do, had to give up, and in some case struggle to represent their country on the biggest stage of all. These players have a desire to be successful, despite many of the challenges, socially and economically, that they may face daily. I’ve seen it first hand. It makes me proud to see these players achieve their dreams.



I’d urge anyone who feels they need to be negative about the women’s World Cup to ask themselves what they would say if their daughter or niece wants to be a professional footballer?

Just stop and think for one second. Would you deny someone the opportunity to achieve their dream through your own bias or lack of regard for women’s football?

I’m pretty sure you wouldn’t.

Player Monitoring & the Four Pillars of Confidence

The idea for this blog came from a presentation at the Kitman Labs Performance Summit in London (March, 2019) by my good friend, Dr. Robin Thorpe. Robin, a sports scientist, is an expert in recovery and regeneration physiology having spent nearly 10 years at Manchester United, before moving to Altis as Director of Performance and Innovation.

As Sport Scientists we collect data, we analyse it and we feedback to coaches. However simple that may seem, it can be easy to fall into the ‘Data Collection for Data’s Sake’ trap. If you don’t know why you are collecting it, then what are you collecting it for? I’m not ashamed to admit that I have previously fallen into that trap (yes, it can be trial and error!). In our support for players and coaches, it is important that the information fed back is accurate. It’s quite easy to make an assumption based on our data collection which may be inaccurate. In turn, this leads to incorrect inferences being made that may effectively reduce the training time and prescription for our players. We should never lose sight that our role should involve the use of scientific principles to improve and enhance our players, and not wrap them in cotton wool. We must look at maximising our players training and playing time. The greater the squad availability, the higher the probability of success (Carling et al., 2015).

In Dr. Thorpe’s presentation he spoke about the ‘Four Pillars of Confidence’ (Reliability, Validity, Sensitivity, Usability) when considering data metrics. A recent study by Starling and Lambert (2018) reported that of the 55 coaches and support staff the interviewed, 96% viewed monitoring of both training load and the training load response as important. However, of the coaches interviewed, it was noted that of the protocols used to monitor players, there was no single protocol that is cost-effective, time-efficient and non-invasive to players. While this may be an issue in some respects, a further issue may appear if the feedback to coaches is inaccurate and incorrect. Thus in the worst case scenario, causing us to lose training time.

In sport science, statistics are probably one of our biggest assets, and one of our most important aspects when making decisions based on data (Buchheit., 2016). However, if our statistical skills are less than proficient, we may end up making decisions that may be incorrect, or send confusing messages to our key stakeholders. This potentially gives practitioner, coach and player little confidence in the data, the data collection process and/or sport science.

Whatever we monitor we must ensure that the tools we use for monitoring are repeatable (Reliability), measure what they are supposed to measure (Validity), sensitive enough to detect meaningful change in the player data (Sensitivity), and subsequently useful (Usability) for the coaches and/or players (depending on who you are feeding back too!)

Therefore, the aim of this blog is to provide an overview of each of the ‘Four Pillars of Confidence’ suggested by Dr. Thorpe, and provide example statistical methods that may allow us to make inferences based on our data to support coaches as opposed to snapshot decisions based on small data.



Reliability may be considered as one of the most important of the Four Pillars as this directly affects the exactitude of our athlete monitoring (Atkinison and Nevill, 1988). For example, if we are to measure daily wellness in our players via a questionnaire, it is important to know what change on the scale would signify a meaningful change (McGuigan, 2017).

Whilst there are various methods to assess reliability, understanding the typical error of measurement; a method that directly measures the error within the test, subsequently allows us to calculate the variation in the monitoring tool. An effective type of typical error of measurement is the coefficient of variation (CV) which is expressed as a percentage. The CV gives us an indication of the spread of our data relative to the mean. Thus, the lower the CV, the lower the random noise, and therefore a higher chance of detecting a real change in the data (Hopkins, 2000). This gives us confidence that any changes in our data are reliable and not down to chance, and we are measuring what we say we are measuring! By calculating the CV, [100 (standard deviation / mean)] we can calculate the reliability of our monitoring tests, and in subsequently have confidence in our reporting of data to coaches and/or players.

This excellent video by Dr. Anthony Turner (Middx Uni) gives an excellent insight into assessing the reliability of your data.


The term ‘validity’ determines if the monitoring tool we use does what it says it does. Does the tool we use assess what we want it to assess? As with reliability there are various forms of validity (construct, ecological, face, content and criterion validity).

However, the types of validity of greatest importance to athlete monitoring, and for the purpose of this article, are construct and ecological (McGuigan., 2017). As a brief overview, construct validity refers to the extent of which a test measures what it was designed to measure (Baumgartner, 2007).

Ecological validity describes how the monitoring tool we select relates to the player’s performance and how well we can apply them in a real world scenario (McGuigan., 2017). However, it is possible to have a tool which has high reliability but little to no validity. Thus, when selecting our monitoring tools it is important that we have both high reliability and high validity. It is important that as practitioners we reduce the ‘noise’ in a test, and keep conditions as consistent as possible when administering any test or monitoring protocol.

Examples of test conditions that may affect the validity of our monitoring may be as simple as the number of observers, music, the preceding instructions on how to perform the test and the volume / frequency of verbal encouragement from testers / peers (Halperin et al., 2015). Thus, to quantify the validity of a test, your measurement (practical) values should be as close as possible to true values otherwise known as the “gold standard”. This is otherwise known as ‘criterion validity’. However, there are two parts to criterion validity: concurrent and predictive. (McGuigan., 2017).

For example, if we used a correlation between a performance test and a criterion measure, we could investigate the relationship between a laboratory based cycling time trial with a cycling competition time trial (Currell and Jeukendrup., 2008).  However, this while this may seem logical, it is far more difficult to replicate the complex demands of a sport such as football, in a performance test. Thus, an example of concurrent validity is high correlation between the Yo-Yo Intermittent Test with high-intensity running in football (Krustrup et al., 2003).

Therfore, Predictive validity is the ability of a performance protocol to predict performance. For example, Hawley and Noakes (1992) used a test of maximal oxygen uptake (V̇O2max) and peak power output (Wmax). The authors subsequently demonstrated that Wmax explained 94% of the variance in 20-km time-trial performance,  whilst VO2max described 82% of the variance.

Therefore, the nature of predictive validity, and its ability to deal with future performance, would have good application in areas such as fatigue monitoring (McGuigan., 2017).

Thus, in the context of our wellness data for this article, it was suggested by Thorpe et al., (2016) that the validity of the potential markers of fatigue (from our wellness data) can be assessed by examining their sensitivity to changes in prescribed training load over periods of time.

unnamedThorpe et al., (2016)


When describing the sensitivity of a monitoring tool, we are referring to its ability to detect the small, but meaningful, changes in performance and/or in another aspect such as fatigue. Thus, sensitivity is related to both the reliability and validity of our monitoring protocol (McGuigan., 2017). For the applied practitioner, any valid marker of fatigue needs to be sensitive to fluctuations in training load (Meeusen et al., 2013). Consequently, and for the purpose of this part of the article, the focus will be on subjective well-being measures.

Recent literature by Thorpe et al., (2015, 2017) demonstrated that self-report measures, and in particular self-perceived measures of fatigue, were sensitive to daily and short-term training  load accumulation. Furthermore, a systematic review by Saw et al., (2016) suggested that subjective measures reflected changes in athlete wellbeing, thus appearing to be sensitive to changes in training load, both acute and chronic. However, there may be challenges in collecting data, and detecting change when using self reported subjective questionnaires (compliance, familiarity etc). Thus, simply taking a mean average of the team’s reported scores may not detect any meaningful change.

The mean is a measure of ‘central tendency’. If you are given a data and calculate the mean it will represent the centre or middle of that data set. The challenge with our monitoring, is that the mean value is influenced by outliers. The larger the outlier in the data, the bigger the change or pull on the data mean. However, using the mean is descriptive, and doesn’t really allow us to make inferences about our data.

In summary, if the total sum is what you are looking for then rather than the typical value, use the mean. For example, if you want to know who those with the highest total distance are, then calculating the mean would be a good idea. Remember, in this example you are only interested in those who are the top runners, so therefore those below the mean are somewhat irrelevant in your analysis. Thus, could you be missing vital information by only looking at a mean value?

If we take daily well being data as an example below we can see the mean average of the group along the top of the table:


With each metric taken on a 1-5 scale (a total of 20) it appears that the average for each metric is as follows; Soreness 3.6/5, Energy 3.8/5, Stress 3.8/5 and Sleep 3.8/5. The mean average for the group is 14.96/20.  This looks ok, and doesn’t show any abnormalities of causes for concern in our athletes – Or does it? If we look closely, we can see some values (e.g., Player 8 and Player 19) are low. However, these mean average scores tells us there is no cause for concern. Thus, is this a true reflection of our data/athletes?

However, what we could do, is to express the data in a different way that is sensitive to these changes in the group of athletes wellbeing data. The example below is the same data, with the addition of a ‘z-score’.


In essence, the z- score allows us to determine the number of standard deviations away from mean a data point is, i.e. how usual or unusual a certain data point is. As it is a standardized score, it allows us to make inferences based on our data (ie, positive or negative). Thus, provides more information than just the raw scores (Turner et al., 2015).


We can calculate a simple z-score with the following equation:

Z-score = Players score (in this case total) – the group mean score / the standard deviation of the group.

When the raw data is converted to a z-score, the normal distribution of the scores will have a mean of 0 and standard deviation of 1, however the z-scores will range from +3 to -3. Thus, a z-score will allow the practitioner and coach to see how many standard deviations from the mean, either below (negative) or above (positive), a player’s scores are.

A further advantage of z-scores is that they can be easily charted and presented in graphs. Thus, allowing the practitioner to compare data, and/or modify a session or programme, or both, if necessary (McGuigan., 2017). Whilst practitioners can set their own thresholds to determine what is significant, it has been suggested that a threshold score of > 1.5 standard deviations (in this case, a negative score) may be effective in identifying risk (Coutts and Cormack., 2014).

The table below gives an example of a monitoring system that can implemented at low-cost to the practitioner, using statistical analysis methods that allow us to make inferences on our data (Clubb and McGuigan., 2018).

Screenshot 2019-05-07 at 12.49.49

It is certainly worth noting, that while a z-score has been used for this article, it has been based on one day’s worth of data for demonstration purposes only. Although beyond the scope of his article, for further longitudinal analysis a modified z-score can be calculated from baseline data (e.g, preseason). The calculation is as follows (Clubb and McGuigan, 2018):

Modified z-score = (player score – baseline score) / standard deviation of baseline

Furthermore, this excellent free resource by Adam Sullivan will help you build a rolling 28 day z-score in Excel to create a daily wellness dashboard for your team.


Arguably the most important pillar for the applied practitioner  – how useful is this data for the coaching & playing staff? This goes back to the point at the start of this article – why collect data for data’s sake? What is important information, and what is not? The latter can be a difficult question for the applied practitioner to ask, but it’s vital we ask. Critical to our success as Sport Scientist’s is our ability to feedback to coaches and players, how we communicate our data with clarity and precision may prove challenging, and depend on those you are working with daily.

As we gain confidence in our data, using various statistical tools at our disposal, we must translate this information to inform practice (McCall et al., 2016). However, as sports scientist’s, having any kind of impact on the training programme and/or practice, is often far from easy (Buchheit. M, 2016). Personally, I believe this comes down to the fourth and final pillar – usability.

Currently,  no single marker within the literature allows us to become totally informed on an athletes wellbeing, and subsequently, no single test performed in isolation is capable of giving us the full picture of athlete wellbeing (Starling and Lambert., 2018). Thus, it is imperative that the data we collect is meaningful and usable for coaching staff.

During the fast paced daily environment of elite football, we must filter the data to ensure usability, and translate it for those whom require it most. The key decision makers in the applied environment may have many plates to spin (technical, tactical, business etc) on a daily basis. Thus, more often than not, they are more concerned with simple and concise answers to their questions, e.g. is this player available to train/play? (McCall et al., 2016).

As practitioners, it is our role to simplify the data for our key stakeholders (players, coaches, physios, medical staff). Thus, we must be able to report, with confidence, that the inferences made from our data our Reliable, Valid, Sensitive (to change) and Usable. Therefore, our ability to translate and communicate the data with practical meaning is absolutely paramount (McCall et al., 2016).

Below is a chart I have created when deciding what we should be look for within a monitoring tool to feedback to our key stakeholders.


Adapted from: Starling and Lambert (2018) and Buchheit., M (2016)

Further recommended resources:

For free downloads and creating athlete monitoring tools:

Adam Sullivan


Excel Tricks for Sports




Special thanks for the help,support and guidance during the writing of this article:

Dr. Jamie Pugh, Postdoctoral Researcher, LJMU (


Atkinson, G. and Nevill, A. (1998). Statistical Methods For Assessing Measurement Error (Reliability) in Variables Relevant to Sports Medicine. Sports Medicine, 26(4), pp.217-238.

Baumgartner, T. (2007). Measurement for evaluation in physical education and exercise science. Boston: McGraw-Hill.

Carling, C., Le Gall, F., McCall, A., Nédélec, M. and Dupont, G. (2014). Squad management, injury and match performance in a professional soccer team over a championship-winning season. European Journal of Sport Science, 15(7), pp.573-582.

Clubb, J. and McGuigan, M. (2018). Developing Cost-Effective, Evidence-Based Load Monitoring Systems in Strength and Conditioning Practice. Strength and Conditioning Journal, 40(6), pp.75-81.

Coutts, A. and Cormack, S. (2014). High-Performance Training for Sports. Pp.85-96.

Currell, K. and Jeukendrup, A. (2008). Validity, Reliability and Sensitivity of Measures of Sporting Performance. Sports Medicine, 38(4), pp.297-316.

Halperin, I., Pyne, D. and Martin, D. (2015). Threats to Internal Validity in Exercise Science: A Review of Overlooked Confounding Variables. International Journal of Sports Physiology and Performance, 10(7), pp.823-829.

Hawley, J. and Noakes, T. (1992). Peak power output predicts maximal oxygen uptake and performance time in trained cyclists. European Journal of Applied Physiology and Occupational Physiology, 65(1), pp.79-83.

Krustrup, P., Mohr, M., Amstrup, T., Rysgaard, T., Johanson, J., Steensburg, A., Pedersen, P. and Bangsbo, J. (2003). The Yo-Yo Intermittent Recovery Test: Physiological Response, Reliability, and Validity. Medicine & Science in Sports & Exercise, 35(4), pp.697-705.

Martin Buchheit. (2019). Chasing the 0.2 | Martin Buchheit. [online] Available at: [Accessed 6 May 2019].

McCall, A., Davison, M., Carling, C., Buckthorpe, M., Coutts, A. and Dupont, G. (2016). Can off-field ‘brains’ provide a competitive advantage in professional football?. British Journal of Sports Medicine, 50(12), pp.710-712.

Meeusen, R., Duclos, M., Foster, C., Fry, A., Gleeson, M., Nieman, D., Raglin, J., Rietjens, G., Steinacker, J. and Urhausen, A. (2013). Prevention, diagnosis and treatment of the overtraining syndrome: Joint consensus statement of the European College of Sport Science (ECSS) and the American College of Sports Medicine (ACSM). European Journal of Sport Science, 13(1), pp.1-24.

McGuigan, M. (2017). Monitoring training and performance in athletes.

Starling, L. and Lambert, M. (2018). Monitoring Rugby Players for Fitness and Fatigue: What Do Coaches Want?. International Journal of Sports Physiology and Performance, 13(6), pp.777-782.

Turner, A., Brazier, J., Bishop, C., Chavda, S., Cree, J. and Read, P. (2015). Data Analysis for Strength and Conditioning Coaches. Strength and Conditioning Journal, 37(1), pp.76-83.

Wallace, L., Slattery, K., Impellizzeri, F. and Coutts, A. (2014). Establishing the Criterion Validity and Reliability of Common Methods for Quantifying Training Load. Journal of Strength and Conditioning Research, 28(8), pp.2330-2337.


Blog at

Up ↑