Let me introduce you to Vilfredo Pareto (pictured left), some of you may have heard of this man previously, however I am sure that many of you have not. Mr Pareto was an Italian engineer, sociologist, economist, political scientist and philosopher (sounds like an over-achiever to me!) who walked the Earth in the early 20th Century.
It has been said that Pareto was observing the peas in his garden, and noticed that 20% of the pea pods contained 80% of the peas. From this simple observation stemmed Pareto’s Law (also known as Pareto Distribution or the 80/20 rule) which states for many events roughly 80% of the effects come from 20% of the causes (Bunkley, 2008).
Indeed Pareto’s Law does seem to apply to many areas of the world, and in some cases the relationship is even more skewed (i.e. 90/10, 95/5, even 99/1):
- The wealthiest 20% of the population own over 80% of all the wealth
- 20% of employees are responsible for 80% of a company’s output
- 20% of customers are responsible for 80% of revenue
Obviously there are no hard and fast rules here, but you can get the picture. When first learning about Pareto and his distribution I could not help but wonder how this applies to the world of sports physiotherapy. Is it in fact true that:
- 20% of athletes suffer 80% of all injuries?
- 20% of clinical presentations account for 80% of my practice?
- 20% of my athletes cause 80% of my headaches?
- 20% of my actions accounts for 80% of athlete/client satisfaction?
- Or even… 20% of my interventions account for 80% of the clinical outcomes achieved?
Let me give you an example from today…
My Experience with Pareto’s Law
Today in the clinic I was treating a patient who had recently undergone a total knee replacement. I was in the fortunate position where I could spend a full hour with this patient and deliver a great treatment. I spent 58 minutes of the treatment undertaking a comprehensive examination and a myriad of interventions: education about the expected clinical pathway, manual treatments, appropriate EPA, exercise prescription and supervsion… really the whole nine yards. I felt as though I was killing it, but I just wasn’t getting the right “vibe” from the patient. I am sure you know what I mean.
The final intervention was to undertake some gait retraining (in the final 2 minutes of the appointment), as the patient displayed the usual post-operative kinematic deviations in gait pattern, including poor knee control and a real lack of flexion during swing. After some stepping practice drills, which the patient performed decently, I attempted to get some functional carry over into their gait. Success! The patient’s gait improved dramatically, with better knee control and better knee flexion from toe-off to swing. Whilst I was certainly happy, the patient was more so, I could tell as their eyes welled up with tears of joy.
Why did I tell this story? Well, I couldn’t help but feel that the vast majority (80% +) of the patient’s satisfaction and maybe even functional improvements in gait where as a result of significantly less than 20% of my time. This Pareto bloke might be on to something. Clearly, I’m not saying your post-op TKR’s don’t need exercises… but it certainly got me thinking.
Why Is Pareto’s Law Relevant To Sports Physiotherapy?
This concept is clearly relevant to the wonderful world of sports physiotherapy. In a practice where you may only have 30 minutes (or less) with an athlete you want to make sure that you are maximising your efficiency; maximal output with minimal (for want of a better word) input. The majority of us do not have the luxury of seeing the athlete on a daily basis.
As an example, in the most recent episode of the podcast Dr Jeff Boyle (who works with the Fremantle Dockers) shares a clinical story about an elite AFL footballer with terrible groin pathology who he treated 3-4 hours a day, 6 days a week, for 18 weeks. Now, if you charge $70 for a 30 minute appointment that means that this player underwent $60,480 worth of physiotherapy treatment! This is more than the annual salary of many physiotherapists, and well out of reach for the normal individual. But of course an elite athlete is worth it!
Thus, it is obvious that most physiotherapists have to be as efficient and effective as possible.
Putting Pareto To Work
It is one thing just to say that 20% of what we do gives us 80% of the results (ignoring the obvious point that we want 100% of the results), but of course we need to know which 20%! So I have included a list of a few things that I try so that I (hopefully) continue to improve in clinical practice and work towards getting the best output out of the input I give to my athletes:
- Meta-cognition: this is just a fancy term for thinking about your own thinking. If you utilise meta-cognition it means you are consciously considering and challenging your own thought processes, clinical reasoning and decisions.
- Ruthless Assessment and Re-assessment: this is just good practice. Assessing and re-assessing outcomes within treatments and between treatments is necessary to identify both effective and ineffective interventions.
- Research: by staying up-to-date with the latest research you will quickly identify what components of your clinical practice are effective and evidence based and what are not.
- Variety: unless you are perfect and know it all, I feel like it is important to vary your treatment techniques, exercise prescription, education techniques etc. Whilst one exercise or dosage may be effective, another may be doubly so. If you repeatedly prescribe the same treatment then you are doomed to fail. Your treatments will not be individualised and furthermore you will not improve as a therapist.
- Put it all together: think about your thinking, change it up, make sure it is evidence backed (in one way or another) and ruthlessly re-assess to ensure improvements. Then… rinse and repeat.
What Are Your Thoughts?
Photo Credit: EmerandSam, WikiCommons
Bunkley, Nick (March 3, 2008), “Joseph Juran, 103, Pioneer in Quality Control, Dies”, New York Times