Tensions and (dis)tensions in the process of physical recovery of professional football players in Rio de Janeiro: a physical therapist’s vision Las tensiones y (dis)tensiones en el proceso de recuperación física de jugadores de fútbol profesional de Rio de Janeiro: desde la mirada del fisioterap

| The purpose of this study is to analyze the role of physical therapists, identifying possible ethical or social problems occurred during their work at football clubs, such as pressures suffered and moments of tension experienced by these professionals. This research is qualitative in nature with a semi-structured interview being the instrument used to collect data. Reports provided by eight physical therapists from professional football clubs in the first division of the state of Rio de Janeiro were recorded. The data were objectively and qualitatively analyzed by means of Content Analysis. Two categories were retrospectively identified with two statements given by the respondents being underlined: the pressures that originate from their own athletes and the pressures that come from the club management. The results showed that these pressures exist and come from all areas; from the clubs in the form of their directors and players and even from their own Sports Medicine department. This process unequivocally results in periods of conflicts and tensions within the working environment, namely: the acceleration of an athlete’s rehabilitation without he/she being able to play. This aspect is earmarked as one of the main aspects of athletes’ health being compromised and of the obstacles in the way of physiotherapy professionals performing more competent work.

Se grabaron ocho relatos de fisioterapeutas de clubes de fútbol profesional de primera división del Estado de Rio de Janeiro.Se analizaron los datos cualitativamente mediante el análisis del contenido, y objetivamente se identificaron dos categorías a posteriori, y se puso de relieve de los relatos de los entrevistados: las presiones de los propios atletas y las presiones de los clubes, mediante sus dirigentes.Los resultados señalaron que hay presiones de todas partes, de los dirigentes de los clubes, de los jugadores incluso del propio departamento de Medicina Deportiva.Este proceso inequívocamente resulta en periodos de conflicto y tensiones dentro del ambiente laboral, tales como la aceleración de la rehabilitación del atleta sin que esté listo para volver a jugar.A ello se señala como uno de los principales aspectos en el comprometimiento de la salud de los atletas y en la imposibilidad de los profesionales de fisioterapia en realizar un trabajo con una mejor calidad.

INTRODUCTION
Despite football being celebrated as one of the most popular sports on the planet due to its aesthetic attraction and excitement, for the professional players involved, this sport represents a problematic dimension for performing their professions.This dimension is related to the large number of players that suffer injuries during its practice.In this sense, some research have demonstrated that these injuries are responsible for 50 to 60% of sporting injuries in Europe and that 3.5 to 10% of physical traumas treated in European hospitals are caused by football 1 .
As a result of this, Waddington 2 investigated the ethical factors related to the work of professionals from English football's Sports Medicine & Sports Science Department.Physical therapists, physicians and physical trainers were included in this analysis with the author concluding that there is an urgent need for ethical reform in care for athletes, since the author diagnosed a series of problems that directly influence the conduct of professionals from this department, in particular that of physical therapists and the difficulties that arise in the physical recovery of these athletes.Based on the testimonies of the physical therapists involved in the research, the author's conclusion that being a physical therapist in a football club is apparently totally different from being a physical therapist in a private institution, or even in the public health system, is substantiated.This difference resulted in a better quality care in private institutions because the experiences of tension or distress that are commonplace in a football environment are never the same in a private care environment.In a football environment there is pressure for a player to recover immediately, while in a private environment the injured person is cared for with the objective of their never needing to return again -to be fully recovered.In other words, there would be a functional (negative) view, which harms professional athletes.
This conclusion suggests that the environment involving the physical recovery of professional football players can -due to the many issues that go hand-inhand with this sport -be fraught with a great degree of tensions and conflicts of interest that can even generate hidden forms of violence.This statement is reinforced based on studies that discuss ethical issues of how to deal with the confidence of professional football players 3,4 and even the question of employability and qualifications of physicians and physical therapists at English football clubs, pointing to a controversial, tense environment that is not widely understood 5 .
Based on this context, the objective of this study was to analyze the tensions involved in work of physical therapists in the high-performance football environment in Rio de Janeiro.The aim is to reflect on whether there are ethical issues, in professional practice regarding the recovery process of professional football players, which can manifest themselves in forms of violence against physical therapists.

Sample characterization
This qualitative study analyzed statements of 8 physical therapists working at the Sports Medicine departments at clubs in the top professional football division in Rio de Janeiro.These physical therapists represent 50% of clubs in the first division from Rio de Janeiro.The dynamic for choosing the respondents was intentional and based on the fact that the chosen professionals could portray a world of which the interviewer did not have a great understanding.The professionals who were interviewed had between 8 and 20 years of professional experience, the average experience being 14 years.Due to the fact that the respondents are portraying something that is unknown to most people, only a small number of interviews were performed.The knowledge acquired from these individuals is deep in nature.According to Alves-Mazzotti 6 , most qualitative studies employ an interview style that largely resembles a conversation, so in this study we focused on questions regarding the issue of the recovery process and the possible tensions that are generated.The interview, in addition to being a method that allows a greater flexibility of the issues developed, gives the interviewer freedom to elaborate on other questions according to how the process goes.In terms of reproducibility and reliability, we can affirm that this model is traditional and can be applied in other studies that require listening to a situation of which little is known.Interviews are widely used in qualitative research.

Instrument
The data analysis section of this research sought to prioritize what the interviewees said, or more precisely, the discourse of the respondents.Thus, Content Analysis was used as the analytical/methodological instrument.According to Bardin 7 , this type of instrument is characterized as an empirical technique that makes it possible to analyze the articulation of the discourses.This instrument is an excellent way to understand the phenomena since it is possible to confront the motivations, desires and employment with the conditions of their production, which are of course related to the type of communication to be analyzed and interpreted -which are the interviews in the case here.The categories used by the researchers were created retrospectively based on what was heard and through analyzing the interviews of the respondents [physical therapists].The categories emerged from the respondents' statements, so they are not "creations" designed by the researchers.

DISCUSSION
It is important to note that the discussions are presented based on reports of what the respondents said, with these being related to the theoretical reference that exists regarding the discussed topic.In addition, upon conducting a survey of Brazilian literature on the topic using the Revista de Fisioterapia e Pesquisa [Physiotherapy and Research Journal] from the University of São Paulo, out of a total of 347 abstracts covering 6 years of publications (we did not have access to other issues of the journal), only one article was found that discussed the issue of the ethics for physical therapists.However, this article was not related to the recovery process of professional football players.It is important to highlight that it is not our intention to discuss the types of injuries sustained during football, but rather the specific recovery process of these professionals in a club environment.We also conducted a survey of the Revista Brasileira de Medicina do Esporte [Brazilian Journal of Sports Medicine], including 10 years of publications covering 849 articles -only one article in the theme was found, albeit with little resemblance to our research.In fact, this article was a publication describing the types of injuries sustained by players from one football club in São Paulo, however, it did not analyze the players' recovery processes.When these two surveys from the Brazilian literature are added together, there are 1196 articles that do not discuss the problems addressed in our research.
When analyzing the interviews given by our respondents, two categories stood out in all of them.These two categories were: (a) pressures coming from the professional athletes themselves; and (b) pressures coming from the clubs, namely from the club managers.In other words, we developed the categories based on the source of the tension or violence, following the relationships between the respondents and the players.These two sources of pressure generally occurred to accelerate the recovery of the athletes.
For example, one of the professionals reports that the pressures in football will always exist, which is mainly due to working with high performance athletes who are of great importance to the club, but also give an opinion that this pressure is indirect and is part of the job.These pressures would be generated according to what the professional expects from his/her work, as was reported by the interviewed professionals.
Dealing (with the pressure) is within an expectation you have of your work, so we have to understand this is not the stuff of dreams, thinking that it is all good regardless of the results.(Respondent 1, personal communication).
I have worked in football for a long time and what some identify as pressure I personally understand as something that is a normal part of the working routine in this sport (Respondent 3, personal communication).
Even at the beginning, I looked at how other more experienced professionals behaved, I tried to emulate some professionals, even those from other areas, and it made a very big difference for me, so I was kind of prepared, at least in my attempt to deal with the pressure in a more peaceful way (Respondent 4, personal communication).
Football is a passionate sport that involves a sense of greatness in everything that surrounds it.Whoever works in the live football world is always under pressure, which can come from the players, managers, fans and businessmen, but this all makes for a normal working environment (Respondent 8, personal communication).
According to these professionals, knowing how to handle these situations and being successfully integrated into the interdisciplinary team, in which the responsibilities are divided, is a requirement.Continuing in his line of reasoning, respondent / 01 shows that the football environment involves a great deal of demand, as it mobilizes the passion of millions of fans, plus, of course, the economic interests of the clubs, athletes and others.A star player who is injured is much missed in the team, so there will always be pressure that is considered a normal situation by the professional interviewed, which he reports as being part of the job.During the interview, he cites one example from the 2002 FIFA World Cup, in which there was a lot of pressure to return important players like Rivaldo and Ronaldo to fitness.According to him, there was concern not only that these two players returned, but mostly that they returned well, because simply coming back while not 100% served no purpose.They would have to return well.Based on this point of view, it was the respondent's professional understanding that perhaps football has the highest level of demand of all high performance sports, due to the media and everything that surrounds it and because many jobs revolve around these results, with millions involved; so these aspects certainly lead to a lot of pressure (Respondent 1, personal communication).
The previously mentioned professional spoke about ethical issues.Professional ethics have been widely discussed in all sections of the media, as well as in our study.We are now reaching better understanding regarding this issue in the context of sports physiotherapy, an increasingly expanding area, however this area brings forward several issues that deserve analysis and discussion.The term "ethics" is derived from the Greek ethos (character, a person's way of being).From a philosophical point of view, ethics is a set of moral values and principles that guide human conduct in society, serving to provide balance and good social functioning without allowing anyone to be negatively affected.In a complementary manner, legal expert Silvio de Salvo Venosa 8 argues that ethics is not simply a regulatory tool.According to the theory, ethics is not only responsible for regulating social behavior, but also social and professional habits.There is a professional ethic, so every type of professional requires devices capable of regulating their activities and conduct.
According to Bento 9 : "ethics are again at the center of the concepts and concerns to cancel the excesses and misrepresentations of this discourse (of rights and duties) and to fill the void and laxity that are seen in the observance of values" (p.38).In this sense, the author goes further, because, according to him, when we talk about the ethical question it is impossible not to think about one of the issues of philosophy, in which the main objective is to determine the purpose of human life and to discover the valid ways of achieving this.To paraphrase Sennett 10 , being ethical is one of the major problems for modern man, because, according to this author, doing good work does not always require good character.
Continuing the discussion to study the tensions and distensions that occur in the football environment, one can see that, in some cases, pressure can be generalized.This professional reports that tension is sometimes exacerbated, which is most commonly seen as a result of decisive games, in which, according to him, the pressure for the athlete to recovery is very heavy indeed.This pressure comes from all sides, the player, the sports medicine department, the technical team and even individuals who make up part of the player's home environment.According to the respondents people who are not involved in football cannot imagine how professional the football environment is or the demands that are placed on you, so there is pressure from everywhere, even to get this athlete resume their activities faster (Respondent 2, personal communication).
the players want to play, they do not wish to remain on the sidelines, and whoever pays them wants to see them play, so this is the circle that we go round in, they have to return quickly, we make demands from the people who pay to see him play, I think that this is the reality of the football environment, when there is pressure in this environment (Respondent 5, personal communication).
An athlete who does not play is inevitably a very high cost for the club.In this case, the pressure can be greater, but there are pressures in all sports activities, especially in activities that have major competitions: volleyball, basketball, athletics, swimming; people always ask, "hey, when are you coming back?" (Respondent 6, personal communication).
When the professional is asked if he considers these pressures to be a type of violence against them, the answer is no.Specifically referring to this perspective, respondent 02 stated that "I think that this is inherent in the profession we have chosen" (Respondent 2).In other words, for him all of this is normal, it is part of everyday life, it is his obligation to live according to his choices and he cannot run from such responsibility.Working with well-paid, high-performance, famous athletes requires a lot of responsibility, which therefore increases the level of pressure.The respondent also highlights the importance of pressure, which at times becomes even more useful for the physical therapist, meaning that professional scannot take it easy and that they must always try to do their best to find a solution to the athlete's problem.
The study of violence is both complex and subtle at the same time, which is due to the fact that we are often greatly involved when it occurs that we do not even realize its range.In the field of sports physiotherapy, violence can appear in various forms, which are identified throughout the course of our study.Therefore, it is understood that originative violence is not only restricted to explicit episodes, so the feeling of insecurity that is part of one of the dimensions of violence would be more related to symbolic issues, that is, veiled violence.
The World Health Organization (WHO), in its World Health Report on Violence and Health 11 defines violence as: "[...] the intentional use of physical force or power, threatened or actual, against oneself, another person, group or community that results in or has a high probability to result in injury, death, psychological harm, impaired development or deprivation".
With the objective of finding a better concept for violence, sociologist Mauricio Murad 12 states that the word violence etymologically comes from the Latin word violentia -semantic root vis = forcemeaning oppression, imposing something on another person or other persons through the use of force, whatever its type, substance, form or sense: force through social, economic, legal or political power, physical force, symbolic force or force of any other nature that is intended (p.77).
According to Minayo and Souza 13 , violence should be seen as a multifactorial, multifaceted and controversial factor.Thus, it is vital to understand the different cultures, social classes, maturation and biological and cognitive needs to understand and explain such a diverse phenomenon.At this point, it is possible to refer to Santos 14 , because, in one of his studies, this author created a system of categories to better explain this phenomenon in the context of sport, while giving emphasis to football.
Based on previous discussions, one case that attracted attention regarding the statements made by the respondents was the pressure exerted by an athlete by saying "do not do a good job".In these cases, the athletes do not want to improve and ask the professional to slow down their recovery process, and in some situations they still complain of pain, even after all possible exams and tests have been done, with no injury being detected.These issues gain more significance when the following comments are analyzed: There are athletes and athletes, right?There are those who want to come back immediately, with all the pressure involved, and those who do not, for whom the pace at which things are being sorted is good, and those who do not want to be well, as long as he is in the medical department, he is happy, there is no demand anywhere (Respondent 2, personal communication).

The athlete does not want to be well, we know that he does not have anything wrong with him, we have done all sorts of tests and exams, none of which show any problem at all, but the patient still claims: "I am in pain". And there is currently no device in existence that can measure pain.
There is pressure from the coaching staff, but they come down harder on the athlete than us (Respondent 2, personal communication).
The respondents' arguments could be classified into various types of violence, including the attempt to mislead them.But, they must be analyzed according to the ethical dimension of the professionals from the medical department.The ethical parameters of the various professions involved in the process are presented below in the form of regulations.Ethics is a key dimension regarding the regulation of professions, which is a fact that transcends the issue of data updating: • Code of Medical Ethics: "it is forbidden for the physician to: Art.29 -Perform harmful professional acts upon the patient, which can be characterized as malpractice, recklessness or negligence" 15 .
• Code of Ethics for Physiotherapy Professionals: "Art.11.Physical and occupational therapists protect the client and the institution in which they work against damage resulting from malpractice, negligence or recklessness" 16 .
• Code of medical ethics: "[...] Art. 5 -Physicians should continually improve their knowledge and use the best options from scientific progress for the benefit of the patient.[...] Article 21 -physicians have the right to: [...] -indicate the most appropriate procedures and observed practices to the patients that are known to be accepted while respecting the current legal requirements in force in Brazil.[...] It is forbidden to physicians to : [...] Art.57 -Cease using all available means of diagnosis and treatment in their power for the benefit of the patient" 15 .
• Professional Physiotherapy Code of Ethics: responsibilities: "Art. 5. Physical and occupational therapists update and enhance their technical, scientific and cultural knowledge to the benefit of the client and development of their professions.[...] Art.7 -Physical and occupational therapists have a duty, in their respective areas of expertise: [...] IV -to use all available technical and scientific knowledge to prevent or alleviate the suffering of human beings and prevent their death" 16 .
Based on the above, it seems that the ethical reference bases, for both physicians and physical therapists, prevent them from disregarding a "cure" or obstructing the process of reducing pain or resolving injury.Thus, if any professional were to stray from this behavior, it would be a betrayal of their commitment to the profession.
For one of our respondents, there is more pressure originating from the club or even internally, since the technical staff itself creates such pressure due to aspects it regards as "old-fashioned", which is thanks to the culture that some member professionals from the technical staff carry with them.Contributing to the understanding of the issue, a respondent speaks about a case that he was involved in with a highlevel athlete, who had already been incapacitated for around 70 days, having passed through a care program designed to help him recover.Upon completion of the program, the athlete was asked by the physical therapist to take 20 more days to rest.However, the team had a big match coming up and within only three days this athlete was on the field, disregarding the agreed rest time.During the first few minutes of the match, the player felt the injury again and was substituted.
The pressure was internal, from the entire technical staff, and the athlete had to be left out of the team for more time, which was harmful for the team as well as for the athlete.Given this fact, we can conclude that the pressures to quickly return athletes to the field most often cause harm to the clubs, since the return timelines established by the sports medicine department are generally not respected, whose main objective is to facilitate the complete and effective recovery of the athlete.To end the interview, the respondent drew attention to the need for physical therapists to deepen their knowledge and maintain a professional, correct and exemplary attitude, even when in tense situations.For him, this is the only way physical therapists will be able to reach the desired changes, i.e., in the words of the respondents, physical therapists have a very large weapon, namely the patient, the athlete.Athletes understand that they cannot do without physical therapists, they are aware of this fact, so nowadays it is the athlete who is the greatest asset in football, he has trust in the physical therapist and understands their importance So, if we know how to work well with this athlete, whether in the technical side or in the awareness side, I am sure we greatly speed up this process of searching for conditioning, respect and organization, which is an inevitable thing (Respondent 4, personal communication).
Physiotherapy in football is a new profession, for a long time it was not used, for a long time only massage was used, so I think there is a little prejudice, that old prejudice of physical therapists being something new, then a lot of people do not give physiotherapy the recognition it deserves (Respondent 7, personal communication).
The above reports enable the introduction of the issue of promoting health in the football environment.Working with health promotion is also one of the roles of the sports physical therapist, which justifies the relevance of the theme discussed in our research.Physical therapists are directly linked to the health of football players, since they are responsible for the entire rehabilitation process of existing injuries as well as the prevention process to avoid future injuries.This is also a suitable point to highlight that it was the unanimous opinion of the respondents -all 8 physical therapiststhat health must come first.
There are several health promotion concepts that focus on the health perspective.A number of essential questions emerge from these concepts, such as: what is a healthy individual?What is it to be healthy?Is health simply the absence of disease?According to the World Health Organization 17 , health is a state of complete physical, mental and social well-being, and not merely the absence of disease and infirmity.
One issue that should be considered is in line with thoughts from Bento 18 , for whom health must be understood not only as a biologistic concept, but rather should be seen within a multifactorial process, and also a subjective issue involving an active quality of life, in other words, acting in a way that deals with the demands of life.
For all the dimensions presented here, the football professionals could not artificially speed up or even precipitate the athletes' return to the field, in view of there not being ideal conditions to practice their sporting tasks.One of the only possibilities to understand this aspect is related to the considerations regarding pain in sports.In this sense, pain caused by undertaking sports is a problem that has led to sleepless nights for athletes and coaches these days, with the subject being a matter of study and debate among many scholars such as Roderick 19 , Bale 20 , Sheard 21 , and Spitzer 22 .The Portuguese dictionary Houaiss 23 defines pain as a "sensation of suffering as a result of injury and from non-visible sources of specialized nerve formations".Physical therapists have a fundamental role to play in eradicating pain, as while eliminating an athlete's pain he helps the athlete return to his/her activities, which is a benefit for all who depend on the income of this athlete.
High performance physical training has a very high body burden index, as it seeks to constantly increase income from competitions.This body burden, when applied in an exaggerated and uncontrolled manner, leads to injuries, which then results in a wide variety of different types of pain 24 .However, according to the author, high performance athletes living with pain have become a constant and normal event, leading to some athletes and coaches believing that pain signifies improved performance in many cases.Pain in an athlete is always a sign that something is wrong with the body and should be investigated by the medical staff to prevent more serious injuries.

FINAL CONSIDERATIONS
In light of all the information presented in this research, we can conclude that the pressures put on the sports medicine departments by athletes and their clubs, in particular on physical therapists, to speed up recovery, have been a factor in the reoccurrence of these injuries, since many protocols established by this team tend to be poorly followed or ignored.This process of acceleration has a negative effect on both the club, which expects a financial return from hiring the athlete, and the athlete himself, who needs to play to keep himself relevant in the area, with a view to secure better contracts and improve their standard of living.This is because these recurring injuries may happen with increasing seriousness, resulting in the athlete being out of matches for longer periods of time, and in many cases, may even lead to the end of his/her career.
In the majority of cases, these pressures are not considered to be a type of violence by professionals, since these individuals understand that this whole process is normal within the physiotherapy environment.They are fully aware that the demand for results for anyone working within football are much greater than in other sports, but as all have worked in this area for many years, they already have enough experience to deal with such day-to-day situations as well as with new ones that still might come up.
From the point of view of the theoretical reference used in this study and from a social point of view, considering these professionals are members of our society, it is worrying that these "actors" do not consider the pressure exerted, by whomever, to be violence, because it can be inferred that these individuals are turning something that should not be natural into an acceptable thing.This fact can explain how humans become "accustomed" to suffering, pain and systematic tension, which are contributing factors to the broader concept of stress.It is important to remember that physical therapists are part of a multidisciplinary team and this kind of pressure can be exerted on other team members, thereby contributing to relationships deteriorating in the professional environment.
Upon considering the above statements, and when compared to the theoretical reference discussed in the review of the study, regarding the culture of "playing while injured being football culture" and "playing while injured with informed consent" by Waddington 3 , these claims can be closely matched with the statements made by the professionals interviewed for this study.In other words, there seems to be a trend in the football environment, even in different cultures, for this phenomenon to repeat itself.It is not our wish to generalize here, because the sample is different from the study mentioned above, however, one cannot help but point this trend out, which can even be used to organize future studies.