We're going to talk on a very different topic from everything that everybody's listened to today, so to change your brain cells a little bit. The title of this proposed project is A Longitudinal Study of Youth Sports Participation, and it's a very interdisciplinary approach. It's an evaluation of musculoskeletal injury rates, psychosocial development, and general physical health and development. And this is a proposal for a pilot study. We've been doing development work, which I'm going to take you through, that has been funded to date by the Department of Orthopedics and the School of Public Health. So just to kind of tell people who's involved so far, I'm Julie Agle. I'm an athletic trainer by ultimate background. Rugby is my sport, not lacrosse, and I've been doing clinical research forever. Brad Nelson is the orthopedic surgeon who's been involved with this, and he is our primary contact with the local school district, and I'll go into that a little bit as we go on. And Todd Rockwood is a sociologist who is a methodology specialist with an emphasis on survey design. And so there's a mix of languages in here between their terminology and our terminology, and hopefully we'll get it all cleared up. So this is the broad view of what has already been done by us, and I'm just going to take you through the timeline so you see how we got to where we are today. So all of this work started when I was a member the first time around on the research committee here, and that was before 2016. You can't see very well. And during that time, we created the AOSSM consensus statement on early sports specialization, and early sports specialization was added to the AOSSM research agenda as a key point of interest. And that's really where all of this work began. Kind of put together the people I just identified for you, and we started projects looking at elite athletes, and my theory was that if we could start with people who were already elite and already specialized, we could go back and find out what their multi-sport participation history was and see if it was indeed important to be specialized in a sport from the age of five in order to succeed in various sports. And then we developed an instrument, and BSD is the Bloomington School District, which is a school district in Minnesota that has agreed to partner with us on all of this work. And that development and piloting of this instrument was to take it from the other end with young kids, first grade, third grade, and just sort of see at what point children transition to sports, formal sports, and specialization in sports. So that's sort of the two-end approach, meeting in the middle, I guess. So 2017 comes along, and we got some follow-up data from the surveys that we were doing, and we began looking at the data to evaluate it for data gaps, and this is cross-sectional, what people are doing at that time, and longitudinal, in that people were doing things on a quarterly basis for us. And then we developed or identified really what we call a minimum data set, and I'll talk about that as I go on, but that really became the focus of our interest in our work, is that we felt that there were a lot of variables missing in the literature from what people are doing. There's lots of stuff in the literature now on early sports specialization, but it's still very uniphasic, and we felt that it was much more complex than that. And so, again, with departmental support from orthopedics and public health, we decided to transition from paper and pencil to a Qualtrics survey in the world of methodology. It's called computer-assisted self-interviewing, but basically you just send them a survey and they answer it. And that has been a huge undertaking because the whole concept of sports, that they're playing, the transition over seasons, so they're not playing, but they're not playing because the season is over, or they're hurt, what the injury was, is a phenomenal loop of survey development that I chose not to show everybody today because it would make your head hurt. And then just to continue in this way, there was a summit in Houston two years ago now that was sponsored by OSSM and AMSSM, and the importance of that will be shown in a minute. So we did the first programming of the survey, we thought, and then we conducted an e-panel study, which is basically we purchased, there are people out there who do surveys for money, and so we targeted people who had children of under 16, and we got 977 surveys up front to sort of see how the survey we had developed was working and what kind of information it gave us. And then of that group, 252 did a follow-up survey for us, and the spectrum of data we got from that was enormous, it was a huge spectrum of sports being played. And another important facet of this is we're also tracking children who don't play sports so that we have the full spectrum of activity on how it impacts their development. So we spent last year, when there were no sports going on, looking at that data, working on the data set again. We did have two abstracts on this topic accepted to the ILC meeting in Monaco, but they were not presented. They are due to be presented over Thanksgiving this year, theoretically. And so far we've been working on preparing the manuscripts, the elite athlete study manuscript with the minimum data set necessary is done. We're still analyzing data that we've collected on the other things, and what we hope to do from here is to design a full-scale general population study using, and this is methodology terminology, but probabilistic sampling. And we haven't quite decided how we will achieve our sample this time around, whether it's through direct contact through the school system or through broad mailing. And the CAP is the shorter version of our title, which is the Children's Activity Project. And the goal would be to start the project, if we are fortunate enough to get funding, we would start with the start of this school year here in September. So this is one of the things that we've come up with, and this will sort of explain our minimum data set. And we think that we've been oversimplifying the analyses to date, and so this is looking at, we've created a simulated data set based on some real data that we collected. This is 1,200 people, but just remember it's simulated data, so there's no conclusion to be drawn that you can take forward. But it looks at years of participation of athletes, which is a proxy for exposure. It also looks at the age of the athletes, because you can specialize in a sport for 10 years. But it makes a difference if you started that specialization when you were five, or if you started that specialization when you were 15. And so the differences in the bars here are going from left to right. Free play is the terminology we've chosen to accept for going out in the playground and playing unstructured play. And then there's competitive participation, so you're playing a sport competitively. You may still be playing other sports, though. Then there's specialized play, so now you are deeming yourself specialized in that. You are spending a portion of your time playing just this sport. And then there's elite-level play. And so this is giving you just a sense of the complexity of the differences and ways of looking at things, and we are working towards combining years of participation, exposure, with the age of the athlete. And this is applicable across sports, so we are not limiting ourselves to any one sport. We think that we will get very different profiles from each sport. So for instance, gymnastics, people believe you have to start early. So age may be less of a contraindication to specialization in gymnastics, whereas in rugby, you don't need to play full-contact rugby at the age of six to develop your flexibility, because no rugby player has any flexibility. So anyway, this has sort of been our unique way of looking at this so far. And we had some sample data, Joe Hannafin, who I don't think is in here, gave us some Olympic development rower access, and those athletes reported not specializing until roughly 18. It's a much older population than others that we have looked at. They believed that specialization had a high impact on achieving their elite-level success. On a scale of 0 to 10, they voted for 8. We also looked at a group of Major League Baseball players, 75% of them reported multiple sport competition in their youth, with basketball being the predominant other sport. And they felt that specialization had a high impact on their need to achieve elite-level success, and they voted for 7. So we have bits and pieces of data that we've used to develop this, correct our mistakes, identify our gaps, and hopefully go forward. And why is this work important? Well, from that meeting I referenced in Houston in 2019, they've just published research priorities that came out of that meeting, and we think we meet most of them. I don't know how readable it is, but roughly it's to conduct methodologic studies with reliable measures, which we think we've developed. Prospective sports studies of child athletic development and performance, so ours would be prospective. Measure the impact of youth sports specialization on psychosocial outcomes, which is embedded within our survey. There's pieces of it that are not injury-related. Conduct prospective cohort assessments, so specialization versus multi-sport. So we have a way to track, you can be playing up to eight sports at any given season within our database. Hopefully nobody hits eight, but it is an option. And then studying injury risk and other physical health outcomes, so we are collecting injury. It is self-reported. It's not going to be anything more detailed than that at this point. And we have a plan for feeding back to the school systems as we go. So that would be our dissemination. So we think that, conveniently, we've addressed the research priorities that have been laid out by groups of people who are looking at this. And how are we going to do the work? We need to finalize our design to meet core standards of their survey methods, representativeness. You know, we've learned a lot over the last five years of doing this. Different ways of looking at sample size. The tailored design method, just for those who care, is a methodologic method of how you present your data, how you contact people impacts greatly their response rate. This is something that Todd has been very thoroughly trained in. And that the survey content meets the minimum data set requirements, which we believe are both looking at chronologic age and years of participation in the sport combined to get a fuller picture versus just years of participation, or, you know, they started at three, but you don't know what the intensity was. And we look at frequency of play, the level of intensity that they play, and how often they play. And those are the components that we're trying to build together. And those variables go way back to the work of Dr. Paffenberger from back in the cardiac days. And that's it. Julie, thanks for the proposal. There's no question that in this day and age, it's a very different time than I feel like when most of us grew up and we were playing, you know, sports for the particular season. We'd go down to a different sport, not play anything year round, not sub-specialized, not play multiple sports at the same time. And, you know, there's no question I think this will have a big psychological impact. So one question I have, you know, this is a shark tank. What is the money from the grant going to be used for? So I guess that's one question here. Yeah, salary. It's really salary. So the Department of Orthopedics and the School of Public Health have underwritten already the expense of Qualtrics. We had to hire somebody. We tried it ourselves and we couldn't do it. We would still be doing it. So strictly for personnel, basically. It's really for personnel and depending on what the funding is that we receive, we would probably bring on either an extra research assistant at a lower level or we have had a couple biostatisticians. There's a lot of interest in this project, but it's a time commitment thing. And then we have two biostatisticians who have stuck their noses in periodically and thankfully provided some advice, which is where the swimmer plot concept is coming from. And we would pay them a little bit too. So it's really, it's salary. The big expense of the programming was already covered. My second question is, you know, there's a lot of factors that can impact sort of the psychosocial development of kids as they, and no question, injuries and kind of, you know, a lot of participation in sports, you know, things like family backgrounds, sort of, you know, socioeconomic factors. I think all this can probably play a role in that too. And so how, how will you kind of tease that out or control for those types of issues? So we have an annual survey and then we have quarterly surveys. In the annual survey has makeup of the family, the salary in reasonable ranges, the ethnicity of the family, and there are a couple of questions about, well, there's comorbidity questions, but there's also questions about mental health embedded in there. So it really is, Todd is a sociologist and we're like, they do, their papers when they submit I've learned are 60 pages long. The idea of 3000 word limit is not in their thing. And they think that short surveys are 100 pages long. So we've had a battle. He gets some stuff in, which has turned out based on those research priorities to be fortuitous. And we are capturing it. We do it as an annual checkup with just a, like two or three mental health questions every quarter as well. And then some of them split up. So they're asked annually, but not as a bolus. So it's in there. How long are the kids follow for as a part of the study? Depends how much funding we get. So our goal is that this will be turned into long-term NIH funding and that if we get funding from here, that will be the platform that proves that the lessons we've learned about how to ask the questions properly, because there's a mix, right? The first and third graders are proxy by parent. As we get higher up, the kids can do this themselves. And the goal, the longitudinal, I've kept it in there because the goal is of our very original plan is to follow these kids, you know, all the way through college. Obviously we're not going to do that with, if you give me all of your money, we wouldn't do that. But the goal would be that this would become the basis and the platform for an ongoing study, which NIH would love to fund, I know in my heart. I think that's a great idea. You know, you mentioned the parents having to fill out or help with the surveys for the younger kids. Would you consider expanding the survey to include parents or to include coaches and not just kids? So how the parents see the sports specialization? Yes. So we have, we actually have a couple of questions about the, about specialization and, you know, it's I'd have to think back to what the original questions were, but it's basically, you know, are they participating? And if they've stopped, is it because it's like too much of your time to get them where they need to be? All life consuming. This goes into one of my pet peeves about return to play and that poster that's like number one or number three downstairs with return to play, because I think return to play is based on you need to, you can't benchmark it to, did they get back to where they were? Because right, if you're playing collegiate football and you get hurt in your senior year, there is no collegiate football anymore. So we try to get it as this reason, other reasons. And so we have some parent options for bailing their kids out, including money, too much money. Hey, Julie, thank you for a great presentation. And Brandon, thanks for a great question. I was involved as a collaborator with some sports psychologists and psychiatrists at Mass General. We published the study a couple of years ago, studying the adolescent parent dyads after stopping sport, whether it was from injury or some other things. And we looked at different problems, including catastrophizing and pain assessment scores and things of that nature. And I subsequently stopped doing that type of work. But what came out of that was that there are a lot of influence on the young athlete from parents and coaches. And that's exactly Brandon's point, is that it would be really interesting to see how the kids answer certain questions. And in our study, we had the parents answer questions on their observations of how their kids are going through things. And the next level study that that group is working on now, without me, is to get the coaches involved. And so as you develop a comprehensive program that's going to get funded, hopefully, by the NIH soon, these additional, I think, perspectives are going to be of interest. And it's just something as you consider it. I know. I'm really glad there was no Zoom link for this, because Todd really wanted to listen in. He's going to be standing up cheering right now, because he totally believes that we're trying to keep it. I mean, there's three of us. And the data has been overwhelming, and the development of the loops to track changes in sports and injury has been terrible. And I am a very black and white short girl, and he is a very, we've got to look at this, this, and this. We've tried to keep it somewhat manageable, but you are totally correct. And these are great offshoot projects that people can feed off of and build off of if we get that platform set. Thank you, Julie. That was wonderful.

longitudinal study

youth sports participation

musculoskeletal injury rates

psychosocial development

general physical health