I know it's been a fruitful but long session, so I will do my best to combine some light stand-up comedy with some takeaways for our clinical practices today. Okay. So I have no disclosures here, and just thank you to the symposium and Sport Health for allowing me to step in on Lindsay's behalf today and to talk about some strategies for improving the implementation of a lot of the preventive training programs that we've been talking about this afternoon. Okay. So I won't belabor this point too much. I think the people ahead of me have done an excellent job already of setting up this point where, you know, sitting is the new smoking. And when we have athletes who sustain these musculoskeletal injuries and start displaying early signs of knee osteoarthritis, we're decreasing their return back to pre-injury levels of participation, right? So then we have this public health problem where they have increased osteoarthritis, less physical activity, so we're seeing these population-level health outcomes. So how can we intervene on this first part to prevent those injuries in the first place? So I'm just going to continue to make plugs for preventive training programs or injury prevention programs. Here is, I'm an athletic trainer by trade, so the NETA has a position statement, but certainly JOSPT has had clinical guidelines that have been updated. And there are dozens of scoping reviews of people just yelling into the void that these programs work and they should be used in different populations because they're effective. And we can see really strong reductions in injury risk and injury rate when the programs are done well and consistently. So how do we kind of get to that point of doing the programs well? So this was kind of covered in some of the previous talks, so again I'm kind of whipping through the background phase of things, but there's no one good program. Certainly FIFA 11, the PEP, CLIP with a K, there are some programs out there that have been shown to be very effective in populations, but they can also be very tailored for whoever your patients are. The kind of main components here, right, as long as we're getting these different types of exercises into the program and really emphasizing that appropriate movement quality and giving accurate feedback, then a preventive training program can take any number of forms and formats. So this is some work from Dai Sugimoto, Greg Myers, and colleagues, but just looking at this idea of compliance. So programs only work when we work them. And so when they're done really well and with high compliance, we see the greater reductions in injury rates. So again, just trying to get to that point of, you know, what's the secret recipe for actually getting somebody to do this? So trying to promote compliance. When I was doing my master's work, I grew up in the Atlanta, Georgia area. I was really excited to see a John Smoltz jersey in the audience, and I did graduate work in New England. And I'm not saying one area is better or worse than the other, but if you've ever been to those two regions, people are different in different places. And so I was defending my thesis, and I had a member of my committee who said, how do you know the program worked? What if you're just nice, so everybody was trying to do their best because you're a nice person? And I was like, that's great. If the answer to getting somebody to change their behavior is to just ask them nicely, I would love to just skip that message across the land for everyone where this is how we get people to stop smoking. This is how we get people to increase their exercise. Just smile and ask them to do it. But unfortunately, that's not the case. So how do we do this? So just some thoughts on ways we can improve implementation. Because from a research standpoint, how we do things matters for replicability, for being able to scale up and sustain these programs. And then clinically, we want these things to work, and we want people to maintain the programs and for things to stick. Because unfortunately, preventive training programs, they're not a Band-Aid, right? It's not kind of a one-and-done program that you can do. It's a multivitamin. We need people to be doing these all the time, and we really need that habit change, again, in order to see all of the great benefits that we've kind of talked about throughout the day. So a kind of framework that is really helpful for the planning process for any community-facing In the implementation science space, there's this quote about theories, models, and frameworks that everybody has. They're like toothbrushes. Everybody has one, but nobody wants to use somebody else's. So this is some shameless promotion of a former mentor of mine, but Darren Padua has done quite a bit of work in military populations and other athletic populations. So this is kind of some of his nuggets of wisdom put into a framework. And I think it's a really useful way of systematically approaching implementation, again, for some of that replicability and for putting effective programs in different types of contexts and populations. So we're just going to walk through it a little bit. So first two steps here are establishing that administrative support. So getting an organization to say, yes, you can come in and work with us. And then also identifying an interdisciplinary team. So that interdisciplinary team is going to look really different depending on who you're working with. The work with the military academies had very different people at the table compared to when I go to a community soccer organization. But just asking that question of whoever your initial point of contact is and saying who else should be at this table, literally, metaphorically, and getting that input. That way you can have richer discussions about what would prevent us from actually successfully implementing this program. So here are some common barriers that are listed. So the next step is kind of identifying barriers. If you've ever listened to the Freakonomics podcast, there's a really great episode about premortem analyses. So fun clinical audience, we're used to postmortem analyses. And this is just, it's kind of a brainstorming exercise. And I like the take that it has on how to think about barriers. But essentially it's getting that interdisciplinary team in the same room and kind of approaching people to think through the question of, all right, we've already implemented this intervention in our setting, but it failed. Why did it fail? And so just getting everybody to list out all of the possible reasons why they see something going wrong. And so I'm just going to kind of talk through some of the more common barriers that we see in both the research and just anecdotally, and some strategies for overcoming those barriers. So I think we've talked about this a little bit today and the idea of, especially in the youth space, you can't give someone a solution if they don't see the problem. And when it comes to an injury prevention lens, a lot of stakeholders just don't see it as a huge problem that they need to prevent. It's a little bit easier to talk about the performance benefits and player durability or resilience in that respect. And that kind of gets people more interested in this in a proactive way compared to if you talk about injury risk variables with them. So there's some good evidence that preventive training programs can improve performance, whether that's more sport-specific tasks or just general athleticism type of tasks. And then when we talk about timing, so again, there's no one right recipe, if you will, for a preventive training program. So we can play around a little bit with what they look like. And these are some data from a Connecticut high school age coaches survey, or coaches training high school athletes, not high school students who coach in their free time. But essentially here, what you'll notice is that five to 10 minute range, that's kind of everyone's patience maximum. So programs that are less than that, they're more likely to implement them or to add them into their practice. So it's just an important consideration of you might have a really great program, but if it's 20 minutes long and someone just doesn't have the capacity to add that into their everyday program, even if they do it sporadically, your athletes might not be getting the dosage that they need in order for the program to truly be effective. So I love this figure. If you're unfamiliar with this study, it's just like a really fruitful visual of the challenges with implementation. So let's see the, oh, all right, cool, laser pointer. So this first, we've got years here across the bottom, and then I'm looking at ACL injury incidence rates. So this was the group's baseline year. And then they started implementing preventive training programs, right? They taught coaches how to do it, but they felt like compliance was pretty low. So then they engaged with physical therapists to help implement those programs. And so we see this really great reduction in injury, it's fantastic. I'm sure we could guess that this upswing is when the research group left, right? And then we see here, this huge decrease, that's when they really injected an effort into the community of let's redo some more training, let's provide people with resources, let's reinforce the importance of these programs. So I think it's just a nice, yes, compliance matters, and how we train people to do things and the messaging around preventive training programs matters for people's behavior. Cool. So a quick example here. So Lindsay does work at the University of Connecticut. If they're a very successful basketball team in general, but in terms of free throw percentage, but they practice them every day, right? So just because they're good at something or feel successful in one way doesn't mean that you don't, again, miss that kind of daily vitamin of still practicing and reinforcing these movements and skills. So it's the same way with preventive training programs. Even if athletes feel like injuries are not a problem or that they do, their motor control is fine, you know, they could still benefit from, again, just that daily reinforcement. So I love that this is a youth athlete session. The best part about working with youth athletes is to establish those habits early and, again, try to catch their motor patterns before they've, I call my, you know, AAU basketball players, they're like baby giraffes, right? They've got all of the limb and less control at that point. So trying to catch them before they get to that stage so that we can really make a high impact so when they get to those more competitive levels, again, they have the motor patterns that are going to hopefully keep them safe and improve their performance. All right. So now we've talked through kind of developing a preventive training program. This is an example with, this is specifically at West Point. It did occur to me this morning, I was like, all of my visuals are with West Point when we're in Colorado Springs. So I apologize for anyone's Air Force related here. But this was also applied at the Air Force Academy, I just didn't have the visuals to match it. But so we're trying to do preventive training programs in the military. It's a very specific warm-up layout in the mornings. And there's 1,200 of them, right, of incoming cadets that are trying to do this warm-up at the same time. So we have, oh, maybe it won't play or go back. Okay. Well, if the video won't play, I will just verbally describe it to you. So you'll notice here, everyone's kind of standing in their formations. And then we have the leader of the exercises here because it was really important to keep everyone on the same cadence. So this was just kind of a way of, they're still performing these exercises that we see with normal dynamic type warm-ups that are preventive training programs, but it's just in a little bit of a different format that follows kind of the needs of the organization where the program is being done. And it is kind of cool to see everyone doing the exercises on the same count. Another strategy for just trying to talk through people of how to develop a preventive training program in their setting is to talk through what they're already doing and to make minor tweaks rather than trying to sell them a whole new program. So if we compare this to the suggestions on which types of exercises should be included in a program, the red are kind of areas or exercises that could still be infused in this example program. So then if we had a conversation where it's, I'm not selling you a new program, but there's just maybe three exercises I want you to add into your existing habit. Oh, I feel like in the Atomic Habits book, if you've ever read that, it's like habit stacking. So you're just asking them to make a much smaller nudge to their daily routine rather than, again, trying to start with a whole fresh program. So this is just kind of a plug for some of the work with the Osteoarthritis Action Alliance where for a number of years we've been trying to develop some of those resources. The phone app is in beta testing right now, but it's just trying to find messaging and ways that make the right choice the easy choice regardless of the coach's experience. So some of the resources that are developed for that, like there's a YouTube page and essentially these videos are going to be inputted into the app where somebody could build a program and then it's kind of on their phone when they're trying to train. This goes to, again, some of that messaging and tailoring that we've been talking about today, but this is just a sample program from some of that military work. And you'll notice it's kind of just little reminders to people who have been trained about which exercises you're trying to do, how to do it correctly, and the feedback to provide if people aren't doing it correctly. When we talk about working with little kids, you'll see that the exercises are similar, but I might not ask a military cadet to perform elephant to flamingo, but if you've ever tried to ask an eight-year-old to do anything recently, that can be a helpful strategy to get buy-in for an exercise when you really want them to learn how to do it correctly. So for some of our teams, they've said, you know what, I would do the exercises more frequently if the first letter of the exercise names spelled a word. That way we were really sure we were covering all the exercises or, again, animal names have been helpful in the youth space. And then just another example of resources that we've provided with populations to try to help train and maintain some of these programs. So the next step is then training the trainers. So you've worked with the interdisciplinary team, everyone's on board, we have a plan for what the program is going to be, so who's ultimately going to be implementing this program? So this is just an example of there were some kind of quiz-type videos that we were giving to cadre to train them on how to implement the program. For other settings like AAU basketball, we've gone in and just kind of one-on-one watched a coach implement their warm-up and then provided some feedback on ways that they can improve their feedback to the athletes. So that's certainly another strategy depending on manpower and if you're able to physically be somewhere versus, you know, something like a video quiz is a little bit more helpful for remote or kind of mass learning. And then fidelity control. So again, a really key component of preventive training programs is going to be that quality of feedback. And if somebody's doing an exercise wrong over and over again, it doesn't really reduce their injury risk as much as we would want it to. So this is just an example, again, of the military work. So it's essentially each of the exercises and then what it's supposed to look like and then evaluating somebody on their performance for implementing it. So it's just if somebody is more receptive to very objective feedback, that might be an effective strategy, again, depending on kind of manpower and ability there. And then the exit strategy. So if you remember back to that Mikkelbust study, when the researchers left, we saw this re-increase in injury rate. So having preemptive conversations with stakeholders on what does this look like when we're in a situation where we're not here anymore to, again, just make sure that they can maintain and sustain the programs, if not scale up to other teams or athletes that they work with. So again, here's the framework. And I'm speaking on behalf of Lindsay DiStefano, so any criticisms can be directed to her email. But if you'd like any positive reinforcement, I'm on the right.

preventive training programs

athletes

injury risk

performance improvement

compliance