You break it, you bought it, right? So actually, like the world's expert on this particular topic is in this room and talking about something else, sports specialization later. And Greg, in a paper he wrote in 2011, defined neuromuscular training in a, I think a really good conceptual way. So it's a conceptual training model that's operationally defined as a training program that incorporates general, for example, fundamental movements and specific, for example, exercises targeted to motor control deficits, strength and conditioning activities such as resistance, dynamic stability, core focus strength, plyometric, and agility that are designed to enhance health and skill-related components of physical fitness. And we're gonna use that. So neuromuscular training is also the cornerstone of primary and secondary injury prevention programs. So for example, these prevention exercises are used both for lower extremity, knee injury prevention programs are pretty much the same, whether you're doing it to prevent these injuries or you're doing it after an injury. This CPG was supported by the Academy of Sports Physical Therapists. I see one of our, a lot of our group over there. And is available open access on the JOSPT website. In fact, we just updated this. So there'll be another one coming out. And it includes the panel's recommendations as well as a lot of supplemental files on exercises including videos. This is another, a very good comprehensive figure from another of Greg's papers, a more recent one in 2016, that really talks about intensity and exercise progression and neuromuscular training. So if you look, he starts with conscious and corrective exercise. That's the point when you're teaching technique. Kids are thinking about it, they're thinking about how they should land, you're giving them, I'll talk about that technique thing in a minute. So and then it gets harder. Stability and endurance exercises, that's pretty standard. Reactive, somebody else has gotta be in the picture. It's really, you're sort of simulating an opponent in a game, right? Somebody's there. Sometimes they're touching you, sometimes they're in your, sometimes they're throwing you a ball. And then functional exercises as you see. And we'll show some more of those. So the technique phase, you're instructing the athlete on the proper technique for each exercise. This is feed forward. Now you're telling them, if they're landing from a jump, you know, knees over toes, soft knees, that kind of stuff. You focus on perfecting the technique of each exercise. And they need immediate feedback. So it's feed forward, then feed back at this stage. Fundamentals phase. You have to make it functional, practical, progressive, and fun, especially for kids. It also works for adults. I mean, to try and make it fun. Training focuses on strength and balance, stability and endurance here. Exercises progress from uniplanar to dynamic, to multiplanar, to sport specific movements that challenge the young athlete. Then the performance phase. So these training skills should expose the athlete to movement patterns that generate greater neuromuscular control. Agility drills, we follow the same sort of thing from straight plane to multiplane, to changes in speed and direction, and also changes on command. So they don't know what's coming. They should progress from previous phases and focus on power and agility. And then the power drills obviously will use advanced plyometrics and explosive movements. And here you might get them on the field, like you see this, on field rehabilitation or training. So let's get to the kids now. Whole body play is neuromuscular training. And I'm gonna really focus on this for a couple of reasons. But let's take jumping for example. Learning how to jump requires that the vestibular, visual, muscular and skeletal systems are all working fluidly together. So let's start with the science and see what's happening here. So Mark David Williams published this new meta-analysis in 2021 in perceptual and motor skills and compared neuromuscular training to sort of generalized training, its effect on motor control. And as you can see on the right hand side there, in that plot, there's a moderate significant effect in favor of neuromuscular training programs on motor control. And interestingly, they found moderator analyses for age and stature that reveal that neuromuscular training programs are more effective in younger, shorter and lighter individuals. The older and heavier an individual is, the less effective body weight neuromuscular training programs became. So these results reinforce the notion that exercise to enhance motor control should be emphasized during childhood and pre-adolescence. So meet Sadie Mackler, my now six-year-old granddaughter. Our six-year-old granddaughter. So resistance and strength training, dynamic stability exercises, core training, agility exercises and sports specific exercise. That's what we're gonna talk about. Playgrounds provide all of these things. On the left is a playground in our town very near our kid's neighborhood, actually approximating it. And that is Sam yesterday in Connecticut with my sister on almost the exact same thing. Sam's eight. But look at all of the kinds of things that they can even have to think for motor planning using a playground. And then for all kids, there are inclusive playgrounds now for kids of all abilities. This is Preston's playground in our town. There are games. It's a card game. You put them up and the kids do it. Balance and coordination. So here's Sadie again doing the big legs, little legs. You can also do that on command. Like flash one and flash the other. Balance and stability. The card says Flamingo. She's doing a tree pose for yoga aficionados. Balance and stability. This one's called the pretzel. So again, you can think about it. They're like flashcards that you can put up and the kids do them. Core and strength. Here's Sam again doing a bridge and a Superman. This is Michael's idea. He was wearing his cape. You'll see more of them in his presentation. So play is neuromuscular training. So last kid, sorry. Sawyer was two when she started working on a balance bike. That was last September. And now look at her. She told me when she's filming this, Grandma, I'm picking my legs up. That takes a heck of a lot of coordination. And this two, almost, not quite three year old is doing this. She's gonna be on a bike very soon. Climbing, whole body movement. Takes balance and coordination. Here's Sadie at four, climbing the tree in front of their house. And here she is around Christmas time climbing a climbing wall. And here they are, same sort of thing. She's swinging on a rope and Sam's on the climbing wall. This is again, this is what my sister does with them. That's why they like to go visit their favorite aunt. Every day is a holiday. But think about not obvious training kinds of things. Jumping on uneven surfaces. They were chasing their shadows when they were doing that. So they're planning and jumping and landing on this uneven sand. Next to it, whole body movements and dynamic reaction. They're boogie boarding, right? This was earlier this summer. So they have to gauge when the waves are coming. They need to go over the first set of waves. They need to gauge when the wave is gonna break so that they can hit it and ride it into shore. So this is again, there's so many ways that kids play. And then climbing, walking on stones in the water. All of this is dynamic balance and strength and coordination. And then sports specific. Greg's gonna talk about sports specialization. I am not a fan, right? They assume he's gonna say the same thing. So they play a lot of sports and they play and they sometimes don't play any, right? So this is Sadie catching a lacrosse ball. She's gonna turn around and hopefully make the net, but most often she doesn't. And then there she is with her soccer, her little soccer team. She's playing goalie. She hardly ever plays goalie, but they all play whatever happens, right? They all switch around and they're learning a lot of different positions and having fun. So what about neuromuscular training on field or in the gym or clinic? So this is on Tennis by Dennis. Look at this little kid. He's awesome with these ladder drills. I'm gonna play the whole thing cause it's really fun. No, he hasn't messed up yet. He does in some of them later, but he's a little kid. It's pretty good, huh? No, he's not. No, I told you, I gave the... No. I don't think we're gonna try this at home. This is the URL. It's a, he's a, he trains kids for tennis. Oops. This is, Kevin Wilk shared this with me and I'm gonna point you at his Instagram. He has all kinds of wonderful dynamic stability drills for training people, but also patients. So what he's doing here, she's doing lateral movements. She's being distracted by somebody off camera who's throwing a ball to her. This is pretty advanced. She's got bands on her thighs and when she jumps, he's doing perturbations on her trunk. So that's a, again, you could do each one of those as a step up before you get to this. But it's a really interesting, you know, what you can do. And again, what does he have? His hands? A TheraBand tied in the back. Some kind of ball, right? That's it. And somebody else to throw it. This is not some, all these, all this fancy stuff. And then getting back to secondary injury prevention. This is neuromuscular training is what we use. So throughout rehab, implement neuromuscular training prevention exercises in a progressive manner. You can start with this stuff very early with, like I said, taking that thing that Kevin was doing and break it apart, right? Do the early patterns first. Promote confidence. And then instill the importance of compliance with rehab and prevention exercises. All right, I'm gonna do a little segue here. We're gonna hear a lot about sex, at which we just did from a biological perspective, as a risk factor for injury. There's a lot of data showing that women and girls have a greater propensity for injury at, for the same number of player hours than boys and men. But this is a group, these are three different, three researchers from three different institutions. In fact, one of them is at Michigan. And they wrote a really interesting paper. They're really focusing on ACL, which is my area. So I read it. About is it sex or is it sort of this sex-gender contribution and performance as an underlying risk for injury. So they talk about motor control, physical and sports performance are forged in childhood, which I just showed you, right? And the pre-sport environment, which that emphasis was. Gendered play develops, and if you let it, and requires different skill sets. And gendered expectations of physical abilities, like throw like a girl. The training environment, gendered socialization that strengthen muscle development is not appropriate for girls, or really focusing on how you look, for example. And weight rooms are highly gendered spaces. And then the competitive environment, there are gendered expectations of appropriate sports for girls and boys that are reinforced over and over and over actually. So we think this doesn't happen now. You all saw this last year, right? Contrast the women's weight room in San Antonio, Texas, bubble for the NCAA basketball tournament in 2021, consisting of an empty ballroom with those things on the right. A small rack of dumbbells and a few yoga mats. That was it. In contrast to their male counterparts who are provided with an entire gymnasium-sized strength and conditioning facility, fully stocked with weights, lifting platforms, racks of dumbbells, squat racks, and other equipment, okay? This is 2021. Now, once this was raised, they had to scramble and figure out how to put in an equivalent space, but that's what they thought. For the top female collegiate basketball players in the United States. I'd say that's a wow, right? I mean, that's a perfect example. So this is what we can do, courtesy of Dr. Sheree Becker, going forward, applying a gendered environmental lens to this. Change norms across women's and men's sports and be more inclusive. Use non-gendered language for equipment and exercise. Evaluate the physical aspects of athlete training and competition environments. Focus on goals, performance gains, physical and mental health, not appearance. Provide diverse role models. We don't really see that very much in strength and conditioning, especially. Determine if gendered roles and responsibilities may interfere with an athlete's progress in sport or participation in physical activity. And reflect on possible differences in expectations and or programming by gender. This is just food for thought, right? These guys are taking off with this in the last couple of years. So we'll see what they come up with. But it certainly makes sense to me. Here's a take home message. Neuromuscular training in children improves motor control and performance. And play is neuromuscular in strength training. She's not, I'm not gonna ever do it again. You can just see her face. She's got her beast face on. Start young. Scooters, balance bikes, ball games, climbing, running, jumping. Whole body neuromuscular training. Go to playgrounds. Make it fun. No gender stereotyping. And I'm gonna end with, go outside. As my Norwegian colleagues say, not, there's no bad weather, just bad clothes. So you can always count on Lynn to raise the key issues and the controversial points, which should steer some good conversation later. But one thing I wanted to question you about, you did say that the younger, lighter, smaller kids do better. But isn't it the older, bigger, weaker guys who need the help? So how are you gonna change that paradigm? Well, I think you start in childhood. And when you get them when they're really young, they're not gonna do it. They're not gonna do it. I think you start in childhood and when you get them when they're older, you start small and work up. That's really, but I think that the, it's an interesting finding. It's a bunch of studies, right? I mean, there were probably on there between more than 10, right? Studies that were clumped together. So. Yeah, no, I see what you're pointing. I agree with it. I took the point out that agreed with the way I was presenting. But to be honest, you know, we do get the people who are older and clumsier and we've got to do this stuff with them too. Just, I mean, you know, it may take a lot longer. So you just start with the basics at an older age? You don't change the paradigm? No, you have to start with, if they have lousy technique, it's a mess, right? So maybe the offensive tackles have to start with balance bikes or something. Yeah, when they're little though. Ballet. Ballet, yes, thank you. Yoga. All right. Okay. Good, thank you. Thank you.

neuromuscular training

physical fitness

injury prevention

motor control deficits

strength and conditioning activities