So starting here, we have Leslie Bonsey. So Leslie Bonsey's a registered dietitian. She's board-certified specialist in sports dietetics and is a sports nutrition consultant for the Super Bowl champion Kansas City Chiefs. She has a company, Performance 365, which provides sports nutrition services for the XFL, the USFL, FCFL, and FCBL. And then next we have Marcel. So Marcel Pastore is in his 23rd season as a strength coach for the Pittsburgh Steelers, and he's serving in his third year as a head strength coach for the team. During his tenure of the 23 years, the Steelers weight room has won the NFL strength coach of the year twice. And then next we have Dr. Joe Alderete. So Joe is a very recently, as of two weeks ago, retired colonel in the Army, and he was the former chief of orthopedic oncology at Brooke Army Medical Center and was the medical director of the Center for the Intrepid, the advanced amputee and limb salvage rehabilitation. He's had four combat deployments to Afghanistan, and he served as positions as staff orthopedic surgeon to deputy commander for clinical services and the task force chief of surgery in Iraq. And then next we have Dr. Ashish Bedi. Dr. Ashish Bedi is the director of sports medicine and joint preservation at North Shore Orthopedics and Spine Institute. He's an adjunct professor of sports medicine and hip preservation at HSS. He's a head orthopedic consultant for the NBA Players Association and the assistant team physician for the Chicago Bears. Next we have Dr. Erica Forse. Erica Forse is a licensed psychologist and sports psychologist. She's a mental performance specialist for the Baltimore Ravens, a registered sports psychologist with the U.S. Olympic Committee, and is an associate director of the CAPS athletics program at Georgetown, where she provides mental health and performance psychology services for the athletes. And then finally we have Stefania Bell. She's a senior writer and injury analyst at ESPN. She's also a licensed physical therapist, board certified orthopedic clinical specialist, emeritus, and certified strength and conditioning specialist. So thank you. Thanks for coming. So as we know, sports optimization doesn't always involve just the healthy athletes. It involves the injured athletes as well. So we're going to start on the injured athlete. And we'll start with you, Dr. Forse. So from a mental health perspective, what contributes to the prolonged recovery of a sports injury? And what contributes to favorable recovery outcomes? I think it's on. Is this on? Okay, perfect. Thank you, Robin. Can you say the question again? I was absorbed and distracted with the microphone. From a mental health perspective, what contributes to prolonged recovery from a sports injury? And what contributes to favorable recovery? Sure. Yeah. So when working with athletes in general, when we're looking at an injury that they've experienced as they go through treatment and the rehab process, sometimes things don't go as planned. Sometimes they may be taking longer than expected and have prolonged recovery, essentially from a mental health perspective. Sometimes an untreated mental health condition can be part of what is causing the delay in their recovery. So sometimes when an athlete, whether they have a pre-existing mental health condition or maybe those symptoms developed while they were going through rehab, if there's not support for that, if there's not treatment, that can get in the way of their recovery process because they may not be as motivated. They may be withdrawn. They may be discouraged if they're dealing with depression. Anxiety might be getting in the way during their physical therapy. So there are aspects of mental health symptoms in general that can get in the way. I think another thing that can get in the way of recovery is having unrealistic expectations. So as an athlete goes through treatment, if they're expecting, you know, if I do more physical therapy, I can maybe get back to my sport faster and that's certainly not usually the case. So those unrealistic expectations can get in the way. And then thirdly, I think looking at their support network. So sometimes there might be certain family dynamics or social stressors going on where they just don't have the right sources of support in general and that can make recovery more difficult if they're not getting to physical therapy. So if it's a younger athlete and they need transportation or if there's issues at home that are going on, those things can get in the way. On the other side, thinking about what helps rehab go more successfully, what's going to help an athlete get back to their sport really is having resilience, having higher self-esteem, a higher athletic identity, certainly having social support, having, you know, a sense of well-being where they feel confident, that internal locus of control that if they focus on these skills and on this physical therapy and work with their providers that they will get back. So kind of believing in the process. I think these are some of the mental skills that are going to help an athlete get back to doing what they want to be doing, which ultimately is their sport. Thank you. That's great, Erica. You guys, if you have any questions, you can also feel free to walk up to the podiums and ask questions, or you can also, through the app, you can ask questions, and we'll have time at the end as well. Marcel, when an athlete's injured, how do you work with the athletic training staff and the physical therapists and the physicians to maximize an athlete's recovery? So for us, we have a great program between, we have a unique situation. Our training staff is awesome. We work hand-in-hand every day. Obviously our team doctors are highly involved in everything that we do. We have base protocols that we use. So we test the guys when they first come into the off season, so we know some of their measurables. And then obviously with some of our devices, our force plates, Nord Board force frames, and our GPS, we have an indication of where the guys are or where they need to be. So it's really simple for us. It's just communication between the doctors, the trainers, and the strength staff, and we all get together, and we try to figure out the best protocol, because not everybody's built the same way. We are in a unique situation. So in the NFL, the strength coaches don't get paid for the guys benching 500 pounds or squatting 900 pounds. We get paid for keeping the guys on the field. And I think that's the best scenario for us, is that we work well with the training staff. And communication is basically everything. So we know what the people have, what they need to do, and when we can push the envelope and when we can't. It's a team effort all around, right? It is 100%. Next, Dr. Beatty, after performing a full workup and evaluation of the player, how do you consult them with regards to playing after an acute injury? You know, what's safe and what's not, and how do you manage that? Thanks, Robin. You said it best, which is, you know, this is certainly a team approach, and with all the wonderful team physicians in the room that have a wealth of expertise, they know this process, which is, there's the initial, of course, reaction and the process as a team physician of diagnosing the injury and getting a sense of, first, what is it and what direction is it going for management? I think step one is informing them. You know, oftentimes in the setting of an acute injury, the immediate concern is that, is my season over? You know, how long am I going to be out? And we're still collecting data and information, you know, is it, what is the, you know, from the moment that you see it on the field to then in the training room, you're collecting incremental information, often with imaging, until you get a sense of where it's maturing. And so, as I've lost more hair and maybe getting more gray hair, I feel like there's a lot of value in allowing the dust to settle a little bit, and based on how a knee or a shoulder or a hip looks the next day, combined with additional data, you start to get a sense of the direction that things are headed. And then you get smarter minds around you with your head athletic trainer and your strength and conditioning team. And then as you put minds together, you all have a consensus of how you're going to approach that with the athlete. And so usually, that for me has served well, where if you inform them and have a discussion with them about the direction or the options that are available, and then their sharing in that participation and that decision making, things feel well aligned. We're fortunate because of the society and people like yourself and great leading surgeons, oftentimes the second opinion doctors that then are consulted are aligned with you when you take that approach. Yeah, it's so true. You know, I always find that athletes, the first question they ask is, when can I get back, right? After an injury, you haven't even taken them off the field, and that's one of the first questions that the coaches are asking you. And so I agree about that dust settling, figuring that out. Dr. Alderete, with recent focus on genomics and identifying the tactical athlete prone to injury or poor recovery, what is the role of the orthopedic surgeon and the entire team in optimizing potential in prevention and recovery, especially for those at risk for poor resilience? You know, we recently among the special operations commands and conventional military at large have spent a great deal of effort trying to figure out who may not respond well to injury. There have been a number of papers out recently that look at, well, this may be a genomic factor for somebody who's going to have a problem with substance abuse or catastrophic thinking or the inability to overcome. I think our role continues as orthopedic surgeons and team physicians to be their heroes and their champions and to pull the team around. It is going to be interesting to note when people have a genomic test for, you probably want to avoid opiates in this individual and use a much more ketamine-based therapy. Our behavioral health partners are going to play a giant role, as do our strength and conditioning teams, for their return to duty after injury and especially from a special operations system. But it's interesting to see that kind of like in the nutrition world, we have all of these bright shiny tools that just putting your hands around people again from humanity and continuing to be their coach as orthopedic surgeons is, I believe, in the experience with Intrepid, what people need. They come to you broken. You tell them, have faith. We will overcome. And they leave whole. Yes. I feel like sometimes there's too much data, right? You have the genomic testing and you have all this testing and for nutrition as well. But like you said, just touching the person and talking to the person and getting their information. Stefania, so over the past 10 years, what are some of the newer recovery and rehab techniques that you think have played the biggest role really in recovery of these athletes? I think the thing that when I first saw it, I felt like it was going to be the biggest game changer in rehab in my professional lifetime. And I think that's bearing itself out is blood flow restriction training. And I first learned about it when we were down at the center for the Intrepid doing a veteran special with the SPN. And it was only being really utilized in the military population. But obviously, our tactical athletes are the best athletes in the world. And you could easily see that there would be an application for this in the athletic population at large. It was interesting because we got Matt Metavo, who was the president of the NFL Team Physician Society at the time, got him on a call with the folks down in San Antonio and started talking about how could this potentially be utilized in the more broad athletic population. And it really took the step of one team physician in Houston with one particular athlete. And when everybody saw the results that they got, everybody wanted to jump on board. And now blood flow restriction training as part of the rehab process is present in every major sports league, in Premier League in soccer, USOC clubs, throughout I think I counted more than 90 universities now that are utilizing it. So it's just blown up. And this is under 10 years that it's been in the population at large. So now what we're seeing is applications of blood flow restriction training beyond conventional rehab and actually being utilized in recovery. And it's really continuum, right, because rehab and return to play and performance and recovery are on this spectrum. And now we're seeing BFR being utilized in recovery. There are a number of NFL teams I know who after game day, they'll just have people on the tourniquets while they're resting because they're starting to see, and there's some scientific studies that are showing that the recovery to full strength and the diminishing of muscle soreness post-event, those numbers are changing with the application of BFR as a recovery tool. So I think the fact that it's well-grounded in science, so many, you know, you ask what are the things that we're seeing, I could tell you all these gadgets that people are utilizing and bells and whistles, but rarely do we see anything that's got well-documented science to back it up. And so to me, that's the biggest. I do think that recovery just in general is the other mode where we're seeing a lot of attention-driven things like float tanks and sensory deprivation to kind of restore wellness and, you know, there's some thought that magnesium benefit from the Epsom salts may be doing things, but there's not a ton of science there, but in terms of getting patient reports of how they feel from some of these different recovery treatments, I think that's going to be another thing that we'll see a lot because in every major league, the biggest problem is having the players on the field or on the court for game day. And every time a league wants to lengthen the season, we start seeing injury spikes and players who want to sit out and broadcast partners don't love it when players sit out. And players don't love it when they're not playing. So that's the ongoing challenge. So I think recovery is going to be a big focus. We'll talk more about that later as well too. So now we're just going to move on from injury to the optimization side of this. And so Leslie, are there any specific things that you assess when you're recommending new nutritional strategies for an athlete such as blood work or BMI, or what do you use specifically when you're? Well, individualization really is the name of the game. It has to be, and working in football, it's collision nutrition is really what we're talking about. But A, we need to think about physique and what are the goals of that athlete and how are we going to achieve that appropriately? B, it's physiology. What underlying things are going on? Athletes come with baggage and some have diabetes and some have digestive issues, et cetera. That needs to be addressed. The third is thinking about performance, right? And what are the goals that that athlete has? And then how do we customize appropriately? And practicality is critically important and that oftentimes gets lost in translation. Second is, you know, when we talk about how do we do this, to realize that food is comfort. Everything that athletes do is not comfortable. It typically is not, and that shouldn't be what happens with food. Oh, I can't eat this and I shouldn't eat this and blah, blah, blah, and on it goes. And that can have deleterious effects across the board. So I need to talk with my athletes, A, about what it is that they're willing to eat. You know, I have a lot of plant-based athletes who don't eat vegetables. Just think about that for a moment. It's an issue. I'm not, all of you work with professional sports. There are athletes that are food insecure. So to be really careful about recommendations that we make, because if they can't afford it then that's not going to help anything. B, the other thing is portions is important, but you know, I can't say to a 300-pound lineman just eat something the size of a postage stamp because, you know, they're going to run out of the room. So have to really think about this from a realistic, practical perspective, and that means individualizing. I don't do team talks with the chiefs, A, because Coach Reed doesn't like it, B, because I find it really very ineffective because I'm not talking to everybody. I'm not talking to anybody when I do that. When I can see people one-on-one, then I can really get at what is important, listen before responding, feelings are never up for debate, and being their advocate across the board. You know, I always think it's hard. I mean, it's hard to prepare food, right? And so for these athletes who've never really had to do that, and now here they are, and they have to prepare food. So how do you educate them on, or make it easier for them? Yeah, well, and certainly at a collegiate level now with NCAA guidelines, you can eat 25 times a day within the cafeteria. And all of a sudden, when you're a professional athlete, maybe it's breakfast and lunch, and then get out the door, you're on your own. I don't follow them around saying, don't go to Five Guys, get that Cheetos out of your mouth. I don't do that type of a thing. But I will take them to the grocery store. I've done that before. I do a lot more video types of things. Here are some very simple things that you can put together, A and B, to get C. There are some athletes that want personal chefs, but that means working with the chef. What do you mean they can't do Keto? And why can't they have a whole cheesecake every day? So making sure that it is customized appropriately for them. And it's really hands on. We do that with our players, our chefs. We'll teach them how to do some really simple things, because that is survival skills. When they're done playing, they still have to know how to do that. Marcel, there are so many tracking devices now available, including these heart rate monitors, GPS trackers, accelerometers, so many things on the market. Are there any specific ones that you use? And then how do you adjust your recommended strength and conditioning program based on that information? So like I was saying earlier, we have force plates. We have the Nord board. We have force frame. We have a bod pod in the facility. And we have Catapult, which measures basically anything on the field, all their movements. So we have a base protocol that we know based on the position and the person. But from a, this is the periodization that you're talking about? No, sorry, this is like, just like, what trackers are your favorite trackers? Are these, again, you have the GPS trackers, the accelerometers, the Norbord, all these different products, but what do you use specifically, or what data do you use? So the data is unique. Obviously, like I said earlier as well, everybody is built differently. You can get two of the same people who are two first round picks. They're both wide receivers. One may have an anterior pelvic tilt, one may have a posterior pelvic tilt, which leads to hamstrings, which leads to hip flexors, which leads to everything else. So there's a lot of different measurables, and you have to try to figure out. We do something similar to FMS. We have an FLS, and it's our functional lifting screen. So we do a handful of different movements that when we bring anybody new to the Steelers, we assess them. We evaluate them just on, with our eyes, to determine, hey, they need to do this a little bit more. We're not gonna stop somebody from squatting or benching if they have certain issues, but what we are gonna do is we're gonna adjust to it. So we have a lot of different testing procedures, like I said, but I think what it comes down to is everybody is so unique. We also use velocity-based training because we know from a velocity-based training that it's not gonna break down its tissue as much as it would. So if we did a heavy day where we're doing eccentric, we obviously know that days after that we're gonna be a little bit more broken down, that if we do velocity-based training, it's more of the concentric speed, so we can get more work in. We get a little bit more neural adaptation out of it. So there's a lot of things that you need to just figure out how it fits in your particular system. Dr. Forrest, what kinds of mental skill training exercises or visualization techniques do you recommend that an athlete incorporates in their training? Sure, so when working with an athlete on their mental skills, first is getting their buy-in and helping them understand that there are different mental skills. Some athletes may already naturally use some of these mental skills, and then there may be areas of improvement. So talking with them about how many hours they put into their training, but at the same time, if mental skills are so important in their sport, how many hours are you actually training the mental side? So I usually give the example of, you would never step onto a football field or a basketball court without warming up your body. And then I ask them, what are you doing to get your mind ready to compete? And so with that, we'll start talking a little bit about when you perform your best, what is that like? How are you thinking? How are you feeling? And they'll naturally start listing off some of the mental skills that are part of that, which is being present, being somewhat relaxed, not overly tense, so having that right level of physiological arousal, and not overthinking. So they talk about, I'm really not thinking anything. So they're present, they're letting their body do what they're trained to do. And then they'll give me examples of when they're not playing well, of what are they're thinking and feeling. And that gives us the sense of, here's what gets in the way of performing your best. So the overthinking, being very tense, being very distracted and thinking about other things. So this sets the stage, and then the mental skills that come out of that is helping an athlete learn skills like, okay, if we wanna be more present and focus only on what you're doing on the field, let's talk about mindfulness and how does that fit. Visualization is a great skill for getting the mental rehearsal in to help build confidence. So when I work with athletes, I think helping them understand how to use visualization properly, I mean, it is like watching a movie in your mind, but there's more to it than that. It's a sense of incorporating all of your senses to make that image as real as possible, and helping them understand, well, how would I put that together? So ultimately, as we learn how to put it together, the next step is then we'll make a script that I can take them through a visualization script that might be five to seven minutes long. And once it gets to the level of what we want it to be, we'll record it, and that athlete can have that and take that with them so that they can listen to it daily, maybe once a day, twice a day, whatever it is, so that they can get practice in listening to that. Then they'll get the hang of it, and they can learn to do that on their own. But that visualization is gonna help them practice anything from an actual sports skill, so if you're a pitcher going through the routine of just before you start a pitch to finishing it successfully, excuse me, to what's the emotional state, how do you want your body to feel when you're pitching, what's your confidence gonna be like? So we try to bring all of those elements into the visualization. Outside of visualization, I think another important skill to incorporate is your self-talk, so understanding your inner dialogue and how that influences you. Helping athletes come up with mantras or cue phrase, things that are gonna help them focus on their intentions of what they want to be focused on in their sport is gonna help them stay on track a little bit. Putting these skills together is somewhat educational, but there's a lot of practice involved, just like any skill, and so we talk about that and then looking at where are you going to practice this, what's this going to look like, and then ultimately, how do you fit this into performance, and so teaching pre-performance or sort of a game day performance routine where they remember, okay, here's my physical warmup, but there's elements of what I'm doing to mentally get ready, and so it's putting it all together, so all kinds of skills can help an athlete perform and optimize their performance on the field, but if they don't practice them and if they don't remember to use them, they're not gonna be very effective, so that last part is really integrating it into what they're gonna be doing to help them play better ultimately and have the confidence that they will handle the unexpected well because they have these mental skills to rely on. It's so interesting because the athletes are so used to training physically, right, but not mentally, and so probably making that adjustment. Right, and I always give the analogy with our college athletes, or at least the example, I'll ask them, how much of your sport is mental on a scale of zero to 100%, and they'll all tell me something over 50%. You know, it's 90, 80%, and I'm like, okay, you're training, you know, NCAA says 20 hours a week. How many of those 20 hours are you practicing your mental skills that you just said are so important, and they look at me, and it's usually zero. I'm like, all right, well, that's what I'm here to help with so we work on that. Yeah. Ashish, so how do you take what you use on the professional side with all these tools and things that we have to your regular patients, and, you know, to help them optimize their performance or their recovery, or? Yeah, a really good question, Robin, and I think Stefania said it more eloquently than I can, which is, you know, there's this continuum between performance that then has bled into rehabilitation that, of course, is part of injury prevention and recovery, and so, you know, BFRT is, of course, a wonderful example of that, where oftentimes some of these latest technologies and tools are available to the elite athletes. It's the NCAA and the professional sports, but the conditions that they're facing and what they're recovering are very much what all of us are encountering in the day-to-day clinics, and so, as I'm seeing tools, whether it's in terms of muscle recovery, you know, motion screens, and the tools that Marcel spoke to, for example, you know, GPS data, or quote-unquote workload data, as you start to see that evolve into the college side, and where there's learnings and principles that then can apply to the general population, I think we've all seen that, and what used to be, at least for an ACL return to play, a Lachman examination and, you know, a leg press test that looked symmetric, and a prayer, for me, more than most, you know, I think, in many ways, has now evolved to sophisticated motion screens, mechanical assessments, much more sophisticated assessments of muscle strength than just a leg press test, and as I think about what's in the professional training room today, it's mind-boggling that when you're establishing or evaluating somebody, you'll hear somebody present more FOMIX data on the muscle volume, then you'll see metabolic data on their ability to perform with serum lactate and VO2 levels and then you'll see heart rate variability data, and you realize all of those parameters are going into their return after a hamstring strain, and so all of those modalities are likely here to come for us for the bigger injuries of return, so I think it's an interesting window, you get into seeing it early and then realizing that much of that is coming for our general population. Which is great, right, because our patients are always asking, oh, what are they doing at the professional level that I can do? Dr. Alderady, are there any updates or recent advancements on the medical research relevant to military athletic performance optimization? I think the majority would be, as Stefania said, would be game-changing, excuse me, as part of the topic for our discussion now would revolve around recovery, resiliency, and really paying attention to the mental game. As we continue to talk the continuum between recovery, performance optimization, your day-to-day job, for the elite tactical athlete, their daily job is something that is very different than when they hit the door in another country, so trying to peel apart the mental aspect, what I'm seeing most is the look in UNC and University of South Carolina's look at lymphatic flow and the brain's ability to take out the garbage, how we can relate that to ketones and sleep and breathing, and suddenly the emotional burden associated with what our special operators do is a lot easier to deal with on a day-to-day basis. So I'm with you guys, I think the majority of what we see from the elite sports athlete or elite killers are going to be resiliency-based and paying attention to emotional health, and I think that's where we're gonna make the majority of our money over the next 10 years. Stephanie, you've covered a lot of athletes over your career at ESPN. Many have suffered significant injuries and have made these incredible return-to-plays at a very high level. What are some similar characteristics that you have seen amongst these athletes? It's interesting because I think the terms I would use have already been brought up by everyone here. One is focus. They tend to have an ability to focus in on the task at hand, don't pay attention to a lot of the outside noise, tend to not have an entourage of people that's telling them all what to do because the more chatter there is in the environment, I think the harder it is for them sometimes to concentrate on themselves. So the very singular focus. A lot of the athletes I talk to when they're recovering or on the other side of it, I think they're really good at focusing on the short-term goals too, with the long-term goal staying out in front of them. In other words, when they're a few days out, they're not worried about, when am I getting back on the field? They may ask that question, Robin's right, they all wanna know how soon they can get back, but they quickly shift to a focus of, well, if I'm gonna be running and cutting and doing whatever on the field of play, I need to be able, they recognize, I need to be able to walk without a limp, I need to be able to straighten my leg fully, I need to be able to do X, Y, and Z. So they're very good at putting the small goals, they can break it down. And I think they recognize that when they have success with the little things, they can build on that success. I think it also helps them stay positive because they can see this measurable success as they go forward. And then the resiliency, I mean, that term keeps coming up, but I do think it's that ability to bounce back. They'll allow themselves a little period of grief for what happened to them, but it's very short-lived and they move right on to focusing on how they're gonna be able to come back and what they need to do to get there. The other thing is I find that the best athletes are the ones who are supremely engaged in their rehab. And I don't say that just as a PT, but because I have seen some pro athletes who have worked with their rehab staff and as they're getting closer to more functional activities, shall we say, they're actually ping-ponging their ideas off the rehab staff to say, well, why do you want me to do this? And they'll get an explanation and they'll say, well, what if I did it this way? Because for what I need to do, I think this will help me more. And it's incumbent upon the rehab personnel to allow that as well and to encourage it because then there's this dialogue between the athlete and the people that they're working with, that they're working towards a common goal together that's very specific to what they need to do. And it's one of the reasons I always loved working with athletes is because I think they are so good. They're mostly so in tune with their bodies. They know what they need to be able to do. And we're all talking about how everybody's unique and it's a unique approach and rehab should be that way too. So even though there are general parameters and general timelines and all of that, there are ways to make each person's program very specific and tailored to what he or she needs to do to get back. And I think those are the people that have the most success. Leslie, how do you manage an overweight or an underweight athlete? Well, first of all, those words are politically very incorrect right now, especially about saying overweight, over fat. It just doesn't go well at all. I've been talking about optimizing body composition and to me, it's always first and foremost, muscle preservation because it needs to be. So just thinking about cutting calories across the board doesn't guarantee that somebody is exclusively losing body fat. They may be losing muscle mass at the same time. Secondly, it is especially on the overweight side is not being extreme with those recommendations. Don't eat this, don't eat this. You have to be an X percent body fat. Let's just stop with that already because there is no science that would be zero to say that somebody has to be X percent body fat to excel at their position, no matter what sport it is. That's not helpful. It's actually bullying to do that to athlete. I've been in this field for 40 some years, so there's no filter in anything that I say. It just is that way. Third, when we're talking about overweight, when we're talking about being overly fat and trying to optimize body composition, I think a lot of athletes truly don't realize that beverages can be their downfall. It's like, oh, it's light beer. It's like, no, if you have a case of it, problem. Or that they don't eat regularly because I think I should just eat once a day and then they eat their arm. I mean, it's things that athletes do in response to the fads that are there that are not helpful. So number one is consistency, eating on a regular basis. Number two, it is increasing protein intake, not to the exclusion of all else, but enough consistently through the day for muscle preservation, as well as to help with satiety between meals. Number three is bringing up fiber intake because that's the fill-up factor. That takes up more real estate in the gut. So if an athlete doesn't want to have something green, they might have something red, orange, or yellow. And I do use smoothies in that regard because I can put a lot of stuff in it that doesn't have a high-calorie cause to be part of that fill-up factor. All those things can be helpful. On the other side, for athletes that need to put on some weight, and I've been doing this for a long time. When our younger son played soccer in high school, his coach over the summer said, put on 20 pounds, and I said, that is so not going to happen. He wasn't ready to do that, and it's just, he wasn't built that way. Now, he's enormous. But nonetheless, we have to realize that some athletes just don't have big appetites. So just to eat more. That's useless if somebody doesn't have a big appetite. So it's optimizing what it is somebody eats to get the most calories with the smallest volume. That can be really helpful. It is making sure that nothing is consumed that is zero calories. So just drinking a lot of water over the day might be something for hydration, but it does nothing in terms of helping a player to put on some mass. Thinking about optimizing at the end of the day. Not to the exclusion of all else, but it's one more opportunity to eat. And there are a lot of athletes, regardless of sport, won't do anything before they exercise. They don't like the way that feels. Or they won't do something after because A, they're too tired to chew. Or B, they don't want to consume the calories. But those, parenthesizing those times, are really part of the solution to helping somebody to optimize. And last but not least, it takes time. Nobody is putting on 10 pounds of muscle overnight. Nobody is losing 10 pounds of fat overnight. And when do we start to make those changes? It is before training camp. It is as soon as season is done. That's when we start to work on it. And refer to a sports dietitian because they really know how to do this. Marcel, what are the principles of periodization? And how can they be applied to help to optimize an athlete's performance? So in our scenario, when I first got to the Steelers in 2001, our off-season program was 14 weeks long. Lo and behold, now we're down to nine weeks. And then the players leave for us for roughly six weeks. And then they come back to training camp, which is a whole beast in itself. And then we have the season. So from a periodization standpoint, we use, I would say like a combination of a few different things. But if you start any periodization type of program, let's talk about like in the off-season program where we have nine weeks. We have 14 different programs for the players when they come in. Because some of the people, you don't even know their name. Some of the people may have pre-existing injuries. So from a periodization standpoint, it's difficult for us really to get into anything too much. We're basically learning each other's name. Do you have certain medical conditions that we need to be aware of when we're taking you into the weight room, out in the field. So our medical staff, our training staff does a great job. And I will get to the periodization aspect, but I want to preface it based on what we're dealing with to know what we can and can't do. Because if you take a guy and there are many of them who haven't done anything from January up until the middle of April, you can't jump them in on day one with, okay, here, we're doing bench press today. And you ask the guys, you've been doing it. Yeah, I've been doing it a bunch. And then your first rep, you're sitting with a pec injury. And then now the whole off season is completely gone. But we move forward to training camp. Training camp is different because of the CBA and the agreements. The first couple of days, we're basically in underwear, we're in shorts and helmets. And then once we get into pads. So from our periodization in training camp, we always work backwards. And we do the same thing during the season. We know that when we have our days off, those are the days, the day prior is the day that we're gonna have our big leg lift because we wanna give them as much recovery. And I know that's one of the questions on here today is recovery. Recovery is such a huge aspect. I've only been doing this for 23 years. There are people who've been doing it for a lot longer than me. But when I got into the league, recovery wasn't even a question. Everybody just, you tried to get the guys to work and now it's the inverse. Now you're trying to get the guys to do less so that you can monitor and take care of all of their needs. But going back to training camp. So in camp, you have to work backwards based on your days. And then once you get to the season, then everything changes. So last year was really fun. So our strength staff sat down. We had a couple of new modalities in the weight room. We were super excited. We were gonna try something brand new. And lo and behold, we play the Bengals, the first game of the season. The game goes to overtime. We had four players with over 100 snaps in the game. Normally in a practice day, these players have 30 snaps, right? So what do you do after they just played 109, 108, 104, and 103 snaps? Everything that we had planned from our periodization standpoint, we went and grabbed all the papers out of all the cubbies for all the different players and we threw them all away. And that's the sport. That's the nature of the sport, which is, for me, it makes it fun because it's never Groundhog Day. You have to go with the flow. If we play a physical team, like if we're playing the Ravens and such, we know our O-line and D-line are gonna be beat up. So we know we have to prepare for that. So I know I'm kind of avoiding the periodization question, but you just have to understand where you're at and what you're doing in order to make sure that you're ready for the next week. You guys have it great. I mean, obviously you've won the NFL Strength Coach of the Year for that reason. So, Dr. Forrest, what techniques or strategies do you use to help athletes manage performance anxiety? Sure, I think first it's normalizing anxiety in general, helping an athlete understand that in a competition situation, it's very common, if not normal, to experience some degree of anxiety. And that sometimes a certain level of lower anxiety can actually help an athlete perform to the sense of it may push them to work hard, be prepared, things that are gonna help them get ready to perform. But we want them to understand their body and what, again, what helps them perform their best and what gets in the way of performing their best. So that self-awareness of how their body feels when their anxiety starts creeping up that scale. And so I usually tell athletes that once your anxiety gets past a certain threshold and it starts interfering with performance, that's when we want to make sure we're aware of that and that you are confident that you have the mental skills to help bring that anxiety back down. What's tricky with performance anxiety is that once it gets to that level 10, sort of that red zone, it's a lot harder to bring it back down to be able to perform well. So we want that self-awareness to be part of the picture so that an athlete can start doing something about it before it escalates to a level where you're not really able to recover. Different mental skills that can help with managing anxiety, and some of this is certainly well before game day. So learning how to manage your self-talk, so the awareness of how you're talking to yourself and having more neutral thoughts. You can say positive, negative thoughts. That's a more simplistic way. You don't have to necessarily have positive thoughts to manage your performance anxiety. It's just being more neutral, focusing on the facts, the data, versus the positive things or the negative things. A lot of times, athletes, when they are getting more anxious, they start having thoughts that escalate, and they'll be, what if I mess up? What if coach pulls me out? Those types of thoughts that tend to become distractions and escalate anxiety. So we want them to be aware of that and how to bring their self-talk back to something that's helpful. So one of the things that can really help with that is helping them focus on their intention. So when they start feeling a little bit more anxious, check in with their self-talk, challenge that, and usually coming up with, again, the cue phrase idea or a mantra. So a lot of athletes I work with will pick some kind of phrase that reminds them what they want to be focused on versus what they don't want to be focused on to help manage that anxiety. So I've had athletes think about focus on the moment or breathe or relax, some kind of word that helps them get centered and have that calm sense of confidence. And they'll do things to remind themselves of that word. So I've had a gymnast, she would write the first letter of each word on her hand. So if it's focused on the moment, she'd have FM or something just to remind her, or a lacrosse player on his stick, he writes breathe, where these little things they're gonna see during their performances that kind of help them get that anxiety in check. Other than the self-talk piece, I think breathing exercises, mindfulness, those are skills that are gonna help manage anxiety in general, where we can't always control all of the physiological responses that happen when we start getting anxious and have that stress response escalating, but you can control your breathing, you can control your muscle tension. And those are two things that can kind of slow everything else down so that then you can control your self-talk. So they're all connected. And we try to work through that to help an athlete connect those aspects. Another piece that can help just with the confidence that can ultimately lower performance anxiety is going back to that visualization piece. So we talk about an athlete, like where do you get most anxious before or during a game? Let's visualize yourself being calm, feeling confident. What would that be like? And they'll mentally rehearse that over and over and get those repetitions in so that when they are there on game day, it's much easier to do. So those are a few of the techniques that we would use. That's great. Let's see. Ashish, how do you manage an athlete in a long season who has a chronic injury or chronic inflammation? Medically or how do you work with a team to manage that? That's a good question. Also a tough one, Robin. I think we all have that with athletes. There's certain things that are the acute issue and then the chronic conditions, the tendinopathies, maybe the recurrent muscle strain patient or athlete. I guess, first and foremost, sort of the principle of identifying what is that and how have they managed it before and what's been effective and what hasn't been effective. Maybe trying to pick an example of that, which is common to all the different sports are the tendinopathies. And I think proof of principle, sticking to some of the conventional modalities, which we definitely know, which is working with a great strength and conditioning staff and physical therapy staff to make sure that they're on the right stretching programs and they're on the right maintenance programs as much in the off season as during the season, because we tend to, as the team physicians, we see them during the season, but much of what's happened in the off season affects their response. I think it was mentioned very well by the panel already that sometimes these chronic conditions present at different times during the season based on the ramp up or when it's later in the season and there's been fatigue. I didn't want to use maybe the controversial word workload, but I think something we have to think about. And then I think other things are to keep an open mind. Certainly in even my time of being a team physician, what used to be conventional anti-inflammatories and corticosteroid as kind of the full arsenal for things beyond rehab has now changed more so towards some biologic options or even things like needle fenestration and modalities that aren't the typical ones that I thought about as an orthopedic surgeon, but have had to have an open mind to. And I think we learn from conferences like this where we're learning each year a little bit more about which biologic might be most appropriate for which condition and that even the term PRP is a bit too heterogeneous. PRP for an intra-articular injection with a chronic arthritic knee in an NFL player might be a leukocyte poor preparation with a specific goal, but a patellar tendinopathy that needs a little bit of deliberate stimulation might be a leukocyte rich formulation and neither of those might be correct for a muscle injury. So those are the things that I'm trying to think about and certainly don't know all the answers to, but I think as we continue to learn the biologic space might be the most exciting one for us to manage the chronic issues. Sounds great. I'm gonna ask one more question and then we'll move to questions from the audience. Dr. Alderete, are there any special resources or support networks in the military to assist athletes with injury rehabilitation, mental health, overall performance? What's different in the military versus in the professional athletes that we have? You know, Robin, great question. And you know, I've spent years talking about it, the military-civilian relationships and we tend to look at our elite sports colleagues and figure that you have the answer to everything as you're looking out or back into the military, especially the special operations commands and say, well, wait, don't you guys have the answer to this? And the funny thing is that we have had to, in the walk before you run phase of understand now that we're the Ranger, the 75th Ranger Regiment SPAR Program now created at Intrepid, as well as some other military-civilian relationships like INOVA and EXOS and Steadman Hawkins, where we reach out as resources in the elite units and our elite operators will go for six or eight week programs and then come back into the system in order to figure out where they are, as Marcius said, in periodization, but where they are in executing mission versus training of a daily time period. So the biggest assets are the three advanced rehab centers in San Diego, San Antonio and here in DC. And then from there, it is the military-civilian programs like we're developing at UT now or the Human Performance Institute, which will largely be both a DOD and civilian sports program. So we've come a long way in trying to get more assets available for the elite tactical operator, but I think we're still running around in the dark a little bit. Well, it's a team approach, right? We all work together and I think that by feeding off each other and learning from each other, that's what helps us. Absolutely. Some of our athletes and patients. Are there any audience questions? Sorry. Steve, can you do me a big favor? I left my phone right down there and so I can't see the questions. I'm so sorry. It's just right in the front bag, yeah. In that bag right there, that bag right there. Sorry. Anyone have questions for that? Come on up. There are no questions and I'll just go on. Let's see. Just give me one second here, sorry. Leslie, are there any hydration strategies that you use or recommend for optimal performance and are there specific metrics that you use? I know there are all kinds of sweat tests and you can weigh the athlete before and after practice, but what's your technique? Yeah, and I would say that after practice, but what's your technique? Yeah, and we do sweat testing and we have a couple of players that are gonna be trying to nix biosensor this year as something brand new and gimmicky, but what I think is also critically important is that we talked about before that it is not one size fits all. You have to have enough, but that upper limit really is going to vary depending upon that individual and his or her sweat rate for the sport that they're doing, number one. Number two is a lot of athletes, regardless of sport, might focus on hydration during activity and then they're drinking nothing the rest of the day, being camels. Well, that's not really helpful because then you're already in catch-up mode. So we have to make sure that baseline needs are met and it may or may not surprise you, not everybody's doing a great job with getting their daily baseline needs met, 2.7 liters for women, 3.7 liters for men, and that does not include what fluid needs are for exercise. Secondly, is a lot of people hear just water. Of course, that is a fluid. It's not the only fluid and whether it's sparkling or oxygenated or hydrogenated or whatever else it is, it's still water at the end of the day. It's still going to be fluid for the body. Right now, because of the preponderance of caffeine containing beverages on the marketplace, which does not dehydrate the body, doesn't, it certainly can interfere with sleep and other things that it does, but we've got a lot of athletes who are overdoing with that. Well, I'm hydrating. It's like, yes, but now you're also too wired and stimulated, that could be a problem. Oh, but can I just do 3.7 liters of beer a day and wouldn't that count? Well, technically, yes, but obviously some issues around that degree of alcohol consumption and then sports drinks is the other component, which yes, maybe for some athletes when they are involved in a rigorous activity, however, electrolyte loss in football is not necessarily enormous. It's going to be a lot more in marathoners, ultra athletes, triathletes than it is in football because it's more stop-start and that is an occasion use on the field, not when somebody's sitting down and eating a meal. So I think the bottom line about this is really needing to optimize and individualize and ask. We can do very simply way in, way out. We can also do P charts. Why color charts? Well, it's kind of a good indication if somebody's not voiding at least five times a day, the chances are they're not well hydrated. And as much as I've said this over 40 some years of doing it, I still say it every day because hydration never takes a vacation and we want to make sure that people are getting enough consistently. All right, so we have actually a lot of questions here and we only have a few minutes. So I'm going to start with the top one, but the top one is for Erica. Have you ever suggested that an athlete watch a movie like a Hoosiers or another video to help motivate them or relax them or distract them? Yes, we've talked about definitely some movies, books, probably a little more often. I think it depends on the timing. So if it's a distraction and they're maybe traveling with a team and they're getting ready for competition, if before they go to bed, if their mind is kind of ruminating on things they're worried about for the competition, yeah, maybe watching a movie that's somewhat motivating. I think that can definitely be helpful. I would just make sure that whatever movie is recommended that you're familiar with it. So you kind of know like what it's going to entail. Because if it has something that could be more distressing or give the athlete something else to worry about, then it's probably not so helpful. Documentaries have been good. Like, you know, there's a documentary with Lindsey Vonn and her recovery from ACL. It's a little traumatic watching her ski and her falls, but at the same time, like her perseverance and resilience getting through her injuries. Like, so sometimes if you have the right person you're working with, I think, yes, they can be helpful to recommend to an athlete. That's great. Let's see. So here's another question. This is for Ashish. With the transfer portal, essentially creating free agency in college, there is an all-time high in athlete movement between teams. How do you deal with onboarding athletes into the circle of trust of the medical athletic training staffs and are they different from the homegrown, recruited or drafted athletes? Yeah, that's a really good question. And there's obviously a number of different ways and there's obviously a number of, you know, NCAA team physicians that are right here that are actively dealing with it. I think what we're increasingly seeing is that environment because of that free agency, if you will, is looking more and more like professional athletics. And so in the past where you sometimes inherited that athlete and you knew that they were there and there was this trust in the journey, it's required, at least on the team physician side, I think a lot more attention to documentation, a lot more frequency of meeting and discussion with the athletes so they feel very informed about what's happening. And obviously even now with representation in the form of what are the equivalent of agents, you know that not only do they need to be informed, but those that they're communicating with may seek those opinions and consultations. So much like there's a importance at the professional athletic level of great documentation and information of the player and the agent. I think the same is true now in the NCAA level. I also think it's great forums like AOSSM, though where all the team physicians who are working with those teams, whether they're at the University of Michigan or University of Iowa or University of Wisconsin, all three of those team physicians are here. And if they're collegial and communicating, usually there's a lot of respect for their care. Great, well, thank you very much. We have a minute to spare, so we'll end it. But thank you, it was a great panel discussion. Our next session is Pushing the Limits, Team Physicians, and we have Dr. Mora and Dr. Yagnan as moderators. Thank you.

panel discussion

sports performance

rehabilitation

experts

mental health

recovery

sports medicine

individualized approaches

technology