Pete, thanks so much. That really was kind of a great roundup of a lot of things we were talking about. So I'll invite the panel up here to have a question and answer before we take a break. And if we're ahead of time, we might, maybe we'll come back and finish the day a little bit early. So we're a few minutes ahead of schedule, which is great. So feel free if anybody has questions, come on up to the microphone and we can get this discussion going. Tim. Almost back on the IR there, thank you. So I think there's a great talks by the whole panel. I think that from, at least from the orthopedic surgeon community, I can speak for that is that we don't get a lot of training of that until we start working with teams. So I would encourage you all just to continue to educate all of your physicians as well. Many people just assume that physicians know all about this stuff and we really don't until we start working with the team. So that's great. I've seen a big change over the last, you know, 15, 20 years of what's done in the training room and we certainly have a lot more gadgets. Julie, well really for everybody. Is there such thing as, you know, it's so important now that to get treatment, we say you got to get a treatment, you got treatment and the athletes want to get better faster. So they're going to go and get treatment. Is there such a thing as overtreatment? I walked by sometimes, let's just use the example as maybe a medial gas drop strain. And I'll see them getting some mechanical work on it and some soft tissue work. And then they go to a meeting and then they come back and they're getting more work. And I just wonder sometimes, it's not always clear. Are they still inflammatory or now are they in the remodeling? And how do you judge that? How do you educate your colleagues in terms of are we overdoing it or can we overdo it? Yeah. Julie, you want to take that one? I think that's a great question. I want to piggyback on top of that. And then they may be getting additional treatment when the workday is done. You talked about your workday with their at-home masseuse or chiropractor that they're seeing on the side. So how do you balance that? Yeah. So I think the big thing with that is education for, especially for the outside part. So talking with your athletes about what you're doing, what you're treating and why you're doing it so that they understand what you're doing. So a lot of the stuff that we're doing. So let's take your calf strain that we were talking about. So yes, we're going to treat the calf, but we treat everything around it. So you're going to go above and below. So while I might spend 15 minutes treating the actual site of his injury, I'm going to spend another hour and a half treating above and below it. So yes, I do think there is a point where you can treat too much, but I think you have to look at what you're treating and why you're treating it. So again, while the distinct injury might be in a certain phase of injury, the other parts around it are not necessarily. Sure, there could be some secondary ischemic damage that you're dealing with, but if you're looking at that ankle joint, that hasn't been damaged in the calf strain. So again, yes, I do think you can treat the injury itself too much, but again, I think you have to take a step back and look a little bit more at what you're treating and why you're treating it. I think the second part of that is that what we're still not really good at with all the new technology that Julie talked about is what order do you do it in? I know if I'm going to piston somebody, I might end with laser, but again, there's all of these different things that we're still trying to figure out what's the best order to do it in. I know I'm going to use heat at the end. If I'm using light energy, I'm going to use that after I use my ice because I want that ATP flying around to create as much healing as possible. So that's some of the stuff I struggle with for sure. Yeah, I think it's all about finding the sweet spot. I think it's a great point. I think sometimes we get stuck in the ways of we're doing things just to say we're doing it. So when a coach or a team walks by, hey, we're doing everything we possibly can, and yeah, we do throw the kitchen sink at them oftentimes, but I think Julie made a great point in our talk is get them moving and we'll spend some time in the athletic training with them, but some part of that's got to be in the weight room as well. We tell them that's part of your treatment, in the meeting room as part of your treatment, on the field doing some kind of alternative exercises as part of your treatment, and it doesn't need to be on the table 24-7. It's case by case, obviously, but some guys, there's a psychological effect to it too. The more you treat it, the more they think about it, and we've got to be aware of over treating the body and the mind at the same time and just trying to find that sweet spot with whatever we're dealing with. I would just add this, like that notion of doing too much, I mean, that's sports as a whole a little bit right now, like let's talk about youth sports in general. I think we talked about it this morning about you've got a calendar year with no scheduled breaks for club soccer, right, or AAU basketball, et cetera. So to Julie's point, I think a lot of it comes back to scheduling and education, but you definitely can do too much from a treatment standpoint. Maybe ask if you all can comment, kind of synthesizing the metrics and the wearable data that we get with some of the return-to-play discussions, we've found to be helpful. Even just simple numbers, as was mentioned, you're coming back from hamstring, usually you're at 22 miles an hour, now you're only at 19, you're not ready. But what have you found to be helpful for using this data both with the player and the coaches for these kind of return-to-play decisions? Yeah, I think it's a couple-fold, right? Like accelerations, decelerations for sure doesn't mirror what they're doing in the game, what the demands of the game are. Speed numbers for certain, high-speed yardage, and again, they're objective tools that help you make decisions, but they're not the be-all, end-all. I can remember having a conversation with Lee Weiss during training camp, we did a joint training camp practice, and he said, hey, we rehabbed his hamstring, I met all the metrics, we hit all the speeds, right, and he was one of six that went out and kind of tweaked himself. So again, they're a tool in the process, they give you good information, but it's that individualized kind of holistic approach that's going to keep your guys on the field. Yeah, I think it can be a double-edged sword, too. You got to blend science with art. You get nervous about the player who's feeling great, doing great, we talk about, and we put a metric on him, and all of a sudden he's 85% of where his speed was, and all of a sudden now I'm not doing as well, and we go in the tank. Sometimes you can use it on the guy that needs that confidence, and say, hey, look, you are at 85% of what you were, that's unbelievable, you were at 65% a week ago, so you really got to know your audience, you got to really know what you're doing, and I don't know if Julie and them put a metric on Patrick before they were returning him, maybe they should've, and it would've held him back a little bit, but you know. Our game. Yeah, that's what I'm saying. So it just depends on who you're treating and what it is, and how you want to utilize it, but science and art, I think you got to blend it. I think with that too, you have to really take into this objective as well, because they might be at 100%, 90%, whatever it is, they're running 23 miles per hour, but they're telling you they feel like crap, or they're running at 15 miles per hour, and they say they feel great. You got to find somewhere in the middle, it doesn't really matter if they can run really well and still feel like crap. So as much as the objective is helpful, you also need to take their subjective into account, and again, I think that's a big part of what we kind of have echoed as athletic trainers, we have that unique relationship with them to really dive into that dialogue with them as far as the mental side of it, and where they are, and what can we do outside of just the treatment, the metrics, things like that, that can help make them feel better. I don't have anything to add to that other than to say that it's just, it's going to be a collaboration now with sports science being there to objectively identify stuff. Sports science, rehab, and performance will come to some type of consensus based on what they're seeing in each room, and that's what's going to happen. You know, one thing we'll actually do with the measurables, much like before you send a guy with a shoulder MRI or a low back MRI, hey, don't be surprised if you have a labral tear, don't be surprised if you have a disc bulge. So before we put a measurable on a guy, I'll say, listen, don't worry about what the result is. This is just us to get some information. Don't worry about it. So if he does well, we can celebrate, and if he doesn't, he's not already going to be disappointed at a result that he's getting. So we kind of preface it for him a little bit to temper the expectations before we put something on there for a turn of play. Yeah, I mean, what we hear a lot, and some of it's mental health, some of it's personality, and kind of resiliency in the player, and kind of mirroring and matching the expectations with the objective data with their personality. I think our coach does an amazing job of that. I mean, he knows if somebody's going to be back from a hamstring in three weeks versus five weeks better than any data can show just by their personality. So I think there's a big part to that. So I guess along those lines, the question we have in the last couple of minutes we keep bringing up is kind of mental health, though, is how do we de-stigmatize it? How do we incorporate care of their mental health in the facility, in their lives? What are some tricks that you guys have found to build your teams? Because it sounds like there's some great teams out there. Joe, you guys have three mental health providers in-house? Yeah, and I think I referenced this. Mental health has to become part of your fabric, right? They become part of just your building day to day. Kyle brought it up, right? You don't want the stigma of the mental health clinician walking up and saying, hey, how you doing? Yeah. Right? That's red flags all over the place. As you have these practitioners in your building, as they build relationships with your players, with your coaches, et cetera, it really, the usage grows exponentially, and the stigmatism of talking to your mental health clinicians really goes away, per se. The first year, so we started mental health in our building in 2013. And for the first two years, utilization was kind of up and down a little bit. But as those clinicians stayed around, as they became part of the fabric, as everybody became comfortable just talking to them day in and day out, no different than any member of your staff, that stigma kind of goes away, the utilization goes up. And again, I just stress, it's not isolated to your players. I mean, it's your staff, it's your coaching staff, it's your personnel staff, right? Everybody benefits from having mental health clinicians in your building. Once they're part of your fabric, you'll see those utilization numbers really go up. Mm-hmm. I echo what Joe says. Again, I think it's just the boots on the ground. I think Kyle said it earlier. I think he said organic. Like, everything's just going to happen organically. I don't think, as much as we want the magic answer for mental health, I don't think there is one. And it's not something that you can force. If you force, you're going to meet resistance from it by them. So it just has to happen organically. David, my coworker here, he makes fun of me and calls me Mama Jules. Like, for whatever reason, sometimes we'll be in the middle of a rehab session and now these guys are telling me their life story. I don't ask them that. It's just what happens between our bond. And that, I think, is what's going to carry over into then. I now know when they come in, if we're having a bad day, okay, what's going on? And where can we make adjustments or how can I help you? And I've literally said to some of these guys, how can I help you? I'll go with you. Do we need to go talk to somebody? We'll go down there and talk to them together. What is it? What do we need to do? So, again, I think it has to start even lower and then kind of work its way up because there is that huge stigma. And like I said, I don't think there's a magic answer. I think Dr. Conquost said it best when he showed the statistics. And I'll back that up. Just in 1989, when I start seeing people in a clinic, I think probably when you do your intake and you ask if they're on any medication, there was probably, I'd say, one to two percent that used mood-altering drugs. When I left the clinic environment in 2019, I would say 30 to 40 percent of the people were on some type of Zoloft, Paxil, you name it, Lexapro. So it shows you where we're at as a society. And remember, these kids, this is tough growing up now. They've had instant gratification with social media. And when things don't work out immediately, they're wondering why it can't be fixed. So I found out it's just best to listen to them, let them say what they want, and just guide them the best you can without offering too much advice. I think a good listener is as effective as most anything. We have a question out there? Yeah. Thank you so much. So along these lines, I don't know if any of you have come across screening tools or even tracking in terms or in regards to mental health. It can be something as simple as I've heard of sort of text messages where they answer three simple questions per day. Just something that's a little bit more effective than, you know, the casual one-on-one conversation. We don't have a formal screening tool, although to Kyle's point during his talk, I think your screening tool is the system in your building. Your screening tool is really everybody that interacts with your players on a daily basis, whether it's your equipment staff, right, somebody in the cafeteria, Julie just referenced like a player may just pull you aside and say something. I think in terms of formal screening tool, no. But I think if you think of mental health as a system and really kind of take that approach, if you see something, say something, and that stigmatism goes away, that's how we see most of them. Yeah, I would agree. It's not a black and white thing. I'm not discrediting forms, whatnot, but if I had to fill a form out every day during COVID, they'd probably put me in inpatient. So I think, you know, it depends day-to-day when you're asking your players questions. I think you can watch them walk through the door and figure something out is going on. The players can see it, the locker room can see it, training room, kitchen, the kitchen staff. We get our kitchen manager involved when we ask how they're interacting. And the guy that's usually jovial is now snapping back on somebody. So that's probably going to tell me more than three questions on the text. But again, it's the organic system that we put in play, like Julie was just talking about as well. And I think we would struggle with guys being honest, because at the end of the day, you know, we're talking about the best for these guys and how we can help them in their healthcare and getting them back on the field. And these guys all want to play. They are pushing themselves. This is how they put a roof over their head, food on their table. They do not want to miss time. So if there's anything that they think might, and again, that stigma of mental health. And I think it was Kyle who was talking about that we can get fined if we start talking about some of this stuff. So like they're trying to destigmatize it, but the guys still don't trust it. They look at the NFL, sometimes the team, like that's the man and we can't tell them things. And I think again, to keep echoing the same point, the organic parts where you're the one they're going to be honest with, because we have let them know that we care about them as people, as an individual, and we care about them, not just in football, but in life. And I think that's what really hits home with them. So if there's something where they just have to like answer, and again, unfortunately our guys don't pay attention to stuff. Some of the answers we get to some questions sometimes are off the wall. So I don't know how honest they would always be with something that they would do every single day like that, versus just the everyday interactions. If someone's acting differently, something's going on. That's how I just look at it. If they're acting differently, they got something going on, something going on at home, something's going on with somebody around them. And then I just keep an eye on that. You know, to build on Julie too, the thing that's difficult for us at our level is these guys are in a business, they have a window of opportunity to make money. And I think the average NFL career is what, like 3.2 years. So they don't want anything held against them that's going to affect them. So when you start collecting that data, the agents will tell them, don't give that information. So it's a fine line. It's a tough line to walk. And we try to do it as organically as possible without putting that stigma or doing something they feel like is going to be held against them. Any other questions from the audience? Well, I think we'll wrap it up here. We had a great session there. Thank you to the speakers and great questions and engaged audience. So we'll be back at 4.30, we'll take a break here. 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sports medicine

over-treatment in athletes

wearable data

mental health in sports

organic approaches to mental health care