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thanks very much for uh that nice invitation bores thanks for inviting me here
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uh and the organising committee i really have enjoyed the lectures and
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just the chance to get together and i share information so hum on
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i'm a canadian i was recruited to stanford university almost twenty
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five years ago to start or sports medicine program
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course the reason i any chance i get to say i'm canadian has to do with recent political events in united states but
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but there's also an expression sort of a ah what behind the ears are being thrown to the walls
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when i started at stanford university it was a very high stakes endeavour
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and at my job was to set up a new sports
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medicine program which included take care of athletes i included
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teaching research setting up sports science lab raising money building a whole new clinic
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there were a lot of pieces to make it work it had to work for the coaches we have a hundred and seventy coaches
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and had to work for the medical school that had to work for a hospital they had to
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somehow make money doing this had to work for the university it had haven't academic enterprise
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so all those pieces had to fit together and was a great deal
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of work i and all that we had good leadership at stanford
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you can you can see that when you're stressed in the middle of
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this kind of high stakes endeavour it's a daunting task we had
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nine hundred athletes and the the director scott that's the us thing
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so unfortunately most of my examples are from the us
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the director's cut is given out each year to the best division
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one a athletic school in america and stanford is one that
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these last twenty three years all these national championships and olympic medals so i've had a
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chance to see the types of problems that is being presented by the lectures
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i also have a chance to see the other side of it because i've been the director sports
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medicine there for this period of time i wanna talk a little bit about the other side
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not to be negative not to be critical not to sort of drag us into another space
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but these are three areas that i think we would benefit from reflecting on
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and thinking about one is how are we doing it preventing sporty injuries the second is
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um what about the long term consequences we've heard more about that
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this morning and then also hobble this issue of promoting
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um exercise to prevent disease so let's begin with injuries
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i'll give you this case example because it's not a muscular skeletal case this was a young
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man transferred to stanford university ah to play football he had he model been se disease
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uh he hadn't had true sickle cell crisis so we're gonna prevent anything happening from this young man
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we need before the season with the coach and with the position coach and with a cardiologist
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with him the taller just with the athletic trainer with the strength the conditioning coach
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with the physical therapist we haven't meeting and a short way into the season
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he has an upper respiratory tract infection slight fever and
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he's asked by an angry coach who directs the
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strength recognition people to put them through a very rigorous anaerobic work out any in fox's spleen
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and you can these pictures here this is uh in this and you can you can see the spleen here this little
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light grey areas the only healthy area of spleen left these arrows to mark the spleen this is this panic artery
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and had a spleen removed so despite the very very best attempts within the system
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that we thought we could manage and control these things um do happen
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so what are we doing about prevention the question is is a good question it turns out a lot is being done
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what we know in united states ten thousand support injuries they are seen in the birds apartment
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sixteen percent um non fatal injuries and athletes are
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sports injuries in children it's forty six percent
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um these are all data gerald have atlantic training association
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but there's been very little change in the overall
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a prevalence of sporty injuries uh in injury surveillance is
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complex but it appears it's very difficult to but
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um the injury rate that's despite journals injury prevention the british
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journal sport medicine with their special injury prevention issues
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a world congress held every third year in disease prevention we're
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doing a lot the question is um has really dropped
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the prevalence the incidence of injury or the way i see it we can
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do three things in relation to injury prevention the first is training
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and by training i mean everything i mean training to prevent
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injuries training for agility strength probe reception speed power
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that's one opportunity we have to do research and implement programs
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a second does equipment all kinds of equipment for protecting injuries
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the third opportunity which was mentioned this morning in the in the first lecture by doctor newman about concussion
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rules and regulations so how are we doing uh i think we're doing pretty well with training
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we've done a lot of research on the benefits of training and i think we're probably doing pretty well on equipment
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the the place that we're not really touching the sweet spot i was
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the phrase used earlier is this this area of rules and regulations
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we went we took a look at this a few years ago and publish all of the studies in injury prevention
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in these three areas one of them is training studies physical training
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state there's a lot of these categories you don't really need
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to look at these are the quality of the studies but you can see from nineteen seventy four up to the present
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there's a lot of studies published every year on on
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various aspects of training no training for muscle training
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and so forth equipment a few less but still eighty publications per year uh in this category
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in that period of time how about regulation studies well almost none
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and the question is why i'm don't we have studies done on
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the rules and regulations that govern the safety pins work um
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i think it's i think it's this reason and you may or may not agree with me it would be
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i'd love to discuss with you what i've seen over the years is these two worlds are different world
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they have different core values that that's not true for exercise in hell for even recreational
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sport and hell but when it comes to competitive sport those values are different
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the values um associate with elf so it's not those two worlds coming together as much as it
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is the person who connects them the coach the physical therapist the athletic trainer that position
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those are the people who connect those worlds by understanding the
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unique demands in the athletic environment and they are unique
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and practised the time under principles of quality help to get that
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balance point the transparent it's discuss that's known by everyone
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acknowledging the strengths and weaknesses in that balance point uh and the potential for
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conflict of interest this is reality that i've experienced over twenty three years
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and we see lots lots of cases um of injury uh in high level laugh it's
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those this is very helpful to me to think that there are two worlds
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and he the issues about the connection between those two world and this is well
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recognise last year harvard university published a study in the national football league
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that said the intersection of doctors uh in their in their care of of athletes
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in the n. f. l. crates ethical and legal quandary that can affect help
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medical personnel caring for these players shouldn't um report directly to teens or coaches no i don't know how
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that sits with you as you hear that but it's a common theme that's starting to appear
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and the reason it is it is there's a conflict of interest
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potential in sport and in madison which we know this was written up in a very
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fit a five hundred page report by the institute of medicine in washington d. c.
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conflict of interest is the set of circumstances it's not
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a person it it's it's a set of circumstances
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the crater risk that professional judgements regarding a primary
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interest will be unduly influenced by secondary interest
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so five if i'm being paid by the team and i get nice clothing that's the secondary interest so is there
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a chance that the environment when set up in that environment predisposed me to make it onto word medical decisions
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and you know i've been involved in these conflict of interest cases um all the way to the
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entertainment industry that the michael jackson case what i what i can tell you is it this
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the secondary interest is psychological weekend the think this isn't ethical or character issue do i have the
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character ethics put myself in a position to be involved with this team and still like
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decisions for the health of the athletes that are in their best interest it occurs at an unconscious level
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and and what i mean by that is that every single one of is in this room no matter what africa
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level we aspire to order what character we we aspire to
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work our rest of being influenced unconsciously bodies effect
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um so conflict of interest it occurs when professional judgement concerning
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a patient's welfare is unduly influenced by secondary interest
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we need to keep that in mind because the sport the competitive sport and the whole world are different
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it's not black and white it's not binary there's actually a level of risk some
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environments are very very high risk and some environments are much lower rates
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but it creates in increased probability of an onto word medical decision
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and you may be able to think back in some of those decisions in your practised but it's very important
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to remember didn't emphasise not integrity character ethics it's unconscious
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we can you can do experiments and people will change the decisions they make based on secondary gain
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how can you reduce it well you can recognise that exists you can discuss
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it amongst all the team members present in a room like this
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you can create a safe environment for frank discourse and you can say
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this is my primary interest another person say that's my primary interest
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and foster that that goes on long way to reducing conflict
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of interest uh in a fireman as an example
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in making return to play decisions you relies in conflict of interest there's three parks
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um the first part here is tissue hell persons coming back from an
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injury how healthy user tissues the bone ligament tendon muscle recovered
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and so fort that's one set of decisions and you you can he
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discuss these openly in the group of professionals that you work with
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and the second is the evaluation of risk well that's what loads are we gonna put on that's got
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and they go back to play their sport what you can look like how's
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it gonna affect the tissue those the risks associated with loading and finally
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aside from the tissue health and the rest of participation there's
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different levels of less tolerance just like we heard
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um in the in the lecture but fun cardiac that not everybody has the same level oppressed alright
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so but so we have transparently an openly discussing this and reducing conflict of interest
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so when you when you break it down include like that open it up look at the various um
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aspects that are our primary interest in secondary interest to the
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people that i think i would like foster improve discussion
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so we're rules and regulations in support so far that's
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being and untouched area i think it's really
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a fantastic opportunity for us to make real progress in injury prevention
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because otherwise we're over here on this medical scientific rehab side
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its borders over here on their side and and we're not influencing either side
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but to be able to truly integrated get together and do what's best for the athlete would be the ideal situation
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okay number two is what about the the long term health problems and there's been a little bit of discussion about that how
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are we doing with that part of it well concussion we've heard about this is the north american football case alex smith
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play for the um sent just the forty niners got a concussion self recorded the concussion or
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the coach so you didn't see the trainer or this is your therapist the doctor
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came off and never played again again for um the served just
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before you know it was traded to kansas city chiefs
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so there's a lot of uh we we've talked a lot about concussion
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but again we bought up against the sport system which values participation
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and the next you know backup quarterback a man so concussion has just
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achieved this mass of attention in the media all over the last
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let's say seven years maybe ten years there's movie out now with with will smith called concussion
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and this doctor bella all that was one of the controversial i say controversial because some people
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believe in the boston research concussion data some people don't and it's like that in
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all areas of science we wish we could be on the same page
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we cannot sports illustrated enormous saying you for bargains child abuse
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so we've gone from spark participation a few years ago
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two now your football this child abuse or the way i feel about ten is it i wanna be
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in the medical profession the leader of this i don't want the media to be the leader
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this begs the question what was i going on the side loans of
00:14:10
football games for the last twenty years was i hoping yeah fleet
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so rather than our profession being dragged into the media's attention to football
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and concussions the question is why are we leaving it where really advocates of hell
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for the athlete remember whatever clears a starting quarterback got his helmet knocked off
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in a game against um the fighting irish notre dame and uh
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you know we've had no injury he was funny actually went back into the game and within minutes the new
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york times was on the phone and i said well you know i don't talk to be one
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and present university phone upset you talk to the media because if you don't talk to me they're gonna suspect worse
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and the media really lead this whole chart what are we doing in terms of advocacy up
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in terms of you we know the short term health effects is also longterm health effect
00:15:07
we need the courage to build a bring those up in a safe environment within which to discuss them
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and another aspect beside concussion is this one of
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long term uh injuries to new joints
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or other joints that are associated with significant injury not overuse injuries
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incredible burst and a roll bar wrote this about a decade ago
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we should question whether we should even be sending athletes back
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to support after an a. c. l. reconstruction we know that the news not normal we know the risk of osteoarthritis is
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already high we're going to produce a generation of people with
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ruptured ligaments unstable joints were going to develop arthritis
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so these questions need to be asked and they need to be a considered
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jim crockett was a quarterback at stanford went on to win the superbowl um
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you won several super bowls and this just came out a week ago my life sucks ass with people
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who have a lot of surgeries i think he's at seventeen surgeries um end up like and the question
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and and then uh for example as we just for what what are we doing
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by clearing um women were high risk for low bone density to
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compete of course the fast they have less body fat
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they're faster than somebody with more body fat and we we
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asked this question to a group of sports medicine physicians
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just to have them at one of the team physician courses uh and they said that um i eighty percent
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of them said they would clear for participation it's email cross country runner with the b. m. i. sixteen
00:16:45
and no waiting for three weeks and no changing bone mineral density the same thing with the bone real narrow a woman
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of the bone mineral density down one point five standard deviations in an area to be my eighteen were clearing up
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is that the right thing to do we've we've got this sort of like a sea of concussion chasing is down now
00:17:05
opted in your times as an article body us football player was charged with murder committed suicide in prison
00:17:11
twenty seven years will be just released his brain biopsy results which said they're the same as the seven year old man
00:17:18
so we've got that and we've got asked your throats is is this our next epidemic
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so this isn't to sound emotional or panicky but i think that we need to be
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advocates we need to think about this and one way to think about it is
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the same way review informed consent if if you're going to have
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minor surgery given in appendix out or some surgery like that
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you are given informed consent these are the risks of an aesthetic that these are the risks of the room coming opened
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the essence these are the risks of wound infection and so forth and you you know what those risks are
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these individuals young motivated and and hoping to to achieve great success
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are are not able necessarily to listen to informed
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consent but these individuals um i found over
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and over i've seen lots and lots of cases that have come back the end
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ah and and that they that have come in later to me and say thank
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you very much for taking you know when i was younger or oh
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for whatever reason so we have to be navigate implements to reasoning include the most uh look
00:18:25
in the church eek when you're seventeen year old student stanford university without your parents
00:18:30
it's likely you're not gonna make your best decisions high level stress intimidation
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if we could get to a point where we can we can provide someone like jim plunkett with informed consent
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and say you know mister plunkett chances when you're sixty nine years all your your life will stock
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they can still do what they want to do but the chances are out
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with all of these injuries they're gonna have a problem informed consent
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involves them um exactly as you said shared decision making so they can make that decision and i think
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that's important otherwise we're sitting back and watching uh instead of being you have to get the third
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i think i think mark brought this up initially this the shoes disease prevention
00:19:13
um i wanna talk about that a bit because it is so very important and somehow it's being thrown
00:19:19
into the world of competitive sport my question is does it fit in this world of competitive sport
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we all know how bad this problem is like every single day there's a new report coming out
00:19:32
doing the neural medicine last year said that obesity increases the risk of thirteen types of cancer
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for women who are obviously haven't eight times greater chance of getting and mitchell cancer
00:19:44
world health organisation physical activity is the fourth leading cause of mortality and it goes on and i got mackenzie
00:19:51
said that in a few years half half of the world is gonna
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be obese and already costs about twenty percent of health care dollars
00:20:00
so i won't go over all those but the key thing is that this is true and all
00:20:05
countries in the world countries like malicious and bangladesh have the highest incidence of diabetes and obesity
00:20:12
that it's it's outstrip aids h. i. v. t.
00:20:15
b. malaria in developing countries thirteen one
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so this is a global problem and those countries deal with
00:20:22
that even less well than we do in western countries
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uh because they just don't have the resources in dollars to do it so the organisation
00:20:31
for economic cooperation development exactly calculated how much this is gonna cost developing countries
00:20:37
our goal here just to review is this kind of occur so here we have aged yeah and here
00:20:44
we have functional capacity much about functional capacity could be
00:20:47
your shrink your bone density mitochondria volume density
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it could be any measure of capacity but over time we have this kind of
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for looks like this and we die you know roughly let's say around eighty
00:21:02
the idea is not necessarily to push 'em life expectancy
00:21:06
that's possible but most studies show it's it's
00:21:08
only a few years back it's didn't that first meeting capacity over a longer period right
00:21:14
that curve not only costs a lot of money but it means that you get these
00:21:18
people cannot walk up a flight of stairs in airport i can't carry their grandchildren
00:21:23
that's the goal is to move this people functional capacity
00:21:27
to this paper which is possible to do so
00:21:32
how do you do it well the world health organisation nineteen seventy
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three said we're dealing with this huge epidemic prevention is difficult
00:21:41
and four years later they said the same thing noncommittal not
00:21:45
communicable diseases account for sixty three percent of deaths worldwide
00:21:50
now we have a lot of research we have a lot of white papers recommendations evidence base standards
00:21:55
and this is really the kind of result we've been seeing in
00:21:59
terms of reduction of the morbidity mortality from chronic disease
00:22:04
so we get frustrated we love to blame the government they need to change policy
00:22:09
they need to do something about the shoulder and they need to do something about the fast food industry schools need
00:22:14
to do a better job of educating students and parents and we need to have his head in schools
00:22:21
we have to bring the food industry although what happens in place like i am or
00:22:26
where they grow corn for corn syrup is it that industry is so well insured
00:22:32
that uh even if you lose your krakow to hail or locust you still get
00:22:36
your money so that's the the sugar industry is just fine in america
00:22:40
we love to blame medical schools they don't teach enough to doctors about this
00:22:44
we love to blame the patient i've told you what to do
00:22:47
you need you better you need changes i need to change excise habit
00:22:51
so there's a lot of blame going around and the sport community
00:22:56
um has just taken this on a sort of a sport
00:23:00
for all everyone's an athlete but here's here's the reality
00:23:05
the disease prevention world is not acquiring for sport governing bodies
00:23:10
and this paper cannot just um i think this summer
00:23:14
twenty sports federations ranking of priorities this is what the
00:23:19
priorities hell for the general population was ranked bottom
00:23:22
i kind of feel that fits they've gotta get competitive athlete out there to
00:23:26
win this is not a priority disease prevention for sport governing bodies
00:23:31
and you know adrian bowman is published this looking at the
00:23:35
outcome of the winter olympics in vancouver twenty thousand children
00:23:39
we're study before and after the olympics had no measurable impact on the
00:23:43
physical activity uh he wrote an article or they rode argo also
00:23:47
related to the the the one the linux which we've talked about
00:23:51
systematic review funding absence of evidence that hosting let the games
00:23:55
improves a general activity here's a us paper the san diego union
00:24:00
tribune said london olympics but for more exercise flops but
00:24:04
what i'd like to say is i don't think that pass
00:24:07
of top down methods will work because this is us
00:24:12
oh what a lot is exercise diet behaviour
00:24:17
the question is the how and that's the important question and it's a big question and it's an important question
00:24:23
and passive talk down mechanisms don't address this question
00:24:29
this is called the knowing doing gap it's being i live in the middle silicon valley it's
00:24:33
been studied in industry it's being it's how they built the i. phone the computer
00:24:37
how do we get people to cross that knowing doing yeah i know what's right i know what's good
00:24:43
what do i do i will one is um data evidence standard requirements that's
00:24:49
really how science and medicine operate they produce that kind of data
00:24:53
and then on the next really is
00:24:58
well is it affected human factors page into a intuition and so forth
00:25:02
so these are two very different worlds and this is a very very complex world it's
00:25:08
not going to be a passive ambassador from olympic sport that make that change
00:25:13
so if we've learned anything about about behavioural change is that it's not top down and just
00:25:20
a couple other things to say about this in the new england journal of medicine um
00:25:25
you know the combination of behaviour and genetic predisposition true expression
00:25:30
uh behaviour is seventy percent if we fine tune healthcare sports science in every aspect
00:25:36
um we will get about ten percent improvement uh in the contribution to to premature
00:25:42
deaf so our our opportunity is behaviour and we need to think differently
00:25:48
and i'd leave you with with this idea somebody you might work near if human
00:25:52
centre design human centre design is nothing short of revolutionary for changing human behaviour
00:25:59
and it's a set of tools that determine the unique needs they care to care about the individual end
00:26:06
user determine the unique needs in design programs around that it's it's um it's a nice though
00:26:12
r. rated set of tools that used widely in industry and i mean widely
00:26:18
um but it's not use in healthcare it's not used in sports science it's not really used and that
00:26:22
isn't so we won't spend time going over that but it is a powerful set of tools
00:26:27
and um i just wanna show you a couple of examples um this is a g.
00:26:32
e. award winning scanner built by g. healthcare madison wisconsin by this engineer dark deeds
00:26:37
he went to the first installation that scanner any saw um to parents and their
00:26:42
little eight year old daughter walking down the whole the daughter was in tears
00:26:47
and he said why inches i don't wanna sit in that dark scanner making all that noise
00:26:52
he went was pretty set you no matter no matter how many a word sweep one for this new scanner she doesn't like it
00:26:58
and they went back and a design this set of adventure scanners pirates in space men
00:27:04
and they reduce the need for conscious sedation from eighty percent
00:27:07
to sixteen percent which means parents could stay home
00:27:10
'kay gets the scan they don't have to come in and be with them during cost conscious sedation
00:27:15
so the key is something to be feasible and viable it works but if it's not desirable
00:27:21
it's not gonna happen and behavioural change for disease prevention
00:27:26
has to be desirable so we need to understand what's important to individual people before we design programs
00:27:33
and finally i'm told wendy tells about when you went to province in rural india
00:27:40
uh upper dash where they have neonatal hypothermia babies are born
00:27:45
and they get cold and they get sick and they get actually serious on this is so
00:27:50
the smartest thing to do ship a bunch of incubators over but the problem is
00:27:54
that little possible has that has an intermittent power grid they kept plugging yeah
00:27:58
so the smart engineers say no problem we will ship over solar panels
00:28:03
and then we can power those incubators the problems they have monsoons in india can someone
00:28:08
said well why don't mother's whole the little baby close to their warm body
00:28:13
that is the right question because culturally they don't do that and they would
00:28:17
have to have a complete change in in nursing education and so forth
00:28:22
another example an older woman of arthritis do you have trouble getting the little offer pill bottle no
00:28:27
her husband who was a meat cutter died ten years ago and she saw as the top off
00:28:32
so our ability to understand people to ask the right questions to find out what motivates them is key
00:28:38
um if we're gonna make a real difference in disease that okay never want progress
00:28:44
with injury prevention requires to begin to focus on rules regulations i think that's really important
00:28:50
and if this team really comes together and cares about what each other does
00:28:54
i think it's possible adverse longterm health care outcomes require that we give athletes informed consent so they
00:29:01
know what they're up against with what you're doing and finally sports who wish to promote hell
00:29:06
we'll need to use some new non top down on

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Conference program

Welcome
Frederic Koehn, President Young Athletes Forum Foundation
21 Sept. 2017 · 1:18 p.m.
3,124 views
Opening address
Boris GOJANOVIC
21 Sept. 2017 · 1:22 p.m.
131 views
Biological Maturation and the Path to Success: Before and After the Fact
Manuel COELHO-E-SILVA, Biological Maturation and the Path to Success: Before and After the Fact
21 Sept. 2017 · 1:31 p.m.
549 views
Designing pathways to success – part kaleidoscope, part microscope
Jason GULBIN, Designing pathways to success – part kaleidoscope, part microscope
21 Sept. 2017 · 1:53 p.m.
372 views
Talent ID and Development: Why doing the “right thing” is not always the “best thing
Ross TUCKER , Talent ID and Development: Why doing the “right thing” is not always the “best thing
21 Sept. 2017 · 2:16 p.m.
332 views
104 views
Resistance training during long-term athlete development
Urs GRANACHER
21 Sept. 2017 · 2:52 p.m.
343 views
The development of aerobic power in young athletes
Grégoire MILLET
21 Sept. 2017 · 3:15 p.m.
1,462 views
Fueling the young athlete
Asker JEUKENDRUP
21 Sept. 2017 · 3:36 p.m.
193 views
Training young athletes: challenges and opportunities
Marco CARDINALE
21 Sept. 2017 · 4:01 p.m.
181 views
TRAINING THE YOUNG ATHLETE - Q&A
Panel
21 Sept. 2017 · 4:33 p.m.
Coaching from junior to the top of the world (Lara Gut)
Patrick Flaction, Elitment
21 Sept. 2017 · 5:20 p.m.
189 views
Knee ligament injuries in immature athletes
Franck CHOTEL
22 Sept. 2017 · 7:48 a.m.
Osteochondral lesions
Franck ACCADBLED
22 Sept. 2017 · 8:11 a.m.
216 views
INJURIES WITH THE ORTHOPEDISTS - Q&A
Panel
22 Sept. 2017 · 8:54 a.m.
Back pain in young athletes
Liba SHEERAN
22 Sept. 2017 · 9:34 a.m.
Long term sequelae of youth overuse injuries
Mark BATT
22 Sept. 2017 · 10:19 a.m.
OVERUSE INJURIES - Q&A
Panel
22 Sept. 2017 · 10:40 a.m.
Concussions in young athletes : myths and reality
Christopher NEWMAN
22 Sept. 2017 · 10:52 a.m.
Screening for heart disease in sports – nonsense or necessary?
Matthias WILHELM
22 Sept. 2017 · 11:16 a.m.
Competitive Sport & Health: hidden issues
Gordon MATHESON
22 Sept. 2017 · 12:04 p.m.
Injury prevention programs : The 11+ Kids Project
Mario BIZZINI
22 Sept. 2017 · 2:12 p.m.
104 views
158 views
Parents’ Knowledge of Sport Psychology and Nutrition
Dr Camilla J. Knight
22 Sept. 2017 · 3:57 p.m.
Closing Address
Frederic Koehn, President Young Athletes Forum Foundation
22 Sept. 2017 · 6:04 p.m.