#76 Sports Medicine & Performance: It Takes a Team

[0:04] Shot clock at 0:05. Vanfleet using his screens. Oh Vanfleet again! His third three pointer! Throws it into Leonard. That's it! It's over, the Raptors win!

[0:18] On the ice with Iginla. Iginla - Crosby scores! Sidney Crosby, the golden goal. And Canada has won the Olympic gold. What a goal!

[0:46] Canada's first Grand Slam Champion.

Grace Jacobs [0:50] Hi, everyone. We're very excited to bring our Raw Talks first podcast collaboration. I'm Grace, one of the executive producers for Raw Talk.

Swapna Mylabathula [0:56] And I'm Swapna, one of the executive producers of Medicine in Motion podcast. And of course, I've been part of the Raw Talk family for about three years.

Grace Jacobs [1:04] Today, we're gonna explore the various perspectives that make up the world of sport and health

Swapna Mylabathula [1:08] From coaching, improving performance to injury management and prevention to the challenges associated with athlete maltreatment and abuse.

Grace Jacobs [1:17] Sports are a huge part of our culture, from the individual level where many play recreational for exercise and social benefits to the national and international level where professional sports are a huge industry worth billions.

Swapna Mylabathula [1:28] Sports can strongly unite people but athletes of every level from the weekend warrior to the professional athlete can face challenges that remind us that there is a team behind the team, helping maintain their mental and physical health.

Grace Jacobs [1:42] Welcome to Episode 76 of raw talk podcast

Swapna Mylabathula [1:46] and a special episode of medicine in motion podcast.

Grace Jacobs [1:49] Let's begin.

Dr. Doug Richards [2:27] Sport medicine is a multi professional field that involves people from many professions and multiple disciplines within each profession. So the profession of medicine, we have people from disciplines of primary care Sport and Exercise medicine, orthopedic surgery, plastic surgery, physiatry, neurology etc. pediatrics all involved in sport medicine and then professions physical therapy, athletic therapy, kinesiology, massage therapy, chiropractic, dentistry, podiatry, or pedority, etc. The list is quite long.

Swapna Mylabathula [3:04] Very multi-disciplinary.

Dr. Doug Richards [3:05] Yeah, well, very and multiple, let's say I'd say multi professional and multidisciplinary within each profession. So not everyone who winds up going into sport medicine like me. I didn't know I was going there. So I didn't study exercise science as an undergraduate. I actually went back to school after I was a physician for 15 years to study biomechanics, because I realized that to be better at my job, I needed those Exercise Sciences that I hadn't studied. I had studied mechanics in engineering, science and so on. So I had a good background, but I hadn't done the biological side of it. So if I was doing it a second time around and I knew I was going to wind up in sport medicine, absolutely. I'd want to study undergraduate Exercise Sciences like in a kinesiology program, before going on to a second entry program in medicine or physical therapy or professional kinesiology or whichever professional branch I wanted to pursue.

Grace Jacobs [3:55] An important aspect of sports that is often not talked about, but for which there is an increasing amount of research is the pervasive maltreatment that can negatively impact athletes at all levels of sports from the amateur to the professional level.

Swapna Mylabathula [4:07] We heard from expert Dr. Gretchen Kerr.

Dr. Gretchen Kerr [4:10] So my name is Gretchen Kerr, and I'm a professor here at the University of Toronto in the Faculty of Kinesiology and physical education. I did degrees in both Kinesiology and psychology, and then liked them both equally. So I did my graduate degrees in sports psychology. And as I was finishing my doctoral work, I got what I thought was my dream job, which was a sports psychology consultant for a team of athletes that were headed into the Olympics. I thought this is a fabulous opportunity. And most of them were young female gymnasts, and I was asked to work with these athletes to make them a little more mentally tough, more resilient. Some of them were crying in training or losing their skills. And my job was to help them with these things. And then I discovered by talking to these young people, that there weren't any issues with them, that they were responding quite appropriately to situations that no young person should have to endure. And so I thought, Well, what do I do? Do I teach them coping skills so they can just go back and try and deal with the abuse they were suffering? Or do I try and change the sporting practices that led to the abuse, and so I fell into the whole area of athlete maltreatment. I tried to work with the coaches and the sport administrators to suggest that there were healthier methods to develop talent in young people. And their response was of course quickly to fire me. So that was a very important lesson, you know, I lost that position. But at the same time, I couldn't stay within that system and work within their conditions. So then I turned my research to athlete maltreatment, and trying to affect coach education so that different strategies would be incorporated.

Grace Jacobs [6:19] Dr. Kerr defines maltreatment as an umbrella term that consists of physical, sexual and psychological abuse, as well as neglect, harassment and bullying. It's kind of an all encompassing term, that's just the experience of harm.

Dr. Gretchen Kerr [6:31] Often the words harassment or abuse are used. In the research realm. We prefer the word maltreatment because it also incorporates neglect, which has shown at least in the child literature to be just as detrimental to young people as the other forms of abuse.

Swapna Mylabathula [6:49] Often we think about or hear about maltreatment that involves coaches impacting athletes, but there can also be athlete abuse caused by other athletes.

Dr. Gretchen Kerr [6:58] Given the amount of research that's been done on bullying. I mean, it's quite massive. And it's focused on young people primarily, in in educational settings, or others. But curiously, there's been very little research done on bullying in sport or sport teams. And the suspicion is that's because there's such a focus on sport teams being cohesive and gelling together that there almost is an assumption that bullying wouldn't occur. We've conducted a number of studies within the last five years primarily with inter-university teams, and have discovered, not surprisingly, that bullying does exist. And bullying in sport differs a little bit from bullying outside of sport, because it tends to be based on ability. So even if you're a senior member of the team, but you don't have the same ability, you're going to be bullied. So it was less so about seniority on the team. As it was athletic ability.

Grace Jacobs [8:10] Dr. Kerr points to a recent prevalent study that showed that maltreatment isn't an isolated issue in just a few sports. The study examined 84 able bodied and para sports in which maltreatment was found to exist.

Swapna Mylabathula [8:22] And it's not clear if maltreatment is more prevalent in some sports over others, though, there is growing evidence that female athletes report it more than their male counterparts. And that pattern is not surprising as it is reflected in non sport literature too including in education, business and the private sector.

Grace Jacobs [8:39] Check out the study linked in our show notes for more information.

Swapna Mylabathula [8:43] As we learn more about athlete maltreatment and its negative consequences. We're also learning more about what aspects of sports lead to maltreatment.

Dr. Gretchen Kerr [8:51] So sports an interesting world because for the most part, it's directed towards performance outcomes, things like winning, you know, gold medals first place and so on. And, in fact, the funding system used in sport in Canada is performance based. So those athletes and teams are those sports that do particularly well, internationally get more funding, and those that don't do as well get less funding. So that leads to a climate in which there's can be a win at all costs attitude; that the focus is on the outcome, regardless of the means by which you get there. And if those means are harmful, and it still leads to a gold medal, the gold medal is what is the focus and I think the the best example of that is the Larry Nassar case in USA Gymnastics, where here we have someone who perpetrated a sexual misconduct against hundreds of athletes across decades. Some of those survivors were on the USA Olympic gold medal team. Which leads us to question two things. Well, many, many more questions. But the some of the questions that leads to include, how much better could those athletes have done if they hadn't experienced sexual abuse? How many athletes were left in the system before they got to the Olympic level because of the sexual abuse? And of course, the question of, there's no way that someone can abuse so many people over such a long period of time, without someone knowing or someone suspecting. And so it's important to look at athlete maltreatment in, in a broad way, look at the whole ecological system around sport. You know, where were the sport administrators where were the coaches where were the physiotherapists and sports psychology consultants in that case, there's lots of pressing questions. And it's not those aren't limited to the Nassar case, we've had our own Canadian examples as well.

Grace Jacobs [11:13] Another reason that athletes can be vulnerable to experiencing maltreatment, in addition to this focus on performance, is that coaching itself is not regulated in any way.

Dr. Gretchen Kerr [11:22] So there are some educational requirements within the coaching realm for coaches, but they're very minimal. And there's no regulatory body, as there is with physicians or teachers. A body that has the authority to say, you know, you've engaged in misconduct, we're taking away your license. And so what we see happen is coaches who engage in misconduct, just move from club to club or from province to province. And and that is also a barrier to dealing with this problem. We have this system in sport that kind of assumes if you've been a good athlete in that sport, you can coach, which, of course bears no resemblance to any other sector. Just because we've all been students doesn't mean we can teach, for example, so but making coaching more professional and having a regulatory body I think would also be helpful. It's not the only answer, but it's a piece of the puzzle.

Swapna Mylabathula [12:28] Maltreatment is a widespread problem that is difficult to tackle, especially because it is often not reported. We asked Dr. Kerr how we can combat athlete maltreatment.

Dr. Gretchen Kerr [12:39] You know, I think certainly part of the answer is around education, education for coaches, and sport administrators, but also for parents, because we can't ignore the crazy things that happen in the stands or on the sidelines, from parents, even in youth sport, where it's all supposed to be about fun. And so, you know, remembering what the purpose of sport is, and educating around that, I think the other thing is at the elite level, there's nothing wrong with focusing on winning, aiming for the medals in the standings. But to think more deeply and critically about how to produce those outcomes. So rather than thinking that we have to yell and scream and be critical of athletes in order to make them mentally tough, to look at, how do we make them as whole and as well as possible, because when, when any of us thinks about when we perform the best at whatever- school, our jobs, in our relationships, it's when we feel good about ourselves and we feel supported. And so, you know, just imagine the athletic performances, we might see if athletes had that kind of support and foundation to produce those those performance outcomes.

Grace Jacobs [14:11] Different coaching styles and strategies can have a huge impact on an athlete's psychological experience and performance. But what is the best coaching staff?

Dr. Gretchen Kerr [14:19] So the research would say that the type of controlling coaching style, more authoritarian, it's similar to you know, the parenting styles along those lines. It's also of interest to note that the way coaches are portrayed in the media, particularly the most popular sport films, you know, Coach Carter, and those types of films all illustrate the coach as being quite autocratic, yelling, screaming using punitive strategies and so on. And this is what we call controlling coaching style.

Coach Carter [15:00] Gentlemen you told me you deserve to be here! Well you're not playing like it. All season long, we play our game- right now, you're playing theirs! When we step on the floor, every second that clock is ticking, we are pedal to the metal! We run the ball! We pressure the ball! And most importantly, we control the tempo of the game! We make them play Richmond Oiler Ball.

Buzzer [15:29] Beep

Coach Carter [15:30] We got 56% from the line. From now on, before you leave my gym, you must pay an exit price of 50 made free throws before you can go. That's everybody.

Dr. Gretchen Kerr [15:45] So this is the style that that has more negative repercussions on on athletes, both their performance as well as their well being. We've also learned that with a controlling style of coach, there's higher dropout rates. So we mustn't forget about all of those young people who could have reaped the benefits of sport participation, but dropped out because of these controlling coaching methods. So on the flip side, what's encouraged in the literature and borne out by research is what we call athlete centered coaching or humanistic coaching or democratic coaching. Lots of words are used for this. But it's it's as it suggests, it's focused on the athletes health and well being first and foremost. It's a style that involves athletes in decision making at an age or developmentally appropriate way. It considers the athletes well being not just while they're in the sport, but in an extended responsibility way. So a coach who coaches in athlete centered way asks the question, How are the experiences that young person is having today, going to affect their development long after they've left sport, and that's a critical piece.

Swapna Mylabathula [17:08] Speaking of different coaching styles, and what works best for youth athletes, Steph had the pleasure of speaking with Karl Subban.

Grace Jacobs [17:16] You may recognize him and his family as they have become a household name, specifically his eldest son, the Olympian and NHL hockey player, PK Subban, who's known both on and off the ice for his talent, charisma and generosity.

Swapna Mylabathula [17:29] Mr. Subban is the ultimate hockey dad. despite never having played the sport himself, the high school principal and father of five has raised three professional players, including two currently playing in the NHL,

Grace Jacobs [17:41] Mr. Subban shared his experience and advice for developing elite athletes and achieving your potential.

Karl Subban [17:49] I've spent my life working with children, I call it in three worlds, the world of education, the world of coach, because I've spent a lot of time coaching children in many sports, and obviously, the world of parenting, you know, obviously, I'm a parent everyday still a parent, and now a grandparent. So I've spent my life working with children. And the one thing I've learned the one takeaway, I think the most important one is working with children to help them to believe in their potential, and then supporting them to fulfill that potential, I think that is the most important work. And once you have that mindset, you just don't know where it's gonna take you. And that's how I think how our story played out. Because, you know, when you look at potential and the parts about having a dream, and it's so important for young people, to have a dream, and my kids have a dream, and, you know, and but you just never know what's gonna take you. And so it has taken them to where they, they want it to go. And but we know that not every dream is fulfilled, just like not every tree will bear fruits, but that tree serves a purpose. And so they fulfill their dreams, they continue to learn and grow. But even if they didn't reach their destination, it you know, that journey still serves a purpose. In terms of peak performance. No parent, or I never did, I can't speak for every parent. But we didn't start out raising our children to be NHLers, you know, we didn't start out raising them to be educators with my, which my daughters are. I mean, we started out spending time with them. You know, and and so that was the the key. I don't mind saying this. I've said it many times before. People want like they've asked me, did PK love skating? At two and a half and three and four? Yeah, I think you enjoyed the activity. But what I can say is that he loved being with his parents. That time with him, is what he looked forward to. Yes- when he was skating, we were there. But I believe that I really believe that if mum and dad, were not there with him, I don't think he would have enjoyed it as much. Because skating, especially when you're learning to skate, it's not fun. No one loves falling down, you know what I mean. And so what he enjoyed was the time we were spending with him. And then the skating started to improve. And I remember one of these things used to say to me, Daddy, Daddy, look at me, look at me. And you could, you could see him getting better. And you could sense that he's feeling better about himself. And when our children are doing something, especially at a young age, and it allows them to feel better about themselves, geez, you know, they start to feel better about their world and their place in it, and you just never know where it's gonna take them. I think that's where it starts in terms of building, you know, elite athletes, I don't think we started out to create an annually child, or to create an Olympian and PK playing the Olympics, but it's really to to spend time with them and develop that relationship with them. That is so important. You know, that's the foundation.

Swapna Mylabathula [21:11] What are different kinds of motivation in sport? And how did his children and he himself as a parent, stay motivated during their journeys in sports?

Karl Subban [21:19] People always wanted to know, if I really pushed my kids to skate. Did I really push them out hard, if I did, hard did I push them. But I often say that Maria and I, that's my wife, Maria, we push them more in the baby carriage than push them to skate. Okay. And, and so but I also on the other hand, I've said that I've never met a child or work with a child who could not have use some pushing. Right? I've never, but if you spend all of your time pushing them, they'll never end up where you want them to be in life. The trick is to inspire them. Parents, the trick is to inspire them, and see motivation. I can motivate PK, but unless he's inspired, it's not gonna last. Motivation is just that a thing that happens now, inspiration is more long term. It's like the long distance is like the marathon. That's what happens when you're inspired. You know, I can motivate you to run, and you do it quickly. And it's done. And so how do we inspire our children because it's not motivating them, it's inspiring them and inspiring them. It's something that happens from the inside, you know, so the trick was for us, and I said it, I said it before, and I'll say it again, it started out with spending time with them, spending time with them. If I said PK go and shoot pucks in the basement, maybe he'd go once or twice, but he's not gonna he's not gonna do it five or six times a week. And he did it because we were there with him. When he was shooting pucks in the basement. I was there with him or mom was there with them. When Taz and chip Taz, you our eldest daughter, nastasia, play basketball at York University. And she was a pretty good player as many records. But we were there with her in the basement when she's doing her dribbling drills, or we take her to the park, you know, we're there with them. Because kids at a young age, they want your attention. And they want your time. And so that's where the inspiration starts. You know, and, and so it starts out with them, loving the fact that you're there. And eventually, they'll start loving what they're doing more than the fact that that our mom's there. You know what I mean? They're not looking out for me as much as they grow older. And that's why I like to say to parents, you know, you're clear the way paved the way and get out of the way. You know, when I saw we started out clearing the way, and then we pave the way then you get out of the way, you know, when PK was young, and I use PK, because everyone knows him. I would carry his hockey bag at one time for him because it was way bigger and heavier than him. And he wasn't strong enough. But I but I can you I always ask this question. Can you imagine if I was still carrying his hockey bag at 14? You know what I mean? And so that's inspiration now- now he wants to carry his bag. I don't have to tell him to there is a point in time around 14. Now between 12 and 14, I didn't have to tell him about the importance of working out. I didn't have to tell him to go train. I didn't have to tell him to go shoot parks. That's inspiration. He's inspired. He has, he has found the passion. He has found his calling. And once kids find their passion, and they find that thing they love to do. We don't have to tell them to do it.

Grace Jacobs [24:44] Environments and higher level sports are competitive, it can be quite intense. What are some strategies for keeping a positive mindset?

Karl Subban [24:51] You know what we want young people to believe in themselves. Okay, and because if you don't believe in yourself, how are you going to fulfill your potential? How will you use those gifts you have to do better in this world. And so sometimes young people will believe in themselves. But we know that we have many who don't. And so I like to tell them to believe in their potential, because and that's why it's so important for young people to know what they're good at. You know, PK, and I use him as an example, he knew what he was good at, at a very young age before he was five, before he was three. And even probably before he could articulate it. He was good at skating. That's one thing he was good at. When children know what they're good at, wow, they become so much better at doing things in school, and in life, that that feeling is transferable to other aspect. And, and so to me, that's how they grew confidence. And that's all they, they will grow that belief in themselves. Potential looks like a three legged stool. It looks like a stool with three legs. I want everyone here to imagine everyone listening, I want you to draw a three legged stool in your mind. In the seat of it. I want you to write the word potential. One leg is a dream leg, that's the first that's an important part of potential having a dream. The middle leg is your belief system is your belief leg. The third leg is your action leg. Because a dream without action. What are you doing? You're just daydreaming. So that's what potential looks like. And so it's that confidence, and that belief in yourself and in your potential, that, "Wow", it makes you powerful. And that helps you to take on that helps you to deal with adversity. Because as you chase that dream, you know the part of potential, you're going to have doubts or people who doubt you, you will have setbacks, you will have challenges. And and so because you believe in your potential, and and because that feeling that you get from knowing what you're good at, and from working to be better, that helps you deal with those that help you to deal with adversities. I really believe that. And so you have this dream, you might not fulfill it. But you never know where it's gonna take you.

Swapna Mylabathula [27:15] Talking with Mr. Subban about fulfilling your potential was pretty inspiring, very inspiring. As he mentioned, you may not always fulfill your dream, but even coming close, or going through the process itself isn't just all for naught.

Stephanie Nishi [28:59] That's hard to hear.

Karl Subban [29:00] Yeah, but you know what, but PK worked through it. You work through it. Working through it- I'm gonna ask you a question. Did that strengthen his belief system and himself or weaken it?

Stephanie Nishi [29:14] I guess it just showed that he had the power to overcome that.

Karl Subban [29:18] We all have the power. We all have the power. Right? Because you see that belief system. It's like a muscle that we must strengthen.

Grace Jacobs [29:27] There are many positive aspects to playing sports. However, the mental health of athletes can be strongly affected, especially if they're in a situation where they're experiencing maltreatment.

Dr. Gretchen Kerr [29:36] So sports certainly has the potential to promote mental health and the whole area. That's called Life Skills Development, which is why a lot of parents put their kids in sport that they'll learn teamwork. They'll learn how to persevere, how to tolerate frustration. The lessons learned from losing, you know all kinds of life skills. That sport can help with and and there's a large body of research that looks at life skill development through sport so that evidence is certainly there. And on the flip side, we know that sport also has the potential to lead to very harmful experiences, maltreatment being one of them. In our latest national prevalence study of athlete maltreatment, we found that the athletes reported connections between their experiences of abuse and neglect. with mental health challenges, like depression and anxiety, eating disorders and disordered eating was a huge piece of that puzzle. And so there are clear ramifications of the very prevalent experiences of abuse and neglect. They often play out in terms of mental health of athletes. The other important piece to note is very few athletes actually report their experiences of abuse and neglect. In fact, less than 10% of our sample of 1000 athletes ever reported their experiences. Now, some of these experiences were characterized by psychological abuse, some with neglect, and some was sexual abuse. And even in the recent disclosure by Megan Brown, a U of T, former U of T athlete track and field athlete who alleges her coach at Guelph engaged in underage sexual relationship with her. She didn't disclose it until, you know, years and years later. And athletes don't disclose or report because of fear of what it will mean for their athletic careers, that they may get their funding cut or they won't get chosen for a team, they're very clear that they don't have a safe place to take their concerns where they won't be punished as a result of reporting.

Swapna Mylabathula [32:00] Luckily, we are moving towards improving how we address and prevent maltreatment.

Dr. Gretchen Kerr [32:05] There is a large movement afoot to lobby the government and sport Canada to create an independent body for athletes to report, where there is an independent body to establish mechanisms to investigate complaints, and to sanction where sanctions are called for. There are countries in the world that have regulated coaching, and required coaches to have a minimum education like bachelor's or master's of teaching, for example, so they understand youth and adolescent development. The counter argument that's used in Canada is that we have such a large volunteer base of coaches. If you go into any community, very often, it's a willing parent who's stepping up to coach the kids team in the fear is that if we incorporate more educational requirements and create a profession, that we won't have enough coaches, at least at the grassroots level.

Grace Jacobs [33:12] And while athlete mental health can be affected by maltreatment and sports, being sidelined by an injury can also be a challenging time.

Dr. Gretchen Kerr [33:18] There's quite a body of research a large body of research that looks at that question about the psychological recovery of athletes when they experience injury. And it's quite significant. If you can imagine, particularly at the higher levels, where athletes kind of put all their eggs in one basket, you know, training for an Olympic Games, for example, and then they become injured. It's not only taking them out of their their dream or their their goal, but it challenges their identity if they've been focusing pretty much exclusively on their athletic careers. The other aspect that's noted with injury is the removal from their social support system. No longer are they with their team, all the time training and so on. They're rehabbing on their own or with a physio or athletic therapist. And there's really a sense of social isolation that athletes report when they're recovering from injury.

Grace Jacobs [34:21] Retirement can also cause an athlete to question their identity. Like during injury recovery, it is time spent away from actively participating in the sport, though in this case, it's long term, Dr. Kerr talks about what happens when an athlete hangs up their jersey.

Dr. Gretchen Kerr [34:38] Retirement transition from sport is is really an area of concern. And it's been an area of attention, because the research consistently shows that for many athletes, it's an extremely difficult transition. Their identities been wrapped up in sport, so they have to do develop a new identity, their social support network has all been in sport. So they need to develop new social supports. It's a very difficult time for for many athletes.

Grace Jacobs [35:13] An injury that is increasingly being recognized and discussed is concussions, recovering from them can also be difficult and take a varying amount of time, depending on severity. Dr. Richards talks about some of the misconceptions about this invisible injury and our understanding of the pathophysiology.

Dr. Doug Richards [35:28] Well, the the misconceptions around concussions have lessened significantly over the span of my career, thanks to the efforts of people like Swapna, and others who've, you know, been on a crusade of sorts to increase concussion awareness. And in fact, the, you know, the first component of Rowan's law is that concussion awareness, education is mandatory in participants in sports that are covered by law in Ontario, which is great, because, you know, being aware of the fact that you don't have to hit your head, you just have to shake it, being aware of the fact that it's invisible many times and there aren't necessarily objective manifestations of disorder, there may be, but there may not be it may be entirely subjective symptoms that are manifesting, but that there nonetheless is a concussion in that situation, that understanding that it takes a variable amount of time so that you can't predict, you know, they're gonna, cause they're going to be out two weeks, you don't know that, you know, everyone's different, and so on. So the increase in awareness, you know, has been great nonetheless, there persist some of these myths, or you weren't hit in the head, you're not concussed whatever. Those those are much less than they were 20 or 30 years ago. The difficulties we face now are, you know, swimming in a sea of ignorance. I mean, we don't really have a super great handle on all the different types or components of pathology that exists within what really is a clinical syndrome, the concussion syndrome because it's a heterogenous beast, there are multiple different components of pathological anatomy that occur with different concussions and, and there may be subtypes based on pathology, but all of this pathology that we learn about from animal models and autopsies and, and some very fancy and expensive MRIs and MR spectroscopy that we can do clinically, is not applicable to clinical care. So, you know, I think, as we learn more about the biology and we improve the diagnosis of concussion to include diagnosis of the of the pathology, rather than just treating it as a purely clinical syndrome, you've got symptoms, you have a concussion because that's still where we're at and in 2020, for the most part, that the treatment will improve.

Swapna Mylabathula [37:55] Dr. Richards mentioned Rowan's law in Ontario, which is the very first concussion legislation in Canada passed in 2018.

Grace Jacobs [38:02] Which Swapna's research is playing a pivotal role in informing.

Swapna Mylabathula [38:26] The first is that they ensure that athletes aged 26 and under the parents of athletes aged 18 and under coaches, trainers and officials all confirm that they have reviewed the concussion awareness resources each and every year.

Grace Jacobs [38:41] Secondly, establishment of a concussion code of conduct that outlines rules and expectations for behavior to help support prevention of concussions and help foster a culture change towards recognizing and reporting concussions and away from behaviors that can contribute to concussion risk. This component came into effect in 2019.

Swapna Mylabathula [38:58] And thirdly, and lastly, establishment of both a removal from sport and return to sport protocol. And that component is to be in effect not too far from now, by July of 2020.

Grace Jacobs [39:10] Rowan's law doesn't stop at sports since concussions don't only occur when somebody is playing one.

Swapna Mylabathula [39:15] This legislation also covers schools with an updated policy that came into effect in January of this year. school boards are expected to have concussion policies which require individual schools all across Ontario, to comply with a number of different concussion related regulations.

Grace Jacobs [39:32] What are some other types of injuries that are commonly seen in a Sport and Exercise medicine clinic? Dr. Richards talks about the common types of injuries as well as how to prevent them.

Dr. Doug Richards [39:41] The most common trauma that we see where people are injured suddenly as result of bad movement or collision are things like ankle sprains and knee injuries and various contusions and acute strain injuries of you know hamstrings or calf muscles and there are a number of things that are fairly common- jammed fingers, very sorts of finger injuries and ball sports. Those types of acute trauma, concussions, unfortunately, facial trauma, dental trauma, all kinds of things happen commonly in contact and collision sports or even in non contact sports that are nonetheless at risk of trauma such as extreme sports, aerial sports, you know, all kinds of things people fall down and get hurt. And then there are the so called overuse injuries and I've got quotation marks around that in the air because it's not just about doing too much, generally, it's about moving badly. Movement quality is probably the most common cause. So for example, running poorly, causes runners knee or patellofemoral pain and throwing poorly causes throw or shoulder or subacromial impingement, the the underlying issues being not just that you ran too much or through too many times, but that you did so poorly. So there are lots of common overuse syndromes as well.

Grace Jacobs [40:58] These are the most common types of injuries in Sport and Exercise. But there are ways we can try to avoid them, as they say, prevention is the best cure. So how do we do that?

Dr. Doug Richards [41:07] Injury prevention involves looking at both what we call extrinsic factors that are related to injury and intrinsic factors related to injury. The extrinsic factors include primarily the choice of activity, which is the primary determinant of the risk of acute trauma, you know, if you jump off cliffs and wingsuits, you are likely to get hurt. If you play collision sports, like tackle football or full body contact ice hockey, you are likely to experience conducive trauma, it's just unavoidable. Other extrinsic factors include the use of safety equipment to mitigate the risk of some injury. So you know, wear a helmet when you're cycling, and you're less likely to die. rules that are based on safety, not hitting the head or checking from behind in hockey, etc. and playing in a safe venue not you know, playing basketball on a paid surface full of broken glass and dirty needles. Intrinsically, we look at people's movement capacity. Those are the main intrinsic variables, there are quite a number, I mean, things like age, and mass and sex are all intrinsic variables that contribute to risk someone. But things that you can do something about are your strength, your flexibility, your motor control, and I think that is the most important one, your ability to control your body in three dimensional space under the influences of gravity and inertia. And to be able to hold your body in correct positions and move your joints in correct sequences in correct alignment. That's what I was talking about poor quality running, the primary fault is to allow the hip to rotate in, bringing the knee medial to or inward from the foot, and the arch of the foot collapses. And this pattern of movement, which is exceedingly common, it happens to all of us, to some extent, is probably the single biggest movement quality issue causing injuries in sport- is poor running, where the knee comes in and the hip rotates internally. So we have the research on this is recent, actually just we're talking about the last couple of decades, and it's evolving and it's at the point where people are doing studies attempting to show prospectively and randomized with controls etc. that doing exercises to strengthen hip external rotators and abductor muscles that strengthening these muscles, improves running quality and reduces the risk of these extremely common overuse problems like Runner's knee, and tibial stress fractures and plantar fasciitis at the end, the list goes on.

Swapna Mylabathula [43:38] Movement quality really matters.

Dr. Doug Richards [43:40] "Quality is job one" to quote an old ad campaign from Ford motors.

Grace Jacobs [43:45] Speaking of moving quality, this aligns with the seven key features of movement that fellow U of T Faculty of Kinesiology and physical education professors and bio mechanist, Dr. Dave Frost and Tyson Beach promote for good movement quality.

Swapna Mylabathula [43:57] These features are things that folks can keep in mind in their everyday lives as well as in sport whenever they're moving and regardless of age.

Grace Jacobs [44:05] There are two for the knee, three for the back, and two for the shoulders. The first

Swapna Mylabathula [44:09] One- thinking about the knees, is keeping your weight over the center of your foot while you're squatting, bending over jumping or any of those movements.

Grace Jacobs [44:18] The second is keeping your foot knee and hip in alignment within the same plane. This is something you can think about when you're running, jumping or picking up groceries, whatever the everyday movement might be.

Swapna Mylabathula [44:28] So the next three are about the back, keeping your back straight, not arched not rounded. Avoid bending sideways unnecessarily and avoid twisting.

Grace Jacobs [44:38] So avoiding these movements helps you avoid inappropriate load over time by moving more with the hips. And the last two are to keep in mind when considering movements of the shoulder. Keep them back and down.

Swapna Mylabathula [44:48] These seven features of movement apply to every movement in every activity. keep these in mind next time you're shoveling snow, lifting your groceries or getting in some extra steps on the stairs.

Grace Jacobs [45:00] Dr. Richard saw many of the common injuries he mentioned during his time working as physician with the Toronto Raptors from their inception to 2004. He talks a bit about his experience with the team, and as a physician and a professional sport league.

Dr. Doug Richards [45:17] I was with them for nine years from the beginning of the franchise in 1995 until the end of the 2004 season and a little while into the summer, I was the primary care physician with the team, the head team physician was Dr. Paul marks the orthopedic surgeon with the team and the two of us worked as partners taking care of the team. As much as I would like to say it was my role to prevent injuries with the team, (it most certainly was not) at that point in the evolution of the franchise, the strength and conditioning, which is really where you get out injury prevention is movement quality and strength and conditioning. And I hate to use the term load management but you know, it wasn't invented by either the Raptors or kawhi. Leonard, it's, it's been around for eons. But gradually progressing with physical activities and and strengthening people appropriately. That was primarily the responsibility of the strength and conditioning coaches, and to a lesser extent, the head trainer, as he was called, or the head therapist who worked with us as physicians, but it's not like we were consulted on what the guy's programs would be, we would sometimes say, hey, this, this was usually in reaction to an injury. If somebody gets jumpers knee, then we'd have a discussion about what sort of squatting or lunging they're doing, and whether they're focused on different phases of the movement, whether they're doing it with one leg or two, and how much weight and how many reps they're doing. But it's not like that was that we were involved in that daily. Since that time, professional sport medicine has evolved in a favorable direction to mimic the Olympic model. It was at the Olympic level that the notion of an integrated support team first arose, and that you should have a team of people working together rather than an isolated silos to do what's best for both health and performance capacity on the team. And an integrated support team needs to have a physician, a therapist, physiologist, a bio mechanist, a strength and conditioning coach, a mental performance consultant, a mental health professional, a coach, the coach has to buy in or doesn't work. So back then we'd loosely had an nice team but we didn't meet. We didn't. When I was with the Raptors, we didn't do physiological testing. I was doing with the Olympic teams I was working for but not with the professional team. They weren't interested. Well, no, they wanted, you know, I got told what they wanted. When we started, they said okay, we want everyone to have a stress test and a stress echocardiogram. And I'm like, why do you need all that? You don't need to stress that going, everybody? Yes, we do- this is the NBA. Completely medically unnecessary. But it was the standard of care in the league.

Swapna Mylabathula [47:58] The athletes best interest health wise doesn't always line up with the interests of a team or league. So what happens when that's the case, Dr. Richard saw this happen during his time with the Raptors, and talks about his thought process, and he explains it through the triangular contractual arrangement.

Dr. Doug Richards [48:15] So I have a doctor patient relationship that is one edge of the triangle, but I have a doctor team relationship, that's another edge and then there's a team athlete relationship. And it is very clear in American law, it's not legislated, but they have a body of case law that makes it clear that the doctors do not actually decide anything, we do not have authority to dictate, you know, Thou shalt not play or thou shalt play. The people who decide whether or not not an athletes gonna play are the other two corners of the triangle, the athlete has to be willing to play or not, and the team has to be willing to put them on the court or ice or field or not. The exception to that which exists only in Ontario (and Canada now) is concussion and Rowan's law, where legislation, (thank you Swapna) has invested authority in the physician. But outside of that legislation, there is no legislated or case law authority invested in the physician, the physician is an advisor to the other two parties. So I could advise an athlete I don't think you should play because of these risks to your health. And I can tell the team I don't think that athletes should play because of those risks to the team. Now, with many teams that I work with, including all teams at the University of Toronto, where it is department policy, that the coach will follow the physician's advice. So then that invests authority in the physician because the sport organization has invested that authority in them and you and then then the coach tells the athlete you have to we have to follow the doc's advice. That is not the case at the professional level. And certainly my advice was always overwritten by both athletes and coaches in the NBA, you know where I give my best advice and say, I think this is what should happen. They're like, thanks, Doc. And then it's their right to decide. So positions are advisors, that is legally the case at the amateur level, except that at the amateur level, such as at university, and even with the Olympic Games I work with, as a matter of policy, the team follows the doctor's advice. But that's the team's decision to do that, not the doctor's decision.

Grace Jacobs [50:29] Dr. Richards shared how he has seen decisions play out in the professional world. And the priorities that come into the picture with these big decisions.

Dr. Doug Richards [50:36] They are willing to accept, risk or even directly fly in the face of health because their choices are informed by competitive desire for victory, to some extent, or to a greater extent than they are lower levels of sport. So even faced with the evidence that you know, you risk having problems later in life, whether it's arthritis or dementia, or whatever it is. I had one Raptor, tell me once, when I said, you know, if you do this, you're not going to be able to walk when you're 50. He said, that's fine, Doc, I'll be able to afford an electric wheelchair to take my money to the bank. He's right, he's a multimillionaire, and he can afford multiple electric wheeled cars and Tesla's and whatever. And so he knew that he was going to give himself near therosis. But he was willing to accept that if he was being driven purely by a health perspective that he wanted to maintain the cartilage in his knees for as long as he couldn't live, so he could dance it as grandkids wedding, he wouldn't have made that choice. But that isn't what he was doing.

Swapna Mylabathula [51:40] In professional sports, especially recently, in NBA basketball, we've heard a lot about load management in the context of recovery from injury. But what is load management?

Dr. Doug Richards [51:51] Load management, when applied to someone who has a chronic injury is a different concept and different beast than load management to prevent injury. Load management in healthy individuals, is well informed by research that is occurred over the last couple of decades. And the most important principle is the rate of progression of activity. In fact, that research suggests there's no limit to how much activity you can do. And there's no such thing as quotes "overuse", because you can run more, it's just like there's no limit to weekly mileage beyond which no one can run without injury. It's a question of how they get there, they have to run well, first quality again, quality is job one. And then they have to progress, the mileage of their running at a suitable rate, such as not more than a 5% per week increase. And we also worry about them taking off too much time during the downtime, because if they go down to zero for two months, they have to start from scratch to build up again. And you can't come in and start the season at full speed. So you need to stay in shape in the offseason. All of that is load management of healthy individuals to prevent injury.

Grace Jacobs [53:03] What about in people managing and existing chronic injury.

Dr. Doug Richards [53:06] So it is a tertiary strategy for coping with incurable disorder of some kind, I presume. And we certainly had people like that on the Raptors, people who had holes in the cartilage in their knees, where if they ran, if they played more than 18 minutes a game their knee would swell. You can't plan for 20 because it was pretty much a guarantee. If he ran for 20, his knee would swell. And we knew he had pathology and he had holes in his articular cartilage and so on. And this stuff was incurable. So managing his load was about preventing his incurable disorder from flaring up to the point where he couldn't run and play,

Grace Jacobs [53:42] Sport culture and what has been accepted continues to change across time, positively, we're moving towards increasingly prioritizing the health of athletes, both physically and mentally.

Dr. Gretchen Kerr [53:52] You know, people are questioning what's been traditionally accepted as just the culture of sport. I don't think you know, people are going to be saying, that's just the way sport is any longer. They've all been forced to self reflect on these practices that we've traditionally accepted in sport, first of all, are harmful. They're not okay anymore. And very importantly, they're not representative of practices used in other sectors where young people reside and work. Teaching strategies have moved from those kind of punitive controlling methods to being child centered and democratic. Parenting has moved from using physical punishment and autocratic styles to more democratic child centered parenting. And I think this has been a wake up call for sport to get in line with the rest of Canadian society's expectations and standards around how young people should be treated. Most Most of the headlines we see in the papers about abuse in sport has to do with sexual abuse. And our prevalence study as well as other prevalence studies have indicated that it's actually the psychological abuse that is the most prevalent. And that's, I think, going to be the hard one to tackle because that's the part that's normalized. That's the yelling, screaming coach, that's athletes exercised for punitive reasons until they collapse. It's those kinds of psychologically abusive practices that are really being challenged now. There's been too many, you know, headline stories in this country, about young people in particular, going into sport because it's supposed to be this wonderful environment for growth and well being and development of skills to be used later on in life, and finding that there are environments characterized by abuse and neglect. So it's, it's led to, I think, everybody in the sport community, regardless of level, contemplating what we do now and how we can do better. And that's a great opportunity. There are new educational tools being created. There's been a universal Code of Conduct established for all stakeholders in sport across the country, there are new mechanisms being developed to enable athletes to have a safe place to go to report their concerns. So as much as it is a crisis, it's leading to some very productive and positive outcomes.

Swapna Mylabathula [56:54] As we're seeing perspectives on maltreatment change for the better. We've also seen quite a bit of evolution in other areas of sport and health, including the field of Sport and Exercise medicine,

Grace Jacobs [57:04] Dr. Richards reflects on how Sport and Exercise medicine has changed as a discipline over the course of his career. And he looks ahead to what he thinks the next few years will hold.

Dr. Doug Richards [57:13] Well, it was a sort of ragtag thing. When I started, it's become more formalized, the educational programs have become more formalized. they've evolved. I think we are. And this is really good news. From my perspective, we are seeing an evolution toward the exercise side of what we now call Sport and Exercise medicine, that it's not mostly about taking care of high performance athletes. It's mostly about fostering healthy exercise, or fostering health through exercise, exercise medicine, and applicable to the broader population. So the educational programs are changing their focus that way, it's not that we're not going to still take care of athletes, there'll still be a sport medicine component as long as people play games, but everyone should be exercising not just people who are playing competitive games. And so some need for health care in relation to the issues that arise around regular chronic physical activity are important, and every physician needs to know something about it.

Swapna Mylabathula [58:17] To hear even more from Dr. Richards, you can check out Episode Three of season one of medicine in motion podcast, and the rest of their shows for even more content on all things movement, and health.

Grace Jacobs [58:28] Check out the show notes for a link.

Karl Subban [58:32] The important thing that I'd like to give to listeners is this. And I know, hockey has defined my family. When you look at the number of young people who sign up to play hockey every year in Canada. It's it's a big number. And then you look at all the American kids who play and European kids, but they're only roughly 700 jobs in the NHL. So that didn't deter us from having a dream. But whether or not it's about the NHL dream, it's really important that we all have dreams, because really, it has given my life purpose. It has given it meaning. And without those dreams have had. I don't think we'd be having the conversation today. And that's the beautiful thing about dreams. You will not fulfill them all. But you just never know where they'll take you. And that's probably one of the most important leg of that stool. Even though all three are important. It starts with a dream. And a dream without action is is not a dream you only daydreaming. So let's dream. Let's believe we can fulfill it and then make it actionable. Do the things that will make your dreams a reality. And you know what, I can't tell you what will happen. But I'll I can tell you, good things will come out of it.

Grace Jacobs [59:51] From running your first five K to scoring that winning three pointer to adding weight to your benchpress to winning gold at the Olympics. Sports and exercise motivate us are central to staying healthy and active, testing our limits, challenging our bodies, and encouraging us and our teammates to step up, all while having fun in the process.

Swapna Mylabathula [1:00:09] But in a world where hard work and perseverance pays off, there is also blood, sweat, and tears. Thankfully, there is a community that rallies behind athletes of all levels. There are skilled researchers, physicians, physiotherapists, psychologists, coaches, trainers, managers, and teammates that helped contribute to maintaining peak performance, mindfulness, injury prevention and injury recovery, all to ultimately help an individual fulfill their full potential, not only in whatever sport or exercise they decide to pursue, but in life too

Grace Jacobs [1:00:45] This episode was co hosted by myself along with swappa.

Swapna Mylabathula [1:00:48] Be sure to check out medicine and motion podcast to learn more about movement and science

Grace Jacobs [1:00:52] Seth, Biren, Thamiya and Zaineb helped with conducting interviews and content development. CJ was our photographer, and Alex was our audio engineer.

Swapna Mylabathula [1:01:01] A big thank you to our esteemed guests for their wonderful insights, Dr. Doug Richards, Dr. Gretchen Kerr, and Mr. Karl Subban.

Grace Jacobs [1:01:09] And of course, thank you for listening. Be sure to tune in to our next episode on gender confirming surgery. And until next time, keep it raw.