So, greetings everybody. Thanks for joining our session. My name is Jonathan Finoff. I'm the Chief Medical Officer at the United States Olympic and Paralympic Committee and a professor in the Department of PM&R at Mayo Clinic in Rochester, Minnesota. And this session is titled Clinical Management of Intentional Sports Injuries or Athlete Abuse in Ambulatory Sports Settings. So, a few housekeeping items to begin with. And by the way, I'm going to be a session moderator and co-moderating with Dr. Carmen Terzik, who is a professor in the Department of PM&R at Mayo Clinic and also the former chair of Mayo Clinic's Department of PM&R. And so, you'll hear from her shortly. But some housekeeping items. We're recording this session, so just be aware of that. Make sure that you mute your webcam and mic during the session. All of your questions should be posted in the chat function. And there are support from the AAPM&R's IT people, so you can use the chat function and request support if you're having any IT issues. So, I have to do my disclaimer because of the OSOPC. So, all opinions, viewpoints, and recommendations contained in this presentation represent those of me alone and do not represent the opinions, viewpoints, or recommendations of any organization with which the author may be affiliated, including, without limitation, the USOPC. And my only disclosure is that I receive royalties from Springer and UpToDate. So, just briefly, this is a really important topic. There have been a number of papers looking at verbal, physical, sexual, mental health types of abuse in elite athletics. And if you look at these three papers, just as an example, really, it's between about 10 and 25 percent of the athletes are reporting that they have some type of abuse during their career. So, this is actually relatively common. And it has become important enough that it is gaining recognition by major medical societies, both nationally and internationally, as can be seen by the position statement from American Medical Society for Sports Medicine, as well as an IOC consensus statement on harassment and abuse in sport. And in particular, I think it's important to realize that there are subgroups that are more prone to this type of abuse. And that includes elite athletics, those that have a disability, those who are young and lesbian, gay, bisexual, and transsexual athletes. These are the high-risk subgroups. And so, if you're working with these groups, be aware of that. So, now I'm going to move on to the introductions of our fantastic speaking group. And so, the first one is going to be Jetsa Twockley, that rhymes with broccoli. That's what Jetsa told me to remember, and that many of her patients evidently call her Dr. Broccoli. So, just remember that. She's going to talk about the athlete abuse, the current state of play in amateur and elite sports. She is an associate professor at both the UPMC Department of PM&R and Yale School of Public Health. She is also the director of the Sports Equity Lab. She is a welfare officer for the IPC, and she is a member of the IOC Harassment and Abuse Prevention Working Group. Next on my list is Kristen Garlinger. She is going to be talking about fostering a trauma-informed organizational climate in sports medicine settings. She is an assistant professor at Mayo Clinic in Rochester, Minnesota. She is board certified in spinal cord injury and has really led, along with Amy, who you'll meet in just a second, the adaptive and parasports clinic that is occurring at Mayo Clinic. I'm going to turn it over to Carmen for the remaining introductions. Thank you, Jonathan. So, Amy Rabatini, she will be the third speaker, and she's going to talk about exploring how PADA and non-disabled athlete abuse may be integrated into clinical workflow. And Amy is an assistant professor here at Mayo Clinic and the Department of Physical Medicine Rehabilitation, pediatric as well, and she has several training backgrounds. So, she's a pediatric rehabilitation physician and also pediatric sports medicine, and she is working also with Kristen in the adaptive parasports clinic. Next slide, John. And Daniel Luthers, he is going to talk about making it work, cost consideration in developing integrated sports medicine care models. And Daniel is a known individual, not only in the area of sports medicine, but also he's playing an important role in the APMNR at the national level in the membership committee, and he's a sports medicine physician in the UPMC. And he's a leader physician also in the Peace Corps Steelers, so that's our stellar group of presenters today. Okay, so I'm going to get started with the presentations. Thank you so much, Dr. Spinoff and Terziq for introducing us. I'm going to share my screen. Let me know if, oh, no, one moment. Yikes. Yikes. If you can see that. Yeah, all right. Perfect. So, as Dr. Spinoff mentioned, my name is Dr. Yetzatwakli Brockley. You can use one. And really, it's a pleasure to start the presentation this morning. I'm just going to lay the foundation and give you a sense of the current state of play when it comes to what some people call intentional sports injuries or non-accidental violence in sports. So, a lot to cover. I'm just going to breeze on through. I have no confidence of interest to disclose. So, in the past couple of weeks, you've probably seen a headline just like this, right? And these stories are often painted as emotional vignettes where feelings more or less outweigh facts. In reality, however, the science of interpersonal traumatic stress or non-accidental violence or abuse, for short, outweighs the emotional and political pull of the same. This is because we know that childhood adversity and interpersonal trauma are reliably associated with a cascade of negative health outcomes in adulthood at the population level. And so, it's natural that because we deal with a subset of that population, adversity will impact our patients' emotional, cognitive, and physiological well-being as well. So, safeguarding is of utmost importance to our community of sports medicine professionals, whether we're doctors, physios, masseurs, psychologists, etc. That said, in this presentation, I'm going to do just two things. First, outline the current state of play when it comes to the science of safeguarding in sport, and then take a deeper dive into two specific subtopics. The first is athletes with disabilities, and the second is the U.S. context. So, the first section is going to be a little bit more globally oriented, and then we'll come down to where we are here at home. So, let's get started with the empirical data. In 2019, at the 23-years-long conference, Play the Game, it was stated that the single biggest threat to modern sport is abuse. Not match-fixing, not doping, not gambling, not cheating. Abuse. This is a major statement. And of course, the Larry Nassar abuse tragedy helped catapult this reality to the forefront. But it's important to know that these topics have been debated in the literature for about 35, 40 years. So, it's not new, but it's taken on a new priority in recent years. What is known, and Dr. Finof touched on this in his introduction, is that a power imbalance, whether it's real or perceived, anchors every form of abuse in sport listed here. And that psychological harm, psychological maltreatment, is the portal through which all other forms occur. So, just keep that principle in mind. As Dr. Finof mentioned, I just wanted to reiterate that. We also know that a range of factors make psychological abuse very common in sport, right? So, there are these unwritten social contracts and entrenched cultural norms, like Bryn and Barrett, walk it off, next man up, no pain, no gain. And then, of course, sexism, gender bias, ableism, racism, and all the rest exist in sport, just like they exist in society. So, these are the organizational factors that make abuse very common. Some of the best available global data suggests a very grim reality. Dr. Finof mentioned a few stats. In the UK, about 75% of youth athletes reported experiencing psychological abuse in one study. In Canada, between 19 and 92% of elite athletes experience sexual harassment and abuse. And then globally, as Dr. Finof mentioned, between two athletes with global disabilities are between two and four times greater risk of various forms of harm. So, I just want to highlight this one study because, you know, the data does not always reflect what's in the news headlines. So, we see a lot about sexual abuse, whether it's harassment or abuse, which summarizes sexual violence. But in a study by Gretchen Kerr in 2019, where she surveyed 1,001 currently competing and recently retired Canadian athletes, she found that neglect was actually the most common form of abuse, followed by emotional or psychological abuse. The same data were found in Daniel Rind's study out of the UK. He looked at World Players Association athletes. So, the data don't always reflect what you see in the headlines. Now, vocabulary is very important, and there's no consensus definition yet, but scientists in the field are leaning in the direction of non-accidental violence or intentional injury to describe volitional acts that result in or have the potential to result in physical injury or psychological harm. The consequences of abuse are many, but I just want to list two of the bookends, everything from motivational decrease to sport dropout, all the way to suicide. So, it's a huge range, very impactful, very harmful to athletes and their entourages and their organizations. As Dr. Finoff said, sport organizations are increasingly promoting safe sport. That means an environment that is free from harassment and abuse. This includes the IOC, FIFA, AMSSM, et cetera. So, let's look now at some of the challenges of safeguarding work and research. So, this is a big deal for me because, you know, as sports scientists, we tend to try to collect data in a very typified way, but current approaches to data collection rely on reporting, self-report, and therefore, these are based on fallacious assumptions of common sense. So, what do I mean by that? If you rely on self-report data, how many concussions have you had this season? Do you have knee pain? Do you have neck pain, et cetera? The underpinning assumption is that everyone or the majority of those in the sports environment, from the coach to the trainer to the teammates, mean well and have good intentions, and that they will all naturally recognize abuse when they see it, but we know from the stories that this is just fundamentally not true. So, how was this mistake made? Usually, injury prevention research in sports follows Van Mechelen's classic model of injury prevention, which starts at establishing the extent of the injury by surveilling and reporting. The issue is that unintentional injuries are dissimilar and completely unequal to intentional injuries. Some of the differences are listed here. Studying intentional injuries or non-accidental injuries is methodologically and ethically challenging, partly because relying on self-report surveys can actually retraumatize your survivors who are your respondents. There are inaccuracies due to shame, mistrust, shame, shame, shame, and fear of retaliation. Just keep that in mind. Generally, in sports, spoiled sports or people who are squeaky wheels are sort of vilified, right, and cheaters are forgiven. Similarly, there are informal but entrenched power imbalances that promote silence and deference among survivors. This may be part of the reason that only 10% of all female and 5% of all male survivors of sexual abuse, inside or outside of sport, ever disclose their injuries. And the average age of disclosure for women is 52 years old, long past the age of athletic prime for most athletes. So let's take a deeper dive into these two subtopics. Athletes with disabilities, as Dr. Sanov mentioned, and as I mentioned at the beginning, have the highest degree of risk, but they are very underrepresented in the safeguarding canon of literature. There are a variety of features that may leave athletes with impairment vulnerable. These include those listed here. Daily personal care needs may put the athlete at an inherent power deficit relative to their attendant. The responsibilities among the entourage can become blurred. This happens in all athletes, actually, but it may happen maybe potentially more in athletes with impairment. And then finally, athletes with disabilities can be in society and in sport infantilized. Let's talk now about the U.S. context, and then I'll give it over to Dr. Garlinger. So the U.S. Center for Safe Sport was created in 2017. A key feature that I find very interesting is the centralized disciplinary database. Before that, all national governing bodies actually had their own disciplinary processes and databases, so you can imagine how heterogeneous that all was. Many of this is publicly searchable. This is what the search output looks like online, if you were to look it up. And if you just look here at the number of cases reported per year, after the center was established, you can see that big jump in terms of the cases that were reported to the U.S. Center for Safe Sport. Now, here are the top 10 sports when it comes to reporting cases out of about 40 sports. Take a look at those first three. USA Gymnastics, USA Swimming, and USA Ice Hockey. Different sports with different gender statistics, different membership statistics, different culture, et cetera, but those are the top three when it comes to reporting. Now, the type of misconduct reported were far and away mostly sexual misconduct at 46 percent, followed by physical, followed by emotional. Perpetrator gender was mostly male. The Paralympic data from the U.S. Center for Safe Sport Central Disciplinary Database further underscores the gap in the safeguarding canon. Look, between 1980 and now, only three Paralympic cases were recorded through that CDD. So again, that just underscores the fact that some athletes are underrepresented in some of this literature. My lab did an ad hoc analysis, a post hoc test, just to see if there were any differences in sport type. And what we found is that actually, yes, sexual incidences were more significantly associated with individual sports, not team sports, low clothing level sports, not high clothing level sports, and then non-contact sports or non-combat sports, not contact or combat sports. So in terms of the sport variables, they do seem to influence the risk of reporting. That's not necessarily influencing the risk of abuse, but just the risk or the frequency of reporting. And then just to summarize the U.S. context for you a little bit more, gymnastics, swimming, and ice hockey have the highest frequency of reporting to the CDD. Swimming has the highest number of cases that mention sexual misconduct. Paralympic sports are underrepresented. Sexual incidents track with sports category, as I mentioned, high individual, low clothing level, and non-contact sports. And then finally, there are humongous ongoing research gaps, including no standard prevention, no standard screening, and no standard treatment processes for non-accidental violence in sport. And currently, in contrast to some other countries, there is no current prevalence study for the U.S. sports context. So hope this lays a good foundation for you, and I'll turn it over to Dr. Garlinger. Thank you. Yeah, so that was beautiful. I'm just going to get the PowerPoint going here. All right. So hopefully everyone can see my slides and just my slides, and shout out if you see my notes. Yeah, so thank you so much for laying all the groundwork and really giving us a vocabulary to work with. Again, my name is Kristen Garlinger, and today I'll be talking about fostering a trauma-informed organizational climate in sports medicine settings. And so for another piece of vocabulary to familiarize everyone with trauma-informed, what does that mean? Well, in a nutshell, it's a practice that requires implementation before a meaningful change can take place, and which organizations, large and small, must first be bought into. There's a lot of content that I'll share in the next coming slides, and they include overviews of structural, cultural, and operational considerations that sports medicine organizations and institutions must keep in mind when integrating trauma-informed whole person care into their clinical practice. In reality, impacts of non-accidental violence reverberate throughout all aspects of victims' lives and are felt by members of the entire sports community, including us. Athlete abuse must be considered a community trauma that causes community impacts. A trauma-informed approach is an athlete's safeguarding strategy, and it is a right for any athlete to feel safe and supported in their environment. Those who are team physicians are serving their athletes, and at the core of any service are genuine, authentic, and compassionate relationships. So what is a trauma-informed approach? Conceptualize this as kind of a fluid and continuous quality improvement project for your organization with no completion date, where the principles of trauma-informed care serve as the conceptual framework to improve your organization and better serve all athletes and sport itself. Knowledge of best and evidence-based practices will continue to advance, and as they do, a trauma-informed organization continues to demonstrate a commitment to compassionate and effective practices and organizational reassessments that will evolve with the needs of the athlete and the sport. Ideally, a trauma-informed system would be built with a diverse group of stakeholders to support an infrastructure that is long-lasting and produces profound results. In PM&R, we are very familiar with the team aspect of delivering care. So our field as a whole is well-suited to lead the activation of multidisciplinary teams and take a multidisciplinary approach to trauma-informed system organization. These core principles of a trauma-informed approach may seem intuitive, yet if we lose sight of any one of these, we may lack the bones or the infrastructure of a solid and meaningful trauma-informed practice. So what are the challenges of creating a trauma-informed approach? Well, ignorance or lack of knowledge would be one. Sports administrators and officials may not ask the questions that elicit any athlete's history of trauma. They may feel unprepared to address trauma-related issues proactively, like Dr. Twakley had mentioned. Or they may struggle to address traumatic stress effectively within the constraints of their role. Another thought is there's an enormous variety of settings where sports medicine is practiced. National team camps, events, academic centers, high-performance training facilities. Thus, that makes the task to inform all stakeholders seem impossible to some. And then finally, what I consider to be one of the most dangerous challenges is fear. Organizational impacts, including reputational damage, loss of players and fans, loss of sponsorship and revenue, reduced medal tally, or Stanley Cups, as seen in one of the most recent intentional abuse cases in the media. The list goes on, reduced public confidence, loss of trust, asset deprecation. People also fear change. However, the sport medicine community has inherent strengths that facilitate trauma-informed practices, which include the cultural cornerstones of sport, things like teamwork, camaraderie, mutual support. They also happen to be important building blocks of group work and therapeutic modalities needed to build a trauma-informed practice. The daunting task of creating a trauma-informed organization from the ground up in your practice or community is not lost on any one of us who have tried to develop a new clinical service line or a clinical intervention or partnership with other departments or community members, for example. But no fear, there is a roadmap here. We'll walk through how to commit, create, assess, involve, reassess, develop, reassess, collaborate, reassess, you get the point. All strategies serve to promote trauma awareness and understanding. Commitment to creating a trauma-informed organization must reach the administration level. Administrators and supervisors need to plan for and demonstrate an ongoing commitment to trauma-informed organizations. It should not be considered just a check of the box, line item on the to-do list. Without the passion and leadership from the top, staff may perceive the steps in the process as time-consuming or yet another demand from the administration that is short-lived beyond the initial thrust of training. Change is not easy and it takes planning, it takes commitment and hard work. For instance, the infrastructure of a trauma-informed practice should include evaluating and reevaluating your organization's mission, vision, value statements regularly and reassess those regularly as well. Should reflect voices from the sports community, create a strategic plan to integrate change and assign a key staff member to champion that change. Create a trauma-informed oversight committee involving key stakeholders that include organizational leaders on one end of the spectrum to the athletes themselves and even their entourages. The committee is responsible for providing ongoing input and direction. Assess whether and to what extent your organization's current policies, procedures and operations support or interfere with a trauma-informed approach. Conduct an organizational self-assessment of trauma-informed awareness where you're obtaining feedback from key stakeholders which will serve like that vocabulary word we heard from Dr. Twakley, the blueprint or the benchmark of progress over time. Develop a written implementation plan with your organization to support trauma-informed care which can be a responsibility of the oversight committee. It should highlight the specific steps, roles, responsibilities and timeframes for the plan and include policies and practices that are being constantly reassessed and re-advised. It should also include a disaster plan. Establish relationships within and outside of the organization. Regularly liaise with collaborators and weave their skills or services into the implementation plan. Re-evaluate your physical facilities and environment to enhance safety and to circumvent preventable re-traumatization. Obtain regular feedback from athletes about their experiences in these environments. Have the awareness of the environment yourself. For example, are there closed, small, dark rooms or hallways? Is there a male versus female staff interactions in situations of privacy versus exposure? And on an ongoing basis, reassess the implementation plan and its ability to meet the needs of the athletes. No further explanation here is required. Develop a strong, vital, engaged peer cohort, whether that be in person or virtual, where open dialogue can flow and evolve. Institute practices that support sustainability. Develop culturally responsive policies, practices, and programs. Use science-based knowledge to guide program development. Implement ongoing training, insist on athlete participation, and consider cost and advocate for sustainable funding. In summary, recognize that athlete abuse is not just an individual trauma, but also a community trauma that has long-lasting, profound, and diverse impact. A trauma-informed practice safeguards athletes, and when power is used constructively, safeguarding is enhanced. There are implementation challenges. However, the cornerstones of sport facilitate a strong foundation for trauma-informed practice. We need buy-in from leaders in an organization to implement a strong and sustainable trauma-informed practice. Trauma-informed practice is a fluid process that will always require reassessment. The core of any service we provide to our athletes in the sport community is a genuine, authentic, and compassionate relationship. And we, as a team in our community, are well-suited to lead the multidisciplinary trauma-informed approach in our community, institutions, clinics, locker rooms, and sidelines. This tweet by Simone Biles to the US Gymnastics Team coach, Dr. Marcia Faustin, who happens to be a high school friend and former teammate of mine, embodies what cultural change can do for an athlete, and what the athlete can do for their sport. Simone says, forever thankful to have such an amazing support system by my side. And Dr. Faustin says, I am so proud of you. Keep inspiring and changing the world. This is the genuine, authentic, and compassionate relationship that I've been talking about, and the sport community is better because of it. Typically, desirable organizational change doesn't occur by accident. It comes from steadfast leadership and a convincing message that change is necessary and it's beneficial for all. Many people naturally resist change. And so an organization's commitment, including a willingness to discuss with staff members that various things such as the impact of, and role of trauma in their service settings, patience in planning and implementation, and the ability to tolerate the uncertainty that naturally accompanies transitions. Thank you. Thanks, Kristen. All right, so transitioning here and hoping to build on what Dr. Chouakle and Dr. Garlinger and Dr. Finoth have already talked about. I'm hoping to explore a little bit about practice integration. So how do we integrate this into our clinical workflow? So a few learning objectives for the next few minutes here. I hope to review a multidisciplinary team approach and convince you why this is really important to trauma-informed care, to describe prevention strategies in the clinical setting, and to identify some resources to get you started. So as Dr. Garlinger alluded to, we have a call to action, especially as physiatrists, and we do already have this kind of multidisciplinary approach to care. However, we really need to use this even more proactively for prevention and treatment of abuse in athletes. And I want to share to you why I think from a clinical perspective, what it looks like and why it's important. This is a really complex topic and a topic that is driven by a lot of different factors. A topic that is driven by fear, as Kristen was saying, and it's integral that we have these different team members who have different roles and different scopes of practice to appropriately care for these athletes. Because for example, a primary care provider working in their scope of practice can't provide what a psychologist can provide or what a social worker could provide, or maybe what other team members can provide, including their coaches, their trainers, their teammates, their entourage. What community organizations can provide and what others can provide in general. And what we have to do is surround these athletes with this multidisciplinary team that will allow them to have the environment to share their experiences. And then that allows us to hopefully help prevent these experiences in these athletes. And again, it also supports the sports administrators and the officials and the team members, because as Dr. Garland, you were saying, they may not feel comfortable eliciting some of the athlete's history of trauma or feel unprepared to address it. And so we really have to help them to be proactive and support them in their roles as well. So how do we do this? Through education and screening, we have to educate and train our athletes and their team members and the people that surround them as well as ourselves. It's so important for us to have that education of care providers and to provide that, to get that vocabulary as we've discussed in that toolkit. So we can acknowledge that trauma is widespread and that this affects their lives. As Dr. Twalkley was showing, it affects athletes into adulthood if it happens at a younger age. We know that to be true, but we also know that there are paths for healing and that we can be a part of that path for healing. That we recognize the signs and symptoms of the traumatic experience in these athletes. If we don't know what we're looking for, we're not gonna see it. And so how do we get that involved into our clinical workflows? And then we have a responsibility to respond. And that's, we have to fully integrate the knowledge that we have about trauma into our policies, into our procedures, into our practices, into, I saw someone in the comment, into mandated reporting and put that into our workflows. So thinking about kind of primary prevention strategies, again, with this foundation of acknowledge, recognize, respond, and therefore I hope then prevent, we have to think about how do we deter the direct and this secondary trauma that is happening and how do we integrate that into our workflow? And as Dr. Garlinger laid out, the trauma-informed care involves that commitment to building this competency and this vocabulary and clinical practice with programmatic standards and clinical guidelines that support our delivery of this trauma-sensitive service, such as I have on here, ACEs Aware, that's adverse childhood experiences for training that can occur with this. And thinking about it in terms of this quality improvement project that is ongoing, again, without that end date, but the ultimate goal is to make sure that we have screening that maybe includes clinician or self-administered surveys that can be sent out before you even see the athlete. What part of your pre-participation is being done to make sure that you're getting the right information and that you're getting what part of your pre-participation evaluation can be highlighted to help promote these dialogues? Having written plans, as Dr. Garlinger was talking about in procedures, what do we need to do when it's identified and how do we handle and support that athlete? The challenge is, is there's nothing, there isn't a kind of pick up the toolkit and implement this into your workflow because every organization and every athlete interaction is different. But what we need to do is start to really inform ourselves and inform that vocabulary so we can start to engage and educate. And so important to be thinking about how are these athletes going to present? Like I talked about recognizing. So in an athlete that comes in, are there changes in their physical health, new GI or GU symptoms, new headaches, new fatigue, new dysmenorrhea that can't be tied to something else in their performance? If a mental health issue or challenge comes about, depression, anxiety, sleep disruption, eating disorder, suicidality, is that the telltale that something has happened or vice versa? And then again, as Dr. Twakley mentioned, the sport related changes. You may have a conversation about their impaired performance, new injuries or dropping out of their sport. Those all can be signs that we need to recognize something has occurred within this athlete's history or recent experiences. And so it's really important to encourage, to promote this ability to have this conversation. So encouraging support seeking behavior, maybe if something hasn't happened to the athlete, but it might be that conversation that makes them aware that, gosh, this has happened to somebody else or put them at a higher ability to say something may occur in my environment. And we'll talk a little bit more about this on the next slide, but making bystanders become upstanders. So how do you recognize this and how do you become an upstander for yourself or for your team? And then identify and acknowledge positive behavior. When you see them advocating for themselves or advocating for a team member, or even within your team, when you start to see this culture and ability to support these athletes develop, it's really important to recognize that and to celebrate that. So in consideration of secondary and tertiary prevention, so again, with that foundation of acknowledge, recognize and respond, how do we help with short-term and long-term prevention of harm? So it could be EMR screening. Again, maybe that is the one time that you have that interaction with that athlete to make them aware and to have that, open that conversation for that safe place to be. And within that trauma screening, maybe we can start to dismantle myths about assault and open that conversation. And again, the bystander training to upstander. So I really think this is an important concept of, it's kind of the, if you see something, say something, but it's also then do something about it too. And so empowering our athletes, our team members, the multidisciplinary team members to feel empowered to act on what they see and to really get this rooted in the culture of our clinical workflows and to teach people how to be proactive in supporting our athletes and making a safer and more supportive environment for them. Group level interventions can be really powerful because again, there's power to that comfort of a group at times. So we can start to address and discuss post-trauma symptoms and build those resources and skills to decrease risk. Again, building all of our vocabulary in how we care for our patients. And then also thinking about the kind of tertiary things maybe, what are the laws that hold onlookers and institutions accountable? Again, that kind of mandated reporting. So potential outcomes of all of these prevention strategies and getting this integrated into our clinical workflows might be mandated reporting. Improving our ability and our referral to psychology, to psychiatry, to behavioral health services that can support these athletes. Getting our social workers involved, law enforcement involved when we need to in case management and really creating our comfort level in how do we support these athletes. And then really banking and using our community-based organizations for group support as well. So what are some tools that you can use now? So again, like I said, there isn't kind of a pick up a clinical workflow and just start using it. But it's so important if we're gonna acknowledge and recognize and respond to these occurrences, we have to have tools and we have to have the responsibility on ourselves to take online training. For example, the ACEs Aware training that's free online, looking at resources from other outside of the sports medicine and outside of our PM&R world people who are doing trauma-informed care. So using the tools from the behavioral health services and this is a really great book, ebook on trauma-informed care that I highlight here on our slide. And then reading and learning and having those conversations maybe this is a great journal club to get started. And there's some wonderful articles that I've highlighted here and there's other ones that can help you to have those conversations within your organization within your clinical group and get your QI going. Again, it's that try it. And just because you started it doesn't mean it's working. You got to constantly reassess and to constantly ask your athletes and ask your team members, if you're getting to the point of you're feeling like you're having a trauma-informed organization and a trauma-informed clinical workflow. And so with that, I will turn it over to Dan. Good morning. And thank you to Dr. Twakley, to Dr. Finoff, to Dr. Terzik for the invitation to present and to help expand our discussions and knowledge on this very important topic. I'll have the opportunity to discuss the real world implications and implementation of these principles and considering structural, cultural, and organizational factors, as well as costs associated with implementation. I have no significant disclosures for this topic. So in integrating trauma-informed care into practice, it's important to understand the stakeholders and to be aware that the stakeholders matter really from bottom to top. And really at the top is where it probably has most importance. Understanding the resources available at your organization, at your institution or school, to understand who can offer assistance and help implement a well-rounded team to help implement trauma-informed care. And then to really understand what does trauma-informed whole person care in clinical practice look like and who should be involved. So at the top, it's really critical to have buy-in and engagement from your athletic directors, from CEOs of an organization, and from those in positions of power, the coaches and in the medical providers. But it's also critical to have buy-in from your athletes, from your parents, from your trainers, from your medical staff, that every person involved in athlete care and athletics has importance in executing a trauma-informed culture and organization to contribute to its success and has to have confidence that each other individual from bottom to top has buy-in and engagement and accountability as well. In considering what structural factors are important in trauma-informed delivery of care, it's important that rules and regulations are well-understood and published and well-known so that athletes know that they have rights, that coaches or providers know that there is accountability and to have an understanding about what's expected of everybody and what those responsibilities are and what potential consequences can be and what those ranges of consequences are for infractions. But then it's also important to understand who has the responsibility for implementation and maintenance. And really that each individual important in athlete care and the athletes themselves has a responsibility for implementation and accountability to each other and to those in positions of power and superiority and those in positions of power have an accountability to those that they serve. It's also important to understand that there's a structured response system for handling athlete concerns and whistleblower complaints so that athletes can trust that there is a process to this, that their concerns and questions will be handled with a regular due process, with a resolution mechanism and that there's transparency in how that process and the results are communicated and that the athletes, parents or athletic trainers know where they can register a concern or complaint. And considering the cultural factors, really this comes down to in the culture of an athletic organization, of a university, of an institution, what's prioritized? And this gets very complicated because of all the multitude of factors that go into managing an athletic department, an athletic team and playing athletics. But at its core, really the athletes should be prioritized their success, but also their health and their mental health and this often gets clouded in institutions where certain individuals have outsized influence or financial might, where coaches or other individuals have excessive power over athletes and influence of things like playing time or scholarship. And this becomes an even larger issue as advertising dollars or booster dollars come into play and have a larger impact on the athletes. And so, it's critical that the athletes have influence, but it's critical, a culture is established that shows what that institution believes in terms of trauma-informed care. And this has been described by multiple national organizations and the US Paralympic Committee by the Athletic Trainers Association, but really comes down to stating that all athletes should not be subject to violence and that the welfare of those athletes should be paramount, should be prioritized. And a leader needs to know, needs to show that changing culture can happen if needed. And this has to occur through multiple different mechanisms including education, measures of accountability that leaders and people in violation of those codes violate will be held to, engagement of the athletes, of the parents, of athletic trainers, engagement of academic leadership in buy-in for this trauma-informed care and its importance in culture and athlete safety. And each of those things then engenders a trust, a trust that the athletes must have in their medical providers and in their coaches and in a trust that the leadership can show the athletes in overall building a culture of trauma-informed care. But this isn't easy. What operationalizing such culture changes means is that significant education of staff needs to occur as well as training. You need to have access to an understanding of the experts needed to form a well-rounded team and then in terms of executing claims or whistleblower concerns, a quality control in those processes to ensure that these are adjudicated properly and there's a feedback loop and the athlete has an understanding about how these are handled and what the result is. Then also studying these things to ensure that we are engendering trust in the athletes and greater confidence in their safety and that if change needs to be greater or occur in a different way that that's understood and addressed. So a well-rounded team brings in experts from multiple fields so that each is really acting with their greatest skillset and not overreaching into others because this really takes input from medical experts as well as those on the ground, in the training rooms, sports psychologists contributing to the mental health of the athletes, dieticians who are often ones that help identify the eating disorders that can often be the first manifestation of trauma in an athlete, law enforcement individuals who can help with proper reporting and investigation if a crime has been committed and legal consultants to help assist that at your institution level and then buy-in from the administrators and liaisons to administrators at your institution so that leadership is aware of events that occur and there is accountability across multiple departments to investigate these concerns and to address any culture problems. And then on each team and among peers on a team empowering leaders to help in communication and addressing concerns and maintaining those feedback loops to ensure that what you're doing is having positive effect. And each of these things is expensive. It can be expensive, both in terms of manpower and resources, time and organization and in financial. It can be challenging to account for and add up individually but these are individuals who are often employed at the institution or university otherwise. And so this would be a measure of allocating their time and pulling them into a unified team to achieve this goal. But the costs of not having such a team, the costs of unmitigated events of athlete abuse are exponential, both in financial costs and costs to the athletes, but also in reputation and cultures of these universities as we've seen. And so even though the financial costs might be high in implementing such a multi-specialty team, the costs of not doing so could be much, much greater. And considering how this affects providers and specifically medical providers, it doesn't fit well into the traditional fee-for-service model, which states that if you perform a service, whether that's an E and M and take a history of providing care, performing an intervention, there's a set amount of dollars that are provided to do this because this care will often occur outside of a training room and involve individuals outside of the medical specialty. In a medical training room, this also goes beyond just seeing athletes in the training room or logging hours in the training room, but it's organizing a team of experts and leading an investigative team that might mitigate any concerns and questions. And so what reimbursement for this might look like is a structure that is a stipend or funding to organize, to lead, to maintain such a team from a university or an organization. And considering in the standard fee-for-service model about performing something and achieving an outcome, these are imperfect metrics as well because if we incentivize lower incidence of athlete abuse, we have to question, well, how is that truly being achieved? And is this the right means? Because for history, no news was good news. If there was no reporting of athlete abuse, we assume there was no athlete abuse and statistics have frankly shown us that that's not true. It's either underreported or it's simply hidden. And so that's not, in and of itself, the gold standard of metric worth incentivizing. And so how can we do this better? Well, that really comes down to how we can leverage telehealth and other systems that might already exist to use such a structured team as a consultancy to serve more universities and more groups and to leverage telehealth to have athletes be able to communicate with these providers, these specialists, as they bring up a concern at their university. But what we need to do as well is to research this and to study this and to use better metrics to determine if we are succeeding. And I think what we can assess to determine, what we can assess to determine success would be awareness, both awareness of athletes, of their rights, awareness of the athletes have of the different team members and awareness of how they can report concerns of abuse or harm and the responsibilities of those who are investigating that. The confidence of engagement is important as well, ensuring that you're engaging the athletes, the parents, you're engaging the coaches to have buy-in in this culture change as well as the trainers. And then measures of confidence. How confident are the athletes in their own safety from their team or other individuals? How confident are they that reporting would be taken seriously and investigated and have mechanisms to hold those maybe in violation to account? And then how confident are they in the effectiveness of the accountability that leaders or others would have to this system? And then efficiencies. Are there efficiencies for the athletes in accessing reporting, in making that report, in the process of investigating that report in addressing their concerns and implementing a measure of punishment or a measurement of change? And so I think measuring those things across such a team or across such a system would help to determine its efficiencies and where those could be improved, but also its successes. And so a model in which that information was cataloged across a university organization, implementing such processes would help to harvest valuable data, but also would help to potentially determine things like best practices that can be shared across universities and also to ensure that these mechanisms are working. So this is a very emerging and growing field. There's no template that's been established, but there's a lot of great opportunity and with great resources and leadership, such a process could really be successful in ensuring athlete safety. So I welcome any questions that you might have. I'll be online for the end of our session and I'm available by email as well. Thank you. Well, that was a fantastic session with some outstanding presentations. We have about four minutes left for question and answer. So if anybody has any questions, please put them in the chat area and Dr. Terzik and I will field those questions. In the meantime, I was going to say, Yetsa, what do you think is the biggest challenge of implementing one of these programs at your institution? I know, thank you so much, Dr. Finoff. I think what Dan mentioned towards the end and what both Amy and Kristen mentioned is a big deal. So culture change is this nebulous concept, but it really is what's required. When you try to implement trauma-informed care in any institution without first shifting the organizational climate such that it's taken seriously, respected, prioritized, et cetera, or even just believed, then it's like sprinkling seed on dry ground. So we could have perfect policies and procedures. There was a gentleman in the comment, his name is Ralph. In the comments, he was writing that he felt as though when he was in college, some of the cultural barriers were insurmountable, actually, despite incredibly robust policies and procedures. So I think that's the biggest challenge. And I think, John, there is a comment also by Amy Hempel talking about, and I think it is important, and I would like Daniel's opinion about how to navigate the fine line between defamation. So when an athlete accuses somebody that takes sexual abuse and then the athlete is accused that he or she is a liar. So how to navigate this fine line between these two issues? I think for far too long, when issues like this were raised, we questioned the person accusing, right? We questioned their veracity, what their motivations could be. And I think shifting that paradigm to first trust the athlete, first trust the person raising the issue would help along that measure. And having serious mechanisms in which to investigate these things at both sides, at all sides trust and feel it's fair, I think would help along that line. Yeah, and if you don't mind, I'll just add some empirical support to that comment, Dan. So between two and 8% of disclosures of sexual violence are false. So that means 98% of the time is typically not false. So that data is really, that's nationally. So it's really important to keep that in mind in the back of our minds, as we consider those types of threads and themes, but it's a very small number because of what it takes to overcome the barriers to reporting. And I think it's very important to establish a system within each institution, very strong system in partnership with HR, human resources and confidentiality is key. So whoever report any issue, we need to keep their confidentiality as much as possible while we do the investigation. And as you say, trust. So 92%, you said, are real. So we need to open the investigation, make everybody accountable. I think that this is very important. I think it's important to engage your partners from HR. I don't know if Christine, Amy or John have any other comments about that. Just an additional comment that with the reporting system, you're just empowering, not just the athletes, but the entire support system, including teammates to be able to report as well, kind of playing off of what Amy said, don't be just a bystander, be an upstander. I think that was a huge message that she delivered loud and clear. Yeah. And I think one thing that's important too is just those questions that we ask. Like if we're not opening that door for them to feel comfortable, that 92 to 98% to really actually share their story, how we ask and how we respond is gonna make them comfortable to feel like they are supported and come forward. And if we don't have that, it's not gonna happen. So it looks like we have run out of time. I know that there was one more question. Carrie, maybe you could send an email to our faculty members for an answer, but we really appreciate your time and attention to this super important topic and hope that it leads to some implementation of change in your institutions. So thank you very much. And we look forward to seeing you throughout the remainder of the assembly. Thank you.

Clinical Management

Intentional Sports Injuries

Athlete Abuse

Ambulatory Sports Settings

Trauma-Informed Approach

Sports Medicine

Multidisciplinary Team

Trauma-Informed Care

Education and Prevention Strategies

Clear Policies and Procedures