I'm sorry, I'm going to try that again. Hi and welcome. Thanks for joining us today. I'm Monica Rowe. We're really excited to bring you this topic, Preparing the Team for Tokyo Physiatry at the Olympics and Paralympics. So I know that you had various choices and I would be remiss to say that, you know, although we have a very distinguished panel today, Dr. John Finoff is also someone who obviously very tied in with Team USA for the Paralympics and the Olympics. And he is actually giving a talk concurrently right now. So we thank you for joining us. But we also wanted to certainly highlight that Dr. Finoff was a big part of preparing the team for Tokyo. And so we want to highlight that we recognize his contributions as well. But I'm very excited to introduce the speaker of panels that we have for you today, Dr. Sherry Blout. For those of you who are familiar with the Olympics and Paralympic movement, you are acutely aware of Dr. Blout, who is an Associate Professor in Physical Medicine and Rehabilitation at Harvard Medical School and the Distinguished Chair in Physical Medicine and Rehabilitation at Brigham Health. She's an Attending Sports Medicine Physician at Mass General Brigham, where she serves as the Founding Director of the Kelly Adaptive Sports Research Institute. Dr. Blout is also a former Paralympic athlete in the sport of wheelchair racing, competing for the United States team in three Paralympic Games, Sydney, Athens and Beijing, and bringing home a total of seven Paralympic medals. She's also a two time winner of both the Boston and New York City Marathons. She serves as a member of the International Paralympic Committee's Medical Committee and serves on the Board of Directors for the US Olympic and Paralympic Committee, as well as numerous other leadership roles throughout the Olympic and Paralympic movement. She will be presenting on the National and International Coordination of Medical Care for the Paralympic and Olympic Games. We also have Dr. Ellen Casey joining us today. She is an Associate Professor in the Department of Physiatry at the Hospital for Special Surgery and Weill Cornell Medical Center or College. She also serves as a Research Director for the Department of Physiatry at the Hospital for Special Surgery. She and I served as Co-Directors of Women's Sports Medicine Program at the Rehabilitation Institute of Chicago from 2010 to 2014, and the Co-Director for the Penn Center of the Female Athlete from 2016 to 2017. After years of competing at an elite level of gymnastics nationally, and holding a place in Penn State history for scoring a perfect 10 on her floor routine, she became the Co-Head Team Physician for USA Gymnastics in 2019. She'll be presenting on the Medical Care of USA Women's Gymnastics for Tokyo 2020, Unprecedented Challenges and Opportunities. And then of course there's me. I am probably not fit for any athletic duties other than to carry Dr. Blowett and Dr. Casey's water and equipment. So I am an Associate Professor at Northwestern University Feinberg School of Medicine. I'm the Head Team Physician for the U.S. Women's National Soccer Team, and I'll be presenting on Common Goal, Preparing the U.S. Women's National Soccer Team for Tokyo. So this is our agenda for today. Dr. Blowett will present first, I'll go second, Dr. Casey will go in the final position, and then we'll open it up for a lively, hopefully a lively Q&A session once all the presentations are done. So I'm going to now turn it over to Dr. Blowett. All right, thanks Dr. Rowe, and just give me one moment to load up my slides here. All right, great. Quick thumbs up, look good. Okay, great. So thanks everyone, really a pleasure to join you today, and I'm going to kick us off by providing some of the national and international level context regarding the coordination of medical care for the Olympic and Paralympic Games. Before I started, I also wanted to shout out to the audience that all three of us, Dr. Rowe, Dr. Casey, and I are sporting our Team USA gear in solidarity and, you know, as a recognition for our experience in supporting Team USA in Tokyo. A brief agenda, I'm going to talk a bit about the decision that went into this historic call to postpone the Olympic and Paralympic Games in March of 2020. Clearly it was sort of a case study in crisis leadership and crisis decision making, pretty interesting, and I thought you might like to hear some inside baseball around that. I'm going to talk a little bit about stakeholder ramifications, the impact that that had on things like revenue, politics, of course, but also certainly athletes. Talk a little bit about how we then pulled everything together to host the games in July and August of 2021, which was an absolutely stunning feat, and then talk a bit about other contextual factors that impacted the Olympic and Paralympic movement through this time. So how did the call happen back in March of 2020? Well, clearly we all know that in that time frame the pandemic was ramping up. It was such a stressful time. Everyone was concerned about their personal health. Athletes were concerned about their training opportunities. Organizing committees and people involved in the administration of sport were totally stressed about the future of their events. So it was really this time in which stress levels were high and the future was really unclear as it related to some of these major sporting events like the Olympic and Paralympic Games. In the first part of March, a lot of questions started to emerge, especially from our athletes, and rightfully so. Many were concerned about their personal health, and of course they were concerned about their performance and their ability to train. This is a screen grab from a survey that was published in the New York Times of track and field athletes in early March of 2020, and it really demonstrates the mindset of our athletes in that phase. When they asked about whether the game should be postponed, 78% said yes. Whether it should be canceled, 22% yes. And whether their preparation had been adversely infected, 87% resounding majority said yes. So in that time frame, over March 18th and 19th of that year, our board of directors met. And as you can imagine, agenda item number one, number two, and number three, really the whole meeting, was dedicated to discussing this absolute conundrum about the ramping up of COVID-19, the upcoming Tokyo Games, the concerns that were being expressed by our athletes, and ramifications on the global movement. In that same time frame, we started to see other large countries start to really draw a line in the sand and say, look, we're just not doing this. One of the first to pull out was Canada. This was announced publicly over that same time frame. And we really, especially the large countries involved in the movement, started to put pressure on the International Olympic Committee and the International Paralympic Committee to say, look, we just can't move forward with this. It's not fair to our athletes. It's not fair to the staff and people who would be putting their own health in danger in order to try to compete. So ultimately, all of this led to the games being postponed. This call was made on March 24. This is an image of that moment. This is the Prime Minister of Japan at the time, Shinzo Abe, having a call with Thomas Bach, the president of the International Olympic Committee. And it was then, therefore, announced that the games would be postponed. So this, of course, had significant ramifications at several levels. I'm going to talk a little bit about revenue, reputation, and politics. But of course, this decision impacted so many. From the standpoint of revenue, some of the major sponsors of the Olympic and Paralympic movement had significant concerns regarding the future of the games, whether even the postponement would ultimately be successful. The NBC broadcast was at threat. There was a lot of threat to the revenue that's generated from philanthropic programs and donors. Many people support the Olympic and Paralympic movement so that they can then have the opportunity to engage in it and to go to the games and to see these incredible athletes on the field of play. And although it's certainly not all about revenue and about money, of course, all of this impacts the services that we're able to provide to athletes, including things like sports medicine and supporting athlete mental health services and other critically important programs that don't themselves generate revenue, but we know we need to provide. There were reputational ramifications. Of course, there was this concern about putting sport over public health, a lot of discontent from the Japanese public, and ultimately that also had political ramifications. The games, you know, through that whole year of postponement were still pretty unpopular if you surveyed the public. The prime minister at the time after Abe finished was a gentleman named Yoshihide Suga, and he only served for one year. And many people think that this was probably because of the fact that Japan pushed through to host the games and that ultimately probably had a negative impact on his political career. So yes, it's sport, but sport impacts our world very broadly. And ultimately, this also impacts, you know, the ability of future host cities and for the IOC and the IPC to say, you know, look, hosting the games is a good thing and you should invest in this. And ultimately, when there are these types of challenges, it can impact the number of cities that are interested in hosting into the future. Most importantly, of course, there were profound ramifications for athletes. Athletes experienced difficulty accessing opportunities for training, but also importantly for competition. When the games were postponed in March of 2020, most athletes hadn't yet qualified to compete in Tokyo because for many sports, that qualification period is right before the games. And for this reason, athletes, once the postponement occurred, athletes had to think about that whole year ahead and how they would continue through their training cycle, how they would hit the performance that they need at the time of qualification, then a year later. So a lot of challenges. Of course, this led into concerns about deconditioning and impact on physical health, a lot of concerns regarding athlete mental health. And many of those mental health concerns from athletes had to do to some of these other stressors, things like the financial impact of the postponement on their personal lives. Many athletes had already delayed their education and their careers or family planning in order to compete and train for the games. And then to ask them to do that for an entire another year, frankly led to a lot of stress. Through that timeframe, there were quite a few publications that talked about the impact on mental health and stressors to athletes because of COVID-19 itself, as well as the games postponement. These are a few of those papers. And I encourage you to take a look and just to know there's a lot more out there, because this was certainly something that the sports medicine community was deeply concerned about. So, you know, that's the doom and gloom, right? And the challenge that faced the movement, particularly through the early part of 2020. But I want to now focus forward and talk about Tokyo Reboot. So clearly the games did happen in July and August of 2021. And they happened quite successfully. Athletes were able to compete and put their best performance forward on the field of play. We saw some spectacular athletic competitions. You know, the world was able to tune in because of the broadcast. And although the climate and the social context was a bit different because of the lack of spectators and only essential staff being able to attend, you know, it was still a spectacular feat. And, you know, we owe a lot of thanks and credit to the Tokyo Organizing Committee and the Tokyo, the Japanese government to helping to pull this together to ultimately, at the end of the day, enable athletes to be able to live their dream and compete at the Olympic and Paralympic Games. Well, how did that occur? So this is a snapshot of the testing protocol that was necessary in order to protect the bubble, so to speak. And I know that Drs. Rowe and Dr. Casey will also talk about this from their sport-specific experience. In order to travel to Tokyo, every athlete as well as member of the delegation had to have two negative PCR tests via a nasopharyngeal swab within 72 hours of departure. The image on the right is the image of one of my tests before leaving. In order to have these certified, you had to take a picture of the test as well as a picture of yourself doing the nasopharyngeal swab. You had to upload it to an app, have that certified, and then be able to present a QR code at the time of landing in the Japanese airport in order to even be able to leave the airport. In addition, upon landing, you had to do another test, a qualitative antigen test to be a saliva sample, and wait for that to return before you could leave. Once you got into the village or any of the other, you know, host hotels or venues, you had to undergo daily saliva testing for all accredited athletes and staff. If one of those tests returned positive, then a PCR test would be run in the same sample. And if that returned positive, then a second PCR test would be run in a new sample via, again, a nasopharyngeal swab. And if all three of these came back positive, then an athlete would be required to quarantine. Of course, this extensive testing was for the purpose of avoiding false positives and asking athletes to quarantine, you know, which of course could have a devastating impact on their performance and their ability to compete at this pinnacle event in their athletic career. It's also important to note that there are false positives, right? People can still shed non-infectious viral material. This three-step testing protocol really ensured that if you were going to go into quarantine, it was for the right reason, and it was truly necessary. The isolation hotel was a fairly austere environment. These are two images from the isolation hotel at the Paralympic Games, which was a different hotel than at the Olympic Games. And these are images courtesy of Dr. Stuart Willick, who was one of the primary medical delegates there. The standard period of isolation was 10 days, although an athlete could be released a bit early if they had two negative PCR tests on day seven and day eight. The image on the left is the fresh air room at the hotel, where an athlete could go for a short period of time on a daily basis in order to open the window and get some fresh air. Otherwise, they had to be in their room with the window closed the whole time. Clearly, a very challenging environment for an athlete competing at the Olympics and Paralympics. The image on the right is a sample of the cuisine at the isolation hotel, which, of course, is not super appealing if you imagine yourself as an athlete traveling internationally to compete in Tokyo. Suffice it to say that athletes, of course, weren't thrilled being there and wanted to get back to the village and their competition as quickly as possible. Ultimately, if we look at the overall numbers, there were 24 confirmed positive tests in over 11,000 athletes at the Olympics and 13 confirmed positive tests in over 4,000 athletes at the Paralympics. The Paralympic positive rate was slightly higher than the Olympic rate. But at the same time, it's important to note that the Paralympic Games took place almost a month later. And at that time, the Delta variant was really ramping up in Japan. So risk of exposure was, frankly, higher at the time of the Paralympic Games. There were no serious illnesses or deaths, of course, thank goodness. And most positive tests that were picked up were upon landing at Tokyo Airport or within the first few days on site. So it seems that once an athlete was on the premises, you know, living in the village or in one of the host hotels and really in that bubble environment, that this planning was quite successful for avoiding positive tests. Over 1 million tests were performed throughout the whole period of the Games. And the Tokyo Organizing Committee collaborated with the Japanese government to run this IDCC, which had 50 to 75 people doing results management almost 24-7. So really, again, an incredible effort. All of this was overseen by the IOC and the IPC. And overall, the operations were considered a major success and certainly provide some lessons learned for Beijing, which is expected to be even more challenging because there will be three separate villages. The Beijing Organizing Committee is even more stringent and rigid, frankly, than their counterparts in Tokyo. So it'll be really interesting to see how this is carried out. But bottom line, a lot of lessons learned for the future. I'm going to end with bringing up just a few contextual factors that certainly impacted our athletes profoundly in the preparation for Tokyo. It's important to note and always remember that sport doesn't happen in isolation. And all of our athletes are, of course, subject to other social influences and other things that are happening within their environment and across the world. Touching briefly upon racial, social justice, disability rights, and climate change. So of course, through 2020, as we were preparing for the postponed Games, there was also this absolute push towards racial justice and diversity, equity, and inclusion across the world and also impacting sport. And after the death of George Floyd in the summer of 2020, our athletes, rightfully so, were speaking up about wanting to do more as Team USA. And for that reason, there was a convening of the Team USA Council on Racial and Social Justice, which was athlete-led and also supported by other experts in racial justice. And they put forward a number of recommendations through the course of 2020 and also early 2021 that are being taken very seriously when we think about enhancing our diversity and commitment towards social justice as an organization. One of the things that came into play was the council really recommending that we take a stand on what's called IOC Rule 50, which is part of the Olympic Charter that says that athletes can't demonstrate at all, whether it's for political, religious, racial, you know, any reason in any Olympic site, venue, or other areas. And there had been some precedent leading up to Tokyo. For example, at the Pan-American Games in 2019 in Lima, we had two athletes who did decide to demonstrate on the podium. And there was a lot of discussion about how this should be handled and what would happen in the lead-up to Tokyo. And ultimately, in December of 2020, I'm very proud to say that the U.S. took a stand and said that we would not punish athletes for peaceful protests anywhere, you know, on the field of play or in any of the training and competition venues. This really broke from the IOC and, frankly, ruffled a lot of feathers internationally. But it has led to, I think, an even greater elevation of this discussion. Ultimately, no athletes were disqualified in Tokyo. There were some very subtle peaceful protests that took place, and athletes were able to express themselves and really, you know, claim their rights as they should be able to do. But what happens in the international context is still very much an active issue. The other thing is issues around equity for our Paralympic athletes. There's been a lot of progress over the last several years. In 2018, the organization decided to provide equal medal payment for Olympians and Paralympians and then change the name of the organization in 2019 to be the U.S. Olympic and Paralympic Committee. And leading into Tokyo and through the time of the Tokyo Paralympic Games, the coverage was very much elevated, exponentially more hours on TV so that U.S. audiences could tune into the Paralympic Games. So these are three examples of progress. But that said, we still have a lot of challenges. And one major challenge we faced going into Tokyo was that one of our very well-known swimmers, Becca Meyer, decided to withdraw from the team because she wasn't able to bring the PCA or the personal care assistant of her choosing, which was her mom, to the Games with her. And it was just a very challenging issue because, of course, Becca should be enabled to bring her PCA of her choosing. That's very much a premise of the disability rights movement here in the U.S. But at the same time, the environment was so restricted in Tokyo and the number of accreditations that were available was so restricted that the team felt like they simply couldn't do it and instead offered a PCA from within the team, which Becca wasn't comfortable with and led her to withdraw. So this has led to, of course, a very active discussion, the formation of a working group to look at accreditation and PCAs moving forward. And it really taught us and leads us to continue to learn and improve the ability to support athletes moving forward. So in closing, clearly the Tokyo Games were unprecedented and important to note that although COVID-19 was a huge challenge, they didn't occur in a vacuum and all these lessons learned will set precedent for future games. And we in physiatry definitely have a role to play in some of addressing some of these salient challenges of our time. I'll personally say that it's been an absolute honor and privilege to be an athlete competing for Team USA and now also serving on the board and being able to be that liaison to some of our official government delegates. The picture on the right is a picture with the first gentleman or Doug Emhoff, who is Kamala Harris's husband. And it was very fun and very cool to be able to talk to him and educate him about the Olympic and Paralympic movement and to ensure that we continue to have the support we need from our country. So with that, I will turn it over to Dr. Rowe. All right. Thank you so much, Sherry. That's wonderful. I think what everyone hopefully will come to see is that, you know, Sherry really provided a macroscopic view of what was going on behind the scenes. I think what we're going to shift into a little bit more is myself and Dr. Casey are going to provide a little bit more of a microscopic view. So you're going to see some of the same themes, but at a different from a different angle here. So I'm here to talk about the common goal preparing the U.S. Women's National Soccer Team for Tokyo. I have no disclosures other than the fact that you kind of see that Dr. Blowett, Dr. Casey and I are all themed because we did all get Team USA gear that we're all sporting today. So I guess that would be our disclosure. So what I want to do in my talk today is discuss the approach and strategies for preparing a sports team to train during a global pandemic. And then I also want to go over a little bit of the Tokyo 2020 Olympic COVID protocol put into place to ensure safety from the perspective of being a part of an NGB that went or part of a team that actually went to the games. And so I can give you the flip side of the perspective that Dr. Blowett already just laid the foundation for. So let me take you back to March 5th, 2020. So this is actually right before the last in-person AAPMNR in Orlando, Florida and the Women's National Soccer Team was playing in the She Believes Cup against Spain, England and Japan. So actually on March 5th, we played a game in Orlando, Florida. On the day before the game, I actually had to get up in front of my team and my staff and I gave a presentation on what we knew about coronavirus. And I actually remember that was the very first time I heard the term COVID-19 when I was going through my research and preparation for that team meeting. And I answered questions that I never thought I'd ever have to answer as a sports medicine physician, like what's the difference between an outbreak and a pandemic? And are these games going to be canceled? And I really do feel like that conversation was the first real moment that the players started to think that the Olympics were going to be canceled. And then of course, the next day we went into a stadium of 25,000 fans and we played a game. And I took these pictures, my sister's family came to this game and I jumped into the crowd at that time at the end of the game to take some pictures. And it's really hard to imagine that we did all this knowing what we know now. And you all remember the rest. Hopefully you were all at that AAPMNR conference. That conference, physicians were asked to leave early by their home institutions. We were awkwardly giving each other fist bumps and elbow bumps for the first time ever in a professional setting. And then of course, you all know in March 12th, the NBA canceled its season and everyone started to feel like this is real. It's fascinating to me how many people have equated that cancellation of sporting activity as this is a real thing. It wasn't real until the NBA canceled that season. So we all went into lockdown, everything changed. And then as Dr. Blau announced on March 24th, the IOC announced that the Olympic and Paralympic games would be postponed. And from my perspective, postponing the Olympics was a relief and a welcome. And I speak for only myself, but I welcome the decision because of all the activity and uncertainty going on here at home and preparing the team for a sporting event just didn't seem right at the time. But we did have to forge on and move forward. And so at U.S. Soccer, by mid-June of 2020, we started discussions about how we were going to return to sport and not necessarily knowing when that was going to be, but understanding that once we did, we would actually need to have a new process and new protocols in place to ensure the safety and wellbeing of our athletes, staff, and the public. We met once a week and through the leadership of our chief medical officer, Dr. George Champas, we had numerous discussions and created this COVID-19 manual for U.S. Soccer. Those of you may not remember, but technically the National Women's Soccer League was the first professional sports league in America to start playing again. And U.S. Soccer was also integral in helping the NWSL League start up again as well. And the first iteration of this manual was essentially 44 pages. It addressed aggressive testing regimens, behavior compliance, an uninterrupted supply of PPE, contact tracing, the development of this new role at U.S. Soccer, which was basically a safety officer to oversee all COVID-related manners during the national team camps. And there was significant discussion and concern around that time about who was going to be the COVID police, right? So when it came to enforcing these policies, was it going to fall on the physician? Was it going to fall on the ATC? And how is that going to impact these people's relationships with the players and the coaching staff? And so ultimately U.S. Soccer made this decision that they were going to create this new role of a safety officer to do the enforcement, which was actually very welcome in our environment because certainly we weren't sure how people were going to react to all these different protocols that we're going to have in place. And it was nice to be able to keep it separate. Now, certainly as a physician, it is our responsibility to enforce safety measures. And so the physician continued to enforce safety measures, but this role became such a big, large role. And you'll see a similar role was established for teams at the Olympics as well. And it was such a large role in terms of coordinating the testing, coordinating the test results, coordinating if a test turned falsely positive or was real positive, all the activity that cascaded on after that. And it was very important that we had this role. And so this manual established a protected environment for our athletes and staff. We didn't really want to call it a bubble because it really wasn't a bubble where you really couldn't go in and out, but it was a protected environment. So when we first went back to training, which was in the end of October, 2020, this is the protocol that we had in place. Now, since then, things have evolved with vaccines, with the arrival of vaccines and vaccinations, and our protocol has evolved. But when we first went back, this is what we did. We required two negative PCR tests prior to departure. So it would be 10 days before and 72 hours before. Then we would also test everyone three and five days after returning home. We actually created a U.S. soccer app where we did daily symptom screens, we did daily temperature checks, and then we had the availability of PCR and point of care testing on site. When all of our athletes and our staff first got to the site, they were quarantined or isolated until a negative PCR and POC test was confirmed. And then we did testing every other day after the first two days of camp. And essentially all athletes, staff, hotel personnel, anyone who was driving us were tested at this frequency. So down here is kind of a picture. We commandeered a ballroom just to turn it into our own little private testing center. Our big goal was transmission risk mitigation. And so the things that were very important to this was masking at all times except for players when they're on the field. Obviously hand hygiene we all know about. You know, previously we would have our players share rooms with each other, but during this time we actually separated all the players out and put them into individual rooms. We had assigned seats in the meal rooms. We had assigned seats on the bus and in the meeting rooms so that contact tracing could be easier. We did not allow the players initially to use rideshare. All transportation was arranged by U.S. soccer to and from airports with people with individuals who were tested by U.S. soccer. And essentially we didn't want anyone to leave the protected environment unless there was a medical reason. Other things that we had to do, you know, with soccer usually you have a rack of water or water bottles and everyone just shares. We actually stopped doing that. No more shared water or electrolyte drinks. Typically post training we would have ice baths set up for everyone to just jump into. We stopped doing shared ice baths. The training room visits were made by appointment only to minimize the number of people in the room at one time. We did no self-service of food at mealtimes. We had tested hotel staff and full PPE with face shields on and they were essentially serving all the food. And initially we didn't even have food delivery services come in and feed our players. We basically, eventually we did get this lifted and food deliveries ended up being wiped down by the equipment managers and then distributed out. There were a couple of keys to our success. Obviously masks were a big part of this. Social distancing was a big part of this as well. But ultimately it was buy-in. And so we had buy-in from the top down, from our coach, from the top veteran players. They really wanted us to be successful as a team. They wanted to protect everybody in our environment. And that really is what made the easiest transition for us to be a successful team when it came to COVID risk mitigation. Truthfully, I had no idea what was going to happen. And so it's interesting to hear Dr. Blowett's perspective being inside the room where it actually happened. But we were holding these camps and we were scheduled from October to June to have these training camps. And I was on all these medical calls. And even in May of 2021, it was still, I thought up in the air, whether or not this was going to happen. And so COVID cases, if you remember back at that time in the spring of 2021, they were surging globally. And as Dr. Blowett alluded to, Japan didn't seem to want to have the Tokyo games happening in their country. They were wildly unpopular. And then of course the Delta variant was looming large. And so there was a lot of uncertainty in the air, but we were given information that there was going to be fairly strict travel requirements going into Japan. And so one of the things that we heard very early on was that any individual with a positive COVID test would not be allowed into the country, regardless of when the test first became positive, their vaccine status or their symptom status. So as many of you know here, the CDC recommends in the U.S. that after a positive COVID test, if you're asymptomatic after 10 days, you're considered no longer infectious. We were being told by the Japanese government at that time is they would not be following that protocol. And if there was a positive test, regardless of how long ago that positive test first turned positive, or that person first turned symptomatic, they were not going to allow that person in the country. So of course, this was something that was significantly concerning to our players. I would say three months before we were leaving for the games, we had a very strong talk with our players saying, listen, there's a lot we can do, but if you turn positive from this point on and you stay positive, there's nothing we're going to be able to do about that. And so really a lot of our players for those three months were very cautious. And if you remember the summer of 2021, just this past summer, a lot of things were opening up again. The vaccine seemed to have been working. Our COVID rates were down. Everyone was opening up again. Yet I will tell you everyone on our team really got that message. Even though the whole world is opening up around you, we all stayed fairly locked down to make sure that we could stay on the roster to go to the Olympics. So all teams were asked to identify this COVID liaison officer. And this person was someone on your team that got all the communication from the Tokyo 2020 Organizing Committee. They got all the information from the USOPC, and they were really the big liaison for the team. And all COVID-related information was passed to this CLO. It was the hardest job in the games. I have heard numerous people say that. I really do feel like the person who was given this job was given the hardest task. Dr. Blatt went over our pre-travel testing. I have my picture of my negative nucleic acid amplification test. There were some required items that the Japanese government wanted everyone to have. They wanted you to bring your own digital thermometer. You had to have a smartphone, and you had to download these apps. And essentially these apps, some of the apps actually tracked you, and they did not want you. You had to submit your movement plan one month prior to arriving at the games. And they were essentially tracking to make sure that you were always where you said you were going to be. You were not allowed to stray from that path. We did have to do a daily screening along with our saliva test. We had to enter in our digital temperature, talk about if we had any symptoms, and then we had to submit our saliva samples every day. Our team actually opted out of the Olympic Village. I do think that there were initially some concerns about the dining hall. As Dr. Blatt mentioned, those concerns seemed to not pan out because they actually did not have a large infection rate within the village. When we were in Tokyo, our team stayed at the Hilton Shinjuku, which is in one of the business districts of Tokyo. And by this time, Japan was in a state of emergency, and the country itself was in a lockdown. And I had grown up seeing pictures of crowded streets of Tokyo all the time, but every day outside the training room window, this is essentially what I saw on the left. It's like a deserted business district. Even though our hotel was still open to the public, we were able to share our space with USA Basketball and USA Tennis. And there were strict rules in the hotel. We were actually not allowed to walk outside. We were not allowed to go into the lobby of the hotel. Our rooms were all on one floor, and no other guests were on our floor with us. There was essentially a service entrance where we could use to get on and off our bus. And the hotel did actually give us outdoor time. They gave us access to a tennis courts from 7 to 11 p.m. to walk around outside. As you can see, there's all these fences, high fences, because we're in the business district, and I'm sure they didn't want tennis balls flying out. But as you can imagine, when we saw this, these two tennis courts with the high fences, our team started to lovingly refer to this time as our yard time, because it did feel a little bit like we were in prison from time to time. And so I'll tell you, in Tokyo, this was our home base. But when we traveled to other cities, we were in these IOC-controlled hotels. And I'll tell you, those hotels actually had stricter rules. There were a lot more security. There were thermal scanners all around. I did get to go to the Olympic Village for about an hour to pick up my credentials. And, you know, it was very different from my experience in the Paralympic Village in Rio. Obviously, the dining hall was beautiful, but it was really interesting, as you could see, this construction on the outside that looked different. And I heard that this was them outfitting the building with more air filtration systems, because obviously the dining hall was an area of significant concern. But you can see here, they put plexiglass up in between each individual eating station to try to decrease transmission rates. So essentially, you know, this COVID Games was really unusual for us. There were no fans in the stands. It was really unusual for me to go to our soccer games, because certainly when I travel with the Women's National Soccer Team, it's typically a very different fan experience. This was in stark contrast to 2019, when we won the Women's World Cup, and there were 80,000 people in the stands. But again, I think we learned a lot of lessons on how to stage a world event in this new era we're in. I think it's going to be fascinating to see how global events are going to be run moving forwards. Ultimately, our team had some good moments. We had some bad moments. You know, Dr. Blout mentioned mental health as a challenge. Dr. Casey is going to talk about mental health as a challenge as well. I do think the lack of freedom of movement was a mental health challenge to our team as well. And those are things that we addressed internally and tried to mitigate as much as possible. But yeah, ultimately, our team was able to stay strong. We did make it to the podium. We came home with the bronze medal, which our team rebranded as Rose Gold. And it was truly a Games unlike any other. I hope I provided some insight into the preparation that went into this and getting the team to the podium at the end. So thank you for your attention. And I'm going to turn it over to Dr. Casey now. All right, so tough act to follow these two wonderful speakers. But I'm going to talk a little bit about what it was like hearing for USA Women's National or National Gymnastics team at the Olympic Games. And for disclosures, I guess I have no financial disclosures besides the clothes. The other point I want to make is I'm not an employee of USA Gymnastics. The contract for my work exists between USA Gymnastics and the Hospital for Special Surgery. And as Dr. Rowe mentioned, I've been doing in this role for about three years. I share the role with my wonderful colleague, Dr. Marcy Faustin, who's a family medicine and sports medicine physician at UC Davis. And I think you probably are all aware that it was a very unique and challenging situation to step into this role given in the wake of Larry Nassar and the terrible sexual abuse of over 500 women over the course of years who previously had this role. And I think it goes without saying that what that transition has been like and what we've tried to do in changing some of the culture and our roles as team physicians is a lecture in and of itself. But for the sake of time today, what I will say is that that piece of this job, we've really tried to focus on establishing direct and open communication previously to when we shared this role. Really, the medical team and the national team staff and the coaches had discussions about the medical care and what was going on in the athlete. And certainly the parents really weren't part of that discussion. And we've tried to change that significantly. There were also feelings from the athletes and coaches that if they shared that they had an injury or pain somewhere, that that would negatively impact their ability to be named to a team or come to different camps. And we have worked very hard with the national team staff to change that belief and prove and show that if people are seeking care early on, that it can prevent injuries from becoming more chronic, but certainly will not negatively impact their ability to be considered for different assignments. And within changes post-larinaster, certainly safe sport has been instituted not only within gymnastics, but all sports. And the biggest thing for us, since so many of our national team and even Olympic team members are minors, we have to make sure and work hard to have all of our interactions, whether that's a phone call, a text message, evaluation in the training room, that has to be observable and interruptible at all times. And so we have really restructured the way that we deliver care while we're at an event or, you know, in the athlete recovery center after, you know, training for treatments to make sure that we are safeguarding our athletes and, you know, certainly keeping them comfortable and as safe as possible. And I will say too, that, you know, like many other circumstances with terrible acts of abuse over years, what you, what we found within gymnastics is that it's certainly not just one person, but what this uncovered was a culture of systemic abuse and sort of what enabled all of this to happen. And so it has been, I think, very challenging, but also rewarding, an incredible experience to hopefully be part of the change to establish a much more safe and nurturing environment for these athletes. So as you've already heard from Dr. Rowe and Dr. Blauwet, there were certainly highs and lows of the, you know, Tokyo 2020 Olympic experience, and I will say that was definitely the case for women's gymnastics. You have heard enough about COVID thus far today, so I'm not going to belabor this slide, except that just to add, as Dr. Rowe mentioned, we needed lots of apps. There were actually seven different apps that you had to have working at any given time to, you know, see where you were and make sure you weren't exposed to anyone and for contact tracing. As our, you know, own initiatives within our team, we tried very hard to do as much social distancing as we could on the bus, within eating, keeping our reserve athletes and our named team athletes as separate as possible, though we were training in the same facilities, and as it turned out, that, you know, became very important as we, you know, went on through our time in Japan. So as you guys probably know, you know, we did have an athlete, one of our reserve athletes test positive for COVID, and certainly that was in sports medicine, you prepare for the worst and hope for the best, and it certainly was something that we were hoping didn't happen, but, you know, I'll share with you sort of how that transpired and the way we reacted to that. Kara and all of what I'm sharing has been shared in the media and through her own social media and the coaches, so this is all information that's publicly available at this point. As you can see here, I've got a picture of the same Lucera test here, but I'm the only one with a picture of a positive test, which was certainly the last thing that we wanted to see with any of our athletes, but for the athlete who tested positive, she was fortunately vaccinated, and like everyone else, she had had her negative PCR tests prior to leaving the country. Like everyone else, she had her negative saliva antigen tests when we arrived in Japan, and then, like Dr. Rowe said, we were getting our daily testing, saliva testing. What I did not realize at the time, unlike when people were in the Olympic Village or close to there, there was very rapid turnaround of those tests. These tests were being processed in the town of Narita where we were staying, and they were taking 24 hours at minimum to be processed, so the athlete gave a sample on July 16th, and on July 17th, we found out that it had come back positive. I had a few more Lucera tests in my bag, and she had no symptoms, so I tested her quickly in the hotel, and that test was negative, which let us breathe a little bit easier, and then we waited for the health department within the town that we were staying in to tell us what the next step was, so I went with her to, there was an actual hospital within the airport that had been built to deal with any COVID-related issues, so that's where we were taken for testing, and that testing was also a PCR, and that was negative, so during the daytime when we were reacting to the first positive test, we had everybody stay in their rooms, you know, food was delivered, all training sessions were canceled, and everyone was just sort of waiting to see these results, and fortunately, well, at that time, we thought it was a false positive. Then the next day, we all gave our saliva tests again on July 18th. The following day, we got a notification just with a knock on the door that Kara's test was positive again. I gave her another Lucera test in the hotel, and just as our translator came to the door to take us to the airport hospital, we saw that the Lucera test was positive, you know, which was certainly concerning, and then the follow-up PCR testing was positive as well. At this point, she said she had a mild sore throat, but that was really the only symptom that she had at any point in time during this. As you can imagine, there was a lot of conversation and preparation and training led by Dr. Finoff in the USOPC about what was going to happen should an athlete test positive, and we had gone through, you know, scenarios and tried to understand that process. What I wasn't fully aware of, you know, until this happened to us is that we were technically in what was called a pre-game scenario, so we were not in, you know, active training or preparation or competition within, you know, the Olympic schedule, but we had arrived early enough so that our athletes could get, you know, get acclimated and adjusted to the time and have some extra training time there. So, we were staying, as I said, in a town called Narita, which was a little over an hour away from Tokyo, and so at that point in time, we didn't really fall under that algorithm, you know, kind of within what was going to happen through what we've been told through the USOPC, though I will say I will be forever grateful for Dr. Finoff picking up the phone at 2 a.m. when I received these results to kind of talk through, you know, what the next steps were, but essentially, I served as basically the point person for the team for all of the contact tracing which took place over the phone. Hours and hours of conversation translated over the phone going through each of our members of the delegation and where people had been and, you know, how close they were on the bus and meals and everything else, and ultimately, what was decided by the Department of Health was that Kara, who had tested positive for COVID, would be put in isolation for the 10 days, and we did have a roommate situation, unlike U.S. women's soccer. We had debated that point numerous times prior, but the decision was made to have them have roommates, and so Kara's roommate was her teammate from home, unfortunately had decided to not get vaccinated before the games, and because she had been within, you know, the guidelines of what qualified as a close contact, she was also determined to need to quarantine. Both of these athletes were alternates, but we really didn't know for quite some time how this was going to affect the rest of the team, and as you can imagine, again, we've had a whole day of shutdown, then we feel okay, we thought it was a false positive, and then we're back to cancelling, you know, two more training sessions and people just waiting in their rooms, wondering if their Olympic, you know, dreams were over. So, you know, it certainly was a very challenging time, but ultimately, the rest of the team, the delegation, we were scheduled to leave for Tokyo at that point and start more our, you know, training within the Olympic facilities, so that all was able to happen. Kara had to do 10 days of isolation. I will say one of the biggest accomplishments of this, I think, on my end, was to convince them not to send them to those COVID hotels, you know, because they were already in a room by themselves by that point. We had separated them and, you know, they let them at least stay in the Hilton Narita rather than the pictures that Dr. Blauwet showed you, which were certainly, you know, would make this even harder on these athletes. They couldn't actually leave as soon as their quarantine and isolation was done because, as you can imagine, the airlines weren't excited to have them back, but we had to go through some, you know, sort of paperwork and discussions with the airline to ultimately, you know, get them home. And from a sports medicine, you know, physician perspective, I, as I said, was the point person not only for the Department of Health, but these athletes who were 18 and 17, their parents who were, you know, across the world and obviously very concerned, the coaches, the, you know, the national team staff, and then, you know, dealing with what do we tell the media and how to, you know, how to deal with releasing this information. So not an experience we wanted to have, but one that was, I think, a very, you know, important learning experience, you know, within that realm. And certainly anybody who watched any women's gymnastics at the Olympics is well aware of then what, you know, later became a bigger issue than our COVID positive athlete when Simone withdrew from the team competition finals, and we'll kind of talk more about what led up to that. So for those of you who aren't familiar with how the team competition works in gymnastics, you have a preliminary competition and the top eight teams from that preliminary competition move on to team finals. And then the team will compete three athletes on each event, and all of those scores count, unlike in other competitions where you can drop the lowest score. So the stakes, of course, get a little bit higher. The United States started on vault, and you can see here, this is a still sequential frame of Simone's vault. What she was planning to do is a vault called a Yurchenko two and a half. And so what that is, as you can see, she's running down the runway. She does a round off, lands on the board with her back to the vaulting table, then does a back handspring onto the vaulting table, and then, you know, gets her typical, you know, insanely high amplitude. And she's supposed to do one flip with two and a half twists. And what I think you can see really well here is she comes off the table, she twists to the left. So here at the top of her amplitude, she is, the left shoulder is dropped. She's looking towards the left side, all of which is technically appropriate. And as you see in this area that's circled here, she starts to open up at one and a half twists. So to stop a twist, you would open your arms. And as you can see, she starts looking to the right, which is absolutely not anything you would ever want to see a gymnast do during this skill, because it's very dangerous to open up, obviously, in the middle, your head looking completely different way. It was very clear from this that she was disoriented to where she was in space. And quite frankly, amazing that she actually landed on her feet. Certainly wasn't any landing that she wanted. But, you know, it was miraculous that she didn't injure herself here. These are just two other pictures to give you an example of sort of this opening up position and looking to the right when she's supposed to be twisting left. And you can see that in a just a front view here as well. So, as I mentioned, I share this job with Dr. Marcy Faustin, and I had just left Tokyo the night before and was, you know, home, watching this with the rest of the world, you know, I'm streaming in my kitchen, Dr. Faustin was, you know, just transitioning into, you know, was going to cover the rest of the games. And, you know, really what we knew at this point in time is that Simone's training had been her usual, you know, excellent, you know, training the entire time we were in Japan, there were no red flags with her, you know, behavior or interaction with anyone, you know, that anyone had observed or really that she had felt, I think, kind of until it got closer to this event. As I'm not sure anyone else mentioned, all of the athletes were screened using the IOC mental health screening tool prior to arriving in Japan. And she, like the rest of our athletes, again, screening tests are just what they are screening tests, but everything seemed okay. She did have some small uncharacteristic errors in the preliminary competition, which for others, you wouldn't really bat an eye for her, as I said, uncharacteristic, but nothing that seemed concerning from a safety perspective. She did have a feeling of loss of air awareness during training the day between preliminary competition and finals, but was able to make adjustments within training. And then when she was warming up this vault, she did that same thing where she opened up at the one and a half and then did it again in competition. And I think, you know, as we think about this now, I think she was hoping that she could push through this and muscle, you know, through it as she has done, competed at Worlds with a kidney stone and, you know, all sorts of other things. But she knew very clearly that this was not something that she was going to be able to push through. So she ultimately, you know, Dr. Fossen got on the floor, they had a quick conversation and went into the medical area where, you know, after an assessment, the determination was made that she was not safe to continue to do gymnastics, mostly because of how she was, you know, feeling and clearly what had happened on that vault. And for those of you not aware about gymnastics, you don't have subs that you can just kind of pop in and out. The start list is the start list and that's who has to compete. And so if they didn't fill out the appropriate paperwork and kind of get this done within the five minutes that they had in moving from vault to bars, the U.S. would have basically forfeited, you know, the rest of the event. So it was certainly a very high stress, high pressure situation, difficult to be, you know, home in my kitchen looking at the text thread. What I was doing was basically calling our sports psychologist who was, you know, in Tokyo trying to make sure she was ready and available to, you know, be there and help Simone and everyone else at the, you know, end of the competition. So as you can imagine, you know, mental blocks in any sport are certainly nobody even wants to talk about them sometimes because you don't want to, you know, encourage the idea. This obviously was referenced in, you know, Ted Lasso about the yips. And while what happened to Simone I think is a bit different than the yips, I mean, we all know that there's this, it can be this sick cycle of either there could be anxiety and stress that sort of lead into this lack of, or change in performance, which then people sort of start to process and perseverate on and worry about and try harder. And then it happens again, and it's a self-fulfilling prophecy. You know, and if anyone's interested in learning more about this, Simone actually was doing sort of a video diary during the time. This is a picture of her, it's blurry, but she's doing standing fulls. So a flip with a full twist on her bed, repetitively in our hotel in Tokyo, because she was feeling like she didn't have control and didn't know where she was, but she was trying to convince herself, it's okay, I can do this. It's okay. You know, and so you can imagine that mental space where she, you know, was trying to make something happen where she really needed time and, you know, counseling and sort of to process this and sort of break down the skill to learn it again, which is the way you have to address this in gymnastics. But the difference in gymnastics, of course, and if you have the yips in golf or a pitching issue, you know, in softball here, is that the consequences certainly could have been life altering, life ending, you know, that has certainly happened where people have had such significant injuries related to, you know, bailing out in the middle of a skill that this really was significantly worrisome for her and certainly the rest of us. So as you all know, what happened is she, you know, said, you know, I can't do it for my own safety and we will completely not, you know, lose our chance at a medal if I keep going because I cannot control what I'm doing or I've lost, you know, the ability to understand where my body is in space, you know, so she cheered and carried chalk and moved mats and certainly, you know, you're well aware of the outcome, which was an achievement for the entire team for sure. And then what happened is certainly she was working with the USOPC sports psychologist who's assigned to gymnastics. She's not someone that Simone has necessarily worked with a ton before, but was familiar to her. And she had had, you know, people from home that she could connect with as well as really connecting with her family. Every single day she and her coaches, instead of going to the training and the training provided by the Olympics, which had no soft surfaces and no safe place to sort of relearn some of these skills, she went back to that gym in Narita where it'd been before where you can see there's a lot of soft mats and tried to figure out how to get control over these skills. Ultimately, she had far too much twisting in her, you know, bars and floor and vault to be able to do those events. So she, you know, was not able to compete there. She did change her beam to take out any twisting, including her dismount, you know, and was able to participate in that final event of the competition. So, you know, in retrospect, a lot has been discussed about this, certainly from Simone's end and many others, and it's a unique experience to be intimately involved in a situation that is part of a global conversation. But from my standpoint, what is obviously important to note about this is this happened despite ongoing screening and resources for mental health. And that's not to say that, you know, we couldn't have done a better job or, you know, figured out a different way to, you know, help her through this. But there's certainly the intent, you know, was there. And like a physical injury, it's possible that you can't always prevent these things. I think, you know, that the best possible decision was made in that moment and facilitated by teamwork between the coaches and the medical staff in five minutes. I mean, that's just really incredible that they made that happen. And if you think back to, you know, the culture of USA Gymnastics or gymnastics in general, where people, where female athletes have historically been stripped of their agency to advocate for themselves, the fact that she was able to do that in that moment, and not a single person from the national team staff or coaches blinked an eye, it was okay, this is what you have to do, you know, let's move forward, I think is, you know, suggestion of progress, at least that's how I, you know, hope that that's what this represents. And certainly, as a team physician, you always have many, many roles. And in Tokyo, I think it was to continue to safeguard our athletes, as we've been trying to do for so many years, you know, in the climate that we've inherited. And, you know, it's certainly were it's important to be there in those moments of, you know, excitement and, and victory, but also in their darkest moments as well. And I think it remains to be seen what Simone's legacy is within the sport, but it's certainly going to be far beyond gymnastics. And I would like to say, of course, that this is a just a quick example of how you can have fun as a team physician, too. So our athletes, you know, are great with their social media, here's a picture of Dr. Fawcett and I showing that we can, you know, do some of their same crazy poses. So with that, we will turn it over to the Q&A. Thank you so much, Dr. Casey, I think all of us would could spend another hour listening to you and Dr. Blowett, I think all of us could spend another hour listening to you. Unfortunately, due to the schedule for the AAPMNR, we will not be able to do a Q&A right now, I apologize. But they are keeping us on a tight schedule here. But thank you so much all for joining us today. Hopefully there's an opportunity to talk about this in the future. And again, thanks to Dr. Casey and Dr. Blowett for your leadership, clearly making a huge impact in the Olympic and Paralympic committee or community. So so it's really an honor to share the spotlight with you guys, and the other physiatrists involved in the Tokyo 2021 Olympics and Paralympics. So thanks again. Have a great day. I apologize we couldn't get to the Q&A. My apologies for that. But thank you all for showing up and listening to our talks today. Have a great one. Thank you.

medical team

Tokyo 2020 Olympics

Tokyo Paralympics

COVID-19 pandemic

challenges

protocols

athletes

quarantine

mental health

teamwork