 Welcome to our fourth annual Injury Prevention Symposium, our first virtual symposia. We all know we've been going through some very difficult times, but the reality is that we'll come out of it much stronger. I want to thank all of you for attending and especially our faculty. We have an amazing lineup and I'm looking forward to this great symposium. It's an honor to introduce you, our keynote speaker, Professor Raul Barr. Dr. Barr is the Professor of Sports Medicine in the Department of Sports Medicine at the Norwegian School of Sports Science and also the Chair of the Oslo Sports Trauma Research Center. He's also the Chief Medical Officer and Chair of the Medical Department at the National Olympic Training Center, Olyan Patopen. Professor Barr is also the Director of Aspitar Sports Injury and Injury Prevention Program at Aspitar Orthopedic and Sports Medicine Hospital in Doha, Qatar. It's an honor to have him with us. We're looking forward to your lecture, Dr. Barr. Thank you. Good morning and thank you very much for the kind invitation and the invitation to speak. I am, like you, sorry to not be able to be there in person. So I speak to you from Norway where this is day 48 in lockdown, but we are doing well as I hope you are. I want to emphasize from the start that this presentation is not a one-man job. I've added Ben Clarkson on the title slide. He has been instrumental in setting up the program I will discuss. And as you will see, our entire team is involved in the project. So if I accidentally say I during this presentation, it should be we. And in truth, most of the times it should be they. But let me begin by describing who we are. So the Norwegian sports model is unique in that all of Norwegian sports, amateur, able-bodied, disabled, professional is united in one governing body. And as you can see, the name it gets quite long. But Olympia Toppen is like the Olympic Committee, except it's the operative department for elite sports development in our elite sports model. So Olympia Toppen, we are responsible for challenging as well as supporting our best athletes. Yet the responsibility for results in each of the sports rests with the National Federation. Ours is one of supporters and challengers. Let me spend a minute on the values underpinning Norwegian sports. And as you can see on the slide, these are honestly joy of sport, health and community. And if we ask ourselves how this translates to elite sports and particularly focused on health aspect, we have said health is a prerequisite for quality of life and for performance. But if you spend a minute thinking about this value set, I think most people see health and sports as overlapping entities. Think of the extremely fit athlete. But the question is how much do the value sets underpinning these two entities overlap really? If we first take medicine or health, it is about wellness, it's about functionality, it is about disease prevention. Whereas if we look at sport, especially elite sports, it's about winning, it's about competitiveness, it's about performance, it's about entertainment and it may be argued that there's actually no overlap between the two. So for the medical department or the Department of Sports Medicine at Olympia Toppen, what we have communicated very clearly is that the first and foremost responsibility of our department is the long-term health of the athlete. This should weigh more than winning medals in the short term. And that our primary motivation should be the health of the athlete, not performance. In other words, we cannot be the athlete's fan. There are enough people focusing on the performance aspect of science. Our main role or one of our main roles is to balance this out by arguing the health aspect, when difficult decisions need to be made. The expectations are clear. We are to deliver top quality services, diagnosis and treatment. We need to be accessible, easily available for the elite athletes. We need to be able to work in teams, cross-disciplinary and we need to have good access to an international network that we can consult with when needed. The main goal of the department as such is to provide optimal medical treatment for today's and tomorrow's elite athletes, as well as focus on working interdisciplinary to prevent injury and illness. This is the staff. It looks like a lot of people, but when you do the math, this equates to five full-time physicians working in our team. These are the physical therapists. And again, it's about five full-time physicians. Which means that we do have enough to do. I'd like to especially highlight two of the members of this team. One is Ben Clarkson as mentioned before and the other is Lars Haupoldt, who is currently the project manager for the screening and monitoring project in our department. And it's important again to reiterate everyone in the department is involved in this program. The medical department's scope is Olympia Top Athletes. These are people, athletes who already have shown medal potential in Olympic games and such. But we're also open to all other national team athletes, senior and junior, as well as athletes, students at the Leedsport High School. So we are operating as a normal medical clinic, if you like, for these athletes groups. But we also have the specific tasks of following up our scholarship athletes. These are the Olympia Top and Athletes, and especially Olympic Paralympic candidates, as well as lead the medical team for Paralympics and other of the many multi-sports events that are being organized these days. So what are the challenges in providing medical support to an Olympic and Paralympic team? Well, first of all, we have lots of small teams. We're not a big country, so we might sometimes have a team of one athlete in one sport who can compete at the elite level. Our athletes live all over the world and they travel constantly. There are a few sports that have year-round medical coverage. The Federation simply cannot afford to have a medical team in place. And many of our best athletes relate to multiple medical providers. Imagine someone who is a professional cyclist living in France, but also with a home in Norway. He relates maybe to us, to the national team, doctor and physio, to his professional club team, and may also have a local family physician in Monaco or wherever he lives. This is a challenge for communication between medical providers, and we have learned that athletes can be slow in reporting new health problems. This sometimes results in problems being under the radar and without a clear management plan. This slide illustrates the challenge with organization and with providing medical care. This actually depicts the candidate teams for the Pyeongchang Winter Games and Paralympic Games. As you can see from the symbols here, these are the teams that actually do have a team physio or team doctor hired by the Federation or organized by their own Federation. What we need to do to provide care for all of these athletes is go in with resources from our medical department and assign the responsibility for each of these teams who do not have their own medical support. We typically begin this program about two years before every Olympic and Paralympic Games, and this starts with medical screening, which is intended to result in an action plan, targeted action plan, and then an injury and illness monitoring program, which I will describe shortly. So in many ways you could say this is the main tool, this is how we from Olympia Top and Side try to support the athletes and the Federations during each Olympic cycle preparing the athletes for the Games. This program has been running now since London 2012 and expanded and revised along the way, and I will describe our current program in the following slides. What I would like to emphasize first though before I go into details is that this primarily is a clinical program to optimize athlete health. Keep them healthy and hopefully in that way win more medals. Under the surface we also collect data that we use for epidemiological research, but the guiding philosophy of the program is that it is not a research project that may or may benefit athletes sometime in the future. Our screening and monitoring program should have direct and immediate benefits for all the stakeholders, athletes, medical staff and coaches. So let's have a look at the program the way we run it with our Norwegian athletes. First, there's the screening component. And if we go back a little over 10 years, this group of experts met in Lausanne to write an IOC consensus statement on the periodic health evaluation of elite athletes or pre-participation examination if you like. And in this several reasons outlined for why you may want to perform an examination like this. First, it could be about identifying the high risk athlete. So the question of looking into the future who is going to be who is at risk for injury. The second could be identify existing problems. So who is injured and ill? What are their problems currently? Third, baseline testing could be valuable to have something to compare to if the athlete is later injured or ill. Fourth, importantly to review medications and supplements that athletes may be taking and make sure that they're not in conflict with World Anti-Doping Code. Fifth, to establish the relationship with the athlete. Not just the athlete meeting you or you meeting the athlete, but also the athlete getting to know you as a medical provider. And then finally, in some international federations and national organizations, there are legal requirements that athletes pass a medical, so to speak, before they're allowed to perform. So let me first just quickly address the top issue. Is it possible to identify who the high risk athlete is? So that would be looking into the future using some kind of a test to say, well, your test score puts you at very high risk of getting an injury. And the question is, can we do that better than just flipping a coin? I will not go more into detail on this, but I'd direct, of course, if you're interested in that topic. To this paper published about four years ago, where I argue why screening tests to protect injury do not work. And with a sad addition here, and probably never will. So in the Norwegian Olympic Committee, we do not use tests to identify who the high risk athletes are or try to look into the future. But we do the examination to try and identify existing problems among athletes. And of course, health problems do exist. This slide shows non-injury health problems at the time of screening of the Tokyo Olympic team. And as you can see here, nearly half of athletes suffer from some sort of allergy. The Paralympic athletes to the diagram. You can see that in this group you also have the added burden of chronic disease. Musculoskeletal problems at the time of screening. Basically half of the athletes present at screening with some sort of problem and the same injury problem. And the same applies to the Paralympic athlete population. So screening does detect multiple health problems. The idea is then to use screening and make sure that they're optimally managed. What about the next issue then, baseline testing? This is an example of an athlete suffering in ACL injury after being screened. And here you see the result from isokinetic knee extension testing and vertical jumps. The intention then is of course that the screening examination is followed up with an action plan. Targeting specific areas that needs to be worked on by the athletes, by the medical team, by the coaching team. This clearly is a challenging task because it does require the engagement of so many people, essentially all those working with each athlete. This then brings me to the second part and that is the monitoring program. So when we've completed the screening athletes are entered into an injury and illness monitoring program. This is based on the Oslo Sports Storm Research Centre questionnaire and health problem, which we designed a few years ago in order to be able to capture all types of injury and illness problems in athletes, not just the major ones, those causing time loss from sport and from training. So before I describe how it is important to point out that the program has meant to serve two purposes. One on the individual level and one on the big picture, so let's call it the team level. On the individual level the surveillance and monitoring program helps with communication between athletes and their medical staff. It helps identify new problems early and it allows us to monitor known problems, chronic problems that athletes have on how they fluctuate over time. At the big picture level, so that would be the Olympia Topin level or the team level, we can identify patterns of injuries and illnesses, what, who, when. We can identify areas where we might decide to focus prevention efforts and we can assess the effect of anything that we do to try and prevent injury and illness in the team. So then let me explain how this is done. The normal injury and illness surveillance program is typically done by the athlete reporting to the medical team and then the medical team reporting to the manager or the database, collecting overall data for the entire team or a group of teams. Now the difference to this program is that it works weekly, their health status to a database. The medical team is alerted through an online health dashboard and are then expected to provide individual follow-up on each problem and at the same time record diagnosis information in the database. Let's have a look at how this looks for the athlete. So every week athletes get an alert on their cell phone to respond to four key questions on the consequences of any health problems they may have. These questions focus on sports participation, on training modification, have they had to change their training because of a health problem at any time, has performance been affected because of a health problem and do they have any symptoms typically pain if it's a question of injuries. If they have reported a health problem they will be asked, well, is it an injury or an illness? Which region does it affect? What were your symptoms in terms of if it's an illness? Is it a new problem? Did you lose any time from training or competition? And who knows about it and any comments? Once the answer is completed the questionnaire which goes into There is an alert sent when a new health problem is reported via email or SMS or both to the medical team and expected to follow up individually and record the diagnosis in the database. So in Olympic Toppen we have an overview, we have access to an overview of the health of all the athletes on our teams and then each health provider has his or her own team and you see here the example of five athletes, the colors represent each box represents one week, the colors represents whether the athlete is healthy, shown as green or injured, shown as yellow, orange, red, which indicates the severity of the health problems reported. And if you then click in on any of these athletes you will get a view like this. So this is an example of an athlete with an overuse injury of the knee and where the severity of the injury each of the weeks going back one year is indicated by the height of the green area in this diagram. And we have seen here with multiple health problems suffered by an athlete over the same time period and you can see a list of all the problems down here. Again giving a detailed overview of the status of each athlete on the team. So let's have a look at some example data, big picture data on our Olympic. And the data I'm about to show to share with you is on our candidates for the Tokyo Games, Olympic and Paralympic Games, covering a 16 month period until the end of last year. And this is obviously an ongoing monitoring as the games have now been postponed until 2021. The questions we can ask, the big picture questions that we can ask and answer are questions like how often do our athletes get injured or ill? How much training is missed because of injury and illness? How many of our athletes are sick or injured at any given time? And identify the biggest health problems affecting our team or our teams. So first, how often do our athletes get sick or ill? Our data show that on average each of our athletes report five health problems each year, three injuries and two illnesses. And we obviously also have the ability to look at these data on a team basis. This is one example only because time is limited. I will have to limit myself to overall data for the end of the period. So the next question is then how much training is missed due to injury and illness? And it turns out that on average our Olympians and Paralympians lost 34 days last year because of health problems. 34 days of training lost, 26 days on average due to injury and 8 days due to illness. So clearly injuries and illnesses represent a key factor in being able to train and then subsequently being able to perform. The next question is how many of our athletes are sick or injured at any given time? And I underline that this is any health problem, even very minor problems. So one in three of our athletes have a health problem at any time. Mainly this is about physical complaints and to a lesser degree illness problems. Of course varies from sport to sport. And the final question here is what are the biggest health problems affecting our team? So a risk matrix as shown in this slide is a good way to illustrate which problems should be the key priorities. This then shows the same data for the entire Olympic and Paralympic team. And for those of you who are not familiar with these matrices on the vertical axis is a measure of severity. In this case the average number of time lost days for each of the health problems depicted in the figure. And on the horizontal axis is the incidence. So how often do these injuries happen? Obviously the product of severity and incidence is a measure of how important or what the burden of this health problem would be. And that also means that the darker the orange color the more important is the problem. And overall you will see that there is one type of injury that differs from the rest. And that's knee injuries and the circle shows that this is acute knee injuries. So the by far biggest burden in our Olympic and Paralympic team is from knee injuries. So risk matrices like this can then be created for each team, each subgroup of athletes, whatever you like to identify focus areas for prevention. So the question then becomes what are the critical factors for a program like this to work? One key issue is of course response rates. Athletes need to respond. And as you can see over the period we've just been discussing, the average response rate has been 83% and currently it sits at 85% I think last week. And we're very happy with that. And we have learned by trial and error I must admit that technology is critical. It's very simple really. Everything needs to work every time and the users, the athletes and the practitioners have to like the system. And in choosing between the character and the stick, another thing that we've learned is that in order for a system like this to work, it's only a character approach that is going to help you. So it's important that rather than being a research project that Olympia Toppin does that may or may not benefit athletes in the future, our monitoring program should have direct and immediate benefits for all stakeholders, athletes, medical staff and coaches. This cannot be said often enough, also within our team. So the question of the athlete is what's in it for me? The question of the medical team is the same, what's in it for me? The question the coach asks is what's in it for me? How is this program going to help us keep our athletes healthy? And the way we try to address those questions is well for the athlete, it's better, more timely medical care perhaps. For the medical team it helps them do a better job knowing what the athletes are doing at any time in terms of health problems. And for the coach it's all about getting more training days, keeping the athletes healthy. And then the final question which I threw in for fun I guess is does it help Norway win medals? So if we go to the greatest sporting nation, the website that polls statistics from all sports, Olympic and non-Olympic sports, it clearly shows that the by far best sporting nation in the world is the United States. So congratulations on that. And Norway is all the way down in 11th place. But if you take the population size into account, we're doing okay, perhaps butting above our weight class. But you might say well that's because you do so well in the winter sports. And yes that is. But if you take a historical perspective on this, this has not necessarily always been the case. Going back to Torino 2006 and looking at the medal table there, you will see that Norway is all the way down in 13th place with only two gold medals. And as the media like to depict that illness within the team, perhaps a norovirus epidemic, may have been a major contributing factor to Norway not performing as expected during those games. And in fact 17% of the athletes on the team were ill or injured during games time. If we go to Vancouver 2010, when Ularensen was the CMO of the team, we will see that only 5% were ill and Norway climbed on the medal table until 4th place. And then Sochi 2014, second place with a similar number of ill and injured athletes. And finally now in Pyeongchang keeping that number low and stable, Norway was able to climb into first place. And of course we were very happy as were the athletes. And now you ask yourself well did we prepare perfectly for those games? And I'll end by showing this video which was taken here halfway through the Olympic Games from the cafeteria at the British Olympic Training Centre. Where you can clearly see that the demonstration had not prepared for any event during the games. I thank you very much for your attention. But I would also like to take this opportunity to invite you to re-invite you I should say to Monaco for the IOC World Conference on Prevention of Injury and Illness in Sport. And of course as many of you know we were forced to postpone this until 2021. But here are the dates for it through 6th of March 2021. I wish all of you welcome to Monaco where we will run basically the same program as you were invited to this year. However with adjustments as needed for new evidence and new knowledge that has come about during this year. And yes I do expect the Covid pandemic to be an issue that we will cover in detail during the conference. So welcome to Monaco nearly a year 11 months from now. Thank you very much.