Nick Allen Ph.D., M.Sc. (Sports Med), M.C.S.P., S.R.P., Clinical Director of the Birmingham Royal Ballet, discusses his experience and journey to creating high performance potential at the Johns Hopkins Department of Orthopaedics Sports Medicine Grand Rounds.
well, thank you everyone for joining our second installment on the performance. Mhm Medicine, sports medicine and rehabilitation. Grand rounds at Hopkins. I'd like to introduce dr Nick Allen. Nick is the clinical director of the Birmingham Royal Ballet Company. He is a postgraduate degree in sports medicine and also on the National Institute of Dance Medicine and Sciences Steering committee. Dr Allen has worked previously with great Britain gymnastics, hockey, and the lawn tennis Association's high performance center, amongst many other things. Um I've had the privilege of knowing Nick uh now for Over 15 years and have followed his work as he has been a leader and innovator in the integration of a sports medicine mindset into the care of the um performing artist and very much looking forward to his discussion today. Uh and thank you again, nick for joining us. Thanks. That's very kind. Thank you very much for inviting me, gosh, this is, this is a really, really nice thing to be invited to kind of talk about. And I'll be honest when, when ken first approached me about this, he was, he was also kind enough to leave it very open as to what I wanted to talk about, which is always a privilege. But sometimes that blank canvas is difficult to, to kind of fill in. So, you know, I thought about it and I thought about what I could do in this session and you know, I do a lot of talks, a lot of case presentations and I'm sure your program is gonna be filled with lots of case presentations and so I decided not to do that. I wanted to maybe try to give you a little bit of insight as to how do we work this side of the pond, How do we work in elite level professional dance And I hope some of the things that I'm gonna be talking about now form part of my own personal clinical reasoning process when I see a patient, but also form part of my process in when I actually set up and run a service when I set up and run and help design the National Institute of Arts and Science. So what is it that we use? How do we do that? How do we create success with our patient groups? Whether or not there are any equals one or they're an entire organization. So, so that's what I'm gonna do today is I'm going to kind of walk through that uh, and, and a lot of this is a reflection on, on my own personal journey. If I'm honest, as ken said, I've, I've had a really fortunate career so far, I haven't worked an elite level performance or sport for over 20 years now and in that time I've been able to work with british, european world, commonwealth, olympic and paralympic champions across a variety of different sports and I've learned lessons all the way through that. Uh, and one of the things that sort of struck me in this journey is, is the amount of data that we have access to now. And so I'm going to talk a little bit about that data collection. I'm also going to throw in some of the graphs and some of the data that we collect with some of the work that we do here as well. Uh As King alluded to, I like to draw things from all different sources. I like that cross fertilization coming from sport to dance, dance back into sport. But actually I like some of that wider cross fertilization as well. So I'm going to talk a bit about some of the books I read and some of the messages I've taken and implemented as a result of those uh and how maybe they form part of your business plan it and then you know, we can't be sitting in the middle of a worldwide pandemic and not talk a little bit about epidemics. So I'm going to throw a bit of that in as well but maybe try to put a slightly more positive spin on what we're gonna find there. But before we start, I thought I would just start off with a little quiz. I don't know how well I've done this before on zoom and it's gone okay. So just in the chat function, I just want you just to say basically coffee, Is it good for us or is it bad for us? Just quickly? one word, good or bad. So those of you probably a bit like me who's thinking it's, it's something good? Well, actually, yeah, it's good for short term memory, but as an energetic aid, we've seen the combination of caffeine, improved carbohydrate absorption from that gold standard of one g per minute to anything to up to about 1.78 g. So actually, when you're looking at some of our endurance athletes, you know, a caffeine shot is not a is a very useful bonus there, but it's also kind of bad for you as well. And it's been linked linked to heart disease. It's been linked to blood pressure changes and things like that. These are gonna get slightly more controversial as we go along by the way. So at the moment we're starting off light but it's going to get worse. So when we're talking about sunshine, what do we think? Good or bad? So we did some research here a little while ago actually, quite a while ago now, and we looked at vitamin D levels in our dances. And when we looked at it in our Winter season, 100% of our population group were either insufficient or deficient in our summer group. We had 80% of the population insufficient or deficient. So we know we're lack of vitamin D. We know actually there's a good good level of research around there. Around its impact on bone health and immune function as well. But we also know that actually sometimes maybe not so good for us either. So again it's kind of getting into this point of what data, how do we use this data? I told you it's gonna get slightly more controversial for those who like chocolate, is it good? Is it bad? What are we thinking? Well, for those who sit in the good camp, there's some good stuff out there, you know? So maybe the reducing risk of cancer, risk, healthy hearts, certainly an impact on mood, if I ask my wife, but it is high in refined sugars. Yes, it's been linked to diabetes. Yes, it's been linked to heart distance. So, final one of these alcohol. What are we thinking? Tell me, are there students on this call? Because that might influence the decision making around this. We might find that the good side maybe shifts a little bit stronger on the on the answer in there. But actually, there is some evidence out there that it might actually reduce risk of middle aged heart disease, but as we all know, it is actually a poison, it's processed by the liver. It's a depressant, it's linked or sleeping patterns. So, the evidence is inconclusive and I think the reason for that is just to kind of bring your attention to to this this idea of data, the amount of data that's out there, a lot of us have research strands to the work that we do and we're evaluating levels of data. But, you know, I work in professional environments where gosh, you know, we don't over we don't only just have evidence based medicine when we're looking at systematic reviews, but we have GPS data. So I've got so much stuff coming into me at the moment that I'm trying to use for my decision making. And it comes to a point where you generally cannot see the wood for the trees. And even if you take some of those leaves away, we could all be looking at the same data set but we might be seeing two different things. Some of us might be looking at this scene, the vase. Some of us might be seeing two people playing the longest game of who's going to blink first and see the two faces. So even people looking at that very same dataset might start to interpret it differently. So what do we know? Well, with all this information around us, we know that information itself. It's not actually knowledge. One of my dancers keeps pointing out to me as you can see their knowledge is knowing that smarter as a fruit, but genius. That's not putting it in a fruit salad. So what is genius? Well Winston Churchill talked about that capacity of evaluating uncertain, hazardous conflicting information. And I certainly think when you start to look at some of the data that's coming in with your patient groups with your wider patient groups, you could probably find that that uncertainty sits there. So what information should we be collecting? Why should we be collecting it? And what are we going to be using with that information to try to make the right decision, be it for an individual patient, albeit for a wider group that you're responsible for. So when I started to think about that and I said I have I have a joint role, I have a clinical role and I have a strategic role within the organization around overall overarching strategy. And when you start to put that together, It doesn't matter if you're talking, you know, you're 1-1 patient and you're starting to say, so what are we trying to achieve? What does our patient orientated outcomes? What do they need to do? My daughter needs to jump and jump high. So what are the outcomes that I'm going to put with that? Or if I'm thinking strategically, is it my vision? Is it the mission statement? The value proposition? They all have different names when we put them together, but ultimately they usually at an elite level, boiled down to one singular thing. We're trying to achieve excellence. Nobody is setting out there to be 2nd best. Nobody is sitting out there to be mediocre. We're going out there to try to be the best that we can be and get the best out of our of our interventions so that the patient has the best possible outcomes. So if excellence is our driver, what are we doing about it? So as I said, I have this split roll both clinical and strategic and when I think about my strategic a my vision for this organization, it's very simply we are talking about optimizing performance potential and we are building for the future. So we are trying to create the best possible performance on stage but that that can grow as well so that our dancers coming through our system as young dancers going through to the ends of their career and beyond for that matter, that we continue to have good quality coming out there. But if I try to take that into my individual dancer as a patient sitting in my consulting room with an injury, I actually have the same agenda there. I want to try to do the best to optimize their performance potential. They're the ones with the talent. Gosh, people like mission shouldn't dance, not even if they're drunk and what am I trying to do? Well, I'm trying to build for the future. I actually have a role that sits on arthritis research UK. And one of my very big drives is to ensure that the decision making that we make with our dancers not only allows them to enable their performance potential while they're dancers, but reduces the risk of quality of life changes as a result of those decisions. So that later on in life they're actually enjoying what they had as a career and not paying the price for it later. So then I start to think about why why are we doing that well, if I'm thinking about our organizational wide, well I came from a background in sport and it it sport and dance have the capacity to both inspire and challenge our audiences and that is really tangible. That is something that you see when you sit front of house and you watch how people get moved by, what happens on stage and it affects people's lives. That for me is a wonderful opportunity to be part of. I'm also a big advocate of movement and exercise. So from an individual dancer perspective, the fact that I've got exercising individuals that are low bearing through their bones, I think for me is a fantastic opportunity, but there comes threats and that's what I need to be thinking about and my threats very simply things like injury and illness. And so when I start to think what I'm going to do about minimizing and reducing those threats, I have those as a focus. And then my first question comes is do I actually have that operational capacity to deliver that strategic vision? Do I have the tools in place to actually deliver this optimal performance, potential, this building for the future, and what do I need, what do I have to have in order to deliver that? And so as a typical epidemiologist, we like to sit with our with our various stages, this is a very, very well known model approach for stage approach from, from Michelin, where we talk about these four stages and actually again whether or not I'm looking at my my cohort of 60 to 70 elite level dancers or whether or not I'm talking to a individual dancer. I go through these four stages. I need to understand the extent of the injury problems or illness. Should it be illness? I need to understand the risks associated with it. What was the mechanism of injury? Are there intrinsic risks? Are there extrinsic risks that I need to need to know about? What are the surface is doing? What are the workloads doing that all influence. And tell me a little bit about this and then I've got to do something about it. So I've got to introduce a management program in place whether or not to be a prevention program to stop this happening or a rehabilitation program to address the injury that occurred as a result of it. And then I need to assess that effectiveness and that effectiveness needs to be exit criteria through the various stages of that rehabilitation program as well as the overall effectiveness of that program across the wider group. And are we reducing the risk of time loss injuries across our group? So that's not an unusual approach to have. We have a very similar approach here. So I collect a lot of data. We're really fortunate that we worked with this this particular software company from Australian based company and we wrote the underlying coding for this which allows us to draw a huge amount of data from our medical resources. So we can start to understand the impact of injury. So we can start to look at the cost of it to an organization as well as the cost of it to an individual dancer and their career. Because this is this is a this is a short career at times. And sometimes if you step off that escalator, your opportunities can be lost. So time loss injuries become a really relevant part of somebody's career and and their potential the provincial trajectories really. And so understanding this data analyzing this data across the various months of the year. If you look at those, I know that the text is quite small, but you can see that actually when I start my season the beginning of august I have my biggest increase of injuries because they come from a five week break and then they come into full blown work. So we need to get better at that. You'll then see around november december. I have my next biggest fluctuation in injuries. Well that's nutcracker season for us. That's full length 40 50 shows back to back, we're doing 8, 10 shows a week really hard workload and then we come back in february again and we usually put some big classical ballet on. We get to the end of the season with running some contemporary stuff and it gets a lot easier for us. So analyzing this data makes a very big difference as to how I'm going to plan my season. But I drill a little bit deeper. I look at which injury should I be focusing across the group? Because I've got a big amount of people that I'm dealing with and a small amount of staff to deliver that. So I I look for low, low lying fruit. I look for my ankle injuries. I look for my foot injuries and what big programs can I put in place to try to reduce that impact. But one of the questions I wanted to poses, does that give you the whole picture? Does that tell us everything that we need to know. So I want to introduce you to a typical patient of mine. This is not a patient. He's at us. He was at our sister company down in London. Uh, I'm going to hope that the video actually works. I'll give you a short clip of what he does. So you get an appreciation for those of you? Probably a bit like me that hadn't seen very much dance. I hope it gives you an idea as to what sort of loads people go through. But if it doesn't work, I might just have to move it on. I love it's got you because everybody's disapproval. Should, should turn sooner if the heavens ever did speak. She's the last true mouthpiece. Every sunday's or fresh each week we were born, I heard them say my church offers no absence. She tells me where she's been heaven when I was going to and me to be with mm hmm. Okay. You know, in my life showers you like a dog at the shrine of your life. I believe that in my life she demands a it's something shiny. What have you got in the stable of starving, faithful hungry words Take me so you can sharpen your knife offer. Take me to our black and dog after. I'll tell you everybody I'm gonna read. Take me to church showers, dog and my sins. And you can sharpen your knife offer me shower black dog. And so it probably moves a little bit away from maybe that stereotypical image. You might have a ballerina in a royal company with a 2 to and a bun. Uh Sergei has been very open about some of the challenges that he's had. That's from an interview that he did in one of our broadsheets here in the Guardian, uh, you might also notice those self harm scars on his chest. See that's alongside his tattoo of Pewter as well. So, mhm. Understanding the prevalence of ankle sprains might not quite be the amount of information that we need if we're going to be successful managing patients in this sector. So as I said, I like to read a lot of books and I like to learn a lot from other organizations. So our first recommendation from this week's Book club is the lean startup. Now, this is a book designed for entrepreneurs starting your own business. And what it talks about is some of its key principles is precision about being agile in your decision making, having those evaluations and the ability to pivot. And I found it really useful to take some of these principles of business management and apply them into the clinical setting. But I want to draw some of the work out of it. I just want to talk a little bit about precision itself and when we're talking about precision, it's understanding some of that specificity now they'll talk about customer discovery and I did the same here. And I suppose one of the questions is why why talk about them being customers and not patients, You know, these are all just patients who might have a duty of care. But actually there is a big difference because what we're looking at here is we we need people to adhere to what we're talking about what we're advocating as part of their management programs, not just that blind compliance and so having them as the sheer focus to buy into this principle, that's where we're going to see some of those coming through. So what I wanted to do was to understand those challenges that dancers might face and that's both from a 24 hour cycle through the rest of their week, through their entire season, because our season changes considerably and through their entire career and then take that information. But the question is, what do you do with it? How do you use that information? So it takes me to the second book in the Book Club this week, and that's Malcolm. Gladwell's tipping point, Fantastic read, if you haven't read it, and this is where Malcolm starts to explore epidemics, and he draws off three key principles, He talks about law of the few, sticking his factor and the power of context. Now, I'm not going to focus too much on sticking his factor today, but I'm going to talk a bit about law of the few and then bringing power the context at the end as well. So the simple premise around the law of the few is that it only needs a small amount of change to create success, but there is something critical in that they do have to be the right few things. Now, two of our probably most successful sports coaches here in the UK is Sir Clive Woodward, who was the coach behind the England Rugby team when they won the World Cup in 2000 and three, and today Brailsford, who was head of british cycling, came back from Beijing with virtually every single medal at the olympics offer for cycling has since been successful with the sky and now Team Ineos World cycling team in the Tour de France and some of the World Series And both of them have been big fans of taking this law of the few Clive used to talk about 1%ers. So Dave Brailsford, he talked about the aggregation of marginal gains and I don't know if that's come across the pond to you guys, but it's talked about a lot here in the UK, but when we talk about marginal games, it's a really simple premise. Everybody does their New Year's resolutions and says, I'm going to exercise a lot this year and they go to the gym a couple of times in the first week, in january and they don't do anything else and there's no benefit, there's no improvement. Whereas actually, if they keep that going through the year, they'll see an exponential change in their health and their fitness. But what's really important as well is that we recognize the potential of marginal decline. So we're gay that one cigarette. Yeah. That's not going to kill you one cigarette every single day for the rest of your life. Well, there's a bigger chance that's going to create exponential decline in your house. And that's a really important part to think about when we're talking about, how do we make those changes is recognized where there might be risk of marginal decline. The other point I just wanted to make here is that when we work at Elite level and, you know, I've been privileged to see athletes worth, you know, multi millions of pounds of value to organizations and clubs and things like that. Some of the most expensive players in the world actually. Uh and sometimes you feel that we need to kind of do something extraordinary in order to get success there. Actually, no, it's around finding those little simple decisions and implementing them on a regular basis where we find that success. So I'm going to go back to that, that sort of strategic plan of creating excellence or whether or not I'm sitting with an individual patient and saying, how are we gonna get you better at what you do because of your injury or whatever it is? Ah well, performance is a very simple equation for me, and the equation is, it's the talent that that individual has multiplied by their ability, multiplied by their behavior. And we're gonna come onto this a little bit later on, but it's the behavior that has a multiple effects. So how do we do that here? Well, when it comes to talent, well, that's down to the artistic staff, they're the ones who audition, have a look at and offer contracts to my dancers, but I get a little bit of influence because I get to see movement patterns because I like collecting some data. I have a system in place and I look at normal movement patterns because one of the things that I've learned coming from sporting to dance is that dancers are incredibly skillful and as a result they can do ballet specific stuff in a really, really skillful way. But what we're looking for is we're looking for the ability of dancers to control and have movement competency. And this is how I assess it. The other area around performance is is the ability to actually just be present. And we've all gone through Covid. So we went through a process where through the entire organization, I evaluated vulnerability to covid and we set criterion places to say whether or not you should even be in the workplace at this time. And once we've established that we could then move on to a position of going what happens on a day to day basis. So my system in place tells me straight away as soon as I see a dancer that I've got a low risk patient, I don't need to be concerned. I've got all my normal mitigations in place. I can carry on working with this person. We then had to get masses of people into the building and out in a closed situation where ventilation is poor. So we developed an app attached to our medical notes system and we had a daily symptom checker where we used that alongside various other protocols to ensure that we have the best availability of dancers to put productions on. We also ran alongside their vaccine status. So I knew if I had an outbreak in the organization who might be more vulnerable. So the other big thing when I think about availability is what is potentially going to take somebody away from their ability to perform and in sport, we've had a number of episodes in high profile sport that have shown the risk of cardiac events. There was one in the european football championships last season where Erickson had a cardiac event on stage, he's had an implant since and has now returned back to professional football. We've had a number of tragedies in world sport. And so one of the things that I wanted to do was to understand potential risks of things like sudden cardiac death syndromes and we follow european guidelines. And so we published them work around cardiac characteristics in elite guards. So we put a research program together to understand what potential changes were happening within dancers heart as a result of their training. So that study looked at both resting EKGs echocardiogram and a family history and a blood profile. And what we could do with that is compare that to the data that we had across the Football Association and the cardiac screen program that they did. And we came up with a final recommendation that as part of a screening program arresting E G 12 TTG alongside family history was a suitable way to reduce the risk of cardiac events within our population group. And I've put their around vaccine status. Obviously everybody would have seen some of the comments and some of them, albeit very, very low prevalence of micro otitis with certain vaccines, we've had probably about four cases within the UK across the dance sector of micro itis. So we actually monitor that alongside it. So we will have our Sgs uploaded onto our medical notes system. We'll have all the screen data, all the family history will be recorded there, but I'll also have a link to which vaccine they they had in case there's something there that they need to be aware of. But probably the biggest threat to ability and availability in my world. It's injuries, that's our bread and butter, that's what we have. So what we have very simply is we have a color coded system that tells all staff that need to know very quickly what needs to happen. And I drew this color coded system from my experiences of working on pitch. So if any of your of the delegates today actually work on pitch and have to run onto onto a field of play to make a medical assessment on pitch. And you've always got the coaching team, the management team in your ear asking what the injury is to actually explain an injury on pitch takes too long. So we came up with a color coded system where I would have QR code and a number if I told you it was black that was a head injury and that meant somebody had to be extricated off and have a head injury assessment if it was red, it was a muscular little or a blood injury and I would tell you whether or not we needed to close that wound to keep them on and there would be a color, there will be a number code afterwards to say whether or not we would do that on pitch or we would take it off and we would have that color coded system. So we've done the same here and we've taken a color coded system from the IOC, the recent International olympic committee's injury data collection recommendations and consensus statement. And so we have somebody who is off whose read that might be modified with pathology. So they are unable to do all that's required but they will be available in class or rehearsals, potentially performances, they will be unmodified with pathology. So they are actually still carrying an injury but they're able to do everything that they're required to do. And finally that they are unrestricted. So they would be green. We use that same system on our rehab planners. So they'll go through an introduction where it's orange, they'll go through a progression which becomes yellow and they'll become unrestricted in that activity which becomes green. So they know that from that point on, they'll be able to do anything and everything they wanted to do and then we bring all this information together. We sit with our coaching team and the dancer and we put down what the specific needs are because when you look at raw data you can sometimes get a little bit misinterpreting what actually means functional outputs. So this slide is actually pulled from some of the work that we did. We were commissioned by the BBC british broadcasting to do a program for them. And what I wanted to demonstrate was some of the things that I've learned from coming from sport to dance. So we needed a visual way of demonstrating power and there's a good correlation with a six second power test on an exercise bike to a countermove jump which is obviously very relevant to a lot of sporting populations including dance. So on the screen there on the left hand side we've got a rugby player next to him is a professional footballer. We had a contemporary answer and on the far right is a classical ballet dancer. And we did this test once we did that we actually looked at counter move jump and we measured all of that input. And so the person on the left of that screen is dr Ranjit Singh. He's a kind of tv personality but he's also a doctor. So it helped used in somebody who could understand the data that we were working with and then what we said was how do you apply that physiological data in the really specific nature of what people do because the outcomes were very interested Because by and large pretty much everybody had the same jump height. So they all had around about 40 cm of jump height. But if you look at their power outputs, the rugby player pushed out 1600 watts as his peak power Compared to the footballer. A. 1000. And my ballet dancer 600. Obviously body weight comes into it and we know that. But if you go to those efficiency schools, that's where you see the difference. Because actually my dancer is far more efficient with the power that they have. So that becomes really relevant and understanding that true value of data is that if you just looked at power schools you might be diminished in thinking I just need to create power in this person. Maybe not, maybe it's around efficiency. So we use that information and say what does it mean within our strategic goal. How do we use the precision that we learned from our customer journey and how do we apply that? So well look at things like energy systems training And we know that what we've tested there is their peak power. So we're literally looking at the 80 PCP energy system. But we know that our dancers will also need six hours worth of rehearsal. So within that period I'm looking at 20-30% of that peak power in something like a functional threshold test. So I can then translate that information specifically to other testing environments to ensure that I have balanced across those energy systems. So I've got a rounded dancer who can both do the explosive work, but also the aerobic long endurance based stuff. The muscle endurance that they need. The final bit of this equation was behavior and we talked about this having this multiplying effect. So the last book in my book club, I'm a South African actually I grew up watching rugby, I've worked in rugby and if you don't watch a lot of rugby, you may not know this. But the All Blacks, the new Zealand rugby team are head and shoulders when it comes to rugby. These guys have the best winning record across the board. They basically have won more matches than they've ever lost. Only eight countries have ever actually beaten them. They've won the World Cup three times and that's out of the 10 or so and now that that's hosted. So these guys are head and shoulders and I was really fortunate to work with head of fitness and conditioning for the All Blacks for awhile. And so learned a lot about how they work. But this book really highlights some of the big, big principles that sit behind the success that the All Blacks have had and the belief systems that they have. One of the things that they talk about is around this sort of group dynamic and how they really work as a team and that's sort of one selfish person within that can infect that collective culture. We talked very early on about the the potential of marginal decline and that's where that one individual has ability to start to influence behaviors across an organization and all of a sudden it's not just one, you've got an entire organization that's actually in decline. So understanding behavior and maybe how to measure it to therefore influence it becomes a really big part of my job. So how do I measure behavior? But actually behavior is influenced by a lot of things. Training load. If you are adequately prepared for something, you probably feel a bit better about it. But if you're overtrained or under trade that, that creates anxiety if you fail to recover or you're if you're presented with lots of muscle soreness, you don't feel great about it. Your behavior changes if you've not had a great sleep, if you're injured or your mood is affected. All of those affect how we're going to behave. So we try to measure it, we try to collect this data so the dancers actually input their training load, they actually input their mood, their muscle soreness, stress, pressure, sleep, all of that comes through. But as I said, I need to be precise about my data if I'm going to believe it. So I actually have a way of understanding compliance with my data sources. So I know whether or not this is data worth following. The other thing that affects it is the environmental context and the environmental context is huge and it comes back to one of the things that Malcolm Gladwell talks about in tipping point is that we are very much influenced by the environment around us. And the broken window theory very simply says you're you're less likely to pick up a stone and fling it through a window of a of a shop. But you'll be surprised when you walk through a direct part of tire town to see that lots and lots of windows are broken. So in an environment where there's lots of broken windows, people think it's acceptable behavior to pick up a stone and just be part of it. Whereas if you go to the central business district where all the all the buildings are all looked after, people are throwing stones there, we are really sensitive to the environment around us. So it's really important that we get those, those those areas correct. So for me it's around getting a professional context all the way through what the dancers do. So we have, again, an app system that tells them even if they're scheduled that day is going to change, so we know what's happening, they know what's happening, There's no surprises, but the environmental context is created by my team, my medical team and so I want to know that their environment is a positive one and it's professional. So one of the things that we did was we ensured that the electro medical notes system that we use was recently we worked on updating it. So when the olympic commission put out their new data collection advice, we immediately updated our systems so that we did that I actually have required cells in our Medical Notes system. So you can't just skip through things. We need that information that details. I'm ensuring that people are thinking through all of those influential influential data points that will make the success of that final outcome more achievable. And we set our KPI we set our key performance indicators through those systems because we can pull reports off them to see how long did it take. Did we get the affected timelines that we were looking for? So I'm mindful of time. I was hoping to leave some time for questions. I don't know if you guys have got time. I'm happy to stay for a little bit longer but I just wanted to wrap up with a couple of final thoughts. So whether or not you're looking to plan your strategy across an entire organization. Whether or not you're just sitting with that single patient in your consulting room, there's a few things maybe you can be, you can reflect on from today's talk that will that will help whether or not you take this lead startup approach where you may not have all that data in front of you but as long as you're agile with your decision making and you're prepared to pivot and change as you go through that rehabilitation journey, that's where your success comes from. Because actually data doesn't give us all the information we've still got to navigate through that understanding that marginal gain and picking the right key things to focus on and to and to actually to repeat and continue to repeat and become habit is really important. But being mindful of marginal decline and so we cannot leave things. We cannot leave movement patterns in that rehabilitation program unchanged because they will come back and bite us. They will grow exponentially and be the reason for exacerbations and re injuries coming through. But behaviors are the biggest influence on our success. And we were asking our questions in our in our medical histories and our and our mechanisms of injury, we don't often find ourselves asking how well did you sleep the night before, You know, what's the mood like at the moment? How are things going at home? We don't necessarily always ask these questions, but maybe we should take time to reflect a little bit more about how those behaviors will influence those outcomes, learn and find out a little bit more. So when we take that patient on that journey, we have that as part of our understanding because trust me behaviors are influential and they can be exponentially influential and it can be the biggest difference between success and failure despite all the wonderful biomechanics, muscle skeletal stuff was thrown into the equation. So hopefully that's a whistle stop tour through the sort of things that go through my head when I'm working, uh I'm not sure ken if we've got time for questions and mindful, I've probably gone over. No, no, I've kind of hit times, I'm okay, but if there are any questions happy to answer and nick. Thank you. That was a great presentation. And as always, you're just a fantastic communicator as well. Uh taking your experiences complex concepts and making it weaving it into this um work of art. No doubt. So, thank you for that. Um One of the questions I had was regarding your, where you sit within the team, obviously there's the Birmingham Royal Ballet. Uh and and Derwood has a very robust um team that participates with the care of your company. Can you talk a little bit more about how you, what is the frequency of your meetings and your communication, um how do you connect the dots through your, through your portal, your data portal? So Probably the structure of our week. So our dancers will come in and they'll do their pre activation and they're pre training before class, which is usually 1030 for about an hour and a half. They'll have a small break and they'll go into rehearsals and they'll have various breaks scattered through those rehearsals, anything after about six hours for the raptors all that day and that's six days a week. So what we tend to do is I have a clinic on a monday morning which is a general medical services clinic. It's run almost as a GP clinic. So we might be doing contraceptive pill checks. We might be doing dermatology reviews because the answers were a lot of makeup and actually they have reactions. Homeowner, lots of those sort of things will happen in that general medical. I had that 1:30 a 74 year old with me pain. Who has a replacement. Oh so I think somebody's not on mute, mute, mute. Uh huh. So from that I go into a meeting then with my wider medical team and that happens midday on monday and I run top to bottom through the entire company list and I will ask my team how people are doing. I will ask where we are injury status, where we are on availability. Are we restricted our were unlimited. That then gets summarized and gets taken across to the artistic team. There is a member of the artistic team who sits in my team and does the technical rehabilitation. So he comes in at the back end of that meeting where we'll do a crossover meeting and talk about technical rehabilitation that has to take place within that time as well. So he will plan his week around some of our rehabilitations. I'll then have a senior management team or a senior leadership team on the Tuesday which will have our executive and I then report to our board as well where I'll update them as to where we are status wise and some of that might be a little bit more strategically going into a big performance. What is it looking like one of our risks to performance? Do we think that we are at a vulnerable position of not having availability to actually put a performance on? So do we need to get some numbers in? Do we need to actually contract some new dancers in by the thursday? I have a second meeting with my shorter team, my medical team and I understand what progress has been made through that week. So I have a second touch point with my team around what's going on. We have a very fluid communication with our artistic team on a daily basis anyway. So if the status changes, we get consent from a dancer and we immediately update the dancer artistic team to say a particular dancer will be unavailable to to partner but can be in rehearsals so they can't lift because the shoulder problem but they can do everything else. We're really careful about not disclosing medical information. We need consent before we do. So it's all controlled. We're allowed to say what they can and can't do but we just can't say why. So it's not always easy and I can understand answers wanting to keep some of that stuff personal but from unemployment law perspective they also need to be aware as to what dancers can conduct. So how many therapists do you have on staff for the people that directly report to you? Can you tell me a little bit more about your team specifically? So we were down on staff at the moment I am recruited so we're at the moment we would typically run off, I would have probably three full time physiotherapists. I would have one of those will be my clinical lead, one of those will be my rehabilitation lead and they will line manage those under them as well. So more junior company physios would sit under those. I will have a, what we would say is our dance scientists who actually double as a massage therapist. I'm not I'm not a huge fan of massage therapy, I want to see people being a lot more active and proactive in preventing injuries through conditioning. So I purposefully recruited a massage therapist who I knew had actually mentored when they were still the dancer themselves and have put them through strengthened additional qualifications. So they have a hybrid role of actually taking dancers through conditioning as well. And then we have our technical rehabilitation so we're actually really small team alongside that, I have a few consultants, so I do have a GP I have a sessional physiologist, I have sessional psychology. Okay I then bring in some group programs. So from a a well being psychology perspective if some of you have come across another book, Chip management professor steve Peters, really good book, worth having a look at. I had a chat steve a few years ago. He's done some incredible work with our athletes here in the UK and we have his group coming and deliver across the organization around behavioral management in high performance environments. How do you optimize behavior in high performance environments? How do you prevent burnout? They do a lot of work in our national health service here in the UK and done some incredible work with our teams that have had real torrid times through covid and really been successful with that management program. So I've got a lot of stock in chip management and how they work. And so we have an ongoing program with them. I have a confidential psychology service as well which I have no visual sight of. So it is completely confidential. Anybody in my organization can access it. All I get is a bill. I don't know who did it. So it's one of those things that I put in place personally because I know there are things that are sensitive and although you know, given what people say to me, they're very open with what they're prepared to talk to me about. But I'm also aware that there are some things that they just don't want to bring into the workplace. So I've opened a portal for that to happen. It happens off site, it can be face to face, it can be via remote and they can access private counseling services as well, wow. Yeah. Yeah. I mean I've watched you build really an amazing empire over the last couple of years. So it's it's really a testament to your leadership too. So it's very inspirational. Thank you, keeps us busy. They're a great lot to work. I mean, they are absolutely fantastic to work with. You know, we get our challenge is actually get our challenges. Were doing a lot of work at the moment on relative energy deficiency and really going into that really difficult challenge of what's a disordered eating secondary aiming career. How do you do it? How do you how do you screen for that? You know, we're starting to put a program together if anybody on this call that is interested in things like resting metabolic rate ratios and actually measuring that as a predictor of somebody going into metabolic decline. That's the sort of stuff that we're going into because again, we have our challenges. But as a group, as a set of people. What a wonderful group to work with. Nick. I want to thank you. That was incredibly thought provoking talk and certainly gave us a lot to discuss and we we applaud your work and continue to look forward to following your career and invite you back in the near future. Oh, that's very kind of you to say, I'll be more than happy to come chat a bit more about what we do if you need to. Um, I have a question, I guess. Where did you start with like, how many were on your team to like where you are now, but also where do you recruit from? Are there certain physios that go through training that you're looking for? Um just how do you develop that kind of younger clinician or knowing that they're a right fit for the company and the workplace that you're in? That's a really good question. And that, that last bit there about being the right fit, you know, I sat in an interview panel for another organization and I said that the person that they interviewed was clinically not up to the job, but they were the right person for the job and if they can up skill and support this person they will be an asset because I believe a lot as you can see in behaviors and personality from a clinical perspective, I have to university positions where we talk a lot about dance medicine, specificity of working in dance, those sort of things. But I'm a firm believer and when the faculty of Sport exercise medicine was created in 2000 and four in the UK, Professor Mark Battle is a good friend of mine set it up and was involved in setting the curriculum for developing sport exercise medicine within the UK and we talked a lot about where dance medicine sits within that and I wholeheartedly agree that it sits under sports medicine. It's just the specificity if you work in, in football, in rugby, in running, you know, there's all those specificities that you need to have, and that's really, that's where the foundations of your training come from. And then as you specialize a little bit more, yes, you learn that specificity. But you know, one of the questions was, where do I recruit from? I actually recruit from an organization called UK sport. So UK sport fund all elite level sport in the UK. And so I recruit there because I want people in a foundation of sports medicine, the dance stuff we can teach on site, but if the building blocks aren't there, it's not gonna work. So I always always go to UK sport first, if I'm honest, I'm sometimes a little apprehensive if I have somebody who was a dancer and then goes on to want to work and dance because it can be difficult. And the same happens in sport. I was the same when I when I, when I headed up medical teams in sports, is it sometimes it's difficult to leave that role behind and become the next person. And so actually having somebody with no previous biases, I know nothing about dance. I'm a cultural heathen. So I have to learn everything without making any sort of suppositions about what it is that you're going through as a dancer. I've got to ask the question. So I don't bring any biases into it. So I love recruiting from different backgrounds and different environments because I think it gives me a wonderful mix of experiences, but I also think it gives me the right tools to be asking the right questions without any biases coming into the equation. That's interesting just coming from my personal dance background and wanting to work with dancers and you know, I run the fellowship program here at Hopkins with our physios and so it's interesting to hear that you're looking for just different backgrounds and those people that are eager will adapt and kind of step up. So very, very interesting if you look now. So I was head of Medical Services, one of the Premiership teams before I came here, the current medical director at English National Ballet had the same role that I did. And the current clinical director at the Royal Ballet down in London came from british athletics. So all of the major companies in the UK, all of their medical leads have come from sports, which is great because I write with dance medicine, we're kind of trying to follow the lead with sport or trying to kind of, you know, merge the two that there are a lot of these similarities where we've had these deficits for so many years of care, so to hear your programming and bringing that sport side into it. It's just renowned and they're very fortunate to have you all as a medical team, but also have an organization. So it's, it's just great to know that it's out there. Um, and hopefully there's more, more companies that will have services like you all have. I think it's definitely think it's grown. I think it's, it's moving towards the mainstream of medicine, sports medicine and stuff, so I'm optimistic as to which way, which way we're going in the direction. Yeah, it feels that way too. That's great. Thank you. Are there any other questions before we wrap it up? I guess. That's a no nick. Thanks again. Really. That's phenomenal. So we'll stay in touch and connect offline, brilliant. Thank you very much for the invitation. Hopefully everybody enjoyed it. Yeah, we'll speak soon. Thank you. Bye bye. Hey guys.