Impact case study database

Improving knowledge and changing attitudes on factors affecting participation in sport and exercise among teenage girls

Based on her research showing how factors associated with, and concerns about, breasts negatively affected participation in sport and exercise (3.1), Brown and colleagues developed ‘ Treasure Your Chest’, an educational workshop that has been freely downloadable since May 2018. The ‘ Treasure Your Chest’ website and new resources were relaunched in 2020 and have been downloaded by 137 schools and organisations across England, Wales, and Scotland. The workshop comprises videos, activities and interactive tasks to empower girls to increase their breast knowledge, feel more confident talking about breasts, and make positive changes to their breast habits. During 2020 the ‘ Treasure Your Chest’ workshop was delivered to 408 schoolgirls aged 11-15 years. The workshop was scheduled to be delivered to over 1,000 schoolgirls, however school closures because of the COVID-19 pandemic meant this full schedule could not be delivered.

Following the workshop, 98% reported an increase in breast knowledge, 78% were more confident talking about their breasts, 90% reported more positive attitudes towards their breasts, and 97% wanted to make a positive change to their breast habits (e.g., check their bra fit, wear a sports bra when taking part in sports and exercise, and check for healthy breasts) ( 5.1). Those attending the workshop highlighted that it also made them feel more confident with their bodies when exercising ( 5.1). Teachers, assistant head teachers, wellbeing coordinators, and directors at schools that received the workshop have recognised benefits in their pupils following attendance at the workshop. Specifically, they have seen improvements in self-confidence and knowledge, with this increased knowledge having secondary benefits as the pupils have commented that they have shared their knowledge about the importance of a well-fitting bra and how to check for healthy breasts with family and friends ( 5.1). These school representatives confirmed they will recommend the workshop to colleagues at other schools and will be incorporating the materials within their school curriculum ( 5.1).

Development of a new sports bra and education concerning bra-fit

Recognising that teenage years are a critical time for females, when many drop out from sport (3.1), along with the impact of breast pain and bra-fit issues upon exercising females (3.3, 3.4), Brown’s research has been used by [text removed for publication], a sports apparel company, to inform design of a new sports bra. This company aims to encourage girls to participate in sport and reduce drop-out through the development of bespoke products and has used Brown’s research to inform the design and development of a new product line of sports bras that are specifically designed and engineered for teenage girls to help the company achieve its commercial aim ( 5.2).

The Women’s Sports Network is a not-for-profit organisation that works with the educational, commercial, and charity sectors, as well as national governing bodies. It combines a desire to educate, inform, and empower, along with the aim of increasing sport participation levels amongst women and girls. To help achieve this, they invited Brown to contribute her research (3.1) on breast health and bra-fit to inform their range of ‘MoJoManuals’. MoJoManuals are an educational resource to help girls overcome issues and barriers they face in sport and have been translated into multiple languages. More recently, MoJoManuals have been tailored to specific sports with the rowing version (ROWMoJo) containing breast specific advice and education, which has been distributed by Rowing Australia to every girls’ school in Australia that rows and adopted by World Rowing/FISA as part of their global initiative to get more girls rowing ( 5.3).

The ‘SmartHer’ Programme

Brown’s research on how breasts affect sport and exercise, as well as that by Pedlar and Burden investigating the influence of the menstrual cycle, have been used by the English Institute of Sport (EIS) to inform their nationwide SmartHER programme as part of their initiative to better support female athletes, enhance performance, and improve overall health and wellbeing. The EIS has used research from St Mary’s to provide better breast support to athletes and to adapt training and sport science techniques through an enhanced understanding of how the menstrual cycle affects athletes ( 5.4). SmartHER roadshows have been delivered to 102 athletes across 15 sports within the UK High Performance system. The SmartHER roadshows have also been delivered to coaches and sport science and medicine practitioners who work with the athletes; in total 122 staff from 25 different sports, including 30 coaches and 17 multi-disciplinary teams, have attended. As a result, sport science and medicine practitioners working within the EIS and sport national governing bodies have an enhanced knowledge base and can provide better informed and more impactful support to athletes ( 5.4). The ultimate beneficiaries are the female athletes, who now receive bespoke and evidence-informed coaching and sport medicine support to improve their training and performance ( 5.4). Collectively, this has enabled the EIS to create environments where female athletes can thrive and pursue world class performance ( 5.4).

Development of ‘FitrWoman’ Mobile Application

Research by Pedlar and Burden on the menstrual cycle and iron deficiency (3.5, 3.6) has been instrumental in the development by Orreco, a company specialising in sport- and data-science, of the FitrWoman mobile application which helps to optimise athletic performance ( 5.5). The App allows users to track their menstrual cycle and, using research findings from St Mary’s, to train smarter by providing personalised training and nutritional advice. The App has been downloaded in over 200 countries and has benefitted recreational users by facilitating improvements to diet and training through an enhanced understanding of their bodies ( 5.6). It has also been adopted by high performing teams and organisations, including the World Cup winning US Women’s National Soccer Team. Their team manager, Dawn Scott, testifies how research from St Mary’s on female physiology and menstrual bleeding greatly influenced her management and preparation of players in training and during tournaments, and was an important factor in their FIFA World Cup win. In her current role as the FA’s Senior Women’s Physical Performance Manager, the impact of St Mary’s research continues to be realised in enhancing physical programming, preparation, and coaching in women’s football ( 5.7).

Medical practitioners have benefitted from St Mary’s research on the menstrual cycle (3.5, 3.6) as they report greater awareness of the potential for heavy menstrual bleeding in female athletes. Where athletes present with these issues, medical practitioners use research findings from St Mary’s to ensure a more evidence-driven and individualised approach to address iron-deficiency ( 5.8, 5.9).

Collectively, the research from St Mary’s on female health and the menstrual cycle has been important in highlighting the gender gap in biomedical research, which has been recognised by the Wellcome Trust’s public engagement team. Based on this, the Wellcome Trust subsequently developed a new sports and health related project strategy focusing on the three Ms: Menstruation, Motherhood, and Menopause that is informed by the issues identified in research from St Mary’s (3.5, 3.6) ( 5.10).

Application of Blood Flow Restriction Training for Rehabilitation from Injury

Based on our research showing that application of BFR training was inconsistent and often misaligned with research evidence (3.1), organisations have seen the importance of policy to guide its use. The English Institute of Sport (EIS), which is the largest single provider of science, medicine, technology, and engineering services within the sport sector to Olympic and Paralympic sports in the UK, have collaborated with Patterson and Hughes to write their first ever policy on BFR training ( 5.1). The policy ensures that all EIS clinical practitioners, across each of its nine sites, are using the same guidelines, and has helped the organisation realise a higher quality and more consistent application of BFR training. The EIS has benefitted by enhancing its risk screening processes and use of methods to determine limb occlusion and training pressures ( 5.1). Practitioners at the EIS now individualise all limb occlusion pressures, in the position of the chosen exercise, and have revised their screening processes based on recommendations from our research (3.1, 3.2) ( 5.1).

Based on his empirical findings concerning the use of BFR training, Patterson brought together researchers from around the world to write the world’s first set of guidelines that outlined recommendations for methodology, application and safety when using BFR training. National governing bodies, including the Football Association (FA), Rugby Football Union (RFU), and Lawn Tennis Association (LTA), have used our empirical research findings outlined in Sections 2 and 3 as well as Patterson’s collective guidelines to inform their application of BFR training. The RFU invited Patterson to present at a performance services meeting in 2015 to advise on how BFR training could be implemented within the structures of England Rugby and, more recently, Hughes delivered an invited presentation to advise on the application of BFR training in the Rugby 7s set-up. England men’s and women’s Rugby 7s now implement BFR training in rehabilitation programmes for all injured players to recover muscle and strength losses. The research informs practice to reduce pain (3.3), to select the appropriate cuff pressures (3.2), and to inform the choice and schedule of exercises (3.3), with all aspects underpinned by Patterson’s collective guidelines for the application of BFR training ( 5.2). Similarly, the FA now incorporate BFR into rehabilitation programmes for all players recovering from injury. Using our research, the FA’s rehabilitation team at St George’s Park have a greater understanding of how to best apply BFR and have particularly benefitted from research on implementing BFR training with those suffering ACL injuries (3.3) ( 5.2). The LTA also now employ BFR training as part of their therapy, rehabilitation, and strength and conditioning services to British tennis players, with their guidelines also informed by Patterson’s research findings and recommendations ( 5.2).

Our research has also informed practice at professional sports teams. Patterson delivered an invited workshop on BFR training to Sporting Lisboa Benfica, following which their Human Performance Department incorporated BFR training in its rehabilitation strategy for injured players. Practitioners at the club use Patterson’s recommended guidelines to direct the application of BFR training, with research in populations suffering ACL injury (3.3) being especially informative ( 5.3). The Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar, has also benefitted particularly from our research on applying BFR for rehabilitation post-ACL surgery. The hospital is the largest in the Middle East, providing inpatient and outpatient care to all registered and professional athletes in the country, and it conducts over 400 ACL surgeries each year. Their rehabilitation pathway for those undergoing these surgeries now incorporates BFR training that is informed by Patterson’s research and guidelines (3.3) ( 5.4).

The American Physical Therapy Association (APTA) represents over 100,000 physical therapists and seeks to improve health and quality of life through the application of education and research. Using Patterson’s research findings and associated recommendations, APTA have adopted the use of BFR training in their scope of practice for the first time in their 99-year history. All APTA members who include BFR training in their practice are directed to guidelines on its use written by Patterson ( 5.5).

The impact of our research on BFR training has translated beyond sport. Owens Recovery Science Inc. is a company specialising in BFR training in clinical settings. They have used Patterson’s research evidence and guidelines on BFR use to form the core of their global medical training programme, which is used by their 5,378 trained medical providers around the world who perform an estimated 3.5 million BFR training sessions annually. Recommendations from Patterson’s research form the foundation of training programmes offered by Owens Recovery Science, which are delivered to some of the largest healthcare systems in the USA and provide clinical rehabilitation to NASA, the USA Olympic Team, and sports teams across the National Basketball Association (NBA), National Football League (NFL), National Hockey League (NHL), and Major League Soccer (MLS). BFR training, informed by Patterson’s research, is now on workers’ compensation in every professional sports league in the USA. Owens Recovery Science have also used Patterson’s research (3.1, 3.2, 3.3) to inform their use of BFR training to aid recovery from lower limb trauma in military personnel and cite the research as having a major impact on the way lower limb trauma is treated. The lower limb was the most injured body region of US soldiers during conflicts in Afghanistan and Iraq, and Owens Recovery Science have used Patterson’s research on BFR training to restore calf strength and lower limb blood flow to make crucial advances in their limb salvage programme. BFR training, using Patterson’s guidelines is now used throughout the Department of Defense (DOD) and includes every major military treatment facility and Special Operations base ( 5.6).

Monitoring Workload to Reduce Injury Risk and Optimise Performance

Tallent’s research has been influential in shaping the practice of sport scientists and strength and conditioning coaches in professional cricket, with impact realised at domestic, national, and international levels. The England and Wales Cricket Board (ECB), as the national governing body for cricket, have adopted the workload monitoring methods that were devised by Tallent and colleagues (3.5). With accompanying findings relating workload to injury occurrence, and team injury status being associated with likelihood of match and tour success (3.4), the ECB now monitor, record, and manage workload of their players to reduce injury risk. Since applying Tallent’s research findings to monitor and manage workload, there has been a reduction in injury rates of England players on international tours, with Tallent’s research acknowledged as “undoubtedly contributing to England’s team success” in international series and tours ( 5.7). The ECB are also responsible for developing best practice of strength and conditioning coaches working in domestic county cricket and have disseminated Tallent’s research findings on workload monitoring, injury, and performance to over 40 coaches who support over 300 professional cricketers and thousands of youth players ( 5.7), meaning impact has been realised domestically as well as nationally and internationally. County cricket coaches acknowledge the impact of Tallent’s research in their practice ( 5.8). Coaches monitor and record workload to ensure players are not overloaded and placed at undue risk of injury and to maximise their performance potential- employing specific strategies such as player rotation to realise this ( 5.8). As with the national team, county cricket coaches identify Tallent’s research as contributing to improved performance of players and team successes as well as stating that Tallent’s research has improved health and wellbeing of players ( 5.8).

The validated method to assess training load in ballet dancers (3.6) has been adopted by The Royal Ballet Company at The Royal Opera House who employ over 100 professional dancers. With similarity to the example of professional cricket outlined above, this means their practitioners have increased knowledge and understanding of the workload accumulated by their dancers. This knowledge is being employed to reduce risk of injury to dancers and optimise their performance effectiveness. Specifically, data collected is being used to inform how rehearsals and performances can be best scheduled to manage dancers’ workload and lessen risk of injury. Practitioners within the healthcare team are now able to gain an accurate picture of class and rehearsal intensity as well as quantify individualised accumulated workloads, meaning training schedules can be managed at an individual level to a) reduce risk of injury, b) ensure each dancer is optimally prepared for performance, and c) make it easier to graduate a return to dance post-injury. Further, using epidemiology research from St Mary’s, the Royal Ballet Company have identified common sites and mechanisms of injury in their dancers which has led to the development and application of targeted injury prevention programmes ( 5.9).