Impact case study database

Strategic Approach to Dissemination (education, training and public engagement)

With the aim of translating our research to produce impact, the CHS group have engaged in high-profile dissemination activities with multiple end-users throughout the period 2014-2020. This has included clinical, scientific and sports groups in the UK including British Cardiovascular Society, British Society of Echocardiography, British Sports Symposium and globally including European College of Sports Sciences, European Society of Cardiology and the European Society of Preventative Cardiology. We have undertaken PPS training for healthcare practitioners in the UK including St Georges Park and Wembley Stadium for the FA in 2016, 2018 and 2021, annual MSc in Sports Cardiology and the first Cardiac Imaging in Athletes and Cardiomyopathy focused course (2018) at St Georges University, London and annual 2-day PPS workshop at LJMU. We have also delivered internationally at the ASPETAR Conference on Cardiac Screening and Vascular Adaptation in Athletes – Qatar in 2015, Pre-Competition Cardiac Assessment Workshop for Footballers - Saudi Arabia in 2014, Exercise and Sport Science Australia Research to Practice Conference in 2016, Hong Kong Symposium in Sports Medicine in 2016 and Pre-Competition Cardiac Assessment Workshop – Egypt in 2018. Public engagement activity has also been a strategic priority to reach all those involved in sport beyond elite level competition and has included media platforms such as the BBC, Sky Sports, Goal.com, the Conversation, CNN and primetime Egyptian television. Evidence of broad awareness of our research is that key outputs (e.g. Sec.3, Ref.4) are in the top 5% of all research outputs scored by Altmetrics (a marker of the attention outputs receive).

a) Impact on International Consensus Statements/Position Stands/Expert Criteria

Through dissemination of research papers, collaboration with key stakeholders and membership of the FA cardiology consensus committee (JS and DO), research from the CHS group at LJMU has had a significant impact on the decision-making criteria/algorithm[s] employed in PPS globally through the production of consensus statement documents, position stands and expert criteria. These documents are a standard method of changing practice and clinical decision marking with respect to PPS. Advancements in practice include developing the predictive capability as well as improving the sensitivity and specificity of specific criteria/algorithms. Important examples of this are the “International Criteria for Interpretation of ECG in Athletes” (Sec.5, Source A), the ESC position statements “Recommendations for the Indication and Interpretation of Cardiovascular Imaging in the Evaluation of the Athlete’s Heart” (Sec.5, Source B) and ‘Pre-participation Cardiovascular Evaluation for Athletic participants to prevent sudden death’ (Sec.5, Source C) that refer to our research (Sec.3, Ref 1-4). These documents have become the standard tools for ECG and echocardiographic interpretation during PPS globally due to their adoption by the International Olympic Committee, FIFA and the Union Cycliste Internationale amongst many global sporting bodies. Over the past 5 years in excess of 2000 athletes have been screened by the CHS group utilising these new criteria and guidelines. In addition, the FA and Cardiac Risk in the Young have screened over 15,000 athletes in the UK employing these updated standards. Although it is difficult to establish the absolute numbers of athletes screened globally, the International ECG Criteria based on our research and others have been adopted by Sports Cardiologists worldwide.

b) Impact on PPS Policy and Education

A direct consequence of the change in global PPS consensus statements has been new adoption or changes to PPS policy documents in many sports organisations and clubs. Empirical research undertaken by members of the CHS group have explored the efficacy, feasibility and outcomes of PPS in football and rugby (Sec.3, Ref.3 and 6) and through CHS representation at the FA and the British Society of Echocardiography these have led directly to the production of new PPS policy documents (e.g. GB Cycling; Sec.5, Source D) as well as driving changes to treatment pathways (Sec.5, Source E). Since 2018, GB Cycling Team have committed to undertaking PPS on all of their athletes every 2 years with 200 cyclists screened since 2018 as part of their initial PPS. Furthermore, the FA have changed their policy, on the basis of consensus panel review (DO/JS) of the developing literature base, to screen scholar players at age 14 years, 16 years and 20 years in order to reduce the risk of a missed developing phenotype of cardiac disease. CHS research (Sec.3, Ref.4 and 5) has extended our understanding of the multi-faceted phenotypical presentation of the upper normal limits to physiological cardiac adaptation. These data have been directly incorporated into bespoke educational material and practice guidelines for PPS in the UK. DO has been a member of the Education committee and Chair for the Research and Audit Committee since 2014 and was approached to lead on a guideline document produced by the British Society of Echocardiography and endorsed by the charity Cardiac Risk in the Young (Sec.5, Source F). This document has changed the role of echocardiography during PPS of athletes in the UK advocating on-site use, providing best-practice guidelines and a minimum dataset to maximise sensitivity and specificity of the technique. All UK echocardiographers are required to adhere to this policy statement during acquisition and interpretation of images during PPS and at follow-up. This document has been disseminated to over 4000 UK and international members of the British Society of Echocardiography. This has systematically enhanced service delivery in all clinical echocardiography departments in the UK.

c) Impact on PPS provision, and Secondary Care of Athletes

Our research work influenced the development of appropriate and effective cardiac screening processes and guidelines and since 2014 members of the CHS group have undertaken PPS using these guidelines in approximately 2000 athletes from various sporting disciplines and professional sporting organisations across the UK including the FA, Liverpool FC, Everton FC, Tranmere Rovers, Blackburn Rovers FC, Derby County FC, GB Cycling, Widnes RFL, Salford RFL, St Helens RFL and the Football Referees Association (Sec.5, Source G). As a consequence of undertaking more PPS activity some athletes have required follow-up investigations, however, there has been a relative reduction in the referral rate of athletes into secondary care from 10% to 4% primarily due the application of the new guidelines (Sec.5, Source H). This has reduced healthcare costs to the individual, club or organisation as well as reducing the unnecessary psychological and cost burden of false positive findings. In those with a true-positive PPS outcome this has led to potential life-saving interventions/treatment in over 100 athletes. In 2020, members of the CHS group developed a protocol, ‘The Somauroo Model’, which provides guidance on cardiac considerations for ‘return to play’ in professional footballers during the Covid-19 pandemic. The application of this model allowed the CHS group, upon direct invite, to screen over 30 Premier and Football League Footballers from Liverpool FC, Wigan Athletic, Tranmere Rovers and Blackburn Rovers as part of their ‘return to play’ following contraction of the virus.

CHS staff were invited to develop and run a joint Sport Cardiology Clinic at Liverpool Heart and Chest Hospital. This clinic provides secondary care for athletes where further investigation is required following PPS. This clinic has supported 278 new and 314 follow-up patients, since its inception in 2018 (Sec.5, Source H). This initiative now provides complete cardiac care pathways for athletes within the North West region. Clinical decision-making and patient pathways are based on the research that underpins the guideline documents for diagnosis and management of cardiac conditions in athletes (Sec.3, Ref 1-6; Sec.5, Source E). CHS staff are expert members on the Cardiology Consensus Panel for the FA that has led to changes in PPS policy and education within the organisation. The development of patient pathways have drawn on CHS research (Sec.3, Ref 1-6; Sec.5, Source E) and have changed the management of football players with underlying cardiac conditions, that was previously lacking. Internationally, CHS staff have had a significant impact on large scale PPS provision in Qatar by undertaking PPS training and supporting PPS activity through 2 PhD studentships (Sec.5, Source I). In addition, we were invited to develop, launch and support an Athlete’s Heart Centre (the first of its kind in Egypt) at the Wadi el Neel Hospital in Cairo based on research and policy documents from the CHS group. The Athletes Heart Centre has been established for 12 months and has undertaken PPS on 200 athletes (Sec.5, Source J).

Our research has documented the dangers of current weight-making practices in professional jockeys, investigated safer strategies to make weight, and then used this to change dietary plans. These dietary plans have been implemented (and evaluated), and have proven to be successful in helping jockeys to make weight, changing their risky and unhealthy weight making practices and improving their physical and mental health. As well as direct changes to jockey behaviours and health, this work has contributed to a change in the rules of the sport. Furthermore, our nutritional guidelines now feature in every racetrack in Great Britain. As part of a significant communication strategy around this work, the team have been invited around the world to share our expertise with other international racing authorities (see below for list of countries). The work has featured on numerous mainstream media TV channels including Channel 4 Racing (UK), ITV Racing (UK), Racing UK (UK), At The Races (UK), and Dubai Racing TV (UAE), as well as Radio such as BBC Radio 5 Live (UK), Talk Sport (UK) and ESPN (USA).

The main impacts of this research are described below and relate to rule changes, nutritional support programmes, industry cultural changes and educational models in horseracing.

1. Minimum Riding Weight Rule Change

Our research has resulted in a unique rule change by horse racing authorities in GB which has reduced the severity of weight-making. Racing weights for jockeys in GB were amongst the lightest worldwide, despite having statistically the tallest and heaviest jockeys compared to those from other leading racing nations. REF 1 and 2 determined the physical, physiological and mental health risks of jockeys “making-weight”. With the industry already aware of the potential problems caused by continuous acute weight loss and prolonged periods of energy restriction, REF 1 and REF 2 were the first studies to document and prove the problem. This detailed information was a catalyst in the increase in GB minimum riding weights from 49.3 kg to 50.8 kg as confirmed by the BHA Chief Medical Officer Dr Jerry Hill ( Evidence 1). This rule change led to a reduction in emphasis on the rapid and excessive weight loss techniques that have detrimental health and performance effects . Sir AP McCoy (the most successful jump-jockey of all time) reported in a BBC interview about our research, that falling when dehydrated is when you “do the most damage” ( Evidence 2) highlighting the impact and importance of this rule change that was based upon our research .

2. Jockey-specific Lab-based Testing & Sports Science Support

Our research has resulted in the development and implementation of a jockey-specific diet and lifestyle intervention programme which has improved the physical and mental health of jockeys. Collectively, the research ( REF 3,4 and 5) has directly changed and improved the diets of jockeys through improved understandings of the nutritional requirements of jockeys along with a proven strategy as how to make-weight safely without resorting to starvation techniques. All jockeys are now invited to LJMU for nutrition testing and education with diets prescribed based upon on our research. By providing evidence and showing jockeys how this can be successfully applied to them, the new dietary plans have had a dramatic effect on their weight-management practices as well as physical health, and psychological wellbeing. We also developed a battery of assessments based upon our jockey-based research which has now resulted in an intervention support program exclusively for jockeys and endorsed by the industry bodies. The service is promoted by the BHA and PJA and features on a series of short education documentaries for jockeys (Evidence 7) and promoted during jockey licensing (Evidence 6). To date, over 500 jockeys from around the world have visited LJMU for dietary and physical assessments and advice with our guidance documents now available in most major horse-racing nations. Indeed, in an interview for the BBC, the wife of jockey Paul Mulrennan said “I thought his lifestyle would kill him” but this all changed when he followed the research advice from LJMU ( Evidence 2). The effectiveness of this research, and the change to jockey health has also been endorsed by Dr Jerry Hill ( Evidence 1) whilst on Channel 4 horseracing Frankie Dettori MBE discussed how in 24 years of being a professional jockey he had never had sport science support to help him make weight safely ( Evidence 3).

3. Development of Novel Racecourse Catering Regulations

Our research has resulted in cultural changes around the horseracing world such that new catering guidelines have been produced and changes to the minimum racecourse standards for food provision have occurred as a direct consequence of our work. The competition calendar in racing spans 362-days of the year, meaning jockeys are required to make weight and attend racecourses daily. Existing food provision was poor and deemed non-conducive to health, weight-management, or riding performance ( REF 6). Our research directly influenced the development and implementation of Racecourse Catering Minimum Standards ( Evidence 4). This development was endorsed by the BHA and made both mandatory and legislative. These new catering regulations cited the research from LJMU ( REF 3 and 5). As a result, all 60 racecourses in GB, for the 1508 race meetings, are now required to provide catering provision based upon REF 5 that suits the needs of jockeys. This improved food provision has reduced the perpetuation of rapid weight loss through dehydration, starvation, laxative use or self-induced vomiting ( Evidence 1, 2 and 3). Moreover, every racecourse now displays nutrition education posters to translate our suggested new diet and exercise regime ( REF 5) into language accessible by jockeys ( REF 6) with LJMU clearly credited on these posters ( Evidence 5).

4. Updated the Jockey Licensing Education

Our research has directly changed the model and content of jockey education provided within the British Racing School and Northern Racing College. During the two-week licensing courses for apprentice (flat) and conditional (jump) jockeys, the nutrition module now incorporates the evidence-based guidelines produced by LJMU ( REF 1-5) including how best to translate this research ( REF 6). The new curriculum is available in Evidence 6 and has been received by approximately sixty new professional jockeys to date. In addition, the Jockey Education and Training Scheme (JETS), a charity that provides support and education to jockeys, have produced a series of “Jockey Matters” education films based on our research which are shown in racecourses across the world ( Evidence 7). The Professional Jockeys Association now has their own nutrition support service using methods developed by LJMU ( Evidence 8) whilst the Injured Jockeys Fund have incorporated the research from LJMU into the rehabilitation of injured jockeys ( Evidence 9) via nutrition behavioural profiling and dietary guidance as part of their return-to-ride protocol. To date this has been used on approximately 60 jockeys. Based on our work the BHA and PJA have launched their #jockeyathlete diet campaign ( Evidence 10) which Dr Jerry Hill (Chief Medical Adviser) described as a key visible outcome of the LJMU team’s nutrition research. Paul Struthers, the Chief Executive of the Professional Jockeys Association when launching this campaign stated that “a lot of progress has been made [with regards to jockeys’ diet and health] thanks to the support from LJMU ( Evidence 10).

Building on fundamental research, a large-scale EU funded international clinical trial documented in high quality publications has led to the recent authorisation of nitisinone to treat AKU. The formal approval by the European Medicines Agency makes the treatment available for the first time to all adult AKU patients in Europe and potentially worldwide. Parallel research in gait analysis informs the clinical management of all AKU patients in the UK, translating novel research techniques into clinical practice. A critical finding arising from our research is that AKU affects the young and the findings have triggered new research in this direction. The advanced concepts derived from AKU research are disseminated to practitioners who attend the annual Gait Course of ESMAC followed by secondary dissemination in their home countries.

Developing drug treatment through biochemical research (UR1): Professor Jarvis’ work in AKU mice showed that nitisinone prevented pigmentation in the joints, the earliest sign of tissue pathology. The data supported the application (2011) to the EU for the clinical trial of nitisinone in AKU. That trial ran from 2014 to 2019. Nitisinone was effective in humans to reduce circulating homogentisic acid, as it had been in mice (Ranganath et al., 2020). A licence from the European Medicines Agency now authorises use of nitisinone in AKU ( CS1). Jarvis oversaw the fundamental work in mice and held the statutory permissions required. A series of publications demonstrated a new stain for ochronotic pigment in joints, the time course of pigmentation and the dose-response for nitisinone to reduce pathological change. The research programme also supplied plasma and urine samples for metabolomics and new mass spectrometric assays for key metabolites in AKU.

Advanced descriptors of human gait uncover progressive deterioration of gait (UR2 and UR3): The LJMU team conducted internationally excellent research using mathematical models of artificial neural networks to quantify objectively the deviation of abnormal movements from normality (Barton et al., 2012, 2015). These methods now enable clinicians to integrate the results of complex gait analysis into their clinical decision-making. Prof. Barton and his group at LJMU started collaborating with the clinical research team at the National Alkaptonuria Centre established in 2012 at the Royal Liverpool Hospital. Annual gait analysis for all AKU patients in the UK started at LJMU in 2013 ( CS2) and a long-term agreement secures gait analysis as part of the NHS specialist commissioned AKU service (£26K per annum indefinitely) [F5]. Clinicians at the NAC use the MDP gait deviation index routinely in their clinical decision-making in patients with alkaptonuria which currently affects a total of 72 known patients in the UK (UR2, UR3: Barton et al., 2012, 2015. The gait deviation profile of patients is presented on the first page of their annual gait report produced after their gait analysis at LJMU ( CS3) and so directly affects the treatment of all patients in the UK with the condition ( CS4, CS5, CS6 testimonials). The provision of yearly research-informed gait analysis for all AKU patients in the UK as part of an NHS service is a unique asset and serves as a model for collaborators in Europe and the US ( CS7).

Gait summary measures showing that AKU affects the young (UR2 and UR4): A paradigm shift in the clinical management of AKU was achieved through our research in AKU gait analysis funded by the EU (as part of SOFIA, £52K) [F6]. Our findings provided new evidence that the condition affects not only adults and older patients but also the younger population (16-20 years). The clinical implications were published (UR4: Cox et al., 2019) “Impact on clinical practice: This study supports nitisinone therapy from age 16 years in AKU. An AKU paediatric study is needed in those younger than 16 years.” Based on this evidence, an externally funded research project started in 2019 (Childwick Trust) in children with AKU. The results will inform further clinical trials to determine when to start intervention in children with AKU, to minimise cost and potential side effects of early nitisinone treatment.

Gait modifications (UR5): Our research in AKU gait analysis has changed how gait analysis is taught in Europe and beyond. Although the new drug will transform treatment for European patients, many patients across the world will not have immediate access to nitisinone because of international licensing and financial barriers. We have described a gait modification (UR5: Anderson et al., 2018), that could be used to reduce joint loading and pain in AKU as a substitute or in addition to nitisinone treatment. A link to this paper is now included in the ‘Moments’ smartphone app ( CS8) which has been used by clinical gait analysts attending the Gait Course of the European Society for Movement Analysis in Adults and Children (ESMAC) every year, confirming impact on teaching and learning of clinical biomechanics ( CS8). Since 2018 several clinicians and academics have asked permission to use the app in their regional gait courses, clinical work and academic teaching ( CS9). The total number of downloads is currently 926.

Beneficiaries and scope of reach:

All patients with AKU in Europe will now have access to a new drug and the clinical management of all 72 patients in the UK is enhanced by incorporating the advanced analysis of their gait function in clinical decision-making. Widening the scope of clinical management and research to children will improve their health by preventing irreversible tissue damage and long-term deterioration in later life. New knowledge derived from research informs the training of clinicians as part of the annual instructional gait course by ESMAC at a European level.

The PAEx have a strategic approach to translation with evidence disseminated locally to project partners, to policy makers within the Local Authority and NHS as well as more broadly via international conferences, journal articles and published reports. We are able to disseminate directly into LCC via formal Board roles and the GAC project as the Academic Partner alongside The Association for International Sport for All (TAFISA), Evaleo (a non-profit sustainable health organisation) and the International Olympic Committee (IOC). Evidence of change, including its significance and reach are outlined below, and the process, beneficiaries and nature of the impact are explained.

Process and pathways to Impact: PAEx projects and outputs underpinned and evaluated the Liverpool Active City strategy (LAC, 2005-present, [EV1], REFERENCES 1-4). Our work with LAC led directly to PAEx supporting collaborative programme delivery with TAFISA (e.g., Triple AC, 2012-present **[EV2]**). This relationship was the precursor to the Global Active City project (GAC, 2015-present) which is purposefully modelled on LAC. In 2015, as the academic partner for GAC, PAEx staff Boddy, Knowles and George were appointed as Expert Advisors [EV3] to provide continuous input to the project (2015- to present). Marsden, jointly funded by LJMU and GAC, was appointed as the Director of the GAC development programme and continues as an International Active City Advocacy and Development Officer at LJMU working in tandem with TAFISA. These staff, their expertise and organisational roles that informed and influenced developments provide a clear and direct link between our research and the GAC initiative as well as the cities and organisations involved in the GAC project. For example, the GAC project involves an introductory workshop, a diagnostic visit/report, the formation of a Physical Activity and Sport for All alliance (PASA) and strategy, and an independent audit. PAEx research was integrated into, shaped and supported delivery in all stages of this process. In the audit each city must meet an ISO compatible standard to achieve GAC status. PAEx research was used as underpinning evidence during the development of the ISO compatible standard and provided illustrative case studies for cities to inform their own research/evaluation plans (directly linked to REFERENCES 1-6). For example, Boddy, Knowles and George provided direct feedback on all iterations of the ISO compatible standards (2016), attended 2 expert meetings and the 2016 final consultation event when standards were finalised [EV4].

The PAEx delivers expert advice and support to GAC candidate cities (involving municipal representatives, academics, clinicians/health practitioners) on a bespoke basis, including leading workshops that utilise PAEx research throughout. During the GAC project (2016-to date), our research was used to highlight the importance of PA promotion and explain methods used to conduct health surveillance (REFERENCE 1 EV5), support cities in identifying KPIs and how to evaluate interventions (REFERENCES 1-3, EV5, EV6), and integrated within PA measurement training central to the work with Buenos Aires (REFERENCES 4-6, EV5). Research was integrated within 2 introductory workshops, 11 training workshops, 10 diagnostic visits and reports, 7 conferences/congresses, and written documents including case studies. The diagnostic report for Havana, Cuba is presented as an example and directly refers to PAEx research (REFERENCE 3 and SportsLinx, EV7) as part of the guidance for the development of evaluation processes.

Since Buenos Aires gained GAC accreditation status in 2018, PAEx have continued to work closely with relevant teams in the city to further develop their research/evaluation strategy. One Buenos Aires city government delegate attended a workshop on evidence-based practice in Liverpool in 2018. Following the success of that workshop we hosted six delegates at LJMU (3 x government employees, 3 x academics) to provide bespoke training on PA measurement and evaluation in May 2019. In EV5 Buenos Aires staff reflect on the impact of specific PAEx research (REFERENCE 6) in this process. In 2019 we submitted a successful collaborative research funding proposal and data collection was due to commence in March 2020. This has been suspended during the Covid-19 pandemic but is now planned for September 2021.

Beneficiaries: For the certification process all candidate GAC cities receive the ISO standards and accompanying documents (total to date=21). In the pilot/development project, 7 cities across 7 countries were successfully certified as GACs in 2018. From the initial introductory meetings held in 2016, cities established a multi-sector PASA Alliance and developed a PASA strategy to meet the accreditation requirements. As an example, Buenos Aires provide testimony [EV5] that their work was informed by PAEx research (REFERENCES 1,3,6) and led to the development of an Alliance that includes over 40 organisations spanning government, universities, professional sports clubs, charities, healthcare providers and industrial partners [EV5]. Therefore, a wide range of organisations and individuals are beneficiaries of the certification process.

The beneficiaries of the impact of GAC currently include over 5.8 million citizens from the original 7 certified cities. The professionals in each city involved in the GAC process also benefit in terms of knowledge, expertise and potential career enhancement. Direct change has occurred for city professionals and citizens. For the specific example of Buenos Aires, LJMU, Univiersidad Favaloro and the City Government of Buenos Aires signed letters of intent in 2019 to continue long-term collaborative work around PA, cardiovascular health and the sport and exercise sciences [EV5].

Partner organisations are beneficiaries as well. LJMU was acknowledged in 2020 with the award of the TAFISA Mission 2030 Academia Award on the basis of contribution to the GAC programme: ‘Their [LJMU] openness and readiness to share their expertise with the world, and train other stakeholders, universities and cities worldwide to promote physical activity make them a logical recipient of the award’. [EV2, EV8a]. TAFISA has identified Active Cities as key theme in the TAFISA Mission 2030 and has thus changed its policy focus [EV8b, c].

Nature and extent of impact: All accredited GACs have developed the necessary systems and policies to satisfy accreditation requirements designed to promote PASA for all of their citizens. This includes the PASA alliance, active city policies [EV9], mass participation events, and PA programmes. Therefore, the certification process and associated changes at the municipal level have impacted upon society, public policy and services and the sport sector. Immediate impacts include employment opportunities within the PASA or organisations (e.g., 2 new full-time jobs in Buenos Aires, Argentina, **[EV5]**) thus benefitting the economy and changes to funding structures (e.g., the budget for the Sports Department was raised from € 3.2 million to 4 million in Graz, [partner city] **[EV6]**).

The GAC process and city-specific work has resulted in the promotion of PA opportunities, for example through policies and environmental changes (e.g., new walking routes in Lausanne, [EV6, EV8d] and ‘radical’ urban planning initiatives in Hamburg **[EV8e]**). Post workshop feedback has also described the positive impact of PAEx research on cities, for example feedback from Lausanne: ‘The evidence presented (REFERENCES 1-6) have helped to demonstrate the importance to act in the field of PASA at a local level’ [EV6].

The GAC certified city of Liverpool provides evidence of longer-term change of the Active City model by demonstrating reduced levels of inactivity (27.4% in 2015 to 23.5% in 2018) thus benefitting health, increased economic benefits associated with health (from £417.9 million in 2015 to £456 million in 2018) and increases in the total economic value of sport (£157.6 million in 2015 to £226.8 million in 2018) [EV10]. Liverpool is one of 7 certified cities therefore the long-term cumulative educational, environmental, economic and health impacts of GAC are likely to be substantial and demonstrates the extensive and worldwide reach of this impact.

The FEx has strategically engaged in a number of dissemination events with external stakeholders to communicate and translate the group’s research to change practice. This has included a number of industrial advisory and consultancy roles for members of the FEx with clubs in the English Premier League [i.e., Everton FC (Close 2016-2019), Liverpool FC (Morton, 2010-2015; Drust 2006-2019), Manchester United FC (Gregson, 2008-present), Aston Villa FC (Close 2020-present)], national associations [i.e., The Football Association (Close, 2017-present), Qatar FA (Gregson, 2012-present)] and governing bodies [i.e., UEFA (Morton, 2018-2020]. The international reach is further evidenced in a number of keynote addresses and committee roles for staff, and the appointment of the FEx as the strategic partner of Isokinetic Medical Group at their annual international conference ( Evidence 1). In addition, FEx staff have supported development of the global industry’s first digital knowledge exchange platform ( https://fellows.aspire.qa/index.aspx). Launched in 2014, Aspire in the World enables elite clubs and national associations from over 30 countries to share practice on elite player development (~190k hits to date). The FEx has also been integral in the School’s Professional Doctorate in Applied Sport and Exercise Sciences (DSPORTEXSci). Validated in 2015, the programme has supported the development of a significant number of practitioners (i.e., 19) working as researching professionals nationally and internationally in applied football environments (e.g., English Premier League, Scottish Premier League, Football League, The Football Association, Major League Soccer and the Professional Referees Organisation. Evidence of change, including its significance and reach are outlined below, and the process, beneficiaries and nature of the impact are explained in detail.

1. Development of contemporary player tracking technologies which have revolutionised performance analysis capability across the global football industry

1. Stats Perform computerised performance analysis system

Data derived through advanced computerised technology in relation to the performance of players during match-play is now universally adopted across the global football industry. Our research ( REF 1) was crucial in initially allowing Stats Perform (formerly Prozone) to demonstrate the accuracy and reliability of its computerised performance analysis system. Consequently, these data were instrumental in allowing Stats Perform to gain acceptance across the global football industry as the leading provider of automated tracking solutions. Over the period 2014-2020, Stats Perform global market share has continued to grow with its client base and revenues increasing by more than 400% ( Evidence 2). Validation of the system also provided the foundation for our subsequent research undertaken as part of an award-winning KTP ( Evidence 3 https://educatenorth.co.uk/2016-winners/). The KTP, completed in 2015 (jointly funded by Stats Perform and the ESRC), led to the development and implementation of the global football industry’s first commercially available software for tactical profiling and playing styles analysis of elite teams ( https://www.statsperform.com/team-performance/football-performance/match-analysis/) ( Evidence 2). Released in 2019, the software has changed the interpretation of game-related statistics by coaching and performance staff in elite football clubs. This change in interpretation has proved valuable for practitioners who utilise such data to develop performance plan(s) of players, teams and organisations. This can be demonstrated by the use of these data and processes by the Head of Performance and Research at English Premier League team Wolverhampton Wanders ( Evidence 4). Since its release, the software has attracted a global client base spanning 10 countries ( Evidence 2).

1. Catapult Sports wearable global positioning system (GPS) technology for evaluating the physical demands of football

Wearable global positioning system (GPS) technology has revolutionised the ability to evaluate the physical demands of training in football and therefore enhanced the capability of practitioners to optimise performance, mitigate injury risk and facilitate safe return to play following injury. At the elite level, the precision of GPS data is of critical importance. The detailed information in REF 2 has directly led to changes in the algorithms which underpin the software utilised by Catapult Sports ( Evidence 5). As the world’s leading provider of wearable GPS tracking technology in sport with a global client base of over 1200 users, our research has therefore directly impacted the quality of data now available to elite sports team on a global level ( Evidence 5). REF 2 directly influenced the development and implementation of a unique national player tracking programme in Qatar as part of the countries preparations for hosting the 2022 FIFA World Cup ( Evidence 6). The research findings underpinned a successful grant application to FIFA (£1.5 m) which financed the provision of GPS technology to all elite clubs in Qatar together with QFA youth and senior national teams. Implementation of this technology together with a contemporary data management system and ongoing coach education has significantly changed the capability of Qatar’s coaches to develop training programmes which optimise player development ( Evidence 6). For example, the ability to measure precise running speeds using GPS, as shown by our research ( REF 2), has provided staff with data to help guide, control and optimise the training stimulus, thereby enhancing both the quality of team training and the process of rehabilitation for injured players ( Evidence 6).

2. Enhancing elite player development and performance

1. Development and implementation of a framework to evaluate player training status which has contributed to a significant reduction in player injury at an elite football club

The demands of training and match-play can induce a high degree of physical stress on elite football players which leads to injury. Prior to our research virtually no evidence was available concerning the validity and utility of practical assessment techniques for evaluating the training status of elite soccer players in the field. Our research directly resulted in the development and implementation of a series of assessments which formed the basis of an assessment framework to evaluate player training status ( REF 3). The framework was used by the club’s first team coaches, medical and performance staff in their daily practice. This change in practice was significant in contributing to increases in match availability of approximately 14% per season in the first team playing squad through a reduction in injury-related unavailability over three competitive seasons (2014-2015 to 2016-2017) ( Evidence 7). In light of the significant financial costs associated with injury related (team underachievement and player salaries) decrements in performance, the change in practice driven by our research had a significant positive impact on “return on investment” to the club ( Evidence 7).

1. Development of evidence-based nutrition policy and practice guidelines to influence player development during the pathway from adolescent to adult professional player

Our data ( REF 4-6) now informs both policy and practice of world leading governing bodies and professional soccer teams. As recognised research-informed practitioners, members of the Football Exchange were appointed to an Expert Advisory Group to co-author the 2020 UEFA Expert Group Statement on nutrition in elite football ( Evidence 8). This work was published in the British Journal of Sports Medicine in an Expert statement that has already been downloaded over 18,000 times. The papers cited in section 2 were referenced accordingly as evidence-based research papers that inform the daily energy requirements for both adolescent and adult players. Our research is also directly informing practice within professional football environments in relation to both body composition strategies and the wider nutritional philosophy underpinning the club’s performance nutrition programme. In relation to the former, our data now informs coaching and sport science practice in that adolescent players should not be aiming to reduce absolute fat mass. Rather our research supports the rationale for players to engage in well evidence-based nutritional and training practices that promote the growth of fat free mass ( Evidence 9). Moreover, English Premier league teams are now using the cited research (alongside a wider body of nutritional related research from the Football Exchange) to underpin the evidence based nutritional philosophy of the club’s performance nutrition programme ( Evidence 10).