Can Athletes Design their own Technology Solutions? Athlete Voice Driving Co-Design in Sports Technology Development and Implementation

Athlete’s voice and lived experience in sports medicine and technology research is rarely included in optimising research into athletic performance and health. Upper limb injuries have a high incidence and prevalence in water polo. Increased goal shooting volumes and shorter rest times between shots have been associated with an increased likelihood to report shoulder symptoms – yet no measurement method existed to quantify shooting volumes.

Three Olympic athletes in various roles (competing athlete, physiotherapist-researcher and swimwear entrepreneur) collaborated to include the athlete’s voice in co-designing sensor pockets to be used in a longitudinal study to develop a novel upper limb inertial measurement unit monitoring system. Team used a six iteration design process to design, refine and test the sensor pockets in-the-field.

Design evaluation included self-trialling in training, field notes and athletes’ feedback. Sensor data visual inspection revealed taping and pocket placements were comparable. 
Athletes indicated that sensor pocket addition did not alter suit position/comfort, nor their performance – increasing long-term technology adoption likelihood. It also eliminated allergic skin reaction from the alternative use of sports tape affixation of the device.

Including the athlete’s voice in sports research can lead to better outcomes for those most affected by research: the athletes themselves.

Key Words: Patient Public Involvement, Technology Research, Olympic Athlete, Athletes’ Feedback

Enhancing athlete involvement in research offers many benefits – development of research questions aligned with athletes’ needs, better research quality and translation (11). Yet, athlete involvement in wearable technology development for injury prevention is rare (8). Athlete co-design has occurred sporadically in sports science, medicine and technology development (2, 8,15). Though emerging as a research field in sports medicine, athlete involvement in research has enabled success in advancing sports-specific feedback optimisation and methodological rigour, as well as pushing boundaries and redesigning collaborative relationships to progress technology development in the field (8). For example, Jørgensen et al engaged athletes, coaches and sports leaders in a co-design collaboration to produce a personal development intervention for high performance sport. The authors reported that end-user involvement enabled intervention success by informing intervention logo development, activity bank, delivery format, scheduling and individualized approach. (2). Mencarini et al used an extensive consultation process to understand end-users technology perspectives and values whilst designing a sports-climbing communication device (7). Drawing from such perspectives and values, the authors designed and implemented the device. The evaluation with end-users indicated the programme was successful because it respected values such as trust and autonomy which are important in sports climbing (7). Likewise, Ageberg et al. (2022) co-created an injury prevention program with a youth handball team and argued that the engagement of coaches and athletes in the development process and evaluation led to the successful program development and implementation (1). Relatedly, some have argued that athlete’s voice, perspectives and co-design approaches in sports research are paramount for optimising research, athlete’s health and performance (14, 15). Encouraging athlete collaboration and co-design in sports technology research can have many far-reaching benefits in optimising research implementation and translation.

Previous research also highlights difficulties in recruiting high-performance athletes as research participants (9). Authors have called for embedding researchers within high-performance staff to address recruitment challenges and optimise co-design approaches that address issues most relevant to athletes (9). In response to such calls, the first author (MK) undertook a PhD. Project impetus arose from MK’s work navigating complex water polo shoulder injury management, return to play and injury prevention uncertainties. MK witnessed the athlete mental and emotional impact of these injuries as the Queensland Academy of Sport water polo physiotherapist; with some athletes being forced to retire due to their injuries. Notably, complex water polo shoulder injury management remains an open research question despite a high incidence and prevalence and a lack of sports-specific evidence-based research to guide rehabilitation and return to play (16). MK’s PhD project aimed to develop an athlete wearable technology measurement method to quantify water polo overhead movements. Coaches and athletes could then use this information to systematically plan and progress training and competition; thereby avoiding large overhead movement volume changes. These changes have been previously associated with an increased likelihood of reporting shoulder symptoms (17). In this concept study, we present an example of how we collaborated with athletes and industry partners to co-design a custom sensor pocket to be used during the development of a novel external training monitoring tool in elite women’s water polo. In terms of athlete involvement, we used the health research co-design definition by Slattery et al. (2020) as follows: Meaningful end-user engagement that occurs across any stage of the research process, from the research planning phase to dissemination of research findings (12). Here, we wish to give a practical example of how a collaborative approach can be applied in-the-field within elite sport technology development. While the concept of consumer involvement is not new, their involvement in the field of sports science and technology could be considered innovative given it is not common practice, with relevance for the process reported here. The Guidance for Reporting Involvement of Patients and the Public (GRIPP2) short form has informed the reporting of this process (13).

As overhead movement volumes had been linked with upper limb soreness (17), we conducted semi structured interviews with Australian athletes, coaches and support staff on their perspectives, beliefs and experiences of upper limb injury management and training load monitoring in elite women’s waterpolo (4). Participants perceived that objective measurement of training was a potential mechanism for facilitating more consistent communication and thereby increasing opportunities for collaboration and coordination. We conducted a proof of concept study to assess the feasibility of the measurement method (6) and then applied this across a training session (5). However, some athletes reported sports tape allergies and that upper back sports tape adherence was uncomfortable. A larger-scale longitudinal study was to be carried out to assess the feasibility and sustainability of long-term technology use (3). Study risks included athlete disengagement and sports tape allergic reaction. MK discussed with the athlete group potential solutions to avoid sports tape allergic reaction to enable the project to be completed.

Several different options were discussed with the athlete group over three informal discussions prior to training sessions. The athlete group mentioned that friction between the sensor and the suit was a potential issue as was the orientation of the sensor if it was placed on the zip. Athletes also raised issues with placing the sensor pocket on the strap of the suit or near the armpit as these were areas that were commonly grabbed in a game to wrestle opponents. We investigated using only one sensor over a training session with one athlete to negate sports tape use, however, it was discovered that this did not give adequate information for data collection. The research group investigated other areas for the sensor to be attached such as the upper arm yet these did not give the axial orientation of the body that was needed for the algorithm. 
In our previous qualititative study, a key finding was that athletes needed to feel that they could have relationships founded on trust and care with coaches and support staff (4). The therapeutic alliance and trusting relationship between the lead researcher and physiotherapist (MK) and the athlete cohort likely facilitated open discussions about longitudinal sensor data collection implications. In one of these discussions, one athlete suggested that the sensor be embedded somehow in the water polo suit akin to what she had seen in women’s soccer/Australian rules football. To further explore this idea, a small collaborative group was then formed between MK (a retired Olympic rowing athlete, lead researcher and program physiotherapist), BK (a competing Olympic water polo athlete as well as a public health, biomedical science and law graduate) and TM (a retired Olympic water polo athlete and leading swimwear industry expert). Six other senior athletes within the squad were involved in giving feedback at six design iterations.

BK and MK co-led the development of the sensor design and investigated sensor pockets from other sporting codes for their appropriateness to add to a water polo suit. BK then found previous water polo heart rate monitor sports bras for design translation and sensor adaption as these had been used in a previous Olympic cycle. Unfortunately, no sensor pocket existed that was appropriate for our needs. BK then initiated the design development with sketches, proposed locations and fabric suggestions to maximise athlete comfort. MK then contributed with reference to the sensor device specifications and data collection capacity. Together, BK and MK consulted with TM regarding potential fabrics, feasibility and location. BK and MK then trialled several sensor pocket designs in a circular iterative process with consultation with each other and then with TM at each of the six design iterations. Six other senior squad athletes also gave their feedback on each design iteration. BK and MK discussed with TM balancing data collection requirements with athlete comfort, practice sustainability and athlete autonomy in putting on/taking off the device. This process occurred at six in-person meetings between BK and MK, recognising the need for time and space to co-create and formulate new ideas. The process also involved multiple email correspondence with TM, as he was not geographically co-located with MK and BK, with multiple designs being sent electronically. TM’s unique skill set, being both a retired Olympic athlete and a swim wear entrepreneur, led to his unique contributions and perspectives on feasibility, fabric selection and durability.

Design process evaluation occurred with in-person attendance at training in the form of self-trialling in training (BK), field notes (MK) and athletes’ feedback. The latter included the observation that the addition of the sensor pocket did not alter suit position and comfort. Athletes also highlighted that the pockets eliminated sports tape skin allergic reactions, increasing the likelihood of long-term technology use as it did not alter the athlete’s ability to perform. As a final step, data quality and accuracy between the sensor pocket and sports tape method for positioning the sensors was assessed for parameter checking. To this end, MK measured the raw uniaxial values of the accelerometer and gyroscope for each movement (e.g. blocking with and without ball contact, high and low intensity throwing, swimming) using both positioning methods over one training session. Visual inspection of the data has shown these values were similar between both positioning methods and were therefore deemed comparable. This collaborative sequence is summarised as a process illustration (figure 1).

Based on the above feedback, the custom pockets were successfully implemented during the longitudinal study over two three-month periods. From an experimental execution perspective, data quality was unaffected by the addition of the pocket with data being collected in a timely fashion. No athletes withdrew from the longitudinal study, nor was there any negative feedback regarding the pocket addition. 
BK, TM and MK each drew from their experiences of being part of the design journey and noted their key reflections and thoughts on this process. From these reflections, they perceived that the process set a precedent for collaborative athlete research involvement whilst balancing athlete training demands, progressed innovation whilst maintaining real-world practicality and upheld an athlete-centred design focus. Positive reflections included having strong, clear communication channels, a proactive problem-solving approach and commitment of all involved to a positive outcome. Challenging aspects included production delays, back-and-forth adjustments, prototype challenges and balancing dual roles as a clinician-researcher.

We hope that our collaboration to design custom sensor pockets will be an example of athletes being key contributors to the research process. Retired athletes who have specific areas of expertise should be encouraged to re-engage with the high-performance system as their lived experiences’ as athletes and other professional skills may be valuable in such a context. Future athlete research involvement could go further and have athletes generating their own research questions based on their performance challenges in-the-field with the support of researchers and staff members. Yet it remains unclear how best to facilitate this co-leadership within the hierarchical system of elite high-performance sport. When sports are developing new monitoring methods, it is recommended that athlete consultation and co-design occur early in the process. Engaging the athlete’s voice and lived experience in sports research was an enriching and uplifting process for us and like others, we believe such an engagement can lead to better outcomes for those most affected by research: the athletes themselves.

Conflict of Interest
The authors have no conflict of interest.

Acknowledgements
The authors would like to acknowledge the athletes for their contribution and support of this project.

Ethical Approvals
Ethical approval was not sought due to the consumer involvement nature of the investigation (in Australia, consumer involvement of this nature does not require ethical approval (10)), which further informed the subsequent longitudinal study (11). The longitudinal study mentioned in the above article has been approved by the University of Queensland (Ethics Approval Number: 2020001700) and the Australian Institute of Sport (Ethics Approval Number: 20210301).

Disclosure of Funding
Marguerite King is a Queensland Academy of Sport Sports Performance Innovation and Knowledge Excellence scholar and PhD Candidate at the University of Queensland receiving an Australian Government Research Training Program and Research Living Allowance scholarship. She has received funding from Water Polo Australia and the Queensland Academy of Sport.

The athlete’s voice and lived experience have many benefits to enriching and refining the research process. 
This study describes a collaborative process to co-design sensor pocket technology for an elite women’s water polo longitudinal study and the process undertaken.

We found that using an iterative athlete-led co-design process led to elimination of skin allergy from adhesive fixation and an optimisation of sensor placement, which did not alter suit position/comfort or impede athletic performance – thereby increasing the likelihood of long-term adoption of the sensor technology.