Online technology dominates our era and eHealth has become a reality for sports clinicians and researchers. Contemporary online platforms enable self-monitoring and provide tailored feedback to the different stakeholders who play a role in the health and care of athletes. Innovations such as digital monitoring, mobile applications and connected hardware provide the critical tools to solve current enigmas in sports medicine research, and to streamline and facilitate injury prevention, management and rehabilitation. eHealth is not an emerging future of sports medicine—the technology to move our field forward in terms of research and practice is already available. This Analysis is based on Evert Verhagen's keynote presentation at the IOC World Conference on Injury and Illness Prevention in Sport (Monaco, 12 April 2014). It outlines the use of eHealth in research, implementation and practice, and provides an overview of possibilities and opportunities that existing and emerging eHealth solutions provide for sports and exercise medicine and physiotherapy.
- Social media
- Knowledge translation
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We live in an era dominated by online technology. Nearly the entire world has access to the Internet1 ,2 and it has been estimated that about 90% of the world's population now has a mobile phone.2 ,3 In addition, social media platforms like Facebook and Twitter have 1.2 billion and 255 million active users, respectively.4 Consequently, whether we like it or not, eHealth has entered our daily routines in research and clinical practice. Within the field of sports medicine, as well as in other medical fields, opinions on this development seem to vary. However, eHealth is a reality and the importance of its role in our field will only increase.5
eHealth is defined by the WHO as “the practice of medicine and public health supported by electronic processes and communication’.6 This does not necessarily imply an interaction between humans and computers. We have been practising eHealth longer than we think. By this definition, a simple telephone consultation can already be regarded as an eHealth intervention. However, if truth be told, things become much more interesting with the wide-scale availability of smaller devices packing a punch of computing power, and the availability of online communication platforms. This is where the term ‘mHealth’ comes in; it refers to nothing more than the application of eHealth via portable (mobile) devices. Also, up and coming is the use of social media in this regard, for which no official abbreviation exists. Nonetheless, all these terms apply to the same electronic and technological developments and the way we interact with contemporary technologies. As such, in general, one simply uses the term eHealth to refer to any of the technological uses outlined above.
With contemporary technology, online platforms enable self-monitoring and are able to provide tailored feedback to different users. Some platforms even have the additional appeal of portability and all-round availability. This feature makes mobile solutions particularly interesting for the dissemination of information on the prevention and treatment of injuries or other health issues which are generally encountered in a sports setting, and which demand instant action or information. Although a formal evaluation of eHealth approaches in our field of sports medicine is still lacking, several commercial eHealth solutions have found their way to research, the pitch and the clinic. This is worrisome as these products are not always up to par with the most recent evidence within our rapidly increasing pool of knowledge.7 ,8
This manuscript will give an overview of the possibilities and opportunities that existing and emerging eHealth solutions provide for research, implementation and practice in the broad field of sports medicine.
eHealth in research
A tool for research
Recently, Grindem et al9 investigated the reliability of an online activity survey to prospectively record the monthly participation in all sports relevant to a patient group of athletes recovering from an ACL reconstruction. Their study exhibited the benefits of the use of online questionnaires in clinical practice and research. They found that, next to being a reliable method to capture sports participation, the survey provided more complete data than a routine ‘paper’ activity questionnaire.
There is more happening in this area, like the option to track injuries via text messaging. A recent study by Ekegren et al10 serves as a good example of the high retention rates that can be achieved with such a method in prospective injury surveillance studies. They reported response rates of 90% and higher to a weekly injury registration that ran during a full football season. This method of injury registration is also described in other recent prospective studies.11 ,12 Text messaging, although it sounds outdated, is a viable method of data registration while it presents a study participant with an easy and short stimulus to respond; in contrast to, for instance, an email with an external link.13
Verhagen et al14 touched on a number of positive aspects of electronic approaches towards the registration of data:
Respondents enter data directly into a database. This eliminates manual data entry by researchers, increasing efficiency and data fidelity.
Data fields can be predefined to contain only a specific range of possibilities, eliminating erroneous and out-of-range data.
Respondents may receive notice when questions are skipped, reducing the amount of missing data.
Through branching of questions (ie, guiding respondents through a questionnaire based on their answers), the time burden for participants is minimised through which the likelihood of continued study participation is increased.
Recent developments such as outlined above may suggest that we have found the Holy Grail for epidemiological research. Nonetheless, there are a number of drawbacks. First of all, there is the concern that eHealth tools only reach a ‘digitally-literate’ population.15 Arguably, this may become less and less of a problem, whereas digital access and digital literacy continues to mature.16 Nonetheless, a residual issue is that different populations—or even subgroups within a population—use technology for different chores and in different ways, for example, adolescents versus adults.17 ,18 This implies that we have to attune our methodology or approach to our target audience. Also, validity issues continue to pose a reason for concern.19 Often, what happens is that a traditional ‘paper’ questionnaire is simply digitised, neglecting the fact that text is read differently onscreen than on paper. Onscreen reading is defined by short and concise text, while paper reading allows for longer paragraphs.20–22 Finally, through branching, the interpretation of some questions may get lost while a subset of questions remains hidden for the respondent after a specific answer.
Answers to contemporary sports medicine enigmas?
Despite the apparent disadvantages, which for the most part can be dealt with, there are many interesting things one can do with the readily available technologies. As an example, data collected through mobile and online technologies can be obtained remotely in large quantities and large populations (big data). It is even possible to collect data in real time that can be used, for instance, to adapt a treatment protocol based on (daily) patient reported clinical outcomes. Additionally, from a research perspective, continuous monitoring can be used for real-time predictive modelling. Longitudinal changes in predisposing injury factors can be charted, which would allow for a better understanding of the multifactorial and dynamic nature of injury risk. This in turn may be of specific interest for research on overtraining, injuries without a clear onset, injury exacerbations and recurrences.
eHealth and implementation
Social media is the means of interactions among individuals in which they create, share and exchange information and ideas in virtual communities and networks.23 Most are likely aware of the mainstream Social media platforms (eg, Twitter, Facebook, WhatsApp, Linkedin, ResearchGate, etc), but there are many more, each with their own services and own group of users. In essence, all of these networks provide the same mode of interaction (figure 1). In regular media, like this manuscript, there is a sender and there are receivers. A single message is sent to all receivers; we wrote this text and you are reading this. Social media, in contrast, facilitates and thrives on interaction. Again, there is a sender and there are receivers, but now the sender will only target a few receivers. Receivers will then share the initial message within their social networks and chatter starts. This process can be efficiently used for the dissemination of scientific knowledge to the field.
Social media provides an efficient method to communicate a message to a larger population. Moreover, the sender can monitor how the message is received by the target audience, allowing for evaluation of the approach and to make adjustments where needed. In addition to efficiency, social media also provides a stronger message. Social media draws attention to a message through word-by-mouth communication among a target audience. This is a strong advertisement while any social media revolves around networks of like-minded people; if my friend recommends this, it must be good.23
The use of social media is also embraced by the BJSM, and is integrated in the journal's strategy to disseminate quality content, promote member society information and listen to the clinical sports medicine community.24 The journal's website is for instance integrated with the BJSM blog, podcasts, Facebook and Twitter.
It has been proposed that research lessons can be transferred to a broader population through social marketing.25 ,26 In the context of sports of exercise medicine, social marketing can be referred to as the improvement of healthy and safe sports behaviour in target audiences through the combined use of social media and marketing techniques. Social marketing revolves around the knowledge that individuals use their online presence primarily for ‘fun’ and ‘relaxation’.27 ,28 The creation of appealing messages that are stumbled on through such online engagement is the key to success in conveying a message with a serious undertone. The ultimate goal would arguably be to create a so-called viral message, of which a recent example is the ‘ice-bucket’ challenge that raised public awareness for ALS. However, it should be borne in mind that social media by itself does not create a viral message; it only enables individuals to share content. Consequently, Social media campaigns are not a guarantee for success, but guidelines exist to maximise the potential:29
The message must be appealing to most of the audience;
The message must be worth sharing with friends and family;
The content of the message is of good quality;
A large social media platform must be used (eg, YouTube or Facebook);
There has to be an initial boost to gain attention (eg, seeding, buying views or sharing with Facebook fans).
The main strength of social media is, at the same time, also the primary drawback. Content shared is open for anyone to see. As such, social media's use is limited when dealing with patients, athletes and research information.30 Even when clinicians and researchers are aware of privacy issues, it should be considered that users could be negligent and unknowingly share delicate information in an open environment. Additionally, one must not forget that social media platforms, and some Apps too, are commercial products that make revenue by sharing users’ information for commercial and marketing purposes. Apart from issues around the sharing of sensitive information, this may pose issues for, for instance, informed consent in research. A participant may have consented to participate in a study, but has not consented for commercial use of their information by a third party.
Social media as a data source
Not being too pessimistic, specifically for research purposes, the open nature of social media can also be used to our advantage. In essence, we have access to a global and freely accessible ecological research cohort. This use of social media in sports medicine is illustrated by a cluster of recent studies on concussion.30–35 Sullivan et al34 investigated Twitter traffic over a 7-day period (July 2010) using eight concussion-related search terms. A total of 3488 unique tweets were identified, recognising social media as a powerful broadcast medium for information and education in relation to sports medicine. However, at the same time, there is a dearth of quality-controlled information available on social media. Williams et al,31 for instance, identified and classified the content of concussion-related videos available on YouTube. It was found that news and media organisations were the predominant source of concussion-related videos, with very few being uploaded by professional or academic organisations. Social media, if approached correctly, provides at many levels a wealth of new opportunities for the field of sports medicine.
eHealth in practice
eHealth can support in the provision of better clinical, rehabilitation and preventive care. Technological solutions that can be engaged in the optimisation of care processes are available for specialised care, but also widely accessible to the masses. We would like to focus on the latter by discussing mHealth, that is, the practice of sports medicine supported by mobile devices. The majority of individuals nowadays have access to the hardware required for mHealth, smartphones.36–38 More and more tracking devices are being built into modern smartphones (eg, GPS and accelerometers), or available as connected external tools (eg, heart rate monitors and scales). The phone is the hub where health information is gathered, channelled and analysed. It is not only the widespread availability and the technology that provides opportunity, but also the extent to which smartphones are used in daily living.39
Smartphone applications, the so-called Apps, provide the means of interaction with smartphones. Through Apps we are able to provide users tailored information with the ease of self-monitoring,7 by which Apps are particularly interesting for the channelling and dissemination of information on prevention and treatment in sports medicine. Again, a word of caution is needed here. There is a vivid market for Apps, and there are a lot of commercial solutions available that lack evidence-based content.7 ,8 ,40 The surge in availability of such sham Apps in a mostly unregulated market raises concerns as to the appropriateness of their content for different groups of end users. In the affluence of Apps, the few that do have a solid evidence base remain unnoticed.41 Consequently, in order to guide and inform users in their choice of Apps, we argue that the field needs to develop a certification that identifies Apps that contain the best available evidence. The BJSM has stepped up to this by openly supporting the Ankle App, which contains an evidence-based preventive ankle exercise programme.42 ,43
There is not always a need to develop Apps to aid clinical practice. One can use Apps that are readily out there and used by the masses. WhatsApp may be a good example, a free messaging service that uses your phone's data connection.44 It provides a cheap and efficient way to transfer messages, pictures, sounds and videos. WhatsApp delivers a very resourceful tool for communications in athlete care, for example, between therapists and athletes. Athletes’ reactions to rehabilitation exercises can be tracked and adapted where and when needed. Therapists can stay up to date and provide feedback on present or new injuries while athletes are away. In group-chats among a team of therapists, an entire team can share expertise and stay up to date with the health of their athletes. We just want to point out that services like WhatsApp can be used effectively in athlete care in which providing ethics around the sharing of medical information is dealt with accordingly, but the centre of this example is human interaction. New approaches in athlete care, in which Telecare replaces the physical contact with a therapist, are positioned in practice. They are mostly targeted at the masses and amateur athletes. These are disturbing developments. Patients do not physically see their therapist anymore, and all care from diagnosis to rehabilitation is provided via electronic communications. Certainly, this may lead to efficiency in care processes, but in our opinion a patient requires a proper physical examination. Such from-a-distance-approaches are, in our opinion, cash cows predatory to the eHealth hype.
So far, this manuscript discussed eHealth technologies as stand-alone solutions in sports medicine. With the available tools, it is possible to provide an integrated approach that encapsulates all the sports medicine aspects outlined above: research, implementation and care (figure 2). During a season, a variety of information may be obtained from an athlete or a group of athletes, ranging from preseason assessments through to injury reports and subsequent injury follow-up. When this information is digitised and centrally stored, it becomes accessible for the entire athlete's (medical) support team for review and support of decisions. Even further, such a system could also provide tailored feedback in a clear and understandable way for the athlete and coaches. In this process, it is possible to provide team members with specific information that applies to their role in the health of the athlete, facilitating their regular communications among each other and further improving the performance and health of the athlete.
Such an integrated approach provides us with the scientific tools to solve current enigmas in sports medicine research, with an opportunity to learn our target audience better and engage them in injury prevention, management and rehabilitation, and with practical solutions to streamline and optimise injury prevention, management and rehabilitation. This should not just be the future of sports medicine; the technology to move our field forward in terms of research and practice is readily available. We just need to grasp this potential to propel our field into a new era.
The authors would like to thank ACRISP. ACRISP is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC).
Contributors EV and CB contributed equally to the conception and writing of this manuscript.
Competing interests EV is the developer of the Ankle App, which is a not-for-profit application. EV is an associate editor of the BJSM.
Provenance and peer review Not commissioned; externally peer reviewed.