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In 1983, Ekstrand et al 1 published the first randomised controlled trial (RCT) of an injury prevention programme for team ball sport. Three decades on from this landmark study, it is worth reflecting on the progress made and the current ‘state-of-play’ in the field of team ball sport injury prevention research. The volume of published research has grown considerably with a recent systematic review of team ball sport injury prevention exercise programmes (IPEPs) identifying over 50 published trials.2 The scale, quality and outcomes of recent RCTs are also encouraging with a Swedish trial including over 4500 female soccer players and demonstrating a 64% reduction in the rate of anterior cruciate ligament (ACL) injuries.3
In 2013, a subsequent subanalysis of the original Swedish RCT, published in this journal, highlighted the importance of adequate IPEP compliance in preventing injuries. The ACL injury rate was 88% lower in highly compliant players, compared to those with low compliance.4 A 3-year follow-up,5 also published in this journal, investigated if coaches from the original trial and others in the same target population were still using the IPEP, and found that many had modified it (74–77%) or had not implemented it regularly across the season (52–60%). Others did not know about the programme, or had chosen not to adopt it.5
How big is the problem?
Considering that only compliant players had a reduced injury rate in the original RCT, the results of the above implementation study are of concern and demonstrate that it takes more than the existence of an IPEP to prevent injury. Even highly efficacious IPEPs risk losing much of their effect under real-world conditions, unless they are successfully adopted, implemented and maintained. A major challenge currently facing injury prevention in team ball sports is translating the positive outcomes of RCTs into injury reductions under real world, less controlled conditions. Unfortunately, little guidance is available in the sports medicine literature to help researchers and clinicians tackle this challenge. Our recent systematic review evaluating 52 published IPEP trials using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework2 identified major gaps in the reporting of key implementation aspects, particularly those relating to Adoption and Maintenance. The proportion of trials reporting the RE-AIM's eight items of adoption averaged just 4%. The corresponding figure across the nine measures of maintenance was less than 1%.2
What can be done?
While numerous IPEPs with demonstrated efficacy exist, making a significant real-world impact on sport injuries now requires specific focus on enhancing implementation. Adopting frameworks from the field of health promotion and implementation science can provide guidance on how to do this.6 ,7
Reach the target audience
To maximise preventive impact, IPEP implementation needs to target multiple levels of the team ball sport system, including players (the health beneficiaries), coaches and other staff (the IPEP deliverers) and administrators (the policymakers).6 ,8 Reaching the target audience can be enhanced by embedding IPEPs in coach education, using social media and endorsement of IPEPs by sporting organisations and high-profile figures. All target groups need to understand the relevant benefits (eg, injury reduction, physiological benefits and improved team performance) and potential negative side effects (eg, muscle soreness).
Having knowledge of an IPEP, and good intentions to use it, do not ensure adoption. Key considerations are how an IPEP will be delivered and by whom. Consulting all levels of the system when developing IPEPs and their related implementation plans can identify potential barriers to programme adoption (eg, lack of knowledge, time or programme acceptance).2 ,7 These barriers can be tackled with appropriate programme development or modification, information, training, funding, incentives and policies.
Coaches and sports medicine staff often modify IPEPs, most likely to improve the fit with their specific practical context, without knowing how this impacts programme effectiveness. They also frequently fail to implement IPEPs regularly and consistently.5 Programme fidelity can be enhanced through adequate resourcing (manuals, apps, online resources, etc), training, feedback and mentoring.7
Finally, players, coaches and administrators need support to maintain IPEP implementation over multiple seasons. A key here is establishing systems, policies and procedures at the team, club, league and association level.6 In addition, ongoing support in the form of evaluation, funding and mentoring are needed.
Three decades on from Ekstrand et al's1 landmark study, significant progress has been made in the field of team ball sport injury prevention. The existence of efficacious IPEPs demonstrates what could be done. Unfortunately, the question of how best to do it remains unanswered.2 By focusing research efforts on understanding IPEP implementation, along with better reporting of key implementation components to inform others of how to improve their prevention programme delivery, future decades of sports injury prevention research will ensure IPEPs are not only efficacious, but also highly effective under real-world conditions.
Twitter Follow James O'Brien at @_jamesobrien and Caroline Finch at @CarolineFinch
Funding This work was led by JO'B as part of his PhD studies, supervised by CFF. JO'B was supported by a Federation University Australia Postgraduate Scholarship. CFF was supported by a National Health and Medical Research Council (NHMRC) Principal Research Fellowship (ID: 1058737). The Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.