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Towards the reduction of injury and illness in athletes: defining our research priorities
  1. Caroline F Finch1,
  2. Roald Bahr2,3,
  3. Jonathan A Drezner4,
  4. Jiri Dvorak5,
  5. Lars Engebretsen2,
  6. Timothy Hewett6,
  7. Astrid Junge5,7,
  8. Karim M Khan8,
  9. Domhnall MacAuley9,
  10. Gordon O Matheson10,
  11. Paul McCrory1,11,
  12. Evert Verhagen12
  1. 1 Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia
  2. 2 Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo Sports Trauma Research Center, Oslo, Norway
  3. 3 Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  4. 4 Department of Family Medicine, Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
  5. 5 Department of Neurology, Schulthess Clinic Zurich, Zurich, Switzerland
  6. 6 Mayo Clinic Biomechanics Laboratories and Sports Medicine Center, Departments of Orthopedics, Physical Medicine and Rehabilitation and Physiology & Biomedical Engineering, Mayo Clinic, Rochester and Minneapolis, Minnesota, USA
  7. 7 Medical School Hamburg (MSH), Germany
  8. 8 Department of Family Practice, University of British Columbia, Centre for Mobility and Health, Vancouver, British Columbia, Canada
  9. 9 Faculty of Life and Health Studies, University of Ulster, Jordanstown, UK
  10. 10 Division of Sports Medicine, Department of Orthopaedic Surgery, School of Medicine and Human Biology Program, School of Humanities and Sciences, Stanford University, Stanford, California, USA
  11. 11 Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
  12. 12 Department of Public and Occupational Health, Amsterdam Collaboration on Health and Safety in Sports, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Professor Caroline F Finch, Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, P.O. Box 663, Ballarat, VIC 3353, Australia; c.finch{at}federation.edu.au

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Introduction

A decade ago, Blair1 pondered the future of physical activity research, much of which has since come to pass. More recently, a BJSM Blog2 invited readers to consider how their future research would look. Given the increased international focus on reducing injury/illness in athletes, it is timely to consider what research needs to be undertaken and acted on to achieve feasible reductions over the next 10 years.

‘Future Studies’3 or ‘Thought Leadership’ happens when a defined group of experts calls attention to what they think will be important for their field in the future. This is common in social science disciplines (eg, finance) and in scientific areas with major implications for policy development (eg, in climate control/environmental science). It has been less commonly applied in medicine, though it has underpinned discussion in areas like cancer research4 and academic medicine.5

Thought leadership involves big picture thinking and can lead to new ideas for major developments over time. There is evidence that such exercises can significantly shape research agenda and priority setting. This novel approach was applied to Sports and Exercise Medicine through asking a select group of international experts to contribute their priority research directions for the next 10 years. This is intended as a starting point only, to stimulate discussion with, and elicit responses from, the broader community interested in the prevention of injury and illness in athletes.

The experts

International experts were invited to participate if they had delivered ≥1 keynote addresses at the International Olympic Committee (IOC) World Conferences of Prevention of Injury and Illness in Sport in 2011, 2014 or their precursor conferences organised by the Oslo Sports Trauma Research Centre in 2005 and 2008. Of 21 keynote speakers, 12 contributed their views to this paper. The experts covered a range of disciplines, including clinical sports medicine, biomechanics, biostatistics, epidemiology, physiotherapy and sport science. Most were active researchers with all but three having current clinical interactions with athletes and/or other patients.

Research interest areas

Collectively, the experts’ multiple self-stated research interests could be grouped into the following main themes: (1) sports injury prevention (n=7); (2) injury/health management overall or for specific conditions like head injury, doping, orthopaedics, etc (n=7); (3) population health/public health/epidemiology in relation to injury prevention and/or physical activity promotion (n=4) and (4) cardiovascular health (including sudden cardiac death (SCD) prevention in athletes) (n=4). Their perspectives ranged from clinical to population-health research and from primary to tertiary prevention.

The task: defining a vision

Experts were asked to visualise the priority research for the prevention of injury/illness in sport over the next 10 years. This was related to the six research stages of the Translating Research into Injury Prevention Practice Framework6 (extended to include illness): (1) injury/illness surveillance (TRIPP stage 1), (2) determining the risk factors and mechanism of injury/illness (TRIPP stage 2), (3) developing strategies to prevent injuries/illness (TRIPP stage 3), (4) assessing the efficacy of prevention measures in ideal condition trials (TRIPP stage 4), (5) determining how to best implement injury/illness prevention strategies (TRIPP stage 5) and (6) determining the effectiveness of these strategies (TRIPP stage 6). Boxes 1 6 show the collective vision for the future.

Box 1

Future state of research into health or injury surveillance (TRIPP stage 1) in 10 years time

Sports injury prevention

Mandatory activities such as the preparticipation evaluation are likely to have standardised, using widely enrolled databases. Other attempts to create uniform injury surveillance instruments are likely to happen within organised sporting organisations and structures (at least as far as competitive sport goes). Surveillance will remain difficult for recreational sport injuries. Leaving the business of surveillance to the ‘interaction’ of sport and medicine/science will not serve us well. One party needs to ‘own’ surveillance

Monitoring of injuries at the population level will continue to be a challenge, especially at the individual participant level. Population-level registries will be established to monitor the most severe injuries such as concussion, spinal cord injuries and fatalities during sport. There will be an increased focus on regular monitoring of important behavioural precursors to injury and adoption of safety practices such as protective equipment use, game rules/regulations and preparatory training.

We will have advanced from paper-based forms to digital tools. More data will be collected directly from the athlete, not by the medical team. Systems will have been refined to allow the reliable collection of data on overuse injuries, illness and other health problems, avoiding the current bias favouring acute injuries inherent in many of the standard injury surveillance programmes in effect around the world today. The surveillance data will be available in real time, with benchmark values from the relevant sport and performance level, allowing the surveillance data to form an integral component of the risk management for the team.

Injury/health management

Health surveillance will have become routine, and mobile devices will be used to register relevant parameters (continuously or very frequently).

Poor health and injury-related factors will be measured in real time and will be linked to other related factors, providing big data on injury research.

We will have predictors for injury, SCD, genetic predisposition for developing cardiovascular diseases, osteoarthritis, cartilage engineering and development of global prevention strategies.

Population health/public health/epidemiology

We will have more specific exercise prescription advice; there may be some genomic/metabolic markers for responsiveness to exercise but they will be for a small proportion of people; we will have recognised the risks of too much medicine and will be doing less surgery for things like ACL and hip FAI. We will understand the mechanistic pathways better in conditions such as tendinopathy and osteoarthritis; we will have more guidelines and agreement statements for minimal reporting, and there will be large multicentre RCTs across nations in our field (mirroring the large drug company trials of the past and present). Physiotherapy research will be stronger than sports physician or orthopaedic research in relation to exercise studies.

Cardiovascular health

SCD incidence data will be better and more accurate, but still incomplete. More athlete populations or perhaps countries will have implemented mandatory reporting systems for sudden death, so incidence estimates will be more accurate and move beyond media reports as the primary source. More will be known about incidence based on other variables such as gender, race, age and type of sport.

TRIPP stage 1:6 ,9 This involves surveillance of injury/illness to count and describes the occurrence of these conditions.

Box 2

Future state of research into establishing the aetiology and mechanism of injuries or health states/conditions (TRIPP stage 2) in 10 years time

Sports injury prevention

Advances in aetiology will depend on the quality of data for epidemiological research. New technology will help determine advances in mechanisms of injury.

Customised risk assessment for injury, and appropriate decision for sport selection will be used, with the higher the performance ambitions, the more narrow the selection criteria applied.

Video analyses will be improved with more knowledge in the field.

We will be able to link different (longitudinal) data sources together and provide a stronger multifactorial and longitudinal view on aetiology.

We will have a better understanding of the injury mechanisms, based on more advanced methods for a video review of actual injuries for many more injury types and sports. We will have a better understanding of the relationship between training loads and overuse injuries/other health problems. More risk factor studies (prospective cohort studies) will have been conducted with appropriate sample sizes—and using standardised screening tests allowing the pooling of data from various cohorts. We will have realised that attempting to predict injury risk from preparticipation screening tests is futile.

We will not have made as much progress as we might like to in this area. The reason is that most sport injury mechanisms have multiple aetiologies and preventive efforts are likely to be less specific and more global.

Injury/health management

For tendon injury, we will understand mechanistic pathways better, the role of pain and CNS will be better understood, and RCTs will guide us on better treatment.

Multiple and combined research approaches will be used to prevent and treat injury and disease.

The new surveillance methods and their routine use will have contributed much to the understanding of the aetiology of impaired health and of injury.

Population health/public health

A lot of the collection of this information will be driven by new technologies for instrumented clothing and local environmental modelling, and the like, with data downloaded in real time to apps with feedback. From an analysis perspective, data mining approaches will be very common. Application of recent statistical developments in causal modelling and system thinking approaches to understanding the broader context of adverse health injury occurrences at the population level will start to become the standard in epidemiological studies spanning more than just 1 year.

Cardiovascular health

This area will be markedly improved. Current aetiology data are derived from autopsy reports performed without standard protocols and without routine examination by a cardiovascular pathologist. Autopsy protocols for sudden death in the young are being more widely implemented, and importantly, genetic testing of structurally normal hearts (autopsy negative cases) is both more common and a quickly evolving field that will help clarify the many aetiologies causing SCD in young athletes.

TRIPP stage 2:6 ,9 This involves the conduct of prospective studies to establish aetiology and causal mechanisms to understand why injuries/illnesses occur.

Box 3

Future state of research into developing preventive measures (TRIPP stage 3) in 10 years time

Sports injury prevention

A large body of evidence on various exercise programmes will be available based on large-scale RCTs, addressing more sports, more injury types and a range of different populations (age groups, gender and performance level). We will understand better which components of the current multipart exercise programmes are responsible for the observed effects; programmes will therefore have been refined and have become more effective with less time spent. We will have developed effective programmes for more injury types (body regions), with particular progress for overuse injuries.

Of the three areas typically considered, domains of injury prevention, physical preparedness and prehabilitation and protective equipment seem to be nearly complete. The third, changes to rules and the environment, is fertile for developing new preventive measures.

Over recent years, there has been a very strong bias towards sports injury prevention research focusing on internal risk factors. There will be a swing back to more studies that also (or instead) focus on external factors that impact on injury risk, especially in non-elite sport. This will lead to the development of more regionally relevant preventive measures (eg, sporting grounds), enhanced policy solutions and options (eg, jurisdictional or peak sports body level) and approaches that more directly reflect how sport is delivered

Preventive measures will be developed by the end-users through participatory approaches.

Preventive measures will be developed for individuals and/or programmes will be modified to the individual needs. Athletes will receive daily instructions on their training and nutrition needs, and injury risk.

Injury/health management

For tendon injury, we are likely to have identified high-risk states with imaging such as UTC. We are unlikely to be using biomarkers. For OA, we are likely to have identified high-risk states with imaging such as MRI with special sequences (eg, T2 Rho). It is unclear if we will use biomarkers. Exercise will be considered medicine—exciting interventions like the DPP (Diabetes Prevention study) for various conditions will be used.

Population health/public health

It is likely to be technology-driven.

Multidisciplinary and cross-disciplinary research teams, which involve the injury prevention stakeholders from the outset, will be the norm. There will be recognition that different forms of preventive measures are needed for elite and recreational sport.

Cardiovascular health

How to perform better cardiovascular screening remains a major challenge and point of constant debate, with ECG at the crux of the discussion. ECG screening of identified high-risk athlete groups (ie, basketball, American football and soccer) will be more widely practised, if not considered the standard of care. Facilitating research in this area will be wider use of and improvements in ECG device technology that provides athlete-specific interpretation with greater accuracy than the clinician, thus eliminating physician infrastructure gaps while also ensuring better interpretation accuracy.

Measures used will be different and more likely individualised.

TRIPP stage 3:6 ,9 This involves the conduct of basic mechanistic and clinical studies to identify what could be performed to prevent injuries/illnesses with the goal of developing potential preventive measures.

Box 4

Future state of research involving the conduct of ideal conditions scientific evaluations (TRIPP stage 4) in 10 years time

Sports injury prevention

Ideal conditions for scientific evaluations are very much dependent on funding. It would be great if IOC and IFs would invest more in research on health protection of elite and recreational athletes. It is well possible that there will be some pressure from insurance companies

In community sport, there will be fewer trials conducted under formal controlled conditions. Evidence will be taken from trials in elite athletes, meta-analyses and systematic reviews to develop modified interventions that are trialled in different study designs using quasi-experimental pre–post implementation testing, interrupted time series modelling and novel methods of collecting and adjusting for exposure measures.

Injury/health management

It is likely to reduce within wider sports medicine. Some areas will be researched as part of the expansion of core medicine into sports and activity-related research.

We will benefit from electronic means of gathering data. Opening up new areas of control over adherence to study protocols and opening up the availability of research participants outside localised geographical areas.

Population health/public health

Progress will be made in this area when we begin to realise that implementation of scientific evidence is only one part of prevention. The other part is finding out the factors important to the individual, those that govern behavioural change. The area of human-centred design will become ever more prominent and important for prevention.

This will continue to develop in each field—this will not stop even if we argue that we need more pragmatic and effectiveness studies

Cardiovascular health

This area will be much advanced but still incomplete. Currently, outcomes data are very limited on athletes detected with cardiac conditions through screening. I predict that with the development of outcomes registries, either multicentre or perhaps multinational, we will gather critical data to guide our screening practices and the management of the cardiovascular conditions associated with SCD in athletes. The paradigm of early detection, risk mitigation through individualised medical management, and return to sports will become the norm (and not the exception). A better understanding of how to manage athletes with at-risk conditions and if those interventions allow a safer return to sport (or warrant disqualification) can only be advanced if we improve early detection and investigate closely our medical decisions.

TRIPP stage 4:6 ,9 This involves the conduct efficacy studies to determine what works in a controlled setting (eg, randomised controlled trials) to understand what works for prevention/treatment under ‘ideal’ conditions.

Box 5

Future state of research into describing the intervention context to inform implementation strategies (TRIPP stage 5) in 10 years time (ALL RESPONSES)

Sports injury prevention

A stronger move towards mixed methods approaches will be made, and I foresee participatory observations providing a strong base for description of intervention contexts.

Since we will know the aetiology and mechanisms of injury, we will be able to describe the intervention better.

This will be the sort of study that is the norm for injury prevention in non-elite sport. Current trends towards research conducted with, and on, coaches and athletes will be extended to also routinely include sports administrators, sports policymakers and referees.

Injury/health management

Close monitoring of relevant parameters will result in individual recommendation for prevention. Ideally, sports federations cooperate in their joint efforts to protect the health of their athletes. Elite athletes will serve as role models, and hopefully, the general population will adopt similar health prevention strategies.

Population health/public health

I am hoping this is where there will be giant steps through collaboration. Funding may be a challenge depending on the global economic situation. The other costs of NCDs may force governments to do more.

I expect this will shrink. The public are becoming much more cynical about high-level sport and the context will be functional fitness

The context is a combination of the needs, wants, desires, strengths and limitations of the end-user. Determining (measuring) these is essential for understanding the intervention context.

The translation of scientific evidence into layman's language will be more common.

Cardiovascular health

Individualised interventions will be used

This will be much advanced. Currently, research on SCD prevention (ie, screening) includes only centres with significant experience. Growing interest and expanding recommendations are fostering wider implementation of ECG screening, and research studying the impact of this in the ‘real world’ (ie, by physicians or centres with less experience) will be an area of active research. Only then will we identify the additional knowledge gaps needed to bridge scientific research with best practice.

TRIPP stage 5:6 ,9 This involves the conduct of ecological studies to understand the implementation context to understand the intervention implementation context including personal, environmental, societal and sports delivery factors that may enhance or be barriers.

Box 6

Future state of research into evaluating the effectiveness of preventive measures in implementation contexts (TRIPP stage 6) in 10 years time

Sports injury prevention

There will be a very close and constant feedback loop between surveillance/monitoring, recommendation of behaviours and measuring of behaviour and its effect.

Sports medicine and injury prevention studies, especially in the population health and clinical settings, will routinely incorporate implementation science, knowledge translation, behavioural science and health promotion principles. There will be strong engagement with stakeholder groups across all research stages which will include evaluation of intervention content and intervention context for their impacts on injury.

A mixed methods approach will have found its way, providing objective and subjective outcomes to judge effectiveness of measures.

Injury/health management

There will be many more long-term prospective studies on the effect of professional and recreational sport on health (eg, heading in football, osteoarthritis in elite athletes).

Population health/public health

The greatest gains will be that new measures of effectiveness will have been developed and used.

The big growth area—this is where it is at! Implementation, scale up, bring it on!

Cardiovascular health

Outcomes registries for athletes with identified cardiovascular conditions will provide critical information.

TRIPP stage 6:6 ,9 This involves the conduct of effectiveness studies in the context of real-world sports delivery (ideally in natural, uncontrolled settings) to understand what works in the ‘real world’ for injury/illness prevention and treatment.

Will this be the future?

Thought leadership is increasingly being used in health and medicine. To the best of our knowledge, there has been no prior application of this to sports and exercise medicine research priorities to drive reductions in injury/illness in athletes. It is interesting to note the similarities across experts regarding improved data collection/analysis systems and the rapidly occurring technological advances for monitoring and treating individuals.

The extent to which these expert views will inform the direction of future research and allocation of appropriate resources is yet to be seen. As field-specific experts, the authors’ individual thinking would have been influenced by their personal past experiences, vision of the future and intuitions.7 Experts drawn from other backgrounds, including the end-user beneficiaries of research (ie, coaches, athletes, etc), may well suggest other priorities and it has been suggested elsewhere that these views be considered in future research.8

Importantly, this initial thought leadership exercise has focused on research conduct only. Priorities for actions to implement research findings to actually prevent injury/illness in athletes may be different. This will be important for ongoing thought leadership considerations, as just doing more and better quality research to address research priorities could run the risk of moving this away from the desired patient and population outcomes. It should be the clinical and population-health questions that drive research, not the other way around.

Do these research needs and focus areas resonate with you? Perhaps we will re-evaluate in another 10 years. We are keen to hear your thoughts about these experts’ priorities through whatever medium is easiest for you—email, Twitter (to @BJSM_BMJ), Facebook posts or via comments (rapid responses) adjacent to the paper.

Acknowledgments

Dr Joanne Kemp and Dr Alex Donaldson, of ACRISP, are thanked for their assistance with facilitating the online survey used to collate expert views.

References

Footnotes

  • Twitter Follow Caroline Finch @CarolineFinch

  • Contributors The study was conceived by CFF. All authors provided direct input to the study through their responses to an online survey and contributed to the writing and/or editing of the manuscript. Apart from the first author, who initiated this work, all other authors contributed equally to this manuscript and are listed in alphabetical order.

  • Funding CFF was funded by an NMHRC Principal Research Fellowship (ID: 1058737). Aspects of this study were funded through IOC Research Centres Programme support to the Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP) at Federation University Australia.

  • Competing interests None declared.

  • Ethics approval Federation University Australia Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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