May 2014

Out on a limb: Prevention Whac-a-Mole

1Limb-JordanaJordana Bieze Foster, Editor

Say what you will about FIFA’s political entanglements—soccer’s international governing body has set the standard for developing injury prevention programs that are effective not just in a controlled research setting but also in the real world.

For the last six years or so, study after study has demonstrated that the warm-up program developed by FIFA’s Medical Assessment and Research Centre (F-MARC) is associated with significant reductions in injury rates in elite-level athletes, primarily soccer players. But the plus sign in the FIFA 11+ program’s name is there for a reason. It’s a symbol—literally—of the effort required for an intervention to achieve real-world effectiveness long after it has passed the necessary tests of scientific efficacy.

The original FIFA 11, some of you may remember, wasn’t all that well accepted by soccer coaches, who claimed the training was inconvenient and didn’t leave athletes warmed up, which meant additional warm-up time was required. And despite the fact that the injury-prevention potential for all of the components of “the 11” was supported by high-level evidence, a 2008 cluster randomized controlled trial famously found no difference in injury rates between teams that used the intervention and those that didn’t—probably because only 14 out of 58 intervention teams completed more than 20 training sessions in eight months.

Undeterred, the F-MARC team went back to the drawing board. In collaboration with other experts, they revised the program specifically with the goal of implementation in mind. And sure enough, the next cluster randomized controlled trial found that the FIFA 11+ program was associated with significant reductions in overall injuries, overuse injuries, and severe injuries. Not surprisingly, compliance with the program was much higher—77%.

The challenges of implementing injury prevention programs occupied a lot of discussion at this year’s IOC World Conference on Prevention of Injury & Illness in Sport, held last month in Monaco (see conference coverage). Studies are pointing out issues with coaches’ buy-in, protocol modifications, and nonexperts’ inability to administer training.

Some of those issues are still coming up with regard to the FIFA 11+ itself—which just goes to show that conquering barriers to implementation is a little like playing Whac-a-Mole: No sooner have you knocked one down than another one pops up.

But poor compliance doesn’t have to be a sign that an injury prevention program won’t work in the real world. The program may just need some tweaking. Identifying the specific variables affecting compliance is the first step toward making the necessary tweaks, and it’s encouraging that so many researchers are already approaching this challenge in a scientific way.

The next World Conference on Prevention of Injury & Illness in Sport will be held in 2017. I fully expect that when we all convene again, we’ll be talking a lot less about barriers to implementation and a lot more about the solutions that have been identified and the positive outcomes that have been achieved as a result. That’s a discussion I’m really looking forward to covering.

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