Guest blog by @CarolineFinch

In the recent BJSM blog Is high level snowboard too dangerous to allow your children to participate? Prof Engebretsen raises an important question, namely how to prevent injuries in a sport where pushing the extremes of physical performance in challenging and harsh environments is both an individual athlete and sporting organisation goal.[1]

Most recent advances in sports injury prevention have tended to focus directly on the athletes, themselves, with the aim of making them more resilient to the injury risks they are faced with in their chosen sport. I wonder if, for sports such as snowboarding where most injuries result from acute energy exchange beyond the body’s tolerance, it is time to go back to first principles for injury prevention and revisit the application of Haddon’s 10 countermeasure strategies.[2] In this hierarchy of injury control, “Make what is to be protected more resistant to damage from the hazard” is only the eighth strategy. There are seven higher order control strategies that could (and should) be applied to also reduce injury risks and hazards.

Engebretsen [1]also queries whether leaders of the sport really have true awareness of the risks in elite snowboarding. The fact that so little ongoing attention seems to have been given to identifying and implementing solutions meeting many of the higher-order Haddon countermeasure strategies would seem to support this. Interestingly, a recent blog by Laura Robinson at playthegame.org also queries whether “sports officials’ tendencies to put the fight for new viewers by making the sports more dangerous and exciting” are more favoured than the safety of the athletes of snow sports.[3]

We published a review of the evidence for preventing snowboarding injuries in 1999, with the main focus on recreational participants of this sport as it was still a very new activity in Australia.[4] At that time, the sport was considered similar to other snow sports and so most safety advice was derived from that for more general snow/ski safety. One of our conclusions was:

“the rapid international growth of the sport has not been matched by a detailed epidemiological evaluation of the injuries specific to snowboarding or of the countermeasures to prevent them” (page 118).

It would seem that the situation has not changed that much. All sports injuries occur within an ecological context in which multiple levels of the sports delivery system interact with the physical environments in which sports are undertaken and the specific characteristics of the athletes who participate in them.[5] This applies equally well to high performance and professional sport as it does to the more recreational forms. Future safety gains for snowboarding, as indeed other sports, will only be achieved if all stakeholder groups:

1. are engaged and united from the outset;
2. share common goals for the ongoing development of the sport;
3. prioritise the safety of their athletes; and
4. jointly invest in the development, implementation and evaluation of cost-effective injury prevention solutions according to Haddon’s hierarchy of control as translated to this sport.

References

1.         Engebretsen L. Is high level snowborrd too dangerous to allow your children to partcipate? Posted 1/03/2012.: BJSM blog – social
media’s leading SEM voice; 2012.

2.         Haddon WJ. Energy damage and the 10 countermeasure strategies. 1973;13:321-31.

3.         Robinson L. Faster, Higher … Deader. Posted 23/03/2012. playthegame.org; 2012.

4.         Finch C, Kelsall H. Preventing snowboarding injuries – what is the evidence? 1999;6:117-26.

5.         Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br J
Sports Med. 2010;44:973-8.

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Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are
published by the BMJ Group.

Caroline can be followed on Twitter @CarolineFinch

 Guest Blog by @CarolineFinch

Cross Fertilising ‘Injury Prevention’ journal (IP) and BJSM

Compared to many other health issues, it seems that it is not hard to get media stories about sports injury into our daily newspapers.  What seems to be hard, is the coupling of such stories with positive injury prevention messages.

An interesting paper in the February 2012 18(1) issue of Injury Prevention reports an analysis of US new stories and their use of the phrase “freak accident” in the reporting of injury events. The Editor’s Choice paper by Smith et al identified 250 human injury stories over a 5-year period that used this phrase. The vast majority of stories (61%) related to injuries sustained by professional athletes and these mainly focussed on the nature or impact/outcome of the injury. Only 9% of the professional athlete injury news stories contained any clear prevention content.

This study is consistent with the findings from an Honours student project I supervised in 2009 (Sarah Hester, University of Ballarat).  We undertook a daily hand check of three Victorian (Australian) newspapers and identified 3215 media stories mentioning injury or injury-death and recorded the context in which those injuries occurred.  We also found the majority of stories to relate to injuries in sport (64% of the total) and hardly any of these mentioned injury prevention at all (<1%) (unpublished data).

There is ample anecdotal evidence that many people believe sports injuries to be an inevitable consequence of participation in sport.  It is not surprising that this view is common if the popular media fails to mention prevention, either directly or indirectly, in their stories.  The term “freak accident” just reinforces any belief that injuries in sport cannot be prevented and further implies that they are the result of just bad luck.  Public health orientated injury experts have long argued against the use of the term “accidents” because of the connotations of this word, and its use has been banned in BMJ journals since 2001.  Readers of the British Journal of Sports Medicine (BJSM) also well know that sports injuries in result from a combination of factors, and are certainly not freak events with no aspect of predictability or preventability.

Perhaps it is time for sports injury prevention researchers and sports medicine practitioners to actively work towards also have the word “accident” banned from all popular media coverage of sports injuries in both professional and recreational athletes. 

As long as major attitudinal barriers to sports injury prevention such as “there is nothing I can do to reduce my risk of injury in sport” and “of course everyone who plays sports get injured” prevail, all of our broad-based population efforts to implement injury prevention programs will largely fail.  Rather than just talking about the impact of injuries in terms of a need for ongoing medical treatment and time away from sport, we should also be routinely providing journalists and the media with simple messages about how the same sorts of injuries could be prevented in the future. What a better situation it would be for a future media analysis to find a strong reporting theme relating to guaranteeing lifelong participation in sport precisely because injury prevention is inevitable.

Success stories:

The AMSSM Annual Meeting (April 21, 2012) opens with a keynote session on Injury Prevention. It includes international sports injury prevention stars including Roald Bahr (Norway), Per Holmich (Denmark), Mark Saffron (US) and Martin Schwellnus (SA)

BJSM publishes 4 Sports Injury Prevention Themed issues annually. These are called the ‘IPHP’ issue of BJSM – Injury Prevention and Health Protection. You can find the archive of IPHP issues here

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Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

Guest blog by George Murley

There is an increasingly strident debate on the use of minimalist/barefoot versus traditional sports footwear in running, and there appear to be advocates for both sides who believe there is no need for a rational discussion.

Screen shot from: The Barefoot Professor - by Nature Video

The debate appears to have escalated following publications by Richards and colleagues (2008) ‘Is your prescription of distance running shoes evidence-based?’ and later by Lieberman and colleagues (2009) ‘Foot strike patterns and collision forces in habitually barefoot versus shod runners’ and McDougall’s book — ‘Born to Run.’

The main issue in this very messy debate seems to be whether ‘some’ barefoot/minimalist shoe running is beneficial. This is related to the first vertical impact force, minimalist shoes are meant encourages a forefoot strike and  decrease this force, which in turn dampens the first vertical impact force. This however has some individuals suggesting that running barefoot may lead to injuries related to loading of the Achilles and direct impact of the forefoot. A second part of the argument is that footwear is supposed to weaken foot muscles whereas barefoot running challenges muscles and presumably leads to stronger/hypertrophied muscles that in turn have a positive effect of function.

Clinically we are primarily interested in the effect on injury.  There are strong views and some limited evidence supporting arguments about the relationship between the first vertical impact force and injury.  One perspective is that first vertical impact force causes injury whereas others argue injury is related to the ‘active’ forces of push off.

There are a ton of unanswered questions:

Does athletic shod or unshod running affect injury risk?

How does shod and unshod running interact with comfort and performance?

Which biomechanical parameters are related to injury risk?

Does footwear or unshod running reverse biomechanics parameters related to injury risk?

What is important is that clinicians and scientists approach this debate in a reasoned and calm way as there may be merit in both sides of the argument. Having only one perspective and fighting amongst ourselves is not necessarily going to help answer the questions or help the sportspeople make informed decisions about their footwear.

References:

Podiatry Arena (extensive blogging on this issue)

Simon Bartold’s presentation

Lieberman et al (2010) ‘Foot strike patterns and collision forces in habitually barefoot versus shod runners’ published in Nature’s International Weekly Journal of Science

The Barefoot Professor: by Nature Video

Author Chris McDougall’s book — ‘Born to Run’

Richards et al (2008) ‘Is your prescription of distance running shoes evidence-based?’ published in the British Journal of Sports Medicine

Related BJSM Blog

To Strike or Not to Strike? That’s not the only question (for running and injury prevention)

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Dr George Murley is a Podiatrist who graduated from La Trobe University with Honours in 2002. He then commenced teaching at La Trobe and completed his PhD related to the effect of foot posture and foot orthoses on lower limb muscle activity. Dr Murley was awarded the Stephen Duckett Higher Degree Research Prize for best PhD thesis in the Faculty of Health Sciences in 2010.

Guest blog by Professor Lars Engebretsen

Photo by Aktivioslo, Flickr CC

The recent World Championship in Snowboard in Oslo, Norway led me to the question in this blog’s title. I am a sports doc with extensive experience in treating high level athletes in almost all kinds of sports (except Aussie rules football and cricket).

Since 2000, I have been involved in studies aiming at preventing sports injuries. We have targeted football (soccer), team handball and Alpine skiing and have had some success.  Newer sports however, keep popping up. Almost like the doping hunters  - often being too late to prevent new, effective performance drugs – it seems that we are too late to prevent injuries in some of the new sports.  I was reminded of this during the recent Snowboard Championship in Oslo: new venues for cross, half pipe and slope style situated beautifully in the Oslo countryside. The first days had bad weather and difficult light and there were some serious injuries- not life threatening, but nevertheless serious.

I have noticed a similarity with the last few Olympic games: the venues get bigger, the athletes better trained and with ever increasing abilities. Unfortunately, there is also an increase in injuries. The numbers from Vancouver showed that 35% of snowboard cross and 13% of half pipers experienced injuries.

What can we do to prevent these? We can count injuries, identify risk factors, study how to reduce these and aggressively implement our knowledge. In the meantime, the sporting venues get larger and more challenging and knowledge from our studies become yesterday’s news. I know that the majority of the athletes appreciate the danger, but I am not sure that the top leaders of the sport have the same awareness.

I need ideas to help the athletes operate in a safer environment- any ideas?

Note that the BJSM publishes 4 issues a year dedicated to Injury Prevention and athletes’ Health Protection (IPHP). You can find these issues of BJSM by clicking here. The next IPHP issue will launch in June and will focus on Olympic Sports. IPHP issues are published as part of BJSM’s partnership with the International Olympic Committee.

Nik Zoricik dcath: News story here. (added March 10th). Updated March 15th

Related Articles

Bakken A, Bere T, and Bahr R et. al. 2011. Mechanisms of injuries in World Cup Snowboard Cross: a systematic video analysis of 19 cases. Br J Sports Med. 45:1315-1322 Published Online First: 15 November 2011.

Lars Engebretsen L and  Steffen K. 2009. Warm up The importance of sports medicine for the Vancouver Olympic Games. Br J Sports Med. 43:961-962.

J Torjussen J,  and Bahr R. 2006. Injuries among elite snowboarders (FIS Snowboard World Cup). Br J Sports Med. 40:230-234 .

Engebretsen L, and Bahr R. 2005. Injury prevention – Leader An ounce of prevention? Br J Sports Med. 39:312-313.

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Lars Engebretsen MD PhD is a professor and director of research at Orthopaedic Center, Ullevål university hospital and University of Oslo Medical School and professor and co-chair of the Oslo Sports Trauma Research Center. He is also Chief Doctor for the Norwegian Federation of Sports, and headed the medical service at the Norwegian Olympic Center until the autumn of 2011. In 2007 he was appointed Head of Science and Research for the International Olympic Comittee (IOC). Professor Engebretsen is Editor of the IPHP issues of BJSM (Injury Prevention & Health Protection)

Photo courtesy of Andrew Malone, Flickr CC

Running biomechanics and footwear’s (from bare feet to orthotics) relationship to injury generates lively debate.  And not just among sports clincians. A recent NY times article boldly asked – Does Foot Form Explain Running Injuries? The article profile’s the running professor, Daniel Lieberman’s (Evolutionary Biologist, Harvard) and Mr. Daoud’s (Medical Student, Stanford) research on 4 years worth of data gathered from Harvard’s cross-country running team. The researchers investigated footstrike (heel vs. toe) and rate of injury.

Beyond running style, Lieberman advocates for daily physical activity. In the BMJ podcast, Evolved to Run (that also features Steven Blair and Karim Khan), you’ll hear Lieberman say:  “we live in an abnormal world where people sit all day long.” What Lieberman positions as ‘normal,’ from an evolutionary perspective, is human bodies adaptation to having physical activity integrated into daily activities. In short – ‘the abnormality’ results from the dissonance between being ‘built to run’ and the post-industrial epidemic of sedentary behavior. You’ll hear more on the impacts of physical inactivity and the ‘ physical activity dose’ required’ to increase health from Blair and Khan on that  podcast.

Lieberman and Daoud concluded that “runners who landed on their heels were considerably more likely to get hurt,” but a forefoot running strike did not neccessarily prevent injury. Also, the researchers caution against changing your running style if you are injury-free.

And BJSM readers will know that ground/foot impact is not the only factor to take into account. What about knee and hip control? Also from Harvard, PT Professor Irene Davis illustrated that gait retraining – providing runners with feedback about landing forces – swiftly reduced anterior knee pain. Read the (free) Editor’s Choice article here.

So, while it may be premature to (run or) jump to conclusions about any one ‘superior’ approach to running, it’s clear  that 30-60 minutes of forefoot and/or heel striking is better than no strike at all.

Related BJSM Articles

RF Pinto, TR Souza, and CG Maher. 2012. External devices (including orthotics) to control excessive foot pronation. Br J Sports Med. 46:110-111.

K Mills,  P Blanch,  P Dev,  M Martin,  and B Vicenzino. 2011. A randomised control trial of short term efficacy of in-shoe foot orthoses compared with a wait and see policy for anterior knee pain and the role of foot mobility . Br J Sports Med. Published Online First: 18 September 2011

A Hirschmüller,  H Baur,  S Müller,  P Helwig, H-H Dickhuth,  F Mayer. 2011. Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study. Br J Sports Med. 45:959-965 Published Online First: 12 August 2009

RTH Cheung, RCK Chung,  GYF Ng. 2011. Efficacies of different external controls for excessive foot pronation: a meta-analysis. Br J Sports Med 2011;45:743-751 Published Online First: 18 April 2011

Cross Fertilising ‘Injury Prevention’ journal (IP) and BJSM

Photo courtesy of Maggie Osterberg, Flickr CC

The December 2011 issue of Injury Prevention, BJSM’s sister journal, highlights that musculoskeletal and activity-related injuries occur in both the old and the young. These are great targets for sports medicine professionals to ensure high quality of life through lifelong functionality and sustained active working lives. How? Through delivery of specific exercise and other interventions.
There is considerable scope for better integration of exercise and sports medicine approaches into the management of hip fracture patients. Bertram et al shows that hip fractures sustained by older people are associated with significant long-term disability. They concluded that 29% of older people who sustain a hip fracture do not reach their pre-fracture activity of daily living functionality, even one year after their fracture. Critically, this long term burden on both individuals and society could be significantly reduced if more was done to prevent the falls that lead to hip fractures from occurring in the first place. As a BJSM paper by Soo Lee and Ernst shows, delivery of exercise programs such as Tai Chi are effective for falls prevention.

In the same issue of the IP journal, Wilkinson et al describe injuries in British army infantry soldiers.The  youngest army soldiers were most at risk of injury during pre-deployment training and this was most related to participation in sport and physical training activities. As an observational study, it is not fully clear why those with a younger chronological age should be most at risk but it could be related to the fact that the younger solders had spent a shorter time in training. They were also more likely to have a lower military rank and it was possible that this may have meant that they were inherently exposed to higher risk situations in their training because of the nature of the activities they were required to undertake. Despite the high physical nature of their training activities, aerobic fitness levels were not a risk factor for the traumatic injuries in this study. There could be scope to better design some of the pre-deployment training components to reduce the risk of injury in the future.

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Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia. She specialises in implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group. Caroline can be followed on Twitter @CarolineFinch

Guest Blog by @CarolineFinch

Cross Fertilising ‘Injury Prevention’ journal (IP) and BJSM

Tejvanphotos, Flickr cc

Sports injury epidemiologists with a methodological bent will benefit from two papers published in the October issue of the BJSM’s sister journal, Injury Prevention.
In the first paper, Davie et al. discuss how to identify re-admissions for the same injury from hospital discharge data. Although only the tip of the iceberg for sports injury occurrences, hospital admissions data can be a good source of information about severe sports injuries. Some people get admitted to hospital for injury several times within a specified period of time and this could indicate either (i) recurrent injuries (each new episode of care is for treatment of a new occurrence of the same type of injury), (ii) people at risk of multiple injuries (new episodes of care for different injuries sustained in different injury events, because of the inherent risks and hazards they are exposed to) or (iii) previous treatment failure/incomplete rehabilitation (leading to episodes of care relating to ongoing treatment of the same injury). The paper concludes that to identify-readmissions properly it is important that injury data collections routinely record a unique person identifier and the date of injury, as well as the admission and discharge dates for the episodes of care.

In the sports medicine context, it is alarming how few sports injury data collections collect all this information and our modelling of sports injury incidence rates in the future would benefit from attention to these issues.

The second paper I highlight is a study protocol for a case-crossover design to better understand the link between bicyclists injuries and the cycling environment by Harris et al. In case-crossover studies are particularly useful for adjusting for exposures to risk factors that are transient (i.e. differ) over time and place but which are also associated with distinct acute events. In injury research, this study design has most commonly been applied to road crash studies in which cases are injured road users and people serve as their own controls where the control condition (i.e. with no injury) is at a different point in time when the road conditions are different (e.g. traffic density, weather conditions, earlier in the day, on a different part of the route, etc). The majority of epidemiological risk factors studies in the sports injury area do not consider transient risk factors, but rather assess injury risk in relation to baseline factors. There could be an opportunity to consider how risk factors themselves might vary over a playing season if case-crossover study designs were considered. This paper gives one example of how this approach could be included into a study.

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Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia. She specialises in implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.

Follow Caroline on Twitter @CarolineFinch

Image source: www.spotflick.com

The August 2011 issue of Injury Prevention (sister journal to the BJSM ) included an editorial from me with my views on an apparent unfortunate divide between sports medicine and injury prevention researchers.   The two groups rarely meet at the same conferences or read the same journals and so there is somewhat of a lack of knowledge about relevant research across the two sectors. I have vowed to help reduce this gap by establishing cross-journal Blog posts to directly alert readers of one journal about relevant research in the other, and vice versa.  Of course, my hope is that this will not be necessary in the long-term and that cross-fertilisation of ideas becomes the norm.

In this first IP to BJSM  cross-Blog, I’d like to alert injury researchers to several papers describing methodological issues of relevance, also published in the August IP issue.

One paper by Lawrence discusses the use of the controlled vocabularies of the commonly-used literature search engines PubMed/MEDLINE and PsycINFO for finding articles on injury prevention and safety promotion.  It highlights specific indexing problems that could impact on the quality of literature search strategies that rely solely on those methods to identify papers to include in reviews.

Another paper by Khan et al focuses on the statistical issue of how to best model injury count data, when there are excess zeroes. This is a common occurrence in injury studies where most people sustain no injuries, many only one or two injuries and fewer people sustain more injuries.  Such data should not be analysed by traditional Poisson counts and more appropriate statistical modelling applied instead.

Finally, Cryer et al present a new theoretical definition of injury death, which should overcome the short falls of current surveillance systems which are known to under-enumerate injury deaths.  Even though deaths in sport are rare compared to those in other settings, these new definitions are relevant to anyone who uses routine mortality data to monitor injuries.

Caroline Finch is an injury prevention researcher specialising in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

The topic of a new BJSM podcast is Ankle sprains and rehabilitation, with human movement specialist Evert Verhagen.

He addresses accurate diagnosis, whether to tape or brace (and when), principles of return to sport, and issues of cost-effectiveness. This podcast is geared to clinicians treating patients after ankle sprain  — and preventing these injuries in the first place. See Evert’s e-learning module at the BMJ [link http://learning.bmj.com.] and his editorial on injury prevention with Professor van Mechelen.

If you haven’t checked out our podcasts, go there now. Feel free to post your comments below.

Stretching, or not, has been a controversial issue.

This month’s BJSM helps to unravel (or add to) this puzzle.

In an entirely web-based study (that gained awareness through media coverage), 2377 physically active adults were recruited in an effort to determine whether stretching modifies injury risk and soreness.

The verdict? In the short-medium term stretching reduces the risk of soreness and does not reduce the all-injury risk.

For a link to this article and to make up your own mind, see the November  BJSM.