Over recent years there has been increasing concern that some children are being exposed to increasing levels of injury risk because they are playing too much sport. The issue is particularly pertinent for children who are identified as having sporting talent and who may be participating in intensive sporting competitions over a short period of time. Similar concerns have been raised in the broader context of potential links between fatigue, training volumes and injury rates across different sports and athlete groups, including endurance sport.

Given this background, a paper in the 2012 May issue of the British Journal of Sports Medicine caught my attention. The USA Cup soccer tournament attracts boys and girls aged from 12-19 years, with some playing up to seven games over five days. Over two separate tournaments and for each competitor who was treated at the central medical facility for injury or a medical condition, Waibel et al recorded the number of tournament match hours played, the occurrence of any injuries during specific games and the games missed due to injury. They concluded that the scheduling of games in this competition did not significantly increase the need for medical treatment later in the competition, as has also been previously reported by Rosenbaum and colleagues in a 2009 issue of Injury Prevention.

This type of study is important because, as previously noted by Rosenbaum et al., more research is needed into better understanding how to schedule the density of games in a multi-day tournament so as to avoid physical overload that can lead to injury. Both the Waibel et al and Rosenbaum et al. studies are based on relatively small samples but they do give some reassurance that our young people are unlikely to be being placed at excessive risk of injury during intensive soccer tournaments over successive days.

However, there is still much work to be done in this area. A lack of good quality, large-scale epidemiological studies directly linking fatigue to injury risk in sport and the generally poor quality fatigue measurement tools used in the published studies need to be addressed. Optimizing training loads for performance and other benefits is already being adopted by professional sport. It is now time for us to also translate similar strategies to community sport, whilst also ensuring that injury risk is kept to a minimum.

Additional reading

Finch CF, Williamson A, O’Brien B. An overview of the epidemiological evidence linking injury risk to fatigue in sport. Identification of research needs and opportunities. In FE Marino (2011). Regulation of fatigue in exercise. Nova Science Publishers Ltd. 2011:155-176.

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 Institute, 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

María Seguí Gómez
Our board member, Maria Segui, has been appointed General Director of Public Health, Drug Dependency and Consumption for the Government of Castilla-La Mancha, Spain. Comment: This is a huge tribute to Maria’s extraordinary talents but a great loss to European Centre for Injury Prevention at the University of Navarra in Pamplona, Spain which she founded only a few years ago.

Kate Carr
Kate Carr became President and CEO of SafeKids Worldwide on October 2, 2011. Previously Carr was Managing Director and Chief Development Officer of Malaria No More, a nonprofit organization. She was also President and CEO for the Elizabeth Glaser Pediatric AIDS Foundation from 1998 – 2005.  Comment: Welcome to the world of injury prevention, Ms Carr.

Gary Smith
The work of Gary Smith, director of the Center for Injury Research and Policy in New Mexico, is highlighted in a warm report.  www.medpagetoday.com Smith has pediatric and public health training and over many years has proven to be an effective advocate.  His most recent contribution relates to falls from high-rise windows but as the piece notes, his interests are wide-ranging and include: choking, furniture tip-overs, bath and shower slips, bunk bed crashes, cheerleading falls, gymnastics accidents, bumps from cribs and playpens, and problems on the playground.” Believing that “We know what works, we just need to apply it” he helped establish the hospital Center. Comment: What is there not to like in this laudatory report?  The title! “Accidents Leading Cause of Death in Kids”. I am still convinced that using the term ‘accidents’ (as the writer, not Smith, does) makes it much harder to achieve our goals. I wonder if any readers still agree?

Herb Simpson
The Governors Highway Safety Association’s (GHSA) most prestigious award, the James J. Howard Highway Safety Trailblazer Award, was presented posthumously to Dr. Herb Simpson for his outstanding contributions to the field of highway safety through his groundbreaking research. Dr. Simpson’s work was instrumental in identifying hard core drunk drivers as a significant contributor to highway fatalities and helped pioneer the concept of graduated driver licensing (GDL), among many other contributions.

Gerald Waters
The Traffic Injury Research Foundation (TIRF) announced that this year’s Sweedler Award recipient was Gerald Waters, a road safety advocate from New Zealand. After Waters lost a friend to a repeat drunk driver, he wrote to the Justice Minister asking for a review. He then appeared before a parliamentary select committee and spoke of the need to do more to address recidivist drunk drivers.  Although not an academic, he wrote a paper ‘The Case of Alcohol and Other Drug Treatment Courts in New Zealand’ highlighting the connection between drugs, alcohol and crime and emphasized the value of alcohol interlocks as part of the solution.

Authorities in Spain have fined the producers of Hollywood film Larry Crowne £25,000 for failing to ensure the lead actors, Tom Hanks and Julia Roberts,  were wearing helmets as they rode on a scooter on the film’s promotional poster. The absence of headgear is a violation of Spain’s strict traffic rules. These rules ban “any publicity, in print, audio or video that may incite excessive speed, reckless driving, situations of danger or any other circumstance involving conduct contrary to the principles of the law”. Apparently, the producers thought the fine was a joke and added that  in the film, all actors riding on scooters wore helmets.

P.S.  The singer Shakira was fined last year for failing to wear a helmet in one of her music videos.

Comment: We need much more such action. Can we give credit to Maria Segui-Gomez?

When I was 7 years old I fell off a slide on which has been placed a see-saw to prevent 7-year-olds from using the slide. I broke my wrist. Here was the bill my family received. (Note the spelling error!)

This month’s editor’s choice is Injury Prevention and Risk Communication: a mental models approach by Laurel Austin and Baruch Fischhoff.

We’ve published this special feature (which is free online) to highlight an empirically-grounded, systematic approach to thinking about health behavior, behavior change and intervention design. I suspect many of us use a ‘mental models’ framework as we think about prevention interventions, but fewer explicitly design and test their work in this fashion. And that’s a shame.

The authors make a strong case for the utility of a mental models approach and point to examples where the technique has been used to improve risk communication and preventive intervention. They outline 5 steps in systematically applying a ‘mental models’ framework to problem analysis and intervention:

1. Elicit domain expert beliefs and integrate them in a formal model of the risk situation.
2. Elicit lay beliefs about the same domain.
3. Compare expert and lay beliefs to identify consequential gaps and misperceptions.
4. Use structured surveys to estimate the population prevalence of beliefs.
5. Develop and empirically evaluate contextually relevant communications.

Have a look at the paper here and let us know what you think.

We’d love to see submissions to the journal that make explicit use of this approach in understanding health behavior and designing preventive interventions.

This link was sent to me by Tim Albert who is a freelance scientific writer trainer. It is a powerful indictment of the traditional publishing model and makes a strong case for open access journals. I have written about this before. In essence, although I approve of the moral argument, the problems with OA need to be acknowledged and addressed. One problem for retired folks like me is the huge author fee that is levied. I have not tested the extent to which a good OA journal would offer a reduction or waiver but unless this is generous and widespread many authors would have no access to these journals. But do read the Guardian article and the comments that follow.

Academic journals: an open and shut case | Editorial | Comment is free | The Guardian.

Successful prevention program implementation and dissemination of advice requires careful planning.

An editorial by Donaldson and Finch in the April 2012 46(5) issue of the British Journal of Sports Medicine (BJSM) stresses that such planning must be strategic, systematic and contextual. This editorial also emphasises that the perspectives of the end-users in relation to any preventive program should be a critical consideration in its design from the outset. This is because these end-users will only adopt an injury prevention intervention or participate in a safety promotion program if they can see that is directly relevant to them and easy for them to adopt. They want to know: “How is it better than what I usually do?” “Will it fit with what I usually do?” “Can I try it?” “Is it easy?” and “Can I see the results?” Importantly, the only way to ensure that these contextually relevant questions are addressed during program implementation is to engage with the end-users from the outset. This applies to end-users from all ecological layers of the settings in which implementation of programs are to occur.

This same issue of the BJSM contains papers about two screening procedures that are currently of great interest in the sports medicine community – screening for risk of sudden cardiac death and identifying when athletes are ready to return-to-play after concussion. The issue of end-user engagement with advice coming from screening programs, as one form of preventive measure, is particularly relevant.

Anderson et al. describe some of the ethical issues associated with screening athletes for risk of sudden cardiac death in sport. Whilst medical screening can be useful for identifying health concerns, its value in preventing sudden cardiac death is only as good as the efforts following this to protect the identified at-risk athlete. In some countries, this action is mandatory exclusion from further participation in the sport. The authors argue that whilst doctors can provide appropriate advice to athletes found to be at-risk, it is not their role to exclude them from sport. Rather, they consider, athletes need to be provided with enough information to make their own informed decisions about what personal level of risk they are willing to take. This study therefore considers the at-risk athlete to be the intended end-user of information provided to them by sports medicine professionals.

Another group of end-users of sports medicine screening approaches are the practitioners who need to make decisions about when concussed players should return-to-play – they require an accurate screening tool that is easy to use. Current international concussion assessment guidelines require players to be assessed for readiness to return to play with a tool such as the Sport Concussion Assessment Tool-2 (SCAT2), which includes both a symptom inventory and an objective assessment of physical signs, such as a balance examination. In their study of 214 US high school athletes, Jinguji et al. administered the SCAT2 to provide a baseline concussion assessment of this group. The authors concluded that there is considerable inter-athlete variability for some of the SCAT2 physical sign assessments. Without a baseline to compare against, decisions made based on a post-concussion SCAT2 alone could be incorrect. The practitioner end-users of SCAT2 assessments clearly need this important baseline information when using the SCAT2 after concussion because they need to determine when an athlete returns to their pre-concussion functioning and can safely resume their sport participation.

These three papers all show that prevention of injury, its adverse outcomes and sudden death in sport all require that the right information be disseminated to the relevant end-users. Achieving this will ensure that they are able either to make the appropriate decisions to guide their own safety decisions or to guide the actions they will then take to ensure the safety of others. Not considering end-user needs and perspectives from the outset, may mean that subsequent efforts to translate the latest information and advice to them will fail, largely because appropriate dissemination strategies have not been developed specifically for these target groups.

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

In his recent blog about Twitter feeds for injury prevention, Editor Brian Johnston highlights the value of this social media tool for keeping abreast of injury prevention knowledge. His message is aimed mainly at the researcher, practitioner and policy readers of Injury Prevention. As someone who has been actively using and accessing Twitter over six months now, I would totally agree with him about its value.

But Twitter is also used by the general population more widely, and anyone can express an opinion on any topic with the potential for their views to spread far and wide across social networks. A paper in the March 2012  46(4) issue of the British Journal of Sports Medicine by Sullivan et al, demonstrates this well. However, from the  analysis of time-limited tweets relating to sport-related concussion presented in this paper, it would seem that dissemination of specific injury prevention messages may be lagging behind other concussion-related (i.e. post injury) messages.

Sullivan et al undertook a content analysis of 1000 randomly selected tweets identified as being related to concussion in sport over a seven day period – this corresponded to about 30% of all relevant tweets over that time. Using a qualitative content analysis method, they identified nine major themes. The top three themes were: “news stories” (33%), typically relating to new injuries in high profile professional players; “sharing personal information/situation” (27%), mainly by those suffering from concussive symptoms; and “inferred management” (13%) which were messages about what to do post-concussion. Injury prevention, or primary prevention of concussion, did not appear in any of the nine themes.

This suggests that information about prevention of injuries from occurring in the first place is not having high prominence in public discussion. At least in this sports injury context, the discussion seems to focus on what people want to know about what to do after they have been concussed or their interest in following the outcomes of star players with concussion. It is unlikely that there is no public desire for information about how to prevent concussion or other injuries from occurring in the first place.  But where is the loud public voice about primary prevention of concussion and other injury?

As injury prevention practitioners, advocates and researchers we need to make sure that our messages about primary injury prevention reach our target audiences and have strong currency in current public discussion. We cannot assume that appropriate or accurate information dissemination will occur without our prompting and continual input.  There is a clear need for more of us to be actively engaging with social media on a regular basis to ensure that correct information is provided to the general population. As noted by Sullivan and colleagues, the easy access to Twitter means that misconceptions and misunderstandings are also widely disseminated, as not everyone has the knowledge to directly assess or value the accuracy of tweeted information. Such commonplace views and information content will remain unchallenged and uncorrected if injury prevention professionals do not become major credible contributors to Twitter discussions.  We also run the risk that our own knowledge of the preventablilty of injuries will remain just that (i.e. our own), and not shared with the population who needs to also hear this.

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

Avoid the misuse of literally! It is often (not) literally correct!..

The Montreal Gazette runs a column by Mark Abley on writing. This is one of my favourites, reprinted with his kind permission.

..”When the global oil companies run your country,” the B.C. columnist Murray Dobbin wrote a few weeks ago, “when they own your government, economic and environmental catastrophe are literally guaranteed.” I tend to share his sentiment, but I’d like to take up arms against his adverb. It would, I realize, be a futile battle – metaphorical uses of “literally” seem unavoidable. They can also be ridiculous. For sheer absurdity, it’s hard to top a recent statement by Britain’s Deputy Prime Minister, Nick Clegg: “It makes people so incredibly angry when you are getting up early in the morning – paying your taxes and then you see people literally in a different galaxy who are paying extraordinarily low rates of tax.”

markabley@sympatico.ca