Injury researchers commonly study elite athletes because they participate in athletics year-round and thus have an increased chance of sustaining an injury. However, most athletes participate at the recreational or community level. (According to the NCAA, only 1.9% of American, high school, soccer players become professional players!)
Understanding that there is a difference between the physical profile of an elite player and a community player is imperative for making recommendations for injury risk factor management. The latest publication by Finch, et al. focuses on this matter.
In the current issue of Injury Prevention, Finch, et al. provide more evidence for targeted neuromuscular control exercise programs for decreasing knee injuries and lower limb injuries (LLI). The randomized-controlled trial (RCT) evaluated 18 male, non-elite, community Australian football clubs with data from more than 1,564 people. As profiled in the study, individuals who participated in the neuromuscular control intervention had a reduced rate of LLI as compared to control players.
The intervention was implemented as a “warm-up” prior to training. The program was based on the Preventing Australian Football Injuries through eXercise (PAFIX) study ; the control group participated in a “sham” program that included similar exercises. Although not in the published article, I was curious to know what PAFIX training fully entailed. The PAFIX training manuals include a detailed look at the neuromuscular exercises implemented, including a variety of plyometric training, stability and balance exercises, and change-of-direction drills.
Despite no statistically significant findings, this “analysis indicates that clinically relevant reduced knee injury and LLI rates can be achieved through targeted exercise training programmes in men’s community AF” (Australian Football).
This finding struck me as particularly important because of the vital role of community sport and recreation programs in providing nonelite athletes with the opportunity to gain the physical literacy skills needed to benefit from participation in sport and physical activity.
I look forward to more injury research which could potentially be generalized for nonelite, athletic communities.
Dr Soomro kindly agreed to answer a few questions for the blog!
Q1. Tell us about Cricket Predict; what is it and how did you come up with the concept?
I’ve been interested in prediction for a long time now. Today, we use technology and science to predict everything from the weather to cardiovascular risk. This carries into Sport as well: If you have a look at NFL, previous injury is used extensively in determining injury risk; Rugby players are similarly triaged using GPS data and the number of tackles per game. My aim was to develop a similar system for Cricket.
Cricket predict is a mobile app that harnesses technology in the surveillance of injuries, measures risk factors for injury and ultimately, aims to predict (and prevent!) injury. By tracking risk factors for injury in real-time, medical and coaching staff can receive alerts when an individual player’s risk profile is high – and interventions can be implemented. Further, whenever a player is injured, there is an electronic injury form which can be filled out through the app that goes onto a central online database, helping with identification of injuries.
Q2. Cricket predict utilises a number of different risk factors to help predict injury, what is the evidence for using these risk factors specifically? The risk factors that are used in Cricket Predict are all validated in the literature. They include:
I. Cricket workload, such as number of balls bowled
II. Non-cricket workload e.g. Strength and conditioning sessions, cross-training
III. Psychological status – measured by a modified Profile of Mood States (POMS) questionnaire, usually 76 items but modified to 10 items to be cricket-specific and “player-friendly”.
IV. Sleep, a measure of fatigue and documented risk factor for injury, measured by an accelerometer and analysed by Activ Graph.
V. Previous injury profile
VI. Pre-season strength parameters, including Internal Rotation to External Rotation ratio (predicts injury in Throwing Athletes), Hamstring to Quadriceps ratio (predicts hamstring injury)
Cricket Predict’s algorithm incorporates all of these risk factors and displays to the user a graphical representation of the player’s injury risk. However, exactly how predictive these risk factors are in cricket players is yet to be studied and my research group is running a prospective validation study to do just that. Q3. What are the implications of the findings of this study for readers?
There are 2 main implications of this research:
One of the biggest implications of my research is the integration of technology into Sports Medicine, which I see as the way forward. Its one of the reasons I developed this mobile app. Developing an electronic injury surveillance system makes data collection very easy, and numerous studies have demonstrated that electronic injury surveillance systems are superior to paper-based systems. Additionally, with the advent of wearable technology, large amounts of quantitative data can be incorporated.
Secondly, if the algorithm in Cricket Predict is validated, this research will revolutionise the way that Sportspeople play the game. Based on what we prove and validate, the coaches are going to change their coaching techniques, they will be able to select the best players for their teams, and develop policies for junior players as well.
Q4. Has this type of research been undertaken in other sports?
There is a recent article by Tim Gabbett which studied an injury prediction model in Australian Rugby League in which he was able to predict approximately 50-80% of soft-tissue non contact injuries over the course of 2 seasons. In the course of a tournament, an injury to a key player can change the balance of a team. Even if an algorithm can predict 10-20% of injuries, for an elite team that is very significant.
Q5. This research is heavily reliant on Technology, where do you see Technology and Medicine, or Technology and Injury Prevention going forward? A lot of data that we get these days is subjective data from players, and I think the best way to quantify data and validate data is to get data electronically from the use of sensors. Sensor-based technology and imaging technology is going to go very far in terms of performance analysis and the usage of physical characteristics of players. I see the usage of wearable technology being really big in sports. What I mean by this is the use of accelerometers or gyroscopes to look at movement patterns, similar sensors to look at medical data such as the amount of perspiration, and the amount of stress hormones such as Cortisol that can be measured in saliva and also in sweat. We can also look at blood sugar levels, heart rate, oxygen saturations – all of these things can be measured using wearable technology which can send wireless information to the medical and coaching staff. One of the most important things coaches can get out of this is the amount of fatigue of their players. If we can use technology to quantify this fatigue, that is going to revolutionise sport.
If you’d like to keep this conversation going, or be involved with Cricket Predict in the future, please get in touch with Dr Najeeb Soomro via email email@example.com or Twitter @CricDoctor. Specifically, if you are a cricket club, sports scientist or health professional interested in doing injury surveillance or helping to validate the app, Dr Soomro is happy to share the app with you! Let us know what you think @BMJ_IP too!
David Bui is a final year medical student at the University of New South Wales and outgoing President of the University of New South Wales Sports Medicine Society. He has an interest in Orthopaedics, Sports Medicine and Injury – in all forms! @David_Bui_
A cursory keyword search in Injury Prevention shows that snow sports injury prevention research in this journal is largely focused on head injuries and attitudes towards helmet use. Matt paints a picture below of a different, yet common-sense and just as important, consideration for snow sports safety.
Well we do, we get a lot of it. This year alone we have seen multiple evacuations from different places in Tasmania of people being snowed in. Snowboarders trapped in their car, and even a group of 10 people who needed to be airlifted out of a national park. Considering that winter is nowhere near over, awareness of the possibility of injury and even death needs to be articulated, not only our community, but to the international community as well. Last year (2014) we saw some tragic events occur over our winter, whether it was avalanche deaths, or injury and death occurring in organised ski areas.
These are not the first, and will not be the last, but the numbers may be limited with better injury prevention awareness campaigns. There is never going to be a seatbelt for skiing and snowboarding, but ensuring adequate health promotion of the risks of injury and death are needed on a wider scale.
As an interesting parallel to this, I (SB), have some Canadian friends living here in Australia (shout out to Wagga Wagga) who have told me that they never felt the cold as much in Canada as they do here. In fact, they would agree that Australian houses are just glorified tents in winter (read the interesting research linked in the article which shows that the poor quality of housing is behind many preventable deaths from exposure to cold in Australia).
“If you are a parent, you know that kids love to keep making circles” ~ Takaharu Tezuka
This charming Ted Talk from architect Takaharu Tezuka captured my imagination. It beautifully illustrates how architecture can positively influence physical activity levels – and we all have heard that sitting is the new smoking – however, I could not help but notice the take-away message that we are left with:
“My point is don’t control them, don’t protect them too much, and they need to tumble sometimes. They need to get some injury. And that makes them learn how to live in this world. I think architecture is capable of changing this world, and people’s lives. And this is one of the attempts to change the lives of children”
So, can child injury prevention include healthy risk promotion? A special feature in Injury Prevention explored this very question. This piece takes the reader on an interesting journey from the developmental benefits of risky play (via parenting and societal perceptions of risk, playground safety standards and children’s play space design, bubble-wrapped recreation, the public policy perspective, risk-benefit assessment, the state of the evidence) through towards calling for a culture of reasonableness:
“The challenge is to broaden the focus and commit to a child-centric approach—one that includes not only the mitigation of injury but also optimal child development, which necessitates exposure to competence-appropriate risky play in a hazard-free play space”
Of course, there are varying stances on risk within the injury prevention world. Recently, Barry Pless posted his own opinion right here on the Injury Prevention blog in The Safety Hysteric Speaks Again, stating that:
“In some circles I am regarded as an injury prevention fascist, safety hysteric, protect the children fanatic, a wuss, or worse. This has come about because I consistently push for more prevention and less risk taking. I am not at all convinced that risk-taking is good for child development, as some would have us believe. Nor am I convinced that having a serious injury with possible life-long (if not life-threatening) consequences builds character, or whatever”
It seems that this topic is a can of worms, and one which many researchers are (rightly?) wary of engaging in outside of carefully crafted research papers. Our opinions are carefully kept out of the public eye – however social media is rapidlyhas changed this. A large element of the advocacy that I wrote about last week applies here: why allow others to own the conversation that we, as injury prevention researchers, have all the tools to constructively address?
Our opinions can, and should, be fluid and in flux – and certainly differing too – this is the very nature of advancing our life’s work. Fostering an open and ongoing conversation remains necessary to that very nature of our work, and is one which I believe we should all be partaking in more often.
Blog 3: So today I wanted to share some more background on our blogging team. As an applied social psychologist, I find this information very interesting indeed!
What excites you about being part of the Injury Prevention social media editorial team?
Sheree Bekker: The invaluable conversation that has sprung up around scholarly work through the collaborative power of social media and blogs inspires me to no end. I tend to find more relevant scholarly content through Twitter than through traditional platforms, and Injury Prevention has played a big part in that. As researchers, I believe that we should own our voice on social media, and constructively add value to this conversation.
David Bui: Through my studies in medical school I have seen the costs of injuries to society and individuals worldwide. This is a great opportunity to harness the underutilised power of Social Media in health promotion and Injury Prevention, across multiple disciplines and multiple borders.
Angy El-Khatib: Being a part of the Injury Prevention social media editorial team is a great opportunity personally and collectively. By being a part of the social media editorial team, I am able to stay up to date on various topics within the realm of Injury Prevention while acquiring different perspectives from individuals from different backgrounds, disciplines, and locations. I’m also excited to be able to potentially increase readership and engage readers to create a conversation around the latest Injury Prevention research and ideas.
Klara Johansson: I am very interested to explore ways to share and disseminate knowledge and research results, outside the “old-school”, regular channels. I look forward to learning from my new co-editors, who all seem to be great communicators.
Joseph Magoola: The opportunity to work and collaborate with a variety of scholars on the injury prevention platform is nothing short of exciting. It also excites and inspires me to have an opportunity to represent Africa since low and medium income countries bear the brunt of the injury burden.
Julian Santaella-Tenorio: It is really exciting to be part of this team and to have a space to communicate and express ideas on ways to improve injury prevention, and to discuss about new studies and topics relevant to this field. I am very motivated to learn more and continue growing as a researcher as I walk through this experience.
What are you passionate about?
Sheree Bekker: Intersectional issues drive my life’s work, and my aim is that my research is, and always will be, an extension of that.
David Bui: Passionate about bringing people and ideas together.
Angy El-Khatib: I am passionate about translating scientific evidence and research into public health action. My goal is to improve the health and wellbeing of myself as well as my community. Outside of my work, I am passionate about health, fitness, and wellness.
Klara Johansson: Open discussions and innovative research in collaborative teams with high scientific ambition + high levels of tolerance and kindness; I also enjoy making difficult subjects understandable to students and the general population. Passions on my free time: nature, gardening, books, movies, writing fiction, playing music (clarinet, harmonium, piano, accordion).
Joseph Magoola: Writing on my social media accounts (facebook, twitter and my blog) as a way of reaching out to the masses. I am also interested travelling a lot, especially by road and as such, ensuring road safety is part and parcel of my aims to contribute towards reducing the carnage of our roads.
Julian Santaella-Tenorio: I am passionate about things that can make people have a better, healthier and happier life. I am inspired by ideas challenging previous knowledge, creative thinking finding answers from different angles, and the power of multidisciplinary groups. That is why I am passionate about public health research.
I hope you are looking forward to hearing from our bloggers, starting next month!
Today I will share more about our blogging team members.
Blog 2: Explain your injury prevention research and interests.
Sheree Bekker: My research investigates safety promotion and injury prevention policy and practice within community sport in Australia. I have a particular interest in dissemination and social marketing. The overall purpose of my research is to allow people to be safe, as well as feel safe, whilst participating in sport or physical activity.
David Bui: Undertaking a number of different projects currently; my injury prevention research focuses on Hip fracture and Falls Prevention research, working with Neuroscience Research Australia. I am also looking into Social Media and its utility in healthcare and civilian settings, and I believe that it represents a powerful new medium in health promotion and injury prevention.
Angy El-Khatib: I am interested in integrating public health approaches with athletic training practice. Athletic training has traditionally focused on the individual but may be able to maximize the effectiveness of prevention efforts by using population-level approaches to improve health and wellness.
Klara Johansson: I am not currently doing research on injury/safety. But I am interested in social difference in injury risk – and also how perceived risk of injuries affects people’s daily lives, mobility, fears and physical activity; and how perceived and real injury risks interrelate with each other and with gender and socioeconomics. Main focus on adolescent safety; real and perceived. Also interested in open data and availability/accessibility of injury statistics globally.
Joseph Magoola: My research interests center around prevention of injury, especially through generation of data for evidence-based decision making and policy action. I am also interested in the use of media to disseminate research findings and for advocacy.
Julian Santaella-Tenorio: At the moment I conduct research on policy evaluation, specifically on policies that impact injury-related outcomes. I am interested in looking at substance use policies and firearm-related legislation and their effects on the health of populations.
In some circles I am regarded as an injury prevention fascist, safety hysteric, protect the children fanatic, a wuss, or worse. This has come about because I consistently push for more prevention and less risk taking. I am not at all convinced that risk-taking is good for child development, as some would have us believe. Nor am I convinced that having a serious injury with possible life-long (if not life-threatening) consequences builds character, or whatever. But I was not the least bit surprised when I recently came across two newspaper accounts one of which challenged these views. I responded to it but not yet to the other.
The first was in Canada’s National Post (NP). It was written by its editorial board who were prompted by a municipality’s ban on tobogganing on certain hills. That action was based in part on the work of Dr. Charles Tator, a renown pediatric neurosurgeon and founder of ThinkFirst Canada. Tator’s study revealed huge risks of a ‘catastrophic injury’ from tobogganing. (http://www.tandfonline.com/doi/abs/10.1080/17430437.2011.614787?journalCode=fcss20#.VLapHsZpwyE) To be specific, his research found that over 4 years tobogganing had the fourth highest chance of grave risk, exceeded only by diving, snowmobiling, and parachuting. In that time frame about half of the serious injuries involved the head and one quarter the spine. This placed tobogganing among the most dangerous of all recreational activities. Tator made it clear that he was not suggesting that tobogganing be banned or regulated, but he did urge greater caution.But the lawyers for the municipality fearful of liability suits had other ideas.
In contrast to the ill-informed NP editorial board, a wiser and more responsible health reporter, Andre Picard, argued that tobogganers should not have to “pay for ‘liability chill.” He acknowledged that tobogganing is a “high-risk” activity but that the risks can easily be reduced. He added, “What is more difficult to contain is the voracious appetite of personal injury lawyers and the financial fearfulness of cash-strapped municipalities.” He went on to write, “In fact, while helicopter parents and overly cautious public health officials often get blamed when ridiculous bans on tobogganing, road hockey, skateboarding and the like are instituted, the real culprit is a torts system that has lost touch with reality.” As Picard summarized, “risks can be reduced by improving control and better head protection”. Importantly, he also quoted Drs. Tator and Francescutti (former Canadian Medical Association president) who asserted that “municipalities should provide information on how to ride safely rather than block off popular hills”.
In contrast, in its infinite wisdom, the National Post editorial that bordered on ridiculing Tator and which encouraged many commentators to contribute their mostly foolish and irresponsible views. (The link to the editorial is http://news.nationalpost.com/2015/01/05/national-post-editorial-board-the-freedom-to-toboggan/) Only a few commentators, (including, ironically, the editors themselves), acknowledged that the community had an obligation to remove dangerous obstacles, etc. I was disgusted with the tone and content of the piece and posted this comment. Undoubtedly, as is true for most letters I write to editors, it will do little except make me feel a bit better.
“It is hard to imagine why a supposedly responsible editorial board of a respected paper should ridicule the important message Dr. Tator issued. For the editors to make the comparison with car crashes is entirely inappropriate and ironic because I assume they have no problem with laws that regulate how cars are used! Similarly the comparison with personal responsibility with feeding grizzlies is simply embarrassing. Surely even Post editors would agree that at the very least the community shares the responsibility to prevent injuries of all kinds; that it is not simply up to the individual. That is why grizzlies don’t wander freely and communities notify snowmobilers that lakes are half frozen. This is a disgusting editorial that comes close to ridiculing one of Canada’s leading neurosurgeons and one of the few who makes a huge effort to keep people out of his operating room. Praise, not mockery, is the morally correct response and the editors owe Dr. Tator and their readers a huge apology.”
To which “John Smith” (??) wrote: “@barrypless – your angst is what is ridiculous. Are you Dr. Tator’s houseboy? Be thankful for writers and editors that don’t kneel down and kiss the ring of someone with a bit of fame and are willing to question their statements. And yes, it is up to the individual. Grow something in that mansack.”
Then, just as I was getting ready to post this blog, I came across a report from the Irish Times based on an editorial in the BMJ that criticized rugby’s “tribal, gladiatorial culture”. (Note: European rugby is not the same as American football). The editorial describes the rugby culture as one that “sees parents, coaches and schools encouraging excessive aggression and playing on when injured.” As the author, a paediatric neurosurgeon, Michael Carter wrote, “Anyone who has spent an hour picking skull fragments out of the contused frontal lobes of a teenage rugby player is entitled to an opinion on the safety of youth rugby.”
One possible solution offered by Carter is that the age of contact rugby be increased to 12 years. He noted, however, that a 14-year-old sustained three head injuries in one game and speculated that the increased interest in rugby is related to it becoming a professional sport. That has lead to a preference for hulk-like players. These problems seem similar to those now experienced by the National Football League in the US. Carter called attention to New Zealand’s approach to the issue which entails “teaching people how to play the game safely and correctly. “
The BMJ editor, Fiona Godlee, added: “Let’s call the current state of monitoring and prevention of rugby injury in schools what it is: a scandal. It needs urgent remedy before more children and their families suffer the consequences of collective neglect.”
My reaction is, “Right on, Fiona!” (although I doubt if more monitoring will help much). To my surprise and pleasure, so far most of the Responses in the BMJ have been supportive and constructive. Eventually, however, I expect we will hear some vociferous ‘risk-is-good’ voices but somehow I doubt that their owners would accept a spinal cord injury if risk-taking continues to be encouraged.