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Injury prevention strategies: An ideal opportunity to translate scientific evidence
S192
Friday 2 November Papers / Journal of Science and Medicine in Sport 15 (2012) S188–S264
hensive approach to injury causation in response to the prevailing paradigm of accident prevention. This paper aims to present a systematic ecological framework in which to design sustainable, community based, safety promotion interventions. Method: A literature review was undertaken of Englishlanguage articles addressing the topics of “ecological injury prevention or safety promotion”, “ecological health promotion”, “sustainable economic, health or ecological systems” and “steady state”, with 143 articles retrieved and reviewed. Results: Injury prevention is a biomedical construct, in which injury is perceived to be a physical event resulting from the sudden release of environmental energy producing tissue damage in an individual. This reductionist perspective overlooks the importance of psychological and sociological determinants of injury. A number of recent studies have emphasised the importance of the social determinants of injury. Safety has physical, psychological and sociological dimensions. It is inherently an ecological concept. Interventions aiming to achieve long-term improvements in community safety must seek to develop sustainable safety promoting characteristics within the target community. We propose a visual metaphor “the injury iceberg” as an ecological metaphor of injury causation. In this system the individual is only the “tip of the iceberg”. The most enduring way to reduce an individual’s risk of injury is to systematically address the environmental and sociological issues “hidden beneath the water line”. Discussion: Haddon rightly observed that injury prevention and safety promotion is an ecological concept. Safety, in particular, has physical, psychological and sociological dimensions. We must capitalise on what has been achieved through re-engineering the physical environment by simultaneously re-engineering the social environment. To reduce a community’s risk of injury and sustain this lowered risk, it is necessary to take a whole of system view of injury causation and safety promotion. http://dx.doi.org/10.1016/j.jsams.2012.11.470 468 Physical (in)activity and injury risk E. Verhagen ∗ Department of Public and Occupational Health/EMGO Institute for Health and Care Research Introduction: Regular participation in physical activity and sports is beneficial for health. Thereby, safety in sports and physical activity is an important prerequisite for continuing participation in sports, as well as maintenance of a healthy physically active lifestyle. However, injuries are side effects of otherwise healthy activities and should not be neglected. This holds especially true for that part of the population that transfers from (relative) inactivity to a more active lifestyle for health gain. Methods: A series of (randomized) controlled trials in youth and novice runners will be discussed. Results: For youth there is an increasing amount of evidence pointing towards physical inactivity being a risk factor for physical activity and sports related injury. In absolute sense the number of injuries might be low in the participants with lowest exposure to sports and physical activity. However, when injury risk is expressed against actual exposure (i.e. n per 1,000 hours of participation) risk for injury is over 10-fold higher in the least active part of the population. The reason for this finding remains elusive, as this relationship seems to exist without influence of BMI and motor fitness, albeit both are also affected by relative physical inactivity. Similar
relationships are also reported for adult populations in which, for instance, it has been found that novice runners have higher risks of injury than experienced runners. Discussion: The consistent findings that relative inactive individuals are at increased risk for injury pose an important issue in regards to public health. It is this part of the entire population that is encouraged through various channels and millions of dollars to become more active for health reasons. However, injury risks are neglected in these health messages. This warrants a new approach towards injury prevention for a public health perspective. There is great potential health gain and health protection if injury prevention becomes an integral part of physical activity promotion. Injuries and associated costs are prevented in a large population, and drop-out from otherwise healthy activities due to injury is prevented. One should be aware though that most of the available evidence on prevention stems from active sports populations and is not necessarily transferrable to this large population of interest. http://dx.doi.org/10.1016/j.jsams.2012.11.471 469 Injury prevention strategies: An ideal opportunity to translate scientific evidence D. Twomey 1,∗ 1
University of Ballarat
Introduction: Injury prevention is commonly defined as the ability to reduce the likelihood, incidence and severity of injury and to be successful requires a multi-faceted approach. It has been argued that successful injury prevention strategies need a foundation of solid scientific evidence, but it could also be contested that the development of injury prevention interventions provide an excellent conduit for applying the knowledge acquired in a laboratory or controlled setting. The aim of this paper is to present examples of injury prevention intervention/strategies that have been underpinned by sound scientific evidence. In doing so, it will explore how the evidence was accrued, the implementation/delivery of the intervention, and any available evaluations. Methods and results: The examples will be drawn from neuromuscular based interventions, for example the Preventing Australian Football Injuries through eXercise (PAFIX); equipment based strategies, for example headgear or helmet wearing in sports such as cricket, rugby and snow sports; and rule modifications, for example body checking in ice hockey. The examples will demonstrate the importance of scientific evidence within injury prevention research and more importantly highlight the role it plays as only one facet of injury prevention research. Furthermore, the importance of evaluation to inform future scientific research will be illustrated through the examples presented. Discussion and Implications: As scientific knowledge is constantly evolving, new and often exciting opportunities for innovative injury prevention strategies emerge. Not only are advancements in equipment and technology occurring but knowledge regarding optimal implementation and translation of scientific evidence is also being regarded as playing a critical role in successful injury prevention strategies into the future. A limitation of many evidence-based prevention strategies is the lack of high quality evaluations that would inform and direct additional advanced scientific work. There is little doubt that if there are continued efforts to improve the mechanistic understanding of injuries combined with sound evaluations of evidence-based interventions,
Friday 2 November Papers / Journal of Science and Medicine in Sport 15 (2012) S188–S264
the value and role of scientific evidence in the realm of injury prevention will remain requisite. http://dx.doi.org/10.1016/j.jsams.2012.11.472 470 Developing evidence-based, context specific sports policy–an AFL experience L. Woodman 1,∗ , A. Donaldson 2 , N. Ames 1 , C. Finch 2 1
Australian Football League (AFL) Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Monash Injury Research Institute, Monash University 2
Introduction: Sports trainers (i.e. first aid providers) play an integral role in the provision of both immediate care and preparation of participants in many sporting contexts and hence their level of competency is critical to enable the fulfillment of this responsibility and to make participation safer. The aim of this paper is to present an example of how a national governing body of a sporting organisation recognised the need to clarify the competencies required of sports trainers, engaged in a research process to establish these competencies, and is in the process of implementing a new evidence-based and context-specific policy within the sport. Methods: Firstly, a literature review was conducted to identify the injury profile that sports trainers within the sport were required to be competent to manage. This was followed by a three stage Delphi consultation process to collate the opinions of sixteen experts on a set of draft sports trainer competencies and to develop consensus regarding their inclusion in the final policy and training structure documents. Subsequently, a Sports Trainer Policy and Training Structure were proposed and an on-line community consultation process was undertaken to seek the views of the broader Australian Football community. Finally, implementation of the policy was planned and initiated (a long term process). Results: During the Delphi process consensus was achieved on the expected and desirable competencies required by a sports trainer to successfully manage the range of injuries expected to be sustained by participants in non-elite Australian football. Key themes that emerged from the community consultation phase were: the need to acknowledge the volunteer intensive nature of community sport and the transient nature of sports trainers in community Australian football for successful implementation of the new policy; and the challenges associated with developing and implementing a ‘one-size-fits-all’ sports trainer policy in an environment in which resources and need vary enormously and are constantly changing. Discussion: Successful community club implementation of this type of centrally developed micro-level sport policy requires that policy-makers identify, understand and address the contextspecific issues that will impact successful policy implementation. http://dx.doi.org/10.1016/j.jsams.2012.11.473
S193
Biological mechanisms underlying musculoskeletal soft tissue injuries: Why it is clinically relevant?
471 Keynote Club Warehouse and Australian Institute of Sport Supported Speaker M. Collins 1,2,∗ 1 MRC/UCT Research Unit for Exercise Science and Sports Medicine of the South African Medical Research Council (MRC) 2 Department of Human Biology, University of Cape Town (UCT), South Africa
Musculoskeletal soft tissue injuries such as Achilles tendinopathy and anterior cruciate ligament ruptures are common among elite athletes, recreational athletes and physically active individuals. The consequences of injury may be devastating and prevent the recreational or competitive athlete from reaching their potential or lead to a premature end to their careers. Although these injuries have been well described at a clinical level, the biological mechanisms causing these injuries are poorly understood. A further understanding of the biological mechanisms underlying the injury will assist the treatment and management of these injuries. In addition, understanding the biology is an important prerequisite in developing models that can be used to effectively identify risk, as well as, implement personalized prevention, treatment and rehabilitation programmes. Both intrinsic, including genetic variants, and extrinsic risk factors have nevertheless been implicated in the aetiology of these injuries. The genes implicated in musculoskeletal soft tissue injuries encode: i) structural components of connective tissue (collagens and glycoproteins); ii) extracellular matrix (ECM) proteinases (MMPs); and iii) cytokines and growth factors. Some of these genes are also associated with performance and flexibility. Although seemingly unrelated, these injury and performance phenotypes are associated directly or indirectly with the mechanical properties of musculoskeletal soft tissue. We therefore hypothesize that variants in several of the genes implicated with these phenotypes alter fibril architecture and structure and, thereby, mechanical properties. We also proposed that genetic risk factors would in the future be included in multifactorial models developed to understand the molecular mechanisms that cause musculoskeletal soft tissue injuries or related pathology. Clinicians could eventually use these models to develop personalized training programmes to reduce the risk of injury as well as to develop treatment and rehabilitation regimens for the injured individual. The objective of this lecture will be to review the evidence for the genetic predisposition to musculoskeletal soft tissue injuries and the implicated biological mechanisms, as well as the application of this data in the prevention, treatment and management of musculoskeletal soft tissue injuries. http://dx.doi.org/10.1016/j.jsams.2012.11.474 472 Are we chained to our desks? Assessing desk based sitting using a new objective measure of occupational sitting time G. Ryde ∗ , H. Brown, N. Gilson, W. Brown The University of Queensland Introduction: Detailed data on sitting time at desks is required to understand and effectively influence occupational sitting habits.
Friday 2 November Papers / Journal of Science and Medicine in Sport 15 (2012) S188–S264
hensive approach to injury causation in response to the prevailing paradigm of accident prevention. This paper aims to present a systematic ecological framework in which to design sustainable, community based, safety promotion interventions. Method: A literature review was undertaken of Englishlanguage articles addressing the topics of “ecological injury prevention or safety promotion”, “ecological health promotion”, “sustainable economic, health or ecological systems” and “steady state”, with 143 articles retrieved and reviewed. Results: Injury prevention is a biomedical construct, in which injury is perceived to be a physical event resulting from the sudden release of environmental energy producing tissue damage in an individual. This reductionist perspective overlooks the importance of psychological and sociological determinants of injury. A number of recent studies have emphasised the importance of the social determinants of injury. Safety has physical, psychological and sociological dimensions. It is inherently an ecological concept. Interventions aiming to achieve long-term improvements in community safety must seek to develop sustainable safety promoting characteristics within the target community. We propose a visual metaphor “the injury iceberg” as an ecological metaphor of injury causation. In this system the individual is only the “tip of the iceberg”. The most enduring way to reduce an individual’s risk of injury is to systematically address the environmental and sociological issues “hidden beneath the water line”. Discussion: Haddon rightly observed that injury prevention and safety promotion is an ecological concept. Safety, in particular, has physical, psychological and sociological dimensions. We must capitalise on what has been achieved through re-engineering the physical environment by simultaneously re-engineering the social environment. To reduce a community’s risk of injury and sustain this lowered risk, it is necessary to take a whole of system view of injury causation and safety promotion. http://dx.doi.org/10.1016/j.jsams.2012.11.470 468 Physical (in)activity and injury risk E. Verhagen ∗ Department of Public and Occupational Health/EMGO Institute for Health and Care Research Introduction: Regular participation in physical activity and sports is beneficial for health. Thereby, safety in sports and physical activity is an important prerequisite for continuing participation in sports, as well as maintenance of a healthy physically active lifestyle. However, injuries are side effects of otherwise healthy activities and should not be neglected. This holds especially true for that part of the population that transfers from (relative) inactivity to a more active lifestyle for health gain. Methods: A series of (randomized) controlled trials in youth and novice runners will be discussed. Results: For youth there is an increasing amount of evidence pointing towards physical inactivity being a risk factor for physical activity and sports related injury. In absolute sense the number of injuries might be low in the participants with lowest exposure to sports and physical activity. However, when injury risk is expressed against actual exposure (i.e. n per 1,000 hours of participation) risk for injury is over 10-fold higher in the least active part of the population. The reason for this finding remains elusive, as this relationship seems to exist without influence of BMI and motor fitness, albeit both are also affected by relative physical inactivity. Similar
relationships are also reported for adult populations in which, for instance, it has been found that novice runners have higher risks of injury than experienced runners. Discussion: The consistent findings that relative inactive individuals are at increased risk for injury pose an important issue in regards to public health. It is this part of the entire population that is encouraged through various channels and millions of dollars to become more active for health reasons. However, injury risks are neglected in these health messages. This warrants a new approach towards injury prevention for a public health perspective. There is great potential health gain and health protection if injury prevention becomes an integral part of physical activity promotion. Injuries and associated costs are prevented in a large population, and drop-out from otherwise healthy activities due to injury is prevented. One should be aware though that most of the available evidence on prevention stems from active sports populations and is not necessarily transferrable to this large population of interest. http://dx.doi.org/10.1016/j.jsams.2012.11.471 469 Injury prevention strategies: An ideal opportunity to translate scientific evidence D. Twomey 1,∗ 1
University of Ballarat
Introduction: Injury prevention is commonly defined as the ability to reduce the likelihood, incidence and severity of injury and to be successful requires a multi-faceted approach. It has been argued that successful injury prevention strategies need a foundation of solid scientific evidence, but it could also be contested that the development of injury prevention interventions provide an excellent conduit for applying the knowledge acquired in a laboratory or controlled setting. The aim of this paper is to present examples of injury prevention intervention/strategies that have been underpinned by sound scientific evidence. In doing so, it will explore how the evidence was accrued, the implementation/delivery of the intervention, and any available evaluations. Methods and results: The examples will be drawn from neuromuscular based interventions, for example the Preventing Australian Football Injuries through eXercise (PAFIX); equipment based strategies, for example headgear or helmet wearing in sports such as cricket, rugby and snow sports; and rule modifications, for example body checking in ice hockey. The examples will demonstrate the importance of scientific evidence within injury prevention research and more importantly highlight the role it plays as only one facet of injury prevention research. Furthermore, the importance of evaluation to inform future scientific research will be illustrated through the examples presented. Discussion and Implications: As scientific knowledge is constantly evolving, new and often exciting opportunities for innovative injury prevention strategies emerge. Not only are advancements in equipment and technology occurring but knowledge regarding optimal implementation and translation of scientific evidence is also being regarded as playing a critical role in successful injury prevention strategies into the future. A limitation of many evidence-based prevention strategies is the lack of high quality evaluations that would inform and direct additional advanced scientific work. There is little doubt that if there are continued efforts to improve the mechanistic understanding of injuries combined with sound evaluations of evidence-based interventions,
Friday 2 November Papers / Journal of Science and Medicine in Sport 15 (2012) S188–S264
the value and role of scientific evidence in the realm of injury prevention will remain requisite. http://dx.doi.org/10.1016/j.jsams.2012.11.472 470 Developing evidence-based, context specific sports policy–an AFL experience L. Woodman 1,∗ , A. Donaldson 2 , N. Ames 1 , C. Finch 2 1
Australian Football League (AFL) Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Monash Injury Research Institute, Monash University 2
Introduction: Sports trainers (i.e. first aid providers) play an integral role in the provision of both immediate care and preparation of participants in many sporting contexts and hence their level of competency is critical to enable the fulfillment of this responsibility and to make participation safer. The aim of this paper is to present an example of how a national governing body of a sporting organisation recognised the need to clarify the competencies required of sports trainers, engaged in a research process to establish these competencies, and is in the process of implementing a new evidence-based and context-specific policy within the sport. Methods: Firstly, a literature review was conducted to identify the injury profile that sports trainers within the sport were required to be competent to manage. This was followed by a three stage Delphi consultation process to collate the opinions of sixteen experts on a set of draft sports trainer competencies and to develop consensus regarding their inclusion in the final policy and training structure documents. Subsequently, a Sports Trainer Policy and Training Structure were proposed and an on-line community consultation process was undertaken to seek the views of the broader Australian Football community. Finally, implementation of the policy was planned and initiated (a long term process). Results: During the Delphi process consensus was achieved on the expected and desirable competencies required by a sports trainer to successfully manage the range of injuries expected to be sustained by participants in non-elite Australian football. Key themes that emerged from the community consultation phase were: the need to acknowledge the volunteer intensive nature of community sport and the transient nature of sports trainers in community Australian football for successful implementation of the new policy; and the challenges associated with developing and implementing a ‘one-size-fits-all’ sports trainer policy in an environment in which resources and need vary enormously and are constantly changing. Discussion: Successful community club implementation of this type of centrally developed micro-level sport policy requires that policy-makers identify, understand and address the contextspecific issues that will impact successful policy implementation. http://dx.doi.org/10.1016/j.jsams.2012.11.473
S193
Biological mechanisms underlying musculoskeletal soft tissue injuries: Why it is clinically relevant?
471 Keynote Club Warehouse and Australian Institute of Sport Supported Speaker M. Collins 1,2,∗ 1 MRC/UCT Research Unit for Exercise Science and Sports Medicine of the South African Medical Research Council (MRC) 2 Department of Human Biology, University of Cape Town (UCT), South Africa
Musculoskeletal soft tissue injuries such as Achilles tendinopathy and anterior cruciate ligament ruptures are common among elite athletes, recreational athletes and physically active individuals. The consequences of injury may be devastating and prevent the recreational or competitive athlete from reaching their potential or lead to a premature end to their careers. Although these injuries have been well described at a clinical level, the biological mechanisms causing these injuries are poorly understood. A further understanding of the biological mechanisms underlying the injury will assist the treatment and management of these injuries. In addition, understanding the biology is an important prerequisite in developing models that can be used to effectively identify risk, as well as, implement personalized prevention, treatment and rehabilitation programmes. Both intrinsic, including genetic variants, and extrinsic risk factors have nevertheless been implicated in the aetiology of these injuries. The genes implicated in musculoskeletal soft tissue injuries encode: i) structural components of connective tissue (collagens and glycoproteins); ii) extracellular matrix (ECM) proteinases (MMPs); and iii) cytokines and growth factors. Some of these genes are also associated with performance and flexibility. Although seemingly unrelated, these injury and performance phenotypes are associated directly or indirectly with the mechanical properties of musculoskeletal soft tissue. We therefore hypothesize that variants in several of the genes implicated with these phenotypes alter fibril architecture and structure and, thereby, mechanical properties. We also proposed that genetic risk factors would in the future be included in multifactorial models developed to understand the molecular mechanisms that cause musculoskeletal soft tissue injuries or related pathology. Clinicians could eventually use these models to develop personalized training programmes to reduce the risk of injury as well as to develop treatment and rehabilitation regimens for the injured individual. The objective of this lecture will be to review the evidence for the genetic predisposition to musculoskeletal soft tissue injuries and the implicated biological mechanisms, as well as the application of this data in the prevention, treatment and management of musculoskeletal soft tissue injuries. http://dx.doi.org/10.1016/j.jsams.2012.11.474 472 Are we chained to our desks? Assessing desk based sitting using a new objective measure of occupational sitting time G. Ryde ∗ , H. Brown, N. Gilson, W. Brown The University of Queensland Introduction: Detailed data on sitting time at desks is required to understand and effectively influence occupational sitting habits.