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The delivery of injury prevention exercise programmes in professional youth soccer: Comparison to the FIFA 11+
Accepted Manuscript Title: The delivery of injury prevention exercise programs in professional youth soccer: comparison to the FIFA 11+. Author: James O’Brien MASc Warren Young PhD Caroline F. Finch PhD PII: DOI: Reference:
S1440-2440(16)30087-1 http://dx.doi.org/doi:10.1016/j.jsams.2016.05.007 JSAMS 1334
To appear in:
Journal of Science and Medicine in Sport
Received date: Revised date: Accepted date:
20-1-2016 1-5-2016 26-5-2016
Please cite this article as: O’Brien J, Young W, Finch CF, The delivery of injury prevention exercise programs in professional youth soccer: comparison to the FIFA 11+., Journal of Science and Medicine in Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.05.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The delivery of injury prevention exercise programs in professional youth soccer:
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comparison to the FIFA 11+.
James O’Brien MASc (corresponding author)
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Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) Federation University Australia
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SMB Campus, PO Box 663, Ballarat, VIC 3353 Australia
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[email protected]
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Tel: +43 664 600781093
Associate Professor Warren Young PhD
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Faculty of Health
Federation University Australia
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Australian Centre for Research into Injury in Sport and its Prevention (ACRISP)
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Australia
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SMB Campus, PO Box 663, Ballarat, VIC 3353
Professor Caroline F Finch PhD
Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) Federation University Australia
SMB Campus, PO Box 663, Ballarat, VIC 3353 Australia
Word count structured abstract: 3185 Word count manuscript: 250 Number of Tables: 1 Number of Figures: 1 3
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The delivery of injury prevention exercise programs in professional youth soccer:
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comparison to the FIFA 11+.
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Objectives Injury prevention exercise programs (IPEPs) for amateur soccer have gained
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considerable attention, but little is known about their relevance and adaptability to
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professional soccer settings. The first aim of this study was to evaluate the delivery and
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content of IPEPs used by professional youth soccer teams, compared to the industry
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standard IPEP for soccer, the Fédération Internationale de Football Association’s FIFA 11+.
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The second aim was to document specific challenges to implementing IPEPs in this context.
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Design Prospective observational study.
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Methods The participants were soccer coaches, fitness coaches and physiotherapists
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(n=18) from four teams in a professional youth soccer academy. Each team’s chosen IPEPs
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were observed weekly across an entire soccer season (160 sessions). The delivery and
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content of the programs were documented on a standardised worksheet and compared to
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the FIFA 11+. Specific implementation challenges were recorded.
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Results Fitness coaches were the primary deliverers of IPEPs, with support from
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physiotherapists. Multiple delivery formats and locations were employed, along with the
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extensive use of equipment. Across all IPEP sessions, a median of one FIFA 11+ exercise
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was performed in its original form and a further four in a modified form. Implementation
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challenges included poor staff communication, competing training priorities and heavy game
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schedules.
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Conclusions Although the basic components of the FIFA 11+ hold relevance for
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professional youth male teams, the delivery and content of IPEPs require considerable
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tailoring for this context. Recognising this will inform the development of improved, context-
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specific IPEPs, along with corresponding strategies to enhance their implementation.
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Keywords: injury prevention; implementation; exercise programs; coaches; sport
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29 Introduction
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Soccer is the world’s most popular sport,1 but injuries are both common and associated with
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considerable costs, participation loss, decreased team performance and long-term negative
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side effects.2-4 In recent years, there has been increased research interest in the prevention
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of soccer injuries, particularly the use of injury prevention exercise programs (IPEPs). The
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efficacy of established IPEPs, including the Fédération Internationale de Football
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Association’s FIFA 11+ and a Swedish IPEP called Knäkontroll, has been demonstrated in
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large-scale randomised controlled trials (RCTs).5, 6 However, it has also been emphasised
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that establishing an IPEP’s efficacy is only one of several steps in successfully preventing
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real-world injuries.7, 8 Recent research has highlighted the challenges of reaching target IPEP
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audiences, enhancing adoption and ensuring adequate compliance over time.9-11 For
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example, in a trial of the Knäkontroll program in amateur female Swedish teams, players with
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high compliance experienced an 88% reduction in the rate of Anterior Cruciate Ligament
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(ACL) injuries, whereas the rate among players with low compliance did not differ
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significantly from the control group.10 In a further example, Norwegian female players with
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high compliance to the FIFA 11+ program, demonstrated a 35% lower risk of injuries
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compared to players with intermediate compliance levels.12
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To enhance the real-world impact of sports injury prevention interventions, researchers and
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evaluators have begun to embrace implementation frameworks from the broader field of
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health promotion, such as the Reach Effectiveness Adoption Implementation Maintenance
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(RE-AIM) framework.13-15 This framework outlines a range of factors influencing the
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successful translation of evidence-based interventions into real-world practice.15 A recent
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systematic review of team ball sport IPEP trials, employing RE-AIM, demonstrated the
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paucity of current knowledge on implementation factors, particularly relating to aspects of
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adoption and maintenance.16 Other recent RE-AIM studies in soccer settings have
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highlighted the challenge of convincing soccer coaches to adopt IPEPs, perform them as
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intended and maintain them over time.9, 11, 17 In a three-year follow up to the Knäkontroll RCT,
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approximately three-quarters of coaches had modified the original content of the program, or
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had failed to perform it with the prescribed frequency.9 In a study of Oregon high school
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soccer and basketball coaches, 52% were aware of IPEPs, but just 21% reported using one
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and only 9% reported performing the program as originally designed.17
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Recent sports injury prevention implementation research has emphasised that a key first
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step to enhancing an intervention’s success is developing an understanding of the specific
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context in which it is to be delivered.8, 18 The design and delivery of IPEPs require tailoring to
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the specific target setting, with consideration of factors such as player age,19, 20 knowledge
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and beliefs,21 competitive level22 and climate.18, 23 Recent studies have evaluated the
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perceptions of players and staff members towards injury prevention programs within the
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specific setting of professional male soccer24 and professional youth male soccer.25 The
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respondents in these teams expressed strong support for the use of IPEPs, and also
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identified multiple factors influencing the successful implementation of these programs in
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their context. These factors related to both the content and nature of the IPEP itself (e.g.
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exercise variation/progression), and the delivery and support of IPEPs (e.g. staff
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communication and coach acceptance). In professional male teams, only 30% of
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respondents believed that the FIFA 11+ contained adequate progression and variation for
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their context.24 In professional youth male teams, the majority of respondents were aware of
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the FIFA 11+, but fewer than a third actually used it and mostly in a modified form.
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Taken together, the results of the above studies suggest that established IPEPs require
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considerable tailoring for use in professional soccer teams. However, there is currently a lack
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of published information on the content and delivery of IPEPs in these settings.24 Hence, the
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aims of the current study were:
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To directly observe the delivery and content of IPEPs in a professional youth soccer academy at weekly intervals across an entire season.
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To document the specific IPEP implementation challenges experienced by staff. 5 Page 5 of 23
Methods
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The study design was a prospective weekly observation of four teams across one entire
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soccer season. The targeted participants were all soccer coaches, fitness coaches and
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physiotherapists from four professional youth male soccer teams during the 2014/2015
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season. The four teams were all based in a professional European soccer academy and
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were selected based on existing connections to the researchers. Three teams (Under-15,
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Under-16 and Under-18 age groups) were competing in the premier national under-age
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league and one team (Under-23) was competing in the second highest national adult league.
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The teams typically trained 6-7 times per week.
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All participants completed informed consent forms and the study was approved by the
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University Human Research Ethics Committee. Prior to the current study, all consenting
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participants completed a web-based survey, detailing their perceptions of soccer injuries,
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IPEPs in general and the FIFA 11+. Participants were prompted to follow a link in the survey
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to the official FIFA 11+ website, to familiarise themselves with the program. The results of
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this survey have been previously reported.25
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During the pre-season, the first author met with the staff of each team. In a semi-structured
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interview, each teams’ strategy for implementing IPEPs in the coming season was
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discussed. In addition to the planned content of IPEPs, aspects of delivery (e.g. format,
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location and staffing) were discussed.
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Each week, during the 49 week soccer season, the delivery of one IPEP session from each
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of the four teams was randomly selected for observation and documented on a standardised
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worksheet. A block randomisation method was used to ensure a balance in the number of
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observations at different time points across the training week. In cases where block
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randomisation was not possible (e.g. short-term cancellation of the selected session), one of
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the remaining sessions in the week was chosen at random using an online generator
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(www.random.org).
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A standardised data collection sheet (Supplemental file), structured around the industry-
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standard IPEP for soccer, the FIFA 11+, was developed in Microsoft Excel™. At every
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observation, the team’s use of each FIFA 11+26 exercise was coded by the first author as
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either (1) performed as prescribed, (2) performed modified or (3) not performed. Exercises
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were considered modified when progressions or equipment, other than those outlined in the
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original FIFA 11+,26 were observed. Additionally, the location where the IPEP was delivered
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(e.g. outdoor pitch, gym), the training format (e.g. warm-up, cool-down), the number and type
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of staff members delivering the IPEP (e.g. fitness coach, physiotherapist) and the use of
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equipment (e.g. weights, balance pads) were documented. For each session, staff also
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provided the current number of players in the squad, along with the number and reasons for
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any player absences. Throughout the season, both at staff meetings and following every
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IPEP observation, staff members were asked verbally to explain any facilitators and barriers
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to IPEP implementation. This information was solicited through casual questioning as
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opposed to formal, structured interviews.
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The data from all IPEP observations was summarised and analysed using Microsoft Excel™,
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with all teams combined. The types of IPEP delivery format, types of IPEP delivery location
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and primary IPEP deliverer were summarised descriptively (total number, percentage of all
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observations, mean and range). The primary deliverer was defined as the staff member who
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took on the main role of instructing players during the IPEP. The minimum, 25% quartile,
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median, 75% quartile and maximum number of FIFA 11+ exercises performed, performed
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modified and not performed across all observations in the entire season were calculated. The
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facilitators and barriers to implementing IPEPs, identified by staff members, were categorised
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according to themes identified in earlier studies of professional soccer teams.25, 27
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133 Results
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Eighteen (90%) of the 20 eligible staff members, including nine soccer coaches, four fitness
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coaches and five physiotherapists, agreed to participate. The remaining 2 (10%) cited lack of
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time as the reason for not participating.
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During the initial team meetings, all four teams reported planning to use IPEPs in the coming
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season and had a defined strategy for the content and delivery of these programs. None of
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the teams intended to use the FIFA 11+ in its original form, but their IPEPs were structured
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on basic exercise components overlapping closely with those of the FIFA 11+ (e.g. strength,
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balance, jumping/landing and core stability). Fitness coaches and physiotherapists decided
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on the program content, with consideration given to player age, published research, injury
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statistics and past experience. Fitness coaches were responsible for delivering the IPEPs,
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while physiotherapists assisted with the supervision and correction of exercises. Head
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coaches ultimately decided on the number and length of IPEPs in each training week, with
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consideration of the game and training schedule. All teams planned to use multiple delivery
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formats (e.g. warm-up, separate sessions) and multiple delivery locations (e.g. outdoor pitch,
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gym). Incorporating different preventive training cycles across the season (e.g. a cycle
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focussing on strength) was also considered important. Staff emphasised the need to tailor
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IPEP content to the chosen delivery format (e.g. including more running and dynamic
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stretching exercises in warm-ups).
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Across the 49 week soccer season, 160 IPEP sessions were observed across the four
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academy teams (range per team 35-43). In 28 instances, a team did not perform any IPEP
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session during a calendar week (range per team 4-12) with the most common reasons being
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season breaks and training interruptions due to heavy game schedules or athletic
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performance tests. In a further eight instances (range per team 1-3), an observation could
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not be performed due to short-term changes to the training plan (e.g. the last session in a
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week, randomised for observation, being cancelled by team staff) or the observer being ill/on
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educational leave. Hence, from 168 potential weekly observations, 160 (95%) were
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completed.
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The observed IPEP format, location, primary deliverer, duration, active staff members, player
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absences and number of training equipment types per session are summarised in Table 1.
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---Insert Table 1 here---
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A median of four players were absent, with the most common reasons being injury, illness,
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national team/first squad selection and participation in other parallel training sessions (e.g.
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goalkeeper training). Across all IPEP sessions, a total of 53 different types of training
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equipment (e.g. balance pads, dumbbells and resistance bands) was observed, with a
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median of 26 (range 21-30) across the four teams.
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The number of the 15 FIFA 11+ exercises performed in their original form, performed in a
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modified form and not performed are summarised in Figure 1. A median of one FIFA 11+
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exercise was performed in its original form and a further four in a modified form. Examples of
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modifications included performing squats with added weight and performing single-leg
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balance exercises on balance pads, while kicking a soccer ball to a partner. Exercises from
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part two of the FIFA 11+26 (strength, plyometrics and balance) were more frequently
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performed that exercises from parts one and two of the FIFA 11+ (running exercises). The
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proportion of total IPEP sessions in which the six exercises in part two were performed,
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either in original or modified form, ranged from 43-73% (median 65%) across the six
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exercises. The corresponding figures for the nine running exercises were; range 2-68%
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(median 21%). Full details regarding the use and modification of each individual FIFA 11+
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exercise are reported elsewhere (O’Brien et al. under review).
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---Insert Figure 1---
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The participants reported multiple barriers and facilitators to implementing IPEPs
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(Supplemental file 2) relating either to the content and nature of the programs (e.g. variation,
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progression, adaptability), or their delivery and support (e.g. staffing, teamwork,
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communication). Aspects of IPEP delivery and support spanned multiple levels of the
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professional youth soccer system, including the player (e.g. personality and motivation),
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team staff (e.g. coach acceptance and staff communication), the club (e.g. sports director
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acceptance), governing bodies (e.g. game schedules) and the external environment (e.g.
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weather).
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192 Discussion
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This is the first study to directly observe the implementation of IPEPs in any form of soccer
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on a weekly basis. This provided a detailed insight into IPEP delivery, content and
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implementation challenges in a real-world, professional soccer setting. The vast majority of
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observed sessions were delivered by fitness coaches, using a range of different locations,
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training formats and training equipment. Taken as a median across the season, over a third
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of the FIFA 11+ exercises were included in the observed IPEP sessions, albeit mostly in a
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modified form. Team staff provided a comprehensive list of barriers and facilitators to
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implementing IPEPs, relating either to the program itself, or the delivery and support of
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IPEPs at different levels of the professional soccer system. The findings of this study will
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inform the design and delivery of future IPEPs for professional youth soccer, other soccer
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settings and other team ball sports.
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The ultimate impact of IPEPs in real-world settings will depend on the efficacy of the
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programs and the extent to which they are successfully adopted, performed and maintained
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by the targeted audiences.28 Whilst players are the intended health beneficiaries of IPEPs,
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the individuals delivering the programs (e.g. team staff) also play a key role in achieving the
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desired injury-prevention outcomes.29 To date, much of the research on IPEPs has focussed
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on amateur soccer settings, with coaches being identified as key IPEP deliverers.30 However,
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as highlighted by this study, fitness coaches are the primary IPEP deliverers in professional
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soccer settings. Compared to the technical and tactical focus of soccer coaches, fitness
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coaches are primarily focussed on the physical conditioning of players, and are likely to have
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different educational backgrounds, injury prevention perceptions and specific training goals.
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For example, the fitness coaches in this study referred to the published sports science and
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sports medicine literature to inform the design of their IPEPs and aligned the content/delivery
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of the programs to athletic goals and training cycles.
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The IPEP delivery formats and delivery locations observed in this study also differ
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considerably to the recommendations in the industry-standard program for amateur soccer,
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the FIFA 11+. Whereas the FIFA 11+ is promoted as an on-pitch, warm-up program requiring
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minimal equipment,26 the teams in this study employed IPEPs in several formats (e.g. warm-
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up, separate sessions, split sessions), different settings (e.g. outdoor pitch, indoor pitch,
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gym) and with extensive use of equipment. The challenges and opportunities arising from
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these contextual differences in professional soccer settings need careful consideration when
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planning the design and delivery of future programs.
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The fact that modified FIFA 11+ exercises were frequently incorporated into the IPEPs
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observed in this study suggests that the certain components of the FIFA 11+ hold relevance
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for professional youth teams. However, staff emphasised the need for adequate variation
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and progression of IPEP exercises in professional soccer settings, including
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fun/challenging/competitive exercises, the use of equipment and different training cycles. The
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staff also emphasised the importance of IPEP adaptability, with the length and content of
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programs requiring tailoring to the specific training format (e.g. warm-up vs. cool-down),
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athletic training goals and the different ability levels of individual players.
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The number and diversity of barriers and facilitators provided by staff highlights both the
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complexity of the IPEP implementation context and the importance of targeting multiple
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levels of the professional soccer system when implementing programs. This aligns closely
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with established implementation frameworks such as the RE-AIM Sports Setting Matrix.13 At
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the player level, the success of an IPEP will be facilitated by adequate education, motivation
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and more supervision (e.g. more staff or smaller groups). The significant proportion of player
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absences observed in this study holds implications for IPEP implementation strategies.
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Programs that players can perform separately from the team training may compensate for
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missed team sessions. Staff also require strategies for re-integrating players following
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absences due to injury/illness or involvement with other teams.
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The reported implementation facilitators at the team staff level included communication,
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coach acceptance, staff stability and the team work. The detailed list of factors identified in
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the study builds considerably on previous findings from professional soccer settings25, 27 and
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illustrates the key role of team staff in IPEP implementation. At club level, IPEP acceptance,
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planning and stability were identified as important factors. Friendly games and tournaments,
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planned by club officials, can disrupt teams’ regular training schedules, hence limiting the
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available time for injury prevention. Game scheduling was also the primary facilitator/barrier
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identified at the level of governing bodies (e.g. leagues and national governing bodies). As in
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previous IPEP studies,18, 23 weather conditions were reported as a factor influencing IPEP
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implementation, with favourable weather facilitating variation in the training location and
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performing exercises on the ground. Although the teams in this study had access to indoor
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facilities, changes to the delivery location (especially short-term) demanded a degree of IPEP
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adaptability, along with sufficient planning/organisation of shared facilities and equipment.
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Modifications of FIFA 11+ exercises were frequently observed in this study. For example,
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squats were performed with additional weight and unstable surfaces were used to increase
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the difficulty of balance exercises. Full details regarding the use and modification of individual
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exercises are reported elsewhere (O’Brien et al. under review). Future research should
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evaluate the efficacy of IPEPs that have been specifically tailored to professional soccer
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settings, along with their effectiveness under real-world conditions.
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It is important to note certain limitations of this study, including the moderate sample size,
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which was dictated by the real-world soccer setting under investigation. Hence, care is
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warranted in extrapolating the results to other populations and settings. The observation
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worksheet was not formally tested for validity or reliability (beyond face validity), but was
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structured on an established, industry-standard IPEP. The coding of FIFA 11+ exercises as
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performed, performed modified or not performed was judged by a single observer and
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proved challenging at times. In particular, it was difficult to decide if certain observed
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exercises should be considered (considerable) modifications of FIFA 11+ exercises, or
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separate exercises, not related to the FIFA 11+. In such cases, the observer erred on the
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side of including the exercises in the category of “performed modified”; this may have
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resulted in an over-estimation of modified FIFA 11+ use. While all staff members provided
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feedback at team meetings, fitness coaches and physiotherapists were more likely to give
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feedback directly following IPEP sessions, due to their role as the primary IPEP deliverers.
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276 Conclusion
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The delivery and content of injury prevention exercise programs used by professional youth
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soccer teams differ significantly to the recommendations in the industry-standard program for
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amateur football, the FIFA 11+. Fitness coaches are the key IPEP deliverers and employ a
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range of different delivery formats, locations and training equipment. The successful
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implementation of IPEPs is influenced by a wide range of facilitators and barriers, relating
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either to the content and nature of the programs (e.g. variation, progression, adaptability), or
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their delivery and support across different ecological levels in the professional youth soccer
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system (e.g. staffing, teamwork, communication). Addressing these factors in the design and
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delivery of future IPEPs will enhance the ultimate real-world impact of IPEPs in this context.
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Practical Implications
Fitness coaches play a key role in the delivery of injury prevention exercise programs (IPEPs) in professional youth soccer.
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The delivery and content of IPEPs for professional soccer need to be tailored
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to fit different training formats, training locations, player ability levels and
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athletic goals.
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A wide range of factors, across multiple levels of professional sport, influence the successful delivery of IPEPs. 14 Page 14 of 23
296 Acknowledgements
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** led this work as part of his PhD studies. He designed the study, led its conduct, had the
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major role in paper writing and is responsible for the overall content. ** and ** contributed to
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the design of the study, interpretation of the data and the writing of the paper. ** is supported
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by a University Scholarship. *** is supported by an NHMRC Principal Research Fellowship
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(ID: 1058737). The Australian Centre for Research into Injury in Sport and its Prevention
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(ACRISP) is one of the International Research Centres for Prevention of Injury and
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Protection of Athlete Health supported by the International Olympic Committee (IOC). ** and
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** have no conflicts of interest that are directly relevant to the content of this paper. ** is
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employed at the professional soccer academy involved in this study. It is possible that the
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author's relationship to academy staff influenced the results.
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308 309
Figure Legends
310 Figure 1: The number of FIFA 11+ exercises performed by four professional youth soccer
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teams in 160 injury prevention sessions.
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injuries in female adolescent football players: secondary analysis of an RCT. Br. J.
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Sports Med. 2013; 47(15):974-979.
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Frank BS, Register-Mihalik J, Padua DA. High levels of coach intent to integrate a
us
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ACL injury prevention program into training does not translate to effective
346
implementation. J. Sci. Med. Sport. 2015; 18(4):400-406.
347
12.
an
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Soligard T, Nilstad A, Steffen K, et al. Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br. J. Sports Med. 2010; 44(11):787-
349
793.
351 352
14.
Donaldson A, Finch CF. Applying implementation science to sports injury prevention.
Br. J. Sports Med. 2013; 47(8):473-475.
15.
355 356
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context for community sport. Br. J. Sports Med. 2010; 44(13):973-978.
353 354
Finch CF, Donaldson A. A sports setting matrix for understanding the implementation
te
13.
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Virginia Polytechnic Institute and State University. 2014 RE-AIM. Available at
http://www.re-aim.org/. Accessed 15 September 2015.
16.
O'Brien J, Finch CF. The implementation of musculoskeletal injury-prevention
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exercise programmes in team ball sports: a systematic review employing the RE-AIM
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framework. Sports Med. 2014; 44(9):1305-1318.
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17.
Norcross MF, Johnson ST, Bovbjerg VE, et al. Factors influencing high school
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coaches' adoption of injury prevention programs. J. Sci. Med. Sport. 2015; 19(4):299-
361
304.
362
18.
Twomey DM, Doyle TL, Lloyd DG, et al. Challenges when implementing an evidencebased exercise injury prevention training program in community-level sport. J App
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Case Studies Sport Ex Sc. 2015; 1(1):29-39. 19.
cr
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Rössler R, Donath L, Bizzini M, et al. A new injury prevention programme for children's football - FIFA 11+ Kids - can improve motor performance: a cluster-
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randomised controlled trial. J. Sports Sci. 2016; 34(6):549-556. 20.
an
368
us
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Hammes D, Aus der Funten K, Kaiser S, et al. Injury prevention in male veteran football players - a randomised controlled trial using "FIFA 11+". J. Sports Sci. 2015;
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33(9):873-881. 21.
McKay CD, Steffen K, Romiti M, et al. The effect of coach and player injury
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knowledge, attitudes and beliefs on adherence to the FIFA 11+ programme in female
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youth soccer. Br. J. Sports Med. 2014; 48(17):1281-1286. 22.
375
Silvers-Granelli H, Mandelbaum B, Adeniji O, et al. Efficacy of the FIFA 11+ injury
prevention program in the collegiate male soccer player. Am. J. Sports Med.
376 377
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Published Online First: 16 September 2015. DOI: 10.1177/0363546515602009.
23.
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Steffen K, Emery CA, Romiti M, et al. High adherence to a neuromuscular injury
prevention programme (FIFA 11+) improves functional balance and reduces injury
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risk in Canadian youth female football players: a cluster randomised trial. Br. J. Sports
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Med. 2013; 47(12):794-802.
381 382
24.
McCall A, Carling C, Nedelec M, et al. Risk factors, testing and preventative strategies for non-contact injuries in professional football: current perceptions and
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383
practices of 44 teams from various premier leagues. Br. J. Sports Med. 2014;
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48(18):1352-1357.
385
25.
O'Brien J, Finch CF. Injury prevention exercise programmes in professional youth soccer: understanding the preceptions of programme deliverers. BMJ Open Sport
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Exerc Med. 2016; 2(e000075): doi:10.1136/bmjsem-2015-000075. 26.
Fédération Internationale de Football Association. 2016 FIFA 11+ a complete warm-
cr
388
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up programme. Available at http://f-marc.com/11plus/home/. Accessed 20 January
390
2016.
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understanding the perceptions of the end-users. Clin. J. Sport Med. 2015; In press.
394
Med. Sport. 2006; 9(1-2):3-9. 29.
396 397 398 399
O'Brien J, Finch CF. A systematic review of core implementation components in team
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Finch C. A new framework for research leading to sports injury prevention. J. Sci.
M
28.
ball sport injury prevention trials. Inj. Prev. 2014; 20(5):357-362. 30.
te
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O'Brien J, Finch CF. Injury prevention exercise programs for professional soccer:
an
27.
Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in
Ac ce p
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us
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various player groups worldwide-a narrative review. Br. J. Sports Med. 2015; 49(9):577-579.
20 Page 20 of 23
400 401
Table 1: The delivery of injury prevention exercise programs (n=160 sessions) in four
402
professional youth soccer teams. Type
Number (%) across 160 sessions
Median (range) across 4 teams
Format of IPEP delivery
warm-up
66 (41)
20 (0-26)
cool-down
11 (7)
2 (0-8)
separate1
69 (43)
14 (9-32)
split2
9 (6)
combination
5 (3)
outdoor pitch
42 (26)
indoor pitch
59 (37)
gym3
6 (4)
2 (0-3)
sports hall4
30 (19)
6 (1-17)
motor skills park5
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1 (0-3) 12 (0-17) 13 (6-27)
1 (1-2)
18 (11)
4 (0-10)
fitness coach
147 (92)
37 (34-39)
physiotherapist
12 (8)
3 (1-5)
soccer coach
1 (1)
0 (0-1)
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deliverer
1 (0-8)
5 (3)
combination Primary IPEP
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Location of IPEP delivery
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Category
Duration of the IPEP warm-up session (minutes) cool-down
35 (12-70)
separate1
46 (15-75)
split2
19 (14-25)
other
66 (19-90)
all sessions
39 (10-90)
25 (10-46)
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Number of active staff
fitness coach
1 (0-2)
physiotherapist
1 (0-2)
soccer coach
0 (0-2)
all staff
2 (1-5)
Number of
4 (0-17)
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players absent Proportion of
16% (0-71)
Squad absent
3 (0-12)
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Number of training equipment types
us
403 1
A session performed separately from soccer training (>15mins prior/post).
405
2
A session performed with the squad split into groups, rotating through injury prevention and
406
an
404
soccer technical/tactical stations. 3
A room with weight-training equipment.
408
4
A large hall used for various sports (e.g. soccer and basketball) and equipped with
409
gymnastic apparatus.
410
5
411
climbing skills.
412
6
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An outdoor training course with multiple stations focusing on strength, balance, agility and
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The staff member who took on the main role of instructing players during the IPEP.
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Figure 1: The number of FIFA 11+ exercises performed by four professional youth
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soccer teams in 160 injury prevention sessions.1
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415 416
1
417
maximum number of FIFA 11+ exercises
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Box Whisker Plot indicating the minimum, 25% quartile, median, 75% quartile and
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S1440-2440(16)30087-1 http://dx.doi.org/doi:10.1016/j.jsams.2016.05.007 JSAMS 1334
To appear in:
Journal of Science and Medicine in Sport
Received date: Revised date: Accepted date:
20-1-2016 1-5-2016 26-5-2016
Please cite this article as: O’Brien J, Young W, Finch CF, The delivery of injury prevention exercise programs in professional youth soccer: comparison to the FIFA 11+., Journal of Science and Medicine in Sport (2016), http://dx.doi.org/10.1016/j.jsams.2016.05.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
The delivery of injury prevention exercise programs in professional youth soccer:
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comparison to the FIFA 11+.
James O’Brien MASc (corresponding author)
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Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) Federation University Australia
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SMB Campus, PO Box 663, Ballarat, VIC 3353 Australia
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[email protected]
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Tel: +43 664 600781093
Associate Professor Warren Young PhD
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Faculty of Health
Federation University Australia
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Australian Centre for Research into Injury in Sport and its Prevention (ACRISP)
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Australia
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SMB Campus, PO Box 663, Ballarat, VIC 3353
Professor Caroline F Finch PhD
Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) Federation University Australia
SMB Campus, PO Box 663, Ballarat, VIC 3353 Australia
Word count structured abstract: 3185 Word count manuscript: 250 Number of Tables: 1 Number of Figures: 1 3
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The delivery of injury prevention exercise programs in professional youth soccer:
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comparison to the FIFA 11+.
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Objectives Injury prevention exercise programs (IPEPs) for amateur soccer have gained
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considerable attention, but little is known about their relevance and adaptability to
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professional soccer settings. The first aim of this study was to evaluate the delivery and
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content of IPEPs used by professional youth soccer teams, compared to the industry
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standard IPEP for soccer, the Fédération Internationale de Football Association’s FIFA 11+.
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The second aim was to document specific challenges to implementing IPEPs in this context.
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Design Prospective observational study.
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Methods The participants were soccer coaches, fitness coaches and physiotherapists
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(n=18) from four teams in a professional youth soccer academy. Each team’s chosen IPEPs
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were observed weekly across an entire soccer season (160 sessions). The delivery and
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content of the programs were documented on a standardised worksheet and compared to
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the FIFA 11+. Specific implementation challenges were recorded.
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Results Fitness coaches were the primary deliverers of IPEPs, with support from
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physiotherapists. Multiple delivery formats and locations were employed, along with the
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extensive use of equipment. Across all IPEP sessions, a median of one FIFA 11+ exercise
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was performed in its original form and a further four in a modified form. Implementation
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challenges included poor staff communication, competing training priorities and heavy game
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schedules.
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Conclusions Although the basic components of the FIFA 11+ hold relevance for
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professional youth male teams, the delivery and content of IPEPs require considerable
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tailoring for this context. Recognising this will inform the development of improved, context-
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specific IPEPs, along with corresponding strategies to enhance their implementation.
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Keywords: injury prevention; implementation; exercise programs; coaches; sport
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29 Introduction
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Soccer is the world’s most popular sport,1 but injuries are both common and associated with
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considerable costs, participation loss, decreased team performance and long-term negative
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side effects.2-4 In recent years, there has been increased research interest in the prevention
34
of soccer injuries, particularly the use of injury prevention exercise programs (IPEPs). The
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efficacy of established IPEPs, including the Fédération Internationale de Football
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Association’s FIFA 11+ and a Swedish IPEP called Knäkontroll, has been demonstrated in
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large-scale randomised controlled trials (RCTs).5, 6 However, it has also been emphasised
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that establishing an IPEP’s efficacy is only one of several steps in successfully preventing
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real-world injuries.7, 8 Recent research has highlighted the challenges of reaching target IPEP
40
audiences, enhancing adoption and ensuring adequate compliance over time.9-11 For
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example, in a trial of the Knäkontroll program in amateur female Swedish teams, players with
42
high compliance experienced an 88% reduction in the rate of Anterior Cruciate Ligament
43
(ACL) injuries, whereas the rate among players with low compliance did not differ
44
significantly from the control group.10 In a further example, Norwegian female players with
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high compliance to the FIFA 11+ program, demonstrated a 35% lower risk of injuries
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compared to players with intermediate compliance levels.12
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To enhance the real-world impact of sports injury prevention interventions, researchers and
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evaluators have begun to embrace implementation frameworks from the broader field of
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health promotion, such as the Reach Effectiveness Adoption Implementation Maintenance
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(RE-AIM) framework.13-15 This framework outlines a range of factors influencing the
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successful translation of evidence-based interventions into real-world practice.15 A recent
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systematic review of team ball sport IPEP trials, employing RE-AIM, demonstrated the
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paucity of current knowledge on implementation factors, particularly relating to aspects of
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adoption and maintenance.16 Other recent RE-AIM studies in soccer settings have
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highlighted the challenge of convincing soccer coaches to adopt IPEPs, perform them as
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intended and maintain them over time.9, 11, 17 In a three-year follow up to the Knäkontroll RCT,
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approximately three-quarters of coaches had modified the original content of the program, or
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had failed to perform it with the prescribed frequency.9 In a study of Oregon high school
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soccer and basketball coaches, 52% were aware of IPEPs, but just 21% reported using one
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and only 9% reported performing the program as originally designed.17
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Recent sports injury prevention implementation research has emphasised that a key first
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step to enhancing an intervention’s success is developing an understanding of the specific
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context in which it is to be delivered.8, 18 The design and delivery of IPEPs require tailoring to
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the specific target setting, with consideration of factors such as player age,19, 20 knowledge
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and beliefs,21 competitive level22 and climate.18, 23 Recent studies have evaluated the
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perceptions of players and staff members towards injury prevention programs within the
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specific setting of professional male soccer24 and professional youth male soccer.25 The
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respondents in these teams expressed strong support for the use of IPEPs, and also
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identified multiple factors influencing the successful implementation of these programs in
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their context. These factors related to both the content and nature of the IPEP itself (e.g.
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exercise variation/progression), and the delivery and support of IPEPs (e.g. staff
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communication and coach acceptance). In professional male teams, only 30% of
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respondents believed that the FIFA 11+ contained adequate progression and variation for
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their context.24 In professional youth male teams, the majority of respondents were aware of
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the FIFA 11+, but fewer than a third actually used it and mostly in a modified form.
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Taken together, the results of the above studies suggest that established IPEPs require
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considerable tailoring for use in professional soccer teams. However, there is currently a lack
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of published information on the content and delivery of IPEPs in these settings.24 Hence, the
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aims of the current study were:
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1)
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To directly observe the delivery and content of IPEPs in a professional youth soccer academy at weekly intervals across an entire season.
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Methods
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The study design was a prospective weekly observation of four teams across one entire
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soccer season. The targeted participants were all soccer coaches, fitness coaches and
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physiotherapists from four professional youth male soccer teams during the 2014/2015
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season. The four teams were all based in a professional European soccer academy and
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were selected based on existing connections to the researchers. Three teams (Under-15,
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Under-16 and Under-18 age groups) were competing in the premier national under-age
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league and one team (Under-23) was competing in the second highest national adult league.
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The teams typically trained 6-7 times per week.
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All participants completed informed consent forms and the study was approved by the
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University Human Research Ethics Committee. Prior to the current study, all consenting
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participants completed a web-based survey, detailing their perceptions of soccer injuries,
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IPEPs in general and the FIFA 11+. Participants were prompted to follow a link in the survey
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to the official FIFA 11+ website, to familiarise themselves with the program. The results of
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this survey have been previously reported.25
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During the pre-season, the first author met with the staff of each team. In a semi-structured
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interview, each teams’ strategy for implementing IPEPs in the coming season was
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discussed. In addition to the planned content of IPEPs, aspects of delivery (e.g. format,
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location and staffing) were discussed.
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Each week, during the 49 week soccer season, the delivery of one IPEP session from each
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of the four teams was randomly selected for observation and documented on a standardised
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worksheet. A block randomisation method was used to ensure a balance in the number of
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observations at different time points across the training week. In cases where block
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randomisation was not possible (e.g. short-term cancellation of the selected session), one of
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the remaining sessions in the week was chosen at random using an online generator
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(www.random.org).
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A standardised data collection sheet (Supplemental file), structured around the industry-
110
standard IPEP for soccer, the FIFA 11+, was developed in Microsoft Excel™. At every
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observation, the team’s use of each FIFA 11+26 exercise was coded by the first author as
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either (1) performed as prescribed, (2) performed modified or (3) not performed. Exercises
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were considered modified when progressions or equipment, other than those outlined in the
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original FIFA 11+,26 were observed. Additionally, the location where the IPEP was delivered
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(e.g. outdoor pitch, gym), the training format (e.g. warm-up, cool-down), the number and type
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of staff members delivering the IPEP (e.g. fitness coach, physiotherapist) and the use of
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equipment (e.g. weights, balance pads) were documented. For each session, staff also
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provided the current number of players in the squad, along with the number and reasons for
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any player absences. Throughout the season, both at staff meetings and following every
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IPEP observation, staff members were asked verbally to explain any facilitators and barriers
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to IPEP implementation. This information was solicited through casual questioning as
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opposed to formal, structured interviews.
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The data from all IPEP observations was summarised and analysed using Microsoft Excel™,
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with all teams combined. The types of IPEP delivery format, types of IPEP delivery location
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and primary IPEP deliverer were summarised descriptively (total number, percentage of all
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observations, mean and range). The primary deliverer was defined as the staff member who
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took on the main role of instructing players during the IPEP. The minimum, 25% quartile,
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median, 75% quartile and maximum number of FIFA 11+ exercises performed, performed
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modified and not performed across all observations in the entire season were calculated. The
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facilitators and barriers to implementing IPEPs, identified by staff members, were categorised
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according to themes identified in earlier studies of professional soccer teams.25, 27
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133 Results
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Eighteen (90%) of the 20 eligible staff members, including nine soccer coaches, four fitness
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coaches and five physiotherapists, agreed to participate. The remaining 2 (10%) cited lack of
137
time as the reason for not participating.
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During the initial team meetings, all four teams reported planning to use IPEPs in the coming
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season and had a defined strategy for the content and delivery of these programs. None of
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the teams intended to use the FIFA 11+ in its original form, but their IPEPs were structured
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on basic exercise components overlapping closely with those of the FIFA 11+ (e.g. strength,
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balance, jumping/landing and core stability). Fitness coaches and physiotherapists decided
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on the program content, with consideration given to player age, published research, injury
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statistics and past experience. Fitness coaches were responsible for delivering the IPEPs,
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while physiotherapists assisted with the supervision and correction of exercises. Head
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coaches ultimately decided on the number and length of IPEPs in each training week, with
147
consideration of the game and training schedule. All teams planned to use multiple delivery
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formats (e.g. warm-up, separate sessions) and multiple delivery locations (e.g. outdoor pitch,
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gym). Incorporating different preventive training cycles across the season (e.g. a cycle
150
focussing on strength) was also considered important. Staff emphasised the need to tailor
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IPEP content to the chosen delivery format (e.g. including more running and dynamic
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stretching exercises in warm-ups).
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Across the 49 week soccer season, 160 IPEP sessions were observed across the four
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academy teams (range per team 35-43). In 28 instances, a team did not perform any IPEP
155
session during a calendar week (range per team 4-12) with the most common reasons being
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season breaks and training interruptions due to heavy game schedules or athletic
157
performance tests. In a further eight instances (range per team 1-3), an observation could
158
not be performed due to short-term changes to the training plan (e.g. the last session in a
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week, randomised for observation, being cancelled by team staff) or the observer being ill/on
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educational leave. Hence, from 168 potential weekly observations, 160 (95%) were
161
completed.
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The observed IPEP format, location, primary deliverer, duration, active staff members, player
163
absences and number of training equipment types per session are summarised in Table 1.
164
---Insert Table 1 here---
165
A median of four players were absent, with the most common reasons being injury, illness,
166
national team/first squad selection and participation in other parallel training sessions (e.g.
167
goalkeeper training). Across all IPEP sessions, a total of 53 different types of training
168
equipment (e.g. balance pads, dumbbells and resistance bands) was observed, with a
169
median of 26 (range 21-30) across the four teams.
170
The number of the 15 FIFA 11+ exercises performed in their original form, performed in a
171
modified form and not performed are summarised in Figure 1. A median of one FIFA 11+
172
exercise was performed in its original form and a further four in a modified form. Examples of
173
modifications included performing squats with added weight and performing single-leg
174
balance exercises on balance pads, while kicking a soccer ball to a partner. Exercises from
175
part two of the FIFA 11+26 (strength, plyometrics and balance) were more frequently
176
performed that exercises from parts one and two of the FIFA 11+ (running exercises). The
177
proportion of total IPEP sessions in which the six exercises in part two were performed,
178
either in original or modified form, ranged from 43-73% (median 65%) across the six
179
exercises. The corresponding figures for the nine running exercises were; range 2-68%
180
(median 21%). Full details regarding the use and modification of each individual FIFA 11+
181
exercise are reported elsewhere (O’Brien et al. under review).
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---Insert Figure 1---
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The participants reported multiple barriers and facilitators to implementing IPEPs
185
(Supplemental file 2) relating either to the content and nature of the programs (e.g. variation,
186
progression, adaptability), or their delivery and support (e.g. staffing, teamwork,
187
communication). Aspects of IPEP delivery and support spanned multiple levels of the
188
professional youth soccer system, including the player (e.g. personality and motivation),
189
team staff (e.g. coach acceptance and staff communication), the club (e.g. sports director
190
acceptance), governing bodies (e.g. game schedules) and the external environment (e.g.
191
weather).
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192 Discussion
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This is the first study to directly observe the implementation of IPEPs in any form of soccer
195
on a weekly basis. This provided a detailed insight into IPEP delivery, content and
196
implementation challenges in a real-world, professional soccer setting. The vast majority of
197
observed sessions were delivered by fitness coaches, using a range of different locations,
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training formats and training equipment. Taken as a median across the season, over a third
199
of the FIFA 11+ exercises were included in the observed IPEP sessions, albeit mostly in a
200
modified form. Team staff provided a comprehensive list of barriers and facilitators to
201
implementing IPEPs, relating either to the program itself, or the delivery and support of
202
IPEPs at different levels of the professional soccer system. The findings of this study will
203
inform the design and delivery of future IPEPs for professional youth soccer, other soccer
204
settings and other team ball sports.
205
The ultimate impact of IPEPs in real-world settings will depend on the efficacy of the
206
programs and the extent to which they are successfully adopted, performed and maintained
207
by the targeted audiences.28 Whilst players are the intended health beneficiaries of IPEPs,
208
the individuals delivering the programs (e.g. team staff) also play a key role in achieving the
209
desired injury-prevention outcomes.29 To date, much of the research on IPEPs has focussed
210
on amateur soccer settings, with coaches being identified as key IPEP deliverers.30 However,
211
as highlighted by this study, fitness coaches are the primary IPEP deliverers in professional
212
soccer settings. Compared to the technical and tactical focus of soccer coaches, fitness
213
coaches are primarily focussed on the physical conditioning of players, and are likely to have
214
different educational backgrounds, injury prevention perceptions and specific training goals.
215
For example, the fitness coaches in this study referred to the published sports science and
216
sports medicine literature to inform the design of their IPEPs and aligned the content/delivery
217
of the programs to athletic goals and training cycles.
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The IPEP delivery formats and delivery locations observed in this study also differ
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considerably to the recommendations in the industry-standard program for amateur soccer,
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the FIFA 11+. Whereas the FIFA 11+ is promoted as an on-pitch, warm-up program requiring
221
minimal equipment,26 the teams in this study employed IPEPs in several formats (e.g. warm-
222
up, separate sessions, split sessions), different settings (e.g. outdoor pitch, indoor pitch,
223
gym) and with extensive use of equipment. The challenges and opportunities arising from
224
these contextual differences in professional soccer settings need careful consideration when
225
planning the design and delivery of future programs.
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The fact that modified FIFA 11+ exercises were frequently incorporated into the IPEPs
227
observed in this study suggests that the certain components of the FIFA 11+ hold relevance
228
for professional youth teams. However, staff emphasised the need for adequate variation
229
and progression of IPEP exercises in professional soccer settings, including
230
fun/challenging/competitive exercises, the use of equipment and different training cycles. The
231
staff also emphasised the importance of IPEP adaptability, with the length and content of
232
programs requiring tailoring to the specific training format (e.g. warm-up vs. cool-down),
233
athletic training goals and the different ability levels of individual players.
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The number and diversity of barriers and facilitators provided by staff highlights both the
235
complexity of the IPEP implementation context and the importance of targeting multiple
236
levels of the professional soccer system when implementing programs. This aligns closely
237
with established implementation frameworks such as the RE-AIM Sports Setting Matrix.13 At
238
the player level, the success of an IPEP will be facilitated by adequate education, motivation
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and more supervision (e.g. more staff or smaller groups). The significant proportion of player
240
absences observed in this study holds implications for IPEP implementation strategies.
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Programs that players can perform separately from the team training may compensate for
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missed team sessions. Staff also require strategies for re-integrating players following
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absences due to injury/illness or involvement with other teams.
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The reported implementation facilitators at the team staff level included communication,
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coach acceptance, staff stability and the team work. The detailed list of factors identified in
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the study builds considerably on previous findings from professional soccer settings25, 27 and
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illustrates the key role of team staff in IPEP implementation. At club level, IPEP acceptance,
248
planning and stability were identified as important factors. Friendly games and tournaments,
249
planned by club officials, can disrupt teams’ regular training schedules, hence limiting the
250
available time for injury prevention. Game scheduling was also the primary facilitator/barrier
251
identified at the level of governing bodies (e.g. leagues and national governing bodies). As in
252
previous IPEP studies,18, 23 weather conditions were reported as a factor influencing IPEP
253
implementation, with favourable weather facilitating variation in the training location and
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performing exercises on the ground. Although the teams in this study had access to indoor
255
facilities, changes to the delivery location (especially short-term) demanded a degree of IPEP
256
adaptability, along with sufficient planning/organisation of shared facilities and equipment.
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Modifications of FIFA 11+ exercises were frequently observed in this study. For example,
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squats were performed with additional weight and unstable surfaces were used to increase
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the difficulty of balance exercises. Full details regarding the use and modification of individual
260
exercises are reported elsewhere (O’Brien et al. under review). Future research should
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evaluate the efficacy of IPEPs that have been specifically tailored to professional soccer
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settings, along with their effectiveness under real-world conditions.
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It is important to note certain limitations of this study, including the moderate sample size,
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which was dictated by the real-world soccer setting under investigation. Hence, care is
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warranted in extrapolating the results to other populations and settings. The observation
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worksheet was not formally tested for validity or reliability (beyond face validity), but was
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structured on an established, industry-standard IPEP. The coding of FIFA 11+ exercises as
268
performed, performed modified or not performed was judged by a single observer and
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proved challenging at times. In particular, it was difficult to decide if certain observed
270
exercises should be considered (considerable) modifications of FIFA 11+ exercises, or
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separate exercises, not related to the FIFA 11+. In such cases, the observer erred on the
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side of including the exercises in the category of “performed modified”; this may have
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resulted in an over-estimation of modified FIFA 11+ use. While all staff members provided
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feedback at team meetings, fitness coaches and physiotherapists were more likely to give
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feedback directly following IPEP sessions, due to their role as the primary IPEP deliverers.
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276 Conclusion
278
The delivery and content of injury prevention exercise programs used by professional youth
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soccer teams differ significantly to the recommendations in the industry-standard program for
280
amateur football, the FIFA 11+. Fitness coaches are the key IPEP deliverers and employ a
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range of different delivery formats, locations and training equipment. The successful
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implementation of IPEPs is influenced by a wide range of facilitators and barriers, relating
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either to the content and nature of the programs (e.g. variation, progression, adaptability), or
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their delivery and support across different ecological levels in the professional youth soccer
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system (e.g. staffing, teamwork, communication). Addressing these factors in the design and
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delivery of future IPEPs will enhance the ultimate real-world impact of IPEPs in this context.
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Practical Implications
Fitness coaches play a key role in the delivery of injury prevention exercise programs (IPEPs) in professional youth soccer.
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The delivery and content of IPEPs for professional soccer need to be tailored
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to fit different training formats, training locations, player ability levels and
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athletic goals.
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A wide range of factors, across multiple levels of professional sport, influence the successful delivery of IPEPs. 14 Page 14 of 23
296 Acknowledgements
298
** led this work as part of his PhD studies. He designed the study, led its conduct, had the
299
major role in paper writing and is responsible for the overall content. ** and ** contributed to
300
the design of the study, interpretation of the data and the writing of the paper. ** is supported
301
by a University Scholarship. *** is supported by an NHMRC Principal Research Fellowship
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(ID: 1058737). The Australian Centre for Research into Injury in Sport and its Prevention
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(ACRISP) is one of the International Research Centres for Prevention of Injury and
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Protection of Athlete Health supported by the International Olympic Committee (IOC). ** and
305
** have no conflicts of interest that are directly relevant to the content of this paper. ** is
306
employed at the professional soccer academy involved in this study. It is possible that the
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author's relationship to academy staff influenced the results.
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308 309
Figure Legends
310 Figure 1: The number of FIFA 11+ exercises performed by four professional youth soccer
312
teams in 160 injury prevention sessions.
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16 Page 16 of 23
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400 401
Table 1: The delivery of injury prevention exercise programs (n=160 sessions) in four
402
professional youth soccer teams. Type
Number (%) across 160 sessions
Median (range) across 4 teams
Format of IPEP delivery
warm-up
66 (41)
20 (0-26)
cool-down
11 (7)
2 (0-8)
separate1
69 (43)
14 (9-32)
split2
9 (6)
combination
5 (3)
outdoor pitch
42 (26)
indoor pitch
59 (37)
gym3
6 (4)
2 (0-3)
sports hall4
30 (19)
6 (1-17)
motor skills park5
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1 (0-3) 12 (0-17) 13 (6-27)
1 (1-2)
18 (11)
4 (0-10)
fitness coach
147 (92)
37 (34-39)
physiotherapist
12 (8)
3 (1-5)
soccer coach
1 (1)
0 (0-1)
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deliverer
1 (0-8)
5 (3)
combination Primary IPEP
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Location of IPEP delivery
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Category
Duration of the IPEP warm-up session (minutes) cool-down
35 (12-70)
separate1
46 (15-75)
split2
19 (14-25)
other
66 (19-90)
all sessions
39 (10-90)
25 (10-46)
21 Page 21 of 23
Number of active staff
fitness coach
1 (0-2)
physiotherapist
1 (0-2)
soccer coach
0 (0-2)
all staff
2 (1-5)
Number of
4 (0-17)
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players absent Proportion of
16% (0-71)
Squad absent
3 (0-12)
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Number of training equipment types
us
403 1
A session performed separately from soccer training (>15mins prior/post).
405
2
A session performed with the squad split into groups, rotating through injury prevention and
406
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404
soccer technical/tactical stations. 3
A room with weight-training equipment.
408
4
A large hall used for various sports (e.g. soccer and basketball) and equipped with
409
gymnastic apparatus.
410
5
411
climbing skills.
412
6
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An outdoor training course with multiple stations focusing on strength, balance, agility and
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407
The staff member who took on the main role of instructing players during the IPEP.
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Figure 1: The number of FIFA 11+ exercises performed by four professional youth
414
soccer teams in 160 injury prevention sessions.1
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413
415 416
1
417
maximum number of FIFA 11+ exercises
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419
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Box Whisker Plot indicating the minimum, 25% quartile, median, 75% quartile and
23 Page 23 of 23