From control to causation: Validating a 'complex systems model' of running-related injury development and prevention.

INTRODUCTION: There is a need for an ecological and complex systems approach for better understanding the development and prevention of running-related injury (RRI). In a previous article, we proposed a prototype model of the Australian recreational distance running system which was based on the Systems Theoretic Accident Mapping and Processes (STAMP) method. That model included the influence of political, organisational, managerial, and sociocultural determinants alongside individual-level factors in relation to RRI development. The purpose of this study was to validate that prototype model by drawing on the expertise of both systems thinking and distance running experts. MATERIALS AND METHODS: This study used a modified Delphi technique involving a series of online surveys (December 2016- March 2017). The initial survey was divided into four sections containing a total of seven questions pertaining to different features associated with the prototype model. Consensus in opinion about the validity of the prototype model was reached when the number of experts who agreed or disagreed with survey statement was ≥75% of the total number of respondents. RESULTS: A total of two Delphi rounds was needed to validate the prototype model. Out of a total of 51 experts who were initially contacted, 50.9% (n = 26) completed the first round of the Delphi, and 92.3% (n = 24) of those in the first round participated in the second. Most of the 24 full participants considered themselves to be a running expert (66.7%), and approximately a third indicated their expertise as a systems thinker (33.3%). After the second round, 91.7% of the experts agreed that the prototype model was a valid description of the Australian distance running system. CONCLUSION: This is the first study to formally examine the development and prevention of RRI from an ecological and complex systems perspective. The validated model of the Australian distance running system facilitates theoretical advancement in terms of identifying practical system-wide opportunities for the implementation of sustainable RRI prevention interventions. This 'big picture' perspective represents the first step required when thinking about the range of contributory causal factors that affect other system elements, as well as runners' behaviours in relation to RRI risk.

Developing a contributing factor classification scheme for Rasmussen's AcciMap: Reliability and validity evaluation.

One factor potentially limiting the uptake of Rasmussen's (1997) Accimap method by practitioners is the lack of a contributing factor classification scheme to guide accident analyses. This article evaluates the intra- and inter-rater reliability and criterion-referenced validity of a classification scheme developed to support the use of Accimap by led outdoor activity (LOA) practitioners. The classification scheme has two levels: the system level describes the actors, artefacts and activity context in terms of 14 codes; the descriptor level breaks the system level codes down into 107 specific contributing factors. The study involved 11 LOA practitioners using the scheme on two separate occasions to code a pre-determined list of contributing factors identified from four incident reports. Criterion-referenced validity was assessed by comparing the codes selected by LOA practitioners to those selected by the method creators. Mean intra-rater reliability scores at the system (M = 83.6%) and descriptor (M = 74%) levels were acceptable. Mean inter-rater reliability scores were not consistently acceptable for both coding attempts at the system level (MT1 = 68.8%; MT2 = 73.9%), and were poor at the descriptor level (MT1 = 58.5%; MT2 = 64.1%). Mean criterion referenced validity scores at the system level were acceptable (MT1 = 73.9%; MT2 = 75.3%). However, they were not consistently acceptable at the descriptor level (MT1 = 67.6%; MT2 = 70.8%). Overall, the results indicate that the classification scheme does not currently satisfy reliability and validity requirements, and that further work is required. The implications for the design and development of contributing factors classification schemes are discussed.

A framework for the etiology of running-related injuries.

The etiology of running-related injury is important to consider as the effectiveness of a given running-related injury prevention intervention is dependent on whether etiologic factors are readily modifiable and consistent with a biologically plausible causal mechanism. Therefore, the purpose of the present article was to present an evidence-informed conceptual framework outlining the multifactorial nature of running-related injury etiology. In the framework, four mutually exclusive parts are presented: (a) Structure-specific capacity when entering a running session; (b) structure-specific cumulative load per running session; (c) reduction in the structure-specific capacity during a running session; and (d) exceeding the structure-specific capacity. The framework can then be used to inform the design of future running-related injury prevention studies, including the formation of research questions and hypotheses, as well as the monitoring of participation-related and non-participation-related exposures. In addition, future research applications should focus on addressing how changes in one or more exposures influence the risk of running-related injury. This necessitates the investigation of how different factors affect the structure-specific load and/or the load capacity, and the dose-response relationship between running participation and injury risk. Ultimately, this direction allows researchers to move beyond traditional risk factor identification to produce research findings that are not only reliably reported in terms of the observed cause-effect association, but also translatable in practice.

The use and modification of injury prevention exercises by professional youth soccer teams.

The efficacy of injury prevention exercise programs (IPEPs) for amateur youth soccer has been established, but little is known about their adaptability to other soccer populations. This study aimed to assess the use of individual injury prevention exercises by professional youth soccer teams, against the industry-standard, FIFA 11+ program. Four teams' chosen IPEPs were observed across one season and documented on a standardized form. The use of each FIFA 11+ exercise was coded as "performed", "performed modified" or "not performed". The proportion of the 160 observed sessions containing each individual exercise was calculated. Staff provided reasons for their use and modification of FIFA 11+ exercises. On average, individual FIFA 11+ exercises were conducted in original form in 12% of the sessions (range 0-33%), and in modified form in 28% of sessions (range 2-62%). The five most frequently observed exercises, in either original or modified form, were "bench" (72%), "squats" (69%), "running straight" (68%), "single-leg stance" (66%), and "sideways bench" (64%). Staff modified exercises to add variation, progression, and individualization, and to align with specific training formats and goals. Professional youth soccer teams often use injury prevention exercises similar to those in the FIFA 11+, but tailor them considerably to fit their implementation context.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for primary prevention of osteoarthritis by joint injury prevention in sport and recreation.

The risk of post-traumatic osteoarthritis (PTOA) substantially increases following joint injury. Research efforts should focus on investigating the efficacy of preventative strategies in high quality randomized controlled trials (RCT). The objective of these OARSI RCT recommendations is to inform the design, conduct and analytical approaches to RCTs evaluating the preventative effect of joint injury prevention strategies. Recommendations regarding the design, conduct, and reporting of RCTs evaluating injury prevention interventions were established based on the consensus of nine researchers internationally with expertise in epidemiology, injury prevention and/or osteoarthritis (OA). Input and resultant consensus was established through teleconference, face to face and email correspondence over a 1 year period. Recommendations for injury prevention RCTs include context specific considerations regarding the research question, research design, study participants, randomization, baseline characteristics, intervention, outcome measurement, analysis, implementation, cost evaluation, reporting and future considerations including the impact on development of PTOA. Methodological recommendations for injury prevention RCTs are critical to informing evidence-based practice and policy decisions in health care, public health and the community. Recommendations regarding the interpretation and conduct of injury prevention RCTs will inform the highest level of evidence in the field. These recommendations will facilitate between study comparisons to inform best practice in injury prevention that will have the greatest public health impact.

The incidence and burden of hospital-treated sports-related injury in people aged 15+ years in Victoria, Australia, 2004-2010: a future epidemic of osteoarthritis?

OBJECTIVES: Previous sports injury is a known risk factor for subsequent osteoarthritis (OA), but population-based rates of sports injury are unknown. The aims of this study were to: (1) describe the trends in the population incidence and burden of all hospital-treated sports injury in Victoria, Australia in adults aged 15+ years; (2) determine the incidence of lower limb and knee injuries; and (3) quantify their population health burden as average direct hospital costs per injury and lengths of stay. METHODS: Health sector data relating to adults aged 15+ years, for 2004-2010 inclusive, was extracted from the Victorian Admitted Episodes Dataset (VAED) and Victorian Emergency Minimum Dataset (VEMD). Data relating to sports injuries were identified using activity codes in each dataset Trends in injury frequency and rates were determined, and economic burden was calculated. RESULTS: The overall annual rate of hospital treated sports injuries increased by 24% (P = 0.001), and lower limb injuries by 26% (P = 0.001) over the 7 years. The associated accumulated economic burden was $265 million for all sports injuries and $110 million for lower limb injuries over the 7-years. CONCLUSIONS: The findings of this study show a significant increase in sports injuries in the state of Victoria, Australia over a 7-year period. As previous sports injury is a risk factor for the development of OA, the future incidence of OA will escalate, placing an even greater burden on health care systems. Population-wide preventative strategies that reduce the risk of sports injury are urgently required in order to reduce the future burden of OA.

Injury surveillance in community sport: Can we obtain valid data from sports trainers?

A lack of available injury data on community sports participants has hampered the development of informed preventive strategies for the broad-base of sports participation. In community sports settings, sports trainers or first-aiders are well-placed to carry out injury surveillance, but few studies have evaluated their ability to do so. The aim of this study was to investigate the reporting rate and completeness of sports trainers' injury records and agreement between sports trainers' and players' reports of injury in community Australian football. Throughout the football season, one sports trainer from each of four clubs recorded players' injuries. To validate these data, we collected self-reported injury data from players via short message service (SMS). In total, 210 discrete injuries were recorded for 139 players, 21% by sports trainers only, 59% by players via SMS only, and 21% by both. Completeness of injury records ranged from 95% to 100%. Agreement between sports trainers and players ranged from K = 0.32 (95% confidence interval: 0.27, 0.37) for date of return to football to K = 1.00 for activity when injured. Injury data collected by sports trainers may be of adequate quality for providing an understanding of the profile of injuries. However, data are likely to underestimate injury rates and should be interpreted with caution.

Changes in muscle activation following balance and technique training and a season of Australian football.

OBJECTIVES: Determine if balance and technique training implemented adjunct to 1001 male Australian football players' training influenced the activation/strength of the muscles crossing the knee during pre-planned and unplanned sidestepping. DESIGN: Randomized Control Trial. METHODS: Each Australian football player participated in either 28 weeks of balance and technique training or 'sham' training. Twenty-eight Australian football players (balance and technique training, n=12; 'sham' training, n=16) completed biomechanical testing pre-to-post training. Peak knee moments and directed co-contraction ratios in three degrees of freedom, as well as total muscle activation were calculated during pre-planned and unplanned sidestepping. RESULTS: No significant differences in muscle activation/strength were observed between the 'sham' training and balance and technique training groups. Following a season of Australian football, knee extensor (p=0.023) and semimembranosus (p=0.006) muscle activation increased during both pre-planned sidestepping and unplanned sidestepping. Following a season of Australian football, total muscle activation was 30% lower and peak valgus knee moments 80% greater (p=0.022) during unplanned sidestepping when compared with pre-planned sidestepping. CONCLUSIONS: When implemented in a community level training environment, balance and technique training was not effective in changing the activation of the muscles crossing the knee during sidestepping. Following a season of Australian football, players are better able to support both frontal and sagittal plane knee moments. When compared to pre-planned sidestepping, Australian football players may be at increased risk of anterior cruciate ligament injury during unplanned sidestepping in the latter half of an Australian football season.

An anterior cruciate ligament injury prevention framework: incorporating the recent evidence.

Anterior cruciate ligament (ACL) injury rates have increased by ∼50% over the last 10 years. These figures suggest that ACL focused research has not been effective in reducing injury rates among community level athletes. Training protocols designed to reduce ACL injury rates have been both effective (n = 3) and ineffective (n = 7). Although a rationale for the use of exercise to reduce ACL injuries is established, the mechanisms by which they act are relatively unknown. This article provides an injury prevention framework specific to noncontact ACL injuries and the design of prophylactic training protocols. It is also apparent that feedback within this framework is needed to determine how biomechanically relevant risk factors like peak joint loading and muscular support are influenced following training. It is by identifying these links that more effective ACL injury prevention training programs can be developed, and, in turn, lead to reduced ACL injury rates in the future.

Air temperature and the incidence of fall-related hip fracture hospitalisations in older people.

UNLABELLED: Observation-driven Poisson regression models were used to investigate mean daily air temperature and fall-related hip fracture hospitalisations. After adjustment for season, day-of-week effects, long-term trend and autocorrelation, hip fracture rates are higher in both males and females aged 75+ years when there is a lower air temperature. INTRODUCTION: This study investigated whether there was an association between fall-related hip fracture hospitalisations and air temperature at a day-to-day level, after accounting for seasonal trend and autocorrelation. METHODS: Observation-driven Poisson regression models were used to investigate mean daily air temperature and fall-related hip fracture hospitalisations for the period 1 July 1998 to 31 December 2004, inclusive, in the Sydney region of New South Wales, Australia, which has a population of 4 million people. RESULTS: Lower daily air temperature was significantly associated with higher fall-related hip fracture hospitalisations in 75+-year-olds: men aged 75-84 years, rate ratio (RR) for a 1°C increase in temperature of 0.98 with 95% confidence interval (0.96, 0.99), men 85+ years RR = 0.98 (0.96, 1.00), women 75-84 years RR = 0.99 (0.98, 1.00), women 85+ years RR = 0.98 (0.97, 0.99). Moreover, there were fewer hospitalisations on weekends compared to weekdays ranging from RR = 0.81 (0.73, 0.90) in women aged 65-74 years to RR = 0.89 (0.80, 0.98) in men aged 85+ years. CONCLUSIONS: After adjustment for season, day-of-week effects, long-term trend and autocorrelation, fall-related hip fracture hospitalisation rates are higher in both males and females aged 75+ years when there is a lower air temperature.

Functional data modelling approach for analysing and predicting trends in incidence rates--an application to falls injury.

SUMMARY: Policy decisions about the allocation of current and future resources should be based on the most accurate predictions possible. A functional data analysis (FDA) approach improves the understanding of current trends and future incidence of injuries. FDA provides more valid and reliable long-term predictions than commonly used methods. INTRODUCTION: Accurate information about predicted future injury rates is needed to inform public health investment decisions. It is critical that such predictions derived from the best available statistical models to minimise possible error in future injury incidence rates. METHODS: FDA approach was developed to improve long-term predictions but is yet to be widely applied to injury epidemiology or other epidemiological research. Using the specific example of modelling age-specific annual incidence of fall-related severe head injuries of older people during 1970-2004 and predicting rates up to 2024 in Finland, this paper explains the principles behind FDA and demonstrates their superiority in terms of prediction accuracy over the more commonly reported ordinary least squares (OLS) approach. RESULTS: Application of the FDA approach shows that the incidence of fall-related severe head injuries would increase by 2.3-2.6-fold by 2024 compared to 2004. The FDA predictions had 55% less prediction error than traditional OLS predictions when compared to actual data. CONCLUSIONS: In summary, FDA provides more accurate predictions of long-term incidence trends than commonly used methods. The production of FDA prediction intervals for future injury incidence rates gives likely guidance as to the likely accuracy of these predictions.

A sports setting matrix for understanding the implementation context for community sport.

There has been increasing recognition of the need for effectiveness research within the real-world intervention context of community sport. This is important because, even if interventions have been shown to be efficacious in controlled trials, if they are not also widely adopted and sustained, then it is unlikely that they will have a public health impact. There is very little information about how to best conduct such studies, but application of health promotion frameworks, such as the RE-AIM framework, to evaluate the public health impact of interventions could potentially help to understand the implementation context. Care needs to be taken when directly applying the RE-AIM framework, however, because the definitions for each of its dimensions will depend on the level/s the intervention is targeted at. This paper provides a novel extension to the RE-AIM framework (the RE-AIM Sports Setting Matrix (RE-AIM SSM)), which accounts for the fact that many sports injury interventions need to be targeted at multiple levels of sports delivery. Accordingly, the RE-AIM components also need to be measured across all tiers of possible influence on the rate of uptake and effectiveness. Specific examples are given for coachdelivered exercise training interventions. The RE-AIM SSM is specific to the community sports setting implementation context and could be used to guide the delivery of future sports safety, and other health promotion, interventions in this area.

Head, face and neck injury in youth rugby: incidence and risk factors.

OBJECTIVES: In this study, the incidence of head, neck and facial injuries in youth rugby was determined, and the associated risk factors were assessed. DESIGN: Data were extracted from a cluster randomised controlled trial of headgear with the football teams as the unit of randomisation. No effect was observed for headgear use on injury rates, and the data were pooled. SETTING: General school and club-based community competitive youth rugby in the 2002 and 2003 seasons. PARTICIPANTS: Young male rugby union football players participating in under-13, under 15, under 18 and under 21 years competitions. Eighty-two teams participated in year 1 and 87 in year 2. MAIN OUTCOME MEASURES: Injury rates for all body regions combined, head, neck and face calculated for game and missed game injuries. RESULTS: 554 head, face and neck injuries were recorded within a total of 28 902 h of rugby game exposure. Level of play and player position were related to injury risk. Younger players had the lowest rates of injury; forwards, especially the front row had the highest rate of neck injury; and inside backs had the highest rate of injuries causing the player to miss a game. Contact events, including the scrum and tackle, were the main events leading to injury. CONCLUSION: Injury prevention must focus on the tackle and scrum elements of a youth rugby game.

Methodological approaches used to assess the relationship between parental supervision and child injury risk.

OBJECTIVE: To describe and rate the quality of methodological approaches used to measure parental supervision in relation to injury risk in children aged 0-14 years. DESIGN: A systematic review of the literature related to supervision and injury risk. METHODS: A comprehensive search of electronic databases from the earliest records available to the end of 2007, and supplemental hand-searching of relevant journals, reference lists of studies identified through database searches, and bibliographies of systematic and non-systematic reviews. A classification scale was used to rate the methodological quality of studies. RESULTS: 30 papers met the inclusion criteria. They varied substantially in quality, and no meta-analyses or randomised controlled trials were identified. Fifteen studies used self-report approaches, asking parents or care givers to report through recording diaries, interviews and questionnaires and were considered of low quality; 11 studies reconstructed injury outcomes retrospectively. Observational studies were conducted in both laboratory and natural settings (n = 6), and these studies were generally of higher quality than self-report methods. CONCLUSIONS: The quality of many supervision and child injury risk studies is low to moderate. Further development of methodological approaches is needed to improve studies of the relationship between supervision and child injury risk.

Spatial temporal modeling of hospitalizations for fall-related hip fractures in older people.

UNLABELLED: The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization and sociodemographic data. There was significant spatial temporal variation in hospitalized hip fracture rates in New South Wales, Australia. INTRODUCTION: The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization data. METHODS: All New South Wales (NSW), Australia residents aged 65+ years who were hospitalized for a fall-related hip fracture between 1 July 1998 and 30 June 2004 were included. Bayesian Poisson regression was used to model rates in local government areas (LGAs), allowing for the incorporation of spatial, temporal, and covariate effects. RESULTS: Hip fracture rates were significantly decreasing in one LGA, and there were no significant increases in any LGAs. The proportion of the population in residential aged care facilities was significantly associated with the rate of hospitalized hip fractures with a relative risk (RR) of 1.003 (95% credible interval 1.002, 1.004). Socioeconomic status was also related to hospitalized hip fractures with those in the third and fourth quintiles being at decreased risk of hip fracture compared to those in the least disadvantaged (fifth) quintile [RR = 0.837 (0.717, 0.972) and RR = 0.855 (0.743, 0.989) respectively]. CONCLUSIONS: There was significant spatial temporal variation in hospitalized hip fracture rates in NSW, Australia. The use of Bayesian methods was crucial to allow for spatial correlation, covariate effects, and LGA boundary changes.

Relative survival after hospitalisation for hip fracture in older people in New South Wales, Australia.

UNLABELLED: Survival after hospitalisation for hip fracture by age group and sex relative to survival in the general population was assessed in people aged 65+. Men had double the risk of death compared with women to 1 year, but age effects lasted only to 3 months. Clinical outcomes need to be improved. INTRODUCTION: We assessed the relative survival of hospitalised fall-related hip fracture patients aged 65+ years leaving hospital in New South Wales, Australia, between July 2000 and December 2003. METHOD: We carried out a population-based study of all hospital separations for NSW residents with a principal diagnosis of hip fracture (ICD-10-AM S72.0 to S72.2) and first external cause of fall (ICD-10-AM codes W00 to W19), linked to NSW death data. A total of 16,836 cases were included. Relative survival 3 to 36 months post-admission by 10-year age groups and sex was calculated, using NSW life tables for 2002-2004. Relative excess risk was modelled using a generalised linear model with Poisson error structure, using the life table data. RESULTS: One-year cumulative relative survival in 65- to 74-year-olds was 82% (men), 90% (women); in 85+-year-olds 65% (men), 80% (women). Men have a relative excess risk of death of 2.2 (95% CI 2.03-2.38) times that of women. Only 21% of deaths mention the hip fracture as contributing to death. CONCLUSION: There is a need to reduce the number of hip fractures and improve clinical outcomes for older people hospitalised with hip fractures.

Do inadequacies in ICD-10-AM activity coded data lead to underestimates of the population frequency of sports/leisure injuries?

AIMS: To assess the use of the International Classification of Diseases Australian Modification (ICD-10-AM) activity sub-codes for identifying sports/leisure injury hospitalizations and the impact of missing codes on population incidence estimates. METHODS: Injury-related hospital separations in New South Wales, Australia, for the period 2003-04 were examined with sports/leisure cases identified by the ICD-10-AM activity codes. RESULTS: Over 30% of all injury hospitalizations had either a missing or unspecified activity code. Among cases with valid activity codes, 13.9% of all injury hospitalizations were associated with sports/leisure. When adjusted for underreporting associated with undefined or missing activity codes, sports/leisure injuries accounted for up to 20% of injury hospitalizations. CONCLUSION: Defining sports/leisure injury cases on the basis of activity codes is likely to lead to an underestimate of their contribution to the overall injury burden. Improvements need to be made to the completeness of activity coding of hospitalization data.

Use of field-based tests to identify risk factors for injury to fast bowlers in cricket.

OBJECTIVE: To identify risk factors for injury to cricket fast bowlers using field-based tests. DESIGN: Prospective cohort study. SETTING: High performance Australian cricket. PARTICIPANTS: Ninety-one male adolescent and adult fast bowlers (aged 12-33 years). ASSESSMENT OF RISK FACTORS: A field-based pre-participation screening, consisting of musculoskeletal, fitness and anthropometric assessments and analysis of bowling technique was undertaken. Bowlers were prospectively monitored over the 2003-4 season and bowling workload and injuries were recorded. Logistic regression was used to identify injury risk factors. MAIN OUTCOME MEASUREMENT: Repetitive microtrauma injury to the trunk, back or lower limb associated with fast bowling. RESULTS: Two variables were identified as independent predictors of injury in the multivariate logistic regression analysis. Bowlers with hip internal rotation of < or =30 degrees on the leg ipsilateral to the bowling arm were at a significantly reduced risk of injury (OR 0.20, 95% CI 0.06 to 0.73) compared with bowlers with >40 degrees of rotation. Bowlers with an ankle dorsiflexion lunge of 12.1-14.0 cm on the leg contralateral to the bowling arm were at a significantly increased risk (OR 4.03, 95% CI 1.07 to 15.21) than bowlers with a lunge of >14 cm. Bowlers with a lunge of < or =12 cm were also at an increased risk, but not significantly so (OR 1.38, 95% CI 0.40 to 4.84). CONCLUSIONS: Biomechanical research is needed to investigate how these two intrinsic risk factors increase injury risk so that appropriate interventions can be developed.

Injuries to junior club cricketers: the effect of helmet regulations.

OBJECTIVE: Despite the popularity of cricket at the junior community level, few studies have described injuries for this level of play. This study describes the epidemiology of cricket injuries in junior club cricket across three playing seasons to identify priorities for prevention. DESIGN: Prospective on-field injury data collection during match observation of acute injuries. Pre and post observational evaluation of mandatory helmet wearing. SETTING: The Sutherland Shire Junior Cricket Association, New South Wales, Australia during the 2002-03, 2003-04 and 2004-05 playing seasons. PARTICIPANTS: All junior teams (Under 8 (U8)-U16). INTERVENTION: Compulsory headgear introduced for all batters before the 2004-05 season. MAIN OUTCOME MEASURES: Frequency of injury according to age level, grade of play and playing position, and injury rates per 100 registered players. RESULTS: 155 injuries were reported. No U8 player sustained an injury, and injury frequency increased with age. Traditional cricket was associated with more injuries than modified cricket. At each age level, the most skilled players had the lowest frequency of injury. Overall, batting accounted for 49% of all injuries and 29% occurred when fielding; contact with a moving ball was responsible for 55% of injuries. The most commonly injured body region was the face (20%), followed by the hand (14%). In batters, the frequency of head/neck/facial injuries fell from 62% in 2002/03 to 35% in 2003-04 to just 4% in 2004-05 after headgear use was compulsory. CONCLUSIONS: Injury rates in junior players are low, but increase with age and level of play. Use of protective headgear, particularly by batters, leads to a significant reduction in injuries.