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1 Prevention of running injuries by warm-up, cool-down, and stretching exercises WILLEM van MECHELEN,* MD, PhD, HYNEK HLOBIL,* MD, HAN C. G. KEMPER,* PhD, WIM J. VOORN, PhD, AND H. ROB de JONGH, PhD From the *Department of Health Science, Faculty of Human Movement Sciences, Vrije Universiteit, and the Central Computer Department, and the Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands ABSTRACT The purpose of this study was to evaluate the effect of a health education intervention on running injuries. The intervention consisted of information on, and the subsequent performance of, standardized warm-up, cooldown, and stretching exercises. Four hundred twentyone male recreational runners were matched for age, weekly running distance, and general knowledge of preventing sports injuries. They were randomly split into an intervention and a control group: 167 control and 159 intervention subjects participated throughout the study. During the 16-week study, both groups kept a daily diary on their running distance and time, and reported all injuries. In addition, the intervention group was asked to note compliance with the standardized program. At the end of the study period, knowledge and attitude were again measured. There were 23 injuries in the control group and 26 in the intervention group. Injury incidence for control and intervention subjects was 4.9 and 5.5 running injuries per 1000 hours, respectively. The intervention was not effective in reducing the number of running injuries; it proved significantly effective (P < 0.05) in improving specific knowledge of warm-up and cool-down techniques in the intervention group. This positive change can perhaps be regarded as a first step on the way to a change of behavior, which may eventually lead to a reduction of running injuries. t Address correspondence and repnnt requests to Willem van Mechelen, MD, PhD, Department of Health Science, Faculty of Human Movement Soences, Vnje Universiteit, van der Boechorststraat 7-9, 1081 BT Amsterdam, the Netherlands 711 The popularity of running as a form of exercise and recreation has grown rapidly since the 1970s, first in North America and later in Europe. Reasons for jogging include health and fitness, pleasure or relaxation, and competition or personal performance.lo>3 From a health point of view, benefits from regular physical activity include reduction of risk factors for cardiovascular disease, such as obesity, hypertension, and 5, smoking. On the other hand, runners, as any other athletes, sustain sports injuries. In the Netherlands, van Galen and Diederiks2 performed a telephone survey on sports injury incidence with a 4-week recall period. They used a representative sample of the Dutch population and included all self-reported injuries, both medically treated and not medically treated. Based on their results, calculations were made for injury incident for the total Dutch population. The total number of sports injuries was estimated at 2,700,000. In absolute numbers, running was ranked 4th for the number of injuries incurred, with 126,000 injuries per year (54,000 medically treated), behind outdoor soccer, volleyball, and indoor soccer. If running exposure was taken into account, running was ranked as the 14th injury sport, with 3.6 injuries per 1000 hours of running (44% medically treated). Most running injuries are localized to the lower extremity, with a predominance in the knee.6 1, ,31,33,37,47,48 Running injuries are of a diverse nature and vary, as outlined by Powell et al.,39 from metabolic abnormalities such as anemia, amenorrhoea, hypothermia, and hyperthermia to extrinsic hazards such as dog bites and traffic collisions. However, most running injuries are musculoskeletal injuries associated with overuse. 2,1 15,17,29,36 This is understandable since running involves the constant repetition of the same movements. According to Powell et al.,39 the etiologic factors related to musculoskeletal running injuries can be roughly divided into factors related to the runner, factors related to running, and factors related to the running environment. In relation to sports in general, some authors have sug-

2 712 gested stiffness of the muscles of the lower extremity and subsequent lack of range of motion of adjacent joints as an athlete-related etiologic factor for musculoskeletal injuries. 1,11,19, 22, 36, 41,42 In terms of the prevention of lower extremity injuries, it seems advisable to recommend stretching exercises of muscles of the lower extremity. It is known that hip flexion can be improved by such exercises. 21 In line with stretching exercises, a lack of or improper use of warm-up and cool-down techniques is mentioned as a risk factor for musculoskeletal overuse injuries of the lower extremity in sports in general22,41 and for running in particular. 35,39 Sound epidemiologic evidence for the preventive effect of warm-up, cool-down, and stretching exercises on lower extremity running injuries is scarce and contradictory. Jacobs and Berson,24 as well as IJzerman and van Galen,23 found injured runners stretched significantly more before running than noninjured runners. Jacobs and Berson reported that certain stretching exercises, such as the hurdler stretch, can lead to injury of the medial collateral ligament and to the medial meniscus. Both studies suggested that runners, who are at high risk of sustaining recurrent injury, stretch because they have previous injuries, thereby biasing research results. Walter et al. 41 found runners who &dquo;sometimes&dquo; stretch to be at greater risk for injury, in contrast to runners who &dquo;always, usually, or never stretch.&dquo; They leave this finding unexplained. Blair et al. found that frequency of stretching was not associated with running injuries. Macera et al. 32 found that stretching before running was not associated with running injuries. With regard to warmup, Walter et al. 41 found that runners who say &dquo;they never warm up&dquo; had a significantly smaller risk of running injury compared with runners who say they &dquo;always, usually, or sometimes&dquo; warm up. In the same study, regular use of cool-down exercises was not related to running injuries at all. There may be a negative, rather then a positive, relation between the above-mentioned preventive measures and the risk of lower extremity running injuries, although the findings are inconclusive. The purpose of this study was to investigate the effect of a health education intervention program by which runners were provided with information that encouraged them to perform standardized warm-up, cool-down, and stretching exercises to reduce the incidence of injuries of the lower extremity. Health education by providing information is only effective if it is put forward as a planned strategy. Kok and Bouter2 argued that such a planned strategy should be aimed at a favorable modification of the determinants of health behavior. Kok and Bouter described attitude as an important determinant of healthy behavior. They refer to attitude as the knowledge and beliefs of a person concerning the specific consequences of a certain form of behavior. An attitude is the weighing of all consequences of the performance of the behavior as seen by the individual. Consequently, this study was also aimed at the effect of the health education intervention on knowledge and attitude of runners with respect to the prevention of running injuries in general and with respect to warm-up, cool-down, and stretching exercises in particular. DESIGN AND SUBJECTS Design An experimental black-box design was chosen in which two groups of subjects, a control and an intervention group, are compared with respect to differences in running injury incidence as a direct effect of the health education intervention. Both groups were also compared with regard to differences in knowledge and attitude toward the prevention of running injuries in general and warm-up, cool-down, and stretching exercises in particular as intermediate effects of the health education intervention. We know that age and weekly running distance can be considered important predictors of running injuries.39 We therefore decided to match control and intervention subjects for these two variables. If one assumes that a health education intervention by providing information will lead to the performance of the standardized program of warm-up, cooldown, and stretching exercises, one should realize that this requires a modification of behavior. This process of behavior modification comprises a number of stages that must be completed if any modification is to be achieved.44 These stages are as follows: knowledge modification leads to attitude modification leads to intention modification leads to behavior modification. Since knowledge is the starting point in the chain of events leading to behavior modification, we decided to match control and intervention subjects for their knowledge on the prevention of running injuries as well. Subjects and matching If one assumes a yearly running injury incidence rate of 60%, and if the intervention should lead to a significant (25%) reduction of injury incidence rate,45 both the control and intervention groups should contain at least 237 subjects by the end of the experiment if a one-tailed chi-square test was to be applied.4 To recruit such a number of subjects for this study, 32,506 questionnaires were sent to all civil servants employed by the city of Amsterdam, with a request to participate in a study on running; 1057 questionnaires were returned from 982 men and 75 women. For reasons of homogeneity and because of the relatively small number of responding women, we decided to exclude all female volunteers. The responses of 463 civil servants met the criteria set to enter the study: healthy, no current injury, not home from work on sick leave, running at least 10 km/week all year-round, not performing sports as a part of their profession (police officers and firefighters were excluded), and written consent to participate in the study. Age and estimated weekly running distance for these subjects were gathered from the questionnaire. To facilitate the matching procedure, we had to first assess the level of

3 713 knowledge on the prevention of running injuries of each subject. This was done using a knowledge and attitude questionnaire, which was mailed to all 463 volunteers; 421 questionnaires were returned. From the questionnaire, a knowledge and attitude score was calculated, but only the knowledge score was used for matching. Subsequently, 421 subjects entered the matching procedure (Fig. 1). Classes were defined in such a way that for each variable the number of subjects in every class was approximately equal. Subjects were subdivided into three classes for estimated weekly running distance: 10 to 18 km/week (N 126), 19 to 32 km/week (N 146), and 32 km/week or more (N149). Subjects were also subdivided into 3 classes for age: born after October 1, 1953 (N 129), born between October 1, 1946 and September 30, 1953 (N 155), born before October 1, 1946 (N 137). Finally, subjects were subdivided into 5 classes depending on their score on the knowledge questionnaire. Consequently, 45 different cells (3 x 3 x 5) were filled with a minimum of 2 to a maximum of 18 subjects (Table 1). From each cell, subjects were randomly selected for the intervention (N 210) or the control group (N 211). METHODS General outline of the experiment The intervention was aimed at a change of behavior by providing information with regard to warm-up, cool-down, and stretching exercises. If such an intervention is to be effective, the &dquo;message&dquo; should meet criteria like attracting attention, simplicity, recognizability, and clarity. Also, the estimated reliability of the sender of the message is important, as well as the fact that the proposed behavior should not greatly deviate from the current behavior of the recipient of the message.26 The actual intervention was planned taking these factors into account. Figure 1. Flow chart representing the selection of subjects. TABLE 1 Distribution of subjects according to estimated weekly running distance and knowledge of prevention of running injuries&dquo; a Knowledge 1 very low, knowledge 5 very high; details. see text for After matching, all subjects from the intervention group received a booklet with written instructions on the standardized program. This booklet was specially prepared for use in this study with the help of the coach of the Dutch National Marathon team and several other experts. During each of 4 evenings, about 50 to 60 subjects were instructed by the same coach on why and how to perform the program. All exercises were practiced in a gymnasium to make sure that all subjects had understood the contents of the intervention. Then a 16-week intervention period started, which lasted from September 12, 1988 until January 1, All subjects were asked to continue running in the same way as they had done before the start of the intervention and they were asked to keep a daily diary on running distance, running time, and the occurrence of a running injury. They were also asked to record their daily compliance with the program: whether warm-up, cool-down, and stretching exercises were performed in the prescribed way. This obligation to write down daily compliance was part of the intervention strategy and can be regarded as a &dquo;cue to action.&dquo;14 Diaries covered four 4-week periods and were mailed to and from subjects. At the end of the 16-week intervention period, postintervention knowledge and attitude scores were assessed in both the control and intervention groups using the same knowledge and attitude questionnaire used to obtain the baseline scores. In addition to this questionnaire, the control group was asked to fill in a supplementary questionnaire on their warm-up, cool-down, and stretching behavior during the intervention period. To enhance continuous participation of all subjects throughout the experiment, all subjects were given a t-shirt and a subscription to the monthly magazine, Runners. Knowledge and attitude questionnaire A questionnaire measuring knowledge of and attitude toward the prevention of running injuries was constructed on the

4 714 basis of a literature survey.35 The initial knowledge questionnaire contained 79 questions that were scored on a 3- point scale (3 points for &dquo;true,&dquo; 2 points for &dquo;don t know,&dquo; and 1 point for &dquo;false&dquo;) and 45 attitude questions that were scored on a 5-point scale varying from 5 points for &dquo;total agreement&dquo; to 1 point for &dquo;total disagreement&dquo; with an attitude statement. This questionnaire was tested for validity and reliability in a pilot study 12 according to a method described by Swanborn.43 This method applies principles as described by Ebel.16 The final version of the knowledge and attitude questionnaire as it was used in this intervention study contained 56 knowledge questions and 31 attitude questions. Neither part of the questionnaire contained questions with an item-rest correlation coefficient of less than 0.20 (this means that the correlation coefficient of each item with the total score was at least 0.2). Cronbach s alpha of the knowledge part of the questionnaire was 0.89 and of the attitude part From the questionnaire, the following seven scores were calculated: 1) general knowledge of the prevention of running injuries, 2) specific knowledge of warm-up exercises, 3) specific knowledge of stretching exercises, 4) specific knowledge of cool-down exercises, 5) general attitude toward the prevention of running injuries, 6) specific attitude toward warmup, and 7) specific attitude toward cooldown. Intervention The content of the intervention, as described in the booklet and as explained during the instruction evening, was based on a literature survey.35 The intervention consisted of a warmup of 6 minutes of running exercises, 3 minutes of loosening exercises, and 10 minutes of stretching to be performed before each running session. The stretching exercises included three bouts (10 seconds each) of static stretching of the iliopsoas and quadriceps muscles, the hamstrings, and the soleus and gastrocnemius muscles. A cooldown after each running session consisted of the inverse of the warmup. Stretching exercises were performed as outlined above twice a day regardless of running performance. Injury registration A running injury was defined as any injury that occurred as a result of running and caused one or more of the following: 1) the subject had to stop running, 2) the subject could not run on the next occasion, 3) the subject could not go to work the next day, 4) the subject needed medical attention, or 5) the subject suffered from pain or stiffness during 10 subsequent days while running. Any injury that met this definition was to be noted in the daily running diary. Every injury was also to be reported by a special postage-paid reply form. Every reported injury was seen by one of the two physicians involved in the project. Location, injured structure, type of injury, and most likely medical diagnosis were noted. In case of a reported injury, a subject was excluded from reentering the study. All diary data gathered after the reported date of onset of injury were excluded from data analysis. Data analysis Incidence was calculated taking exposure into account and expressed as the number of newly sustained running injuries per 1000 hours of running. If applicable, overall differences between the intervention and control group were analyzed by applying a two-tailed t-test, a chi-square test, or by calculating a relative risk and its 95% confidence interval. Differences in baseline attitude scores between the control and intervention group were tested by applying a two-tailed t-test. The effect of the intervention was assessed by analyzing differences per cell by means of a one-tailed sign test between the control and intervention group with regard to injury incidence per exposure. The effect of the intervention was also assessed by applying the same procedure for differences between baseline and postintervention delta values with regard to knowledge and attitude scores. For all tests, P < 0.05 was considered statistically significant. RESULTS All materials (diaries and questionnaires) were returned by 168 control and 159 intervention subjects. However, at the end of the intervention 1 cell contained only 1 control subject, which made comparisons between control and intervention values for this cell impossible. For this reason, this cell and its subject were excluded from data analysis at cell level, thereby reducing the number of cells from 45 to 44. Whenever data analysis was performed at group level the results of this subject were included. Consequently, results from 167 control and 159 intervention subjects distributed over 44 cells were analyzed at cell level, and results from 168 control and 159 intervention subjects were analyzed at group level. The total drop-out rate after 16 weeks was 94/421 x 100% 22.3%. In Table 2, overall descriptive values of running performance are summarized for the control and intervention groups. None of the variables show any statistically significant (Student s t-test, P > 0.05) difference between the control and intervention groups. The average runner in this study ran about 2.7 times a week for 8.8 km per session at a speed of 12.4 km/hr. Table 3 summarizes compliance with the prescribed intervention as reported by daily diary by the intervention group. Table 4 summarizes information from the control group on the performance of warm-up, cool-down, and stretching exercises during the intervention period. This information was obtained at the end of the intervention period by questionnaire. Since the two methods of data collection with regard to the performance of warm-up, cool-down, and stretching exercises during the intervention period were different for both groups, the results from Tables 3 and 4 can only be globally compared. The tables show that in both groups a

5 TABLE 2 Mean and standard deviation of running variables as written down a by subjects during the 16-week intervention period&dquo; Differences between the intervention and control groups were tested by a two-tailed t-test. (No comparisons showed significant difference, P > 0.05.) TABLE 3 Compliance with intervention by the study group (N 159)a Data derived from daily diaries. TABLE 4 Performance of warm-up, cool-down, and stretching exercises among the control group (N 167) form of warmup and cooldown was performed by about 90% of the runners, whereas a form of daily stretching exercises was performed by about 58% of the runners. Forty-nine injuries, 23 in the control group and 26 in the intervention group, were registered in the diaries. Of these 49 injuries, 44 were also reported by means of a postagepaid injury reply form and subsequently evaluated. This means that no information on the nature and location of the injury was available from 5 subjects. From these 5 subjects, we know only the date on which they reported themselves in the daily diary as being injured. Injury incidence analysis was performed using data referring to the 49 injuries as registered in the diaries. There were no significant differences between these 2 groups (chisquare 0.45, df 1, P > 0.05). For both groups, injury incidence was calculated taking exposure into account. In the control group, 4.9 injuries per 1000 hours of running (95% confidence limit: 3.1 to 7.4) were calculated, and in the intervention group 5.5 injuries per 1000 hours of running (95% confidence limit: 3.6 to 8.0); the relative risk for injury was 1.12 (95% confidence limit: 0.56 to 2.72). To evaluate the effect of the intervention program, the injury incidence per 1000 hours of running was calculated per cell for both the intervention and the control groups. In 13 cells the injury incidence of the control subjects exceeded the injury incidence of the intervention subjects, in 14 cells the opposite was found, and in 17 cells no difference was found with regard to injury incidence between groups. By applying a one-tailed sign test, these differences proved not significant (P > 0.05). We concluded that the intervention program did not result in a reduction of the incidence of running injuries per 1000 hours of running. Differences in injury pattern between the control and intervention groups were analyzed by a chi-square test (P < 0.05 is significant) using information from the 44 evaluated injuries. No differences were found between the intervention and control groups with regard to all registered variables: location of injury, injured anatomic structure, medical diagnosis, and nature of injury (acute versus overuse and recurrence of injury). The locations of the 44 evaluated injuries are presented in Table 5. All injuries were equally distributed on the left and right sides of the body. The injured anatomic structures were: muscle (11), tendon (9), joint (9), tendon-muscle (8), tendonbone (4), bone (2), and skin (1). The distribution of the most likely medical diagnosis was as follows: strain (16), inflammation (11), sprain (3), blister (1), chondromalacia (3), miscellaneous (3), and diagnosis not clear (3). Seventy-five percent of the injuries were classified as overuse injuries that had developed over the course of hours or days; 25% of the injuries were classified as acute. Thirty percent of the runners had sustained a similar injury some time during their running careers. Mean data of both groups were calculated for six knowledge and attitude questionnaire scores. The general knowledge score is not included because the subjects were matched on this score over the control and intervention groups. Analysis by means of a two-tailed t-test proved that the differences between the intervention and the control groups were not significant (P > 0.05) concerning baseline score for which the two groups were not directly matched (baseline score general attitude, baseline score specific knowledge of warming up, baseline score specific knowledge of cooling down, baseline score specific knowledge of stretching exer- TABLE 5 Localization of 44 evaluated injuries

6 716 cises, baseline score specific attitude toward warming up, and baseline score specific attitude toward cooling down). We concluded that at baseline there were no differences between the intervention and control groups with respect to general attitude and specific knowledge and attitude scores. The effect of the intervention was also assessed by analyzing the difference per cell between the intervention and control groups with respect to general and specific knowledge and attitude scores. For both groups per cell the mean difference (delta score) between the baseline and postintervention scores was calculated for each questionnaire variable. In Table 6, the mean difference (delta score) between baseline and postintervention scores is summarized for each variable. From Table 6 we concluded that, except for specific knowledge scores of stretching exercises by subjects in the intervention group, all knowledge and attitude scores in both groups had improved at the end of the intervention in comparison with the score at baseline measurement. The improvement of scores of the intervention group with regard to specific knowledge about warming up, specific knowledge about cooling down, specific attitude toward warming up, and specific attitude toward cooling down was significantly greater when compared with the improvement of scores of the control group. We identified, per cell, whether this mean difference (delta score) was in favor of the intervention or the control group or whether there was no difference between both groups with respect to the mean difference (delta score) between baseline and postintervention scores. The differences in mean difference (delta score) were then analyzed for significance by means of a one-tailed sign test. The results of this procedure are summarized in Table 7. We concluded that, in comparison with the control group, the intervention program had led to a significant improvement of specific knowledge of warming up and cooling down in the subjects of the intervention group., DISCUSSION This study was aimed at a change of behavior of runners with regard to warm-up, cool-down, and stretching exercises. An important prerequisite in this study is the assumption that there is a positive relationship between preventive behavior (i.e., warm-up, cool-down, and stretching exercises) and injury prevention. If this prerequisite is valid, one must conclude that the intervention in this study has not been successful since there was no significant effect on the incidence of running injuries per 1000 hours of running at the level of the matched cells or at group level. Yet, since the study concerned a health education intervention in which the provision of information played a major role, the effect of the intervention can also be judged at the level of the matched cells from changes in knowledge and attitude of the runners with respect to the prevention of running injuries in general and from changes in knowledge and attitude with respect to the specific preventive measures related to the desired change in behavior. We can therefore conclude that the intervention has been successful, given the significant improvement of the specific knowledge scores of warmup and cooldown in the subjects of the intervention group compared with the control group. None of the other measured differences between baseline and postintervention knowledge and attitude scores showed a significant difference between the control and intervention groups. From the standpoint of health education by providing information,&dquo; this improvement of knowledge of warmup and cooldown can be regarded as a positive effect of the intervention. Some remarks with regard to the effects of the intervention must be made. Damoiseaux 13 has argued that the extent of the modifying effect of health education by providing information depends on the way in which the information is provided to the target group: on an individual (person-toperson) basis, on a group basis, or on a mass media basis (Table 8). In the present study, the information was provided on a group basis by means of a booklet and an evening of instruction. The improvement of knowledge with regard to warmup and cooldown, but not of attitude or of injury incidence, is in line with the modifications one may expect if health education information is provided on a group basis. Other factors that influence the effect of this kind of health education intervention are who provides the information and whether the provided information &dquo;appeals&dquo; to the recipients. Ooijendijk and van Agt37 conducted a study on running injury prevention. Two hundred fifty-six men and 60 women with an average age of 39 years and an TABLE 6 Mean value and standard deviation of the difference (A score) between the baseline and postintervention scores for each questionnaire variable for both the control and intervention group Small differences in numbers of subjects (N) within each group are because of missing values on some questionnaire scores not significant. b P >

7 717 TABLE 7 Comparison of A scores between the control and the intervention groups Figures given are number of cells in which the score differed. b NS, not significant. TABLE 8 Effect of modifying effecta The X indicates the maximal expected extent of the modifying effect of health education by providing information with respect to the modification of knowledge, attitude or of behavior, depending on how the subject is approached. Adapted from Damoiseaux.l3 average weekly running distance of 30 km served as subjects. These runners were asked by questionnaire if they wanted to obtain information on injury prevention and, if so, in what way and from what person. Seventy-six percent of the runners were interested in information on injury prevention: 78% wanted to obtain information from leaflets and 40% by oral instruction given by either a fellow runner (61%) or a coach (41%). In light of these results it seems valid to conclude that the way of providing information in our study (booklet in combination with an instructional group session using a well-known coach as instructor) must have appealed to our subjects, thereby not hindering the transfer of information. The aim of our study was to bring about a reduction in the incidence of running injuries by the performance of a standardized behavior concerning warm-up, cool-down, and stretching exercises. From the results as presented in Tables 3 and 4, we concluded that in both the intervention and control groups a form of warmup and cooldown was performed by about 90% of the runners, whereas a form of daily stretching exercises was performed by about 58% of the runners. On the basis of this finding, one should question whether the aim of the study in terms of a change in behavior with regard to warm-up, cool-down, and stretching exercises to prevent running injuries, was a realistic one to start if the same proportion of the control and intervention group show a more or less similar behavior. From the study of Ooijendijk and van Agt,37 we know that most runners (93%) perform some sort of warmup. In their study, 88% of the subjects performed stretching exercises as a part of the warmup, and 64% performed a cooldown. From a preventive point of view, it seems better to focus future health education intervention strategies on behavior that is not already conducted &dquo;naturally&dquo; to such an extent as warm-up, cool-down, and stretching exercises, such as the early detection of symptoms of overuse injuries, full rehabilitation after injury to avoid the recurrence of injury, and the distribution of training load (running frequency, weekly running distance, and running speed). These factors are important predictors of running injury.32,33,47 We know of only 2 large-scale prospective studies concerning running injuries. In the study by Macera et all monthly diaries were used as a method of data collection. In their 1-year study, data were analyzed on all subjects who returned 80% of their monthly diaries, including the last diary. The drop-out rate in this study was 39% (310 male subjects). In our study, with a drop-out rate of 22.3%, data were analyzed only from subjects who had all diaries and questionnaires present at the end of the study. When comparing these two drop-out rates, it should also be noted that the Macera et al. study lasted 1 year and our study lasted 16 weeks. In a 1-year prospective study by Walter et al., 47 data were collected by telephone survey 4, 8, and 12 months after the start of the study. In their study, 88% of all planned telephone contacts took place. In light of these two prospective studies, the drop-out rate in our study seems acceptable. The drop-out rate may have been influenced by the fact that the intervention took place at the end of autumn and the beginning of winter when weather condition are usually not as good as spring and summer. However, a recent national survey on sports participation conducted in the Netherlands showed that participation in recreational running is not much influenced by the season. 21 The runners in this study were all men who ran on the average about 2.7 times a week for 8.8 km per session at a speed of 12.4 km/hr. If compared with the populations of other studies, the average runner in our study can be considered as representing the recreational runner who runs for pleasure and health rather than for competition, and who participates in an organized roadrun every now and then 6,20,28,32,33,37 Although many researchers in the field of sports etiology research advise taking exposure to sports participation into account,3,7,25.30,31,34,46.49 this is seldom the case. We know of only 3 studies regarding running that calculate injury incidence per 1000 hours of running. van Galen and Diederiks2

8 718 found in their retrospective national survey an overall incidence for self-reporting running injuries of 3.6 per 1000 hours of running. Lysholm and Wiklander 31 performed a 1- year prospective study with competitive male and female runners from various disciplines: sprint, middle-distance, and marathon. They found incidences for running injuries varying from 5.8 injuries per 1000 hours of running for sprinters to 2.5 injuries per 1000 hours of running for marathon runners. Finally, Bovens et al. found, in a prospective study of 58 men (average age, 35 years), injury incidences varying with average weekly running distance from 12.1 injuries per 1000 hours of running (average weekly running distance, 24 km/week) to 7.0 injuries per 1000 hours of running (average weekly running distance, 44 km/week). The injury incidences in the present study fall within the range of incidences found in the above-cited studies. However, it should be kept in mind that these figures may be difficult to compare because of differences in definitions and research methods.3 No attempt was made to compare the injury pattern found in this study with the pattern found in other studies since potential differences between studies can be explained by differences in definitions and research methods, as well as by research outcome. 3 CONCLUSIONS 1. In a 16-week prospective intervention study in which subjects were matched for age, weekly running distance, and general knowledge regarding the prevention of running injuries, the running injury incidence was found to be 4.9 injuries per 1000 hours of running for the control group and 5.5 injuries per 1000 hours of running for the intervention group. 2. A health education intervention, consisting of providing information by means of booklet and an instructional group session aimed at a change of behavior with regard to warmup, cool-down, and stretching exercises, did not result in a reduction of running injury incidence expressed per hours of running exposure. The intervention did lead to a positive change of specific knowledge with regard to warmup and cooldown. No further knowledge or attitude changes were observed. In terms of health education by providing information, this change can be regarded as a positive effect of the intervention. 3. Regardless of the intervention, 90% of both the intervention and control group performed some form of warmup and cool-down exercises, whereas some sort of daily stretching exercises was performed by about 58% of the runners. It therefore seems advisable not to focus the prevention of running injuries by a modification of behavior a modification of with regard to these measures, but by behavior with regard to the early detection of symptoms of overuse injuries, full rehabilitation after injury to avoid the recurrence of injury, and the distribution of training load. ACKNOWLEDGMENTS This study was funded by the Dutch Ministry of Health Welfare and Cultural Affairs as the Dutch contribution to a coordinated research project of the Council of Europe: &dquo;sports for All: Sports Injuries and Their Prevention.&dquo; This study was also financially supported by the Municipal Health Authority of the city of Amsterdam and by Sportcom, publisher of Runners monthly magazine. The authors express their gratitude to Mrs. Inge Crolla, MSc, for her work as research assistant. REFERENCES 1 Agre JC Hamstring injuries Proposed aetiological factors, prevention and treatment. 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9 719 ZA (eds) Voorlichting en sportblessures Rijswijk, Ministry of Health, 1986, pp Kok G, Bouter LM On the importance of planned health education Prevention of ski injury as an example Am J Sports Med , Koplan JP, Powell KE, Sikes RK, et al An epidemiological study of the benefits and risks of running JAMA , Lehman WL. Overuse syndromes in runners Am Fam Physician , Loes M de, Goldie K Incidence rate of injuries during sport activity and physical exercise in a rural Swedish municipality Incidence rates in 17 sports Int J Sports Med , Lysholm J, Wiklander J Injuries in runners Am J Sports Med , Macera CA, Pate RR, Powell KE, et al Predicting lower-extremity injuries among habitual runners Arch Intern Med , Marti B, Vader JP, Minder CE, et al On the epidemiology of running injuries Am J Sports Med , Mechelen WV 25 jaar schade door sport Geneeskunde en Sport 23(5) , Mechelen WV, Hlobil H, Kemper HCG How Can Injuries Be Prevented? NISGZ publication no 25E Oosterbeek, Netherlands Institute of Sports Health Care, Mirking G The prevention and treatment of running injuries J Am Podiatr Med Assoc , Ooijendijk WTM, van Agt L Preventie van hardloopblessures Geneeskunde en Sport 23(4) , Paffenbarger RS, Hyde RT Exercise in the prevention of coronary heart disease Prev Med , Powell KE, Kohl HW, Caspersen CJ, et al An epidemiological perspective on the causes of running injuries Physician Sportsmed 14(6) , Rumke CL, With C de De grootte van groepen bij het vergelijken van twee percentages of twee kansen NTVG , Safran MR, Seaber AV, Garrett WE Warm-up and muscular injury preventon. An update Sports Med , Shellock FG, Prentice WE Warming-up and stretching for improved physical performance and prevention of sports-related injuries Sports Med 2: , Swanborn PG Schaaltechnieken, Theone en praktijk van acht eenvoudige procedures Meppel, Boom, Vent de TGM, Hlobil H, Mechelen WV Sports injuries prevention by information and education a preparative study Report No 51, Consumer Safety Institute, Amsterdam, November Vulpen AV Sport for All Sport Injuries and Their Prevention Oosterbeek, Council of Europe, Netherlands Institute of Sports Health Care, Oosterbeek, Wallace RB Application of epidemiologic principles to sports injury research Am J Sports Med 16 S22-S24, Walter SD, Hart LE, Mcintosh JM, et al The Ontano Cohort Study of running-related injuries Arch Intern Med , Watson MD, DiMartino PP Incidence of injuries in high school track and field athletes and its relation to performance ability Am J Sports Med , Wiktorsson-Moller M, Oberg B, Ekstrand J, et al Effects of warming up, massage, and stretching on range of motion and muscle strength in the lower extremity Am J Sports Med , 1983

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