Lower Limb Preventive Training Program Best Practice and Implementation

Transcription

1 @_hjroot Lower Limb Preventive ing Program Best Practice and Implementation Arizona Athletic ers Association 41 st Annual Winter Symposium January 27, 2018 Hayley J. Root, PhD, MPH, ATC Post-Doctoral Research Fellow Pediatric Sports Medicine Learning Objectives 1. Discuss the current state of evidence for preventive training programs (s) 2. Describe the 7-Steps for successful design and development 3. Prepare strategies for implementation in different sportspecific or setting-specific scenarios Current Evidence 7-Step Implementation Current Evidence Sport- & Setting-Specific Strategies 3 1

2 New NATA Position Statement CURRENT EVIDENCE Current Evidence 7-Step Implementation Sport- & Setting-Specific Strategies NATA Position Statement 5 2

3 Injury Risk, Injury Rate, and Sport-Performance CURRENT EVIDENCE Current Evidence 7-Step Implementation 6 Sport- & Setting-Specific Strategies What is a Preventive ing Program? min pre-participation dynamic warm-up Components typically include: - Flexibility - Balance - Agility - Plyometrics - Core Strength - Sport-specific movements Emphasis on feedback/cuing à improving neuromuscular control 7 3

4 Set-Up Yellow to Red Cones ~10 yards or to the freethrow line Dynamic Exercise Red to Blue Cones ~10 yards or to half court Progressive jog to run Blue to Yellow Back to starting line Recovery jog 8 Benefits: Injury Rate When controlling for time to complete warm-up, equipment needs, and compliance there are consistent ~50-75% reductions in lower extremity injury rates for COACH-LED s Author Year Population Mandelbaum 2005 Youth, female soccer Kiani 2010 Youth, female soccer LaBella 2011 HS female basketball and soccer Walden 2012 Youth, female soccer 9 4

5 Benefits: Injury Risk Decrease knee valgus moment Myer (2005), Myer (2007), Chappell (2008), Zebis (2008) Hamstrings:Quadriceps Ratio Chimera (2004), Holcomb (2007), Lim (2009) Stability/Balance Paterno (2004), Holm (2004), DiStefano (2010) Movement Technique Zebis (2008), DiStefano (2009), DiStefano (2011) 10 Benefits: Sport Performance IPPs can improve performance measures such as vertical jump height. (DiStefano 2010) Youth athletes Improvement in sport-specific skills (Barbara- Westin) Junior tennis players 6-week program 11 5

6 Benefits Correlate with Compliance Outcomes are linked to compliance (Sugimoto 2012) Adoption, implementation, and maintenance of interventions is directly related to how well the intervention can be integrated into a local context (Feldstein 2008, Chor 2015) ~20% of coaches implement s (Norcross 2015, Joy 2013) 12 7-STEPS FOR SUCCESSFUL DESIGN AND DEVELOPMENT Current Evidence 7-Step Implementation Sport- & Setting-Specific Strategies 13 6

7 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 14 Establish istrative Creating a common ground of understanding Negative effects of injury Positive effects of injury prevention What is success? Establishing mutually beneficial goals and appropriate metrics Permission for implementation ers 15 7

8 ers Strategies: Establish istrative Player Durability Win/Loss % Relative Advantage 16 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 17 8

9 Interdisciplinary Include stakeholders at different levels improves feasibility and odds of longterm maintenance Coaches / Players Parents / Strength and Conditioning ers 18 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 19 9

10 ers Barriers and Duration Session Frequency personnel ers Time Personnel Organization Environment Goals Current Behaviors Equipment Location Padua (2014) 20 ers Barriers and : Time Program duration Frequency of dosage per week Duration of season Program effectiveness is directly related to program dosage (Padua 2012, Sugimoto 2014) 10

11 ers Barriers and : Personnel Head Coach Assistant Coach Captain Player Self-Guided Athletic er Not just who will implement but who will be there to train and support? ers Barriers and : Personnel Theory of Planned Behavior (Ajzen 1991) Knowledge Beliefs Attitudes Norms Self-Efficacy Intentions Skill BEHAVIOR 11

12 ers Barriers and : Environment Equipment Space Sport-specific constraints Military setting 24 ers Barriers and : Organization Relative Advantage (Norcross 2015) Current program? Perceptions of Fatigue (Root 2014) Role of screening high risk (Gilchrist 2008) Program customization v. generalization What programs work for who, when, and under which circumstances? 12

13 ers Barriers and Duration Session Frequency personnel ers Time Personnel Organization Environment Goals Current Behaviors Equipment Location Padua (2014) 26 ers Strategies: Barriers and Pre-mortem Analysis Silent Brainwriting Imagine that the program has failed Write down own list for 5-10 minutes Put paper in center, take another person s list, and then agree or add thoughts Debrief and create comprehensive list of barriers with multiple solutions (Gilmartin 2017) 27 13

14 ers Example: Barriers and Identified Barrier Time Solution(s) Total program should take minutes upon mastery of format Focus on a few key exercises to begin with and add more exercises with each practice Have more athletes perform the exercise at one time 28 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 29 14

15 ers an Evidence-Based No magic program FIFA 11+ (Junge 2002, Sadigursky 2017) Other Programs (Sugimoto 2015, Taylor 2015) 30 an Evidence-Based Key Components ers - Flexibility - Balance - Agility - Plyometrics - Core Strength - Sport-specific movements Options to pro- and regress exercises 31 15

16 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 32 ers ing the ers How do we encourage autonomous behavior change? Adoption: does the team start implementing a : extent to which program is followed (are exercises performed as prescribed?) Maintenance: long-term compliance 33 16

17 ers ing the ers What would a workshop look like? Education materials (web based or mail) (Hewett 1999, Steffen 2008) In-person training (Junge 2002, LaBella 2011, Mandelbaum 2005, Pfeiffer 2006, Soligard 2008, Steffen 2008, Steffen 2013, Walden 2012) 34 ers ing the ers In-Person ing Considerations: Who are you training? One-time preseason workshop as effective as a workshop plus expert help throughout season (Steffen 2013) Tailored v. Targeted Strategies Positive effect in health and wellness strategies and medical school curricula (Linnan 2015, von Pressentin 2016) 35 17

18 ers ing the ers Example: Youth Soccer and Basketball (Root, unpublished) Targeted Workshop: education on general behavior determinants found to be relevant for a coaching population Tailored Workshop: used setting-specific needsassessment to determine barriers, facilitators, and needs to focus on during the workshop 36 ers ing the ers Educational Techniques to Include: Discourse (Malone 2011) Social Cognitive Theory (Bandura 1989) Understand positive and negative consequences Observe the behavior Actively practice the behavior (DiStefano 2018) 37 18

19 ers ing the ers Effectiveness Regular Feedback Alignment Injury Risk Injury Rates Performance Self-Efficacy Knowledge/ Positive Attitude (Padua 2014) 38 ers ing the ers Effectiveness Regular Feedback Alignment Organizational Goals Implementation constraints? Self-Efficacy Knowledge/ Positive Attitude (Padua 2014) 39 19

20 ers ing the ers Effectiveness Regular Feedback Alignment Who? What? When? Where? Why? Self-Efficacy Knowledge/ Positive Attitude (Padua 2014) 40 ers ing the ers Effectiveness Regular Feedback Alignment Ability and confidence to perform exercises and implement Self-Efficacy Knowledge/ Positive Attitude (Padua 2014) 41 20

21 ers ing the ers Effectiveness Regular Feedback Alignment Simple, positive reinforcement and ways to improve Self-Efficacy Knowledge/ Positive Attitude (Padua 2014) 42 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 43 21

22 ers Low fidelity linked to poor outcomes (Carow 2016) LEADERSHIP Cadre Performance Score A. Platoon set in correct formation (expanded spacing B. All Instructors correctly demonstrate exercises C. All Instructors maintain good cadence (slower is better) D. Cadre are mobile in platoon and provide general coaching cues E. Cadre are moving to cadets with many errors and provide targeted coaching cues Leadership Score (Sum of Scores for A-E) (Padua 2014) 44 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 45 22

23 ers an If the experts leave, what happens? Who will champion the ideas? Re-assess and update during off-season Implement Determine Improvements Measure, Analyze, & Assess Feedback 46 7-Step Framework (Padua 2014) the ers and Users 4. an Evidence-Based 3. Logistical Barriers and 2. an Interdisciplinary 1. Establish istrative 47 23

24 7-Step Framework (Padua 2014) Understand the evidence, align your goals, and communicate early, often, and effectively. 48 SPORT- AND SETTING- SPECIFIC STRATEGIES Current Evidence 7-Step Implementation Sport- & Setting-Specific Strategies 49 24

25 What does implementation look like? Youth Sports Expert-Led Coach-Led Adolescent Athletes AAU Basketball High School Sports Military 50 How do we measure success? Athlete-based measures Injury Risk Injury Rate Sport Performance Perceptions and feedback from program implementors 51 25

26 Landing Error Scoring System (LESS) 52 Landing Error Scoring System (LESS) (Padua 2015) 53 26

27 YOUTH SPORTS SPORT- AND SETTING- SPECIFIC STRATEGIES Current Evidence 7-Step Implementation 54 Sport- & Setting-Specific Strategies Youth Sports: Considerations Diversity of coaches: Age, sex, etc. Years of experience playing the sport Years of experience coaching the sport Level of time commitment 55 27

28 Youth Sports: Expert-Led Research Outline Does a preventive training program with simplified cuing improve injury risk and performance? (DiStefano, In Preparation) Population: 420 Youth Soccer Athletes Outcomes: Injury Risk: Landing Error Scoring System Performance: Standing Long Jump, Y-Balance Time points: PRE, POST, Retention 1, Retention 2 56 Youth Sports: Expert-Led Implementation Structure Pre-season meeting with league directors Pre-season meeting with all coaches Top Down Expert trained in implementation came to every practice throughout the season Coaches had no requirement or expectation to either assist in implementation or in performing the warm-up 57 28

29 Youth Sports: Coach-Led Research Outline Does a coach s previous experience with preventive training programs influence effectiveness of s? (Pryor 2017) Population: 89 Coaches of Youth Athletes and 90 Youth Soccer Athletes Outcomes: Injury Risk: Landing Error Scoring System Performance: Standing Long Jump Compliance: Compliance and of prescribed 58 Youth Sports: Expert-Led Implementation Structure Pre-season meeting with league directors Pre-season meeting with all coaches Bottom Up Optional pre-season 1-hour long workshop with coaches Experts checked in once per month to monitor and provide feedback if necessary/requested Athletes reduced injury risk (as measured by the Landing Error Scoring System) after 8-week season 59 29

30 Youth Sports: Lessons Learned Find champions for your cause Parents, coaches, league administrators, etc. Create feedback loops and encourage dialogue to ensure synergy of goals Make programs fun and memorable Example: Exercise names Technology and material needs Electronic versions, hard copies, etc. 60 ADOLESCENT SPORTS SPORT- AND SETTING- SPECIFIC STRATEGIES Current Evidence 7-Step Implementation 61 Sport- & Setting-Specific Strategies 30

31 Adolescent Athletes: AAU Basketball Research Structure Does a tailored preventive training program influence injury risk and performance measures in an adolescent female basketball population? Population: AAU Organization (~10 teams) Outcomes: Injury Risk: Landing Error Scoring System (Overall Score, High/Low Risk) Performance: Agility Other Outcomes: Injury Rate, Injury History, Sport History 62 Adolescent Athletes: AAU Basketball Research Results LESS Score Mean Difference ( # errors) LESS Score Mean Difference by Risk Group Overall High Risk (PRE LESS >5 errors) Low Risk (PRE LESS < 5 errors) 63 31

32 Adolescent Athletes: AAU Basketball Implementation Structure Pre-season meetings with league administrators Pre-season screening of all athletes to identify muscle imbalances and movement deficits by team Single leg squat Double leg squat Jump landing task Agility run -based warm-ups were created to specifically address team needs 64 Adolescent Athletes: AAU Basketball Implementation Structure 65 32

33 Adolescent Athletes: AAU Basketball Implementation Structure Expert was assigned to each team and implemented warm-up with a tapered schedule: 1x / week for first 3 weeks 1x every other week for next month 1x every 2-3 weeks depending on team needs for remainder of season During implementation, head and assistant coaches watched, asked questions, and demonstrated different components of the warm-up. 66 AAU: Lessons Learned Motivated coaches will find ways and strategies to make the program fit their plans Find what motivates your population Competing at a high level and remaining injury free 67 33

34 Adolescent Athletes: High School Athletics Implementation Structure Pre-season meeting with athletic director to gain permission Individual meetings with coaches for each of the fall sports Needs-assessment per team based on: current warm-up structure, coach goals, environment constraints, etc. Created team-based warm-up for each sport and monitored bi-weekly for compliance 68 High School: Lessons Learned Each coach will create an independent culture for their team but administrative support is vital for scheduling Formatting and marketing may vary between teams Football v. Volleyball v. Field Hockey 69 34

35 MILITARY SPORT- AND SETTING- SPECIFIC STRATEGIES Current Evidence 7-Step Implementation 70 Sport- & Setting-Specific Strategies Military Setting Implementation Structure (Padua 2014) ing the trainers Who then trained the trainers Limited amount of time and space Exercises done in place Need for synchronicity Exercises done to a cadence Feedback provided daily Dimeinjuryprevention.weebly.com 71 35

36 Military: Lessons Learned Top-Down support is vital Compromise and adaptability are possible 72 SUMMARY 73 36

37 Current Evidence s have been shown to reduce injury risk and injury rate, as well as improve sport performance in a variety of populations. However, outcomes are linked to program compliance and dosage. Current Evidence 7-Step Implementation Sport- & Setting-Specific Strategies 74 Implementation 1. Establish administrative support 2. interdisciplinary team 3. barriers and solutions 4. evidence-based 5. the trainers Current Evidence 7-Step Implementation Sport- & Setting-Specific Strategies 75 37

38 Sport- and Setting-Specific Strategies Understand the goals and needs of your sport or general setting Understand the value of two-way, reciprocal feedback to always improve Empower autonomous implementation Current Evidence 7-Step Implementation Sport- & Setting-Specific Strategies Thank you. 38

39 References Norcross MF, Johnson ST, Bovbjerg VE, Koester MC, Hoffman MA. Factors influencing high school coaches' adoption of injury prevention programs. J Sci Med Sport Joy EA, Taylor JR, Novak MA, Chen M, Fink BP, Porucznik CA. Factors influencing the implementation of anterior cruciate ligament injury prevention strategies by girls soccer coaches. J Strength Cond Res. 2013;27(8): References Slauterbeck JR, Reilly A, Vacek PM, et al. Characterization of Prepractice Injury Prevention Exercises of High School Athletic s. Sports Health. 2017: Pryor JL, Root HJ, Vandermark LW, et al. Coach-led preventive training program in youth soccer players improves movement technique. J Sci Med Sport. 2017;20(9): Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4): Chor KHB, Wisdom JP, Olin S-CS, Hoagwood KE, Horwitz SM. Measures for predictors of innovation adoption. Adm Policy Ment Health Ment Health Serv Res. 2015;42(5): Junge A, Rosch D, Peterson L, Graf-Baumann T, Dvorak J (2002) Prevention of soccer injuries: a prospective intervention study in youth amateur players. Am J Sports Med 30 (5): Sugimoto D, Myer GD, Foss KD, Hewett TE (2015) Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in young females: meta-analysis and subgroup analysis. Br J Sports Med 49 (5): doi: / bjsports Taylor JB, Waxman JP, Richter SJ, Shultz SJ (2015) Evaluation of the effectiveness of anterior cruciate ligament injury prevention programme training components: a systematic review and meta-analysis. Br J Sports Med 49 (2): doi: /bjsports Sadigursky D, Braid JA, De Lira DNL, Machado BAB, Carneiro RJF, Colavolpe PO. The FIFA 11+ injury prevention program for soccer players: a systematic review. BMC Sports Sci Med Rehabil. 2017;9:18. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR (1999) The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med 27 (6): Labella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK (2011) Effect of Neuromuscular Warm-up on Injuries in Female Soccer and Basketball Athletes in Urban Public High Schools: Cluster Randomized led Trial. Arch Pediatr Adolesc Med 165 (11): doi: /archpediatrics Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, Kirkendall DT, Garrett W, Jr. (2005) Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 33 (7): doi: /

40 References Pfeiffer RP, Shea KG, Roberts D, Grandstrand S, Bond L (2006) Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am 88 (8): Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini M, Junge A, Dvorak J, Bahr R, Andersen TE (2008) Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ 337:a2469. Carow SD, Haniuk EM, Cameron KL, Padua DA, Marshall SW, DiStefano LJ, de la Motte SJ, Beutler AI, Gerber JP (2016) Risk of Lower Extremity Injury in a Military Cadet Population After a Supervised Injury-Prevention Program. J Athl 51 (11): doi: /