The 11+ injury prevention programme decreases rate of hamstring strain injuries in male collegiate soccer players.

OBJECTIVES: To investigate if the 11+ injury prevention programme decreases the risk of hamstring injury and improves recovery time and determine whether compliance with the 11+ affects hamstring injury risk. METHODS: This study is a secondary analysis from a prospective cluster randomised controlled trial that included 65 National Collegiate Athletic Association (NCAA) division I and II men's soccer teams over the fall 2012 season. Thirty-one teams were randomised to the intervention group that were using the 11+ as their warm-up and 35 teams to the control group that continued to use their traditional warm-up. Each certified athletic trainer (ATC) collected data on demographics, hamstring injury (HSI), mechanism of injury, position, playing surface, time lost due to injury and compliance to the 11+ programme. RESULTS: The 11+ decreased the risk of HSI by 63% compared with the control group (RR=0.37, 95% CI 0.21 to 0.63). Difference in return to play after HSI between the control (9.4±11.2 days) and intervention groups (10.2±11.3 days) was not significant (p=0.8). High compliance (>2 or more doses on average per week) reduced the risk of HSI by 78% (RR=0.22, 95% CI 0.06 to 0.87) compared with low compliance (<1 dose on average per week), and moderate compliance (1 to <2 doses on average per week) decreased the risk of HSI by 67% (RR=0.33, 95% CI 0.11 to 0.97) compared with low compliance. There was no significant difference between high and moderate compliance. CONCLUSION: The 11+ decreased the risk of HSI by 63% but did not improve recovery time. High to moderate compliance is essential and makes the programme more effective at reducing HSI.

Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport.

OBJECTIVES: To investigate current clinical practice of Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction (ACLR) from pre-operative rehabilitation until return to sport (RTS). We assessed optimisation strategies in daily practice and the perceived barriers to these optimisations, and evaluated whether there was a relevant difference in clinical practice for physiotherapists with post-graduate certification in sports physiotherapy or deep clinical experience and those without such experience. DESIGN: Cross-sectional survey. SETTING: Online survey platform. PARTICIPANTS: Swiss physiotherapists. MAIN OUTCOME MEASURES: The survey comprised six sections: participant information, pre-operative rehabilitation, post-operative rehabilitation, RTS, re-injury prevention, and optimisation strategies and barriers. RESULTS: A minority of physiotherapists treated ACLR patients pre-operatively. Overall, 91% included quadriceps open kinetic chain exercise in their treatment, 37% used patient-reported outcomes measures (PROMs) and 39% considered psychological criteria when making decisions about RTS. Most physiotherapists (67%) felt limited due to the time available, the number of prescriptions and the tariffication system. CONCLUSION: This study highlights areas within ACLR rehabilitation practice in Switzerland that could be improve. Improvements in understanding of the barriers to implementation of best evidence in practice and a redefinition of the clinical process around ACLR rehabilitation in Switzerland are necessary.

Evaluating Functional Performance Tests in those with Non-arthritic Intra-articular Hip Pain: An International Consensus Statement.

Background: Non-arthritic intra-articular hip pain, caused by various pathologies, leads to impairments in range of motion, strength, balance, and neuromuscular control. Although functional performance tests offer valuable insights in evaluating these patients, no clear consensus exists regarding the optimal tests for this patient population. Purpose: This study aimed to establish expert consensus on the application and selection of functional performance tests in individuals presenting with non-arthritic intra-articular hip pain. Study Design: A modified Delphi technique was used with fourteen physical therapy experts, all members of the International Society for Hip Arthroscopy (ISHA). The panelists participated in three rounds of questions and related discussions to reach full consensus on the application and selection of functional performance tests. Results: The panel agreed that functional performance tests should be utilized at initial evaluation, re-evaluations, and discharge, as well as criterion for assessing readiness for returning to sports. Tests should be as part of a multimodal assessment of neuromuscular control, strength, range of motion, and balance, applied in a graded fashion depending on the patient's characteristics. Clinicians should select functional performance tests with objective scoring criteria and prioritize the use of tests with supporting psychometric evidence. A list of recommended functional performance tests with varying intensity levels is provided. Low-intensity functional performance tests encompass controlled speed in a single plane with no impact. Medium-intensity functional performance tests involve controlled speed in multiple planes with low impact. High-intensity functional performance tests include higher speeds in multiple planes with higher impact and agility requirements. Sport-specific movement tests should mimic the patient's particular activity or sport. Conclusion: This international consensus statement provides recommendations for clinicians regarding selection and utilization of functional performance tests for those with non-arthritic intra-articular hip pain. These recommendations will encourage greater consistency and standardization among clinicians during a physical therapy assessment.

Gamification of Physical Therapy Exercises Using Commercial Entertainment Content: A Safety and Feasibility Study.

Independent physiotherapy at home is a crucial element of rehabilitative care for a wide range of conditions as it constitutes a large portion of the overall therapy dose. However, up to 80% of individuals who are prescribed at-home physiotherapy do not consistently adhere to their treatment schedule, resulting in poor treatment outcomes. This is likely due to a lack of motivation and progress tracking in the current standard of care. We have developed a novel software prototype that allows users to control commercial entertainment content, such as video games or interactive music videos, with their movements during physiotherapy. By connecting therapy to proven entertainment content, we aim to improve on the current motivational deficits. This study investigated the safety and feasibility of this concept in a controlled environment over four physical therapy sessions with seven patients suffering from musculoskeletal and neurological conditions. As a secondary outcome, patients were asked about their enjoyment, perceived competence and effort using the Intrinsic Motivation Inventory (IMI) questionnaire. All participants were able to interact with the presented entertainment content and completed the study with no adverse events. Despite the diversity in pathology, age and training scenarios, the entertainment content maintained the patients' enjoyment with a high average rate of 6/7 on the IMI scale. Interacting with commercial entertainment content by doing physical therapy exercises was feasible, safe, and well-received over the six-week study period.

High Compliance with the 11+ Injury Prevention Program Results in Better Win-Loss Records.

Background: The 11+ injury prevention program (IPP) has been shown to decrease injury rates. However, few studies have investigated compliance and its overall relationship to team performance. Hypothesis/Purpose: To examine if level of compliance while implementing the 11+ would impact team performance outcomes (wins, losses and ties). The authors hypothesized that higher team compliance to the IPP would be consistent with improved overall team performance (more wins and fewer losses). Study Design: Prospective, cluster randomized controlled trial. Methods: This study was conducted in NCAA men's soccer teams for one season and examined the efficacy of the 11+ IPP. The outcome variables examined were levels of compliance and team performance record: wins, losses, and ties. Twenty-seven teams (n=675 players) served as the intervention group (IG) and used the 11+ program while 34 teams (n=850 players) served as the control group (CG). Compliance and team performance were recorded. There were three compliance categories that were defined prospectively, low (LC, < 1 dose/week), moderate (MC, >1 and <2 doses/week), and high (HC, >2 doses/week). Descriptive and inferential tests were used to compare the CG, the IG, and compliance to team performance. Three independent t-tests were used to analyze outcome to group (IG vs. CG). A one way-MANOVA test was used to analyze compliance to win/loss/tie record, followed up by one-way ANOVA tests to analyze how compliance impacted wins, losses and ties, independently. Partial η2 measures were calculated to determine the effect size of level of compliance on outcome. A Tukey post-hoc analysis was used to analyze specific differences between levels of compliance and specific outcome measures. Results: There were significantly more wins (IG: 10.67±2.63 versus CG: 8.15±3.83, CI, 7.95 - 9.69, p = 0.005) and fewer losses (IG: 5.56±1.97 versus CG: 8.12±3.59, CI, 5.66 to 7.43, p = 0.002) recorded for the teams using the 11+ program. There was a statistically significant difference between levels of compliance (high, moderate or low) on the dependent variables (wins, losses, and ties), F(3, 22) = 3.780, p =0.004; Wilks' Λ = .435; partial η2 = .340. Conclusion: The 11+ has the capacity to improve overall team performance in male collegiate soccer teams. The higher the compliance, the more favorable the team performance. This research may be a vital addition when attempting to persuade coaching staffs to adopt an IPP into their training regimen. Level of Evidence: Level I.

Hip muscle strength in male and female patients with femoroacetabular impingement syndrome: Comparison to healthy controls and athletes.

OBJECTIVES: To examine hip muscle strength deficits in patients with femoroacetabular impingent syndrome (FAIS), with special emphasis on potential sex- and comparison-related (between-subject vs within-subject) differences. DESIGN: Cross-sectional comparative study. PARTICIPANTS: Forty FAIS patients (20 women), 40 healthy controls (20 women) and 40 athletes (20 women). MAIN OUTCOME MEASURES: Hip abduction, adduction and flexion isometric strength was tested using a commercially-available dynamometer. Two between-subject comparisons (FAIS patients vs controls and FAIS patients vs athletes) and one within-subject comparison (inter-limb asymmetry) of strength deficits were conducted, based on the calculation of respective percent differences. RESULTS: For all hip muscle groups, women were 14-18% weaker than men (p < 0.001), but no sex-related interactions were observed. For all hip muscle groups, FAIS patients were 16-19% weaker than controls (p = 0.001) and 24-30% weaker than athletes (p < 0.001). For FAIS patients, the involved hip abductors were 8.5% weaker than the uninvolved ones (p = 0.015), while no inter-limb asymmetry was observed for the other hip muscles. CONCLUSION: Sex had no influence on hip muscle strength deficits in FAIS patients while a major impact of comparison method/group was observed. Hip abductors showed consistent deficits for all comparison methods, suggestive of a possible greater impairment compared to hip flexors and adductors.

Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention.

The Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This guideline focuses on the exercise-based prevention of knee injuries and provides an update on the 2018 guideline, J Orthop Sports Phys Ther. 2018;48(9):A1-A42. doi:10.2519/jospt.2018.0303 J Orthop Sports Phys Ther. 2023;53(1):CPG1-CPG34. doi:10.2519/jospt.2023.0301.

Effects of the FIFA 11+ program on performance, biomechanical measures, and physiological responses: A systematic review.

BACKGROUND: The side effects of the FIFA 11+ program on performance have not been generally reviewed. The objective of this study was to synthesize the literature on the effects of the 11+ on players' performance. METHODS: Five online databases (PubMed, Scopus, ScienceDirect, Springer, and Google Scholar) were searched (from April 2006 to March 2022) using predefined keywords and sub-keywords. The potential references were primarily recorded through Endnote and imported to Covidence. Out of the 123 references screened by 2 blinded researchers through the software, 59 full texts were assessed for eligibility, 33 of which were ultimately included. The quality of the studies and the risk of bias were then assessed. Study ID, title, place, aim, design, start/end dates, population description, study criteria, statistical analysis, and outcomes were extracted. RESULTS: Studies were conducted on male and female players aged 10-32 years old. The quality of the studies was moderate to high, and except for unclear bias for blinding outcome assessment, the risk of bias for all domains was low. Long-term application of the 11+ improved most biomechanical measures and physiological responses except for lower extremity stability, ankle evertors time latency, ankle dorsiflexion, and proprioception. Conversely, the 11+ showed acute negative effects on physical performance compared to dynamic warm-ups and non-significant effects on technical abilities. CONCLUSION: Mid-to-long-term implementation of the 11+ improved the majority of biomechanical and a couple of physical measures but showed no effects on technical skills. Precaution must be observed for using the 11+ before competitions, as it could acutely decrease physical/technical performance. Given the contradictory nature of the literature, further studies should evaluate the short-to-mid-term effects of the 11+. Further studies are required to address ankle responses to the 11+ intervention.

The FIFA 11+ Kids Injury Prevention Program Reduces Injury Rates Among Male Children Soccer Players: A Clustered Randomized Controlled Trial.

BACKGROUND: The Fédération Internationale de Football Association (FIFA) 11+ Kids is an exercise-based injury prevention program developed by an international group of experts to prevent injuries among child soccer players. HYPOTHESIS: It was hypothesized that the FIFA 11+ Kids program would be more effective than performing a typical warm-up regimen in reducing overall injuries among soccer players aged 7 to 13 years. STUDY DESIGN: A clustered randomized controlled trial. LEVEL OF EVIDENCE: Level 1. METHODS: A total of 94 boys' soccer teams, including 780 players, were randomly allocated into an experimental or control group. Complete datasets were collected from 45 teams (377 players) and 43 teams (363 players) in the experimental and control groups, respectively. The experimental group underwent the FIFA 11+ Kids program as a warm-up during training sessions and matches at least twice a week, and the control group continued performing their usual warm-ups. Participants were prospectively followed during 1 season (6 months). The primary outcomes included the incidence of overall and recurrent injuries and their mechanism and severity. The secondary outcome was the rate of compliance with the intervention program. RESULTS: A total of 43 injuries were reported in the experimental group in 50,120 hours of exposure (0.85 injuries/1000 exposure hours). A total of 86 injuries were reported in the control group in 42,616 hours of exposure (2.01 injuries/1000 exposure hours). The injury risk ratio was 0.43 (0.29-0.61), suggesting that the experimental group experienced 57% fewer injuries than those in the control group. CONCLUSION: The FIFA 11+ Kids program reduced overall injury rates in children playing soccer more than the usual warm-ups. CLINICAL RELEVANCE: The results of this study provide evidence for children's coaches to consider including the FIFA 11+ Kids program in their warm-up regimen. Such a program may prevent injury risk and decrease absenteeism and injury-related financial burdens.

Context of injury prevention strategies in Swiss basketball: survey of athletes, medical staff and coaches.

Objectives: This project aims to assess opinions, attitudes, knowledge, beliefs, practices and perceived barriers and facilitators of injury prevention (IP) strategies in Swiss basketball teams. Methods: An online survey was sent to athletes, coaches and medical staff of the three best basketball leagues in Switzerland. The survey was subdivided in four sections: (1) characteristic of participants, (2) knowledge, opinions, attitudes and beliefs, (3) practices and (4) barriers and facilitators. Results: Among 105 persons (n=45 female, n=60 male) who answered the survey, more than 60% (n=68) considered the risk of injury for basketball athletes as being high to very high. The ankle, knee and the hand were considered as being the most at risk. More than 80% of participants considered that recovery, training load and the warm-up quality were very important factors for IP. More than 90% of participants considered IP as either important or very important with 53 (50.5%) of the participants indicating using exercise-based IP in their clubs. Athletes and coaches' motivation and compliance were judged as either important or very important for successful IP implementation by more than 80% of participants, with the coach being reported as the most influential person. Environmental barriers towards human or infrastructural resources were also reported as factors influencing IP strategies, namely by female participants. Conclusion: Good knowledge and positive attitude towards IP were reported by participants, but exercise-based IP strategies lack implementation. The coach was considered as the most influential person and was reported with the athletes as playing an important role towards successful implementation.

Mid-term outcomes of exercise therapy for the non-surgical management of femoroacetabular impingement syndrome: are short-term effects persisting?

OBJECTIVES: To investigate the mid-term outcomes of exercise therapy in patients with femoroacetabular impingement syndrome (FAIS). DESIGN: Follow-up study. SETTING: Clinical setting. PARTICIPANTS: Twenty-six patients with FAIS who completed a 12-week semi-standardized, progressive exercise therapy program. MAIN OUTCOME MEASURES: At a mid-term follow-up of 4.6 years, therapy outcome was assessed using (i) the Global Treatment Outcome questionnaire for hip pain, (ii) the Hip Outcome Score (HOS) for hip pain and function in activities of daily living (ADL) and Sport and (iii) the Hip Sports Activity Scale (HSAS) for sport activity level. Mid-term outcomes were compared to pre-symptomatic, pre-therapy, as well as to short-term follow ups (18 weeks). RESULTS: In patients who completed the exercise program and did not undergo hip surgery (N = 19), mid-term HOS ADL and HOS Sport (P = 0.002) were higher than pre-therapy, and comparable to the 18-week follow-up. Mid-term HSAS was lower than the pre-symptomatic status (P = 0.022), but comparable to the 18-week follow-up. CONCLUSION: At a mid-term follow-up of 4.6 years, FAIS patients with no subsequent hip surgery maintained the good exercise therapy outcomes and the level of sport activity achieved at short term.

Sports injury prevention programmes from the sports physical therapist's perspective: An international expert Delphi approach.

OBJECTIVE: To provide consensus on how to plan, organize and implement exercise-based injury prevention program (IPP) in sports. DESIGN: Delphi. SETTING: LimeSurvey platform. PARTICIPANTS: Experienced sports physical therapists from the International Federation of Sports Physical Therapy member countries. MAIN OUTCOME MEASURES: Factors related to sports IPP planning, organization and implementation. RESULTS: We included 305 participants from 32 countries. IPP planning should be based on an athlete's injury history, on pre-season screening results, and on injury rates (respectively, 98%, 92%, 89% agreement). In total 97% participants agreed that IPP organization should depend on the athlete's age, 93% on the competition level, and 93% on the availability of low-cost materials. It was agreed that IPP should mainly be implemented in warm-up sessions delivered by the head or strength/conditioning coach, with physical training sessions and individual physical therapy sessions (respectively, 94%, 92%, 90% agreement). CONCLUSION: Strong consensus was reached on (1) IPP based on the athlete's injury history, pre-season screening and evidence-based sports-specific injury rates; (2) IPP organization based on the athlete's age, competition level, and the availability of low-cost materials and (3) IPP implementation focussing on warm-up sessions implemented by the strength/conditioning coach, and/or individual prevention sessions by the physical therapist.

Home-Based Nonoperative-Side Quadriceps Neuromuscular Electrical Stimulation Prevents Muscle Weakness Following Anterior Cruciate Ligament Reconstruction.

We compared the effectiveness of a home-based neuromuscular electrical stimulation (NMES) program applied to the quadriceps of the nonoperative side against sham-NMES as a complement to standard rehabilitation on knee extensor neuromuscular function in patients following anterior cruciate ligament (ACL) reconstruction. Twenty-four patients completed the 6 week NMES (n = 12) and sham-NMES (n = 12) post-operative interventions and were tested at different time points for neuromuscular function and self-reported knee function. Isometric, concentric, and eccentric strength deficits (muscle weakness) increased significantly from pre-surgery to 24 weeks post-surgery in the sham-NMES group (p < 0.05), while no significant changes were observed in the NMES group. On the stimulated (nonoperative) side, quadriceps voluntary activation and muscle thickness were respectively maintained (p > 0.05) and increased (p < 0.001) as a result of the NMES intervention, contrary to sham-NMES. Self-reported knee function improved progressively during the post-operative phase (p < 0.05), with no difference between the two groups. Compared to a sham-NMES intervention, a 6 week home-based NMES program applied to the quadriceps of the nonoperative side early after ACL reconstruction prevented the occurrence of knee extensor muscle weakness 6 months after surgery. We conclude that nonoperative-side NMES may help counteract muscle weakness after ACL reconstruction.

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels.

SYNOPSIS: There is an absence of high-quality evidence to support rehabilitation and return-to-sport decisions following shoulder injuries in athletes. The Athlete Shoulder Consensus Group was convened to lead a consensus process that aimed to produce best-practice guidance for clinicians, athletes, and coaches for managing shoulder injuries in sport. We developed the consensus via a 2-round Delphi process (involving more than 40 content and methods experts) and an in-person meeting. This consensus statement provides guidance with respect to load and risk management, supporting athlete shoulder rehabilitation, and decision making during the return-to-sport process. This statement is designed to offer clinicians the flexibility to apply principle-based approaches to managing the return-to-sport process within a variety of sporting backgrounds. The principles and consensus of experts working across multiple sports may provide a template for developing additional sport-specific guidance in the future. J Orthop Sports Phys Ther 2022;52(1):11-28. doi:10.2519/jospt.2022.10952.

The FIFA 11+ Shoulder Injury Prevention Program Was Effective in Reducing Upper Extremity Injuries Among Soccer Goalkeepers: A Randomized Controlled Trial.

BACKGROUND: Soccer is one of the most popular sports worldwide. Goalkeepers are more likely to injure their upper limbs, particularly their shoulders, than outfield players. To reduce upper extremity injuries, the FIFA 11+ Shoulder Injury Prevention Program (FIFA 11+S) was developed. PURPOSE: The purpose of this study was to assess the effectiveness of the FIFA 11+S program in reducing the incidence of upper extremity injuries among amateur soccer goalkeepers. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 726 goalkeepers, who were blinded to study intent, were randomly assigned to the experimental group (n = 360) or control group (n = 366). The experimental group was instructed to perform the FIFA 11+S program before all training sessions for 1 season (6 months). The control group was instructed to continue performing their usual routine warm-up program before training sessions for 1 season. Primary outcomes included the incidence of upper extremity injury and incidence of mechanism, type, and severity of injury measured using injury risk ratios (IRR); compliance with the experimental and control interventions was also recorded. RESULTS: A total of 50 injuries (0.62 injuries per 1000 exposure-hours) were reported in the experimental group, and 122 injuries (1.94 injuries/1000 hours) were reported in the control group. The FIFA 11+S program reduced the total number of upper extremity injuries by 68% (IRR = 0.32 [95% CI, 0.27-0.34]) compared with the usual warm-up. The FIFA 11+S program reduced the incidence of contact injury (IRR = 0.30 [95% CI, 0.25-0.31]), noncontact injury (IRR = 0.40 [95% CI, 0.35-0.43]), initial injury (IRR = 0.34 [95% CI, 0.29-0.36]), recurrent injury (IRR = 0.20 [95% CI, 0.17-0.21]), and overuse injury (IRR = 0.40 [95% CI, 0.35-0.43]). Participants in the experimental group demonstrated a significant decrease in injuries of minor (IRR = 0.32 [95% CI, 0.27-0.34]) and moderate severity (IRR = 0.33 [95% CI, 0.29-0.35]) compared with the control group. We noted no difference in compliance between the experimental and control groups (80% vs 73%, respectively; P = .92). CONCLUSION: The FIFA 11+S program resulted in 50% fewer upper extremity injuries among soccer goalkeepers, compared with a regular warm-up. REGISTRATION: ACTRN12618001080213 (Australian New Zealand Clinical Trials Registry).

Perceived Barriers to and Facilitators of an Injury Prevention Program Among Professional Male Ice Hockey Players and Staff Members.

CONTEXT: Injury prevention programs for the lower extremities are effective in team-sport athletes. OBJECTIVE: To identify barriers and facilitators among professional ice hockey players and staff members for adhering to an injury prevention program. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: A questionnaire about barriers and facilitators related to knowledge/perceptions, beliefs, adoption, and habits about injury prevention was filled out by Swiss professional male ice hockey players and staff members. MAIN OUTCOME MEASURES: Frequencies of ratings were calculated and binary logistic regression analysis was applied to predict a relationship between a high/low perceived benefit of an injury prevention program and player characteristics. RESULTS: Knowledge, perceived benefit, and relevance of injury prevention as well as awareness of high risk of injuries in ice hockey were identified as important facilitators. Players' habit of exercise performance was identified as a barrier. Program understanding of staff members was identified as a facilitator and barrier. No significant relationships were observed between a high/low perceived benefit of an injury prevention program and age (P = .85), nationality (P = .53), level of education (P = .63), National League experience (P = .50), or occurrence of lower-extremity injuries in the previous season (P = .10). CONCLUSIONS: Players and staff members clearly rated perceived benefits of an injury prevention program, which can be considered an important facilitator of the uptake and adoption of such a program in ice hockey teams. Players should be educated about well-performed injury prevention exercises. Staff members should be educated about the aim of a regular injury prevention program. An injury prevention program might be implemented in players of all ages, levels of education, and experience in the National League, irrespective of previous injuries. Identified barriers and facilitators should be addressed when implementing an injury prevention program in a setting of professional ice hockey teams in the future.