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Invited Commentaries

See the Forest for the Trees: Making Injury Risk Mitigation Programs Work for You

Clifton, Daniel R. PhD, ATC1; Gribbin, Timothy C. MEd, ATC1; Beutler, Anthony I. MD2; de la Motte, Sarah J. PhD, MPH, ATC1

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Current Sports Medicine Reports: May 2020 - Volume 19 - Issue 5 - p 175-177
doi: 10.1249/JSR.0000000000000714
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Introduction

Musculoskeletal injuries (MSK-I) are burdensome on the U.S. health care system and are the most common reason for emergency room visits for athletes and first responders (1–3). Several injury prevention programs, perhaps more aptly called injury risk mitigation programs, have been developed and implemented in research-oriented capacities to attempt to decrease sports and training-related MSK-I, as well as their short- and long-term consequences. On smaller scales, individual athletic trainers, strength and conditioning professionals, and often coaches, are tasked with devising their own strategies for preventing injuries. Such programs, which are designed to reduce the risk of MSK-I (hence the shift in language from “prevention” to “risk mitigation”) have proven effective in reducing the likelihood of injury in scientific studies (4,5). However, scientifically studied programs have not been consistently implemented in the “field.” The lack of translation to clinical practice is due to a multitude of reasons including, but not limited to, a general lack of knowledge, information, and available assistance on how to tailor a program to specific settings. Practical but difficult considerations such as time and personnel constraints, as well as a lack of formalized training for individuals implementing the programs (e.g., coaches), often mean that risk mitigation programs go unimplemented or are not followed as designed.

The Translating Research into Injury Prevention Practice (TRIPP) framework is an expanded MSK-I risk mitigation tool commonly used in the development, implementation, and evaluation of injury risk mitigation programs (6). It is particularly useful for the development of and planning for risk mitigation programs specifically designed to meet the needs of a particular population and, therefore, can provide medical providers with a roadmap for tailoring MSK-I risk mitigation programs into their specific settings. The purpose of this commentary is to introduce medical providers to the TRIPP framework and explain how it can be used to guide the development and implementation of an injury risk mitigation program.

Translating Research into Injury Prevention Practice

The TRIPP framework developed by Finch (6) expanded the original four-step sports medicine injury prevention model described by van Mechelen (7) into a six-step model (Figure), which includes describing the implementation or intervention context where programs will be utilized and specific issues uncovered when programs are implemented in the real world. The purpose of the TRIPP framework is to take the efficacious program (which works under ideal conditions) and make it effective in a real world setting where conditions are rarely ideal.

Figure
Figure:
TRIPP framework by Finch.

Measuring the Extent of the Problem

Measuring the extent of the problem in a setting-specific context would involve identifying which injuries are occurring most commonly and what the short- and long-term consequences of the injuries may be to prioritize what injury risk mitigations programs should target. A health care provider may prioritize preventing anterior cruciate ligament (ACL) injuries over ankle sprains even though ankle sprains are more prevalent because of the severity of ACL injury and the increased likelihood of developing osteoarthritis.

Identify Etiology and Mechanisms

Using best available evidence on common mechanisms and risk factors for injury will indicate which intrinsic and extrinsic factors programs should address to reduce the likelihood of injury. Injury occurs when multiple factors interact in a complex manner, and these factors are both modifiable (e.g., balance) and nonmodifiable (e.g., sex). In order for an intervention to be effective, it is important that focus be placed on that which can be altered, such as improving balance or movement control.

Develop Optimization Strategy

Developing an optimization strategy is a vital component of tailoring a prevention program to an individual setting. This component should involve communication among all stakeholders (e.g., athletic director, coach, athletic trainer, medical director, etc.) to develop a program that meets everyone's needs and overcomes barriers to implementation. There is an abundance of literature describing common barriers to adopting an injury risk mitigation program (8–11). Common barriers include not having enough time in a practice session or the program being too long, belief that the program will decrease athletic performance, no access to training resources, and lack of buy-in (8–11). To foster adoption of the injury risk mitigation programs, barriers to successful implementation need to be considered during program development and addressed before, during, and after implementation.

Assess Effectiveness

When using a scientifically studied program, it is important to understand the effectiveness of that program (as studied in a research context) and whether the likely impact would be beneficial enough to justify the time and cost of implementation. Implementing a prevention program that would benefit 1 of every 50 athletes may be worthwhile if it is implemented among multiple sports teams (e.g., 3000 total athletes) but it may not have a large enough impact to be cost-effective if only implemented on a small team (e.g., 15 athletes).

Describe Intervention Context

Understanding the context in which an injury risk mitigation program was developed is important when determining if the program is appropriate in a specific setting. The targeted sport, patient age, and training level of individuals administering/supervising the program can provide insight into the environment in which the program might be successful, and conversely, the environment in which it might be unsuccessful. Understanding details of the intervention context also should be incorporated into development of the optimization strategy.

Implement in Real World and Assess Effectiveness

An important component to making a prevention program work in a specific setting is assessing its effectiveness during and after implementation. This step is vital to determining if the optimization strategy developed has resulted in desired outcomes (e.g., less injuries) in both the short- and long-terms. Information gleaned from this step should then be used to adjust the optimization strategy to improve effectiveness over time. An effective program also may change the prevalence and incidence of injuries in a setting, altering the extent of the problem. As a result, it is important to continually evaluate the extent of the problem to determine if a program should begin to target different conditions to meet new needs.

Using the TRIPP Framework in Practice

To demonstrate how the TRIPP framework can be used in practice, we will use an example of an athletic trainer (Jane) at a small university who wishes to implement an injury risk mitigation program in a women's soccer team. Jane reviews medical records from past seasons to determine which injuries should be targeted (extent of the problem) and identifies that the team is averaging two ACL injuries per year over the past 3 years. Although the team is averaging 10 ankle sprains over that same period, the surgical nature of ACL injuries warrants prioritizing in her opinion. Jane searches the literature (identify etiology and mechanism of injury) to identify the most common risk factors for injury that her program should target (e.g., neuromuscular control, balance, etc.).

A meeting is scheduled with the coach, medical director, and Jane herself to develop an optimization strategy. Jane conveys her intention for the program, and the three individuals agree to implement an ACL injury risk mitigation program and identify barriers to successful implementation. The coach states that she does not want to take time away from practice to perform the program, so they must have a solution that can be implemented during team warm-ups. The three individuals decide to meet at four time points over the season to evaluate the program (assess effectiveness in real world): end of preseason, midpoint of regular season, end of regular season, and end of postseason (if the team makes the postseason). While searching for a program, Jane comes across the FIFA 11+ program and believes it is appropriate to use given her environment. Specifically, it can be applied in college female soccer players and can be implemented in a warm-up. Jane then proceeds to train herself and the coach in administering the program so adherence can be maintained if Jane is unable to attend a practice or game.

At the end of the year meeting, Jane finds that the team had only one ACL injury that season and would like to continue the program in future years. The coach agrees but indicates that changes need to be made to accommodate time constraints during the regular season and postseason. Class and examination schedules forced the coach to cut down on practice time and, therefore, there was less time in warm-ups to administer the injury risk mitigation program. Although they administered the program 90% of the time, that is not sustainable in the long-term under the constraints. Jane, the coach, and the medical director decide for future years that the full program will be implemented in the pre-season but the program will be shortened the rest of the season to accommodate time constraints. All parties agree that future monitoring of injuries is important to evaluate for changing dynamics and to examine potential causes of resurges in injury rates.

Conclusion

Programs designed to reduce the risk of MSK-I are often effective, but they are not often performed consistently in the “field” and are often not sustained over time. This commentary described the TRIPP framework and how it could be used to develop and implement an injury risk mitigation program that is tailored to a specific setting. Implementing a program using the TRIPP framework can prevent injury in a cost-effective, sustainable, and realistic manner.

The authors declare no conflict of interest and do not have any financial disclosures.

References

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