Running Every Time, Planking Sometimes: Youth Adherence to a Neuromuscular Training Program : Translational Journal of the American College of Sports Medicine

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Original Investigation

Running Every Time, Planking Sometimes: Youth Adherence to a Neuromuscular Training Program

Räisänen, Anu M.1,2; van den Berg, Carla2; Owoeye, Oluwatoyosi B.A.2,3; McKay, Carly D.4; Emery, Carolyn A.2,5,6,7,8

Author Information
Translational Journal of the ACSM: Fall 2022 - Volume 7 - Issue 4 - e000209
doi: 10.1249/TJX.0000000000000209
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Abstract

INTRODUCTION

Physical education (PE) supports students in leading an active life through learning to appreciate the importance of physical activity (1). PE class provides an opportunity to introduce healthy lifestyle practices, such as injury prevention strategies, to all students because it is not limited to those participating in sport and recreational activities. Introducing injury prevention strategies in PE aims to prevent injuries during PE class and in all sport and recreational activities outside of PE class.

Neuromuscular training (NMT) warm-up programs have been shown to be effective in reducing injury rates in youth team sports (2,3). NMT warm-up programs typically include four components—aerobic, strength, balance, and agility exercises—and take 10–20 min to complete (4). The use of NMT programs in PE classes has not been studied as extensively as in the team-sport setting, but there is evidence supporting the use of NMT programs in the school setting (5–7). Collard and colleagues (8) established that the iPlay program was effective in improving injury prevention knowledge in primary school students. Richmond and colleagues (6) reported that the Implementing a School Prevention Program to Reduce Injuries Through NMT (iSPRINT) warm-up reduced sport-related injuries and also improved measures of adiposity and fitness in a pilot study with junior high school students. Emery and colleagues (7) reported that the iSPRINT warm-up was effective in reducing rates of all injuries (46%), lower extremity injuries (64%), and medically treated sport and recreational injuries (71%) in female junior high school students (ages 11–16 yr), but not in males.

NMT warm-up programs only prevent injuries when they are properly implemented (9–11). Modifying NMT programs to meet the needs of the group and the environmental constraints is common (12–14). The ability and willingness of the teacher or coach to adapt the program have been identified as a way to overcome some barriers of implementation (15,16). However, there are concerns that adaptation could lead to important components of the program being left out, which could influence the effectiveness of the program (17).

Adherence to NMT warm-up programs is often reported on the level of cumulative utilization, referring to the number of sessions (i.e., PE class, training, match) in which the NMT warm-up program was completed out of all sessions, often expressed as a proportion (18). However, Owoeye and colleagues (19) recommend reporting additional levels of adherence to fully capture its dimensions, such as utilization frequency (i.e., number of NMT warm-up sessions completed per week) and utilization fidelity (number of exercises or number of program components completed per warm-up session).

The aim of this study was to determine adherence to the iSPRINT program in junior high school PE considering the program, components (aerobic, strength, balance, agility), and exercises (15 exercises). To best understand the level of adherence across the participating schools, most measures are reported on the school level to allow for reporting of all values instead of group averages, whereas weekly sessions (utilization frequency) is reported on the class level. The findings of this study will inform the future design and implementation of NMT warm-up programs in PE settings.

METHODS

Study Design and Participants

This study is a secondary analysis of intervention group data from iSPRINT, a cluster-randomized controlled trial (RCT) in junior high schools (youth ages 11–16 yr) in Calgary, Alberta, Canada (2014–2017) (7). The participating schools were from two school boards that had regular PE programming. PE is compulsory in junior high schools in Alberta. In school board A (schools 1, 2, 3, and 4), PE classes take place every day; whereas in school board B (school 5), classes were scheduled based on a 6-d rotation, resulting in two to four PE classes per week.

The intervention group comprised six schools, but one (from school board B) was excluded from this analysis because of inadequate collection of warm-up adherence data. The study design, including recruitment strategy, has been described in detail elsewhere (7). Ethical approval was obtained from the Health Research Ethics Board of the University of Calgary (REB14-0470). All participants provided written informed consent for participation in the study. The study was performed in accordance with the Declaration of Helsinki (2008).

Intervention

iSPRINT is a 10- to 15-min NMT warm-up program that comprises four components: aerobic (six exercises), agility (three exercises), strength (four exercises), and balance (two exercises) (7). The full program is described in Table 1. The program was piloted as an RCT in two Calgary schools before carrying out the larger RCT (6,7). Teachers instructing PE classes from schools randomized to the intervention arm attended an in-person, active workshop to learn the iSPRINT program before the beginning of the study. Workshops included an in-depth review of all exercises in the program, including practicing delivery instructions and feedback, as well as strategies for implementing the program in the PE class setting.

TABLE 1 - Cumulative Utilization (%) for Each Exercise.
Exercise All Schools School 1 School 2 School 3 School 4 School 5
Aerobic component
 Forward run 95.5 95.0 86.5 81.4 99.4 100.0
 Forward running with skipping 82.5 95.0 82.0 78.4 99.4 32.4
 Forward running with knee lifts 82.1 95.0 82.9 81.4 99.4 27.6
 Forward running with heel kicks 82.2 95.0 75.7 78.4 99.4 35.9
 Sideway shuffles 79.5 95.0 72.1 75.5 99.4 25.5
 Speed runs 74.6 95.0 69.4 47.1 95.6 29.7
Agility component
 Zigzag running 70.7 94.0 47.7 61.8 90.6 26.9
 Forward running with intermittent stops 36.3 95.0 71.2 59.8 9.4 18.6
 Jumping 77.4 84.0 58.6 75.5 95.6 41.4
Strength component
 Plank 66.3 53.0 91.9 72.5 77.0 22.8
 Side plank 57.2 32.0 26.1 70.6 76.5 39.3
 Hamstrings 66.9 78.0 70.3 32.4 83.9 36.6
 Lunges 78.7 87.0 77.5 65.7 90.9 50.3
Balance component
 Wobble board balance 52.8 78.0 63.1 26.5 53.7 42.1
 Airex pad balance 70.9 78.0 64.9 39.2 85.0 55.9

Data Collection

Adherence data were collected at the class level. Teachers were asked to deliver the program at the beginning of each PE class over the 12-wk study period and to complete a diary for each PE class, reporting iSPRINT implementation. The diary included an open-ended question on iSPRINT warm-up duration (in minutes), a checklist to mark which iSPRINT exercises were completed, and an open-ended question to describe any adaptations made to the program. An investigator visited each school weekly to collect the diaries. If a diary was not completed for a day when a PE class was scheduled, it was interpreted that the iSPRINT warm-up was not completed that day. This assumption was confirmed by conversations with teachers at all schools after the intervention period.

Outcome Measures

Adherence measures were based on the recommendations by Owoeye et al. (19). Utilization fidelity was measured as the average number of iSPRINT exercises completed per iSPRINT warm-up session. Cumulative utilization for the program was calculated as the total number of iSPRINT sessions out of all PE classes during the study period. Cumulative utilization by component/exercise was calculated as the total number of times a component/exercise was completed out of the total number of sessions that the iSPRINT program was completed during the study period. Utilization fidelity and cumulative utilization are reported on the school level to allow for reporting of all values and not only averages, making it possible to observe the adherence profile of each school.

Utilization frequency for the program was the average number of times the iSPRINT program was completed weekly during the study period. Utilization frequency by component was the average times a component (aerobic/strength/balance/agility) was completed per week during the study period. Utilization frequency is reported on the class level to allow for comparisons of weekly utilization.

Optimal adherence was defined as performing at least two sessions per week (11). For an iSPRINT session to be counted for optimal adherence, the session had to include at least one exercise from each component (aerobic, balance, strength, agility) and at least 12 of the 15 exercises (80%).

Statistical Analysis

Descriptive statistics were used for all outcome measures. All analyses were performed using SPSS (version 26; IBM, Armonk, NY).

School level

Utilization fidelity was calculated as the median (Q1, Q3; range) for each school and for the sample of five schools. Cumulative utilization was calculated as the proportion (%) of iSPRINT sessions out of all PE classes for each school and for the sample of five schools.

Cumulative utilization by exercise was calculated for the 15 exercises as the proportion (%) of sessions an exercise was used out of all iSPRINT sessions. Cumulative utilization by exercise was calculated for each school and the sample of five schools.

Class level

Utilization frequency was calculated for each classroom as the median (Q1, Q3) of weekly iSPRINT sessions. The median of medians was calculated for the sample of 32 classrooms. Optimal utilization was calculated on the class level as the median of weekly sessions that met the criteria of an optimal iSPRINT session.

RESULTS

Students from a total of 32 classes participated in the study (Table 2). During the 12-wk study period, a total of 1572 PE classes were scheduled for the participating classes and a total of 858 iSPRINT warm-ups were completed, making cumulative utilization of the iSPRINT program 54.6%. Warm-up duration was reported for 584 iSPRINT sessions (missing n = 274). Median duration was 10 min (Q1, Q3: 10, 15).

TABLE 2 - Number of Classes, PE Classes, and iSPRINT Sessions and Utilization Fidelity.
School 1 School 2 School 3 School 4 School 5
Classes total 3 4 6 12 7
 Grade 7 1 2 2 4 2
 Grade 8 1 1 2 4 2
 Grade 9 1 1 2 4 3
Total scheduled PE classes during the study, n 162 216 312 648 234
iSPRINT sessions during the study, n (%) 95 (58.6) 114 (52.8) 143 (45.8) 361 (55.7) 145 (62.0)
Utilization fidelity, median (Q1, Q3) (per 15 exercises) 14
(14, 14)
12
(8, 13)
10
(6, 13)
13
(13, 14)
5
(5, 6)
Utilization fidelity, range 7 to 15 1 to 15 2 to 15 4 to 15 2 to 9
iSPRINT sessions refers to warm-ups in which ≥1 exercise from the iSPRINT program was performed.

Nineteen teachers delivered the warm-up program in PE classes across all five schools. Teacher demographics are presented in Table 3. Eleven (91.7%) of the 12 teachers who reported holding additional coaching certifications were certified through the Coaching Association of Canada’s National Coaching Certification Program (NCCP). The remaining teacher obtained their certification through the school sport association’s provincial governing body. None of the teachers indicated that they had previous education or exposure to injury prevention warm-up programs; of the two coaches who indicated exposure, one reported that it was a taping course, and the other reported that it was a general lifestyle fitness course.

TABLE 3 - Characteristics of the PE Teachers Delivering iSPRINT.
Characteristics School 1 School 2 School 3 School 4 School 5 Total
Teachers, n 2 4 5 4 4 19
Female, n (%) 0 (0) 1 (25) 2 (40) 2 (50) 1 (25) 6 (31.6)
Male, n (%) 2 (100) 3 (75) 3 (60) 2 (50) 3 (75) 13 (68.4)
Years teaching PE, median (range) 10.5 (7–14) 2.0 (1–3) 13.0 (8–20) 12.5 (1–17) 8.0 (5–9) 9.0 (1–20)
Exposure to injury prevention programs, n (%) 1 (50) 0 (0) 1 (20) 0 (0) 0 (0) 2 (10.5)
Teachers with coaching certifications, n (%) 2 (100) 1 (25) 3 (60) 4 (100) 2 (50) 12 (63.2)

Utilization Fidelity and Cumulative Utilization

Across all schools, the median number of exercises included in an iSPRINT session was 13 out of 15 (Q1, Q3: 7, 14; Table 2). Cumulative utilization for the 15 exercises ranged from 36.3% for forward running with intermittent stops to 95.5% for forward run. Cumulative utilization for each exercise is presented in Table 1.

At the component level, cumulative utilization was highest for the aerobic component, with 98.4% of iSPRINT sessions including at least one (32.7%) or all (65.7%) of the six exercises comprising this component (Table 4). Lowest cumulative utilization, 78.5%, was reported for the balance component, with 32.8% of sessions including at least one and 45.7% of sessions including the two exercises in this component.

TABLE 4 - Cumulative Utilization (%) for Each Component.
All Schools School 1 School 2 School 3 School 4 School 5
Aerobic
 Full 65.7 100 43.4 43.0 95.6 2.1
 Partial 32.7 0 52.2 51.0 4.4 96.6
 None 1.6 0 4.4 6.0 0 1.4
Agility
 Full 23.2 88.4 38.9 47.0 3.1 2.1
 Partial 65.3 11.6 36.3 42.0 95.6 64.1
 None 11.4 0 24.8 11.0 1.4 33.8
Strength
 Full 40.5 7.4 15.8 28.0 76.4 1.4
 Partial 49.4 84.2 78.9 56.0 15.2 84.1
 None 10.1 8.4 5.3 16.0 8.6 14.5
Balance
 Full 45.7 82.1 59.8 23.0 53.6 6.9
 Partial 32.8 0 7.1 21.0 31.9 84.1
 None 21.6 17.9 33.0 56.0 14.4 9.0

Utilization Frequency and Optimal Utilization

The medians for the number of times per week the classes completed the iSPRINT program ranged from 1.0 to 3.5, with a median of 2.0 across all classes. None of the 32 classes in the study reached optimal adherence of at least two iSPRINT sessions, with at least 80% of the exercises completed on every week of the 12-wk study period. Utilization frequency and the number of optimal iSPRINT sessions each week are presented in Fig. 1.

F1
Figure 1:
Number of weekly iSPRINT sessions and optimal sessions (≥2 sessions during the week, including ≥12 exercises, ≥1 from each component). On each box, the central mark indicates the median, and the bottom and top edges of the box indicate the 25th and 75th percentiles, respectively. The whiskers extend to the most extreme data points not considered outliers, and the outliers are plotted as dots. One dot can represent more than one class. The gray line indicates the median for weekly sessions across the classes.

For the 12-wk study period, the median times per week that classes completed at least one exercise from the aerobic component ranged from 1.0 to 3.5. The range was 1.0–3.5 for agility, 1.0–4.0 for strength, and 0.5–2.5 for balance. The median across all classes for each component was 2. Utilization frequency for each component by week is presented in Fig. 2.

F2
Figure 2:
Number of weekly iSPRINT sessions by component. On each box, the central mark indicates the median, and the bottom and top edges of the box indicate the 25th and 75th percentiles, respectively. The whiskers extend to the most extreme data points not considered outliers, and the outliers are plotted as dots. One dot can represent more than one class.

DISCUSSION

Utilization fidelity was high, with 13 out of 15 exercises completed on average per session. This is similar to utilization fidelity of 12 out of 13 exercises that has been previously reported in youth basketball, with similar workshop delivery methods (20). Although the average utilization fidelity was good, school 5 completed, on average, only five exercises in each iSPRINT session. Interestingly, the school did not seem to exclude any components; at least one exercise from each of the four components was used in at least 39% of all iSPRINT sessions in this school. Utilization fidelity can be impacted by different factors. For example, time is the most frequently reported barrier to NMT warm-up program implementation in both sports and PE (15,21). Time constraints could lead to exercises being left out of the NMT warm-up program. The school with low utilization fidelity was the only school in the study that did not have PE every day of the week. With less time for PE during the school year compared with the other schools, it is possible that teachers felt constrained by time and chose to shorten the iSPRINT warm-up to fit their needs.

Teachers’ experience teaching PE ranged from 1 to 20 yr and was particularly lower in school 2 (median, 2; range, 1–3 yr across all four teachers). This school also only had one teacher who reported holding an additional coaching certification. However, the teachers’ lower experience did not seem to impact program adherence; patterns were similar to those observed in other schools. Most of the teachers with a coaching certification had an NCCP certification. Although content on injury prevention warm-up programs has not been included in the NCCP modules to date, the teachers’ coaching backgrounds may have contributed to their willingness to implement warm-up program components.

Cumulative Utilization on the Program, Component, and Exercise Levels

Cumulative utilization of the iSPRINT program during the study period was 54.6%, indicating that at least some exercises from the iSPRINT warm-up were implemented in over half of the PE classes scheduled over the 12-wk period. It is not possible to compare this finding with previous studies because there is paucity of research on adherence to NMT warm-up programs in the PE setting. A previous qualitative study among teachers and students from four iSPRINT schools identified program length as the most important barrier to implementation (15), which is consistent with studies on sport-specific NMT warm-up programs (14,21,22). It is very likely that lack of time was also a reason why forms were not completed for many of the PE classes during which the iSPRINT warm-up was not implemented. However, it must also be kept in mind that cumulative utilization alone does not provide a lot of information about the dose of the NMT warm-up program, and therefore, it is important to explore a variety of adherence measures.

Cumulative utilization for the six aerobic exercises ranged from 75% to 96%. This is not surprising because these exercises, such as forward run and running with knee lifts, are very traditional warm-up exercises and can feel familiar and easy to use. Out of all 15 exercises, the one with lowest cumulative utilization was forward running with intermittent stops, an agility exercise that was used in 36% of all iSPRINT sessions. Interestingly, cumulative utilization was not low across all five schools; one school used this exercise 95% of the time, whereas the lowest recorded cumulative utilization was 9%. This indicates that this exercise is not problematic across the board but that there might be factors related to the teacher, students, or environment that create barriers for the use of this exercise in some schools. This exercise does require students to be able to decelerate and stop safely and a teacher might not feel competent in teaching this, or gym space could be limited. The forward running with intermittent stops exercise is the only one in the program that required a leader (e.g., teacher or student champion) to facilitate the exercise. Specifically, external cues are used to direct the students to stop and start running, which may have been a barrier for some classes because of the extra supervision and organization needed.

The two balance exercises were utilized 53% and 71% of the time. This was surprisingly high considering that both exercises required a piece of equipment, an Airex® pad (Sins, Switzerland) and a wobble board. The need for equipment has previously been identified as a barrier to implementation for the iSPRINT program, mostly because of the time it took to get all the equipment out of storage and to return them (15). Similarly, the Nordic hamstring curl, a strength exercise that typically requires the use of a mat or an Airex® pad as a cushion for the knees, was used 67% of the time. This cumulative utilization varied across schools; three of the schools included this exercise over 70% of the time, whereas the other two only used it approximately one-third of the time. Previous studies have identified some barriers related to the implementation of the Nordic hamstring curl among youth in different settings, like the difficulty of the exercise and the risk of delayed-onset muscle soreness (15,23). Although comparisons to previous studies are limited because of the different contexts and reporting, it seems that the cumulative utilization of the Nordic hamstring curl and the other strength exercises was similar to what was reported for youth soccer where, for strength exercises, the cumulative utilization was lower than for aerobic exercise but higher than for balance exercises (23).

Different patterns of cumulative utilization at the component level were observed across the five schools, yet there was not a component that was utilized all of the time. Unsurprisingly, the aerobic components were utilized the most frequently, whereas consistent implementation of the agility, strength, and balance components was lower. This highlights the need to emphasize the importance of including agility, strength, and balance exercises within warm-ups performed in PE classes, because they are key for injury prevention.

Utilization Frequency

On average, the program was used twice per week. Previous research has reported that the largest preventative effect for lower extremity injuries in youth athletes is observed when an NMT warm-up program is performed two to three times per week, with a weekly volume of 30–60 min (11). This 30- to 60-min recommendation would not be feasible or realistic in a junior high school PE setting given that the PE class length for schools participating in this study ranged from 41 to 58 min, including changing time required at the beginning and end of class. However, recent evidence indicates that weekly volume of <30 min might be adequate; a 10-min NMT program performed approximately twice a week was shown to reduce ankle and knee injury rates in youth basketball (24). However, this finding needs to be confirmed in other settings. Quite interestingly, the median utilization frequency for each of the four components (at least one exercise completed) was two times per week, but when looking at cumulative utilization by component, over 10% of iSPRINT sessions did not include any strength or agility exercises and over 20% did not include any balance exercises. This is another indication of why it is important to use several adherence measures and also to report adherence on different levels (i.e., school/club, class/team, student/athlete).

It is interesting that the mean number of weekly sessions seemed to increase around weeks 6 to 8. Because schools began the intervention at different times in the year (start dates ranged from October to March), it is unlikely that trends in the school calendar year (e.g., holiday breaks) contributed to this observation. It is possible that this indicates the length of time required for participants to become familiar with the program before it became routine.

iSPRINT Implementation in PE Class

In general, the schools adhered well to the iSPRINT program. Although adherence mostly did not meet what was considered optimal by the investigators, it must be taken into consideration that this level of adherence was protective of injuries in girls in these schools (7). It has also been previously reported that the implementation of the iSPRINT program in junior high school can lead to statistically significant and clinically relevant changes in waist circumference in 12 wk (6). The qualitative research on iSPRINT has established that teachers appreciated the structure and organization that the implementation of the iSPRINT program added to the warm-up procedures in PE classes (15). Although the aim of the present study is to generate information that can guide strategies to improve adherence to NMT warm-up programs in the future, it is also important to keep in mind that in practice, when barriers like time and lack of equipment might be limiting what exercises can be performed, doing something is better than doing nothing. The following message was also communicated during the workshop: teachers were encouraged to adapt the program when needed (7). However, it has yet to be established how much an effective NMT warm-up program can be adapted to still achieve a reduction in injury rates and positive changes in health measures. Until further evidence is available about the dose–response effect of each exercise component, it is recommend to incorporate aerobic, balance, strength, and agility exercises in the NMT warm-up.

Strengths and Limitations

This study is among the firsts to analyze NMT warm-up program adherence using several measures as recommended, thus providing a more detailed analysis of adherence (19). Although we are limited to descriptive analyses with only five schools, this sample size makes it possible to report all the school level data, not just averages for the full sample, thus providing detailed information about how the program is utilized in different settings. It is the first study, to our knowledge, to describe adherence to an NMT warm-up program within a school setting in such detail.

iSPRINT was implemented within a representative sample of junior high school students attending urban Canadian schools with regular PE programming, making results from this study generalizable to the broader Canadian youth population. This is in contrast to previous research on NMT warm-up program adherence in youth sport, which includes athletes and would be context-specific within each sport (20,25,26). It is important to note that adherence data were collected in the context of an RCT; teachers may have been more likely to implement the program given that it was part of a study, and adherence data may not accurately reflect adherence to a NMT program observed in the real world. Furthermore, a selection bias exists; the schools that agreed to participate in the study may have been more likely to demonstrate higher adherence to the prescribed program. Regardless, the data demonstrate that adherence was not optimal for any of the components and provide direction on where to focus implementation efforts moving forward. Exercise fidelity (assessment of exercise volume and technique) was not evaluated in the present study (26). In future studies, it would be beneficial to measure how well the exercises are performed as well as determine if exercise volume aligns with what is prescribed in the program (e.g., number of reps, time).

Conclusion

On average, the schools seemed to adhere well to the iSPRINT program, and all components of the program were implemented to some extent. This indicates that there are no program components that are systematically underperformed in the context of the iSPRINT program that would need to be addressed. iSPRINT resulted in statistically significant reductions in injury in females and clinically relevant injury reductions in males compared with the control group, as reported in the original study (7). This is promising, indicating that important benefits still exist even when the program is not performed in its entirety. It is important to provide support for teachers so that they are able to and comfortable in adapting the program to their students’ needs and the school environment while ensuring adequate adherence as is necessary to maintain program effectiveness. With opportunities for adaptations, NMT warm-up programs are feasible to implement in a junior high school setting, and school stakeholders should strive to incorporate NMT warm-up programs within their PE programming (15). PE provides the opportunity to deliver content to youth broadly, not just those who participate in sport. Future research should strive to incorporate measures of adherence not included in the present study, particularly exercise fidelity. Previous research has demonstrated that even when adherence on the team level is considered to be good, exercise fidelity, measured on the player level, can be inadequate (27). Determining exercise fidelity through evaluation of movement quality in a PE-class setting can support NMT implementation strategies moving forward. It is important to provide teachers with opportunities for continued education on NMT warm-up programs to ensure successful adoption of the programs, with a particular emphasis on the importance of including agility, strength, and balance components.

The authors wish to thank all the participating schools and Alberta Innovates High School Youth Researcher Summer program student Sarah Sass from William Aberhart High School in Calgary, Alberta, for their involvement in this research project. The University of Calgary Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. The results of the present study do not constitute endorsement by the American College of Sports Medicine.

The authors have no conflicts of interest or funding to declare.

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