Time-to-event analysis for sports injury research part 1 : Time-varying exposures
- Authors: Nielsen, Rasmus , Bertelsen, Michael , Ramskov, Daniel , Møller, Merete , Hulme, Adam , Theisen, Daniel , Finch, Caroline , Fortington, Lauren , Mansournia, Mohammad , Parner, Erik
- Date: 2019
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 53, no. 1 (2019), p. 61-68
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- Description: Background: 'How much change in training load is too much before injury is sustained, among different athletes?' is a key question in sports medicine and sports science. To address this question the investigator/practitioner must analyse exposure variables that change over time, such as change in training load. Very few studies have included time-varying exposures (eg, training load) and time-varying effect-measure modifiers (eg, previous injury, biomechanics, sleep/stress) when studying sports injury aetiology. Aim: To discuss advanced statistical methods suitable for the complex analysis of time-varying exposures such as changes in training load and injury-related outcomes. Content: Time-varying exposures and time-varying effect-measure modifiers can be used in time-to-event models to investigate sport injury aetiology. We address four key-questions (i) Does time-to-event modelling allow change in training load to be included as a time-varying exposure for sport injury development? (ii) Why is time-to-event analysis superior to other analytical concepts when analysing training-load related data that changes status over time? (iii) How can researchers include change in training load in a time-to-event analysis? and, (iv) Are researchers able to include other time-varying variables into time-to-event analyses? We emphasise that cleaning datasets, setting up the data, performing analyses with time-varying variables and interpreting the results is time-consuming, and requires dedication. It may need you to ask for assistance from methodological peers as the analytical approaches presented this paper require specialist knowledge and well-honed statistical skills. Conclusion: To increase knowledge about the association between changes in training load and injury, we encourage sports injury researchers to collaborate with statisticians and/or methodological epidemiologists to carefully consider applying time-to-event models to prospective sports injury data. This will ensure appropriate interpretation of time-to-event data. © 2019 Author(s).
Time-to-event analysis for sports injury research part 2 : Time-varying outcomes
- Authors: Nielsen, Rasmus , Bertelsen, Michael , Ramskov, Daniel , Møller, Merete , Hulme, Adam , Theisen, Daniel , Finch, Caroline , Fortington, Lauren , Mansournia, Mohammad , Parner, Erik
- Date: 2019
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 53, no. 1 (2019), p. 70-78
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- Description: Background: Time-to-event modelling is underutilised in sports injury research. Still, sports injury researchers have been encouraged to consider time-to-event analyses as a powerful alternative to other statistical methods. Therefore, it is important to shed light on statistical approaches suitable for analysing training load related key-questions within the sports injury domain. Content: In the present article, we illuminate: (i) the possibilities of including time-varying outcomes in time-to-event analyses, (ii) how to deal with a situation where different types of sports injuries are included in the analyses (ie, competing risks), and (iii) how to deal with the situation where multiple subsequent injuries occur in the same athlete. Conclusion: Time-to-event analyses can handle time-varying outcomes, competing risk and multiple subsequent injuries. Although powerful, time-to-event has important requirements: researchers are encouraged to carefully consider prior to any data collection that five injuries per exposure state or transition is needed to avoid conducting statistical analyses on time-to-event data leading to biased results. This requirement becomes particularly difficult to accommodate when a stratified analysis is required as the number of variables increases exponentially for each additional strata included. In future sports injury research, we need stratified analyses if the target of our research is to respond to the question: 'how much change in training load is too much before injury is sustained, among athletes with different characteristics?' Responding to this question using multiple time-varying exposures (and outcomes) requires millions of injuries. This should not be a barrier for future research, but collaborations across borders to collecting the amount of data needed seems to be an important step forward.
Injuries impair the chance of successful performance by sportspeople : A systematic review
- Authors: Drew, Michael , Raysmith, Ben , Charlton, Paula
- Date: 2017
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 51, no. 16 (2017), p. 1209-1214
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- Description: Background Cost-benefit analyses have been proposed for determining acceptable risk of injury regarding training and competition participation. Currently, there is no best evidence synthesis of the literature evaluating the relationship between injury/illness and chance of success or failure. Objective To evaluate the relationship between injury and/or illness and success and/or failure in athletic populations (individual and team sports). Methods This review was prospectively registered (PROSPERO CRD42016036729) and a systematic electronic search was conducted in May 2016. Inclusion criterion was any study design describing the association between injury and/or illness and success or failure in athletic performance. Two independent authors screened search results, performed data extraction and assessed methodological quality and strength of evidence using a modified Downs and Black appraisal tool and a modified van Tulder method, respectively. Results Of 10 546 titles identified, 14 satisfied the inclusion criteria and 7 had low risk of bias. Outcome measures associated with success and/or failure included: (1) availability of team members, (2) injury incidence, (3) injury burden, (4) squad utilisation and (5, 6) precompetition and in-competition injury. There was strong evidence that (1) increased availability of team members/athletes decreased the risk of failure and (2) precompetition and in-competition injuries were associated with increased risk of failure. Conclusions Injuries have a detrimental impact on team and individual athletic success. Increased player availability improves chances of success. Conversely, injuries sustained both prior to and during competition may increase risk of failure. Injury prevention should therefore be a priority for maximising athletic performance. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Is subsequent lower limb injury associated with previous injury? A systematic review and meta-analysis
- Authors: Toohey, Liam , Drew, Michael , Cook, Jill , Finch, Caroline , Gaida, Jamie
- Date: 2017
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 51, no. 23 (2017), p. 1670-1678
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- Description: Background Previous injury is a strong risk factor for recurrent lower limb injury in athletic populations, yet the association between previous injury and a subsequent injury different in nature or location is rarely considered. Objective To systematically review data on the risk of sustaining a subsequent lower limb injury different in nature or location following a previous injury. Methods Eight medical databases were searched. Studies were eligible if they reported lower limb injury occurrence following any injury of a different anatomical site and/or of a different nature, assessed injury risk, contained athletic human participants and were written in English. Two reviewers independently applied the eligibility criteria and performed the risk of bias assessment. Meta-analysis was conducted using a random effects model. Results Twelve studies satisfied the eligibility criteria. Previous history of an ACL injury was associated with an increased risk of subsequent hamstring injury (three studies, RR=2.25, 95% CI 1.34 to 3.76), but a history of chronic groin injury was not associated with subsequent hamstring injury (three studies, RR=1.14, 95% CI 0.29 to 4.51). Previous lower limb muscular injury was associated with an increased risk of sustaining a lower limb muscular injury at a different site. A history of concussion and a variety of joint injuries were associated with an increased subsequent lower limb injury risk. Conclusions The fact that previous injury of any type may increase the risk for a range of lower limb subsequent injuries must be considered in the development of future tertiary prevention programmes. Systematic review registration number CRD42016039904 (PROSPERO). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
The association between social support and physical activity in older adults : A systematic review
- Authors: Lindsay Smith, Gabrielle , Banting, Lauren , Eime, Rochelle , O'Sullivan, Grant , van Uffelen, Jannique
- Date: 2017
- Type: Text , Journal article , Review
- Relation: International Journal of Behavioral Nutrition and Physical Activity Vol. 14, no. 1 (2017), p. 1-21
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- Description: Background: The promotion of active and healthy ageing is becoming increasingly important as the population ages. Physical activity (PA) significantly reduces all-cause mortality and contributes to the prevention of many chronic illnesses. However, the proportion of people globally who are active enough to gain these health benefits is low and decreases with age. Social support (SS) is a social determinant of health that may improve PA in older adults, but the association has not been systematically reviewed. This review had three aims: 1) Systematically review and summarise studies examining the association between SS, or loneliness, and PA in older adults; 2) clarify if specific types of SS are positively associated with PA; and 3) investigate whether the association between SS and PA differs between PA domains. Methods: Quantitative studies examining a relationship between SS, or loneliness, and PA levels in healthy, older adults over 60 were identified using MEDLINE, PSYCInfo, SportDiscus, CINAHL and PubMed, and through reference lists of included studies. Quality of these studies was rated. Results: This review included 27 papers, of which 22 were cross sectional studies, three were prospective/longitudinal and two were intervention studies. Overall, the study quality was moderate. Four articles examined the relation of PA with general SS, 17 with SS specific to PA (SSPA), and six with loneliness. The results suggest that there is a positive association between SSPA and PA levels in older adults, especially when it comes from family members. No clear associations were identified between general SS, SSPA from friends, or loneliness and PA levels. When measured separately, leisure time PA (LTPA) was associated with SS in a greater percentage of studies than when a number of PA domains were measured together. Conclusions: The evidence surrounding the relationship between SS, or loneliness, and PA in older adults suggests that people with greater SS for PA are more likely to do LTPA, especially when the SS comes from family members. However, high variability in measurement methods used to assess both SS and PA in included studies made it difficult to compare studies. © 2017 The Author(s).
The new concussion in sport guidelines are here. But how do we get them out there?
- Authors: Finch, Caroline , White, Peta
- Date: 2017
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 51, no. 24 (2017), p. 1734-1736
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Towards the reduction of injury and illness in athletes : Defining our research priorities
- Authors: Finch, Caroline , Bahr, Roald , Drezner, Jonathan , Dvorak, Jiri , Engebretsen, Lars , Hewett, Timothy , Junge, Astrid , Khan, Karim , Macauley, Domhnall , Matheson, Gordon , McCrory, Paul , Verhagen, Evert
- Date: 2017
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 51, no. 16 (2017), p. 1178-1182
- Relation: http://purl.org/au-research/grants/nhmrc/1058737
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What is the definition of sports-related concussion : A systematic review
- Authors: McCrory, Paul , Feddermann-Demont, Nina , Dvorak, Jiri , Cassidy, David , McIntosh, Andrew , Vos, Pieter , Echemendia, Ruben , Meeuwisse, Willem , Tarnutzer, Alexander
- Date: 2017
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 51, no. 11 (2017), p. 877-887
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- Description: Objectives: Various definitions for concussion have been proposed, each having its strengths and weaknesses. We reviewed and compared current definitions and identified criteria necessary for an operational definition of sports-related concussion (SRC) in preparation of the 5th Concussion Consensus Conference (Berlin, Germany). We also assessed the role of biomechanical studies in informing an operational definition of SRC. Design: This is a systematic literature review. Data sources: Data sources include MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Clinical Trials and SPORT Discus (accessed 14 September 2016). Eligibility criteria for selecting studies: Eligibility criteria were studies reporting (clinical) criteria for diagnosing SRC and studies containing SRC impact data. Results: Out of 1601 articles screened, 36 studies were included (2.2%), 14 reported on criteria for SRC definitions and 22 on biomechanical aspects of concussions. Six different operational definitions focusing on clinical findings and their dynamics were identified. Biomechanical studies were obtained almost exclusively on American football players. Angular and linear head accelerations linked to clinically confirmed concussions demonstrated considerable individual variation. Summary/conclusions: SRC is a traumatic brain injury that is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature. Limitations identified include that the current criteria for diagnosing SRC are clinically oriented and that there is no gold/standard to assess their diagnostic properties. A future, more valid definition of SRC would better identify concussed players by demonstrating high predictive positive/negative values. Currently, the use of helmet-based systems to study the biomechanics of SRC is limited to few collision sports. New approaches need to be developed to provide objective markers for SRC. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved.
Effects of exercise and manual therapy on pain associated with hip osteoarthritis : A systematic review and meta-analysis
- Authors: Beumer, Lucy , Wong, Jennie , Warden, Stuart , Kemp, Joanne , Foster, Paul , Crossley, Kay
- Date: 2016
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 50, no. 8 (2016), p. 458-463
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- Description: Aim: To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA). Methods: A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0-3 months=short term; 4-12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores. Results: 19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD -0.53, 95% CI -0.96 to -0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD -0.49, 95% CI -0.70 to -0.29). There were no medium (SMD -0.23, 95% CI -0.48 to 0.03) or long (SMD -0.22, 95% CI -0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD -0.38, 95% CI -0.88 to 0.13) when compared to minimal control. Conclusions: Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger highquality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term.
Sports-related workload and injury risk : Simply knowing the risks will not prevent injuries : Narrative review
- Authors: Drew, Michael , Cook, Jill , Finch, Caroline
- Date: 2016
- Type: Text , Journal article , Review
- Relation: British Journal of Sports Medicine Vol. 50, no. 21 (2016), p. 1306-1309
- Relation: http://purl.org/au-research/grants/nhmrc/1058737
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- Description: Training loads contribute to sports injury risk but their mitigation has rarely been considered in a sports injury prevention framework. A key concept behind monitoring training loads for injury prevention is to screen for those at increased risk of injury so that workloads can be adjusted to minimise these risks. This review describes how advances in management of workload can be applied as a preventive measure. Primary prevention involves screening for preparticipation load risk factors, such as low training loads, prior to a training period or competition. Secondary prevention involves screening for workloads that are known to precede an injury developing so that modification can be undertaken to mitigate this risk. Tertiary prevention involves rehabilitation practices that include a graded return to training programme to reduce the risk of sustaining a subsequent injury. The association of training loads with injury incidence is now established. Prevention measures such as rule changes that affect the workload of an athlete are universal whereas those that address risk factors of an asymptomatic subgroup are more selective. Prevention measures, when implemented for asymptomatic individuals exhibiting possible injury risk factors, are indicated for an athlete at risk of developing a sports injury. Seven key indicated risks and associated prevention measures are proposed.