Categorising sports injuries in epidemiological studies : the subsequent injury categorisation (SIC) model to address multiple, recurrent and exacerbation of injuries
- Authors: Finch, Caroline , Cook, Jill
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no.17, p. 1-6
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
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- Description: Objective: Sports injuries are often recurrent and there is wide recognition that a subsequent injury (of either the same or a different type) can be strongly influenced by a previous injury. Correctly categorising subsequent injuries (multiple, recurrent, exacerbation or new) requires substantial clinical expertise, but there is also considerable value in combining this expertise with more objective statistical criteria. This paper presents a new model, the subsequent injury categorisation (SIC) model, for categorising subsequent sports injuries that takes into account the need to include both acute and overuse injuries and ten different dependency structures between injury types. Methods: The suitability of the SIC model was demonstrated with date ordered sports injury data from a large injury database from community Australian football players over one playing season. A subsequent injury was defined to have occurred in the subset of players with two or more reported injuries. Results: 282 players sustained 469 subsequent injuries of which 15.6% were coded to categories representing injuries that were directly related to previous index injuries. This demonstrates that players can sustain a number of injuries over one playing season. Many of these will be unrelated to previous injuries but subsequent injuries that are related to previous injury occurrences are not uncommon. Conclusion: The handling of subsequent sports injuries is a substantial challenge for the sports medicine field—both in terms of injury treatment and in epidemiological research to quantify them. Application of the SIC model allows for multiple different injury types and relationships within players, as well as different index injuries.
- Authors: Finch, Caroline , Cook, Jill
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no.17, p. 1-6
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Objective: Sports injuries are often recurrent and there is wide recognition that a subsequent injury (of either the same or a different type) can be strongly influenced by a previous injury. Correctly categorising subsequent injuries (multiple, recurrent, exacerbation or new) requires substantial clinical expertise, but there is also considerable value in combining this expertise with more objective statistical criteria. This paper presents a new model, the subsequent injury categorisation (SIC) model, for categorising subsequent sports injuries that takes into account the need to include both acute and overuse injuries and ten different dependency structures between injury types. Methods: The suitability of the SIC model was demonstrated with date ordered sports injury data from a large injury database from community Australian football players over one playing season. A subsequent injury was defined to have occurred in the subset of players with two or more reported injuries. Results: 282 players sustained 469 subsequent injuries of which 15.6% were coded to categories representing injuries that were directly related to previous index injuries. This demonstrates that players can sustain a number of injuries over one playing season. Many of these will be unrelated to previous injuries but subsequent injuries that are related to previous injury occurrences are not uncommon. Conclusion: The handling of subsequent sports injuries is a substantial challenge for the sports medicine field—both in terms of injury treatment and in epidemiological research to quantify them. Application of the SIC model allows for multiple different injury types and relationships within players, as well as different index injuries.
The reach and adoption of a coach-led exercise training programme in community football
- Finch, Caroline, Diamantopoulou, Kathy, Twomey, Dara, Doyle, Tim, Lloyd, David, Young, Warren, Elliot, Bruce
- Authors: Finch, Caroline , Diamantopoulou, Kathy , Twomey, Dara , Doyle, Tim , Lloyd, David , Young, Warren , Elliot, Bruce
- Date: 2013
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine. Vol. 48(8), p.718-723.
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
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- Description: Objective: To determine the reach and adoption of a coach-led exercise training programme for lower limb injury prevention. Design: Secondary analysis of data from a group-clustered randomised controlled trial. Setting: A periodised exercise training warm-up programme was delivered to players during training sessions over an 8-week preseason (weeks 1–8) and 18-week playing season. Participants: 1564 community Australian football players. Main outcome measurements: Reach, measured weekly, was the number of players who attended training sessions. Adoption was the number of attending players who completed the programme in full, partially or not at all. Reasons for partial or non-participation were recorded. Results: In week 1, 599 players entered the programme; 55% attended 1 training session and 45% attended > 1 session. By week 12, 1540 players were recruited but training attendance (reach) decreased to <50%. When players attended training, the majority adopted the full programme—ranging from 96% (week 1) to above 80% until week 20. The most common reasons for low adoption were players being injured, too sore, being late for training or choosing their own warm-up. Conclusions: The training programme's reach was highest preseason and halved at the playing season's end. However, when players attended training sessions, their adoption was high and remained close to 70% by season end. For sports injury prevention programmes to be fully effective across a season, attention also needs to be given to (1) encouraging players to attend formal training sessions and (2) considering the possibility of some form of programme delivery outside of formal training.
- Authors: Finch, Caroline , Diamantopoulou, Kathy , Twomey, Dara , Doyle, Tim , Lloyd, David , Young, Warren , Elliot, Bruce
- Date: 2013
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine. Vol. 48(8), p.718-723.
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Objective: To determine the reach and adoption of a coach-led exercise training programme for lower limb injury prevention. Design: Secondary analysis of data from a group-clustered randomised controlled trial. Setting: A periodised exercise training warm-up programme was delivered to players during training sessions over an 8-week preseason (weeks 1–8) and 18-week playing season. Participants: 1564 community Australian football players. Main outcome measurements: Reach, measured weekly, was the number of players who attended training sessions. Adoption was the number of attending players who completed the programme in full, partially or not at all. Reasons for partial or non-participation were recorded. Results: In week 1, 599 players entered the programme; 55% attended 1 training session and 45% attended > 1 session. By week 12, 1540 players were recruited but training attendance (reach) decreased to <50%. When players attended training, the majority adopted the full programme—ranging from 96% (week 1) to above 80% until week 20. The most common reasons for low adoption were players being injured, too sore, being late for training or choosing their own warm-up. Conclusions: The training programme's reach was highest preseason and halved at the playing season's end. However, when players attended training sessions, their adoption was high and remained close to 70% by season end. For sports injury prevention programmes to be fully effective across a season, attention also needs to be given to (1) encouraging players to attend formal training sessions and (2) considering the possibility of some form of programme delivery outside of formal training.
Moving physical activity beyond the school classroom : A social-ecological insight for teachers of the facilitators and barriers to students' non-curricular physical activity
- Hyndman, Brendon, Telford, Amanda, Finch, Caroline, Benson, Amanda
- Authors: Hyndman, Brendon , Telford, Amanda , Finch, Caroline , Benson, Amanda
- Date: 2012
- Type: Text , Journal article
- Relation: Australian Journal of Teacher Education Vol. 37, no. 2 (2012), p.1-24
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
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- Description: Non-curricular avenues such as active play during school breaks have been established as a major source for children’s physical and cognitive development, yet there is little information for teachers on the influences affecting primary and secondary school students’ non-curricular physical activity. During this study focus groups and drawing were used to explore the broader influences on primary (n=47) and secondary (n=29) school students’ physical activity behaviour beyond the classroom. Barriers and facilitators to children’s physical activity were categorised using a multi-level social-ecological framework incorporating intrapersonal, interpersonal, physical environment and policy factors. Based on the drawings, comparisons between students’ existing play spaces and their perception of their ideal play space were made. Additionally, students depicted what features within a play space would encourage them to be active. The findings of the study indicate secondary school play spaces may need to incorporate more features to facilitate physical activity. The barriers and facilitators identified in this study provide information for teachers and school decision makers to consider when targeting children’s physical activity beyond school classrooms.
- Authors: Hyndman, Brendon , Telford, Amanda , Finch, Caroline , Benson, Amanda
- Date: 2012
- Type: Text , Journal article
- Relation: Australian Journal of Teacher Education Vol. 37, no. 2 (2012), p.1-24
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Non-curricular avenues such as active play during school breaks have been established as a major source for children’s physical and cognitive development, yet there is little information for teachers on the influences affecting primary and secondary school students’ non-curricular physical activity. During this study focus groups and drawing were used to explore the broader influences on primary (n=47) and secondary (n=29) school students’ physical activity behaviour beyond the classroom. Barriers and facilitators to children’s physical activity were categorised using a multi-level social-ecological framework incorporating intrapersonal, interpersonal, physical environment and policy factors. Based on the drawings, comparisons between students’ existing play spaces and their perception of their ideal play space were made. Additionally, students depicted what features within a play space would encourage them to be active. The findings of the study indicate secondary school play spaces may need to incorporate more features to facilitate physical activity. The barriers and facilitators identified in this study provide information for teachers and school decision makers to consider when targeting children’s physical activity beyond school classrooms.
Ensuring implementation success: how should coach injury prevention education be improved if we want coaches to deliver safety programmes during training sessions?
- White, Peta, Otago, Leonie, Saunders, Natalie, Romiti, Maria, Donaldson, Alex, Ullah, Shahid, Finch, Caroline
- Authors: White, Peta , Otago, Leonie , Saunders, Natalie , Romiti, Maria , Donaldson, Alex , Ullah, Shahid , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 5 (2014), p. 402-403
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Coaches play a major role in encouraging and ensuring that participants of their teams adopt appropriate safety practices. However, the extent to which the coaches undertake this role will depend upon their attitudes about injury prevention, their perceptions of what the other coaches usually do and their own beliefs about how much control they have in delivering such programmes. Fifty-one junior netball coaches were surveyed about incorporating the teaching of correct (safe) landing technique during their delivery of training sessions to junior players. Overall, >94% of coaches had strongly positive attitudes towards teaching correct landing technique and >80% had strongly positive perceptions of their own control over delivering such programmes. Coaches’ ratings of social norms relating to what others think about teaching safe landing were more positive (>94%) than those relating to what others actually do (63–74%). In conclusion, the junior coaches were generally receptive towards delivering safe landing training programmes in the training sessions they led. Future coach education could include role modelling by prominent coaches so that more community-level coaches are aware that this is a behaviour that many coaches can, and do, engage in.
- Authors: White, Peta , Otago, Leonie , Saunders, Natalie , Romiti, Maria , Donaldson, Alex , Ullah, Shahid , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 5 (2014), p. 402-403
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Coaches play a major role in encouraging and ensuring that participants of their teams adopt appropriate safety practices. However, the extent to which the coaches undertake this role will depend upon their attitudes about injury prevention, their perceptions of what the other coaches usually do and their own beliefs about how much control they have in delivering such programmes. Fifty-one junior netball coaches were surveyed about incorporating the teaching of correct (safe) landing technique during their delivery of training sessions to junior players. Overall, >94% of coaches had strongly positive attitudes towards teaching correct landing technique and >80% had strongly positive perceptions of their own control over delivering such programmes. Coaches’ ratings of social norms relating to what others think about teaching safe landing were more positive (>94%) than those relating to what others actually do (63–74%). In conclusion, the junior coaches were generally receptive towards delivering safe landing training programmes in the training sessions they led. Future coach education could include role modelling by prominent coaches so that more community-level coaches are aware that this is a behaviour that many coaches can, and do, engage in.
Independent appraiser assessment of the quality, methodological rigour and transparency of the development of the 2008 international consensus statement on concussion in sport
- White, Peta, Wong Shee, Anna, Finch, Caroline
- Authors: White, Peta , Wong Shee, Anna , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 2 (2014), p. 130-134
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Aim: In recent years, considerable effort has been devoted to the development and revisions to an international consensus statement on concussion in sport (ICSCS). The aim of this study was to obtain expert views on the methodological rigour and transparency with which the 2008 ICSCS was developed, as a precursor to the development of the 2012 update. Methods: Delegates registered for the 2012 fourth International Conference on Concussion in Sport, selected local concussion researchers not involved in any prior international consensus meetings, and all authors of the 2008 ICSCS published paper were invited to assess the methodological rigour and transparency with which the 2008 ICSCS was developed. The online Appraisal of Guidelines for Research and Evaluation (AGREE) II assessment tool, with six quality domains, was used and domain scores were expressed as a percentage of the maximum possible score for that domain. Results: 18 appraisers completed the online AGREE II assessment. Ten appraisers said they would recommend the 2008 ICSCS for use (without modification) and seven said they would recommend its use with some modification. The 'scope and purpose' and 'clarity of presentation' were rated highest, both scoring 78%. The lowest scoring domain was 'applicability' with a score of 55%. Conclusions: The quality of the ICSCS is important because it is used to guide return-to-play decisions and the management of sport-related concussions. This appraisal of the 2008 ICSCS suggests that a greater focus is needed on the actual implementation of future ICSCS and the relationship between implementation and desired health outcomes.
- Authors: White, Peta , Wong Shee, Anna , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 2 (2014), p. 130-134
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Aim: In recent years, considerable effort has been devoted to the development and revisions to an international consensus statement on concussion in sport (ICSCS). The aim of this study was to obtain expert views on the methodological rigour and transparency with which the 2008 ICSCS was developed, as a precursor to the development of the 2012 update. Methods: Delegates registered for the 2012 fourth International Conference on Concussion in Sport, selected local concussion researchers not involved in any prior international consensus meetings, and all authors of the 2008 ICSCS published paper were invited to assess the methodological rigour and transparency with which the 2008 ICSCS was developed. The online Appraisal of Guidelines for Research and Evaluation (AGREE) II assessment tool, with six quality domains, was used and domain scores were expressed as a percentage of the maximum possible score for that domain. Results: 18 appraisers completed the online AGREE II assessment. Ten appraisers said they would recommend the 2008 ICSCS for use (without modification) and seven said they would recommend its use with some modification. The 'scope and purpose' and 'clarity of presentation' were rated highest, both scoring 78%. The lowest scoring domain was 'applicability' with a score of 55%. Conclusions: The quality of the ICSCS is important because it is used to guide return-to-play decisions and the management of sport-related concussions. This appraisal of the 2008 ICSCS suggests that a greater focus is needed on the actual implementation of future ICSCS and the relationship between implementation and desired health outcomes.
Social marketing: why injury prevention needs to adopt this behaviour change approach
- Newton, Joshua, Ewing, Michael, Finch, Caroline
- Authors: Newton, Joshua , Ewing, Michael , Finch, Caroline
- Date: 2013
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 47, no. (2013), p. 665-667
- Full Text:
- Reviewed:
- Authors: Newton, Joshua , Ewing, Michael , Finch, Caroline
- Date: 2013
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 47, no. (2013), p. 665-667
- Full Text:
- Reviewed:
Knowledge about sports-related concussion: is the message getting through to coaches and trainers?
- White, Peta, Newton, Joshua, Makdissi, Michael, Sullivan, John, Davis, Gavin, McCrory, Paul, Donaldson, Alex, Ewing, Michael, Finch, Caroline
- Authors: White, Peta , Newton, Joshua , Makdissi, Michael , Sullivan, John , Davis, Gavin , McCrory, Paul , Donaldson, Alex , Ewing, Michael , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 2 (2014), p. 119-124
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Aim: The need for accurate diagnosis and appropriate return-to-play decisions following a concussion in sports has prompted the dissemination of guidelines to assist managing this condition. This study aimed to assess whether key messages within these guidelines are reflected in the knowledge of coaches and sports trainers involved in community sport. Methods: An online knowledge survey was widely promoted across Australia in May–August 2012 targeting community Australian Football (AF) and Rugby League (RL) coaches and sports trainers. 260 AF coaches, 161 AF sports trainers, 267 RL coaches and 228 RL sports trainers completed the survey. Knowledge scores were constructed from Likert scales and compared across football codes and respondent groups. Results: General concussion knowledge did not differ across codes but sports trainers had higher levels than did coaches. There were no significant differences in either concussion symptoms or concussion management knowledge across codes or team roles. Over 90% of respondents correctly identified five of the eight key signs or symptoms of concussion. Fewer than 50% recognised the increased risk of another concussion following an initial concussion. Most incorrectly believed or were uncertain that scans typically show damage to the brain after a concussion occurs. Fewer than 25% recognised, and >40% were uncertain that younger players typically take longer to recover from concussion than adults. Conclusions: The key messages from published concussion management guidelines have not reached community sports coaches and sports trainers. This needs to be redressed to maximise the safety of all of those involved in community sport.
- Authors: White, Peta , Newton, Joshua , Makdissi, Michael , Sullivan, John , Davis, Gavin , McCrory, Paul , Donaldson, Alex , Ewing, Michael , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 2 (2014), p. 119-124
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Aim: The need for accurate diagnosis and appropriate return-to-play decisions following a concussion in sports has prompted the dissemination of guidelines to assist managing this condition. This study aimed to assess whether key messages within these guidelines are reflected in the knowledge of coaches and sports trainers involved in community sport. Methods: An online knowledge survey was widely promoted across Australia in May–August 2012 targeting community Australian Football (AF) and Rugby League (RL) coaches and sports trainers. 260 AF coaches, 161 AF sports trainers, 267 RL coaches and 228 RL sports trainers completed the survey. Knowledge scores were constructed from Likert scales and compared across football codes and respondent groups. Results: General concussion knowledge did not differ across codes but sports trainers had higher levels than did coaches. There were no significant differences in either concussion symptoms or concussion management knowledge across codes or team roles. Over 90% of respondents correctly identified five of the eight key signs or symptoms of concussion. Fewer than 50% recognised the increased risk of another concussion following an initial concussion. Most incorrectly believed or were uncertain that scans typically show damage to the brain after a concussion occurs. Fewer than 25% recognised, and >40% were uncertain that younger players typically take longer to recover from concussion than adults. Conclusions: The key messages from published concussion management guidelines have not reached community sports coaches and sports trainers. This needs to be redressed to maximise the safety of all of those involved in community sport.
Coding OSICS sports injury diagnoses in epidemiological studies : Does the background of the coder matter?
- Finch, Caroline, Orchard, John, Twomey, Dara, Saleem, Muhammad Saad, Ekegren, Christina, Lloyd, David, Elliott, Bruce
- Authors: Finch, Caroline , Orchard, John , Twomey, Dara , Saleem, Muhammad Saad , Ekegren, Christina , Lloyd, David , Elliott, Bruce
- Date: 2012
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine, Vol.48, p.552-556.
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Objective: To compare Orchard Sports Injury Classification System (OSICS-10) sports medicine diagnoses assigned by a clinical and non-clinical coder. Design: Assessment of intercoder agreement. Setting: Community Australian football. Participants: 1082 standardised injury surveillance records. Main outcome measurements: Direct comparison of the four-character hierarchical OSICS-10 codes assigned by two independent coders (a sports physician and an epidemiologist). Adjudication by a third coder (biomechanist). Results: The coders agreed on the first character 95% of the time and on the first two characters 86% of the time. They assigned the same four-digit OSICS-10 code for only 46% of the 1082 injuries. The majority of disagreements occurred for the third character; 85% were because one coder assigned a non-specific 'X' code. The sports physician code was deemed correct in 53% of cases and the epidemiologist in 44%. Reasons for disagreement included the physician not using all of the collected information and the epidemiologist lacking specific anatomical knowledge. Conclusions: Sports injury research requires accurate identification and classification of specific injuries and this study found an overall high level of agreement in coding according to OSICS-10. The fact that the majority of the disagreements occurred for the third OSICS character highlights the fact that increasing complexity and diagnostic specificity in injury coding can result in a loss of reliability and demands a high level of anatomical knowledge. Injury report form details need to reflect this level of complexity and data management teams need to include a broad range of expertise. Copyright Article author (or their employer) 2012.
- Authors: Finch, Caroline , Orchard, John , Twomey, Dara , Saleem, Muhammad Saad , Ekegren, Christina , Lloyd, David , Elliott, Bruce
- Date: 2012
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine, Vol.48, p.552-556.
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Objective: To compare Orchard Sports Injury Classification System (OSICS-10) sports medicine diagnoses assigned by a clinical and non-clinical coder. Design: Assessment of intercoder agreement. Setting: Community Australian football. Participants: 1082 standardised injury surveillance records. Main outcome measurements: Direct comparison of the four-character hierarchical OSICS-10 codes assigned by two independent coders (a sports physician and an epidemiologist). Adjudication by a third coder (biomechanist). Results: The coders agreed on the first character 95% of the time and on the first two characters 86% of the time. They assigned the same four-digit OSICS-10 code for only 46% of the 1082 injuries. The majority of disagreements occurred for the third character; 85% were because one coder assigned a non-specific 'X' code. The sports physician code was deemed correct in 53% of cases and the epidemiologist in 44%. Reasons for disagreement included the physician not using all of the collected information and the epidemiologist lacking specific anatomical knowledge. Conclusions: Sports injury research requires accurate identification and classification of specific injuries and this study found an overall high level of agreement in coding according to OSICS-10. The fact that the majority of the disagreements occurred for the third OSICS character highlights the fact that increasing complexity and diagnostic specificity in injury coding can result in a loss of reliability and demands a high level of anatomical knowledge. Injury report form details need to reflect this level of complexity and data management teams need to include a broad range of expertise. Copyright Article author (or their employer) 2012.
What do community football players think about different exercise-training programmes? Implications for the delivery of lower limb injury prevention programmes
- Finch, Caroline, Doyle, Tim, Dempsey, Alasdair, Elliott, Bruce, Twomey, Dara, White, Peta, Diamantopoulou, Kathy, Young, Warren, Lloyd, David
- Authors: Finch, Caroline , Doyle, Tim , Dempsey, Alasdair , Elliott, Bruce , Twomey, Dara , White, Peta , Diamantopoulou, Kathy , Young, Warren , Lloyd, David
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 8 (2014), p.702-707
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Background: Players are the targeted end-users and beneficiaries of exercise-training programmes implemented during coach-led training sessions, and the success of programmes depends upon their active participation. Two variants of an exercise-training programme were incorporated into the regular training schedules of 40 community Australian Football teams, over two seasons. One variant replicated common training practices, while the second was an evidence-based programme to alter biomechanical and neuromuscular factors related to risk of knee injuries. This paper describes the structure of the implemented programmes and compares players’ end-of-season views about the programme variants. Methods: This study was nested within a larger group-clustered randomised controlled trial of the effectiveness of two exercise-training programmes (control and neuromuscular control (NMC)) for preventing knee injuries. A post-season self-report survey, derived from Health Belief Model constructs, included questions to obtain players’ views about the benefits and physical challenges of the programme in which they participated. Results: Compared with control players, those who participated in the NMC programme found it to be less physically challenging but more enjoyable and potentially of more benefit. Suggestions from players about potential improvements to the training programme and its future implementation included reducing duration, increasing range of drills/exercises and promoting its injury prevention and other benefits to players. Conclusions: Players provide valuable feedback about the content and focus of implemented exercise-training programmes, that will directly inform the delivery of similar, or more successful, programmes in the future.
- Authors: Finch, Caroline , Doyle, Tim , Dempsey, Alasdair , Elliott, Bruce , Twomey, Dara , White, Peta , Diamantopoulou, Kathy , Young, Warren , Lloyd, David
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 8 (2014), p.702-707
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Background: Players are the targeted end-users and beneficiaries of exercise-training programmes implemented during coach-led training sessions, and the success of programmes depends upon their active participation. Two variants of an exercise-training programme were incorporated into the regular training schedules of 40 community Australian Football teams, over two seasons. One variant replicated common training practices, while the second was an evidence-based programme to alter biomechanical and neuromuscular factors related to risk of knee injuries. This paper describes the structure of the implemented programmes and compares players’ end-of-season views about the programme variants. Methods: This study was nested within a larger group-clustered randomised controlled trial of the effectiveness of two exercise-training programmes (control and neuromuscular control (NMC)) for preventing knee injuries. A post-season self-report survey, derived from Health Belief Model constructs, included questions to obtain players’ views about the benefits and physical challenges of the programme in which they participated. Results: Compared with control players, those who participated in the NMC programme found it to be less physically challenging but more enjoyable and potentially of more benefit. Suggestions from players about potential improvements to the training programme and its future implementation included reducing duration, increasing range of drills/exercises and promoting its injury prevention and other benefits to players. Conclusions: Players provide valuable feedback about the content and focus of implemented exercise-training programmes, that will directly inform the delivery of similar, or more successful, programmes in the future.
Statistical modelling for recurrent events : An application to sports injuries
- Ullah, Shahid, Gabbett, Tim, Finch, Caroline
- Authors: Ullah, Shahid , Gabbett, Tim , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 17 (2014), p. 1287-1293
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Background: Injuries are often recurrent, with subsequent injuries influenced by previous occurrences and hence correlation between events needs to be taken into account when analysing such data. Objective: This paper compares five different survival models (Cox proportional hazards (CoxPH) model and the following generalisations to recurrent event data: Andersen-Gill (A-G), frailty, Wei-Lin-Weissfeld total time (WLW-TT) marginal, Prentice-Williams-Peterson gap time (PWP-GT) conditional models) for the analysis of recurrent injury data. Methods: Empirical evaluation and comparison of different models were performed using model selection criteria and goodness-of-fit statistics. Simulation studies assessed the size and power of each model fit. Results: The modelling approach is demonstrated through direct application to Australian National Rugby League recurrent injury data collected over the 2008 playing season. Of the 35 players analysed, 14 (40%) players had more than 1 injury and 47 contact injuries were sustained over 29 matches. The CoxPH model provided the poorest fit to the recurrent sports injury data. The fit was improved with the A-G and frailty models, compared to WLW-TT and PWP-GT models. Conclusions: Despite little difference in model fit between the A-G and frailty models, in the interest of fewer statistical assumptions it is recommended that, where relevant, future studies involving modelling of recurrent sports injury data use the frailty model inpreference to the CoxPH model or its other generalisations. The paper provides a rationale for future statistical modelling approaches for recurrent sports injury.
- Authors: Ullah, Shahid , Gabbett, Tim , Finch, Caroline
- Date: 2014
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 48, no. 17 (2014), p. 1287-1293
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Background: Injuries are often recurrent, with subsequent injuries influenced by previous occurrences and hence correlation between events needs to be taken into account when analysing such data. Objective: This paper compares five different survival models (Cox proportional hazards (CoxPH) model and the following generalisations to recurrent event data: Andersen-Gill (A-G), frailty, Wei-Lin-Weissfeld total time (WLW-TT) marginal, Prentice-Williams-Peterson gap time (PWP-GT) conditional models) for the analysis of recurrent injury data. Methods: Empirical evaluation and comparison of different models were performed using model selection criteria and goodness-of-fit statistics. Simulation studies assessed the size and power of each model fit. Results: The modelling approach is demonstrated through direct application to Australian National Rugby League recurrent injury data collected over the 2008 playing season. Of the 35 players analysed, 14 (40%) players had more than 1 injury and 47 contact injuries were sustained over 29 matches. The CoxPH model provided the poorest fit to the recurrent sports injury data. The fit was improved with the A-G and frailty models, compared to WLW-TT and PWP-GT models. Conclusions: Despite little difference in model fit between the A-G and frailty models, in the interest of fewer statistical assumptions it is recommended that, where relevant, future studies involving modelling of recurrent sports injury data use the frailty model inpreference to the CoxPH model or its other generalisations. The paper provides a rationale for future statistical modelling approaches for recurrent sports injury.
High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in Canadian youth female football players : A cluster randomised trial
- Steffen, Kathrin, Emery, Carolyn, Romiti, Maria, Kang, Jian, Bizzini, Mario, Dvorak, Jiri, Finch, Caroline, Meeuwisse, Willem
- Authors: Steffen, Kathrin , Emery, Carolyn , Romiti, Maria , Kang, Jian , Bizzini, Mario , Dvorak, Jiri , Finch, Caroline , Meeuwisse, Willem
- Date: 2013
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 47, no. 12 (2013), p. 794-802
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
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- Description: Background A protective effect on injury risk in youth sports through neuromuscular warm-up training routines has consistently been demonstrated. However, there is a paucity of information regarding the quantity and quality of coach-led injury prevention programmes and its impact on the physical performance of players. Objective The aim of this cluster-randomised controlled trial was to assess whether different delivery methods of an injury prevention programme (FIFA 11+) to coaches could improve player performance, and to examine the effect of player adherence on performance and injury risk. Method During the 2011 football season (May- August), coaches of 31 tiers 1-3 level teams were introduced to the 11+ through either an unsupervised website or a coach-focused workshop with and without additional on-field supervisions. Playing exposure, adherence to the 11+, and injuries were recorded for female 13-year-old to 18-year-old players. Performance testing included the Star Excursion Balance Test (SEBT), single-leg balance, triple hop and jumping-over-a-bar tests. Results Complete preseason and postseason performance tests were available for 226 players (66.5%). Compared to the unsupervised group, singleleg balance (OR=2.8; 95% CI 1.1 to 4.6) and the anterior direction of the SEBT improved significantly in the onfield supervised group of players (OR=4.7; 95% CI 2.2 to 7.1), while 2-leg jumping performance decreased (OR=-5.1; 95% CI -9.9 to -0.2). However, significant improvements in 5 of 6 reach distances in the SEBT were found, favouring players who highly adhered to the 11+. Also, injury risk was lower for those players (injury rate ratio, IRR=0.28, 95% CI 0.10 to 0.79). Conclusions Different delivery methods of the FIFA 11+ to coaches influenced players' physical performance minimally. However, high player adherence to the 11+ resulted in significant improvements in functional balance and reduced injury risk.
- Description: 2003011216
- Authors: Steffen, Kathrin , Emery, Carolyn , Romiti, Maria , Kang, Jian , Bizzini, Mario , Dvorak, Jiri , Finch, Caroline , Meeuwisse, Willem
- Date: 2013
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 47, no. 12 (2013), p. 794-802
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Background A protective effect on injury risk in youth sports through neuromuscular warm-up training routines has consistently been demonstrated. However, there is a paucity of information regarding the quantity and quality of coach-led injury prevention programmes and its impact on the physical performance of players. Objective The aim of this cluster-randomised controlled trial was to assess whether different delivery methods of an injury prevention programme (FIFA 11+) to coaches could improve player performance, and to examine the effect of player adherence on performance and injury risk. Method During the 2011 football season (May- August), coaches of 31 tiers 1-3 level teams were introduced to the 11+ through either an unsupervised website or a coach-focused workshop with and without additional on-field supervisions. Playing exposure, adherence to the 11+, and injuries were recorded for female 13-year-old to 18-year-old players. Performance testing included the Star Excursion Balance Test (SEBT), single-leg balance, triple hop and jumping-over-a-bar tests. Results Complete preseason and postseason performance tests were available for 226 players (66.5%). Compared to the unsupervised group, singleleg balance (OR=2.8; 95% CI 1.1 to 4.6) and the anterior direction of the SEBT improved significantly in the onfield supervised group of players (OR=4.7; 95% CI 2.2 to 7.1), while 2-leg jumping performance decreased (OR=-5.1; 95% CI -9.9 to -0.2). However, significant improvements in 5 of 6 reach distances in the SEBT were found, favouring players who highly adhered to the 11+. Also, injury risk was lower for those players (injury rate ratio, IRR=0.28, 95% CI 0.10 to 0.79). Conclusions Different delivery methods of the FIFA 11+ to coaches influenced players' physical performance minimally. However, high player adherence to the 11+ resulted in significant improvements in functional balance and reduced injury risk.
- Description: 2003011216
Implementing an exercise-training programme to prevent lower-limb injuries : Considerations for the development of a randomised controlled trial intervention delivery plan
- Finch, Caroline, White, Peta, Twomey, Dara, Ullah, Shahid
- Authors: Finch, Caroline , White, Peta , Twomey, Dara , Ullah, Shahid
- Date: 2011
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 45, no. 10 (2011), p. 791-796
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
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- Description: Objective To identify important considerations for the delivery of an exercise training intervention in a randomised controlled trial to maximise subsequent participation in that randomised controlled trial and intervention uptake. Design A cross-sectional survey, with a theoretical basis derived from the Health Belief Model (HBM) and the Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Participants 374 male senior Australian Football players, aged 17-38 years. Main outcome measurements Beliefs about lowerlimb injury causation/prevention, and the relative value of exercise training for performance and injury prevention. The data are interpreted within HBM constructs and implications for subsequent intervention implementation considered within the RE-AIM framework. Ordinal logistic regression compared belief scores across player characteristics. Results 74.4% of players agreed that doing specific exercises during training would reduce their risk of lower-limb injury and would be willing to undertake them. However, 64.1% agreed that training should focus more on improving game performance than injury prevention. Younger players (both in terms of age and playing experience) generally had more positive views. Players were most supportive of kicking (98.9%) and ball-handling (97.0%) skills for performance and warm-up runs and cool-downs (both 91.5%) for injury prevention. Fewer than three-quarters of all players believed that balance (69.2%), landing (71.3%) or cutting/stepping (72.8) training had injury-prevention benefits. Conclusions Delivery of future exercise training programmes for injury prevention aimed at these players should be implemented as part of routine football activities and integrated with those as standard practice, as a means of associating them with training benefits for this sport.
- Authors: Finch, Caroline , White, Peta , Twomey, Dara , Ullah, Shahid
- Date: 2011
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 45, no. 10 (2011), p. 791-796
- Relation: http://purl.org/au-research/grants/nhmrc/565900
- Full Text:
- Reviewed:
- Description: Objective To identify important considerations for the delivery of an exercise training intervention in a randomised controlled trial to maximise subsequent participation in that randomised controlled trial and intervention uptake. Design A cross-sectional survey, with a theoretical basis derived from the Health Belief Model (HBM) and the Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Participants 374 male senior Australian Football players, aged 17-38 years. Main outcome measurements Beliefs about lowerlimb injury causation/prevention, and the relative value of exercise training for performance and injury prevention. The data are interpreted within HBM constructs and implications for subsequent intervention implementation considered within the RE-AIM framework. Ordinal logistic regression compared belief scores across player characteristics. Results 74.4% of players agreed that doing specific exercises during training would reduce their risk of lower-limb injury and would be willing to undertake them. However, 64.1% agreed that training should focus more on improving game performance than injury prevention. Younger players (both in terms of age and playing experience) generally had more positive views. Players were most supportive of kicking (98.9%) and ball-handling (97.0%) skills for performance and warm-up runs and cool-downs (both 91.5%) for injury prevention. Fewer than three-quarters of all players believed that balance (69.2%), landing (71.3%) or cutting/stepping (72.8) training had injury-prevention benefits. Conclusions Delivery of future exercise training programmes for injury prevention aimed at these players should be implemented as part of routine football activities and integrated with those as standard practice, as a means of associating them with training benefits for this sport.
Time-to-event analysis for sports injury research part 1 : Time-varying exposures
- Nielsen, Rasmus, Bertelsen, Michael, Ramskov, Daniel, Møller, Merete, Hulme, Adam, Theisen, Daniel, Finch, Caroline, Fortington, Lauren, Mansournia, Mohammad, Parner, Erik
- 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
- Full Text:
- Reviewed:
- 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).
- 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
- Full Text:
- Reviewed:
- 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).
Controlled ecological evaluation of an implemented exercise-training programme to prevent lower limb injuries in sport : Population-level trends in hospital-treated injuries
- Finch, Caroline, Gray, Shannon, Akram, Muhammad, Donaldson, Alex, Lloyd, David, Cook, Jill
- Authors: Finch, Caroline , Gray, Shannon , Akram, Muhammad , Donaldson, Alex , Lloyd, David , Cook, Jill
- Date: 2019
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 53, no. 8 (2019), p. 487-492
- Full Text:
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- Description: Objective Exercise-training programmes have reduced lower limb injuries in trials, but their population-level effectiveness has not been reported in implementation trials. This study aimed to demonstrate that routinely collected hospital data can be used to evaluate population-level programme effectiveness. Method A controlled ecological design was used to evaluate the effect of FootyFirst, an exercise-training programme, on the number of hospital-treated lower limb injuries sustained by males aged 16-50 years while participating in community-level Australian Football. FootyFirst was implemented with a € support' (FootyFirst+S) or a € without support' (FootyFirst+NS) in different geographic regions of Victoria, Australia: 22 clubs in region 1: FootyFirst+S in 2012/2013; 25 clubs in region 2: FootyFirst+NS in 2012/2013; 31 clubs region 3: control in 2012, FootyFirst+S in 2013. Interrupted time-series analysis compared injury counts across regions and against trends in the rest of Victoria. Results After 1 year of FootyFirst+S, there was a non-statistically significant decline in the number of lower limb injuries in region 1 (2012) and region 3 (2013); this was not maintained after 2 years in region 1. Compared with before FootyFirst in 2006-2011, injury count changes at the end of 2013 were: region 1: 20.0% reduction (after 2 years support); region 2: 21.5% increase (after 2 years without support); region 3: 21.8% increase (after first year no programme, second year programme with support); rest of Victoria: 12.6% increase. Conclusion Ecological analyses using routinely collected hospital data show promise as the basis of population-level programme evaluation. The implementation and sustainability of sports injury prevention programmes at the population-level remains challenging.
- Authors: Finch, Caroline , Gray, Shannon , Akram, Muhammad , Donaldson, Alex , Lloyd, David , Cook, Jill
- Date: 2019
- Type: Text , Journal article
- Relation: British Journal of Sports Medicine Vol. 53, no. 8 (2019), p. 487-492
- Full Text:
- Reviewed:
- Description: Objective Exercise-training programmes have reduced lower limb injuries in trials, but their population-level effectiveness has not been reported in implementation trials. This study aimed to demonstrate that routinely collected hospital data can be used to evaluate population-level programme effectiveness. Method A controlled ecological design was used to evaluate the effect of FootyFirst, an exercise-training programme, on the number of hospital-treated lower limb injuries sustained by males aged 16-50 years while participating in community-level Australian Football. FootyFirst was implemented with a € support' (FootyFirst+S) or a € without support' (FootyFirst+NS) in different geographic regions of Victoria, Australia: 22 clubs in region 1: FootyFirst+S in 2012/2013; 25 clubs in region 2: FootyFirst+NS in 2012/2013; 31 clubs region 3: control in 2012, FootyFirst+S in 2013. Interrupted time-series analysis compared injury counts across regions and against trends in the rest of Victoria. Results After 1 year of FootyFirst+S, there was a non-statistically significant decline in the number of lower limb injuries in region 1 (2012) and region 3 (2013); this was not maintained after 2 years in region 1. Compared with before FootyFirst in 2006-2011, injury count changes at the end of 2013 were: region 1: 20.0% reduction (after 2 years support); region 2: 21.5% increase (after 2 years without support); region 3: 21.8% increase (after first year no programme, second year programme with support); rest of Victoria: 12.6% increase. Conclusion Ecological analyses using routinely collected hospital data show promise as the basis of population-level programme evaluation. The implementation and sustainability of sports injury prevention programmes at the population-level remains challenging.
Time-to-event analysis for sports injury research part 2 : Time-varying outcomes
- Nielsen, Rasmus, Bertelsen, Michael, Ramskov, Daniel, Møller, Merete, Hulme, Adam, Theisen, Daniel, Finch, Caroline, Fortington, Lauren, Mansournia, Mohammad, Parner, Erik
- 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
- Full Text:
- Reviewed:
- 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.
- 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
- Full Text:
- Reviewed:
- 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.
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