Monday, November 3, 2008

Cutting Edge Research: Evaluation of FIFA’s “The 11” Injury Prevention Program

Injuries in soccer are an unfortunate but real part of the game. This is particularly true in women who are far more susceptible to non-contact ACL injuries than are men. A few years back F-MARC, an expert medical panel convened by FIFA, developed a structured warm-up program designed to reduce the incidence of injury. The program was designed based on previous research into injury prevention and established practices of rehabilitation. This evidence based and best practice program was named “The 11” and consists of 10 exercises plus one fair play component. The exercises include plyometrics, strength, flexibility and neuromuscular training and are designed to be completed in about 15-20 minutes as part of the regular warm-up.

Two studies just released however, found that The 11 may not be as successful in reducing injuries or improving performance as hoped. However, the authors of these studies provide some specific recommendations for modifying The 11 in an effort to improve its effectiveness.

Two recent studies from the Oslo Sports Trauma Research Center evaluated the effectiveness of The 11 at reducing injury risk and improving performance. The studies involved female players, ages 16-18 years. It was a large scale look at injuries involving some 2100 players. A subset of 34 players was used to evaluate possible performance improvements.

For both studies, half of the teams studied used The 11 prior as part of their warm-up routine. The other teams performed their traditional warm-up. The specific exercises and their descriptions are posted on the FIFA website. They include exercises focusing on core stability, balance, plyometrics and strength. The coaches were instructed on technique and implementation of The 11 and were asked to use it every session during pre-season and early season and at least once per week later in the season. After the instructional training, the coaches were left to use the program on their own.

For the injury analysis, a group of physical therapists recorded each injury and its circumstances. For the performance analysis, players were measured on a series of physical tests (e.g. strength, vertical jump, sprint speed) as well as soccer skill tests (e.g. dribbling speed, kicking distance). Tests were performed before and after the season.

The researchers found that The 11 was not effective in lowering injury rates. The types of injuries and the time lost from practice were not different between the teams that used The 11 and those that did not. This held for teams that were very compliant (performed most of the sessions) and those that were not (performed far fewer sessions than were required). the program was also not effective in improving any of the performance indicators

The most intriguing part of each study was that compliance to The 11 was very low, only 52%. That is, only about half of the required sessions were completed. A few teams were very compliant and performed the majority of the sessions but overall, most of the teams were not. This means that during the later part of the season, most teams used The 11 once every two weeks. This is far too infrequent to elicit any sort of training effect. It is very likely that the lack of effect in terms of performance or injury prevention was due to the low compliance. It may be that the coaches and players failed to see the importance of the program and had little motivation to continue as the season progressed. In order to improve compliance, the authors suggest the need for continuous feedback and encouragement to the coaches, trainers and players, especially later in the season when the “newness” of the program has waned.

The authors also argue another possible reason for the ineffectiveness of The 11 is that the intensity is too low and it does not allow for any progression. The same exercise routines performed at the beginning of the program were used at the end. The number of sets and reps remains constant. Also other programs that have targeted injury prevention lasted some 60-90 min per session compared to only 15 min for The 11 (link to post on ACL prevention programs). They stress that there is also a need for more soccer specific exercises that are dynamic involving running, cutting and landing.

Overall, one can conclude that The 11 has a sound theoretical basis. The exercises are selected based on previous research and clinical practice. The true effectiveness of the program in meeting its objective of lowering injury risk is difficult to evaluate based on these studies since compliance to the program was low. However, this may be an inherent problem with the program and is something that F-MARC should address.

Also, provisions for modification in The 11 need to be made so that the program is more progressive in nature. That is, the number of repetitions or sets should be progressively increased as the players improve. A fundamental tenant of exercise adaptation (i.e. training) is progressive overload, as strength or fitness improves, the training load should be increased. As it stands, The 11 does not specifically address this. Recommendations should be made with regard to increasing the overall intensity of the program.

Those criticisms aside, coaches and trainers should be encouraged to include the types of exercises in The 11 as part of their regular training program. Injury prevention should be a key goal, just important as the technical and tactical aspects of the game. Given the high rate of knee, ankle and hamstring injuries in soccer, particularly in women, training programs that have the potential to lower the risk of injury should be strongly considered. Regardless of the technical prowess that a player possesses, he or she is ineffective if injured and unable to play.

References:

Steffen K, Bakka HM, Myklebust G, Bahr R (2008) Performance aspects of an injury prevention program: a ten-week intervention in adolescent female football players. Scandinavian Journal of Medicine, Science and Sports. 18: 596-604.

Steffen K, Myklebust G, Olsen OE, Holmes I, Bahr R (2008) Preventing injuries in female youth football – a cluster-randomized controlled trial. Scandinavian Journal of Medicine, Science and Sports. 18: 605-614.