Wednesday, December 28, 2011

More Evidence Supporting Injury Prevention Training: Cost Effectiveness

Over the past years, the SSO has posted several articles about neuromuscular training programs designed to reduce the risk of injury. We have been especially concerned about preventing non-contact injuries to the anterior cruciate ligament (ACL) in female players. An ACL tear can be personally devastating to the athlete and result in significant financial costs. Fortunately, the overwhelming consensus is that neuromuscular training programs are highly effective in reducing risk factors as well as occurrence of ACL injuries. A new study by researchers at Northwestern University and the Children’s Memorial Hospital in Chicago trained urban-area, high school basketball and soccer coaches in using a neuromuscular warm-up program. They found teams that using the program substantially reduced injuries to both the knee and ankle. What is unique about this study is that for a small financial investment in training coaches, a large return in injury prevention was realized.

The study was conducted in the Chicago public school system. This is an urban school district that enrolls predominantly low-income students. This is an important aspect of the study as the investigators point out that these schools and athletic teams often have erratic practice conditions (times, equipment and facilities), no athletic trainers on staff and access to health care is lacking for most of the players. Given this, it is clear that the athletes in this school system could benefit greatly from a program designed to reduce the rate of injuries.

All of the 258 head girl’s soccer and basketball coaches in the school district (varsity, junior varsity, sophomore and freshman teams) were contacted and asked to participate in the study. Of those, 95 coaches (37%) representing 111 teams and almost 1500 athletes agreed to participate. The coaches were then randomly divided into control and intervention groups.

The coaches in the intervention group attended a 2-hour training session where they were instructed on how to use the 20-minute neuromuscular warm-up program. A similar program mentioned on the SSO is the FIFA 11+. They were taught the specific exercise that should be used before each practice as well as before games. They were also taught how to distinguish between correct and incorrect form and how to use verbal cues to encourage proper form. Each coach also received a DVD with narrated videos of the exercises, a laminated card for use on the field or court and printed educational materials about knee injuries and neuromuscular training. The compliance rate was very high. The coaches in the intervention group reported that they used the program at 80% of their practices.

The control group coaches received no training in injury prevention and simply went about coaching their teams as done previously.

All of the coaches were asked to complete weekly injury reports. In addition, the researchers met with the coaches and athletes to discuss injuries and to determine the type of injury and how the injury occurred. The investigators were interested in non-contact knee and ankle injuries and whether they were acute (due to a single event) or gradual-onset (developed over the course of several days). No additional information or encouragement to use the warm-up program was provided to the coaches of the intervention group.

The effectiveness of the warm-up program was impressive. The intervention group experienced a 65% reduction in gradual-onset injuries a 56% reduction in acute injuries. Ankle injuries were reduced by 66% in the intervention group. In addition, all athletes sustaining an ACL injury that required surgery were in the control group.

Overall, a 20-minute neuromuscular warm-up program, used prior to training reduced the rate of non-contact knee and ankle injuries by almost two-thirds.

An interesting aspect of the study is the cost effectiveness of the program. The investigators report that the cost of training each coach and providing him/her with a DVD and printed materials was $80 per coach ($4 for each soccer player). The return on this investment was a substantial reduction in medical costs used to treat knee and ankle injuries. For example, using data for ACL tears, for every 11 soccer coaches trained, one ACL injury could be prevented. To put that into perspective, a 6-team high school league could invest $960 towards training 6 varsity and 6 junior varsity coaches in neuromuscular injury prevention (12 X $80). That investment could result in one less torn ACL during the upcoming season. That doesn’t seem like a big impact, but given the costs of ACL surgery and rehabilitation, it translates into a savings of $17,000 to $25,000 in medical costs. Add to that, the personal costs associated with recovery and the increased risk of developing knee osteoarthritis later in life, the total cost savings could be considerable.

It should also be pointed out that this study examined injuries during a single school year or a single season. It seems reasonable that coaches who are trained in the warm-up program would continue to use it during the following seasons. Thus, the cost effectiveness becomes even greater. For example, over a four-year period, the medical cost savings on ACL ruptures alone could potentially approach $100,000. If the costs of other injuries such as ankle and knee sprains are considered, there could be a tremendous return for less than $1000 invested in prevention.

This notion can also be extended to local soccer clubs. Taking into account both recreational and competitive programs, a large club could easily enroll 100-150 high school aged girls. Thus, for a small financial investment in training coaches on injury prevention, there is the potential of lowering knee and ankle injuries by nearly two-thirds as well as reducing health care costs for a number of young female athletes.

In a follow-up commentary, clinicians at the University of Wisconsin at Madison point out that there has been a large increase in the number of for-profit sports performance-training programs available to young athletes. These programs typically emphasize performance but the types of exercises used (strengthening, balance, plyometrics flexibility and agility) mimic the components of a comprehensive neuromuscular injury prevention program. The costs of these programs can range from $100-200 per month or $20-50 per session. This is clearly out of reach for low-income families and young athletes such as those in the Chicago public school system. Thus, a low-cost, school-based training program could provide athletes from low-income families much needed access to injury prevention. Recall that athletes in urban school systems may not have access to athletic trainers. Also, financial situation may prevent them from seeking proper evaluation and treatment by a medical professional. Given this, it is easy to see the potential benefit of such a program in such a population of athletes cannot be underestimated.

The authors of the commentary also point out that more coaches and administrators might be more interested in injury prevention if the program was repackaged as a sport enhancement program. After all, “we play to win the game” and coaches are often more keen to work on sport-specific skills than injury prevention. There is scientific support for this marketing idea. Multiple studies show that neuromuscular training designed to reduce injury risk also improves performance in soccer players as well as volleyball, basketball and tennis athletes. Thus, emphasizing that a neuromuscular training program could improve match performance might entice more coaches to make it a part of their regular training session.

The evidence continues to mount. Neuromuscular training programs are successful in reducing the risk of knee and ankle injuries. In addition, they have the added benefit of being both cost-effective and improving performance in the field or on the court.

REFERENCES

LaBella CR, Huxford MR, Grissom J, Kim K-Y, Peng J, Christoffel KK (2011) Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools. Archives of Pediatric and Adolescent Medicine, 165, 1033-1040.

Brooks MA, McGuine TA (2011) Translating cost-effective injury prevention research into sustainable change on the playing field. The youth injury epidemic. Archives of Pediatric and Adolescent Medicine, 165, 1050-1049.