Feasibility of an Injury Prevention Program Delivered Remotely to Youth Soccer Players

Bellama Thomas¹, Awad Noura², Bray Katherine², Card Rachel², Carter Melanie², DiMercurio Cara², Doran Alexis², Hamilton Patricia², Rosentrater Heidi², Steele Emily², Streeter Jasmine², Wolski Cory², Riley Sean^3
1 Doctor of Physical Therapy Program, University of Hartford, Assistant Professor of Physical Therapy ^a
2 University of Hartford, Physical Therapy Program, 200 Bloomfield Avenue, West Hartford, CT 06117, USA
³ Hartford Healthcare Rehabilitation Network, Senior Author, Lead Physical Therapist ^b

^a 200 Bloomfield Avenue, West Hartford, CT 06117, USA
^b Glastonbury, CT, USA

Abstract

Adolescents injured playing soccer in the Northern Mariana Islands have limited healthcare resources. Injury prevention programs (IPPs) might decrease the need for healthcare resources, but the staff necessary to deliver those programs is limited. This study aimed to determine the feasibility of an IPP delivered remotely by tracking compliance. Secondarily, it aimed to assess IPP impact on biomechanics associated with injuries.
Male and female participants aged 12 to 18 were recruited. They participated in a tuck jump assessment and were provided two evidence-based IPPs weekly for eight weeks. Video links were emailed, and clicks were tracked to determine compliance. If a predetermined % compliance threshold of 33% were reached, the program would continue, the tuck jump assessment repeated, and biomechanics assessed.
Thirty-five participants were recruited and provided IPPs. The compliance rate was 1.61% at eight weeks, so the study was terminated.
Remote delivery of video IPPs via email to adolescent players in the Northern Mariana Islands with weekly reminders did not reach the level of compliance necessary to impact the risk of injury. Future studies should consider alternative delivery methods, utilize additional accountability methods, and create local accountability to maximize compliance to examine the impact on the risk of injury.

Zusammenfassung

Jugendliche, die sich beim Fussballspielen auf den Nörd­lichen Marianen verletzen, verfügen nur über begrenzte medizinische Ressourcen. Programme zur Verletzungsprävention (Injury Prevention Programs, IPP) könnten den Bedarf an Gesundheitsfürsorge reduzieren, aber das für die Durchführung dieser Programme erforderliche Personal ist begrenzt. Ziel dieser Studie war es, die Durchführbarkeit eines aus der Ferne durchgeführten IPP zu ermitteln und die Einhaltung der Vorschriften zu überwachen. In zweiter Linie sollten die Auswirkungen der IPP auf die Biomechanik im Zusammenhang mit Verletzungen untersucht werden.
Es wurden männliche und weibliche Teilnehmer im Alter von 12 bis 18 Jahren rekrutiert. Sie nahmen an einem Tuck Jump Assessment teil und erhielten acht Wochen lang wöchentlich zwei evidenzbasierte IPP. Die Video-Links wurden per E-Mail verschickt, und die Klicks wurden verfolgt, um die Compliance zu ermitteln. Wenn ein vorher festgelegter Schwellenwert von 33% erreicht wurde, wurde das Programm fortgesetzt, die Bewertung des Hocksprungs wiederholt und die Biomechanik bewertet.
Fünfunddreissig Teilnehmer erhielten IPP. Die Befolgungsquote lag nach acht Wochen bei 1,61%, so dass die Studie abgebrochen wurde.
Die Fernübertragung von Video-IPPs per E-Mail an jugendliche Spieler auf den Nördlichen Marianen mit wöchentlichen Erinnerungsschreiben erreichte nicht den Grad an Compliance, der notwendig wäre, um das Verletzungsrisiko zu beeinflussen. Zukünftige Studien sollten alternative Übermittlungsmethoden in Betracht ziehen, zusätzliche Methoden der Rechenschaftspflicht anwenden und lokale Rechenschaftspflicht schaffen, um die Einhaltung zu maximieren und die Auswirkungen auf das Verletzungsrisiko zu unter­suchen.

Schlüsselwörter: Fussball, Adoleszenz, Training, Risikofaktoren

Introduction

Background

Soccer has the highest participation of any team sport worldwide, is readily available in the Commonwealth of the Northern Mariana Islands (CNMI), but healthcare services are limited to manage soccer-related injuries.[1–4] Injury prevention programs (IPPs) decrease injuries relative to control groups and save healthcare systems money.[5–8] However, these programs are administered and supervised by coaches or healthcare professionals.[6–9] In the CNMI, where coaches and healthcare providers are limited, it may be unrealistic for coaches and healthcare professionals to deliver the IPPs so a novel IPP was developed to be administered directly to the athletes.[6–9] Prior data only support the effectiveness of coaches and healthcare providers administering IPPs in decreasing knee injuries in soccer players and female athletes.[10,11] Therefore, this novel delivery of an IPP requires investigation before implementation.
Prior research also indicates that injury reduction in youth soccer players due to IPPs increases with greater compliance.[12–14] A previous attempt at an IPP delivered by video in adolescent female basketball players demonstrated poor compliance, with 52% of participants performing the IPP less than 33% of the time.[15] However, in that study, the investigators did not contact the participants regarding IPP performance during the eight-week intervention.[15] Given the documented effectiveness of IPPs when compliance is high and the unknown compliance of IPPs delivered by video when participants are contacted regularly by the investigators, compliance should be examined first to determine the feasibility of the novel delivery method of this IPP.[12–14]

Objectives

This study aimed to determine the feasibility of implementing a novel delivery of an IPP in the CNMI. The IPP will be deemed feasible if compliance levels of the entire cohort reach a threshold to impact the risk of injury in youth soccer players.[12] If compliance reaches that threshold, a secondary aim is to determine the impact of the IPP on knee mechanics associated with injuries.[16–19]

Methods

Study Design

This study was a single cohort design with secondary data collection dependent on the initial results (University of Hartford, Institutional Review Board Approval April 26, 2023, Protocol 22-12-119). Participants were recruited through the Northern Mariana Islands Football Association (NMIFA), screened for inclusion criteria, and then completed the informed assent/consent process. Next, the participant completed a tuck jump assessment followed by eight weeks of an IPPs, emailed weekly with encouragement. Compliance was assessed at eight weeks. If compliance reached the threshold set a priori, the IPPs would continue for 48 weeks. After 48 weeks, the tuck jump assessment would be repeated.

Participants

Each player must be a member of the NMIFA National Team and be aged twelve to eighteen. This confirms that each participant has passed the required pre-participation medical examination and can complete the assent/consent process.
Setting
In-person recruiting and the tuck jump assessment occurred at the NMIFA Training Facility on June 29-30, 2023. The IPP was performed at locations and times determined by each participant.

Recruitment

One cohort of adolescent soccer players was recruited from the boys’ and girls’ national teams of the NMIFA. Players were screened remotely or in person for inclusion criteria and, if met, continued to the informed assent/consent process. A notice of withdrawal was also provided stating they can withdraw at any time.

Independent Variable/Intervention

The independent variable of this study was the remotely delivered IPP that consisted of two 20–30-minute video exercise programs sent to the participant weekly for eight weeks. Each video demonstrated the exercises with non-verbal cues for areas of focus. The parameters of each exercise were supplied in a document included in each program.
A training video was provided before the first exercise program that reviewed safety measures. Reminders were sent each week with encouragement to perform all exercises and access them individually.
The IPPs were based on AOPT and AASPT guidelines and were tailored to the population.[13] Each program was progressive, increasing the complexity and difficulty of exercises over time.
The IPP was designed to be performed with minimal equipment and limited space. This aimed to improve accessibility by allowing participants to complete it in any location.

Outcome Measures

Compliance was measured by tracking the number of accesses of each exercise of the IPPs. It is reported as a proportion and percentage of total accesses possible if each participant accessed each exercise in each program once.
FPPA of the knees during a tuck jump task would have been measured by video analysis of tuck jumps if compliance of the entire cohort reached a minimum threshold to impact the risk of injury.[12] Because compliance did not reach this threshold, FPPA measurements were never performed on the initial tuck jump assessment, and the post-IPP tuck jump assessment was not performed. The filming and measurement protocols and statistical analyses were established a priori and are detailed in the trial registration (https://osf.io/acqj9).

IPP Procedure

Weekly emails were sent to participants starting in July of 2023 with links to the IPPs and encouragement.
At eight weeks, the compliance data were assessed. While an IPP’s effectiveness in reducing injury depends on compliance, neither a consistent measure of compliance nor a threshold of compliance related to the efficacy of IPPs has emerged in adolescent soccer players.[12–14,21] However, a prior study notes a compliance rate of 33% or less with an IPP resulted in no change in the injury rate compared to a control group.[12]
If compliance with the IPP in the first eight weeks was >33%, the IPP and data collection would continue for 48 weeks and the tuck jump assessment would be repeated. If compliance with the IPP in the first eight weeks was 33% or less, the IPP and data collection would stop and the tuck jump assessment would not be repeated.

Study Size

The first phase of this study consists of one group, and the second phase would have divided that group based on the levels of compliance. No prior data exist to calculate a sample size, so estimates were made. Assuming an effect size of 1, a power of .80, and an α-level of 0.05, a sample of 30 participants per group would be adequate to assess compliance in the first phase of the study and to identify a between group difference in the second phase of the study.[22] To account for participants lost to follow-up, the target number for this study was 35 in each group.

Results

Participant Descriptive Data

Participants included ten females and 25 males with a mean age of 14.5 years (SD 0.9 years) and a range of 12.7 years to 16.3 years (Table 1).

Outcome Data

There were no reports of difficulty with or inability to access the links to the IPPs. There were also no reports of adverse events due to performing the IPP.
The total number of accesses was 9 out of a possible 560, indicating compliance of 1.61% (Table 2).

The study was terminated at eight weeks because the compliance rate was not greater than 33%.

Discussion

In an environment where coaches cannot deliver in-person IPPs due to the demand for technical training, an IPP delivered remotely is a logical alternative. However, the results of this study identify compliance as a limiting factor in the effectiveness of this type of IPP in adolescent soccer players in the CNMI. Given the limited healthcare resources available, it is worth examining the factors that might have limited compliance to allow future studies to address those factors better and potentially reach a threshold of compliance at which the impact of the IPP on the rate of injury can be ­examined.
The use of email decreased compliance in this study. It was used as a readily available resource and a convenient delivery method for the IPPs compared to the alternatives considered by the researchers. However, during the recruitment process, some participants expressed that they did not have an email address and had to use their parent’s or guardian’s email. This might have limited the players’ access to the IPPs. This might have been compounded by the concurrent access to IPPs provided to the coaches for the players not participating in the study but distributed via a mobile device messaging application. This distribution of IPPs not used for data collection would have included the study participants because the coaches were unaware of which players were participating in the study.
The platform on which the video IPPs were delivered might also have limited the participants’ compliance (Microsoft SharePoint 2019). The platform was selected due to the researchers’ existing access but dictated that participants click on links to individual exercises rather than one continuous video. The extra steps in accessing each video might have deterred participants from accessing and completing the IPPs.
Compliance with therapeutic interventions when there is no formal supervision in the adolescent population is challenging.[15,24] Weekly email contact with participants in this study was intended to improve that compliance but was not effective in reaching the desired threshold. Future research may consider additional methods of accountability, such as in-person, formal training in the exercise program.[25] Other suggested methods that may improve compliance include providing adequate background information regarding the intervention, multiple in-person contacts with the individuals receiving the intervention, linking the intervention with a cue or event that occurs daily, or a public commitment to do what is being requested.[24]
Future studies might also consider using the peer leadership structure within the teams to improve compliance. Prior research on adolescent soccer players has shown peer leaders can improve the intrinsic motivation of their teammates.[26]This might translate to an environment where accountability to the IPP is also perceived as accountability to the team.

Conclusion

Remote delivery of video IPPs via email to adolescent soccer players in the CNMI with weekly reminders to complete them did not reach the level of compliance necessary to impact the risk of injury over eight weeks. Future studies should consider alternative methods of delivery of IPPs, utilize additional methods of accountability, and create a structure of local accountability to maximize compliance to examine any potential impact of the IPP on the risk or rate of injury.

Limitations

Limitations of this study include possible underestimation of the number of accesses of the IPPs. This could have occurred if participants accessed the IPPs in groups rather than individually. An underestimate is also possible if the participants performed the IPP but accessed it through the link sent out by the coaches that were not used for data collection and provided to all national team players.
The data collection method may have also overestimated compliance. Accessing the IPP does not mean the exercises were performed or a participant may have accessed the IPP multiple times.

Acknowledgments

We would like to acknowledge the support of the NMIFA coaches, players, and staff for their support in this study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Key Points

• Injury prevention programs reduce the risk of injury in youth soccer players, this study did not support the use of programs provided remotely.
• Injury prevention programs should be provided in person until the feasibility of remotely delivering them is firmly established by further research.

Corresponding author

Thomas Bellama, PT, DPT, OCS
Assistant Professor of Physical Therapy
Department of Rehabilitation Sciences
College of Education, Nursing and
Health Professions
University of Hartford
200 Bloomfield Avenue,
West Hartford, CT 06117, USA
Email: BELLAMA@hartford.edu

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