Injury prevention in paediatric sport-related injuries: a scientific approach.

Youth have very high participation rates in sport, and sport is the leading cause of youth injury in many countries. Canadian studies report that 30–40% of youth (ages 11–18 years) seek medical attention for a sport injury annually. 7 While physical activity prevents all-cause morbidity associated with a sedentary lifestyle, injuries can become a barrier to physical activity. Injury prevention in youth is a critical issue in healthcare and in the promotion of health and wellness in our communities, and is becoming a public health priority. However, there is a discrepancy between the amount of research in this area and the public health burden of injury in youth sport where injuries are often predictable and preventable. An interdisciplinary and rigorous scientific approach is critical to understanding the complexity of injury risks, prevention and safety policies related to sport injury in youth. Studies that examine prevention strategies are paramount in establishing best practices for prevention in youth sport for healthcare practitioners, sport and health administrators, policy makers, athletes, coaches, parents and the public. The results of research in this area are often pivotal in decisions made to continue, discontinue, allocate or reduce funds from given public health, sport and healthcare programmes. As such, a rigorous methodological approach to research in injury prevention in youth sport is essential to inform practice and policy most appropriately. The purpose of this paper is to advocate for a scientific approach to research in injury prevention in child and adolescent sport. FRAMEWORK FOR INJURY-PREVENTION RESEARCH Sixty years ago, Gordon established the use of epidemiological principles often used to study infectious diseases, to examine injury and relate it to host, agent, and environmental factors. Gibson built on this concept by identifying the agent of injury as physical energy (ie, mechanical, thermal, chemical or electrical) and further examining the reduction in tissue damaging transfer of physical energy to the human body. Haddon extended this notion through the construction of a two-dimensional matrix describing injury countermeasures. The first axis relates to temporality (ie, pre-event, event and postevent.) The second axis describes risk factors that may affect the likelihood or severity of injury (ie, host or human factors, agent factors including equipment, physical and social environmental conditions). Through Haddon’s interest in motor vehicle collision, he recommended a shift in focus from crash prevention to proper protection of the body through increasing the focus on agent and physical environmental factors in order to prevent injury. Runyan suggested another dimension to Haddon’s matrix which included policyrelated factors (ie, intervention effectiveness, cost, freedom, equity, stigmatisation, preferences of the affected community or individuals) which would further influence the selection of a specific injury prevention strategy. Ongoing consideration of this dimension will continue to influence the development of further research in injury prevention in youth sport. More recent literature highlights the importance of considering how factors interact to influence risk of injury. 15 16 van Mechelen et al described the research process in four steps: (1) establishing the extent of the injury, (2) establishing the aetiology of injury, (3) introducing a preventive measure and (4) assessing its effectiveness by repeating step 1. Finch further proposed a new framework ‘‘Translating Research into Injury Prevention’’ (TRIPP). Finch further proposes TRIPP stage 5 in which the intervention context is established to inform implementation strategies and TRIPP stage 6 in which the effectiveness of preventive measures are evaluated in the implementation context. Finch highlights translating research into the real-world context considering the current safety practices, motivations/barriers to uptake and player behaviours and sporting culture. Meeuwisse established the sport injury event along a continuum in which there exists a complex interaction between intrinsic risk factors (eg, age, strength, previous injury) and exposure to extrinsic risk factors (eg, field conditions, equipment) that affect susceptibility to injury. An inciting event will ultimately produce an injury in a susceptible sport participant. Bahr and Krosshaug built on this model to highlight the mechanism of injury including biomechanical components, the playing situation and player/ opponent behaviour. Meeuwisse et al build further on this model in light of limitations with the implicit linear paradigm (fig 1). The approach often used in injury prevention studies involves following individuals, exposed to some risk factor(s) and/or intervention over time, to measure the outcome of injury. Meeuwisse et al argue that exposure is a combination of having a risk factor and then participating with it. A participant may be exposed to the same or different risk factors repeatedly through multiple participations, and injuries may or may not occur under similar conditions. In addition, injury does not permanently remove an individual from participation and, therefore, may not represent a finite endpoint. Gissane et al also previously stated that a linear model does not account for what happens after injury. Gissane et al developed a cyclical model for the investigation of contact sports to account for the return of healthy players to sport. It was recognised that injured athletes could return to a lower level of sport, but their approach may not permit these players to return to the same cycle of exposure. What was not emphasised, prior to Meeuwisse et al’s development of a dynamic recursive model, was the notion that there may also be recurrent changes in susceptibility to injury in the course of sports participation with no injury. These inciting ‘‘exposures’’ or ‘‘events’’ may not result in injury but can produce adaptation and continually change risk. Meeuwisse et al highlight that an initial set of risk factors preceding an injury are not necessarily stable over time. Ongoing participation may produce 1 Sport Medicine Centre, Roger Jackson Centre for Health and Wellness Research, Faculty of Kinesiology, University of Calgary, Calgary, Canada; 2 Alberta Children’s Hospital Research Institute for Child and Maternal Health, Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada; 3 Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Canada