1 Introduction
Both a physically active lifestyle and sport participation are recommended because of their inherent health benefits [
1‐
4]. However, they also carry a risk of sustaining injuries. These injuries form a significant public health problem at an individual and societal level, including (temporary) physical inactivity and direct and indirect costs related to medical treatment and work absenteeism. As such, the prevention of sport injuries is important to maintain and increase a physically active lifestyle and sports participation, and to maximise the related health and societal benefits [
5].
Numerous studies and systematic reviews have evaluated the effects of preventive interventions on the risk of sport injuries [
6‐
12], and, as such, these provide an evidence base for implementation efforts [
13]. Differences have been found in the type of preventive measure or intervention under study by injury type and sport [
8‐
10]. Most studies have used a randomised controlled trial (RCT) design [
11]. RCTs are considered the optimal study design to establish a cause–effect relationship and, as such, to establish the effect of an intervention [
14‐
16]. Other study designs have also been used in sport injury prevention studies [
11], as RCTs are not always feasible in a real-world sport setting due to ethical or practical reasons [
14,
15]. This is especially true for evaluating contextual, policy-level interventions (such as legislation or regulation changes) and for interventions that have become common practice. When evaluating such interventions, time trend analyses (e.g. pretest–posttest designs) are considered adequate study designs [
14,
15].
Despite this wide base of knowledge on sport injury prevention, large-scale implementation of effective preventive interventions in real-world sport settings is still a major challenge [
17‐
19]. Actual injury prevention in daily practice requires large-scale adoption and the correct use of evidence-based preventive interventions by the target population [
13]. The majority of the available evidence on sport injury prevention appears to focus on the behaviours and actions of individual athletes, including evaluating the use of personal protective equipment (PPE) and specific training programmes to reduce the risk of injuries [
7,
11,
20]. Implementation of such measures requires a behavioural change on the part of an athlete [
21,
22]. This may be a challenging task, since intervention strategies that predominantly target behavioural modifications in individuals are found to be less effective in injury prevention than those based on contextual modifications, such as regulations, enforcement methods, and environmental and product modifications [
7,
22‐
24]. Moreover, in the sport injury context, injury prevention requires more than just a change in athlete behaviours, but also relies on broad support and behaviour change from sporting federations, coaches, allied health staff and others [
25]. Therefore, a range of potentially relevant strategies should be considered to support and strengthen sport injury prevention efforts.
An overview of sport injury prevention studies categorised by their intervention strategy, i.e. geared at the individual versus geared at the context, is as yet lacking. A useful and valid tool for the categorisation of intervention strategies for the prevention of acute injuries is the Haddon matrix [
24,
26]. This matrix, originating from traffic safety research, has previously been successfully applied to sport injury prevention. An early example of its use to identify possible sport injury prevention strategies is the study by Bahr et al. [
27] for the prevention of ankle sprains in volleyball. A recent review on snow sport injuries also used the Haddon matrix as its conceptual framework [
28].
The aim of this systematic review was to identify intervention strategies for the prevention of sport injuries evaluated in the scientific literature, and to identify potential intervention strategies not yet evaluated (i.e. to identify potential knowledge gaps), making use of the Haddon matrix. The review was restricted to the prevention of acute sport injuries. The specific objectives of this review were to (1) provide a categorisation of sport injury prevention studies by intervention strategy using the Haddon matrix; (2) assess differences in intervention strategies evaluated in studies aimed at the prevention of different injury types and sports; and (3) categorise the number of sport injury prevention studies by study design and intervention strategy. Such an evidence-based overview can facilitate future sport injury prevention efforts by identifying possible strategies to choose from, given an injury problem and context.
4 Discussion
The primary aim of this review was to categorise sport injury prevention studies by their intervention strategy, using a modified version of the Haddon matrix. The majority of the available evidence focussed on strategies that required a behavioural change on the part of individual athletes. These studies predominantly evaluated the preventive effect of various training programmes targeted at improving athletes’ level of physical fitness and/or sport-specific skills before the injury event, and the use of PPE, tape or brace aimed at being effective at the time of the injury event. This corresponds to reports in previous reviews of sport injury prevention [
11].
The current review showed that research related to some specific intervention strategies is underrepresented. Only a few studies were identified that evaluated the preventive effect of strategies geared at rules and regulations in sport, contextual modifications, and sport equipment (other than PPE, tape or brace) on the occurrence of sport injuries. The lack of studies of the preventive effect of rule modifications to prevent sport injuries has been previously identified [
7,
188‐
190]. Studies specifically aimed at preventing re-injuries were a minority, and were mostly related to recurrent ankle sprains.
Questions can be raised as to whether the identified ‘gaps’ in the number of studies evaluating the various intervention strategies represent actual knowledge gaps or are unavoidable as not all intervention strategies are appropriate for all sports, injury types and/or sport settings. This is illustrated by the differences found in intervention strategies used in studies of the prevention of soccer and rugby injuries. By its nature, rugby has a high injury rate due to the multiple contact situations [
191]. This can explain the emphasis in rugby studies on intervention strategies related to PPE use and rules and regulations, as opposed to soccer. Similarly, differences between strategies used to prevent ankle and knee sprains, as opposed to concussions, can be related to the aetiology and mechanisms of these injuries [
10,
192,
193]. However, all possible intervention strategies should be considered when first developing sport injury prevention programmes, and lessons can be learned from strategies used in other sports and injury types. As such, the Haddon matrix presented in this review is a useful tool to identify possible intervention strategies for sport injury prevention.
Based on this review, some knowledge gaps relating to effective sport injury prevention strategies can be identified. New research in these gap areas could be a valuable addition to the current knowledge base of sport injury prevention. This especially applies to research on rule modifications in sport as an intervention strategy. Most research in this area to date has focussed on the preventive effect of mandatory PPE use in the event phase. However, evidence on the effectiveness of rule modifications in the pre-event phase is scarce. Exceptions are two studies on the preventive effect of a new scrum law in rugby [
154] and new karate rules [
166]. Such strategies have the potential to limit or eliminate dangerous situations in play, and hence prevent sport injury events from occurring. Rule modifications can be of preventive value in the post-event phase as well, but no studies on this intervention strategy were found. To this category would belong rules that allow free substitution and off-field medical assessment during play to modify the risk of (recurrent) injuries [
194]. Furthermore, although sport equipment has been a frequently studied topic in sport injury prevention, studies on the effect of equipment modifications in the pre-event phase are rare. Such preventive interventions do exist in real-world sport settings (e.g. different floor types, tyres to prevent falling in bicycle racing), but the potential preventive effect needs to be formally evaluated. Finally, only few studies were identified on the effect of training programmes other than those aimed at improving the physical skills of athletes. Additional studies are recommended to build on current evidence on the effect of improving psychological or cognitive skills, falling, landing and recovery skills, as well as education of athletes, coaches and referees. Overall, with the total number of 25 different sports considered in the studies included in this review, it is clear that many injury-prone sports have not yet been studied in the literature in this way (e.g. equestrian sport, tennis) [
195].
The excess of RCTs used in sport injury prevention studies has been highlighted previously [
11], and is not surprising as this study design is considered the gold standard for establishing the preventive effect of an intervention [
14,
16,
196]. However, 43% of all injury prevention studies did not use a (randomised) controlled design. The Haddon approach showed that study design and intervention strategy are related. In studies evaluating strategies geared at rules and contextual modifications, RCTs/CTs were absent or a minority (17%). As most policies and rule modifications under study were introduced at a national level by a national sporting organisation or by law [
25], randomisation was impossible and/or a proper control group was lacking. The effectiveness of these interventions could therefore not be evaluated using an RCT or CT design [
14,
196]. The frequent use of pretest–posttest designs in these studies appears to be a justified option. Although alternative forms of RCTs have been suggested, including stepped wedge designs (in which an intervention at group level is sequentially implemented if randomisation is impossible) and Solomon four-group designs (to control for the effect of a pretest) [
196,
197], these study designs have not yet been used in sport injury prevention studies to our knowledge. Consideration of the use of these designs may be of value in future sport injury prevention research to strengthen knowledge in this field, especially in studies evaluating the effect of group-based interventions.
Our review has some strengths and limitations. A systematic approach was used to identify all relevant sport injury prevention studies. Application of the pre-defined search strategy and inclusion and exclusion criteria resulted in the exclusion of studies not primarily targeting the evaluation of the efficacy or effectiveness of preventive interventions, for instance, aetiological studies establishing risk factors and injury mechanisms [
7,
13]. Such studies may, however, provide valuable information related to specific intervention strategies, as illustrated by a study on the association between ice hockey injuries and arena characteristics [
198]. The summary provided in this review identifies the amount of evidence (i.e. number of published studies and study designs used) and possible knowledge gaps per intervention strategy in a structured way using the modified Haddon matrix. This can support and strengthen future sport injury prevention efforts. However, additional information about the effectiveness, cost and feasibility of interventions is also necessary for practitioners in order to make a comprehensive decision on what strategy to use for sport injury prevention in everyday practice [
199]. Neither did our review assess the effectiveness of preventive interventions, nor the risk of bias of individual studies (i.e. no assessment of the methodological quality of included studies) as per the purpose of this review. Also, an increasing number of implementation studies have been published in recent years [
7], providing valuable information on effective implementation components in real-world sport settings [
13,
18]. In this review, studies were also included that evaluated the effect of mandatory use of PPE and braces through rule modifications and policy changes. These intervention strategies represent a grey area between evaluating the preventive effect of an intervention and an implementation strategy. However, implementation of a new or modified rule should ideally be accompanied by implementation efforts at various levels [
25].
In this review, we focussed on strategies used in the prevention of acute sport injuries, since the Haddon matrix was not developed for overuse injuries [
26]. Only three studies exclusively targeting overuse injuries were excluded for this reason [
32‐
34]. In addition, we limited our search to injury prevention studies reporting clinical outcomes, containing a quantitative injury measure as an outcome. As such, we excluded studies that reported on intermediate risk factors (e.g. biomechanical/physiological outcome measures) [
200] and necessary behaviour changes related to sport injury risk as an outcome [
201].
The current review may be subject to bias due to our literature search. We included five databases, and limited the search to English-language and peer-reviewed articles. Reference lists from recent systematic reviews and meta-analyses were manually searched for additional literature, which may have contributed to an overrepresentation of (randomised) controlled trials. Another possible source of bias was the exclusion of commuting activities (such as walking and cycling). As a result, studies of bicycle helmets in a general population were not included. These studies may have included helmet use in bicycle racing. However, no study was identified exclusively targeted at bicycle racing. The primary aim of each individual sport injury prevention study was used as a starting point for the categorisation of the extracted data. As a consequence, results of subgroup analyses that dealt with specific injury types or locations were not included in our categorisation.