Psychology of Sport Injury Course 1 PDF

Focus on Application Is the Juice Worth the Squeeze? 48 “An ounce of prevention is worth a pound of cure.” So says an adage ultimately credited to the Dutch humanist Erasmus, who observed half a millennium ago that “prevention is better than cure” (Van Tiggelen et al., 2008, p. 648). Is this in f...

Focus on Application Is the Juice Worth the Squeeze? 48 “An ounce of prevention is worth a pound of cure.” So says an adage ultimately credited to the Dutch humanist Erasmus, who observed half a millennium ago that “prevention is better than cure” (Van Tiggelen et al., 2008, p. 648). Is this in fact true in the realm of sport injury? Does the value of prevention truly exceed that of treatment? Can such a comparison even be made? The evidence discussed in this chapter certainly suggests that a variety of interventions can be effective in reducing the occurrence of sport injury, but how does one go about establishing the worth of preventive activities? One way of evaluating the merits of preventive interventions for sport injury is to examine the “bottom line”—the financial impact. In this vein, McGuine, Hetzel, Wilson, and Brooks (2012) argued persuasively that despite its initial cost, providing all high school American football players with lace-up ankle braces would result in substantial savings against the total comprehensive costs of ankle injuries suffered by high school American football players nationwide. Similarly, J. Williams (2011) conducted a cost analysis of the LaBella et al. (2011) study, in which a neuromuscular intervention akin to the 11+ program (discussed in this chapter’s main text) reduced the injury risk in a sample of high school soccer and basketball players. Based on the reported cost of training coaches to implement the program ($80 per coach), Williams reasoned that all of the varsity and junior varsity coaches in the league could be trained for $960. Furthermore, in light of data indicating that one ACL tear could be prevented for every eleven coaches trained, this investment of less than $1,000 could save in excess of $17,000 in medical costs associated with the surgical repair of a torn ACL. A subsequent investigation provided additional support for the costeffectiveness of neuromuscular training for the prevention of ACL injuries in young athletes (Swart et al., 2014). Clearly, then, one can make a monetary argument for implementing sport injury prevention programs; in other words, an ounce of sport injury prevention may indeed be worth a pound of sport injury cure. If sport injury prevention programs accomplish their intended aims in a cost-effective fashion, then why are they not implemented on a more widespread basis? Despite progress in developing, evaluating, and refining interventions to reduce the occurrence of sport injury, many barriers to widespread implementation remain. These obstacles involve issues of time, money, education, and motivation. With respect to time, even sport health care professionals whose job duties include sport injury prevention are often distracted from implementing preventive interventions by more pressing matters, such as treating acute injuries and directing rehabilitation activities. Coaches also face limitations on the time available in which to implement preventive interventions, and their access to training facilities and to the athletes they coach may also be restricted. Fortunately, some equipment interventions require little extra time, and some training and psychosocial interventions can enhance sport performance even as they help prevent injury. Preventive interventions can also be limited by money concerns when the costs of equipment or services Although insufficient evidence is available to conclude that using protective equipment and devices is efficacious in preventing sport injury in adolescents (Abernethy & Bleakley, 2007), data from randomized clinical trials indicate beneficial effects of protective equipment and devices on injury outcomes in older participants (Aaltonen et al., 2007). For example, the use of ankle supports can decrease injury occurrence in basketball and soccer; similarly, wearing shock-absorbing insoles can reduce the incidence of lower-limb stress frac- tures (Parkkari et al., 2001). Helmets and other forms of headgear have been widely promoted as means of preventing head injury in sports as varied as American football, baseball, bicycling, cricket, equestrianism, rugby, skiing, snowboarding, and soccer. And the available evidence suggests that helmet use is associated with substantial reductions in concussions and other head injuries for most of the sports tested (McIntosh et al., 2011). Despite positive perceptions of the benefits of wearing protective gear (Kahanov, Dusa, B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. in rehabilitation—through use of the word but. & Verhagen, matters further, the Here are2015). some Complicating examples: “That stretching routine qualitymay of online educational resources varies. For work with some athletes, but I don’t think exmy ample,muscles a studywill of mobile (i.e., apps) for respondapplications like everyone else’s. ” “The sport swelling injury prevention revealed that the vast majorhas gone down, but I’m not so sure I’ll be ity were notto scientifically sound (D.M. van Mechelen, back training anytime soon. van Mechelen, & Verhagen, 2014). Thus, even when f. Put doubts in the doubts. When athletes express motivation is adequate, exposure to supposedly edudoubts, either by using the word but in another cational materials may not translate into oradoption of way, sport health care professionals can erode evidence-based practices. their lackis of confidence (i.e., their about confiMotivation central not only to build education dence) by gently challenging their doubts on logisport injury prevention but also to successful implecal or factual grounds (e.g., “What does it usually mentation of preventive interventions. Without sufwhen swelling ficientmean motivation, sport subsides?”). governing bodies will not g. Athlete-clients will bring you health, back where bechange rules to protect athletes’ sportthey adminlievewill they to be. Iffunds sporttohealth istrators notneed authorize purchase protective equipment or enable staff to deliver preventive h. care professionals follow the lead of athletes with interventions, sport health care“buts”) professionals will not injuries and listen (for the long enough, the devoteathletes adequate to prevention as compared are attention likely to make their concerns known. with coaches will not ofdedicate training time i. treatment, Acknowledge the difficulty the change process. to preventive activities, and, perhaps most important, Doing rehabilitation and acquiring the skills to athletes not adhere to preventive interventions. dealwill effectively with injury can be challenging for The motivation to facilitate or engage preventive some athletes; acknowledging that in difficulty can actionhelp canathletes derive from a variety of sources, set realistic expectations for includthe reing the threat of litigation, a sense of professional covery process. responsibility, a need to keep top athletes healthy j. Plan for plateaus and setbacks. Practitioners can and available for competition, and a desire to stay also help athletes establish realistic expectations injury free in pursuit of one’s sport goals. Reminding for recovery by accounting for the likelihood of stakeholders in the sport system of their role-specific periods of little progress (and even reversals of incentives for adopting a preventive stance may inprogress) and helping athletes develop skills to crease the likelihood of realizing the promise of sport cope effectively with such difficult periods. injury prevention. k. Train for generalization. Sport health care professionals should help ensure that athletes with injuries are able to use their newly acquired coping skills in settings beyond the one in which they learned them.training programs, the effecneuromuscular Focus on Application Through decades of experience in counseling athletes exceed the budget—whether of were a sport health to care and supervising trainees who learning doproso, fessional, a coach, a parent, or an athlete—allocated A.J. Petitpas (2000) developed what he referred to as for prevention. Thetoissue is further complicated the injury Littlefoot approach athletic counseling, which by the fact that one group of financial stakeholders in provides guidelines not so much for what to do when sport injury prevention—insurance companies—is not working with athletes but more for how to work with heavily involved in implementing them. The guidelines were originally preventive developed intervenwith psytions in sport settings. As with time restrictions, monechology-focused professionals in mind, but adhering to tary concerns can be eased by interventions that serve the guidelines may help strengthen working alliances the purposes of both performance ofenhancement between patients and practitioners all specialtiesand in risk reduction. sport health care settings. Here are the key aspects of of education theLack Littlefoot approach:can also be a barrier to implementing preventive interventions. This is the case a. Understand the best problem beforetoyou try to fix init. when people in the positions implement One must know howitathletes their own terventions (or to make possibleperceive to do so)—such problems and what sport they want from treatment beas sport administrators, health care professionfore attempting to help them find solutions. als, coaches, and even athletes themselves—are unaware of inquisitive appropriateand interventions lack knowledge b. Be avoid mindorreading. The best of howwayto toputlearn themabout into athletes practice and (Orr how et al.,they 2013). perFortunately, thesituations web provides ceive their is to ask an themeffective, questions lowand cost vehicle disseminating as check toforensure that their information, responses aresuch underthe following: stood correctly. c.• The Pace before you Practitioners should attend rationale for lead. introducing preventive intervento athletes’ immediate concerns and feelings betions to athletes fore intervening. • The content of relevant interventions d. Encourage but avoid discounting. Sport health • Strategies for implementing with have specare professionals shouldinterventions wait until they cific populations built rapport with athletes before offering encouragement, even then they should minimize However, unlessandthe appropriate partiesnotare motithe amount of work required to deal with the best athvated to seek out such information, even the letes’ problems. online resources may go unused (Vriend, Coehoorn, e. Listen for the “but.” Athletes’ doubts about treatment and concerns about recovery can sometimes be identified by noticing when athletes discount the potential benefits of a prescribed course of action—or& diminish progress theyitshave made Wilkinson, Roberts,the2005) and demonstrated efficacy (e.g., Janssen, van Mechelen, & Verhagen, 2014; McIntosh et al., 2011; Parkkari et al., 2001; Schieber et al., 1996) and cost-effectiveness (Janssen, Hendriks, van Mechelen, & Verhagen, 2014) in preventing sport injury, use of protective gear varies and can be extremely low. Among in-line skaters, for example, wrist guards and elbow pads can reduce wrist and elbow injuries by more than 80 percent, but less than 10 percent of skaters wear them (Schieber et al.). As with tiveness of protective equipment is contingent on adequate adherence to the preventive intervention. In simpler terms, even the strongest battle armor fails to protect soldiers if it goes unworn. Therefore, regulatory action is sometimes needed in order to bring about change. Regulation The regulation category is an infrequently examined (and enacted) form of sport injury B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. 49 50 Psychology of Sport Injury prevention. It involves efforts to curb injury by changing the rules, regulations, and even laws that govern sport (Klügl et al., 2010). Despite the rarity of regulatory change as a means of injury prevention, and as a topic of scholarly inquiry, there is no shortage of success stories in which the modification of a rule or a law was followed by a decrease in the occurrence of sport injury. For example, in a study of junior ice-hockey players, the use of fair-play rules—in which teams receive points, regardless of whether they win or lose, for staying below a designated number of penalties per game—was associated with the athletes experiencing nearly five times fewer “notable” injuries and incurring only about half the previous number of penalties (Roberts, Brust, Leonard, & Hebert, 1996). Similarly, in American football, a rule change made in 1976 at the collegiate and scholastic levels to decrease head-down contact and spearing was followed by a steady decrease in catastrophic cervical spine injuries (Heck, Clarke, Peterson, Torg, & Weis, 2004). Decreases in several types of injury have also followed rule changes in Australian football (Orchard, McCrory, Makdissi, Seward, & Finch, 2014). In baseball and softball, data show that the use of breakaway (quick-release) bases is associated with dramatically fewer sliding injuries (for a review, see Janda, 2003); as a result, Little League Baseball and Little League Softball mandated the use of breakaway bases for all league games. In karate, both injuries to the head and injuries to young competitors dropped significantly after the world governing body made rule changes that instituted heavy penalties for uncontrolled blows (Macan, Bundalo-Vrbanac, & Romic, 2006). And in youth cricket, the injury rate dropped markedly following the introduction of rules requiring every player to wear a helmet (Shaw & Finch, 2008). In what is arguably the most comprehensive attempt to reduce sport injury occurrence in the general population, an entire municipality was targeted for an intervention as part of the World Health Organization (WHO) Safe Community program and then evaluated in relation to a comparably sized control mu- nicipality that did not receive the intervention. The intervention initiated fair-play rules in team sports, supervision of youth during horseback activities, and use of protective gear and warm-up activities in soccer. No changes in injury rate were observed for the control community over the six-year study period. For the intervention community, however, a reduction in the injury rate was found among males under the age of 65 years from households in which the “vocationally important” member was employed. Especially noteworthy is the fact that the study was conducted in the mid to late 1980s (Timpka, Lindqvist, Ekstrand, & Karlsson, 2005)! Nevertheless, rule changes alone may be insufficient to reduce the occurrence of sport injury without appropriate regulatory enforcement (Klügl et al., 2010). Psychosocial Intervention Were it not for the restriction of training interventions to physical preparation for sport or exercise, psychosocial intervention could just as easily be placed in the training category because it generally involves training in an area of direct relevance to sport—for example, stress management. Support for the use of psychosocial intervention for sport injury prevention has been obtained through two lines of evidence: anecdotal and case reports and experimental studies. Anecdotal and Case Reports The earliest documentation of the potentially beneficial effects of psychosocial intervention on sport injury occurrence appeared in a series of anecdotal and case reports in which the primary intervention focus was not injury prevention but sport performance (Davis, 1991; DeWitt, 1980; S.M. Murphy, 1988; Schomer, 1990). DeWitt conducted two studies examining the effects of a combined intervention featuring cognitive and electromyographic (EMG) biofeedback training on muscle tension, heart rate, and ratings of sport performance in male collegiate football and basketball players. The cognitive training program included techniques such as cognitive restructuring, mental rehearsal, and relaxation. In postexperimental interviews, participants who received the B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. Sport Injury Prevention   51 intervention reported that they experienced a decrease in minor injuries over the course of the study (DeWitt). In another case, S.M. Murphy (1988) reported that in his role as a sport psychology consultant at the U.S. Olympic Festival, he led a series of relaxation sessions with a team of 12 players (7 of whom were injured) during the period prior to the competition. In an apparent case of tertiary prevention for the athletes with injuries and secondary prevention for the athletes without injuries, the entire team was able to participate in the Festival (S.M. Murphy). In yet another example, Schomer (1990) trained 10 marathon runners to use an associative cognitive strategy that involved monitoring bodily symptoms and other internal, task-related processes. The primary goal was to optimize performance, but Schomer reported that the runners were also able to run at high intensity while avoiding overuse injury thanks to the ongoing attention they paid to their bodies. In the case described at the beginning of this chapter, Davis (1991) implemented a stress management intervention featuring progressive relaxation and mental rehearsal of sport skills with collegiate swimming and American football teams for the purpose of performance enhancement. Both teams experienced not only competitive success but also reduced injury rates relative to the year before the intervention was introduced. As in the studies by DeWitt (1980) and S.M. Murphy (1988), sport injury prevention thus appears to have been an unanticipated bonus of a psychosocial intervention. Experimental Studies From the time of DeWitt’s (1980) anecdotal report, 16 years passed before the publication of an experimental study designed a priori— before the fact—to test the efficacy of psychosocial intervention in preventing sport injury. In that study, G. Kerr and Goss (1996) examined the effects of a stress management program on stress and time lost to injury in a sample of 16 male and 8 female gymnasts who ranged in age from 14 to 25 years and competed at the national or international level. After being matched into pairs on the basis of age, gender, and performance level, participants were randomly assigned to either the experimental group or the control group. The study monitored participants’ injury status (number of injuries and time lost from sport due to injury) and obtained measures of positive general stress, negative general stress, positive athletic stress, and negative athletic stress before the competitive season, at midseason (four months after the preseason assessment), and at the national championships (eight months after the preseason assessment). Participants in the experimental group received 16 individual, one-hour, biweekly sessions based on stress inoculation training (Meichenbaum, 1985), which addressed topics such as negative thought replacement, relaxation, and imagery. Participants in the control group received no treatment. Over the course of the study, all participants sustained at least one injury. Participants in the experimental group had significantly lower levels of both negative athletic stress and total (general plus athletic) negative stress than those in the control group. Although the mean “injury incidence score” was only half as large for the experimental group as for the control group at the final assessment, the difference was not statistically significant. Therefore, although the stress management intervention was effective in reducing stress, it appeared not to have been effective in reducing the occurrence of injury. However, in reviewing the report by G. Kerr and Goss (1996), M.B. Andersen and Stoové (1998) noted that the researchers “were probably too cautious in interpreting the results of an innovative and exploratory study” (pp. 168–169). Specifically, Andersen and Stoové argued convincingly that although the difference between the experimental and control groups in injury incidence was not statistically significant, the effect size (a measure of the magnitude of the difference between the two groups that, in this case, was independent of sample size) was underestimated and was likely to have been indicative of a substantial influence by the stress management intervention on the occurrence of injury. Thus the study B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. 52 Psychology of Sport Injury may have been hampered by the low statistical power afforded by the small sample size. In another study that appears to have been adversely affected by low statistical power, Kolt, Hume, Smith, and Williams (2004) investigated the effects of a stress management program similar to that of G. Kerr and Goss (1996) on injury and stress in a sample of 17 girls and 3 boys who had competed in gymnastics at the national or international level. The program was implemented with gymnasts in the experimental group in a series of 12 one-hour sessions over a 24-week period. Gymnasts in the control group received a placebo treatment in which anthropometric measurements were taken and lectures on nutrition were given. Injury status was assessed by self-report on a weekly basis over the course of the ninemonth study, and measures of general and athletic stress were administered at the start of the study and at three-month intervals thereafter. The study found no statistically significant effects of the intervention on either stress or injury, although a medium to high effect size was reported for injury, which suggests that a clinically meaningful preventive effect on injury may have been obscured by the study’s small sample size and concomitant lack of statistical power. An unambiguous preventive effect of a stress management intervention on sport injury occurrence was documented by Perna, Antoni, Baum, Gordon, and Schneiderman (2003) in a study of 20 female and 14 male collegiate rowers. The rowers were stratified by gender and competitive level and randomly assigned to either the experimental group or the control group. Rowers in the experimental group received a seven-session, athletespecific stress management intervention based on the stress inoculation training approach of Meichenbaum (1985) over a four-week period. In contrast, rowers in the control group participated in a single two-hour session that presented information about stress management. The investigators assessed frequency and duration of injury and illness by reviewing the rowers’ medical charts. They administered measures of life stress, mood, and serum cortisol directly before and after the intervention. Over the course of the study, participants in the experimental group experienced significantly fewer days injured or ill and significantly fewer medical office visits for injury or illness than did participants in the control group. Negative affect was found to partially mediate the relationship between receiving the intervention (or not) and the number of days injured or ill; specifically, receiving the stress management intervention was inversely related to negative affect, which, in turn, was positively related to number of days injured or ill. Thus, the intervention may have exerted a protective effect on injury and illness at least in part by helping the rowers cope with stressors and regulate their mood. Johnson, Ekengren, and Andersen (2005) built on these findings in a study of elite soccer players. After administering measures of life stress, personality, and coping resources to 132 male players and 103 female players, Johnson et al. identified players scoring in the highest 50 percent for life stress and the lowest 50 percent for coping resources as being at elevated risk for injury. Players in the high-risk subsample were then matched on the basis of age, gender, and level of competition and randomly assigned to either the experimental group or the control group. Players in the experimental group received a brief intervention in six individual in-person sessions and two telephone contacts over a 19-week period. The intervention featured “somatic and cognitive relaxation . . . stress management skills . . . goal setting skills . . . attribution and selfconfidence training . . . and . . . identification and discussion about critical incidents related to their [athletes’] soccer participation and situations in everyday life” (p. 34). Players in the control group received no treatment. To make it more likely that the intervention would produce changes in psychosocial variables that would in turn substantially alter players’ injury risk, the researchers introduced the intervention only to players with the greatest psychosocial risk for becoming injured. (This approach accords with the differential effects of neuromuscular training on ACL injuryrisk factors of athletes at high versus low risk of ACL injury as demonstrated by Myer, Ford, B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. Sport Injury Prevention   53 Brent, & Hewett [2007].) Over the course of the study, injury frequency data were collected from coaches six times, and the results were quite striking. In the control group, 13 of 16 players sustained at least one injury, whereas in the experimental group only 3 of 13 players were injured. In other words, the control group averaged 1.3 injuries per player, whereas the experimental group averaged only 0.2 injuries per player. This difference was both clinically and statistically significant. Like Johnson et al. (2005), Maddison and Prapavessis (2005) targeted the most psychosocially vulnerable athletes for receipt of their cognitive-behavioral stress management intervention based on stress inoculation training (Meichenbaum, 1985). The investigators identified 48 rugby players as being at elevated risk for injury due to low scores on social support or high scores on avoidance coping or previous injury, then randomly assigned each player to either an experimental group or a control group. They delivered the stress management intervention to members of the experimental group in six 60- to 90-minute sessions over a four-week period during the preseason; players in the control group received no treatment. Players in both groups recorded the number of injuries they sustained and the number of days of rugby participation they lost due to injury on a weekly basis. The investigators obtained measures of sport-specific competitive anxiety and coping resources before and after the competitive season. The study results indicated that relative to players in the control group, players who received the stress management intervention reported less worry, higher coping resources, and fewer days of rugby lost due to injury. The effects of the intervention on worry and coping resources did not, however, account for the smaller amount of time lost. Therefore, although the intervention had a favorable effect on an important injury outcome (time loss), it is not known how the intervention produced the salubrious effect. More recently, Tranaeus and her colleagues (Tranaeus, Johnson, Engström, Skillgate, & Werner, 2014; Tranaeus, Johnson, Ivarsson, et al., 2014) investigated the effects of a stress management intervention on injury occurrence in elite male and female floorball players. With a total of 346 players, the study possessed adequate statistical power. The intervention consisted of six one-hour sessions designed to furnish the players with skills to reduce the stress response; players in the control group received no intervention. Although players in the intervention group experienced fewer injuries than did players in the control group over the two seasons monitored, the small effect was not statistically significant. Only one experimental study of a psychosocially based preventive intervention featured an approach other than that of attempting to reduce injury risk through stress management. In that study, Arnason, Engebretsen, and Bahr (2005) attempted to prevent or minimize injury occurrence among male soccer players by fostering an awareness of the risk, types, and mechanisms of injury in soccer. Members of nine elite and firstdivision teams viewed a 15-minute video presentation and discussed with a teammate each of the 12 commonly occurring injury incidents depicted in the video. Specifically, they addressed the playing situation that led up to the incident, the incident’s cause or causes, and potential strategies for preventing it. In contrast, control-group members of eight elite and first-division teams received no intervention. Team physical therapists recorded injury outcomes, coaches recorded training exposure, and official records were consulted to obtain match exposure. The results indicated that the intervention and control groups did not differ from each other in injury incidence in either training or match play over the course of the study. Although the findings suggested that awareness of factors associated with sport injury occurrence is not sufficient to reduce the incidence of injury, it should be noted in this case that the validity and use of the injury-avoidance strategies offered by the players was not evaluated. Awareness is likely useful in preventing injury only when it translates into action taken by athletes, but this study involved no sustained effort to translate the intervention content into behavior on the field. B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. 54 Psychology of Sport Injury Biopsychosocial Analysis Effective prevention of sport injury involves biological, psychological, and social components. From a biological standpoint, training interventions can reduce injury risk by acting directly on biological parameters, and equipment interventions can decrease susceptibility to injury by protecting anatomical structures. The psychological component is evident not only in psychosocial interventions themselves, which influence psychological and physiological processes underlying injury occurrence, but also in the adherence behavior that is vital to the success of all kinds of intervention (via training, equipment, regulation, and psychosocial approaches). Regulatory interventions are initiated at the social (i.e., organizational) level, and social factors can also affect the extent to which training-based, equipment-based, and psychosocial interventions are adopted. The case histories reported by Davis (1991) and summarized at the beginning of this chapter serve as examples of primary prevention of sport injury through psychosocial intervention. Because the apparent injury-reducing effects of the intervention were discovered serendipitously, the sequence of events in documenting the effectiveness of stress management interventions departed from the models of sport injury prevention proposed by W. van Mechelen et al. (1992), C.F. Finch (2006), and Van Tiggelen et al. (2008). Issues normally associated with implementing preventive interventions may have been minimized by the fact that the stated purpose of the intervention was to enhance performance rather than prevent injury. Summary Informed by research on predictors of sport injury occurrence, preventive interventions have been developed to address the public health problem of sport injury. In general, preventive interventions either target all athletes in a given population (i.e., primary prevention), target only the athletes in a given population who are deemed at elevated risk for injury (i.e., sec- ondary prevention), or focus on athletes who have sustained injuries in an attempt to minimize the damage (i.e., tertiary prevention). Prevention models have been proposed that are specific to sport injury. In one fourstep model, for example, prevention of sport injury involves identifying the magnitude (i.e., incidence and severity) of the sport injury problem, determining the causes of injury, introducing preventive measures, and assessing their effectiveness. A second model, the TRIPP framework, involves six steps: 1. Conducting surveillance of sport injury 2. Establishing the etiology and mechanisms of injury 3. Using theory and research from multiple disciplines to devise potential interventions 4. Implementing the preventive intervention under ideal conditions 5. Describing the context of the intervention to facilitate planning for implementation in real-world conditions 6. Implementing the intervention in realworld conditions and evaluating its effectiveness These models, particularly the TRIPP framework, highlight the distinction between efficacy (whether the intervention works in a controlled setting) and effectiveness (whether it works in a real-world setting). Preventive interventions can be placed into four main content categories: 1. 2. 3. 4. Training Equipment Regulation Psychosocial interventions Preventive training interventions focus on building attributes such as agility; balance; sport-specific skills; and muscular strength, endurance, and power. Neuromuscular training programs have been shown to be both effective and cost-effective in preventing sport injury. One training program in particular, named 11+, has been widely disseminated via B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. Sport Injury Prevention   55 the web. Equipment interventions involve having athletes play on safer surfaces, wear protective gear, and use protective devices. Regulatory interventions involve changing rules and regulations in sport. In keeping with the stress–injury model, psychosocial interven- tions focus primarily on managing stress; they have received preliminary research support. Adoption of preventive interventions—even ones that have been proven effective—can be limited by factors such as lack of time, money, education, or motivation. Discussion Questions 1. What is the connection between psychosocial interventions to prevent (or reduce) sport injury occurrence and the models of sport injury occurrence discussed in chapter 2? 2. What are some challenges in implementing interventions designed to prevent sport injury in real-world settings? 3. How much of a threat is “risk compensation” to the effectiveness of sport injury prevention programs? 4. How is psychology involved in the potential success of training-based, equipment-based, and regulatory interventions to prevent sport injury occurrence? B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics.