FootyFirst: 5 Questions with Dr. Alexander Donaldson

One of the studies in our May CJSM issue that has already made a big splash is injury prevention work coming to us from researchers in Australia:  “Bridging the Gap Between Content and Context: Establishing Expert Consensus on the Content of an Exercise Training Program to Prevent Lower-Limb Injuries.”  This is work looking at prevention of some very common injuries seen in Australian Rules Football, or “Footy.”

As an American who has yet to visit Australia (for shame!), I have only a dim appreciation of the sport.  I have previously written about Footy in a blog post and I read eagerly the occasional article on the sport that make it into the U.S. press; the New York Times, for instance, had a recent article on the search for American talent that may cross-over to Australian rules football.  Who knew that basketball players may make great ruckmen?  Well, plenty of Australians apparently!!!!

The Twitter chatter about the study has been substantial, and it has hit the mainstream press as well.   Our Editor-in-Chief Chris Hughes has made it one of the ‘Editor’s Picks’ this month–it is freely available for a short time.  And now we have the pleasure of having the lead author, Dr. Alexander Donaldson, join us for “5 Questions with CJSM” to talk about Footy and FootyFirst, the exercise intervention which is the subject of the study.

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1) CJSM:  Asking as an ignorant American:  What are some of the significant differences between Australian football and American gridiron football?  Or for that matter, between Australian football and rugby, a sport with which I do have some familiarity?

AD:  Where do I start to answer this question? Firstly, unlike American gridiron football or rugby, Australian football does actually involve a lot of kicking a ball to gain ground rather than throwing or running with the ball. In fact, to score a goal in Australian football the ball has to be kicked between the goal post, not caught in or carried into an end zone. Another key difference is that unlike any other form of football, Australian football does not have ‘line of play’ or any sort of off-side rule. It is more like basketball or ice hockey in that players can position themselves anywhere on the field at any time and can enter a contest for the ball from any angle or direction. Like American football and rugby, Australian football is a full contact collision sport However, the only protective equipment commonly worn by Australian football players is a mouth guard to prevent dental injuries – no shoulder pads, and only the occasional soft-shell helmet and body padding, usually only worn to protect an existing injury. At the elite level there are some similarities between the way the American football and Australian football are administered with both having a salary cap and a draft system to embed a certain degree of equalization of the competition over time.

2) CJSM:  What is “FootyFirst”? At the risk of conflating two dissimilar interventions:  how may it resemble (or differ from) the FIFA 11+ warmups that have been used in football (soccer)?  As an injury prevention intervention—how much time is required to perform FootyFirst for the teams adopting the program?

AD:  A very good question. FootyFirst and the FIFA 11+ are quite similar. Both focus on preventing lower limb injuries (groin, hamstring, knee and ankle injuries) and both including dynamic stretching and targeted strengthening exercises such as the Nordic hamstring lower and various ‘plank’ type exercises. Both programs also focus on improving balance and technique for cutting/changing direction and landing from a jump. Given that Australian football involves a lot more jumping and landing than football (soccer), there is more emphasis on FootyFirst on jumping and landing technique for ACL injury prevention that is found in the 11+. Both programs are progressive with the 11+ consisting of 3 levels and FootyFirst consisting of 5 levels.

When we talk to community Australian football coaches during the development of FootyFirst they were very clear that they would not be interested in taking up an injury prevention program that took more than 20 minutes to complete. So we made sure that each level of FootyFirst takes between 15 and 20 minutes to complete once players and coaches are familiar with the exercises and activities. The typical community football team trains twice a week with each training session lasting about 90 minutes. Most coaches already feel they do not have enough time with their players to cover all the things they want to cover (like tactics, set plays, skills work, fitness, game plans etc.) so they are not keen to implement an injury prevention program if it takes away a large chunk of training time that they want to devote to other activities.

3) CJSM: @AlexDonaldson13 you are already on twitter! So—in 140 characters or less tell us what you are reporting in your study just published in CJSM?

AD: ‘The exercises in FootyFirst are based on scientific evidence and consensus among Australian football lower limb injury prevention experts’ (FootyFirst?  How about ‘TwitterFirst’?  You rock the 140 character microblog format Dr. Donaldson).

4) CJSM: The study design was a ‘three round Delphi consultation process’—would you first tell us what that is and then would you tell us the areas in which you found the most disparity in forging consensus among the Australian football medical practitioners being surveyed?

CD: As one paper I read recently poetically put it “The objective of most of the applications of the Delphi method is to shed light on zones of uncertainty based on the knowledge of experts to aid in decision-making”. A three round Delphi consultation process essentially involves:

• recruiting recognised experts in the topic of interest
• In Round 1, a questionnaire is used to establish the full potential range of responses to the question of interest. This can be done by asking an open-ended question or, as we did in our study, by using the existing literature to develop a starting point to which the experts can add their ideas. If you start with an existing list of ideas, you can also use Round 1 to ask the experts their opinion on those ideas.
• A questionnaire based on the outcomes of the round 1 questionnaire is administered to the experts again in subsequent rounds, informed at each round by the results and comments generated by the preceding round. In each round, the experts receive the results of the previous round and again express their opinion on the ideas of interest. One of the key ideas is that participants know the de-identified responses of the other members of the group and can maintain or modify their response if they want to. They can also explain their response if they choose to. This round can be reiterated as many times as necessary to reach agreement of the responses or identify the consistent disagreement.
• Key points for any Delphi process are:
  • Anonymity of responses so respondents are influenced by the content of the response, not who made it
  • Iteration with feedback so that respondents can consider their opinion in light of what the other participants have said;
  • quantified analysis of the group responses with qualitative explanations or justifications for responses
• The most disparity we found in responses from the sports scientists, physios and medics who participated in our study was in relation to the groin injury prevention exercises. There was strong agreement early in the Delphi process that the exercises we proposed to include in the warm-up, jumping and landing, cutting/changing direction and hamstring injury prevention sections of FootyFirst were appropriate. By contrast it took two feedback-informed revisions of the groin injury prevention exercises before we got agreement that the exercises and the progressions were appropriate to include in the program

5) CJSM: You are with The Australian Centre for Research into Injury in Sport and its Prevention (ACRISP).Where do you see your injury prevention work going at ACRISP?  Are you focused on ‘Footy’; do you have interests in other sports and work ongoing in those areas as well?

AD: For me personally, I have a background in health promotion and public health so I am keen to pursue my research interest in the implementation of evidence-based sports injury prevention interventions. From my perspective this is all about three key complementary concepts:

• making sure that the implementation context (capacity, resources, values, culture, skills, policies, infrastructure etc.) is taken into account when developing interventions,
• developing implementation plans that maximize the likelihood that whoever is being targeted by the intervention (coaches, administrators, participants, medical staff, parents etc.) will know about the intervention, have a go at it, do it properly and keep doing it
• taking an ecological or systems approach to implementing injury prevention interventions that recognised that individuals are unlikely to change their behaviour unless the systems or environment they operate in supports the desired change.
• The FootyFirst/NoGAPS project is the main piece of research I have been involved in recently but I have also done some work with rugby, football (soccer), and women’s Australian football. In terms of topics I have also been doing some work recently around concussion with a focus on the implementation of concussion management guidelines in community sport
• For ACRISP more broadly, we were re-accredited as an IOC research center in 2014 so that points to an exciting future. ACRISP conducts research across three main focus areas of injury prevention and epidemiology (led by Professor Caroline Finch and Dr Lauren Fortington), implementation of sports safety (led by Professor Caroline Finch and Dr Alex Donaldson, with Dr Peta White and Dr Scott Talpey) and Clinical Sports Medicine (Led by Adjunct Professor Jill Cook and Dr Joanne Kemp). At ACRISP we conduct collaborative research covering a broad range of topics in partnership with local, national, and international research partners. We also have several PhD students who are undertaking projects across the three main focus areas.

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Thanks so much for your time Dr. Donaldson.  We look forward to your forthcoming work!  For readers of this blog, keep your eyes posted to our podcast stream–we’ll be having a podcast with Dr. Donaldson soon!  And, on a personal note, I look forward to meeting you face-to-face sometime soon.