VU Research Portal Who me? I thought you would never ask! Silveira Bolling, C. 2019 document version Publisher's PDF, also known as Version of record Link to publication in VU Research Portal citation for published version (APA) Silveira Bolling, C. (2019). Who me? I thought you would never ask! Applying qualitative methods in sports injury prevention research. General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ? Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. E-mail address: [email protected] Download date: 09. Oct. 2021 WHO ME? I THOUGHT YOU WOULD NEVER ASK! Applying qualitative methods in sports injury prevention research Caroline Silveira Bolling The studies presented in this PhD thesis were performed at the Department of Public & Occupational Health and Amsterdam Public Health at the Amsterdam UMC - VU University Medical Center Amsterdam, the Netherlands, and they were also embedded in the IOC Research Center ‘Amsterdam Collaboration on Health and Safety in Sports’. This PhD was funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq, Brazil, grant number 202242/2015-3. Ministry of Science and Technology Cover photo: Ricardo Bufolin / Panamerica Press/ CBG Cover design: Caroline Bolling ã 2019, Caroline Bolling, The Netherlands All rights reserved. No part of this thesis may be reproduced or transmitted in any form or by any means without prior written permission from the author, or, when appropriate, the publishers of the articles. VRIJE UNIVERSITEIT WHO ME? I THOUGHT YOU WOULD NEVER ASK! Applying qualitative methods in sports injury prevention research ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor of Philosophy aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. V. Subramaniam, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Geneeskunde op woensdag 27 november 2019 om 15.45 uur in de aula van de universiteit, De Boelelaan 1105 door Caroline Silveira Bolling geboren te Belo Horizonte, Brazilië promotor: prof.dr. W. van Mechelen copromotor: dr. H.R.W. Pasman TABLE OF CONTENTS CHAPTER 1 7 General introduction CHAPTER 2 19 Context matters: revisiting the first step of the ‘sequence of prevention’ of sports injuries CHAPTER 3 33 How elite athletes, coaches, and physiotherapists perceive a sports injury CHAPTER 4 49 In our shoes: perspectives of dancers and staff regarding dance injury and its prevention CHAPTER 5 65 From the safety net to the injury prevention web: applying systems thinking to unravel injury prevention challenges and opportunities in Cirque du Soleil CHAPTER 6 85 Letting the cat out of the bag: insiders’ perspectives on how to prevent injury in elite sports CHAPTER 7 105 General discussion SUMMARY 121 LIST OF CONTRIBUTORS 131 ACKNOWLEDGEMENTS 132 ABOUT THE AUTHOR 134 APPENDIX 135 CHAPTER 1 General introduction Chapter 1 SPORTS INJURY PREVENTION CHALLENGES The sports medicine field has evolved in the past two decades and has been moving forward exponentially in the last years. Traditionally, sports injury prevention approaches have been following the ‘Sequence of Prevention’ that was proposed by Van Mechelen and colleagues1 in 1992; a four-step model that presents a systematic logic from injury problem assessment to the design of an evidence–based solution (Figure1). The first step aims to describe the extent of the injury problem, followed by the second step that aims to investigate the etiological factors and the injury mechanisms. The third step’s goal is to develop science-informed injury prevention measures, and the fourth step assesses if the developed measures actually work to solve the problem. This ‘Sequence of Prevention’ framework has guided research and practice towards injury prevention strategies over the last 25 years. Step 1 Step 2 Establish the Establish the extent of the aetiology and injury mechanism of problem injury Step 4 Step 3 Assess the Introduce effectiveness preventive by repeating measures step 1 Figure 1- Sequence of prevention proposed by Van Mechelen et al.1 Following the sequence of prevention, many publications have described extensively the problem of injury in sports in epidemiological terms, as well injury mechanisms and risk factors2. Based on this knowledge, preventive measures have been proposed and randomized controlled trials have evaluated the efficacy of these measures to prevent injuries. Evidence of efficacy, however, does not necessarily equal effectiveness in practice, i.e. effective implementation3. Therefore, implementation of evidence has been presented as a key process to bring controlled research findings into actual sports practice4–6. Finch7 proposed the TRIPP model (Translating Research into Injury Prevention Practice), which added two steps to the above mentioned ‘Sequence of Prevention’ model (Figure 2). These two additional steps are related to (1) the understanding of the implementation context and (2) the evaluation of the implementation process of preventive measures. Studies have applied the RE-AIM (Reach, Effectiveness, Adoption, Implementation and 8 General introduction Maintenance) framework to evaluate the implementation process, and mainly indicated poor adoption and maintenance of introduced preventive interventions3,8–10. These findings indicate that the uptake of interventions by athletes is still limited, despite the implementation efforts. Figure 2- The Translating Research into Injury Prevention Practice (TRIPP) framework proposed by Finch for research leading to real-world sports injury prevention7. WHAT IS NEW IN SPORTS INJURY PREVENTION? The ‘sequence of prevention’ describes a pathway that starts with the description of the ‘injury problem’ from an epidemiological perspective. However, the sports injury problem has recently been described as a complex phenomenon11–14. Bittencourt et al.13 stated that the web of determinants relating to, for instance, the risk for ACL (anterior cruciate ligament) injury of ballet dancers consists of certain risk factors in a certain configuration. However, the risk for ACL injury in basketball players consists of a web of other and/or comparable risk factors, however, with a different relative weight and presented in a different configuration. Injury risk factors will interact and impact differently as the context of sports practice changes. Bekker and Clark14 also suggested that intervention outcomes are influenced by interactions between people and places. Understanding the contextual complexity requires the understanding that intervention success at a population level, or effectiveness, is not only about the efficacy of the intervention. Therefore, it is also about the effect of inter-related contextual factors on the intervention outcome. This paradigm shift suggests that, while the problem is complex, traditional reductionist approaches may not be able to develop effective solutions, while the context of the injury is a significant part of the puzzle towards effective injury prevention in practice. If this holds true, we may need to put our effort in answering different research questions. Rutter made a compelling argument towards the complexity of Public Health interventions15. He argued that researchers should aim to identify “if and how an intervention contributes to reshaping a system in favourable ways”, instead of investigating 9 Chapter 1 whether an intervention fixes a problem. In short, because right now we have “the right answers for the wrong questions”. Although Rutter argues for issues that relate to public health problems in general, it is reasonable to specifically transfer his argumentation to sports injury prevention. Bekker at al16 already claimed that instead of implementation and dissemination efforts, we should focus on different questions that improve the relevance of our research knowledge. The understanding of the context in the injury prevention process currently only follows after the full intervention has been designed, and has been tested out of the context; whereas implementation science tries to find an à priori way to put an intervention into its contextual practice. However, if we do not know for whom, where and how injury prevention strategies are developed and implemented, there is a chance that we may build perfect umbrellas to protect us from the rain for someone living in the desert. Thus, we are to address a problem by building highly efficacious solutions that are completely out of context and that have limited practical relevance. HOW CAN WE INCORPORATE CONTEXT? The challenge is to take the context into account when designing sports injury prevention interventions that can be easily adopted and maintained in practice. To overcome such a challenge, we need to do better by learning more about the athletes’ context already at the beginning of the injury