Implementation of an app-based neuromuscular training programme to prevent ankle sprains: a process evaluation using the RE-AIM Framework

Digital Health Literacy and Social Determinants of Health Affecting Telehealth Use by Athletic Trainers

CONTEXT

While increasing telehealth use throughout sports medicine has improved patients' access to health care, some communities may not have the same opportunities to connect with a provider. Barriers to telehealth implementation can be influenced by internal (eg, provider's digital health literacy and resources) and external (eg, community's social determinants of health or "SDOH") factors. This study aimed to assess the impact of internal and external factors on telehealth use by athletic trainers (ATs).

DESIGN

Cross-sectional survey.

METHODS

In total, 767 ATs participated in the study. Participants (age = 39 [13] y) completed a survey containing the electronic health literacy scale and digital health literacy instrument, reported professional use of telehealth as a provider (yes/no), provided resources at their clinical site, and provided the zip code for the community they served. After data collection, the researchers extracted SDOH information using the zip code data from 2 US databases, including population density, median household income, poverty index, education level, and technology access. Chi-square or independent samples t tests were conducted to compare telehealth use by each SDOH factor.

RESULTS

In total, 62.3% (n = 478/767) of ATs reported using telehealth, and 81.6% of ATs (n = 626) had a dedicated facility to offer health care services. We identified a significant difference in digital health literacy scores between users and nonusers of telehealth (P = .013). We did not identify any significant differences between telehealth users by community type (P = .957), population density (P = .053), income (P = .462), poverty index (P = .073), and computer (P = .211) or broadband internet access (P = .295).

CONCLUSIONS

Our data suggest that internal factors such as digital health literacy and clinical site resources may have contributed to an AT's previous telehealth use in clinical practice. However, the SDOH data extracted from the community zip code where the AT provided clinical services were similar for those with and without previous telehealth use.

Implementation of the injury prevention exercise programme Knee Control+: a cross-sectional study after dissemination efforts within a football district

BACKGROUND

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework can be used for evaluation of implementation initiatives in sports injury prevention. The aim was to evaluate the implementation of the injury prevention exercise programme Knee Control+ among amateur clubs and coaches in one regional football district using all five dimensions of the RE-AIM framework.

METHODS

Dissemination of Knee Control+ during the 2021 season with information and webinars within one regional football district. This was followed by a cross-sectional study with questionnaires to club personnel and coaches after the season.

RESULTS

The reach of Knee Control+ was fair to high, 83% of club personnel and 66% of coaches knew about the programme. 41% of club personnel and 51% of coaches had adopted it. Perceived programme effectiveness was high (6 on a 1-7 Likert scale) among coaches. Regarding implementation and maintenance, 27% of club personnel had informed coaches about Knee Control+ and 57% planned to inform coaches. The coaches had implemented the programme mainly as recommended, but half used the programme once per week or less. Intention to maintain use of the programme was high (7 on a 1-7 Likert scale) among coaches.

CONCLUSION

The reach of Knee Control+ was fair to high, and adoption was fair in clubs, but there was a lack of policies for preventive training. Active strategies probably need to accompany dissemination of programme material. Reach, perceived effectiveness, adoption, implementation and planned maintenance were positive among coaches, but further studies are needed to analyse long-term maintenance.

Effectiveness of a theory-driven mHealth intervention in promoting post-surgery rehabilitation adherence in patients who had anterior cruciate ligament reconstruction: A randomized clinical trial

RATIONALE

Patients with anterior cruciate ligament (ACL) reconstruction often have poor adherence to post-surgery rehabilitation.

OBJECTIVE

This study applied the integrated model of self-determination theory and the theory of planned behavior to examine the effects of a smartphone-delivered intervention on the recovery outcomes of patients with an ACL rupture during post-surgery rehabilitation period. Additionally, we explored the effects of the intervention on participants with different beliefs toward rehabilitation at baseline.

METHODS

The randomized control trial recruited 96 eligible participants (M age = 27.82 years, SD = 8.73; female = 39%) who underwent ACL reconstruction surgery. Participants were randomly assigned to an intervention group (n = 41), which received standard post-surgical treatment (usual-care) and smartphone application ("ACL-Well"), or a usual-care control group (n = 55). The primary outcomes were recovery outcomes from ACL surgery measured by knee muscle strength and laxity, and subjective knee evaluation completed 4-month post-intervention. Secondary outcomes were the psychological and behavioral outcomes measured at baseline, at 2- and 4-month post-intervention.

RESULTS

ANCOVA indicated no significant between-group differences in primary outcomes: knee muscle strength, knee laxity and subjective knee evaluation, Fs(1, 27 to 55) = 0.01 to 1.36, p = .25 to .99, η2 = 0.01 to 0.03. For the secondary outcomes, growth mixture modelling revealed self-determined treatment motivation declined significantly over the intervention period in the control group (M slope = -0.39 to -0.12, p = .01 to .04), but not in the intervention group (M slope = -0.19 to -0.08, p = .06 to .38).

CONCLUSIONS

The smartphone application fell short in promoting orthopedic outpatients' recovery outcomes. Yet, it shows some promises as a mean to maintain patients' motivation and adherence to treatment.

Mixed-methods process evaluation of the injury prevention Warming-up Hockey programme and its implementation

Warming-up Hockey (WUP) is an effective injury prevention programme to reduce acute field hockey injuries among youth. This paper describes the process evaluation of the nationwide scaling-up. We conducted a mixed-methods process evaluation from September 2019 to December 2020 according to the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, focusing on the intervention and its implementation. We collected data through questionnaires, interviews and web/app analytics. Participants were trainers/coaches, technical/board members of hockey clubs (TBMs) and employees of the Royal Dutch Hockey Federation (KNHB). In total, 226 trainers/coaches (61 via WUP and 165 via training courses) and 14 TBMs filled in questionnaires. Ten individuals (four trainers/coaches, four TBMs and two KNHB employees) participated in semistructured interviews. The study showed the following results according to the RE-AIM framework. Reach: According to web/app analytics, 1492 new accounts were registered. Effectiveness: Overall, users were satisfied with WUP and the implementation strategies, and believed WUP could reduce field hockey injuries. Adoption: 63% of the trainers/coaches (enrolled via WUP) indicated they used WUP. Implementation: Most trainers/coaches did not use WUP during every training session or match. Most TBMs promoted WUP in their club. Implementation barriers included lack of integration with other training programmes, 'know-it-all' trainers, lack of supervision on WUP use and delayed start of implementation. Facilitators included perceived added value, information need on injury prevention in small clubs and tailored communication. Maintenance: Users planned to use WUP occasionally. The KNHB intended to integrate WUP in their newly developed Knowledge Platform. To conclude, WUP was evaluated as a useful programme, but adherence to WUP was challenging. Timely preparation and creating an implementation plan based on stakeholder input, including communication at key moments during the sports season and tailored communication, were found to be important during implementation. Findings can be useful for others planning to implement evidence-based injury prevention programmes on a larger scale.

Using the app "Injurymap" to provide exercise rehabilitation for people with acute lateral ankle sprains seen at the Hospital Emergency Department-A mixed-method pilot study

BACKGROUND

Acute lateral ankle sprains (LAS) account for 4-5% of all Emergency Department (ED) visits. Few patients receive the recommended care of exercise rehabilitation. A simple solution is an exercise app for mobile devices, which can deliver tailored and real-time adaptive exercise programs.

PURPOSE

The purpose of this pilot study was to investigate the use and preliminary effect of an app-based exercise program in patients with LAS seen in the Emergency Department at a public hospital.

MATERIALS AND METHODS

We used an app that delivers evidence-based exercise rehabilitation for LAS using algorithm-controlled progression. Participants were recruited from the ED and followed for four months. Data on app-use and preliminary effect were collected continuously through the exercise app and weekly text-messages. Baseline and follow-up data were collected though an online questionnaire. Semi-structured interviews were performed after participants stopped using the app. Results: Health care professionals provided 485 patients with study information and exercise equipment. Of those, 60 participants chose to enroll in the study and 43 became active users. The active users completed a median of 7 exercise sessions. Most of the active users were very satisfied or satisfied (79%-93%) with the app and 95.7% would recommend it to others. The interviews showed that ankle sprains were considered an innocuous injury that would recover by itself. Several app users expressed they felt insufficiently informed from the ED health care professionals. Only 39% felt recovered when they stopped exercising, and 33% experienced a recurrent sprain in the study period. Conclusion: In this study, only few patients with LAS became active app users after receiving information in the ED about a free app-based rehabilitation program. We speculate the reason for this could be the perception that LAS is an innocuous injury. Most of the patients starting training were satisfied with the app, although few completed enough exercise sessions to realistically impact clinical recovery. Interestingly more than half of the participants did not feel fully recovered when they stopped exercising and one third experienced a recurrent sprain.

TRIAL-IDENTIFIERS

https://clinicaltrials.gov/ct2/show/NCT03550274, preprint (open access): https://www.medrxiv.org/content/10.1101/2022.01.31.22269313v1.

Physical activity and mental health in children and adolescents with intellectual disabilities: a meta-analysis using the RE-AIM framework

BACKGROUND

Children and adolescents with intellectual disabilities (IDs) tend to have lower levels of physical activity and poorer mental health than their typically developing peers. Studies on the effects of physical activity on the mental health of children with IDs using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework are scarce.

METHODS

A systematic literature review using six databases (CINAHL, Eric, PsycINFO, PubMed, SPORTDiscus, and Web of Science) was conducted from January 2000 to September 2021. Studies reporting at least one physical activity intervention and mental health outcome in children and adolescents with IDs aged between 5 and 17 years were included in the meta-analysis. Preferred Reporting Items for Systematic Review and Meta-Analysis guideline, Comprehensive Meta-Analysis, and the RE-AIM framework were utilized.

RESULTS

A total of 15 studies that met the inclusion criteria were included in the meta-analysis. The effects of physical activity on mental health in children and adolescents with IDs were significant and large (Hedges' g = 0.897, p < 0.01), with medium effects on psychological health (Hedges' g = 0.542, p < 0.01) and large effects on cognitive function (Hedges' g = 1.236, p < 0.01). Randomized controlled trial (RCT) design and intervention components (> 120 minutes per week, therapeutic, and aerobic exercise) demonstrated the strongest effects. Moreover, study background (publication year, study location, and sample size), participant characteristics (age and sex), and Maintenance (RE-AIM framework) moderated the effects of physical activity on mental health. Based on the RE-AIM framework, there were higher proportions in the dimensions of Reach and Effectiveness than Adoption, Implementation, and Maintenance.

CONCLUSIONS

Physical activity appears to have positive effects on mental health, including psychological health and cognitive function, in children and adolescents with IDs. Physical activity interventions using the RE-AIM framework are recommended to assess short- and long-term impacts and translate scientific evidence into practice.

TRIAL REGISTRATION

The protocol for this meta-analysis was registered with PROSPERO ( CRD42021256543 ).

Nationwide sports injury prevention strategies: A scoping review

National strategies to prevent sports injuries can potentially improve health outcomes at a population level and reduce medical costs. To date, a compilation of the strategies that countries have attempted, and their effectiveness, does not exist. This scoping review sets out to: identify nationwide attempts at implementing sports injury prevention strategies; examine the impact of these strategies; and map them onto the Translating Research into Injury Prevention Practice (TRIPP) framework. Using Levac's scoping review method, we: (a) identified the research questions, (b) identified relevant studies, (c) identified the study selection criteria, (d) charted the data, and (e) reported the results. A search of MEDLINE, Scopus, SPORTDiscus, CINAHL, and Web of Science databases for articles published pre-June 2019 was conducted. We identified 1794 studies and included 33 studies (of 24 strategies). The USA (n = 7), New Zealand (n = 4), Canada (n = 3), the Netherlands (n = 3), Switzerland (n = 2), Belgium (n = 1), France (n = 1), Ireland (n = 1), South Africa (n = 1), and Sweden (n = 1) have implemented nationwide sports injury prevention strategies with 29 (88%) of the included studies demonstrating positive results. Mapping the strategies onto the TRIPP framework highlighted that only four (17%) of the 24 included strategies reported on the implementation context (TRIPP Stage 5), suggesting an important reporting gap. Nationwide sports injury prevention efforts are complex, requiring a multidimensional approach. Future research should report intervention implementation data; examine the implementation context early in the research process to increase the likelihood of real-world implementation success; and could benefit from incorporating qualitative or mixed research methods.

Evaluating the Implementation of Injury Prevention Strategies in Rugby Union and League: A Systematic Review using the RE-AIM Framework

Rugby (union and league) has come under intense scrutiny due to its injury risk. Various interventions have been introduced to protect players from injury, with many deemed efficacious and advocated for use across various worldwide contexts. However, their implementation is less clear. The objective of this systematic review was to determine whether injury prevention interventions in rugby have evaluated their 'reach', 'effectiveness', 'adoption', 'implementation' and 'maintenance' as per the RE-AIM Multi-Dimension Item Checklist. Six electronic databases were searched in November 2019. Inclusion criteria included: English language, peer-reviewed journal article, original research, field-based rugby code, prospective intervention. Of the 4253 studies identified, 74 met the full inclusion criteria. Protective equipment, predominately mouthguards, was the intervention of interest in 44 studies. Other interventions included multimodal national injury prevention programmes, law changes and neuromuscular training programmes. 'Effectiveness' was the highest scoring RE-AIM dimension (55%), followed by 'reach' (26%). All other RE-AIM dimensions scored below 20%. Research currently focuses on determining intervention 'effectiveness'. For injury prevention strategies to have their desired impact, there must be a shift to address all determinants associated with implementation. Consideration should be given to how this can be achieved by adopting specific reporting checklists, research frameworks and study designs.

How much, how often, how well? Adherence to a neuromuscular training warm-up injury prevention program in youth basketball

Adherence is a key implementation outcome that determines the effectiveness of an intervention. This study, an observational design involving coaches and players from 33 high school basketball teams, evaluated the dimensions of adherence to a basketball-specific neuromuscular training (NMT) warm-up program in youth basketball. Coach adherence (daily report of team adherence) was collected prospectively. Adherence measures: cumulative utilization (proportion of total sessions possible), utilization fidelity (average # of exercises completed per NMT session), utilization frequency (average # of NMT sessions completed per week) were calculated and further evaluated for optimal adherence (≥80%, ≥10.4 exercises/session and ≥2 sessions/week, respectively) per coach. Additionally, exercise fidelity (proportion of players performing individual exercises correctly) was assessed. Coach (n = 31; 27-59 years) median cumulative utilization was 80%, utilization fidelity was 12 (of a possible 13 exercises per session) and utilization frequency was 2.3 sessions per week. Optimal adherence ranged from 52% to 71% across measures of adherence. Player exercise fidelity was 48%. Time constraint (47%) was the most frequently reported adherence barrier. While coach adherence to the NMT warm-up program was reasonably high across measures of adherence, a considerable proportion of coaches did not attain optimal adherence levels and player exercise fidelity was low.

Acute Neuromuscular Activity in Selected Injury Prevention Exercises with App-Based versus Personal On-Site Instruction: A Randomized Cross-Sectional Study

Introduction

A significant step towards sport-related injury prevention is the introduction of easily accessible smartphone applications (apps). However, it is unknown whether this type of app-based instruction facilitates similar acute neuromuscular and biomechanical characteristics of the preventive exercises as achieved when instructed on-site by an expert. Thus, the aim was to evaluate acute neuromuscular characteristics observed during a single bout of selected lower extremity injury preventive exercises instructed by an on-screen app versus on-site individual instruction provided by a physiotherapist.

Methods

In a cross-sectional study design, 47 female football and handball players were randomly assigned to receive app instruction (APP group) or on-site instruction provided by a physiotherapist (PHY group) while performing five lower extremity injury preventive exercises. The exercises performed comprised (1) one-legged balance on Airex, (2) vertical drop jump, (3) one-legged horizontal jump onto floor, (4) one-legged horizontal jump onto Airex, and (5) two-hand Kettlebell Swing. Primary outcome was hamstring (biceps femoris and semitendinosus) muscle activity. Secondary outcomes were quadriceps (vastus lateralis and medialis) muscle activity, as well as hip and knee joint angles. Muscle activity was monitored by surface electromyography (EMG) and normalized to the peak amplitude obtained during a maximal voluntary isometric contraction (MVC). Hip and knee joint angles were recorded by a 3D motion analysis system. A linear mixed model was used to evaluate the differences between experimental conditions for each outcome variable.

Results

Medial hamstring (semitendinosus) muscle activity was significantly higher during one-legged jump onto Airex (17 percentage points (95% CI 7 to 27)) and Kettlebell Swing (19 percentage points (95% CI 2 to 36)) in the PHY group than the APP group. Likewise, the PHY group demonstrated 18 percentage points (95% CI 1 to 35) and 19 percentage points (95% CI 0 to 38), greater lateral quadriceps muscle (vastus lateralis) activity during one-legged jump onto floor and one-legged jump onto Airex, respectively, compared with that of the APP group.

Conclusions

Complex exercises, i.e., Kettlebell Swing and one-legged jump onto Airex, are characterized by lower neuromuscular activity when using app-based instructions compared with on-site instruction provided by a physiotherapist. However, the effectiveness of app-based instruction versus on-site individual instruction in injury prevention interventions remains to be investigated in future longitudinally studies.

What do Sport and Exercise Medicine (SEM) doctors look like online? A cross-sectional exploration of the social media presence of SEM doctors in the UK

Objectives

To explore the social media presence of Sport and Exercise Medicine (SEM) doctors from the UK. Secondary aims were to identify whether there were any differences in years since qualification or specialisation between those with and without social media profiles and websites.

Methods

A cross-sectional design was used to investigate the social media presence of UK-based doctors listed as Fellows of the Faculty of Sport and Exercise Medicine. These SEM doctors were identified via their presence on publicly available member lists. Data collected for each SEM Fellow included the presence of profiles on major social media platforms (Twitter, LinkedIn, YouTube and professional Facebook profiles) demonstrated by active profile use and the number of followers/subscribers per platform. The ownership of professional websites and websites hosted by private healthcare providers was also examined.

Results

A total of 175 SEM Fellows were identified and included for analysis. LinkedIn was the most popular platform for this cohort (n=115), followed by Twitter (n=73), while YouTube had far fewer profiles among the SEM Fellows (n=9). No professional Facebook profiles were identified for the SEM Doctors in this study. Almost a third (n=49) of SEM Fellows did not have a profile on any of the social media platforms examined in this study.

Conclusion

Social media is a powerful tool for health promotion and education. The use of these platforms by SEM Doctors and healthcare organisations warrants ongoing guidance and support to enable these practitioners to maximise the utility of these innovative technologies.

Theoretical Advancements in mHealth: A Systematic Review of Mobile Apps

There are now few hundred thousand healthcare apps, yet there is a gap in our understanding of the theoretical mechanisms for which, and how, technological features translate into improved healthcare outcomes. In particular, the technological convergence, within mobile health (mHealth) apps, of the processes of mass and interpersonal communication, and human-computer interaction requires greater parsing in the literature. This paper analyzed 85 empirical studies on mHealth apps using the Input-Mechanism-Output model. We found in the literature that, firstly, there is a greater emphasis on technological inputs (87%) of accessibility, usability, usage, and data quality, than health outputs (52%) such as system process efficiencies and individual level behavioral or health outcomes. Secondly, there is little evidence of explanatory mechanisms (19%) of how the effects of mHealth apps are achieved. While we believe that successful apps would require research that incorporates technological inputs, theoretical mechanisms and health outputs, such studies are a rarity (n = 3). There is a minor increase in rigor with randomized control trials (n = 5), and a preponderance of discussion around social influence (n = 8) and gamification (n = 7), albeit in a scattered manner. We discuss the implications of the trend towards socialization and gamification findings in terms of future research, particularly in terms of study design guided by theoretical mechanisms.

Users' Perspectives, Opportunities, and Barriers of the Strengthen Your Ankle App for Evidence-Based Ankle Sprain Prevention: Mixed-Methods Process Evaluation for a Randomized Controlled Trial

Background

The “Strengthen Your Ankle” neuromuscular training program has been thoroughly studied over the past 8 years. This process evaluation is a part of a randomized controlled trial that examined both the short- and long-term effectiveness of this particular program. Although it was shown previously that the program, available both in a printed booklet and as a mobile app, is able to effectively reduce the number of recurrent ankle sprains, participants’ compliance with the program is an ongoing challenge.

Objective

This process evaluation explored participants’ opinions regarding both the methods of delivery, using RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) Framework to identify barriers and challenges to program compliance. Although Reach, Effectiveness, and Adaptation were the focus of a previous study, this paper focuses on the implementation and maintenance phases.

Methods

Semistructured interviews and online questionnaires were analyzed using qualitative content analysis. Fisher exact, chi-square, and t tests assessed between-group differences in quantitative survey responses. Interviews were assessed by thematic analysis to identify key themes.

Results

While there were no significant differences in the perceived simplicity, usefulness, and liking of the exercise during the 8 weeks of the neuromuscular training program, semistructured interviews showed that 14 of 16 participants agreed that an app would be of additional benefits over a booklet. After the 12-month follow-up, when asked how they evaluated the overall use of the app or the booklet, the users of the app gave a mean score of 7.7 (SD 0.99) versus a mean score 7.1 (SD 1.23) for the users of the booklet. This difference in mean score was significant (P=.006).

Conclusions

Although both the app and booklet showed a high user satisfaction, the users of the app were significantly more satisfied. Semistructured questionnaires allowed users to address issues they would like to improve in future updates. Including a possibility for feedback and postponement of exercises, an explanation of the use of specific exercises and possibly music were identified as features that might further improve the contentment of the program, probably leading to increased compliance.

Trial Registration

Netherlands Trial Register NTR4027; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4027 (Archived by Webcite at http://www.webcitation.org/70MTo9dMV)

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

Players' and coaches' knowledge and awareness of the BokSmart Safe Six injury prevention programme: an ecological cross-sectional questionnaire study

OBJECTIVES

Rugby has a high injury incidence and therefore BokSmart introduced the Safe Six injury prevention programme in 2014 in an attempt to decrease this incidence. In 2015, BokSmart used a 'targeted marketing approach' to increase the awareness and knowledge of the Safe Six. Therefore, the aim of this study was to determine the change in the knowledge of coaches and players of the Safe Six programme, compared with the launch year, following a 'targeted marketing approach'.

DESIGN

Ecological cross-sectional questionnaire study SETTING: The 2014-2016 South African rugby union youth week tournaments.

PARTICIPANTS

Questionnaires were completed by 4502 players and coaches who attended any of the four youth week tournaments during 2014-2016.

OUTCOME MEASURES

Logistic regression (adjusted OR, 95% CI) was performed in comparison to year prior to targeted marketing, separately for coaches and players, for changes in awareness and knowledge.

RESULTS

The awareness of the Safe Six increased significantly for players in 2015 (1.74 times (95% CI 1.49 to 2.04)) and in 2016 (1.54 times (95% CI 1.29 to 1.84)). Similarly for coaches, there was a 3.55 times (95% CI 1.23 to 9.99) increase in 2015 and a 10.11 times (95% CI 2.43 to 42.08) increase in 2016 compared with 2014. Furthermore, a player was significantly more likely to be aware of the Safe Six if his coach was aware of the programme (p<0.05).

CONCLUSIONS

The knowledge and awareness of the BokSmart Safe Six of both players and coaches increased in 2015 and 2016 (compared with 2014) since the launch of the programme. Coaches, the Unions/the South African Rugby Union and social media were the largest contributors to knowledge in coaches and players. While the 'targeted marketing approach' was associated with an increase in awareness, future studies should determine if this translates into behavioural change.

Sport Concussion Management Using Facebook: A Feasibility Study of an Innovative Adjunct "iCon"

CONTEXT

  Sport concussion is currently the focus of much international attention. Innovative methods to assist athletic trainers in facilitating management after this injury need to be investigated.

OBJECTIVE

  To investigate the feasibility of using a Facebook concussion-management program termed iCon (interactive concussion management) to facilitate the safe return to play (RTP) of young persons after sport concussion.

DESIGN

  Observational study.

SETTING

  Facebook group containing interactive elements, with moderation and support from trained health care professionals.

PATIENTS OR OTHER PARTICIPANTS

  Eleven participants (n = 9 men, n = 2 women; range, 18 to 28 years old) completed the study.

DATA COLLECTION AND ANALYSIS

  The study was conducted over a 3-month period, with participant questionnaires administered preintervention and postintervention. The primary focus was on the qualitative experiences of the participants and the effect of iCon on their RTP. Usage data were also collected.

RESULTS

  At the completion of the study, all participants (100%) stated that they would recommend an intervention such as iCon to others. Their supporting quotes all indicated that iCon has the potential to improve the management of concussion among this cohort. Most participants (n = 9, 82%) stated they were better informed with regard to their RTP due to participating in iCon.

CONCLUSIONS

  This interactive adjunct to traditional concussion management was appreciated among this participant group, which indicates the feasibility of a future, larger study of iCon. Athletic trainers should consider the role that multimedia technologies may play in assisting with the management of sport concussion.

The role of interdisciplinary research team in the impact of health apps in health and computer science publications: a systematic review

BACKGROUND

Several studies have estimated the potential economic and social impact of the mHealth development. Considering the latest study by Institute for Healthcare Informatics, more than 165.000 apps of health and medicine are offered including all the stores from different platforms. Thus, the global mHealth market was an estimated $10.5 billion in 2014 and is expected to grow 33.5 percent annually between 2015 and 2020s. In fact, apps of Health have become the third-fastest growing category, only after games and utilities.

METHODS

This study aims to identify, study and evaluate the role of interdisciplinary research teams in the development of articles and applications in the field of mHealth. It also aims to evaluate the impact that the development of mHealth has had on the health and computer science field, through the study of publications in specific databases for each area which have been published until nowadays.

RESULTS

Interdisciplinary nature is strongly connected to the scientific quality of the journal in which the work is published. This way, there are significant differences in those works that are made up by an interdisciplinary research team because of they achieve to publish in journals with higher quartiles. There are already studies that warn of methodological deficits in some studies in mHealth, low accuracy and no reproducibility. Studies of low precision and poor reproducibility, coupled with the low evidence, provide low degrees of recommendation of the interventions targeted and therefore low applicability.

CONCLUSIONS

From the evidence of this study, working in interdisciplinary groups from different areas greatly enhances the quality of research work as well as the quality of the publications derived from its results.

Use of an embedded, micro-randomised trial to investigate non-compliance in telehealth interventions

Background/aims:

Many types of telehealth interventions rely on activity from the patient in order to have a beneficial effect on their outcome. Remote monitoring systems require the patient to record regular measurements at home, for example, blood pressure, so clinicians can see whether the patient’s health changes over time and intervene if necessary. A big problem in this type of intervention is non-compliance. Most telehealth trials report compliance rates, but they rarely compare compliance among various options of telehealth delivery, of which there may be many. Optimising telehealth delivery is vital for improving compliance and, therefore, clinical outcomes. We propose a trial design which investigates ways of improving compliance. For efficiency, this trial is embedded in a larger trial for evaluating clinical effectiveness. It employs a technique called micro-randomisation, where individual patients are randomised multiple times throughout the study. The aims of this article are (1) to verify whether the presence of an embedded secondary trial still allows valid analysis of the primary research and (2) to demonstrate the usefulness of the micro-randomisation technique for comparing compliance interventions.

Methods:

Simulation studies were used to simulate a large number of clinical trials, in which no embedded trial was used, a micro-randomised embedded trial was used, and a factorial embedded trial was used. Each simulation recorded the operating characteristics of the primary and secondary trials.

Results:

We show that the type I error rate of the primary analysis was not affected by the presence of an embedded secondary trial. Furthermore, we show that micro-randomisation is superior to a factorial design as it reduces the variation caused by within-patient correlation. It therefore requires smaller sample sizes – our simulations showed a requirement of 128 patients for a micro-randomised trial versus 760 patients for a factorial design, in the presence of within-patient correlation.

Conclusion:

We believe that an embedded, micro-randomised trial is a feasible technique that can potentially be highly useful in telehealth trials.

Increasing compliance with neuromuscular training to prevent ankle sprain in sport: does the ‘Strengthen your ankle’ mobile App make a difference? A randomised controlled trial

Background

E-health has the potential to facilitate implementation of effective measures to prevent sports injuries.

Aim

We evaluated whether an interactive mobile application containing a proven effective exercise programme to prevent recurrent ankle sprains resulted in higher compliance as compared with regular written exercise materials.

Methods

220 athletes participated in this randomised controlled trial with a follow-up of 8 weeks; 110 athletes received a booklet explaining an 8-week neuromuscular training programme; 110 athletes participated in the same programme in an interactive mobile App (Strengthen your ankle). The primary outcome was compliance with the exercise programme. Secondary outcome measure was the incidence density of self-reported recurrent ankle sprains.

Results

The mean compliance to the exercise scheme was 73.3% (95% CI 67.7% to 78.1%) in the App group, compared with 76.7% (95% CI 71.9% to 82.3%) in the Booklet group. No significant difference in compliance was found between groups. The incidence densities of self-reported time-loss recurrences were not significantly different between both groups (HR 3.07; 95% CI 0.62 to 15.20).

Summary

This study shows that the method of implementing the exercises by using an App or a Booklet does not lead to different compliance rates.

New findings

The use of a mobile App or a Booklet lead to similar compliance and injury rates in the short term.

Trial registration number

The Netherlands National Trial Register NTR 4027. The NTR is part of the WHO Primary Registries.

Mobile Phone-Based Joint Angle Measurement for Functional Assessment and Rehabilitation of Proprioception

Assessment of joint functional and proprioceptive abilities is essential for balance, posture, and motor control rehabilitation. Joint functional ability refers to the capacity of movement of the joint. It may be evaluated thereby measuring the joint range of motion (ROM). Proprioception can be defined as the perception of the position and of the movement of various body parts in space. Its role is essential in sensorimotor control for movement acuity, joint stability, coordination, and balance. Its clinical evaluation is commonly based on the assessment of the joint position sense (JPS). Both ROM and JPS measurements require estimating angles through goniometer, scoliometer, laser-pointer, and bubble or digital inclinometer. With the arrival of Smartphones, these costly clinical tools tend to be replaced. Beyond evaluation, maintaining and/or improving joint functional and proprioceptive abilities by training with physical therapy is important for long-term management. This review aims to report Smartphone applications used for measuring and improving functional and proprioceptive abilities. It identifies that Smartphone applications are reliable for clinical measurements and are mainly used to assess ROM and JPS. However, there is lack of studies on Smartphone applications which can be used in an autonomous way to provide physical therapy exercises at home.