Bmc Sports Science Medicine And Rehabilitation

Bmc Sports Science, Medicine And Rehabilitation
The FIFA 11+ injury prevention program has been recommended and adopted worldwide, owing to its effectiveness and easy application. The main finding of this study was that the program reduced injury risk by 30% (RR 0.70; 95% CI, 0.52–0.93). This result corroborates data from other studies regarding the effectiveness of the FIFA 11+ program for injury prevention in soccer players. One example is a cohort study performed in the USA in 2013 [31], which evaluated the protective effect of the program in male soccer players aged 18–25 years. The study adopted the first stage as the control and the second stage as the intervention evaluation and observed an RR reduction of approximately 72% (RR, 0.28; 95% CI, 0.09–0.85).

Soligard et al. (2010) obtained similar results when they evaluated the same parameters in female soccer players aged 13–17 years. The program was applied 1.3 times a week for 10 months and was associated with a 46% lower risk of injuries in the IG (odds ratio, 0.54; 95% CI, 0.33–0.87). In the same context, a systematic review published in 2014 [19] analyzed cohort and control studies and reported a 30–70% decrease in the occurrence of injuries in soccer players of both sexes aged >13 years. Another systematic review conducted by Mayo et al. (2014) included clinical and cohort studies and showed 33% and 57% reductions in injury occurrence, respectively. Thus, this meta-analysis also used studies that showed the effectiveness of the FIFA 11+ program (Table 3).

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Table 3 Main aspects of references used on the revision

Owoeye et al. [27] studied Nigerian players aged 14–19 years (n = 416, IG: 212, CG: 204) for 6 months and found that the FIFA 11+ program was effective, with a global injury reduction rate of 41% (RR, 0.59; 95% CI, 0.40–0.86; p = 0.006) during the evaluation period. Silvers-Granelli et al. [26] applied the program for American players of the National Collegiate Athletic Association and observed a 46.1% reduction in the injury rate (RR, 0.54; 95% CI, 0.49–0.59; p 24], who were the first to test the FIFA 11+ program, performed a randomized clinical trial with 1,892 female Norwegian players aged 13–17 years (IG: 1,055, CG: 837). The FIFA 11+ program was applied for 8 months, and a 32% reduction in injury incidence was observed (RR = 0.68; 95% CI, 0.48–0.98).

The literature presents a few studies that suggest the ineffectiveness of the use of the FIFA 11+ program in decreasing the injury rate, which highlights the need for an improved understanding of this subject. However, this dichotomy is possibly a result of the lack of a specific program protocol.

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Analysis of the results of the systematic review showed increased heterogeneity (I 2 = 90%). We decided that a relevant approach would be to address this heterogeneity by identifying its main points in order to better understand factors that may interfere with the effectiveness of the program and to propose solutions.

A thorough reference analysis attributed the heterogeneity to clinical factors inherent to the sample, such as sex, age, body mass index (BMI), and clinical characteristics of the injuries. Furthermore, methodological heterogeneity may occur because of the lack of a protocol, type of warm-up adopted by the CG, non-blinded trainers, differences in capacity among training teams, and technical managers, as well as study frequency and duration.

In this review, the sample ages typically ranged from 13 to 25 years old, though the study conducted by Hammes et al. [22] included individuals aged >40 years (IG: 42.5 years old; CG: 43.1 years old). This factor is extremely relevant owing to the increased articular degeneration inherent to the aging process; furthermore, age also affects attitude and behavior during sports practice, physical resistance, and circumstances under which a soccer game is played [32, 33]. In this sense, player maturity is related to a higher commitment level and greater exercise awareness [24]. On the other hand, advanced age was identified as an injury risk factor in men aged >28 years and women aged >25 years [34]. It is worth emphasizing the effect of age on injury profiles, as younger athletes display more aggressive behavior while playing sports. This factor, which is associated with lower motor coordination in teenagers aged 14–16 years, explains the occurrence of higher contusion-type injuries in the lower limbs [35]. However, training is advantageous for young players, considering that they have not yet developed the bad habits of experienced players, which may ensure more correct exercise execution [25].

Another important factor was BMI, which is composed of non-modifiable (height) and modifiable factors (weight). Hammes et al. [23] reported a BMI suggestive of overweight for both groups (IG: 27; CG: 26,1). Some analyzed studies did not report BMI [24,25,26,27], while others presented normal values [28], which hindered analysis. This index modification (overweight or underweight) is related to higher injury occurrence, as overweight suggests less physical conditioning and, consequently, higher articular wear due to overload. On the other hand, underweight is related to reduced muscle mass and decreased ability to stabilize articulations during the game [16, 35].

Sex was another relevant clinical factor. Three studies analyzed men [23, 27, 28], and 3 analyzed women [24,25,26]. The literature presents clear evidence of higher overall injury rates in men [36]. However, women tend to have more ligament injuries [37, 38] and fewer muscle injuries than men [39, 40]. This injury profile may be explained by hormonal factors, especially those associated with sex, which are linked to anterior cruciate ligament injuries [41, 42].

Clinical aspects were also evaluated, and important differences were observed, which may have affected the heterogeneity of the results. Initially, emphasis was placed on the intrinsic subjectivity of injury categorization, even though all studies had declarations of consensus on the injury definitions and data collection procedures used in soccer studies [43] for evaluating player injuries. This means that the concept of injury and its categorization are subjective, both from the examiner’s and patient’s perspectives. This subjectivity may have been increased in the studies where injury was not evaluated by a qualified professional [23] and was diagnosed by the trainer or player.

Another relevant factor was the analyzed player type, as most were amateurs who are more susceptible to injuries because their technical abilities are inferior to those of professionals. In addition, professional players are more likely to adopt prevention programs [24]. Comparisons revealed that amateurs and professionals are more frequently injured during training and during the game, respectively. In addition, less severe injuries occur in professionals, whereas moderate and severe injuries are prevalent in amateurs [44].

Several studies used weekly monitoring [25, 27, 28], whereas other studies used monthly monitoring. Still other studies performed monitoring on demand [26]. Clearly, reliable results were more likely obtained by those who performed more frequent monitoring. When trainers questioned the reports, the programs and monitoring were more effectively conducted. This methodology may also have contributed to reductions in partial or incorrect reporting, which was present in most of the studies.

Attention to proper trainer monitoring and data recording was found to be an essential factor, as the trainers were present in some studies [23, 26, 27], while in other studies, this spare-time role was filled by parents [25] or “advisory players” [23] who complained about the overload inherent to this activity. Such overload combined with trainers lacking knowledge regarding randomization explained the abandonment of the CG in several studies, as many trainers felt discouraged because they were not selected for the IG or were simply not available for data reports.

Methodology was also associated with relevant factors. As previously mentioned, the FIFA 11+ program is easily applicable; however, effectiveness is only obtained if exercises are performed within the existing standards. On the other hand, homogeneity in program application was absent among different reference groups, which affected the results obtained through the combined analysis. A standard protocol for the warm-up program application was nonexistent; thus, application in some studies was according to FIFA recommendations, i.e., 2 or 3 times a week [25, 26], while others used 1-week intervals [23, 24, 27, 28]. Furthermore, differences were observed