ACL Injury Prevention Education Improves Implementation of Neuromuscular Training Among High School Sports Coaches: A Cross-Sectional Survey Study

Abstract

Background:

Neuromuscular training (NMT) programs delivered by trained personnel have demonstrated protective effects against anterior cruciate ligament (ACL) injury among high school sports participants, but few studies have investigated the impact of education on high school sports coaches’ knowledge and incorporation of NMT programs into daily practice sessions.

Purpose:

We sought to evaluate changes in knowledge and behavior among high school sports coaches who completed an NMT-based injury prevention training program.

Methods:

High school sports coaches were invited to complete a free online training course in incorporating NMT into daily practice sessions. Anonymized surveys were administered before and after education and at 3 months to evaluate knowledge level and program effectiveness.

Results:

Of the 13,640 coaches who enrolled in the training course in 2019, 1641 submitted pre- and post-education and 3-month follow-up surveys. Prior to training, 4.4% reported incorporating NMT into daily training sessions and the mean knowledge score was 1.89 ± 1.55. After training, 92.7% of participants reported that they intended to incorporate NMT into their daily training sessions and the mean knowledge score was 4.87 ± 1.11. At 3-month follow-up, 88.9% of participants reported incorporating NMT into daily training sessions. A chi-square test revealed a significant association between pre- and post-education incorporation of NMT into daily practice sessions, and a multiple regression analysis resulted in a significant model with intent to incorporate NMT into daily practice sessions identified as a significant behavior predictor.

Conclusion:

These survey results show that completion of a training course significantly improved ACL injury prevention knowledge among a cohort of high school sports coaches and likely contributed to the sustained incorporation of NMT into their daily practice sessions.

Keywords

ACL coach education health behavior neuromuscular training injury prevention adolescent athletes

Introduction

Sports are popular among U.S. adolescents, with more than 7 million high school students participating in interscholastic sports each academic year between 2004 and 2019 [25]. While the physical and mental health benefits associated with sports participation among adolescents are widely recognized [6,10,13], time-loss injuries that temper these benefits are common [33]. Injuries involving the anterior cruciate ligament (ACL), among the most concerning time-loss injuries among high school sports participants, have been linked to opioid use, diminished athletic performance, post-traumatic osteoarthritis, depression, kinesiophobia, and lower self-esteem and quality of life [1,5,28,32,34,40]. In addition, 50% to 90% of all individuals who suffer an ACL injury will develop post-traumatic osteoarthritis [40], while more than 75% of ACL injuries among high school sports participants result in surgical intervention [14]. To address these issues, sports medicine organizations and researchers have called for sports coaches to adopt injury prevention programs (IPPs) that include neuromuscular training (NMT) [29,36].

Often defined as an exercise-based intervention that improves athletic skills and health-related fitness [24], NMT has demonstrated protective effects against ACL injury when delivered or supervised by specialized medical practitioners [9,12,17]. Early recommendations for sports coaches to add NMT-based IPPs to their practice plans [7,29,37] described specific exercises and proper technique [9,12,17], but widespread adoption of these programs was not realized [15,16,26]. Subsequent studies identified several implementation barriers including significant time requirements, a limited awareness of ACL injuries as a significant health issue, and the need for additional physical resources [15,21,35]. Attempts to address these implementation barriers led to the creation of NMT-based IPPs that coaches could implement as pre-activity warm-ups that included many existing exercises of shorter duration and required little to no equipment [2,11]. Despite high levels of self-reported intent to utilize NMT-based IPPs, researchers failed to persuade sports coaches to adopt these programs at scale [8].

The use of NMT-based IPPs by sports coaches can be considered a health-promoting behavior, but theoretical models that explain or predict the adoption of health-promoting behaviors are absent from NMT-based IPP implementation studies. The Integrated Behavioral Model (IBM), a combination of the Theory of Planned Behavior and Theory of Reasoned Action, was introduced in 2002 to inform the development of communication strategies to change health behaviors [20]. The IBM describes the relationship between several factors that influence human behavior [23] and has been used in the design of a variety of health-promotion and IPPs [4,39].

The IBM includes 5 components that influence behavior: intention to perform a behavior, understanding of the salience of a behavior, elimination of environmental constraints, opportunity for behaviors to become habitual, and acquisition of needed knowledge and skills [30] and may be used to address the needs of high school sports coaches in adopting NMT-based IPPs. While each of the model’s components is critical, the acquisition of knowledge and skills is particularly important to consider. Although investigators have described methods including teaching coaches about exercise selection and technique during NMT-based IPP education programs [17,18,27], few have reported teaching coaches the skills needed to effectively implement NMT: delivering exercise instructions, assessing exercise technique, and providing corrective feedback.

Therefore, we sought to evaluate (1) the knowledge and skills of high school sports coaches before and after completing an NMT-based IPP education course and (2) their implementation and adoption of an NMT-based IPP over a 3-month period. Accordingly, we hypothesized that on completing a NMT-based IPP education course, the coaches would demonstrate statistically significant improvements in knowledge related to NMT-based IPPs and more than half would report incorporating an NMT-based IPP into their daily practice sessions over a 3-month sports season.

Methods

This Institutional Review Board–approved, cross-sectional study included the development and deployment of an online ACL injury prevention training course for high school sports coaches and the use of surveys pre- and post-education and at 3-month follow-up using the IBM as a framework.

The online training course was designed to be completed in less than 30 minutes and included 3 modules. First, it presented ACL injury incidence rates among high school sports participants and evidence linking ACL injuries and poor health outcomes in this population; second, it provided guidance on instructing sports participants verbally and visually, assessing their exercise technique, and giving corrective feedback to those performing exercises incorrectly; and third, it gave video demonstrations of injury prevention experts leading NMT-based warm-ups with high school students.

The course was posted to the online learning center of a national high school sports federation and was accessible to coaches from U.S. public high schools without a registration fee. Federation members were invited to take the course via a social media, print, and news media campaign by the host organization.

Three anonymized surveys were deployed with the course to evaluate education outcomes and effectiveness. The pre-education survey was administered after course registration (prior to the start of the first module) and included questions on user demographics and 6 multiple-choice questions on knowledge of NMT-based IPPs and the skills required for implementing them. The knowledge questions were graded with a single point for each correct answer. The post-education survey was administered after completing the final module and included the same 6 multiple-choice questions, plus Likert-scale questions that assessed participants’ intention to implement the NMT-based IPP and satisfaction with the education. A follow-up survey was administered approximately 3 months after course completion and included Likert-scale questions that assessed the implementation of the NMT-based IPP and satisfaction with the educational experience.

Statistical Analysis

The statistical analyses were completed using SPSS version 28.0. Descriptive and frequency statistics were calculated to summarize the demographic characteristics of the participants. A paired samples t test was used to evaluate changes in knowledge between pre- and post-education time points, and chi-square tests of independence were used to evaluate associations between sex and the intent to incorporate NMT into daily practice sessions, sex and the incorporation of NMT into daily practice sessions, and the intent to incorporate NMT into daily practice sessions and the incorporation of NMT into daily practice sessions. In addition, point biserial correlation analyses were used to evaluate associations between age and the intent to incorporate NMT into daily practice sessions, years of coaching experience and the intent to incorporate NMT into daily practice sessions, age and the incorporation of NMT into daily practice sessions, and years of coaching experience and the incorporation of NMT into daily practice sessions. Finally, multiple linear regression analyses were used to assess the relationship between participant demographic characteristics and behavioral intent and behavior performance. An a priori alpha level of 0.05 was set for all statistical analyses.

Results

Of the 13,640 coaches who enrolled in the training course during 2019, 1641 (12.0%) submitted complete pre-education, post-education, and 3-month follow-up surveys. Descriptive statistics revealed a mean age of 43.8 ± 6.3 years and 8.6 ± 1.7 years of coaching experience. Frequency statistics revealed 1,300 participants (79.2%) identified as male and 341 participants (20%.6) identified as female. In addition, 187 participants (11.4%) reported coaching a high school sports participant diagnosed with an ACL injury, 159 participants (9.4%) reported previously receiving some form of ACL injury prevention training, and 57 participants (3.5%) reported currently incorporating NMT in their daily practice sessions.

The mean pre-education knowledge score among all participants was calculated as 1.89 ± 1.55 (31.5% correct). The mean post-education knowledge score was calculated as 4.87 ± 1.11 (81.2% correct). This 2.98-point difference represents a 157.7% increase in the overall knowledge score. In addition, frequency statistics revealed that upon completing the course, 1,521 participants (92.7%) reported that they were “likely” or “extremely likely” to incorporate NMT into their daily training sessions, 1544 coaches (94.1%) reported that they were either “satisfied” or “very satisfied” with the training course, and 1512 coaches (92.1%) reported that they “would recommend the training course to other coaches.”

Frequency statistics from the 3-month follow-up survey data (Fig. 1) revealed that 1,459 coaches (88.9%) reported incorporating NMT into their daily training sessions, and 85.4-point difference representing a 1926.4% increase, as well as 182 coaches (11.1%) who reported “never” incorporating NMT into their daily practice sessions. Of those coaches, 74 (40.7%) reported “not enough time,” 68 (37.4%) reported “need additional training,” 38 (20.9%) reported “program too complicated,” and 15 (8.2%) reported “not important to me” as barriers to incorporating NMT into daily practice sessions.

Fig. 1.

Reported frequency by coaches of incorporating NMT into daily practice sessions.

Several bivariate analyses were completed. First, a paired samples t test was used to evaluate the difference between pre- and post-education knowledge scores. Results revealed a statistically significant difference between pre- and post-education scores, t(1640) = 60.385, P < .001, with a large effect size (d = 1.49). In addition, chi-square tests of independence found no statistically significant associations were identified between sex and the intent to incorporate NMT into daily practice sessions (P = .997) or sex and the incorporation of NMT into daily practice sessions (P = .896). A statistically significant association was identified, however, between pre- and post-education incorporation of NMT into daily practice sessions (χ² [1, N = 1641] = 7.412, P = .006), though the effect size was small (Cramér’s V = .067).

Point biserial correlation analyses found no statistically significant associations identified between age and the intent to incorporate NMT into daily practice sessions (P = .622), years of coaching experience and the intent to incorporate NMT into daily practice sessions (P = .837), age and the incorporation of NMT into daily practice sessions (P = .927), and years of coaching experience and the incorporation of NMT into daily practice sessions (P = .769).

A multiple linear regression analysis showed that sex (P = .995), age (P = .620), and years of coaching experience (P = .832) were not significantly associated with the intent to incorporate NMT into daily practice sessions. A subsequent multiple linear regression analysis was completed to analyze the relationship between age, sex, years of coaching experience, and the intent to incorporate NMT into daily practice sessions and the incorporation of NMT into daily practice sessions. Results revealed that the overall regression model was statistically significant, R² = 0.628, F(4, 1636) = 692.393, P = <.001, with the intent to incorporate NMT into daily practice sessions, accounting for 79.3% of the variance in incorporating NMT into daily practice sessions.

Discussion

This study produced 2 findings that may have an impact on the future design, distribution, and evaluation of ACL IPP training courses for high school sports coaches.

First, the coaches who completed the ACL IPP training course reported a significant improvement in knowledge of NMT-based IPPs and the skills required to implement them. While many researchers have reported providing ACL injury prevention education to sports coaches [17,19,27], few have described the education in detail or used behavior change theory in the design of education programs. The use of behavior change theory has been shown to contribute to the development of effective public health-based interventions [22]. This study suggests that the use of behavior change theory to inform the development of ACL IPP education for sports coaches may be effective. There is little evidence in the literature on changes in knowledge related to ACL IPP education for sports coaches. While Benjaminse and Verhagen [3] identified a research-to-practice gap related to ACL IPPs and called for education to be part of efforts to bridge this gap, few studies have investigated the knowledge and skills required for effective implementation of NMT-based IPPs.

Second, a majority of coaches who completed the ACL IPP training course reported incorporating NMT into their daily practice sessions. While many studies have identified barriers to NMT implementation [15,16,21,26], few have investigated the impact of education on the implementation of NMT-based IPPs by sports coaches. Ling et al [18] were among the first to investigate the impact of ACL IPP education on adherence to NMT among high school coaches, reporting that coaches who completed pre-season education demonstrated greater adherence to an NMT program than coaches who did not complete it. This study provides further evidence suggesting a positive impact of education on the implementation of an NMT-based IPP by high school sports coaches.

This study has several limitations. First, data from high school sports coaches were collected from anonymized electronic questionnaires and the results may be subject to self-reporting and social desirability bias, the latter a form of conformity bias that reflects a tendency to express opinions or behaviors perceived to be morally or socially acceptable [31,38]. In addition, the knowledge survey questions were not validated prior to use and may be susceptible to measurement errors. Finally, the results of this study represent data collected from a cohort of high school sports coaches and may not be generalizable to all coaches. To address these limitations, future studies may consider using validated survey questions, employing systematic observers to report coaches’ behaviors, and recruiting diverse populations of coaches as participants.

In conclusion, this study found that a cohort of high school coaches completing a theory-based ACL IPP training course reported significantly improved knowledge of NMT-based IPPs and the skills required to implement them. They also reported that this knowledge contributed to the incorporation of NMTs into their daily practice sessions, which may serve as a protective factor against ACL injury for the sports participants they coach.

Supplemental Material

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Supplemental material, sj-pdf-1-hss-10.1177_15563316241236194 for ACL Injury Prevention Education Improves Implementation of Neuromuscular Training Among High School Sports Coaches: A Cross-Sectional Survey Study by Joseph J. Janosky, James Russomano, Connor Duscha, Alexandra Henderson, Alexandra Archer, James J. Kinderknecht and Robert G. Marx in HSS Journal®

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Supplemental material, sj-pdf-2-hss-10.1177_15563316241236194 for ACL Injury Prevention Education Improves Implementation of Neuromuscular Training Among High School Sports Coaches: A Cross-Sectional Survey Study by Joseph J. Janosky, James Russomano, Connor Duscha, Alexandra Henderson, Alexandra Archer, James J. Kinderknecht and Robert G. Marx in HSS Journal®

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Supplemental material, sj-pdf-3-hss-10.1177_15563316241236194 for ACL Injury Prevention Education Improves Implementation of Neuromuscular Training Among High School Sports Coaches: A Cross-Sectional Survey Study by Joseph J. Janosky, James Russomano, Connor Duscha, Alexandra Henderson, Alexandra Archer, James J. Kinderknecht and Robert G. Marx in HSS Journal®

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Robert G. Marx, MD, reports relationships with MEND Nutrition Inc., Springer, and Desmos Health. The other authors declared no potential conflicts of interest.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all participants included in this study.

Level of Evidence

Level IV, cross-sectional survey

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article as supplemental material.

ORCID iDs

Joseph J. Janosky

Robert G. Marx

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