Research in Sports Medicine

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Effect of supervision and athlete age and sex on

exercise-based injury prevention programme
effectiveness in sport: A meta-analysis of 44
studies

Stephanie Valentin, Linda Linton & Nicholas F. Sculthorpe

To cite this article: Stephanie Valentin, Linda Linton & Nicholas F. Sculthorpe (2024) Effect
of supervision and athlete age and sex on exercise-based injury prevention programme
effectiveness in sport: A meta-analysis of 44 studies, Research in Sports Medicine, 32:5,
705-724, DOI: 10.1080/15438627.2023.2220059

To link to this article: https://doi.org/10.1080/15438627.2023.2220059

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RESEARCH IN SPORTS MEDICINE
2024, VOL. 32, NO. 5, 705–724
https://doi.org/10.1080/15438627.2023.2220059

Effect of supervision and athlete age and sex on

exercise-based injury prevention programme effectiveness in
sport: A meta-analysis of 44 studies
a,b
Stephanie Valentin , Linda Lintonc and Nicholas F. Sculthorpe a

a
Sport and Physical Activity Research Institute, University of the West of Scotland, Blantyre, UK; bSchool of
Health and Social Care, Edinburgh Napier University, Edinburgh, UK; cEdinburgh Sports Medicine Research
Network & UK Collaborating Centre on Injury and Illness Prevention in Sport (UKCCIIS), Institute for Sport, PE
and Health Sciences, FASIC Sport and Exercise Medicine Clinic, University of Edinburgh, Edinburgh, UK

ABSTRACT ARTICLE HISTORY

We aimed to evaluate the influence of supervision, athlete age and Received 21 November 2022
sex and programme duration and adherence on exercise-based Accepted 23 May 2023
injury prevention programme effectiveness in sport. Databases KEYWORDS
were searched for randomized controlled trials evaluating exercise- Sport injury prevention;
based injury prevention programme effectiveness compared to supervision; sex; age
“train-as-normal”. A random effects meta-analysis for overall effect
and pooled effects by sex and supervision and meta-regression for
age, intervention duration and adherence were performed.
Programmes were effective overall (risk ratio (RR) 0.71) and equally
beneficial for female-only (0.73) and male-only (0.65) cohorts.
Supervised programmes were effective (0.67), unlike unsupervised
programmes (1.04). No significant association was identified
between programme effectiveness and age or intervention dura­
tion. The inverse association between injury rate and adherence
was significant (β=-0.014, p = 0.004). Supervised programmes
reduce injury by 33%, but there is no evidence for the effectiveness
of non-supervised programmes. Females and males benefit equally,
and age (to early middle age) does not affect programme
effectiveness.

Introduction
In elite sports, injuries impair performance, reduce player availability and significantly
increase costs (Hickey et al., 2014; Maffulli et al., 2010). Similarly, injuries in recreational
sport pose a public health problem and economic burden [estimated to exceed
$20 million in medical costs annually in one American state (Ryan et al., 2019)] and
may limit future engagement with exercise (Caine et al., 2014). Previous meta-analyses
have found exercise-based injury prevention programmes (IPP) to be effective in
reducing injury in sport (e.g. Crossley et al., 2020; Lauersen et al., 2014, 2018;

CONTACT Stephanie Valentin [email protected] School of Health and Social Care, Edinburgh Napier
University, Edinburgh, UK
This article has been republished with minor changes. These changes do not impact the academic content of the article.
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any med­
ium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article
has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
706 S. VALENTIN ET AL.

Vatovec et al., 2020); however, the degree of effectiveness varied, suggesting the
influence of contextual factors. The influence of some factors is known, e.g. IPP
content; strength, proprioception and multi-component programmes have robust
supporting evidence for reducing injury (Crossley et al., 2020; Lauersen et al., 2014,
2018), whereas stretching does not (Brunner et al., 2019; Lauersen et al., 2014).
However, the influence of other factors such as athlete age and sex, or whether the
IPP is supervised or not, are less well understood.
Coaches or sport scientists tend to lead IPPs in sports teams, thus IPPs are implemented in
a structured manner that facilitates athlete engagement. An example of a well-established IPP
is the FIFA11+, a dynamic warm-up originally designed to prevent injury in soccer (Silvers-
Granelli et al., 2017) that has also been successfully applied to other team sports, e.g. basket­
ball, lacrosse, American football and futsal (Longo et al., 2012; Lopes et al., 2020; Slauterbeck
et al., 2019). With the application of IPPs to an increasing number of sports (evidenced by the
increasing number of randomized controlled trials in the area), it is important to evaluate the
effectiveness of IPPs across this more diverse sporting landscape. This is especially relevant
where implementation is more challenging, e.g. unsupervised recreational runners (Linton
et al., 2022). Lack of supervision may lead to exercises not being performed correctly or at the
appropriate level of difficulty, which may cause inadequate tissue exposure to appropriate
injury prevention exercises similar to reduced adherence to IPPs where a dose-dependent
response has been identified (Lauersen et al., 2014; Steffen et al., 2013).
There has been surprisingly little attention paid to the possible effects of participant
sex on the effectiveness of IPPs. A meta-analysis of meta-analyses showed that IPPs were
effective in reducing ACL injury in females, but there was insufficient evidence for males
(Webster & Hewett, 2018), suggesting sex is a potential confounder in ACL IPP effective­
ness. It remains unclear, however, whether males and females benefit similarly from IPPs
across a range of injuries and sports. Should a divergence be apparent in favour of males
or females, then alternative and/or additional components to IPPs may be required.
Similarly, the potential influence of age on IPP effectiveness has received little attention.
Greater benefits of a neuromuscular programme on ACL injury in younger (mid-teens)
versus late teens or early adult female athletes were reported (Myer et al., 2013); however,
no previous analysis has been able to provide conclusions across a wider age range on
any interaction between age and IPP effectiveness more generally. The potential effects of
age on IPP effectiveness may become increasingly important with the encouragement to
engage in sport/exercise throughout the lifespan.
Previous meta-analyses evaluating the effectiveness of IPPs have either focused on one
sport and/or injury/IPP type (e.g. Crossley et al., 2020; Vatovec et al., 2020) or included
a range of sports and injuries but were published almost a decade ago (Lauersen et al.,
2014). With a substantial increase in the number of randomized controlled studies
evaluating IPP effectiveness across an increasing number of sports in recent years,
a refreshed evaluation is needed with additional subgroup and regression analyses to
comprehensively explore athlete characteristics and other potential confounding factors.
Therefore, the primary aims of this systematic review were to determine the overall
effectiveness of IPPs and to evaluate the influence of supervision, sex and age on IPP
effectiveness without restricting to any sport, injury or IPP type. The secondary aim was to
evaluate the influence of adherence and intervention duration on IPP effectiveness. The
findings may indicate the extent to which exercise-based IPPs could be more widely used
 RESEARCH IN SPORTS MEDICINE 707

in practice (e.g. across different sports and for a more diverse range of athlete
characteristics).

Materials and methods

Study selection
This review was conducted according to the Preferred Reporting Items for Systematic
Review and Meta-Analysis (PRISMA) guidelines (Moher et al., 2009). Search terms (see
supplementary material) and inclusion/exclusion criteria were determined a priori
and used to search PubMed, Web of Science (including Medline) and Sports Discuss
from inception to 19 October 2022. Inclusion criteria were randomized controlled
trials, written in English, reporting of musculoskeletal sports injuries, participants
engaging in a named sport, exercise interventions compared to an “as normal”
control group and participants of any age and sex. Exclusion criteria included non-
randomized trials, review articles, protocols, editorials and conference abstracts,
workplace interventions (e.g. physical education teachers), participants engaging in
general physical activity (e.g. physical education), army recruits, inclusion of only
injured participants from the outset, passive interventions (e.g. tape) and animal
studies.
The initial search was conducted by one assessor (SV) who transferred the list of studies
to Zotero (v 6.0.15) and merged duplicate entries. Titles and abstracts were reviewed
independently by a primary and secondary assessor (SV, LL), after which the list of eligible
studies for full review was agreed. The same two assessors independently reviewed the
full texts of the remaining studies and agreed to the final list of included studies. An
arbitrator (NS) was available where needed. Hand searching of the reference lists of
included studies and of previously published systematic reviews and meta-analyses
from the initial search were conducted to identify any further eligible studies.
Corresponding authors were contacted if primary outcome data were not available.
When authors did not respond or the data were no longer accessible, those studies
were excluded.

Data extraction
Data extraction from eligible studies was performed by the primary assessor (SV) and
entries checked by the second assessor (LL). An arbitrator (NS) was available where
needed. The primary outcomes were total number of injuries and total exposure hours
(training and match or specific sports engagement as given in each study) for the
intervention and control groups. Where data for injury number or exposure hours were
not available but injury rate was given, injury number or exposure hours were calculated
and rounded to the nearest whole number.
The secondary outcomes were number of participants, age, sex, type of sport, type of
intervention, duration of intervention (weeks), whether the intervention was supervised
or not (supervised was defined as in-person and led by a coach, researcher or similar, and
unsupervised was defined as no in-person supervision and the athlete was given an
exercise programme to perform independently), intervention adherence (the percentage
708 S. VALENTIN ET AL.

of sessions the IPP was participated with from the total number of expected sessions to be
engaged with) and injury type. A weighted mean age was calculated per study across
intervention and control groups where group mean age data were available.

Risk of Bias
Studies were assessed for Risk of Bias (RoB) using Version 2 of the Cochrane risk-of-bias
tool for randomized trials (RoB 2) (Higgins et al., 2022). This tool scores RoB for studies as
“high”, “some concern” or “low” for each of five categories: randomization process,
deviations from intended intervention, missing outcome data, measurement of the out­
come and Selection of the reported result, after which it assigns an overall categorization
of RoB based on the highest RoB classification from the sub-categories. Screening for RoB
was performed independently by two assessors (SV and LL) and outcomes were discussed
and agreed.

Statisticalanalysis
Review Manager version 5.4.1. (The Cochrane Collaboration, 2020) was used to perform
the meta-analysis. Rate ratio (RR) was determined and a random-effects model on pooled
data used to identify between-group (intervention versus control) differences with all
studies included. Rate ratios less than 1 indicated a reduction in injury risk in favour of the
IPP. The random effects model was repeated on pooled data of studies grouped by sex
(male only, female only and studies including male and female participants) and by
supervision (yes, no). Cochran’s Q and I2 were obtained to identify heterogeneity.
Funnel plot asymmetry was assessed in R using the arcsine test (Rücker et al., 2008) and
by visual inspection of the funnel plot. A random effects meta-regression was performed
using Jamovi version 2.3.18 (The Jamovi Project, 2022) for mean age, intervention dura­
tion and intervention adherence on IPP effectiveness. Throughout, alpha was set to 0.05.
Forest plots were generated using Review Manager 5, and RoB plots were created using
the Cochrane risk-of-bias tool for randomized trials (RoB 2).

Results
The study selection process is shown in Figure 1. From the initial 8303 studies, 44 studies
were included in the final set, totalling 40,409 participants (intervention n = 20,671; control
n = 19738). Almost half of the studies evaluated soccer alone (n = 21). Most studies (n = 32)
included a multi-component programme. Further study details are given in Table 1.

Overall exercise intervention effect

Pooled analysis from 44 studies showed a significant beneficial effect of IPP on injury
reduction (risk ratio 0.71 [95% confidence interval 0.64, 0.78], p < 0.001); see Figure 2. The
study heterogeneity was significant (Q = 214.41, df = 43, p < 0.001, I2 = 80%).
 RESEARCH IN SPORTS MEDICINE 709

Figure 1. Flow diagram of study selection process.

Stratified by sex
Eight studies included female participants only, 18 studies included male participants only
and 18 studies included both sexes. Pooled study effects of female-only were 0.73 [0.56, 0.95],
p = 0.020 (heterogeneity: Q = 42.46, df = 7, p < 0.001, I2 = 84%), male only were 0.65 [0.54,
0.78], p < 0.001 (heterogeneity: Q = 108.16, df = 17, p < 0.001, I2 = 84%) and both sexes were
0.74 [0.65, 0.85], p < 0.001 (heterogeneity: Q = 62.87, df = 17, p < 0.001, I2 = 73%). There was no
 710

Table 1. Summary of studies.

Intervention Injuries Exposure (hrs)
Age (years; Mean
mean or adherence Injury
Study Participants (n) Sex median) Sport Description Duration Sup (%) outcome Int Con Int Con
Fujisaki et al. Int 72 M Mean 16.0 Soccer Strength 16 Yes 98 Groin injury 4 18 16000 14516
(2022) Con 57 weeks
Al Attar et al. Int 379 M Mean 26.5 Soccer (Goal-keepers) ****FIFA 11+S 6 Yes 80 Any upper 50 122 80555 62887
(2021) Con 386 months limb injury
S. VALENTIN ET AL.

Hilska et al. (2021)Int 681 M & F Mean 12.3 Soccer Cardiovascular, 20 Yes 63 Lower limb 310 346 70454 62909
Con 737 plyometrics, landing, strength, core weeks injury
Nuhu et al. (2021)Int 312 M Mean 19.8 Soccer *FIFA 11+ 7 Yes 77 Any injury 168 252 65333 63389
Con 318 months
Åkerlund et al. Int 301 M & F Mean 13.5 Floorball Proprioception, landing, 26 Yes 84 Any injury 197 152 16280 8128
(2020) Con 170 strength, core weeks
Gouttebarge et al.Int 266 M & F Mean 28.5 Volleyball Cardiovascular, core, strength, proprioception 8 Yes 73 Any injury 316 430 28654 25479
(2020) Con 283 months
Hasebe et al. Int 156 M Mean 16.5 Soccer Nordic Hamstring Exercise 27 Yes 88 Hamstring 4 3 45374 28910
(2020) Con 103 weeks injury
Lopes et al. (2020)Int 31 M Mean 26.5 Futsal *FIFA 11+ 20 Yes 89 Any injury 24 34 3768 3081
Con 30 weeks
Pas et al. (2020) Int 286 M & F Mean 41.5 Tennis Cardiovascular, strength, proprioception 12 No Not Any injury 263 286 10366 11710
Con 293 weeks available
Taddei et al. Int 57 M & F Mean 40.9 Running Strength and 8 weeks Yes & 89 Any injury 8 20 5304 6747
(2020) Con 61 No
Zarei et al. (2020) Int 443 M Mean 12.2 Soccer **FIFA 11+ Kids 9 Yes Not Any injury 30 60 31934 32113
Con 519 months available
Halvarsson and Int 30 M & F Mean 24.2 Orienteering Proprioception, plyometric, strength 14 No 55 Lower limb 28 36 2969 3219
von Rosen Con 32 weeks injury
(2019)
Sakata et al. Int 109 M & F Mean 10.3 Baseball Static stretches, dynamic stretching, 12 Yes Not Shoulder and 27 46 15882 14839
(2019) Con 110 proprioception months available elbow
injury
Slauterbeck et al. Int 1825 M & F Not stated American football (M), soccer,*FIFA 11+ 12 Yes 45 Lower limb 196 172 116079 113420
(2019) Con 1786 basketball, lacrosse (M & F) weeks injury
van de Hoef et al.Int 229 M Mean 23.1 Soccer Plyometric 39 Yes Not Hamstring 31 26 27679 18705
(2019) Con 171 weeks available injury
Achenbach et al. Int 168 M & F Mean 15.0 Handball Proprioception, plyometric, landing, strength, core Not Yes Not Any injury 50 32 26278 17929
(2018) Con 111 stated available
(Continued)
Table 1. (Continued).
Intervention Injuries Exposure (hrs)
Age (years; Mean
mean or adherence Injury
Study Participants (n) Sex median) Sport Description Duration Sup (%) outcome Int Con Int Con
Attwood et al. Int 682 M Mean 25.5 Rugby Proprioception, strength, landing/cutting 42 Yes Not Any injury 122 133 9900 9660
(2018) Con 673 technique, plyometric weeks available
Bonato et al. Int 86 F Mean 20 Basketball Cardiovascular, dynamic stretching, strength, Not Yes 78 Any injury 32 79 19277 16844
(2018) Con 74 plyometric, landing technique, agility stated
Rössler et al. Int 2066 M & F Mean 10.8 Soccer Proprioception, balance, plyometric, Not Yes Not Any injury 139 235 140716 152033
(2018) Con 1829 strengthening, core, falling technique stated available
Hislop et al. Int 1325 M Mean 16.0 Rugby Proprioception, strength, plyometric, landing/ 14 Yes 69 Any injury 291 262 37346 32375
(2017) Con 1127 cutting technique weeks
Finch et al. (2016)Int 679 M Not stated Australian football Proprioception, plyometric, landing exercises 26 Yes Not Any injury 335 438 12790 15537
Con 885 weeks available
Zouita et al. Int 26 M Not stated Soccer Strength 12 Yes Not Any injury 4 13 5700 5590
(2016) Con 26 weeks available
Hammes et al. Int 146 M Mean 44.3 Soccer *FIFA 11+ 9 Yes 98 Any injury 51 37 4172 2937
(2015) Con 119 months
H. Silvers-Granelli Int 675 M Mean 20.6 Soccer *FIFA 11+ 5 Yes Not Any injury 284 665 35226 44212
et al. (2015) Con 850 months available
van der Horst Int 292 M Mean 24.6 Soccer Nordic Hamstring Exercise 13 Yes 91 Hamstring 11 25 44000 31250
et al. (2015) Con 287 weeks injury
Owoeye et al. Int 212 M Mean 17.7 Soccer *FIFA 11+ warm-up 6 Yes 60 Any injury 36 94 51017 61045
(2014) Con 204 months
Aerts et al. (2013)Int 90 M & F Mean 24.7 Basketball Plyometric, landing technique 3 Yes 86 Any injury 18 28 5010 5227
Con 93 months
van Beijsterveldt Int 223 M Mean 24.8 Soccer ***FIFA 11 9 Yes 73 Any injury 207 220 21563 22680
et al. (2012) Con 233 months
Bredeweg et al. Int 171 M & F Mean 38.1 Running Plyometric 4 weeks No Not Any injury 26 32 839 1067
(2012) Con 191 available
Longo et al. Int 80 M Mean 14.1 Basketball *FIFA 11+ 9 Yes 100 Any injury 14 17 23640 12648
(2012) Con 41 months
Walden et al. Int 2479 F Mean 14.1 Soccer Strength, core, plyometric, proprioception, landing 7 Yes Not Knee injury 49 47 149214 129084
(2012) Con 2085 technique months available
LaBella et al. Int 737 F Mean 16.2 Soccer, basketball Strength, plyometric, proprioception, agility Not Yes Not Lower limb 50 96 28023 22925
RESEARCH IN SPORTS MEDICINE

(2011) Con 755 exercises, landing technique stated available injury

Eils et al. (2010) Int 81 M & F Mean 24.1 Basketball Proprioception Not Yes Not Ankle injury 7 21 4565 4876
Con 91 stated available
(Continued)
711
 712

Table 1. (Continued).
Intervention Injuries Exposure (hrs)
Age (years; Mean
mean or adherence Injury
Study Participants (n) Sex median) Sport Description Duration Sup (%) outcome Int Con Int Con
Emery and Int 380 M & F Not stated Soccer Dynamic stretching, strength, agility, core jumping, 20 Yes & Not Any injury 50 79 24051 23597
Meeuwisse Con 364 proprioception, landing technique weeks No available
S. VALENTIN ET AL.

(2010)
Gilchrist et al. Int 583 F Mean 19.9 Soccer Running, Static stretching, strengthening, 12 Yes 72 Knee injury 40 58 26538 41948
(2008) Con 852 plyometric, agility weeks
Pasanen et al. Int 256 F Mean 23.8 Soccer Running technique, proprioception, plyometrics, 6 Yes 73 Lower limb 87 102 32327 25019
(2008) Con 201 static stretching, strengthening, landing months injury
technique
Soligard et al. Int 1055 F Mean 15.4 Soccer Strength, plyometric, proprioception, dynamic 8 Yes 77 Any injury 161 215 49899 45428
(2008) Con 837 stretching, agility, landing technique months
Steffen et al. Int 1073 F Mean 15.4 Soccer *FIFA 11+ and balance mat 8 Yes 52 Any injury 242 241 66423 65725
(2008) Con 947 months
Emery et al. Int 494 M & F Median 16.0 Basketball Proprioception 18 Yes & Not fully Any injury 130 141 39369 34955
(2007) Con 426 weeks No available
McGuine and Int 373 M & F Mean 16.5 Soccer and basketball Proprioception Not Yes Not Ankle injury 23 39 20250 20828
Keene (2006) Con 392 stated available
Olsen et al. (2005)Int 958 M & F Mean 16.3 Handball Strength, proprioception, plyometric, landing 8 Yes Not Any injury 103 195 93812 87483
Con 879 technique months available
Verhagen et al. Int 392 M & F Mean 24.3 Volleyball Proprioception 9 Yes Not Any injury 132 102 62477 42960
(2004) Con 340 months available
Soderman et al. Int 62 F Mean 20.5 Soccer Proprioception 7 No 63 Any injury 28 31 5895 8094
(2000) Con 78 months
¶
van Mechelen Int 159 M Not stated Running Stretching 16 No Not Any injury 26 23 4727 4694
et al. (1993) Con 167 weeks available
Note: M = Male, F = Female, Sup = Supervised, Int = Intervention, Con = Control. Proprio = Proprioception, Multi = Multi-component, Plyo=plyometrics.
*.FIFA 11+: Dynamic stretching, proprioception, strength, plyometric, planting/cutting/agility exercises.
†
.FIFA 11+ Kids: Proprioception and coordination, strength, landing and falling techniques.
‡
.FIFA: Core, proprioception, strength, plyometric, landing technique.
§
.FIFA 11+S: Upper limb neuromuscular control, core stability, eccentric rotator strength and agility.
¶
.Adherence is defined as the percentage of sessions from the total number of possible sessions where the intervention was delivered. Where these data were not available or could be
calculated, these were reported as “Not Available”.
 RESEARCH IN SPORTS MEDICINE 713

significant subgroup difference (p = 0.490). A forest plot by sex subgroupings is shown in

Figure 3a.

Stratified by supervision
Three studies (Emery & Meeuwisse, 2010; Emery et al., 2007; Taddei et al., 2020) were
removed for this analysis as it contained both a supervised and unsupervised component,
leaving 41 studies. In 36 studies, the IPP was supervised, and in the remaining five studies,
the IPP was unsupervised. Supervised IPPs were effective at reducing injury (0.67 [0.60,
0.75], p < 0.001) (heterogeneity: Q = 187.71, df = 35, p < 0.001, I2 = 81%), whereas unsu­
pervised IPPS were not (1.04 [0.90, 1.19], p = 0.580) (heterogeneity: Q = 1.23, df = 4, p =
0.87, I2 = 0%). A significant between sub-group difference was present (p < 0.001). Of the
five unsupervised studies, two were in running (Bredeweg et al., 2012; van Mechelen et al.,
1993), one in orienteering (Halvarsson & von Rosen, 2019), one in tennis (Pas et al., 2020)
and one in soccer (Soderman et al., 2000). A forest plot by supervision subgrouping is
shown in Figure 3b.

Regression by age, intervention duration and adherence

The mean age for the intervention and control groups was available for 38 out of the 44
included studies (intervention group mean age range 10.2–43.1 years; control group
mean age range 10.3–45.2 years). There was no significant association between age and
IPP effect: β = 0.009[−0.004, 0.022], p = 0.187 (heterogeneity: Q = 172.4, df = 37, p < 0.001,
I2 = 80%).
Intervention duration data were available from 38 studies. Mean intervention duration
was 25.3 (±11.5) weeks (range 4–52 weeks). There was no significant association between
intervention duration and IPP effect: β = 0.001[−0.008, 0.011], p = 0.766 (heterogeneity: Q
= 179.3, df = 37, p < 0.001, I2 = 81%).
Adherence data were available for 24 studies. Mean adherence was 76.4% (±14.9)
(range 45–100%). There was a significant association between adherence and IPP effect:
β=-0.014 [−0.023, −0.004], p = 0.004 (heterogeneity: Q = 82.7, df = 23, p < 0.001, I2 = 79%).
Adherence explained 33% of variance in the true effects.

Publication Bias and RoB

No significant publication bias was identified from the statistical analysis (regression
intercept = 0.005, p = 0.172), however funnel plot visual inspection suggested that some
publication bias may be present. Overall RoB was classified as “high”, “some concern” and
“low” in 29.5% (n = 13), 65.9% (n = 29) and 4.5% (n = 2) of the 44 studies, respectively (see
supplementary files for RoB figure).

Discussion
This meta-analysis of randomized controlled studies on the effect of exercise-based IPPs
revealed that (1) IPPs are effective overall in reducing the occurrence of injuries in sport,
(2) supervised IPPs are more effective than unsupervised IPPs and more specifically,
714 S. VALENTIN ET AL.

unsupervised IPPs appear to offer no direct benefit per se in injury risk reduction, (3) there
is an inverse association between IPP adherence and injury rate, (4) neither duration of IPP
or age are related to IPP effectiveness and (5) IPPs are equally of benefit to male, female
and mixed cohorts.

Overall IPP effectiveness

Pooled data from the studies included in this meta-analysis demonstrated that IPPs
reduce injury risk in sport by 29%. Others, through meta-analyses, have evidenced
a similarly protective benefit; Crossley et al. (2020) reported a reduced injury risk of
27% in female soccer players from across primarily multicomponent programmes.
Lauersen et al. (2014) identified a 35% and 47% reduction in acute and overuse
injuries, respectively, from across a range of IPP types, which is higher than the
findings presented here, however, that meta-analysis also included studies with non-
sport populations, e.g. military personnel, which may explain some differences. The
current analysis extends the findings of previous meta-analyses through the inclu­
sion of a much greater number of studies and a more diverse range of sports.
Although this has increased the heterogeneity of pooled data, the search and
inclusion criteria match very closely to a previous meta-analysis (with the exception
of restrictions to sport populations only) including 23 studies by Lauersen et al.
(2014), and the larger number of studies simply reflects the growing body of
research in the field.

Supervision, adherence and intervention duration

There was no evidence from this meta-analysis for the effectiveness of non-supervised
IPPs in reducing injury risk, although these findings are based on a relatively small number
of studies with a diverse set of interventions; two studies included a multi-component IPP
(Halvarsson & von Rosen, 2019; Pas et al., 2020), one included a plyometric only IPP
(Bredeweg et al., 2012), one included a proprioception only IPP (Soderman et al., 2000)
and one included a stretching only IPP (van Mechelen et al., 1993). No studies in the
supervised group included a stretching-only IPP. Despite the current evidence on the
ineffectiveness of stretching only IPPs (Brunner et al., 2019; Lauersen et al., 2014), the
study by van Mechelen et al. (1993) was retained as stretching was considered an active
intervention and the study met the inclusion criteria that were set a-priori.
The lack of effectiveness of unsupervised IPPs is in contrast to Vatovec et al. (2020),
where non-supervised and supervised IPPs for hamstring injuries were found to be
equally effective, although only three studies were included in the non-supervised
category and data on one injury type were represented. Moreover, that analysis included
data from two studies which were not possible to include in this meta-analysis; one could
not be included as data were no longer accessible (Askling et al., 2013), and another was
included for the main analysis and sex subgroup analysis but not the supervision sub­
group analysis as it included both a supervised and unsupervised component (Emery
et al., 2007).
The five unsupervised studies in this meta-analysis included a range of sports: two on
running (Bredeweg et al., 2012; van Mechelen et al., 1993), one on orienteering
 RESEARCH IN SPORTS MEDICINE 715

Figure 2. Forest plot of all included studies.

(Halvarsson & von Rosen, 2019), one on tennis (Pas et al., 2020) and one on soccer
(Soderman et al., 2000). The difference in sport types included in the supervised and
unsupervised groups should be acknowledged due to the relatively greater proportion of
running and smaller proportion of soccer in the unsupervised group. It is perhaps not
surprising that running featured more commonly in the unsupervised group due to
running generally being an individual sport and often not coach-led at recreational
level. Previously, the effects of an internet-based source (thus unsupervised) which
included advice on training volume, biomechanics and equipment also showed no
beneficial effect in reducing injury in runners (Cloosterman et al., 2022; Fokkema et al.,
716 S. VALENTIN ET AL.

Figure 3. Forest plot of summary analysis by (a) sex and by (b) supervision.

2019). In contrast, Taddei et al. (2020) showed a significantly lower rate of injury in runners
following a foot core strengthening IPP, which included a supervised and unsupervised
component. It is not clear whether the positive findings in the Taddei et al. (2020) study
were due to the uniqueness of IPP or whether it was due to it containing a supervised
component. That study was excluded from the supervision subgroup analysis due to it
including both a supervised and unsupervised component. Nonetheless, in-person super­
vision of IPPs is difficult to implement for sports which are generally engaged with
independently (i.e. without a coach or similar), therefore further work should determine
what type of IPP is best for runners, orienteers and other “solo” sports, and how potential
limiting effects of non-supervision can be overcome.
 RESEARCH IN SPORTS MEDICINE 717

Poor compliance/adherence is one plausible explanation for the lack of significant

effect of unsupervised programmes since true engagement with interventions (or
correct execution of those exercises) is usually based on athlete reporting and thus
may not be a true reflection of the actual executed IPP. This is particularly relevant as
we showed a significant inverse relationship between adherence and injury, but no
relationship between intervention duration and injury. This would suggest that inter­
ventions included in this meta-analysis were generally of sufficient length and longer
interventions were as effective as those which were shorter, however non/reduced-
compliance reduced their effectiveness. This is similar to other work where increased
compliance with FIFA 11+ in soccer reduced injury rates (Silvers-Granelli et al., 2018;
Soligard et al., 2010). Unfortunately, of the five unsupervised studies in this meta-
analysis, comparisons between high and low compliance were either not performed
(Bredeweg et al., 2012; van Mechelen et al., 1993) or were divergent in outcome;
Soderman et al. (2000) and Pas et al. (2020) did not find a difference in injury
outcomes between high and low compliance rates of their IPPs, yet Halvarsson and
von Rosen (2019) reported injury rates in those with lower compliance to be similar to
the control group, suggesting poor compliance reduced IPP effectiveness. Compliance
in those studies was self-reported, making it challenging to tease out the differential
influence of supervision versus true adherence. Future studies evaluating non-
supervised IPPs should consider the use of tracking technology in mobile delivery
format to monitor adherence more accurately. A further caveat is that reporting of
compliance in studies is highly varied, and the lack of standardization regarding what
constitutes “good” versus “poor” compliance hinders a more meaningful comparison
(Van Reijen et al., 2016).

Sex
The present review demonstrated that exercise-based IPPs significantly and equally
reduce injury risk for males, females and mixed cohorts. Due to female athletes being at
higher risk of musculoskeletal injuries in general and of the knee in particular (Swenson
et al., 2013), it has been suggested that females are in greater need of IPPs (Sommerfield
et al., 2020). Despite this increased risk, the results from this review suggest that females
benefit equally from exercise-based IPPs, hence specific and targeted programmes by sex
do not appear warranted. Similarly, it is unlikely that sex is a confounder in future
experimental studies investigating IPP effectiveness, however high heterogeneity across
the studies in this review should be noted.

Age
Most exercise-based IPPs included in this meta-analysis evaluated athletes who were
adolescents or young adults, and only few studies assessed the effectiveness of such
programmes in adults in their 30s or 40s and none beyond. A previous meta-analysis of 14
studies on the effect of age on ACL injury in female athletes identified greater benefits of
a neuromuscular programme in younger (i.e. mid-teens) compared to slightly older (late
teens or early adult) female athletes (Myer et al., 2013). When that meta-analysis repeated
the analysis by dichotomizing into two age groups (≤18 years or >18 years), similarly
718 S. VALENTIN ET AL.

a difference was found where IPPs were significantly beneficial for the ≤18 years group
but not for the >18 years group. It is not quite clear what the full age range was of the
included studies in that analysis, but the oldest mean age for any one study was 24 years.
In contrast, the meta-regression presented here demonstrated that increasing age does
not reduce the benefit of IPPs, up to early middle age. It must be noted that the majority
of studies in this analysis included participants with a mean age of less than 30, and only
four studies included participants with a mean age of 35–45. The differences between this
meta-analysis and the study by Myer et al. (2013) must be considered, however, i.e. the
type of analysis (meta-regression versus age group comparison), the number of studies
included for age analysis (37 versus 14), sex (males and females versus females only),
injury type (all injuries versus ACL injuries) and the upper age limit (40s versus 20s).
Therefore, further work with a particular focus on the inclusion of athletes older than 30 is
needed, particularly given public health messages regarding exercise for older adults (UK
government, 2019).

Risk of Bias
In almost all cases, RoB in studies was either categorized as “some” or “high concern”.
Frequent causes of higher RoB were the lack of detailed explanation for missing data or
lack of detailed information on the randomization process. Blinding of the study partici­
pants and coaches was generally not performed, and this is commonly difficult to
incorporate in exercise intervention studies. In addition, blinding of the researchers or
those collecting and/or analysing injury data was not always evident or reported.
Other areas that were not always clear or consistently reported were injury status of the
study participants prior to recruitment and what was considered “injury free”. Therefore,
the proportion of participants carrying an injury could have varied which may well have
influenced outcomes, as those injured may well be at increased risk of re-injury. Typically,
due to a whole-team recruitment into a study, it is understandable that consistent criteria
as to what constituted being injury free were difficult to achieve. Similarly, the definition
of adherence was disparate across studies, and variance across studies may be
a limitation. For example, adherence is determined at coach-delivery level, but studies
typically did not further define player adherence, i.e. the number of sessions each player
attended where the intervention was also delivered.

Limitations
This meta-analysis has some limitations that should be highlighted. The number of
unsupervised studies was fairly small (n = 5). Nonetheless, this work highlights the need
for future studies to assess the influence of supervision on IPP effectiveness and in
particular for non-coach led sports where supervision is difficult to implement. Future
work that considers alternative/improved ways of delivering and adapting supervision for
non-coach led sports is also warranted. Heterogeneity was high across studies, and to
allow for this, a random effects model was adopted. Sub-group analysis, e.g. for super­
vision and sex, was used for parts of the analysis presented; however, heterogeneity
within sub-groups continued to be high. Further subgrouping was considered, e.g. by
sport; however, this would yield too few studies for many categories to draw meaningful
 RESEARCH IN SPORTS MEDICINE 719

conclusions. In addition, mean age data were not available for all 44 studies, and this
reduced the pool of studies for that particular analysis to 38. Although this may still be an
acceptable number for meta-regression analysis, the vast majority of studies were skewed
towards younger ages, and further studies incorporating adults aged 30+ are required to
make more robust recommendations. Despite this, the findings from this analysis that age
did not affect programme effectiveness showed promise and should be explored going
forward.

Conclusion
Pooled information from all included studies showed that exercise-based IPPs have
a protective benefit and lower the occurrence of injuries in sport. Encouragingly, this
benefit was present irrespective of athlete sex or age, although studies beyond athletes of
early middle age were not available. Studies that included supervised IPPs were found to
be effective, whereas unsupervised IPPs were not. Whether this is down to poor true
engagement with unsupervised IPPs, incorrect execution of exercises or due to the
physical demands of sports which might be difficult to implement a supervised IPP for
(such as recreational runners), is unclear and requires further evaluation.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
The author(s) reported there is no funding associated with the work featured in this article.

ORCID
Stephanie Valentin http://orcid.org/0000-0002-8568-3458
Nicholas F. Sculthorpe http://orcid.org/0000-0001-8235-8580

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