November 2016

Home-based ACL injury prevention program fails the compliance test

11peds-shutterstock_72300196-copyOversight, feedback may up buy-in

By Chris Klingenberg

The idea of injury prevention training in the comfort of one’s own home is appealing on many levels, and researchers at the University of Wisconsin-Madison are taking steps toward making that type of training feasible and effective for young athletes.

In a recent pilot study on home-based, DVD-delivered training to prevent anterior cruciate ligament (ACL) injuries in female high school athletes, compliance with the protocol fell far short of the researchers’ expectations, but they have identified potential opportunities for improvement.

“Coaches could monitor compliance,” said Jill Thein-Nissenbaum, PT, DSC, SCS, ATC, who is an associate professor in the Doctor of Physical Therapy Program at the university and first author of the study. “For the study, the coaches could not know who was involved in the actual study being done. But I think athletes would be more compliant if they thought it might affect playing time.”

During the 2012-2013 school year, nine high schools in Wisconsin were selected by convenience for study participation. Sixty-six girls who planned to go out for basketball participated in the study, which was conducted in the weeks prior to the basketball season. The majority (40.90%) were in grade 9; the fewest were in grade 12 (13.64%).

“Lack of education regarding the value of performing injury prevention programs is very common.”
-Darin Padua, PhD, ATC

The eight-week injury prevention program was designed by the authors, based on the Prevent Injury and Enhance Performance (PEP) supervised training program. Researchers from the Santa Monica Ortho­paedic and Sports Medicine Foundation in California, who designed the supervised PEP program, have found it effectively reduces ACL injury incidence in female collegiate soccer players, and Korean researchers found it effective for improving ACL injury risk factors in female high school basketball players.

“PEP has been studied in adults as well as fifteen- to eighteen-year-olds,” Thein-Nissenbaum said. “They used the same routine in all of their studies. We had the video designed such that the individual simply had to mirror the DVD (like an aerobics work-out), so the cadence and repetitions did not have to be counted by the subject.”

The DVD-based program was designed to progress the athletes’ strength, balance, and jumping and landing technique with minimal risk of injury. Each training session was approximately 15 minutes in length and was composed of three components: strength training, plyometrics, and balance. The athletes were instructed to do the training three times a week for eight weeks.

After the eight weeks, 27 of the 66 athletes completed a compliance survey and provided feedback on the program. About half (52%) of respondents said they did the training once a week or not at all over the eight weeks. The main reason for poor compliance was lack of time, followed by failing to remember to participate.

Seven respondents (27%) said they completed at least 12 training sessions during the eight weeks, meaning they received at least half the target dose. Most of those athletes said they thought the training would improve their strength and balance and would make them better basketball players.

The findings were published in February by the Wisconsin Medical Journal.

Although the athletes in the Wisconsin study were not given reminders to prompt them to do the training, the authors noted that a 2007 Canadian study of high school basketball players reported low compliance with home-based balance training despite regular face-to-face reminders.

Similarly, though the importance of the training for injury prevention was briefly addressed on the DVD, further education of the athletes and their coaches could help improve compliance, said Darin Padua, PhD, ATC, professor and chair of the Department of Exercise & Sport Science and codirector of the Sports Medicine Research Laboratory at the University of North Carolina at Chapel Hill.

“Lack of education regarding the importance and value of performing an injury prevention program is very common and perhaps a weakness of much research in the area of ACL injury prevention,” Padua said. “We need to do much more to understand how to effectively implement these programs to get more widespread adoption and long-term compliance.”

Athletes might also be more compliant if their home-based training included feedback about whether they were performing the exercises correctly, he suggested.

“Utilization of technology to track movement quality, such as a camera or Kinect or other wearable technology, may be very helpful,” Padua said. “Feedback on movement quality is a critical component to an effective prevention program, so the ability to automate feedback while doing a program at home could be very effective.”

Chris Klingenberg is a freelance writer based in Massachusetts.


Thein-Nissenbaum J, Brooks A. Barriers to compliance in a home-based anterior cruciate ligament injury prevention program in female athletes. WMJ 2016;115(1):37-42.

Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2 year follow up. Am J Sports Med 2005;33(7):1003-1010.

Lim BO, Lee YS, Kim JG, et al. Effects of sports injury prevention training on the biomechanical risk factors of anterior cruciate ligament injury in female high school basketball players. Am J Sports Med 2009;37(9):1728-1734.

Emery CA, Rose MS, McAllister JR, Meeuwisse WH. A prevention strategy to reduce the incidence of injury in high school basketball: a cluster randomized controlled trial. Clin J Sport Med 2007;17(1):17-24.

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