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Engebretsen, L., Bahr, R., Cook, J. L., Derman, W., Emery, C., Finch, C. ...
Steffen, K. (2014). The IOC Centres of Excellence bring prevention to
Sports Medicine. British Journal of Sports Medicine, 48, 1270-1275.

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The IOC Centres of Excellence bring prevention to Sports Medicine!
Roald Bahr,1 Jill L Cook,2 Wayne Derman,3 Carolyn A Emery,4 Caroline F Finch,2 Willem H
Meeuwisse,4 Martin Schwellnus,3 Kathrin Steffen,1,5 Lars Engebretsen1,5

Affiliations:
1
Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
2
Australian Centre for Research into Injury in Sport and its Prevention, Federation University
Australia, Ballarat, Australia
3
Clinical Sport and Exercise Medicine Research, University of Cape Town, South Africa
4
Sport Injury Prevention Research Centre, University of Calgary, Calgary, Canada
5
International Olympic Committee, Department of Medical & Scientific, Lausanne, Switzerland

Corresponding author:
Lars Engebretsen, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences,
Oslo, Norway, lars.engebretsen@medisin.uio.no

Abstract
The protection of an athlete´s health and preventing injuries and illnesses in sport are top
priorities for the International Olympic Committee (IOC) and its Medical Commission. The IOC
therefore partners with selected research centres around the world and supports research in the
field of sports medicine. This has enabled the IOC to develop an international network of expert
scientists and clinicians in sports injury and disease prevention research. The IOC wants to
promote injury and disease prevention and the improvement of physical health of the athlete by:
(i) establishing long-term research programs on injury and disease prevention (including studies
on basic epidemiology, risk factors, injury mechanisms and intervention), (ii) fostering
collaborative relationships with individuals, institutions and organizations to improve athletes’
health, (iii) implementing and collaborating with applied, on-going and novel research and
development within the framework and long-term strategy of the IOC, and (iv) setting up
knowledge translation mechanisms to share scientific research results with the field throughout
the Olympic Movement and sports community and to convert these results into concrete actions
to protect the health of the athletes. In 2009, the IOC also identified 4 research centres that had
an established track record in research, educational and clinical activities to achieve these
ambitious: (i) the Australian Centre for Research into Injury in Sport and its Prevention
(ACRISP), Australia, (ii) the Sport Injury Prevention Research Centre (SIPRC), Canada, (iii) the
Clinical Sport and Exercise Medicine Research (CSEM), South Africa, and (iv) the Oslo Sports
Trauma Research Center, Norway. This paper highlights the work done by these 4 IOC Centres
of Excellence through the 6 last years and their contribution to the world of sport medicine.
IOC Research Centres of Excellence
Since 2007, the International Olympic Committee (IOC) has developed a variety of programs
focused on prevention of injuries and illness as well as protection of the health of the elite and
recreational athlete. One of these programs is in your hand or on your screen/mobile device: the
IOC supports 4 annual special editions of the British Journal of Sports Medicine, focusing on
injury prevention & health protection (BJSM IPHP).

In 2009, the IOC also identified 4 research centres that had an established track record in
research, educational and clinical activities. Currently, 4 IOC Centres of excellence are: (i) the
Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Ballarat,
Australia, (ii) the Sport Injury Prevention Research Centre (SIPRC), Calgary, Canada, (iii) the
Clinical Sport and Exercise Medicine Research (CSEM), Cape Town, South Africa, and (iv) the
Oslo Sports Trauma Research Center, Oslo, Norway. Under the Head of Scientific Activities,
Professor Lars Engebretsen, the IOC wants to promote injury and disease prevention and the
improvement of physical health of the athlete by:

- Establishing long-term research programs on injury and disease prevention (including studies
on basic epidemiology, risk factors, injury mechanisms and intervention).

- Fostering collaborative relationships with individuals, institutions and organizations to improve

athletes’ health

- Implementing and collaborating with applied, on-going and novel research and development
within the framework and long-term strategy of the IOC

- Setting up knowledge translation mechanisms to share scientific research results with the field
throughout the Olympic Movement and sports community and to convert these results into
concrete actions to protect the health of the athletes

The IOC had supported these research centres with an annual grant. “A key part of the grant is
meant to foster collaboration with the four centres internationally. The IOC wants to put a major
thrust behind prevention of injury and the protection of the athlete´s health. The annual funding
is meant to be a catalyst” said Lars Engebretsen and Patrick Schamasch from the IOC Medical
Commission.

This issue of the “BJSM Injury Prevention and Health Protection” highlights the work done by
these 4 IOC Centres of Excellence through the 6 last years. In this paper the leaders of each
centre articulate the Centre’s contribution to the world of sport medicine.

(i) Australian Centre for Research into Injury in Sport and its Prevention
(ACRISP)
The ACRISP is a multi-disciplinary and collaborative research centre covering disciplines as far
ranging as behavioural science, biomechanics, biostatistics, health promotion, epidemiology,
implementation science, public health, safety science, sports medicine, sports physiotherapy, and
sports science. ACRISP is directed by Professor Caroline Finch and its other lead researchers
Adjunct Professors Jill Cook (Deputy Director), Paul McCrory and Andrew McIntosh. The
ACRISP team includes over 25 full-time researchers and/or clinician researchers who are either
staff or students of Federation University Australia (FedUni) or appointed as FedUni Research
Associates whose primary work is elsewhere (e.g. at Monash University, the Australian Institute
of Sport). The core ACRISP research team is supplemented with research associates who
collaborate on specific research grants or PhD projects. Most of the ACRISP staff have salaries
funded from externally generated research income. ACRISP currently has 9 full time PhD
scholars.

The ACRISP research focus

Injury prevention is the science of quantifying the magnitude of, and reasons for, the health and
social burdens associated with injury; and for developing and testing innovative solutions to
address this global public health issue. The ACRISP research program draws on its
epidemiological, clinical, statistical and biomechanical strengths in this work. Safety promotion
focuses on understanding individual/environmental/organizational barriers and motivators to the
delivery and uptake of preventive measures; ACRISP research in this area draws on team’s
behavioural psychology, clinical engagement, health promotion, implementation science and
public health strengths. Major ACRISP research areas are:

1. Sports injury surveillance, coding and classification systems

High quality data is needed about sports injury occurrence and the risk/protective factors
associated with its aetiology. This depends on robust methods to monitor injury incidence and to
collect relevant exposure (i.e. sports participation) with standardized definitions so that results
can be compared and contrasted both spatially (across regions, sports) and temporally (over
time). Together with clinical colleagues, the ACRISP epidemiologists and biostatisticians are
advancing the design of, and reporting from, sports injury surveillance systems; contributing to
international efforts to improve the coding/classification of sports injuries; informing
international consensus statements for sports injury surveillance; and providing guidance on the
appropriate statistical analysis of injury data. The 2 ACRISP research papers in this issue of BJSM
IPHP are key recent outputs from this work to date.1,2

The first paper from the ACRISP team in the current BJSM issue, presents the Subsequent Injury
Classification (SIC) model developed to categorise multiple, recurrent, exacerbation or new
injuries in the context of both acute and overuse injuries that makes provision for all potential
within-person correlations.1 Correct categorisation of subsequent injury of any type requires the
input of significant clinical expertise, and the SIC model combines this expertise with more
objective statistical criteria. This new way of classifying subsequent injuries includes, for the first
time, explicit consideration of the possible relationships (correlations) between different injuries
within an injured person. It has already started to be used with success by other groups, as shown
by recent abstracts from the 2014 IOC Injury Prevention Conference in Monaco3,4 and its
inclusion in the new international Athletics injury definition consensus statement.5

The second paper from ACRISP in this issue gives an overview of the statistical issues that need
to be considered when analysing subsequent injury data.2 The paper compares different types of
survival analysis models for subsequent event data through its application to prospectively
collected professional rugby league injury data over one season. It shows how such models can
be applied and explains why current common methods of analysis are inadequate for subsequent
sports injury data.2 Extension of this meddling approach to risk factor identification has been
published elsewhere.6

On-going sports injury prevention research will be hampered if there is little application of the
more sophisticated statistical models for modelling subsequent injury data. Moreover, predictive
or causal models to underpin sports-related musculoskeletal injury prevention strategies will be
incorrect if they continue to ignore the inherent relationships between injuries or apply
inadequate analysis methods. These two papers from ACRISP now set the basis and direction for
future research in this important area.

2. Prospective monitoring of sports injury incidence and injury causation

Sports injury studies need to incorporate injury experiences over more than one season if they are
to describe the incidence of subsequent injury accurately, as well as to document any non-acute
adverse impacts they might have on health status, future injury risk and on-going participation in
sport. ACRISP research is contributing to the design, validation and analysis of data from large
scale cohort studies to monitor injury experiences (including recurrences), the impacts of these
injuries and sports participation on health (e.g. need for joint replacement or reconstruction
surgery, development of osteoarthritis, impact of overuse injuries, etc.) and future sport
participation (e.g. time away from sport due to injury). ACRISP research combines these
prospective studies with fundamental mechanistic and biomechanical studies to better understand
the ethology of injury and identification of suitable prevention measures. For example, ACRISP
research is contributing to improved diagnostic tools for tendinopathy, and is shaping clinical
management and research into tendinopathy and related musculoskeletal disorders. Other
research is providing new understanding into the biomechanics of injuries, such as concussion
and shoulder injury, is a prerequisite for developing effective equipment and methods to assess
the equipment performance.

3. Intervention effectiveness, implementation, dissemination and sustainability

Implementation research within community sport is critical because, even if interventions have
been shown to be efficacious in controlled trials, if they cannot also be demonstrated to be widely
adopted and sustained, then it is unlikely that they will have any preventive effect. There is very
little information about how to translate research evidence into effective sports injury
interventions and how to implement interventions in sport successfully. ACRISP research is
leading international efforts to contribute new insights into the sports delivery settings and
individual behaviour contexts into which interventions are to be implemented. Our research has
involved detailed investigations into the organizational, policy and individual behavioural barriers
and enablers of evidence-based sports injury prevention interventions in sports settings. Major
work over the past five years has been the development, implementation and evaluation of the
FootyFirst lower limb injury prevention program and delivery plan for Australian Football
nationally. ACRISP’s impact biomechanics research is showing how enhanced knowledge can
lead to improved equipment standards, which are an important mechanism for translating the
science of injury prevention into products bought off-the-shelf.

Community engagement and leadership

The ACRISP research impacts on all those involved in sport and recreation, from the participants
themselves (amateur, professional and recreational) through to those who support those
participants (medical practitioners, clubs and sporting facilities, peak sports bodies, government
agencies) at international, national, regional and local levels of participation.

Research leaders from ACRISP actively contribute to international sports injury management and
prevention at the international level through chairing and/or membership of specific IOC
Medical Commission Working Groups (e.g. on Boxing); membership of expert panels for peak
international sporting federations (e.g. International Rugby Board); contributing to the
development of international injury surveillance definitions and consensus statements; leading the
development of international consensus statements on concussion in sport. ACRISP researchers
are also frequently sought by national sports bodies and government departments to contribute
to the development of sports safety policy, evaluation of injury prevention practices and/or to
contribute new evidence to underpin such actions. Over recent years, these actions within high
performance sport have been undertaken as collaborations with many International and National
Sports Federations – the Australian Football League (AFL), National Rugby League, Australian
Rugby Union, Football Federation Australia, Volleyball Australia, Tennis Australia, Cricket
Australia, the Australian Ballet, Australian Racing Board, the Australian Institute of Sport. A
major part of the ACRISP research program is it’s translation of research evidence developed for
elite/professional sport to the more community forms of sporting activity and this has been
conducted in partnerships with the AFL, National Rugby League, Australian Rugby Union,
Football Federation Australia as well as work with State and National Government Departments
of Sport and Health.

ACRISP summary
The ACRISP research program aims to specifically reduce the public health and sports
performance/participation burdens of sports injury through the identification of the
causes/mechanisms of the injury events, monitoring of the incidence of both short and long-
term adverse outcomes of those injury events and evaluation of implemented strategies to
prevent them. The ACRISP team is leading international research into the real-world
implementation of sports injury interventions and their effectiveness, including identification of
the best way/s to translate this knowledge to reach those who will most benefit from this
research. In order to provide a strong basis for the evaluation of these impacts, ACRISP research
also contributes to new and rigorous methods for injury prevention research and the statistical
analysis of injury data. Most importantly, the ACRISP research program is innovative in that it is
designed from the outset to have maximal impact on, and engagement with, the intended direct
beneficiaries (i.e. the sports participants themselves), the bodies that set and implement sports
safety policy and practice (i.e. government agencies, sports bodies), the sports safety workforce
(i.e. sports medicine practitioners, coaches and club-based staff), and the new generation of
researchers keen to continue this work.

(ii) Sport Injury Prevention Research Centre (SIPRC)

Dr. Willem Meeuwisse and Dr. Carolyn Emery co-chair the Sport Injury Prevention Research
Centre (SIPRC) in the Faculty of Kinesiology at the University of Calgary. The SIPRC focuses
primarily on research related to injury prevention in youth sport and recreation. The SIPRC is an
interdisciplinary research team including research collaborators and community partners
provincially, nationally and internationally. Emery and Meeuwisse and colleagues have lead the
development and execution of several interdisciplinary teams including the Alberta Innovates
Health Solutions funded team “Alberta Program in Youth Sport & Recreational Injury
Prevention” (2013-2018), the Canadian Institutes of Health Research funded team “Mild
Traumatic Brain Injury in Children and Youth: Best Practices in Early Diagnosis and
Management” (2013-2018) and Canadian Institutes of Health Research funded program
“Consequences of knee joint injury in youth sport: Implications for knee osteoarthritis and other
health outcomes” (2014-2017). SIPRC contributes to both the International Olympic Committee
and International Paralympic Committee Injury Surveillance Research Programs (Vancouver
2010, London 2012, Sochi 2014).

The SIPRC research focus

The priorities of SIPRC have been driven by the potential public health impact of evidence
informed practice and policy to reduce the burden of youth sport and recreational injury. There
are 2 highlights where health and policy relevant priority areas have had informed substantive
public health impact:

1. Concussion and injury in youth ice hockey

Ice hockey is one of Canada’s most popular sports with >25% of male youth participating. Ice
hockey is also one of the highest injury producing sports in youth. Concussion has been an
increasing concern in leagues where body checking is permitted.7-9 SIPRC’s most significant
research contributions are highlighted by a 10-year program of research in youth ice hockey that
has informed policy change. Research findings demonstrated that policy allowing body checking
in Pee Wee ice hockey (ages 11-12) leads to a 3-4 fold greater risk of injury and concussion
compared to leagues where body checking is not allowed.10 Further, body-checking experience at
younger ages does not decrease the risk of all injury and concussion in older (ages 13-14)
players.11 This landmark research program evaluating body checking policy and risk factors for
injury and concussion in youth ice hockey has lead initially to provincial (2011) and subsequently
to national policy change delaying body checking in youth ice hockey from age 11 to age 13 in the
USA (2011) and then in Canada (2013). This policy change has had a large public health impact in
reducing the burden of concussion and injury in youth ice hockey. Elimination of body checking
in 11-12 year old leagues is expected to translate to over 1300 injuries prevented in the province
of Alberta annually (400 concussions). The estimated direct medical cost savings nationally
exceed $2M annually in this age group alone. Further research will inform future policy change in
older age groups (ages 13-17) in non-elite levels of play. Programmatic research evaluating
concussion prevention and management strategies in youth sport is a key SIPRC priority. The
youth ice hockey research program also includes examination of preseason evaluation tools in
youth ice hockey players (e.g., neurocognitive, clinical, functional, sport-specific performance,
and neuroimaging) in the identification of risk factors for concussion and predictors of longer-
term sequelae following concussion.12-16 The SIPRC team has evaluated the efficacy of vestibular
and cervical physiotherapy following concussion that has informed concussion management
practice.17

2. Injury prevention to prevent osteoarthritis

The efficacy of neuromuscular training injury prevention program has consistently demonstrated
a reduction in the risk of youth soccer and basketball injuries by more than 30%.18,19 On-going
collaborations with several national and international research groups will focus on development
and evaluation of such programs in other youth community sports (e.g., rugby, football). The
development and evaluation of a physical education (PE) curriculum-based high-intensity
neuromuscular training (NMT) prevention strategy suggests a reduction in sport and recreational
injury risk by >50% as well as a reduction in adiposity in junior high school students (ages 11-15
years).20 Behaviour change and long-term maintenance of such programs are an on-going focus
of inquiry. Based on previous youth RCTs and cohort studies (n>8000), SIPRC has developed a
unique longitudinal cohort examining the long-term consequences of joint injury in youth,
including post-traumatic osteoarthritis (PTOA).21 Outcomes include physical activity
participation, adiposity, functional outcomes, biomechanics, biomarkers and MRI imaging
hypothesized to be associated with PTOA in young people with a history of knee injury. This
research will inform the development of secondary prevention strategies to delay the onset and
progression of PTOA. In partnership with community stakeholders (Alberta Health Services
Strategic Clinical Network and Bone and Joint Canada), SIPRC researchers are leading the
development of provincial and national strategies in the prevention of injury and PTOA.

Community engagement and leadership

The priority of the SIPRC team includes building research capacity provincially, nationally and
internationally in injury prevention in child and adolescent sport and recreation to inform
community sport, school board and health practice and policy. On-going partnerships with
community and government have informed relevant knowledge synthesis, dissemination,
exchange and application. These partnerships have been key to successful implementation of
prevention programs in the community and have facilitated greater public health impact. On-
going collaboration with community stakeholders across several diverse sectors (Canadian
Paediatric Society, Canadian Academy of Sport Medicine, Canadian Physiotherapy Association,
sport governing bodies [FIFA, IOC, IPC, Hockey Calgary, Hockey Edmonton, Hockey Alberta,
Hockey Quebec, Hockey BC, Hockey Canada, Calgary Minor Soccer, Calgary School Boards],
not-for-profit organizations [Parachute, Sandbox Project, Bone & Joint Canada] and
legislative/policy groups (Alberta Health and Wellness)] has informed optimal evidence-informed
practice and policy change.

SIPRC summary
It is estimated that the impact of the evidence and translation to public health policy and practice
will lead to a 20% reduction in injury burden in youth sport and recreation in the province of
Alberta by 2020. SIPRC continues to build research and trainee development capacity in injury
prevention in youth sport and recreation to promote active health and enhance personal health
and wellbeing in our youth population. The practice and policy implications of the SIPRC
research program to date have been a substantial public health impact in reducing the risk of
injury in sport and recreation in youth in Canada. This research is relevant to policy makers
across health care, education and public health priorities. With appropriate knowledge translation
strategies and evaluation, this work will inform best practice across health services and systems,
education, community sport, and public health sectors. A shift in focus from disease management
to injury and chronic disease prevention is critical to the future health of our population.

(iii) Clinical Sport and Exercise Medicine Research (CSEM)

Professor Martin Schwellnus, together with Professor Wayne Derman, directs the Clinical Sport
and Exercise Medicine Research (CSEM) group in the Department of Human Biology, Faculty of
Health Sciences at the University of Cape Town in South Africa. Their research group focuses
primarily on research activities related to protection of the health of athlete as defined in its broad
application of illness prevention (primary prevention), management (secondary prevention), and
rehabilitation (tertiary prevention). This also includes the promotion of a healthy lifestyle
(including physical activity) in the population at large – a vision that is shared by the IOC. In
addition, this group focuses research on injury prevention in specific athlete groups and sports.

The CSEM research focus

In the past 6 years, the research highlights from this group were in the following main areas: 1)
identification of the burden of illness and injury in specific populations of athletes, 2) protection
of the health of the athlete participating in mass community-based endurance sports events, and
3) development and implementation of a comprehensive lifestyle intervention program for
patients with lifestyle related chronic diseases.

1. The burden of illness and injury in specific populations of athletes

The group developed a web based electronic injury and illness surveillance program (WEB-IISS),
that was based on the studies the group conducted together with F-MARC during the 2009
Confederations Cup football tournament,22 and the 2010 FIFA World Cup in South Africa.23 As
part of these early studies, an illness surveillance system was developed and this provided novel
data on illness in football players. The full WEB-IISS, including illness and injury surveillance,
was then applied during the 2012 London Paralympic Games,24-26 and again in the 2014 Sochi
Winter Paralympic Games. These studies were conducted in collaboration with the International
Paralympic Committee (IPC) medical committee. The novel data derived from these studies now
form the basis of an on-going longitudinal injury and illness surveillance program in athletes with
disabilities - an area that has received very little attention in the sport and exercise medicine
literature to date. Several illness and injury prevention strategies can now be identified and their
impact can be assessed in future studies.

This group also developed a similar electronic illness and injury surveillance system for team
sports participating in tournaments.27 Illness data during a 16-week rugby union tournament
showed a high incidence of illness during international travel.28 These data have much wider
application for athletes from other sports codes that travel across multiple time zones to compete
in international tournaments. Once again, these baseline data now form the basis for
implementing prevention strategies to reduce the burden of illness resulting from international
travel. Similarly, data reported in this edition indicates a high risk of injury during the 16-week
rugby union tournament.29 Once again, injury prevention strategies can now be introduced and
the impact of these can be evaluated in future studies.

2. Protection of the health of the athlete participating in mass community-based

endurance sports events
It is well recognized that physical activity plays an important component of a healthy lifestyle to
prevent and manage non-communicable chronic disease. However, it is also well recognized by
participation in moderate to strenuous physical activity can be associated with an increased risk of
sudden cardiac death and other life-threatening medical complications, particularly in endurance
sports. In this regard, the CSEM group focused a substantial component of its research activity
on strategies to reduce adverse medical events in the exerciser (SAFER studies). Several research
studies have been concluded over the past six years in runners participating in a 21 km and a 56
km endurance event – the Two Oceans marathon races. In these studies, higher rate of medical
complications was identified, serious life-threatening medical complications were documented,30
and several risk factors for medical complications were ascertained.31,32 As a result of these data,
an online medical screening tool and educational intervention program was developed to reduce
the risk of medical complications in these recreational athletes. Finally, an extensive medical and
injury history database in over 45,000 recreational runners has been compiled. These data form
the basis of a prospective cohort study to identify risk factors for medical complications and
injury in this group.

3. Development and implementation of a comprehensive lifestyle intervention program

for patients with lifestyle related chronic diseases
The global health and economic burden of lifestyle related chronic diseases are well established.
Therefore, lifestyle intervention programs aimed at the primary, secondary and tertiary
(rehabilitation) level are imperative to reduce this burden. The IOC has recognized this, and
actively promotes physical activity and lifestyle intervention in all population groups. Recently,
there has been a call for the Sport and Exercise Medicine physician to play an active role in
providing a clinical service that focuses on lifestyle intervention for chronic disease. Members of
this research group have developed such a program for patients with established chronic disease.
This program is both patient-centered (not disease-centered) and comprehensive (not single
intervention). In this BJSM IPHP-edition, this program is described and preliminary results are
presented.33

CSEM summary
The research activities in this group have had significant wider impact and some of the highlights
are as follows: Real time (daily) illness and injury monitoring using the WEB-ISS was conducted
during the 2014 Sochi Winter Paralympic Games. Wider translation of this methodology is
possible in other game settings, and there has been interest from other tournament organizations
to use the same methodology. Novel findings on injuries in athletes with impairments have
received attention from manufacturers of prosthetics and other protective equipment. Equipment
to reduce injury risk can be developed and tested. The greater awareness of illness in rugby
tournaments has resulted in the implementation of illness prevention strategies, particularly whilst
travelling across many time zones. This information has also been of interest to sports other than
rugby, where travelling is an integral part of the competition. In the Two Oceans Marathon races,
the medical screening and educational intervention program is now compulsory for all the
runners entering the races.

(iv) Oslo Sports Trauma Research Center (OSTRC)

Professors Roald Bahr and Lars Engebretsen has led the development of the Oslo Sports
Trauma Research (OSTRC) since 2000, when the Center was established at the Norwegian
School of Sport Sciences as a research collaboration between the Department of Orthopaedic
Surgery, Oslo University Hospital, and the Norwegian School of Sport Sciences. Initially, the
OSTRC was based on grants from the Royal Norwegian Ministry of Culture, the Norwegian
Olympic and Paralympic Committee and Confederation of Sports and Pfizer AS. Since 2005, the
activity has been expanded based on grants from the Eastern Norway Regional Health Authority,
from FIFA (the International Football Federation), the IOC (the International Olympic
Committee), and from FIS (the International Skiing Federation).

The Oslo Sports Trauma Research Center has a multidisciplinary team, which does translational
research. The OSTRC has at any time 15-20 PhD-students, part-time or full-time, with a
multidisciplinary background, involved in different research projects. The core research team
consists of physicians, physical therapists and sport scientists recruited from the Oslo University
Hospital and the Department of Sports Medicine at the Norwegian School of Sport Sciences, but
involves scientists and clinicians with a multidisciplinary background from several different
hospitals and laboratories nationally and internationally.

The OSTRC research focus

The main objective of the OSTRC has been to develop a long-term research program on sports
injury prevention (including studies on epidemiology, risk factors, injury mechanisms, and
interventions studies). The program focuses mainly on 3 sports (football, team handball, and
alpine skiing/ snowboarding), as these account for more than 50% of all sports-related injuries
treated in Norwegian hospitals. Aims also include the most common (e.g. ankle, hamstrings) and
the most serious (e.g. ACL, concussions) injuries seen in these sports. Recently, the center´s aims
have been expanded to studies in the prevention of other health issues such as eating disorders,
the female athlete triad, and sudden cardiac death. In addition to injury prevention research, the
cartilage and ligament research group has focused on surgical and nonsurgical treatment options
to prevent future damage to an injured joint (i.e. osteoarthritis).

1. The burden of injury and other health issues in specific athlete populations
The OSTRC has completed a number of cohort studies to describe the magnitude of the
problem in their targeted sports as well as among elite athletes, recreational athletes, and in youth
and children’s sport. Thus, there is ample data on the incidence, patterns and severity of acute
time-loss injuries across most sports and levels of participation. The OSTRC has established key
surveillance systems to monitor the rate of specific injury types or in specific sports, such as the
Norwegian National Cruciate Ligament Register,34 the FIS Injury Surveillance System35 and the
National Football Injury Surveillance System.36 These systems monitor changes in injury patterns
over time. However, overuse injuries have largely been neglected so far, and although a
consensus was reached on how to record and report data in epidemiological studies on injuries,
the OSTRC has recently shown that this standard methodology does not capture overuse injuries.
Overuse injuries may represent as much of a problem as do acute injuries in many sports,37 and
this is the case not just among elite athletes but also recreational athletes, runners and other
“weekend warriors”. As a first step, the OSTRC has therefore developed and now validated new
methods to quantify overuse injuries, taking advantage of new digital technology to record data
directly from the athlete. These studies include a selection of team sports and endurance sports at
different levels of participation. The second step is to employ this novel methodology to conduct
prospective studies to measure the magnitude of key overuse problems in selected sports and at
the same time study their risk factors.38,39 Such studies are on-going, using handball, where
shoulder problems and low back pain are prevalent, as a model. Also, a new PhD-project on the
young elite athlete has just started to monitor load and the risk of developing health issues over
time.

2. Risk factors and mechanisms

The second step in the sequence of injury prevention is to map the causes of injuries, to identify
their risk factors and mechanisms. The OSTRC has developed new research models and methods
to describe and understand the inciting event, the mechanisms of injury, based on video
recordings of actual injuries. Injury mechanisms among elite athletes are often the same as in
recreational or youth sports, and our approach takes advantage of the fact that in elite sports,
injury mechanisms are often captured in detail by TV-recordings. The OSTRC is the only
research center in the world systematically applying video analysis methods with novel model-
based image-matching technology (POSER method) to a range of sports including handball,
football, alpine skiing and snowboarding.40,41 This provides more precise descriptions of the
mechanisms of sports injuries, e.g. for knee injuries, than has previously been possible. The
POSER method is now being used in a number of studies across different injury types and
sports, and OSTRC recently published the most compelling data that exist to explain the specific
biomechanical underpinning of ACL injury in team sports and alpine skiing.42,43

3. Injury prevention and implementation

The final steps in injury prevention research are to introduce measures that are likely to reduce
the future risk and/or severity of sports injuries and document whether they are effective,
preferably by means of a randomized controlled trial. The Oslo Sports Trauma Research Center
has completed 6 large-scale, landmark studies in the field: a case-control study on helmet use in
recreational snowboarders and alpine skiers,44 an intervention study on a balance training
program to prevent ACL injuries among female senior handball players,45 a randomized
controlled trial on an exercise program to prevent lower extremity injuries in youth handball
players,46 an intervention study using a novel eccentric strength exercise program to prevent
hamstring strains in male football players,47 and 2 randomized controlled trials to develop a
warm-up program to prevent injuries among youth female football players.48,49 A general finding
across most of these studies is that injury risk can be reduced by as much as 50% through such
simple measures. Similarly, a recently published 10-year study on knowledge translation and
implementation in Norwegian elite handball could reveal a sustained 50% reduction in ACL
injury risk in Norwegian elite level handball.50

Dissemination of knowledge into practice

The OSTRC is using a number of outlets to disseminate evidence-based information and
programs to prevent, treat and rehabilitate musculoskeletal problems and other health issues. The
strong track record in knowledge translation includes the bilingual website www.klokeavskade.no
(www.ostrc.no for English). This website is mainly directed towards health care professionals and
researchers to inform them about the research activities at the center, on-going projects and their
results, but also includes functionality to reach the media. The OSTRC promotes the website and
other OSTRC discoveries and programs actively using blogs, social media (Facebook – “Senter
for idrettsskadeforskning”, Twitter – “@ostrc1”, other emerging channels). The OSTRC is
working closely together with the national sporting governing bodies on the establishment of
injury prevention in the education of coaches at all levels.
A new mobile application, Get Set, was recently created for the occasion of the 2014 Youth
Olympic Games in Nanjing, China, through collaboration between the International Olympic
Committee, the OSTRC, technology partners, and several international sports federations. The
target group is not only young talents and their coaches, but anyone engaged in physical activity.
Get Set was created to help prevent sports injuries by providing the most effective and evidence-
based workout routines.

OSTRC summary
The OSTRC has established key surveillance systems to monitor the rate of specific injury types
or in specific sports. A novel methodology to reliably collect data on overuse health issues has
been developed and employed in different studies. The Center´s research focus has been
expanded to the protection of other athlete health issues, than injuries alone, such as sudden
cardiac rest and eating disorders. The OSTRC is the only research center systematically applying
video analysis methods with novel model-based image-matching technology (POSER method) to
a range of sports to better understand the injury mechanisms and thereby optimize injury
prevention programs. The results of effective injury prevention programs are disseminated
through an established outreach practice, involving various multi-media channels.

Trainee environment in the 4 IOC Centres of excellence

The strength of the 4 IOC Research Centres ACRISP (Melbourne, Australia), SIPRC (Calgary,
Canada), CESM (Cape Town, South Africa), and OSTRC (Oslo, Norway) leaderships is that they
have remained committed to excellence in research training that maximizes opportunities for all
trainees, including undergraduate students, MSc students, medical students, PhD students, post-
doctoral fellows, and clinician scientists in sports medicine and sport science. All Centres provide
students with a diversity of training opportunities to foster growth in methodological, clinical and
applied research training. The on-going dedication of trainees to research in injury prevention in
recreational and elite sport following their training is a testament to the growing and sustainable
program of research in the field.

References
ACRISP references
1. Finch C, Cook J. Categorising sports injuries in epidemiological studies: the SIC (Subsequent Injury
Categorisation) model to address the issue of multiple, recurrent, exacerbation or new injuries. Br J Sports Med 2013;
In press.
2. Ullah S, Gabbett T, Finch C. Statistical modelling for recurrent events: an application to sports injuries. Br J Sports
Med 2012; Published Online First on 7 Aug 2012.
3. Mount S, Moore I, Ranson C. Injury types and rates in an international cricket team: application of subsequent
injury categorisation (abstract). Br J Sports Med 2014;48:642.
4. Mathema P, Ranson C, Moore I. National team rugby player injury types, rates and risk factors over two-years
(abstract). Br J Sports Med 2014;48:635.
5. Timpka T, Alonso J-M, Jacobsson J, et al. Injury and illness definitions and data collection procedures for use in
epidemiological studies in Athletics (track and field): Consensus statement. Br J Sports Med 2014;48:483-490.
6. Gabbett TJ, Ullah S, Finch CF. Identifying risk factors for contact injury in professional rugby league players –
application of a frailty model for recurrent injury. J Sci Med Sport 2012;15:496-504.
SIPRC references
7. Emery CA, Meeuwisse WH. Injury rates, risk factors and mechanism of injury in minor hockey. Am J Sport Med
2006;34:1960-1969.
8. Houghton KM, Emery CA. Body checking in youth ice hockey. Paediatric Child Health 2012;17(9):509.
9. Emery CA, Hagel B, Decloe M, et al. Risk factors for injury and severe injury in youth ice hockey: a systematic
review of the literature. Inj Prev 2010;16(2):113-118.
10. Emery CA, Kang J, Shrier I, et al. The risk of injury associated with body checking in youth ice hockey players.
JAMA 2010;303:2265-2272.
11. Emery CA, Kang J, Shrier I, et al. The risk of injury associated with body checking experience in youth ice hockey
players CMAJ 2011;183(11):1249-1256.
12. McKay C, Campbell T, Meeuwisse W, et al. The role of psychosocial risk factors for injury in elite youth ice
hockey. Clin J Sport Med 2012;23(3):216-221.
13. Schneider KJ, Meeuwisse WH, Kang J, et al. Preseason reports of neck pain, dizziness, and headache as risk
factors for concussion in male youth ice hockey players. Clin J Sport Med 2013;23(4):267-272.
14. Virji-Babul N, Borich M, Makan N, et al. Diffusion tensor imaging of sport related concussion in adolescents.
Pediatric Neurology 2013;48:24-29.
15. Decloe M, Emery CA, Hagel B, et al. Injury rates, mechanisms and risk factors for injury in female youth ice
hockey. Br J Sport Med 2014;48(1):51-56.
16. Brooks B, McKay CD, Mrazik M, et al. Subjective, but not objective, lingering effects of multiple past
concussions in adolescents. Journal Neurotrauma 2013;30(17):1469-1475.
17. Schneider K, Meeuwisse WH, Boyd L, et al. Cervico-vestibular physiotherapy in the treatment of individuals with
persistent symptoms following sport related concussion: A randomized controlled trial. Br J Sport Med 2014 (in press)
18. Emery CA, Rose MS, Meeuwisse WH, et al. The effectiveness of an injury prevention strategy in high school
basketball. A cluster-randomized controlled trial. Clin J Sport Med 2007;17:17-24.
19. Emery CA, Meeuwisse WH. The effectiveness of a neuromuscular prevention strategy to reduce injuries in youth
soccer: a cluster randomized controlled trial. Br J Sport Med 2010;44:555-562.
20. Richmond S, T Doyle-Baker, Nettel-Aguirre A, et al. A historical cohort study and RCT examining the
effectiveness of a high intensity neuromuscular training program in reducing sport injury and obesity in junior high
school students. Clin J Sport Med 2012;22(3).
21. Whittaker JL, Woodhouse LJ, Jeremko J, et al. Consequences of knee joint injury in youth sport: Implications for
osteoarthritis. Osteoarthritis Research Society International World Congress Proceedings (Paris, FRA April 2014).

CSEM references
22. Theron N, Schwellnus M, Derman W, et al. Illness and injuries in elite football players--a prospective cohort
study during the FIFA Confederations Cup 2009. Clin J Sport Med 2013;23(5):379-383.
23. Dvorak J, Junge A, Derman W, et al. Injuries and illnesses of football players during the 2010 FIFA World Cup.
Br J Sports Med 2011;45(8):626-630.
24. Willick SE, Webborn N, Emery C, et al. The epidemiology of injuries at the London 2012 Paralympic Games. Br
J Sports Med 2013;47(7):426-432.
25. Schwellnus M, Derman W, Jordaan E, et al. Factors associated with illness in athletes participating in the London
2012 Paralympic Games: a prospective cohort study involving 49 910 athlete-days. Br J Sports Med 2013;47(7):433-
440.
26. Derman W, Schwellnus M, Jordaan E, et al. Illness and injury in athletes during the competition period at the
London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS)
for team medical staff. Br J Sports Med 2013;47(7):420-425.
27. Schwellnus M, Derman W, Page T, et al. Illness during the 2010 Super 14 Rugby Union tournament - a
prospective study involving 22 676 player days. Br J Sports Med 2012;46(7):499-504.
28. Schwellnus MP, Derman WE, Jordaan E, et al. Elite athletes travelling to international destinations >5 time zone
differences from their home country have a 2-3-fold increased risk of illness. Br J Sports Med 2012;46(11):816-821.
29. Schwellnus MP TA, Derman EW, Jordaan E, et al. More than 50% of players sustained a time-loss injury (>1 day
of lost training or playing time) during the 2012 Super Rugby Union Tournament – A prospective cohort study of 17
340 player-hours. Br J Sports Med 2014; In press.
30. Schwabe K, Schwellnus M, Derman W, et al. Medical complications and deaths in 21 and 56 km road race
runners: a 4-year prospective study in 65 865 runners-SAFER study I. Br J Sports Med 2014;48(11):912-918.
31. Schwabe K, Schwellnus MP, Derman W, et al. Older females are at higher risk for medical complications during
21 km road race running: a prospective study in 39 511 race starters--SAFER study III. Br J Sports Med
2014;48(11):891-897.
32. Schwabe K, Schwellnus MP, Derman W, et al. Less experience and running pace are potential risk factors for
medical complications during a 56 km road running race: a prospective study in 26 354 race starters--SAFER study
II. Br J Sports Med 2014;48(11):905-911.
33. Derman W SM, Hope F, Jordaan E, et al. Description and implementation of the U Turn Medical comprehensive
lifestyle intervention programme for chronic disease in the Sport and Exercise Medicine setting: Pre-post
observations in 210 consecutive patients. Br J Sports Med 2014;In press.

OSTRC references
34. Granan LP, Bahr R, Steindal K, et al. Development of a national cruciate ligament surgery registry: the
Norwegian National Knee Ligament Registry. Am J Sports Med 2008;36(2):308-315.
35. Flørenes TW, Nordsletten L, Heir S, et al. Recording injuries among World Cup skiers and snowboarders: a
methodological study. Scand J Med Sci Sports 2011;21(2):196-205.
36. Bjørneboe J, Bahr R, Andersen TE. Gradual increase in the risk of match injury in Norwegian male professional
football: A 6-year prospective study. Scand J Med Sci Sports 2012 May 15 [Epub ahead of print].
37. Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. Br J
Sports Med 2009;43(13):966-972.
38. Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse
injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) overuse injury
questionnaire. Br J Sports Med 2013;47(8):495-502.
39. Clarsen B, Rønsen O, Myklebust G, et al. The Oslo Sports Trauma Research Center questionnaire on health
problems: a new approach to prospective monitoring of illness and injury in elite athletes. Br J Sports Med
2014;48(9):754-760.
40. Krosshaug T, Nakamae A, Boden BP, et al. Mechanisms of anterior cruciate ligament injury in basketball: Video
analysis of 39 cases. Am J Sports Med 2007;35:359-367.
41. Krosshaug T, Slauterbeck JR, Engebretsen L, et al. Biomechanical analysis of anterior cruciate ligament injury
mechanisms: Three-dimensional motion reconstruction from video sequences. Scand J Med Sci Sports 2007;17:508-
519.
42. Koga H, Nakamae A, Shima Y, et al. Mechanisms for noncontact anterior cruciate ligament injuries: knee joint
kinematics in 10 injury situations from female team handball and basketball. Am J Sports Med 2010;38(11):2218-2225.
43. Bere T, Mok KM, Koga H, et al. Kinematics of anterior cruciate ligament ruptures in World Cup alpine skiing: 2
case reports of the slip-catch mechanism. Am J Sports Med 2013;41(5):1067-1073.
44. Sulheim S, Holme I, Ekeland A, et al. Helmet use and risk of head injuries in alpine skiers and snowboarders. J
Am Med Assoc 2006;295:919-924.
45. Myklebust G, Engebretsen L, Brækken IH, et al. Prevention of anterior cruciate ligament injuries in female team
handball players: A prospective intervention study over three seasons. Clin J Sports Med 2003;13:71-78.
46. Olsen OE, Myklebust G, Engebretsen L, et al. Exercises to prevent lower limb injuries in youth sports: Cluster
randomised controlled trial. Br Med J 2005;330:449-455.
47. Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an intervention study.
Scand J Med Sci Sports 2008;18(1):40-48.
48. Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young
female footballers: Cluster randomised controlled trial. Br Med J 2008;337:2469.
49. Steffen K, Myklebust G, Olsen OE, et al. Preventing injuries in female youth football - a cluster-randomized
controlled trial. Scand J Med Sci Sports 2008;18:605-614.
50. Myklebust G, Skjølberg A, Bahr R. ACL injury incidence in female handball 10 years after the Norwegian ACL
prevention study: important lessons learned. Br J Sports Med 2013;47(8):476-479.