Active Voice: Preventive Measures are for Athletes, not Injuries By Evert Verhagen, Ph.D. Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM. Evert Verhagen, Ph.D., is a human movement scientist and epidemiologist. He is Associate Professor at the Department of Public and Occupational Health of the VU University Medical Center and the EMGO Institute in Amsterdam. His main research interests include prevention of sports and physical activity injuries and physical activity promotion integrated in everyday life. He is engaged in several international scientific collaborations, holds honorary research positions at the Free University of Brussels and Monash University in Melbourne, and is senior associate editor of the British Journal of Sports Medicine. This commentary presents Dr. Verhagen’s views on the topic of the invited commentary which he authored for the Jan/Feb. 2012 issue of ACSM’s Current Sports Medicine Reports (CSMR), titled “If athletes will not adopt preventive measures, effective measures must adopt athletes.” Sports- and physical activity-related injuries are a significant risk for those participating in what are otherwise healthy activities. There is no doubt that advances in sports injury research have led to a wide array of efficacious and effective preventive measures for various injuries within different sports. As such, in theory at least, injury burden can be significantly reduced. That is, if athletes and other stakeholders would only adopt available guidelines for prevention, safety margins would be greatly improved. Unfortunately, even the guidelines based on the strongest evidence are not widely adopted in practice and ineffective ‘implementation’ has become a trending topic in contemporary sports medicine literature. In current implementation approaches, we try to translate objective research outcomes into the subjective expectations of the end user. As an example, you may try to convince an athlete who has rehabilitated from an ankle sprain that an eight-week neuromuscular training protocol, consisting of three 30-minute training sessions per week, will reduce his or her risk of ankle sprain recurrence. Although this program is very effective when completed in full, compliance has been found to be low - even in controlled research conditions. Athletes simply do not directly feel and notice the positive effects, and after a few training sessions, the program stays in the closet. We attempt to tackle this problem by wrapping a behavioral intervention around an effective program in order to motivate the patient to complete the program as prescribed. We may give the patient background knowledge on the risk and consequences of recurrent ankle sprains, pursuing an attitude change towards injury prevention. Or, in an effort to take away barriers, we provide materials needed for the program, free of charge. However, it is known from studies on lifestyle interventions that altering an individual’s behavior in this manner is very difficult, if not impossible. In my commentary in CMSR I argued for a different approach on tackling this implementation enigma. Contemporary preventive approaches are developed from an injury perspective - we have an injury with known risk factors; take away the risk factors to prevent the injury from occurring. However, in this approach we neglect that the risk factors act within an athlete who needs to take action to alter his or her risk for injury. I argue that during intervention development we already need to take into account the demands, wishes, needs, possibilities, and motivation of the athlete. We need to build the preventive measures around the athlete, not the other way around. One very effective framework in constructing such acceptable, yet evidence-based, intervention programs is the Intervention Mapping protocol (IM). IM captures the process of the development of a health promotion program in a series of six consecutive steps, mapping the path from recognition of a need or problem to the identification of a behavioral solution. The strength of IM lies therein – engaging the athletes and other stakeholders becomes a key part of the development process. If an injury problem is approached through IM, the resulting intervention program is built around the acting behaviors. In a downscaled form the essence of the IM approach can be used in everyday practice as well. Instead of telling athletes and patients what to do based upon the latest evidence, start a discussion on the problem and solution at hand. In this way one can work towards a preventive solution that is based upon evidence, but is also supported by those that need to use it.