Research article - (2014)13, 321 - 328 |
Efficacy of the FIFA 11+ Warm-Up Programme in Male Youth Football: A Cluster Randomised Controlled Trial |
Oluwatoyosi B. A. Owoeye1,, Sunday R. A. Akinbo1, Bosede A. Tella1, Olajide A. Olawale2 |
Key words: Injury prevention, neuromuscular training, FIFA, sports |
Key Points |
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Study design, participants and randomisation |
A cluster randomised controlled trial was conducted. A cluster design was adopted so as to administer the INT programme to teams and not directly to individual players thereby minimising contamination between the INT and CON groups. Data collection procedures and definitions used in the present study were in accordance with international consensus guidelines for injury surveillance in football (Fuller et al., The sample frame for this study consisted of 20 teams (416 players) of the Premier League division of the Lagos Junior League (LJL) registered for the 2012/2013 season. Blocked randomisation technique was used to equally allocate the 20 teams into 2 groups and teams were prospectively followed for a period of 6 months (September, 2012 to February, 2013) through the 2013/2013 league season. The randomisation procedure for this study was based on team clusters with regards to the official list of premier league teams registered for the season. A randomisation block comprising 4 unlabelled teams was chosen based on the intended number of groups (two) (Kang et al., |
Intervention |
The 11+" is a structured, exercise-based warm-up programme aimed at reducing injuries among male and female football players aged 14 years and above (Soligard et al., The purpose and procedures of the study was explained to all the players and coaches of participating teams at a pre-participation screening programme. Furthermore, a pre-season workshop and practical session was organised for the head coaches and assistant coaches of the 10 teams in the INT group prior to the commencement of the 2012/2013 league season. Coaches of teams randomised into the INT group were instructed on the FIFA 11+ injury prevention warm-up exercise programme and to facilitate understanding, compliance, ongoing safety and correct execution, materials such as 11+ posters, booklet manuals and DVDs were also given to them as reference guide for implementing the injury prevention programme with their teams. The information material given to coaches in the INT group explains the proper form for each exercise, as well as common biomechanical mistakes. It also describes the principles of progression in the exercise prescription. The coaches in INT group were also instructed to follow F-MARC’s recommendations for the 11+ which is to use the complete exercise programme as the warm up for at least two training sessions every week throughout the 2012/2013 league season. The CON group players on the other hand were instructed to continue with their usual non-structured warm-up during training periods with no additional training programme. |
Data collection procedures |
Information on players’ age, height, weight, body mass index and body fat were recorded. Information concerning players’ injury history over the past 1-year period was also recorded. In addition, selected physical performance parameters were assessed. A pre-assessment education and demonstration session was held for each participating team in order for players to understand the assessment protocols. Height was measured (to the nearest 0.5 cm) using a non-elastic measuring tape, fastened to a vertical wall, with the player standing on bare feet. Players’ weight and body-fat percentage were measured using the Omron Body Composition Monitor. In assessing players’ performance fitness, each player was asked to perform 3 different fitness tests - standing stork balance test on dominant leg, prone hold core stability test and dynamic leg strength according to standardized protocols (Kilding The physiotherapists compiled information about injuries vis-a-vis exposure, location, aetiology, mechanism and severity on injury report forms. Also, the physiotherapists interviewed the coaches to obtain details of team exposures in the previous week and players’ participation in each training session and match on exposure forms. Number of matches played, training sessions observed and total number of players present (from team register) was documented for each team. Furthermore, weekly information on the extent of team and player compliance with the FIFA 11+ programme was obtained from the coaches in the INT group on separate compliance forms. Teams in the INT group were constantly reminded and encouraged through their coaches to implement the exercise programme through regular phone contacts by one of the authors and during weekly data collection by study physiotherapists at training venues. Data were collected on validated forms in accordance with consensus guidelines outlined for football injury research (Fuller et al., |
Outcome measures |
All injuries were reported in relation to primary and secondary outcomes as described below. The primary outcomes were any time-loss injury to the players, injuries by type of exposure (match/training) and all injuries to the LEs. The secondary outcomes were injuries by body location, injuries by onset (acute or overuse), injuries by aetiology, mechanism and severity. |
Statistical analyses |
Statistical analyses for all data were performed using the Statistical Package for Social Sciences (SPSS) Version 15.0 (SPSS Inc., Chicago, Illinois, USA). Baseline characteristics, measured as continuous variables, were expressed as mean and standard deviation (SD) and categorical variables such as injury history were expressed as percentages. Baseline differences between the 2 groups were evaluated using independent t-test and chi-square test for continuous and categorical variables respectively. Injury rates (number of injuries/1000 player hours) and 95% CI were estimated vis-a-vis the primary and secondary outcome measures for this study. The overall incidence of injuries and those of other primary and secondary outcome measures were analysed and compared between the 2 groups (as injury rate ratios – RRs) using Poisson regression analysis. Comparison of the rates of injury in the 2 groups was done according to the intention to treat principles. Statistical significance was set at p < 0.05. |
Ethical considerations |
Ethical approval for the study was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital, Idi-Araba, Lagos (ADM/DCST/HREC/487) prior to its commencement. Approval to carry out the study was also obtained from the LJL for official access to the various football teams. Informed consent was sought and obtained from players on team basis (each team was represented by the coach) after the purpose and procedure of study had been carefully explained to them at a pre-season screening programme prior to the commencement of the 2012/2013 league season. |
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Descriptive characteristics of players |
The baseline characteristics of the 2 groups are presented in |
Exposure time of players and injuries in both groups |
Players’ exposures to football in both groups are presented in Overall, 104 (25%) of the 416 players included in the study sustained a total of 130 injuries; 36 in the INT group and 94 in the CON group throughout the league season. |
Compliance with the FIFA 11+ intervention programme |
The 10 teams (212 players) in the INT group performed the injury prevention programme in 60% of all training sessions; corresponding to 30 ± 12 (range, 5 – 22) sessions per team. Furthermore, this is equivalent to performing the FIFA 11+ programme an average of 1.6 times per week. Regarding players’ compliance, 74% of all the players in the INT group; corresponding to an average of 14 players per team participated in the programme. None of the teams in the CON regularly performed a structured preventive programme comparable to the INT programme. |
Effects of FIFA 11+ intervention programme |
The incidence of injuries and comparison of injury rates for the primary outcome measures in both groups are presented in |
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The principal finding in this cluster randomised controlled trial is that the FIFA 11+ neuromuscular warm-up programme significantly reduced the overall rate of injuries in male youth football by 41% and LE injuries by 48%. To our knowledge, only 2 RCTs (Soligard et al., An overall injury reduction rate of 41% reported in the present study is comparable with that of Soligard et al. ( The protective effect of FIFA 11+ in reducing specific LE injuries such as thigh and ankle injuries is arguably clinically relevant, despite a lack of statistical significance reported in the secondary outcomes of this study (p = 0.052 and p = 0.080 respectively). Furthermore, a trend towards a reduction in non-contact injuries was also observed, but not to a level of statistical significance (p = 0.056). However, overuse and acute injuries were significantly reduced in the INT group compared to the CON group (p < 0.05). |
Strengths and limitations of study |
To our knowledge, this is the first RCT to investigate the effects of the FIFA 11+ on male youth football players and it is also the first injury prevention trial conducted on any population of football players in Africa. An important strength of this trial is the comprehensive baseline data that included physical characteristics, injury history of players and selected physical performance parameters. This was necessary to completely rule out any potential risk factor for injuries among players in both groups prior to the commencement of the trial. Comparative analysis of baseline data revealed that the groups were well matched. Another strength of this trial is cluster randomisation of teams to avoid contamination between the INT and CON groups. Also, to improve the reliability and validity of the results of this study, an intention-to-treat analysis as advocated for RCTs in the 2010 consort statement was applied (Mohar et al., This study however has some limitations. Firstly, the researchers and assistants could not be blinded to the INT programme because they had to monitor compliance and evaluate injured players in both groups. Secondly, all injuries regardless of severity were diagnosed based on subjective assessment and physical examination of players due to limited funds and resources for the study. In order to minimise the effect of the aforesaid, injuries were not described with reference to type, but by location, aetiology, mechanism and severity. Thirdly, administration of 11+ exercises was done by coaches with occasional supervision by study physiotherapists. The extent to which the INT teams used the programme with fidelity and progressed through the programme is uncertain. However, this approach was preferred so as to resemble a real world situation where no external professional resources would be unavailable to youth football teams as mostly applicable in Africa. Fourthly, information on players’ compliance with the 11+ programme was got from the coaches; hence it is possible that compliance with INT programme might have been over- or under-reported for the teams and players. Finally, the CON group did not perform a standardized programme of warm-up. Each team performed its usual warm-up programme; mostly involving a combination of stretches, jogging and strength exercises a in a non-standardized fashion and we had no control over whether any of the teams in the CON group performed exercises similar to those of the INT group during the study period. However, any possible bias introduced by such contamination of the CON group would only lead to underestimation of the preventive effect found in our study. |
Implications |
Although the pattern of injuries in African players have been noted to be mostly consistent with reports from other parts of the world, a peculiar record of higher injury rates has been documented (Akodu et al., |
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This study has established that the FIFA 11+ programme is effective in reducing the incidence of injury in male youth football players. A country-wide campaign and implementation of the FIFA 11+ injury prevention programme among male youth football players may be pursued by youth football administrators and federations across Nigeria and regions of Africa respectively in order to help minimise the risk of injury among players. The world governing body for football (FIFA) should consider supporting federations and local administrators in achieving this. |
ACKNOWLEDGEMENTS |
We are grateful to F-MARC for providing the FIFA 11+ materials used for this research project. We also thank the study physiotherapists: Yewande Apatira, BPT and Wole Fasuba, BPT, the Lagos Junior League administrators; particularly Mr. Tunde Disu (Technical Director) and Mr. Taofik Aromire (Executive Secretary), coaches and players who participated in this project. |
AUTHOR BIOGRAPHY |
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