Sallie Melissa Cowan

Objectives Evaluate the effect of supported implementation on a co-created injury prevention programme (Prep-to-Play) use and injury incidence and evaluate the dose response relationship between adherence and injury incidence. Methods In this hybrid implementation-effectiveness stepped wedge cluster randomised trial, 165 women’s/girls’ Australian Football teams (2481 players) were randomly allocated to transition from unsupported to supported implementation at one of five time points during 2021/2022. Supported implementation included in-person workshops and support visits for coaches/team leaders. Unsupported implementation was access to online resources. Prep-to-Play includes warm-up, contact and strength activities. Primary (Prep-to-Play use) and secondary (concussion, anterior cruciate ligament (ACL)) outcomes were reported weekly. Weekly Prep-to-Play use (yes/no) was defined as using ≥75% of programme elements, ≥two-thirds of sessions each week. Analyses compared outcomes between supported and unsupported phases, adjusted for clustering, period, age group, competition level and region. Results Average weekly Prep-to-Play use by teams was 13.1% (95% CI 11.5% to 14.9%) in the unsupported and 29.7% (95% CI 27.6% to 31.9%) in supported phase (OR 3.7 95% CI 2.4 to 5.7). The concussion and ACL injury incidence (per 1000 game hours) was 6.80 (95% CI 5.75 to 8.05) and 1.36 (95% CI 0.98 to 1.89) in unsupported, and 3.50 (95% CI 2.72 to 4.52) and 0.69 (95% CI 0.44 to 1.15) in supported, respectively, but the effect of supported implementation on injury incidence was unclear (concussion: incidence rate ratios (IRR) 1.36; 95% CI 0.74 to 2.49; ACL: IRR 2.27 (0.56 to 9.12). Higher Prep-to-Play adherence was associated with fewer total injuries (IRR: 0.95 95% CI 0.92 to 0.99). Conclusions Supported implementation via in-person workshops and support visits was associated with greater Prep-to-Play use compared with unsupported implementation, and greater adherence was associated with fewer injuries. Trial registration number NCT04856241.

Context : Women’s participation in Australian Football has increased rapidly since the Australian Football League’s Women’s launch in 2017. We aimed to describe the sociodemographic factors as well as general medical and women-specific health factors in women playing community-level Australian football. We also sought to investigate the relationship between sociodemographic factors and women’s health conditions. Design : Cross-sectional survey. Methods : Participants were community Australian football players enrolled in a stepped-wedge randomized controlled trial evaluating an injury prevention program for community women’s Australian football. The player surveys were completed online via REDCAP ^® . Data were collated and summarized as frequencies and percentages or means and standard deviations as appropriate. Results : The most common women’s health-specific issues were irregular or absent periods (23.9%) (n = 435), polycystic ovarian syndrome (4.8%) (n = 88), endometriosis (3.6%) (n = 66), and pelvic floor dysfunction (eg, leaking urine when exercising) (3.5%) (n = 34). A total of 478 women (25.6%) (95% CIs, 23.7%–27.7%) reported a history of breast injury. Of these, 385 (80.5%) resulted in pain, 179 (37.4%) in bruising, 18 (3.8%) in swelling, 11 (2.3%) in decreased performance, and 13 (2.7%) in other symptoms. Higher body mass index was associated with a history of breast injury (odds ratio 1.03, 95% CIs, 1.01–1.05, Z = 2.79). Six players reported being pregnant, 41 players were breastfeeding, and 27 players reported they had given birth in the last 5 years. More than 10% of players reported that they regularly relied on their care (6% children; 7% other family members). Discussion : Women playing community Australian football reported diverse health experiences, including menstrual irregularities, breast injuries, and conditions such as polycystic ovarian syndrome and endometriosis. A quarter of players reported a history of breast injury resulting in pain, bruising, and decreased performance. These findings highlight the importance of understanding and addressing women-specific health needs to enhance participation, retention, and well-being in community football.

Objective To synthesise evidence related to the dissemination and implementation (D&I) of injury prevention interventions for female, woman and/or girl (female/woman/girl) athletes. Design Scoping review. Data sources MEDLINE, APA PsycInfo, Cochrane Databases for Systematic Review, Cochrane Central Register for Controlled Trials Registry, EMBASE, CINAHL, SPORTDiscus, ERIC, ProQuest Dissertation and Theses Global. Eligibility Primary research including ≥25% female/woman/girl athletes of any age or people working with them (eg, coaches), participating in sports competition and/or performance, were eligible. Papers reporting D&I outcomes (eg, coach knowledge, adoption and maintenance) related to an injury prevention intervention and/or a factor (eg, coach beliefs) associated with D&I outcomes were included. Results 220 papers with 419 494 participants (96 790 athletes (49% female/woman/girl), 277 923 coaches (59% working with females/women/girls) and 44 781 others) across 81 sports were included. 89% of the papers were from Europe, Oceania and North America. Papers included amateur (n=175), sub-elite (n=10), elite (n=63) and Para sport (n=2) athletes. Interventions were training strategies (n=113), personal protective equipment (PPE, n=41), policy/rules/laws (n=5) or other (n=61, eg, multimodal). There were >650 D&I outcomes; adoption was the most common, followed by athlete and coach perceptions and attitudes about injury prevention. Key facilitators of D&I were previous injury experience, higher competition levels and positive perceptions and attitudes. Conclusion Most studies on D&I of injury prevention interventions for female/woman/girl athletes were descriptive and related to athletes and coaches. Engaging people across the socio-ecological system (eg, parents, health professionals and administrators) and prioritising under-represented regions, populations and D&I-focused trials may enhance D&I outcomes and ultimately reduce injury risk in female/woman/girl athletes.

Objective Our aim was to investigate (1) gender representation, (2) opportunities and training and (3) harassment experiences in Sport and Exercise Medicine (SEM) practitioners working in elite sport in Australia. Methods All titled Australian Physiotherapy Association Sport and Exercise Physiotherapists, SEM Physicians and Registrars and doctors and physiotherapists (SEM practitioners) currently/previously/aspiring to work in Australian elite sport were invited to participate in a bespoke online survey and the Gender Experiences Questionnaire. Results For SEM practitioners currently working in elite sport, men worked more paid hours each week (mean difference (MD) 12.2 (95% CI 5.5 to 19.0)) and more paid weeks each year (MD 6.8 (95% CI 1.2 to 12.5)). Women SEM practitioners (both currently and previously) were more likely than men to work with women, rather than men athletes. All women SEM practitioners experienced significantly more gender harassment, infantilisation, work/family policing and gender policing than men. For SEM practitioners (both current and previous), there were no gender differences in how practitioners found out about or were recruited to their elite sports roles. Women were four times more likely than men to report that their gender or sexual orientation influenced their opportunities in elite sport. Most roles were not advertised with direct approach being the most common method of job recruitment. Conclusion Women SEM practitioners currently working in elite sport worked less paid hours per week and less paid weeks per year. All SEM practitioners were appointed to positions without established procedures, and there were significant challenges for women SEM practitioners in the elite sport workplace with women facing considerably more gender harassment than men.

Background Adherence to injury prevention programmes may improve with greater end-user involvement and application of implementation frameworks during development. We describe the cocreation, initial dissemination and feedback from programme early adopters (coaches), to develop the first evidence-informed injury prevention programme for women playing community Australian Football (Prep-to-Play). Methods We used a pragmatic seven-step process for developing sports injury prevention programmes to (1) gain organisational support, (2) compile research evidence, (3) consult experts, (4) engage end-users, (5) test programme acceptability, (6) evaluate against theory and (7) gain early adopter feedback. All Australian Football-registered coaches of women’s/girls’ teams were sent a postseason survey to determine initial awareness, adoption and implementation (steps 5 and 6). Purposively selected coaches were invited to interviews/focus groups (step 7) to identify competency, organisational and leadership implementation drivers with a deductive thematic analysis applied. Results Prep-to-Play was cocreated using previous efficacious programmes and expert input (steps 1–4), and disseminated via the national sporting organisation in preseason 2019 to all registered coaches (step 5). 343 coaches (90 women) completed the postseason survey and 22 coaches (5 women) participated in an interview (n=9) or focus group (n=13) (steps 6 and 7). 268 coaches (78%) were aware of Prep-to-Play. Of those aware, 218 (81%) had used (at least one element) Prep-to-Play, and 143 (53%) used it at least twice per week. Competency drivers included local expert-delivered face-to-face workshops complimented by online content and ongoing support. Organisational drivers included coach education integrated into existing league/club. Leadership drivers included compulsory injury prevention education integrated into coach reaccreditation processes or incentivisation via recognition (eg, professional development points). Conclusions Cocreation and organisational support resulted in high programme awareness and adoption. However, high fidelity implementation and maintenance may need to be facilitated by competency, organisational and leadership drivers. Responsibility should be shared among all stakeholders.

Objectives We evaluated the implementation of Prep-to-Play PRO, an injury prevention programme for women’s elite Australian Football League (AFLW). Methods The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of Prep-to-Play PRO were assessed based on the proportion of AFLW players and/or staff who: were aware of the programme (R), believed it may reduce anterior cruciate ligament injury (E), attempted to implement any/all programme components (A), implemented all intended components as practically as possible (I) and intended future programme implementation (M). Quantitative and qualitative data were triangulated to assess 58 RE-AIM items (evidence of yes/no/unsure/no evidence) and the 5 RE-AIM dimensions (fully achieved=evidence of yes on >50% dimension items, partially achieved=50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, or not met=evidence of yes on Results Multiple sources including AFLW training observations (n=7 total), post-implementation surveys (141 players, 25 staff), semistructured interviews (19 players, 13 staff) and internal programme records (9 staff) contributed to the RE-AIM assessment. After the 2019 season, 8 of 10 (80%) AFLW clubs fully met all five RE-AIM dimensions. All 10 clubs participating in the AFLW fully achieved the reach (R) dimension. One club partially achieved the implementation (I) dimension, and one club partially achieved the effectiveness (E) and adoption (A) dimensions. Conclusion The Prep-to-Play PRO injury prevention programme for the AFLW achieved high implementation, possibly due to the programme’s deliberately flexible approach coupled with our pragmatic definition of implementation. Engaging key stakeholders at multiple ecological levels (organisation, coaches, athletes) throughout programme development and implementation likely enhanced programme implementation.

Objective: Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury.Design: Systematic review with meta-analysis.Data sources: Seven databases were searched in December 2021.Eligibility criteria: Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury.Results: We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%–25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1–5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5–10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (20.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from −0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI −0.05 to 0.02) to −0.31 (KOOS-sport and recreation, 7 studies, 95% CI −0.36 to –0.26).Conclusions: Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls.PROSPERO registration number: CRD42021205998.

Objectives: We aimed to determine (1) the proportion of women authors overall, in first (lead) and last (senior) author positions, (2) the proportion of women research participants and (3) the association between women in first and/or last author positions and the proportion of women research participants in original research articles and editorials/opinion pieces in four sport and exercise medicine/physiotherapy journals.Methods: The journals evaluated were theBritish Journal of Sports Medicine,Journal of Orthopaedic and Sports Physical Therapy,Physical Therapy in SportandInternational Journal of Sports Physical Therapy.We reviewed all original research articles and editorials/opinion pieces published in 2008, 2009, 2018 and 2019. For each, we aimed to determine the gender/sex of all authors (through gender pronouns, Google Scholar, ResearchGate, institutional profiles, personal websites, photographs and/or social media), and the gender/sex of study participants reported as ‘female’ or ‘male’ or ‘women’ or ‘men’ or ‘girls’ or ‘boys’.Results: We included 952 original studies and 219 editorials/opinion pieces. There were 5146 authors of original studies and 706 authors of editorials/opinion pieces. Compared with 2008/2009, the proportion of women as first and last authors was 3.6% (33.0% compared with 29.4%) and 4.8% (33.2% compared with 27.4%) higher respectively in 2018/2019. On average, the proportion of women participants in original studies remained largely unchanged over the 10-year period, only 10% of all participants were women in studies.Conclusion: Women are strikingly under-represented in first and last author positions, as are women participants in sports and exercise medicine/physiotherapy journals.

Background: Little is known about muscle morphology in people with hip-related pain, without signs of femoro-acetabular impingement syndrome (FAIS). Identifying changes in hip muscle volume, fatty infiltrate and establishing relationships between muscle volume and strength, may provide insight into potential early treatment strategies. Purposes: To: (i) compare the volumes and fatty infiltrate of gluteus maximus, gluteus medius, gluteus minimis, tensor fascia latae and quadratus femoris between symptomatic and less-symptomatic sides of participants with hip-related pain; (ii) compare the volumes and fatty infiltrate of hip muscles between healthy controls and symptomatic participants; and (iii) explore relationships of hip muscle volumes to muscle strength and patient-reported outcome measures in people with hip-related pain. Study Design: Cross-sectional study Methods: Muscle volume and fatty infiltrate (from magnetic resonance imaging), hip muscle strength, patient-reported symptoms, function and quality of life (QOL) were determined for 16 participants with hip-related pain (no clinical signs of FAIS; 37±9 years) and 15 controls (31±9 years). Using One Way Analysis of Co-Variance tests, muscle volume and fatty infiltrate was compared between the symptomatic and less-symptomatic sides in participants with hip-related pain as well as between healthy controls and symptomatic participants. In addition, hip muscle volume was correlated with hip muscle strength, hip-reported symptoms, function and QOL. Results: No differences in all the studied muscle volumes or fatty infiltrate were identified between the symptomatic and less-symptomatic hips of people with hip-related pain; or between people with and without hip-related pain. Greater GMED volume on the symptomatic side was associated with less symptoms and better function and QOL (ρ=0.522-0.617) for those with hip-related pain. Larger GMAX volume was associated with greater hip abduction and internal rotation strength, larger GMED volume was associated with greater hip extension strength, and larger QF volume was associated with greater hip abduction strength (rho=0.507-0.638). Conclusion: People with hip-related pain and no clinical signs of FAIS have hip muscle volumes that are not significantly different than those of matched pain-free controls or their less-symptomatic hip. Larger GMED muscle volume was associated with fewer symptoms and greater strength. Level of evidence: Level 3a