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ORIGINAL ARTICLE
Year : 2020  |  Volume : 20  |  Issue : 2  |  Page : 48-54

Knowledge and practice of FIFA warm-up protocols among Saudi Athletes participated during the 5th Islamic Solidarity Games (Baku 2017) and its relations to events musculoskeletal injuries


1 Department of FCM, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2 Department of Physical Therapy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
3 Saudi Federation of Sport Medicine, Riyadh, Saudi Arabia

Date of Submission26-Jul-2020
Date of Decision25-Aug-2020
Date of Acceptance03-Dec-2020
Date of Web Publication20-Jan-2021

Correspondence Address:
Dr. Mohammed Hakami
Department of FCM, PSMMC, Riyadh
Saudi Arabia
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DOI: 10.4103/sjsm.sjsm_16_20

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  Abstract 

Background: Overall, participating in high level competition carries a high risk of injuries. Conventionally, proper warming up can decrease injury rate; however, there was no evidence based warm up protocol until 2006 when FIFA developed the warm up Program based on many randomized studies to prevent injuries. The FIFA medical research center developed FIFA 11+ Program to reduce injuries in football. The FIFA 11+S program was built according to the FIFA 11 + program and focused on preventing shoulder injuries for a goalie. The FIFA 11+ and FIFA11+S program has also been investigated in other sports and shows a significant decrease in injuries; they are a complete warm-up program with running exercises followed by specific preventive exercises focusing on core strength, balance, and agility. In this study, we assumed there is low adoption of this protocol among athletes, and there is a need to increase self-awareness of this protocol's outcomes.
Methodology: Demonstrated FIFA 11+ and FIFA 11+S warm up components were shown to the athletes to assess their adherence. We also recorded the injuries among the athlete using the International Olympic Committee surveillance form for a daily report of injuries; then, we compared the adherence results and injury results using the Pearson Correlation Analysis Formula to find any association.
Results: The warm up protocol data suggest low adherence giving a low percentage during the descriptive analysis of the warm up components; there was also a statistically significant correlation between the data of FIFA 11 + and the injured body part with a significant P-value of 0.037.
Conclusion: Implementing FIFA 11+ and FIFA 11+ are not easy, but it is crucial giving low awareness of those exercises by athletes and its associations with injuries during the Baku 2019 Olympic Games.

Keywords: Compliance, FIFA 11+, FIFA 11+S, implementation, prevention, sports injuries, warm-up


How to cite this article:
Hakami M, Muaidi Q, Aldukhail A, Afifi A, Kofi M, Al-Otaibi A. Knowledge and practice of FIFA warm-up protocols among Saudi Athletes participated during the 5th Islamic Solidarity Games (Baku 2017) and its relations to events musculoskeletal injuries. Saudi J Sports Med 2020;20:48-54

How to cite this URL:
Hakami M, Muaidi Q, Aldukhail A, Afifi A, Kofi M, Al-Otaibi A. Knowledge and practice of FIFA warm-up protocols among Saudi Athletes participated during the 5th Islamic Solidarity Games (Baku 2017) and its relations to events musculoskeletal injuries. Saudi J Sports Med [serial online] 2020 [cited 2021 Mar 7];20:48-54. Available from: https://www.sjosm.org/text.asp?2020/20/2/48/307519




  Introduction Top


Since 1980, the prevention programs were started gradually; they began to focus on training by improving coaches and athlete awareness of warm-up, regular cooldown, taping unstable ankles, promoting the spirit, and set of exercises that improved coordination, stability, flexibility, and strength.[1]

FIFA 11+ program was developed by the FIFA medical research center to reduce injuries in football.[2] It is a 15–20 min dynamic warm-up program used before training and games. The FIFA 11+ and FIFA 11+S program has also been investigated in other sports and shows a significant decrease in injuries. They are a complete warm-up program with running exercises, followed by specific preventive exercises focusing on core strength, balance, and agility.[3]

Here are more details regarding the FIFA 11+ and FIFA 11 + S: The FIFA 11+ developed to prevent lower extremity injuries among football players; it is divided into three parts: initial and final running exercises with a middle focusing exercises on cutting, jumping, landing techniques, strength, plyometric agility, and balance.[3]

The FIFA 11+shoulder program is also structured into three parts: general warm-up exercises, followed by exercises to improve strength and balance of the shoulder, elbow, wrist, and finger muscles, followed by advanced exercises for core stability and muscle control.[4]

Both FIFA 11+ and FIFA 11+Shoulder warm-up exercises were selected based on recommendations from several studies that showed that high adherence to a neuromuscular injury prevention program improves functional balance and reduces injury risk.[5],[6]

Several randomized clinical trials showed that teams performing the FIFA 11 + at least twice a week (as a standard warm-up before their training) had 37% fewer training injuries and 29% fewer match injuries; also, they found that severe injuries were reduced by almost 50%. Another study showed a decreased proportion of injuries to 70% in athletes using FIFA 11 + and FIFA 11 + S with higher compliance than nonstructural warm-up in the control group 25%.[1],[4],[7]

A study was done on Saudi Arabia professional soccer players during the 2015–2016 seasons, which showed a high incidence of injuries, including knee ligament injuries, hamstring strain, ankle sprains, and contusions.[8] However, there are limited data about the incidence rate and prevalence of injuries among different types of sports, but we assume that it is highly based on several reports from team physicians.

In this study, we evaluated the knowledge and practice of Saudi participants during the Islamic Solidarity Games in Baku 2017 to FIFA 11+ and FIFA 11+S warm-up protocol, and then, we tried to see if that correlated to the injury rate during the events.

We were assuming that there is a lack of awareness of those structured warm-up protocols. A recent study showed that the injuries in Saudi professional league clubs' players were higher than the Australian professional league clubs' players. They suggested that the reason could be due to poor implementation of the FIFA 11+ warm-up protocol in Saudi Arabia to Australia.[9] However, no studies directly correlated the compliance of FIFA 11+ and FIFA 11+S warm-up protocol to the sports injuries among Saudi athletes.

We assume that there is low adoption of this protocol among athletes, and there is a need to increase self-awareness of this protocol's outcomes. The hypothesis here is that Saudi athletes have a poor understanding and implication of preventive warm-up programs before activities are related to a high prevalence of musculoskeletal injuries. The research question was: does low adherence of Saudi athletes to FIFA 11+ and FIFA 11+S warm-up program before activities directly correlate to musculoskeletal injuries?


  Methodology Top


Around 154 Saudi athletes have participated in Solitary Islamic Games Baku 2017. Using data from the previous literature review works, we know the P1 (injury reduction among players using FIFA 11 + and FIFA 11 + S can reach 70%) and P2 (injury reduction among players using nonstructured warm-up program can get around 25%).

It is worth mentioning here that we cannot say that the poor implementation of warm-up protocol was the only culprit of the high injury rate. Other factors may explain that, such as: poor preparation before tournaments and poor recovery after exercises.



Using a comprehensive sampling method, we will interview all participants to increase the power of the study. The data collection instrument was a structural questionnaire interview with FIFA 11+ and FIFA 11+S steps with a demonstration of the applicable steps [Table 1] and [Table 2].
Table 1: FIFA 11+warm-up protocol

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Table 2: FIFA 11+S warm-up protocol

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Before we conducted the study, we did a pilot test of the questionnaire on a small sample; based on the feedback, we decide to demonstrate every step of the FIFA 11+ and FIFA 11+S to the participants during the interview. We documented answers such as Yes if the athlete used specific exercise steps during his warm-up at least twice per week and No if the athlete did not.

The athletes' event's injuries and game information were collected by the International Olympic Committee (IOC) surveillance form for a daily report of injuries and illness. Basically, the IOC surveillance form is a sports-specific coding system used to classify sports injuries in ways different little bit from the International Classification of Diseases coding system [Table 3].[10]
Table 3: International Olympic Committee sports-specific coding system of daily injury reports*

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The IOC Daily Report of Injuries form was used by a group of experts in the 2008 Beijing games and other Olympic activities. Further development of this IOC form was done before the 2010 Vancouver Olympic and 2012 London Olympic Games.[11] The IOC Daily Report on Injuries form was filled by the medical team doctor along with FIFA 11+ and FIFA 11+S questionnaire.

We used FIFA 11+ for football, handball, basketball, and athletics games, which benefits more from warm-up exercises targeting core and lower extremities such as runners, hurdle race, and long jump. In contrast, we used FIFA 11+S for volleyball, wrestling, judo, water polo, tennis, soccer/handball goalie, athletics who need exercises targeting core and upper extremities such as hammer throw, pole vault, shot put, and discus throw [Table 4].
Table 4: Participated Olympic Sports List Baku 2017

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We used this based on the best available evidence at the study's point during the Baku 2017 Olympic Games. We know that games with a high repetitive load on the shoulder, such as discus throw, should benefit from FIFA 11+S warm-up programs. In contrast, games with increased load on lower extremities such as long jump athletes prone to pull hamstring injuries may benefit more from FIFA 11+ warm-up protocol. Since we know, FIFA 11+ has Nordic exercises that reduce the injuries of hamstring injuries, for example.

The statistical package SPSS 22 (SPSS Inc/IBM, Chicago, Illinois) was employed to analyze the data; we used descriptive analysis for our data and the Pearson Formula of Association to see the associations between injury report and FIFA 11+ and FIFA 11+S protocol.

The questionnaire data were entered into the statistical package (SPSS version 22) after recording the questions. There was no incomplete form since all the interviewed participants showed excellent cooperation.

We used descriptive analysis by calculating the percentage of answers among FIFA 11 + and FIFA 11 + S sections; then, we calculate the rate of injuries and injured body parts using the IOC Injuries form. After that, we used the Pearson Formula of Association test to find if there is any correlation.

The ethical process was taken before interviewing athletes; the participants were asked for their permission before filling the questionnaire. We explained the study's nature to the participants and the importance of this study to help prevent injuries in the future; also, we informed the participants of their rights to stop proceeding at any point. We also had the approval from the ethics department before we conduct the study.


  Results Top


Overall, the rate of injuries was higher in weightlifters, athletics, and football players [Table 5]. Surprisingly, most of the injuries happened during training sessions rather than during competitions [Table 6].
Table 5: Rate of injuries

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Table 6: Time of injury (training or round)

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During the events, knee was the most affected injured part, followed by the shoulder and then thigh [Table 7]. The most common reported injuries were muscle spasm, strains, and tendon injuries [Table 8].
Table 7: Injured body part

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Table 8: Type of injuries

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Our theory was the less application to warm-up protocols, the more injuries. The first part of the theory was proven right, giving a low adherence percentage during the descriptive analysis of the warm-up steps [Figure 1] and [Figure 2].
Figure 1: Adherence to FIFA 11+ protocol

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Figure 2: Adherence to FIFA 11 + S protocol

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[Table 9] and [Table 10] prove our second theory; those injuries were correlated to athletes' low adherence to the warm-up protocols; statistically, there was a very significant P value of 0.037 between FIFA 11+ warm-up protocol and injured body parts.
Table 9: There is a statistically significant relationship between the injured body part and low adherence to FIFA 11+protocol

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Table 10: There was no statistically significant relationship between FIFA 11+S, type of injury, and cause of injury and injured body part

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Limitations

Recently, the Norwegian High-Performance Center, in cooperation with the National Sports Federation, launched several individualized, structured warm-up protocols that fit various types of Olympic Sports.[12] Unfortunately, this was unknown during the Baku 2017 study; otherwise, we will use it instead of only FIFA 11+ and FIFA 11+S. More importantly, we noticed that most of the athletes' injuries were due to overuse and not having enough recovery time [Table 11]. Most of the injuries happened during training rather than rounds [Table 6]. Not only poor implementations of the preventive warm-up protocols can explain the high injury rate; instant and short training campaigns before the actual tournament contributed to the high injury rate.
Table 11: Cause of injuries

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  Conclusion Top


Our study shows that the warm-up protocol data suggest low adherence giving a low percentage of the warm-up program components; also, there was a statistically significant correlation between the data of FIFA 11+ and the injured body part.

Implementing FIFA 11+ and FIFA 11+S are not easy, but it can be done in a few steps, including the decision of member association, support from the relevant organization, prepare a plan, have funding, produce material (poster, DVD…), train lead coaches, and finally, continuity of monitoring and assessment of implementation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bizzini M, Junge A, Dvorak J. Implementation of the FIFA 11+football warm up program: How to approach and convince the football associations to invest in prevention. Br J Sports Med 2013;47:803-6.  Back to cited text no. 1
    
2.
McKay C, Steffen K, Romiti M, Finch C, Emery C. The effect of exposure to the FIFA 11+warm-up program on injury risk knowledge and prevention beliefs in elite female youth soccer. Br J Sports Med 2014;48:637.  Back to cited text no. 2
    
3.
Bizzini M, Dvorak J. FIFA 11+: An effective programme to prevent football injuries in various player groups worldwide–A narrative review. Br J Sports Med 2015;49:577-9.  Back to cited text no. 3
    
4.
Al Attar WS, Alshehri MA. 309 does the FIFA 11+shoulder injury prevention program reduce the incidence of upper extremity injuries among soccer goalkeepers? A randomised controlled trial. Br J Sports Med 2020;54(Suppl 1):A127.  Back to cited text no. 4
    
5.
Steffen K, Emery CA, Romiti M, Kang J, Bizzini M, Dvorak J, et al. High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in canadian youth female football players: A cluster randomised trial. Br J Sports Med 2013;47:794-802.  Back to cited text no. 5
    
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Soligard T, Nilstad A, Steffen K, Myklebust G, Holme I, Dvorak J, et al. Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med 2010;44:787-93.  Back to cited text no. 6
    
7.
Silvers-Granelli HJ, Bizzini M, Arundale A, Mandelbaum BR, Snyder-Mackler L. Does the FIFA 11+injury prevention program reduce the incidence of ACL injury in male soccer players? Clin Orthop Relat Res 2017;475:2447-5.  Back to cited text no. 7
    
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Muaidi QI. Saudi professional league: A prospective study of the injuries and illnesses sustained by professional soccer players during the 2015-2016 season. Asian J Sports Med 2019;10: e79930. doi: 10.5812/asjsm.79930.  Back to cited text no. 8
    
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Al Attar WS, Najeebullah S, Peter JS, Muaidi QI. Implementation of an evidence-based injury prevention program in professional and semi-professional soccer. Int J Sports Sci Coaching 2018;12:113-21.  Back to cited text no. 9
    
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Orchard JW, Meeuwisse W, Derman W, Hägglund M, Soligard T, Schwellnus M, et al. Sport Medicine Diagnostic Coding System (SMDCS) and the Orchard Sports Injury and Illness Classification System (OSIICS): Revised 2020 consensus versions. Br J Sports Med 2020;54:397-401.  Back to cited text no. 10
    
11.
Engebretsen L, Soligard T, Steffen K, Alonso JM, Aubry M, Budgett R, et al. Sports injuries and illnesses during the London Summer Olympic Games 2012. Br J Sports Med 2013;47:407-14.  Back to cited text no. 11
    
12.
Moksnes H, Engebretsen L. Return to Play Criteria. Return to Play in Football: An Evidence-Based Approach. 2018 Mar 16:139..  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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