Journal of Sports Sciences

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How much, how often, how well? Adherence

to a neuromuscular training warm-up injury
prevention program in youth basketball

Oluwatoyosi B.A. Owoeye , Carolyn A. Emery , Kimberley Befus , Luz

Palacios-Derflingher & Kati Pasanen

To cite this article: Oluwatoyosi B.A. Owoeye , Carolyn A. Emery , Kimberley Befus , Luz
Palacios-Derflingher & Kati Pasanen (2020): How much, how often, how well? Adherence to a
neuromuscular training warm-up injury prevention program in youth basketball, Journal of Sports
Sciences, DOI: 10.1080/02640414.2020.1782578

To link to this article: https://doi.org/10.1080/02640414.2020.1782578

Published online: 26 Jun 2020.

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JOURNAL OF SPORTS SCIENCES
https://doi.org/10.1080/02640414.2020.1782578

SPORTS MEDICINE AND BIOMECHANICS

How much, how often, how well? Adherence to a neuromuscular training warm-up
injury prevention program in youth basketball
a,b
Oluwatoyosi B.A. Owoeye , Carolyn A. Emeryb,c,d,e,f,g, Kimberley Befusb, Luz Palacios-Derflingherb,d
and Kati Pasanen b,c,f,h
a
Department of Physical Therapy and Athletic Training, Doisy College of Health Sciences,, Saint Louis University, Saint Louis, MO, USA; bSport Injury
Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada; cAlberta Children’s Hospital Research Institute, University
of Calgary, Calgary, Canada; dDepartment of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada;
e
Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada; fMcCaig Institute for Bone and Joint Health,
University of Calgary, Calgary, Canada; gO’Brien Institute for Public Health, University of Calgary, Calgary, Canada; hTampere Research Center of Sport
Medicine, UKK Institute, Tampere, Finland

ABSTRACT ARTICLE HISTORY

Adherence is a key implementation outcome that determines the effectiveness of an intervention. This Accepted 4 June 2020
study, an observational design involving coaches and players from 33 high school basketball teams,
KEYWORDS
evaluated the dimensions of adherence to a basketball-specific neuromuscular training (NMT) warm-up Injury prevention; fidelity;
program in youth basketball. Coach adherence (daily report of team adherence) was collected prospec­ youth sport; implementation
tively. Adherence measures: cumulative utilization (proportion of total sessions possible), utilization
fidelity (average # of exercises completed per NMT session), utilization frequency (average # of NMT
sessions completed per week) were calculated and further evaluated for optimal adherence (≥80%, ≥10.4
exercises/session and ≥2 sessions/week, respectively) per coach. Additionally, exercise fidelity (propor­
tion of players performing individual exercises correctly) was assessed. Coach (n = 31; 27–59 years)
median cumulative utilization was 80%, utilization fidelity was 12 (of a possible 13 exercises per session)
and utilization frequency was 2.3 sessions per week. Optimal adherence ranged from 52% to 71% across
measures of adherence. Player exercise fidelity was 48%. Time constraint (47%) was the most frequently
reported adherence barrier. While coach adherence to the NMT warm-up program was reasonably high
across measures of adherence, a considerable proportion of coaches did not attain optimal adherence
levels and player exercise fidelity was low.

Introduction prevention research, adherence is the proper word for describ­

ing the “extent of completion of an intervention as planned” in
Injury occurrence is a significant problem in youth basketball
implementation trials and compliance in traditional rando­
and other youth sports. (Emery et al., 2007; Emery, 2003;
mized controlled trials (McKay & Verhagen, 2016; Owoeye
Owoeye et al., 2017; Owoeye et al., 2012; Pasanen et al., 2017)
et al., 2018). In essence, studies establishing the efficacy of
Exercise-based interventions, including neuromuscular training
NMT warm-up programs have focused on compliance to pro­
(NMT) warm-up programs comprising aerobic, agility, strength
gram in randomized controlled trials (Emery & Meeuwisse,
and balance components are efficacious in mitigating injury
2010; Owoeye et al., 2014; Soligard et al., 2010). While evidence
risk in youth sports (Emery & Meeuwisse, 2010; Emery et al.,
of program compliance is fundamental for the prospective
2007, 2015; Owoeye et al., 2014; Owoeye et al., 2018). However,
implementation of an NMT warm-up program, it does not auto-
the implementation of NMT warm-up programs in real-world
translate to adherence in real-world applications. An extensive
settings remains a challenge and knowledge on how to suc­
understanding of end-user behaviours as per adherence to
cessfully translate these programs in community settings
NMT warm-up programs is essential to optimize implementa­
remain sparse (Bahr et al., 2015; O’Brien & Hagglund, 2018;
tion (Owoeye et al., 2018).
Owoeye, 2013; Wilke et al., 2018).
Adherence is a multidimensional implementation outcome
Adherence is the extent to which an individual’s behaviour
and extends across multiple levels of intervention users, including
corresponds with agreed recommendations from a provider,
coaches and players. Consequently, a comprehensive assessment
health-care practitioner, program developer or an innovator,
of adherence is necessary to gain meaningful insights into pro­
regarding the completion of an intervention (Owoeye et al.,
gram adherence in implementation trials (Owoeye et al., 2018).
2018; WHO, 2003). Adherence is a key implementation out­
Additionally, given the dose-dependent effect of NMT warm-up
come that moderates the effectiveness of NMT warm-up pro­
programs on injury risk (Hägglund et al., 2013; Soligard et al., 2010;
grams in real-world settings (Owoeye et al., 2018). Regarding
Steffen et al., 2013; Steib et al., 2017; Sugimoto et al., 2014, 2012), it
the appropriateness of terminologies in sports injury
is essential to understand the factors associated with optimal

CONTACT Oluwatoyosi B.A. Owoeye [email protected] Department of Physical Therapy and Athletic Training, Doisy College of Health Science,
St. Louis, MO, 63104, USA
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 O. B. A. OWOEYE ET AL.

adherence to these programs. To develop effective strategies from a program previously implemented and tested in youth
towards optimizing adherence to NMT warm-up programs, floorball (Pasanen et al., 2008) and soccer (Emery et al., 2007;
a necessary first step would be to determine the extent to which Emery & Meeuwisse, 2010). The NMT warm-up is a 10 minute
adherence is a problem and identify associated factors (Owoeye program comprising four components of 13 exercises: aerobic
et al., 2018). There are gaps in knowledge related to the degree of (4), agility (2), strength (5) and balance (2). Eleven of the warm-
adherence to NMT warm-up programs and determinants of opti­ up exercises have two levels of progression; players are advised
mal/good adherence. Particularly, detailed and independent pro­ to start at level 1 and progress to level 2 as their fitness level
spective studies are limited. The Adherence Optimization and technique improves. The NMT warm-up was delivered to
Framework recommended by Owoeye et al (Owoeye et al., coaches through a structured 2-hour workshop that comprised
2018). (Figure 1) has advanced the knowledge base in NMT warm- both theoretical and hands-on practical sessions including an
up adherence research and is applicable in the current study. We overview of injury risk and prevention in youth basketball and
examined the first two steps of this framework to better under­ NMT program practical components. Previous studies have
stand the adherence behaviour of coaches and players to shown that a structured coach workshop is a viable implemen­
a basketball NMT warm-up program. Specifically, we evaluated tation strategy for delivering NMT programs (Owoeye et al.,
the dimensions of adherence to the SHRed Injuries (Surveillance in 2017; Steffen et al., 2013). Coaches were instructed to conduct
High Schools to Reduce Injuries) Basketball NMT warm-up pro­ all exercises with as much fidelity as possible and adapt as
gram in youth basketball and examined the barriers to adherence. necessary. Further, coaches were given laminated handouts
Additionally, we explored coach-related factors potentially asso­ summarizing the NMT warm-up and videos as reference mate­
ciated with adherence. rials. Finally, coaches were advised to replace any existing
warm-ups with the NMT warm-up and perform exercises before
every practice and game through the 2017/2018 basketball
Methods
season.
Study design, participants and ethical considerations
This study was an observational design aligned with a cluster- Outcomes and measurements
randomized controlled trial (RCT) investigating two different
delivery methods for the SHRed Injuries Basketball NMT warm- Evaluation of adherence to the NMT warm-up was based on
up, in high schools during the 2017/2018 season. Coaches in three key considerations: (1) adherence is multilevel; (2) adher­
both study groups attended a coach workshop, but with two ence is multidimensional; (3) a minimum level of adherence is
different delivery methods for the NMT warm-up – with or imperative for best intervention effect. Consequently, adher­
without weekly supervision by study staff. The coach cohort ence data were collected at both coach (i.e., team) and player
included all 33 high school male/female basketball head or levels, and were operationalized based on four (applicable to
assistant coaches (one coach per team) who participated in current study) of the five adherence dimensions recommended
the pre-season coach workshop. Eight teams (four from each by Owoeye et al (Owoeye et al., 2018). These measures were:
RCT group – total of 61 players) of the 33 teams were randomly cumulative utilization, utilization fidelity (to evaluate “how
selected through a simple random technique and invited to the much” of the NMT warm-up was done), utilization frequency
player NMT warm-up adherence evaluation. This study was (to evaluate “how often”), for coach adherence and exercise
approved by the Conjoint Health Research Ethics Board of the fidelity (to evaluate “how well”), for player adherence (Table 1).
University of Calgary, Alberta, Canada (Ethics ID: REB16-0864).
Informed consent was obtained from coaches and informed
Coach adherence
consent or parental consent and player assent was obtained
from players at enrolment, as necessary. Coach adherence was based on the daily report of team adher­
ence and was collected prospectively by team designates (a
student trainer or assistant coach volunteer who was respon­
The SHRed injuries basketball neuromuscular training
sible for daily exposure registration). For each practice or game
warm-up program
session, team designates documented whether their team
The NMT warm-up is an evidence-informed program devel­ completed the NMT warm-up (yes/no); which exercises were
oped to prevent injuries in youth basketball players (Emery performed (checklist); individual player attendance; length of
et al., 2015). Components of the NMT warm-up were derived each warm-up session and practice/game duration. Teams

2. Determine predictors of
1. Identify adherence levels
adherence/non-adherence

4. Evaluate the effectiveness of 3. Develop strategies for

adherence strategies improving adherence

Figure 1. Adherence optimization framework as described by Owoeye et al. (2018).

 JOURNAL OF SPORTS SCIENCES 3

were followed up weekly by study personnel to ensure data behavioural intention in coaches and perceived barriers to
completeness and retrieve weekly forms. A threshold of ≥80% implementation, a post-workshop semi-structured question­
cumulative utilization, ≥10.4 (equivalent to ≥80%) exercises naire, based on the Health Action Process Approach Model,
per session (for utilization fidelity), and ≥2 sessions per week was administered to coaches. The questionnaire was adapted
(for utilization frequency) were indicated as “optimal” for from previous studies that have used the Health Action Process
coach/team adherence measures based on current NMT warm- Approach Model in youth soccer coaches and players (McKay
up dose–response literature in youth sport (Hägglund et al., et al., 2016; Owoeye et al., 2017) The adapted questionnaire
2013; Steffen et al., 2013; Steib et al., 2017; Sugimoto et al., underwent rounds of review by the study investigators to
2014). establish content validity and one round of review by two
youth basketball coaches (who did not participate in the
study) for face validity before it was administered to coaches.
Player adherence Questions relating to coach’s behavioural intention to use the
Player adherence was assessed through individual player NMT warm-up program were measured using a 7-point Likert
observation by study physiotherapist who has extensive knowl­ scale comprising negative (1 to 3), neutral (4) and positive
edge of the specific exercises in the NMT warm-up. Data were responses (5 to 7). Specifically, coaches were assessed on their
obtained during a mid-season direct observation of participat­ level of agreement to the following statement in the post-
ing teams. Player adherence was described in terms of exercise workshop questionnaire, separately for practice and game ses­
fidelity (Table 1) following the protocol used by Fortington sions: “I am planning to use the NMT warm-up program with
et al. (Fortington et al., 2015) in a study evaluating exercise my team before every practice/game session during the
fidelity of players to an NMT warm-up program. The study upcoming season”. Coaches selected either “agree” or “strongly
physiotherapist used an observational checklist adapted for agree”, which were interpreted as “moderate” and “high” beha­
the NMT warm-up exercises from a previously validated check­ vioural intentions, respectively, in final analysis. Lastly, coaches
list – the FootyFirst observational tool (Fortington et al., 2015) – were asked to report barriers to the use of the NMT warm-up
to record individual player NMT warm-up exercise perfor­ with their teams in open-ended questions at pre-season (i.e.,
mance. A physiotherapist observation included an assessment after coach workshop) and post-season.
of the essential performance criteria for each exercise (i.e.,
technique, intensity, volume). For example, the essential criteria
for the single-leg jump over a line included: technique – “toe- Statistical analyses
heel” soft landings; intensity – clear jump over line; and Data analysis was completed using STATA 14.2 (StataCorp;
volume – ≥10 repetitions per leg. Players were randomly College Station, TX, USA). Descriptive statistics of median
observed for one or two exercises completed during practice (because of skewed distribution), first (Q1) and third (Q3) quar­
sessions and for the entire warm-up duration. If an essential tiles, range, frequency and proportions (%) were used to sum­
performance criterion was not performed correctly (on every marize measures of adherence, coach and player characteristics
repetition), a “no” was recorded and a reason noted against the and barriers to adhering to NMT warm-up, as appropriate. To
specific criterion, if performed correctly in all criteria, an “overall accurately estimate coach adherence measures, including
yes” was recorded for an observation. examining variabilities in values, calculations were done at
the individual coach level. Specifically, cumulative utilization
proportion was initially calculated for each coach followed by
Assessments of coach-related factors
the median proportion (Q1, Q3) for all coaches. In the case of
The coach baseline questionnaire assessed demographic char­ utilization fidelity and utilization frequency, the average num­
acteristics that comprised factors that potentially predict adher­ ber of NMT warm-up sessions was initially calculated for each
ence behaviour to the warm-up program, including age, years coach and the median of individual coach averages was subse­
of coaching experience, sex, behavioural intention, and levels quently reported for all coaches. Furthermore, individual coach
of education (i.e., academic, technical, medical education). adherence measures were classified as either optimal or sub­
Additionally, the effect of the implementation support by optimal, and the proportion (%) of coaches with optimal adher­
research staff on coach adherence was assessed. To assess ence presented. Given limited coach sample size, several

Table 1. Adherence measures and definitions.

Adherence measure Definition and Calculation
Coach/Team
Cumulative Utilization Proportion of all possible NMT warm-up sessions
- Total # of NMT warm-up sessions reported ÷ total # of basketball sessions reported
Utilization Fidelity Average # of exercises completed per NMT warm-up session
- Total # of warm-up exercises completed ÷ total # of NMT warm-up sessions reported
- Per component: Total # of NMT warm-up component exercises completed ÷ total # of NMT warm-up sessions reported
Utilization Frequency Average # of NMT warm-up sessions completed per week
- Total # of NMT warm-up sessions completed ÷ total # of basketball weeks reported
Player
Exercise Fidelity Overall proportion of physiotherapist observations in which players performed all aspects of specific NMT warm-up exercises
correctly based on set performance criteria for each exercise
4 O. B. A. OWOEYE ET AL.

factors could not be evaluated at the same time to explore adherence barrier to the program was time constraint (47%).
associations between measures of adherence and coach- Other barriers included limited space and perceived lack of
related factors in multivariable analyses; rather, descriptive player interest (Table 4).
statistics were calculated to describe factors potentially asso­ Younger coaches [median (Q1, Q3): 36 (30, 45) vs. 45 (37, 57)
ciated with adherence to NMT warm-up. years] and coaches with fewer years of experience [median (Q1,
Q3): 5 (2, 15) vs. 16 (8, 27) years] had optimal utilization fidelity.
A higher proportion of female (vs. male) coaches had optimal
Results
adherence in all three measures of utilization. A higher propor­
Thirty-one coaches (13 females, 18 males; 27–59 years) of 33 tion of coaches that expressed high intention (vs. moderate
eligible high school basketball coaches that had completed intention) had optimal cumulative utilization (69% vs. 36% for
coach information and prospective team adherence data practices and 73% vs. 33% for games) and utilization frequency
were included in final analysis for coach adherence. Two of (75% vs. 55% for practices and 80% vs. 50% for games). A lower
the eight teams randomly selected for exercise fidelity observa­ proportion of coaches that expressed high intention had opti­
tions for player adherence evaluation were excluded because mal utilization fidelity (63% vs. 91% for practices and 67% vs.
they did not perform the NMT warm-up on the days they were 83% for games) (Table 5a-c).
visited; thus, a total of 63 observations from 45 players [6 teams;
29 (64%) female players; 14–18 years] were analysed for player
Discussion
adherence.
Coach adherence to the NMT warm-up is presented in This is the first study to conceptualize the evaluation of adher­
Table 2. Coach median (Q1, Q3) cumulative utilization was ence to reflect its complexity as a multilevel and multidimen­
80% (48%, 96%), utilization fidelity was 12 of 13 (10,13) sional implementation outcome, as well as an NMT warm-up
possible exercises per warm-up session and utilization fre­ program effectiveness determinant. Our study addressed
quency was 2.3 (1.6, 3.1) sessions per week. In total, 52% to important gaps in previous studies (Fortington et al., 2015;
71% of coaches/teams had optimal adherence across mea­ Perera & Hägglund, 2020; Steffen et al., 2013; Steffen et al.,
sures of adherence. Adherence measures were similar across 2013), including the limitations of assessing adherence at
supervised and unsupervised delivery methods, except opti­ a single end-user level and not conceptualizing adherence
mal cumulative utilization. More coaches in the supervised (optimal vs. suboptimal) in the context of program effective­
group had optimal cumulative utilization compared to the ness. We explored the first two steps in the Adherence
unsupervised group (59% vs. 43%). Stratifying coach adher­ Optimization Framework proposed by Owoeye et al (Owoeye
ence by session type, coach median (Q1, Q3) cumulative et al., 2018) (Figure 1). This involved determining adherence to
utilization was 91% (67%, 100%) for practice and 69% (30%, the program, using appropriate metrics of adherence, at the
89%) for games, resulting in an optimal cumulative utilization coach and player levels, and evaluating factors potentially
proportion of 74% (n = 23/31) for practices and 39% (n = 12/ associated with optimal adherence. In this study, specific mea­
31) for games. sures of coach adherence were estimated per coach/team to
Details of player adherence are presented in Table 3. reflect variability in adherence estimates and to determine
Essential performance criteria were met for 30/63 observations whether each team reached an optimal adherence threshold.
from 45 players, yielding an exercise fidelity of 48%. Previous studies have examined all adherence/compliance
Based on utilization fidelity, aerobic and agility exercises counts (numerators) and all sessions of exposure (denominator)
were more frequently performed compared to strength and from all teams together (Hägglund et al., 2013; Owoeye et al.,
balance exercises (Figure 2). The most frequently reported 2014; Silvers-Granelli et al., 2018; Soligard et al., 2008; Steffen
et al., 2013; Steffen et al., 2013; Vriend et al., 2015).
A high cumulative utilization, utilization fidelity and utiliza­
Table 2. Coach adherence to the SHRed injuries basketball neuromuscular train­
ing warm-up program. tion frequency were reported. Our findings are comparable
All Coaches Supervised Unsupervised with previous studies that used similar adherence definitions
(Overall) (N = 31) (N = 17) (N = 14) (Steffen et al., 2013; Steffen et al., 2013). Further analysis of
Cumulative Utilization coach adherence measures, based on optimal adherence
Median (Q1, Q3) (%) 80 (48, 96) 80 (56, 97) 75 (37, 92) thresholds, revealed that a substantial proportion of coaches
range: 16–100 range: range:
32–100 16–100 did not conduct the NMT warm-up to the level expected to
Optimal (coaches with 16 (52) 10 (59) 6 (43) evoke optimal injury risk reduction. Twenty-nine to 48% of
≥80%), n (%) coaches/teams did not attain optimal adherence across the
Utilization Fidelity
Median (Q1, Q3) (per 13 12 (10, 13) 12 (10, 13) 11 (10, 12) measures of adherence evaluated and the NMT warm-up was
exercises) range: 5–13 range: range: 5–13 less often performed before games. Similarly, player adherence,
6–13 measured as exercise fidelity (48%), is lower than results from
Optimal (coaches with 22 (71) 12 (71) 10 (71)
≥10.4), n (%) Fortington et al. (reported an exercise fidelity of 67%)
Utilization Frequency (Fortington et al., 2015) and Perera and Hagglund (58%)
Median (Q1, Q3) (per 2.3 (1.6, 3.1) 2.4 (1.8, 2.9) 2.2 (1.2, 3.1) (Perera & Hägglund, 2020). In this study, we allowed coaches
week) range: 0.5–4.7 range: range:
0.9–4.1 0.5–4.7 to modify the program to suit their practice and game settings.
Optimal (coaches with 20 (65) 11 (65) 9 (64) This may have substantially impacted their delivery of the
≥2), n (%) program to their players. Observed differences in exercise
 JOURNAL OF SPORTS SCIENCES 5

Table 3. Player exercise fidelity to the SHRed injuries basketball neuromuscular Table 4. Barriers to implementing the SHRed injuries basketball neuromuscular
training warm-up program. training warm-up program.
# of observa­ Essential performance cri­ *Frequency
Exercise tions* teria met – # of “yes” Projected barriers [pre-season (n = 23)] (%)
Aerobic Time constraints 15 (47)
1 Forward run 6 5 Limited space# 9 (28)
2 Forward run with backward 6 3 Perceived lack of player commitment/interest 4 (13)
variations Limited resources such as balls for players 2 (6)
3 Skipping forward-backward 6 3 None 2 (6)
/sideway Actual barriers [post-season (n = 10)]
4 Forward run with 2 1 Time constraints 7 (50)
progressing speed “Time was an issue especially with late games. We would be
Agility able to complete it all with space but it took a good 10 minutes
5 Single leg jumps over a line 5 1 in order to complete.”
6 Squat/skate jumps 5 1 “It was difficult to get it incorporated at the very beginning of
Strength the season, as we only have 6 practices before our first
7 Planks 4 2 competition and I was not prepared to dedicate large amounts
8 Side planks 5 5 of practice time to teaching the NMT warm-up. I felt better
9 Hamstrings 3 2 about it by the second week of the season.”
10 Walking lunges 6 1 “Warm-ups take too long.”
11 Side lunges 5 1 Space 4 (29)
Balance “Hard to do at tournaments.”
12 Single-leg balance with 5 2 “At away games they didn’t like doing the activities in the
torso rotation/ball roll hallways.”
13 Single-leg balance with ball 5 3 Lack of player commitment/interest 2 (14)
toss/jump catch “The boys on the team wouldn’t take it serious or would rather
All Observations 63 30 be doing their own thing . . . At away games they didn’t like
Exercise Fidelity 48% doing the activities in the hallways.”
*All exercise components were intended for observation and evaluation in each “Players found some exercises to be not enjoyable and
team (total of six teams – random player evaluation); however, some teams did irrelevant (hamstring lowers, etc.).”
not perform specific exercises, hence the total observations is <6 in some cases. None 1 (7)
*Some coaches gave multiple responses
#
5 of the 9 coaches specifically mentioned busy/limited hallway space before
games

constraints and lack of player interest. For example, a coach

specifically mentioned that “Players found some exercises to be
not enjoyable and irrelevant”. Coaches are likely to conduct
exercises they perceive as most relevant to performance in
the face of limited time. Existing literature suggests that the
implementation of exercise-based injury prevention programs
is rarely completed in their original form as exercises are usually
adapted to fit context (Fortington et al., 2015; Frank et al., 2015;
AEROBIC AGILITY STRENGTH BALANCE
EXERCISES EXERCISES EXERCISES EXERCISES
O’Brien et al., 2017). Ensuring a balance between adherence
and adaptation is imperative to maintain program
Figure 2. Utilization Fidelity Proportions (%) for the SHRed Injuries Basketball effectiveness.
Neuromuscular Training Warm-up Components.
Consistent with previous studies investigating barriers to
implementing exercise-based injury prevention programs,
time constraints were the top adherence barrier reported by
coaches (Donaldson et al., 2018; Donaldson et al., 2019; McKay
fidelity values may also be due to disparities in implementation
et al., 2016; O’Brien & Finch, 2017; Richmond et al., 2020).
contexts (Owoeye et al., 2018). The extent to which the various
Additional barriers to adherence included space and perceived
dimensions of adherence impacts the injury prevention effects
lack of player interest. Efforts geared towards addressing spe­
of the NMT warm-up program is unknown and beyond the
cific factors are warranted. Considering current evidence sup­
scope of this study.
porting the effectiveness of structured pre-implementation
Adherence to strength and balance exercises was poorest,
coach workshop intervention on coaches’ behavioural inten­
compared to aerobic and agility components, similar to pre­
tion and self-efficacy (McKay et al., 2016; Owoeye et al., 2017),
vious studies where adherence to strength exercises was poor
providing extensive information on injury risk and conse­
(e.g., Nordic hamstrings) (Bahr et al., 2015; O’Brien et al., 2017).
quences during coach workshops may improve program
The completion of distinct exercises by coaches/teams is
adherence in coaches. This may influence coaches’ decisions
important for optimum injury prevention effects. While
on training schedules that effectively incorporate an NMT
research is still lacking, it appears that core components of an
warm-up program. Post-season qualitative responses from coa­
NMT warm-up (considering dose–response effects) are impor­
ches suggest an interaction among the three key barriers to
tant to complete (e.g., agility, strength, balance). Reduced uti­
adherence (time, space and player interest). For example, coa­
lization fidelity to strength and balance exercises may be linked
ches stated that: “Time was an issue especially with late games
to the barriers highlighted by coaches, including time
and hard to do at tournaments;” “At away games players didn’t
6 O. B. A. OWOEYE ET AL.

Table 5. Descriptive analyses of coach-related factors associated with adherence to the SHRed injuries basketball neuromuscular training warm-up program.
(a) Cumulative Utilization
Variable Optimal (N = 16) Suboptimal (N = 15)
Age [median (Q1, Q3)], years 40 (31, 45); 38 (28, 51)
range: 30–57 range: 27–59
Coaching Experience [median (Q1, Q3)], years 9 (4, 18) 10 (3, 22)
range: 1–25 range: 1–30
Sex, n (%) Female: 8 (62) Female: 5 (38)
Male: 8 (44) Male: 10 (56)
Intention-Practices, n (%)* High: 11 (69) High: 5 (31)
Moderate: 4 (36) Moderate: 7 (64)
Intention-Games, n (%)* High: 11 (73) High: 4 (27)
Moderate: 4 (33) Moderate: 8 (67)
Academic Education, n (%) Graduate: 14 (52) Graduate: 13 (48)
Undergraduate: 2 (50) Undergraduate: 2 (50)
Technical Education, n (%) None: 7 (58) None: 5 (42)
Community Coaching: 3 (30) Community Coaching: 7 (70)
Competition Introduction: 4 (57) Competition Introduction: 3 (43)
Competition Development: 2 (100) Competition Development: 0 (0)
Medical Education, n (%)** Yes: 5 (45) Yes: 6 (55)
No: 7 (47) No: 8 (53)
*N = 15 and 12 for optimal and suboptimal categories, respectively
**N = 12 and 14 for optimal and suboptimal categories, respectively
(b) Utilization Fidelity
Variable Optimal (N = 22) Suboptimal (N = 9)
Age [median (Q1, Q3)], years 36 (30, 45) 45 (37, 57)
range: 27–51 range: 27–59
Coaching Experience [median (Q1, Q3)], years 5 (2, 15) 16 (8, 27)
range: 1–25 range: 3–30
Sex, n (%) Female: 10 (77) Female: 3 (23)
Male: 12 (67) Male: 6 (33)
Intention-Practices, n (%)* High: 10 (63) High: 6 (37)
Moderate: 10 (91) Moderate: 1 (9)
Intention-Games, n (%)* High: 10 (67) High: 5 (33)
Moderate: 10 (83) Moderate: 2 (17)
Academic Education, n (%) Graduate: 19 (70) Graduate: 8 (30)
Undergraduate: 3 (75) Undergraduate: 1 (25)
Technical Education, n (%) None: 9 (75) None: 3 (25)
Community Coaching: 8 (80) Community Coaching: 2 (20)
Competition Introduction: 4 (57) Competition Introduction: 3 (43)
Competition Development: 1 (50) Competition Development: 1 (50)
*Medical Education, n (%)** Yes: 8 (73) Yes: 3 (27)
No: 11 (73) No: 4 (27)
*N = 20 and 7 for optimal and suboptimal categories, respectively
**N = 19 and 7 for optimal and suboptimal categories, respectively
(c) Utilization Frequency
Variable Optimal (N = 20) Suboptimal (N = 11)
Age [median (Q1, Q3)], years 39 (31, 45) 38 (28, 54)
range: 27–57 range: 27–59
Coaching Experience [median (Q1, Q3)], years 9 (4, 18) 14 (2, 27)
range: 1–25 range: 1–30
Sex, n (%) Female: 10 (77) Female: 3 (23)
Male: 10 (56) Male: 8 (44)
Intention-Practices, n (%)* High: 12 (75) High: 4 (25)
Moderate: 6 (55) Moderate: 5 (45)
Intention-Games, n (%)* High: 12 (80) High: 3 (20)
Moderate: 6 (50) Moderate: 6 (50)
Academic Education, n (%) Graduate: 18 (67) Graduate: 9 (33)
Undergraduate: 2 (50) Undergraduate: 2 (50)
Technical Education, n (%) None: 8 (67) None: 4 (33)
Community Coaching: 5 (50) Community Coaching: 5 (50)
Competition Introduction: 5 (71) Competition Introduction: 2 (29)
Competition Development: 2 (100) Competition Development: 0 (0)
*Medical Education, n (%)** Yes: 6 (55) Yes: 5 (45)
No: 10 (67) No: 5 (33)
*N = 18 and 9 for optimal and suboptimal categories, respectively.
**N = 16 and 10 for optimal and suboptimal categories, respectively.
 JOURNAL OF SPORTS SCIENCES 7

like doing the activities in the hallways”. Also, these barriers guide the design and implementation of similar injury preven­
reflect the difficulty of performing the NMT warm-up before tion programs.
games or tournaments and it explains our quantitative result of
low adherence during games vs. practices. A key consideration
for overcoming this implementation barrier and other related
Acknowledgments
barriers may include adapting and tailoring NMT warm-up This study was funded by the National Basketball Association and General
programs to local contexts (Baumann et al., 2017; Owoeye Electric Healthcare and Canadian Institutes of Health Research (CIHR
et al., 2018). Specifically, future implementation efforts could Foundation-C Emery, PI). The Sport Injury Prevention Research Centre is
one of the International Research Centres for Prevention of Injury and
include a pre-season negotiation of the execution of the NMT
Protection of Athlete Health supported by the International Olympic
warm-up program with coaches, including using the program Committee. Carolyn Emery holds a Chair in Pediatric Rehabilitation
during most, if not all, practice sessions with high exercise (Alberta Children’s Hospital Foundation).
fidelity among players if coaches foresee a critical challenge
conducting it prior to games. An additional consideration for
Disclosure statement
addressing program implementation barriers relating to player
interest may include splitting warm-up exercise components No potential conflict of interest was reported by the authors.
into two parts and rescheduling within practice time; for exam­
ple, a part may be completed before practice and another after Ethics approval
practice (Whalan et al., 2019).
Coach-related factors that potentially had an association Study was approved by the Health Research Ethics Board of the University
with optimal adherence were younger age, less years of of Calgary (Ethics ID: REB16-0864).
All authors declare no support from any organization for the submitted
experience, female sex, high coach intention and high level work; no other relationships or activities that could appear to have influ­
of technical education. Given the limitations in the statistical enced the submitted work.
analysis used (descriptive), no inferences can be made from
these findings. However, the aforementioned factors provide
information that may guide the generation of hypotheses to ORCID
be tested in multivariable models in future studies with ade­ Oluwatoyosi B.A. Owoeye http://orcid.org/0000-0002-5984-9821
quate sample size. Additional limitations were identified in Kati Pasanen http://orcid.org/0000-0002-0427-2877
this study. Assessment of adherence was based on self-
report by team designates (for coach/team adherence) and
Data availability statement
direct observation by a physiotherapist (for player adherence).
A limitation of the self-report method is that coach adherence The data that support the findings of this study are available from the
may be overestimated due to the possibility of social desir­ corresponding author, OO, upon reasonable request.
ability bias among team designates. Nevertheless, the meth­
ods we used in collecting adherence were the most feasible References
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