Open access Original research

BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2022-001522 on 29 May 2023. Downloaded from http://bmjopensem.bmj.com/ on June 13, 2023 by guest. Protected by
Can running-­related injuries be prevented
through an online behavioural
intervention in adult novice runners?
Results of a randomised controlled trial
Henrike van der Does ‍ ‍,1 Ellen Kemler ‍ ‍,1 Vincent Gouttebarge ‍ ‍2,3,4,5

To cite: van der Does H, ABSTRACT

Kemler E, Gouttebarge V. Can Objective To evaluate the effectiveness of the WHAT IS ALREADY KNOWN ON THIS TOPIC
running-­related injuries be ⇒ The online intervention Runfitcheck is effective in
Runfitcheck on time until the onset of a new running-­
prevented through an online
related injury (RRI) among adult novice runners. encouraging preventive behaviour in novice runners.
behavioural intervention
in adult novice runners? Methods A three-­arm randomised controlled trial
WHAT THIS STUDY ADDS
Results of a randomised was conducted over 7 months. Adult novice runners
controlled trial. BMJ Open completed a baseline online questionnaire on their ⇒ The online intervention Runfitcheck using the run-
Sport & Exercise Medicine characteristics, running activity, RRIs and injury preventive ner’s profile for a tailor-­made injury prevention pro-
2023;9:e001522. doi:10.1136/ behaviour. Runners were randomly allocated to one of gramme was ineffective in reducing the chance of
bmjsem-2022-001522 new running-­related injuries in adult novice runners.
two intervention groups or the control group (n=238). One
intervention group obtained access to the Runfitcheck
► Additional supplemental HOW THIS STUDY MIGHT AFFECT RESEARCH,
material is published online (n=252), an online intervention to encourage injury
PRACTICE OR POLICY
only. To view, please visit the preventive behaviour, and was fortnightly promoted to use
journal online (http://​dx.​doi.​ Runfitcheck; the other intervention group (n=251) was ⇒ This study showed that changing behaviour does not
org/​10.​1136/​bmjsem-​2022-​ directed towards the Runfitcheck once. Runners were automatically lead to the prevention of injuries. It re-
001522). followed for 4 months, not all starting at the same time mains important to gain more insight and to do more

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over 7 months. The main outcome measure was time to research in preventing injuries in novice runners .
Accepted 15 May 2023 a new RRI using the Oslo Sports Trauma Research Centre
Overuse Injury Questionnaire, and was analysed with
survival analysis Cox regression. Generalised estimating highest, ranging from 9 to 18 RRIs per 1000
equations (GEE) were used to gain insight into the running hours.1 2 Despite the high injury risk,
effectiveness of the Runfitcheck. running is one of the most popular and fastest
Results The time to the occurrence of the first RRI did growing forms of physical activity worldwide.4
not differ between the study groups (Wald χ2=0.893). GEE
Running is an easily accessible sport; you do
analysis showed no difference in the risk of a new RRI in
the group that was referred to the Runfitcheck once (OR
not need much equipment to start and you
1.22, 95% CI 0.86 to 1.74) nor in the active approach can run at any time of the day at almost any
group (OR 1.01, 95% CI 0.71 to 1.45) compared with the place. Furthermore, running also has health
control group. Furthermore, the onset of the new RRIs did benefits.5–7 These are some reasons, among
not change over time (OR 0.96, 95% CI 0.91 to 1.01). others, why it is also one of the most popular
Conclusions The online intervention Runfitcheck was sports for starting to become physically active.
ineffective in reducing the instantaneous risk of new In the Netherlands, 12.5% of the population
RRIs in adult novice runners. More research is needed to participate in running, of which about 30%
determine how injuries in novice runners can be prevented. are novice runners.1
Trial registration number Dutch Trial Registry (ID: The popularity of the sport, in combina-
NL7823).
tion with the high injury risk, warrants good
© Author(s) (or their injury prevention interventions. To develop
employer(s)) 2023. Re-­use effective interventions for injury preven-
permitted under CC BY-­NC. No tion insight in the risk factors for injuries is
commercial re-­use. See rights
and permissions. Published by
BACKGROUND necessary. Previous studies showed several
BMJ. In running, the injury risk is high. Experi- important risk factors for RRIs in (novice)
For numbered affiliations see enced runners have an injury rate of 2.5–4 runners,8–10 such as lack of running experi-
end of article. running-­ related injuries (RRI) per 1000 ence.8 9 Measures such as an individualised
running hours,1 2 and recreational runners training programme, listening to signals
Correspondence to
have been shown to have an injury rate of from your body and favourable training
Dr Henrike van der Does; six to eight RRIs per 1000 running hours.2 3 behaviour (a graded training programme)
​h.​vanderdoes@v​ eiligheid.​nl In novice runners, the risk for injuries is the seem important to prevent RRIs.10–12 Novice

van der Does H, et al. BMJ Open Sp Ex Med 2023;9:e001522. doi:10.1136/bmjsem-2022-001522 1

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BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2022-001522 on 29 May 2023. Downloaded from http://bmjopensem.bmj.com/ on June 13, 2023 by guest. Protected by
runners, since being inexperienced runners, lack the After giving consent and filling out the baseline ques-
experience to assess their training load accordingly8 9 and tionnaire (T0; online supplemental file 2), the runners
should be more encouraged to implement injury preven- were randomly allocated to one of the two intervention
tive behaviour. groups or the control group using a computerised random
Therefore, interventions for preventing RRI in novice number generator (Research Randomizer, https://
runners are important.8 9 Although such interventions www.randomizer.org/). No restrictions were imposed
are limited, the studies available have shown their posi- to achieve a balance between groups in size or charac-
tive effect on behavioural aspects in runners.13 14 Studies teristics for the allocation, and simple randomisation
evaluating the effect of such online interventions on was performed. Concealed allocation was used. All steps
RRIs are limited as well.15 16 One of the studies showed in the randomisation process were performed by one
no effect of an online intervention programme on RRIs researcher (HvdD). Neither runners in the intervention
in recreational runners. It was proposed that this may be groups nor researchers were blinded in this study.
due to the intervention being too generic.16 By contrast,
the study by Hespanhol et al15 showed a positive effect of Patient and public involvement
online tailored injury prevention advice on RRIs in trail Runners were first involved in the study when developing
runners. the Runfitcheck intervention. They were also involved in
Given the high RRI risk in novice runners, there is a evaluating the first version of the intervention. Novice
great interest in developing appropriate RRI preven- runners and running experts suggested the content, and
tive interventions in this population. Runfitcheck is a during its development, these two groups were involved
tailored online intervention (see online supplemental in feedback sessions. The intervention is presented based
file 1), which promotes injury preventive behaviour and on novice runners’ wishes and needs. More detailed
provides tools to runners to listen to their body’s signals information on the development of the intervention
based on the load-­taking capacity profile and running is published elsewhere.15 Previous research in novice
motivation of novice runners.17 This intervention was runners was used as input for developing the research
found effective in encouraging preventive behaviour,14 design, outcome measures and research question. The
but the effectiveness of RRIs is unknown. Therefore, this evaluation at the end of the study focused on the time
study aimed to evaluate the effectiveness of the Runfit- spent on the intervention. The burden of the interven-
check on time until the onset of a new RRI among adult tion was not discussed.

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novice runners.
The intervention
METHODS In this study, there were two intervention groups; one
Design and setting group was given access to the Runfitcheck through an
To evaluate the effectiveness of Runfitcheck on RRIs, a active approach (RFC-­a), and the other was referred to
three-­arm randomised controlled trial with a follow-­up the Runfitcheck once (RFC-­o). For a full description of
of 4 months was conducted between October 2019 and the intervention, see online supplemental file 1. The
April 2020. RFC-­a group was referred to the intervention every
2 weeks through the health monitor email, and the RFC-­o
Participants, recruitment and randomisation was referred to the Runfitcheck just once in the first
The inclusion criteria were: (1) to be 18 years or older health monitor email. The control group was given no
and (2) considering themselves to be inexperienced, information regarding the Runfitcheck and continued
little experienced or somewhat experienced runners, running as usual.
or having less than 1 year of running experience. There
were no criteria on the frequency or the distance they Outcome measures
ran. From August 2019 to January 2020, runners were The main outcome measure was time to a new RRI. An
recruited via social media networks (Facebook, websites, RRI was defined as any physical complaint sustained by a
Twitter, LinkedIn and newsletters) of the collabo- runner during running, resulting in the runner quitting
rating organisations (Dutch Consumer Safety Institute, the current running activity or not being able to start a
Runner’s World and Royal Dutch Athletics Association) new running activity,18 19 including at least 1 day of time
or online registration for a running event of Le Cham- loss. To measure new RRIs, all groups received the Dutch
pion (an event organiser for runners, cyclists and walkers version of the Oslo Sports Trauma Research Centre
in the Netherlands). Runners that applied for a running Questionnaire20 21 every 2 weeks, in this study, referred
event of fewer than 10 km received a confirmation email to as the health monitor. The runners scored between
with a short promotion for the study and a link to the 0 and 25 on each of the health monitor’s four key ques-
study information, including an electronic consent form tions (severity score), where 0 point meant no physical
and the baseline questionnaire. The messages on social complaints. The maximum score for all the questions
media contained the same information. Runners willing was 100 points. A score above 8 on the health monitor
to participate gave their electronic informed consent and combined with at least 1 day of time loss was indicated
were included in the study. as an RRI. The injury score was also used as an outcome

2 van der Does H, et al. BMJ Open Sp Ex Med 2023;9:e001522. doi:10.1136/bmjsem-2022-001522

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copyright.
Figure 1 Study design.

measure in this study for severity, with 8 being not severe the questionnaire continued by asking whether the
and 100 being the most severe. The questionnaire (T1 complaint referred to an illness or injury. In the case of
through T9, figure 1) is designed and validated to register an injury, the runner was asked about the date the injury
sports-­
related health problems, including acute and occurred, the nature of the injury and the body location
overuse injuries over time. It uses four key questions on (see online supplemental file 3). The number of time
the influence of physical complaints on running partic- loss days (the total inability to run) was also registered.
ipation, training volume, running performance and to Subsequently, participants were asked if there had been
what degree physical complaints are experienced while another physical complaint in the last 2 weeks, for which
running. Additional information on running exposure they were asked the same questions as for the first injury.
and exposure to other sports was collected. All questions After these questions had been answered, the health
referred to complaints and exposure in the preceding monitor was finished.
2 weeks.
If the runner experienced minimal complaints, the Procedures
questionnaire was finished by filling in a minimum At baseline, the runners were asked about their running
score on these questions.21 However, if the runner experience, other sports activities, current injury/inju-
reported complaints that affected their ability to run, ries, injury preventive behaviour and knowledge of

van der Does H, et al. BMJ Open Sp Ex Med 2023;9:e001522. doi:10.1136/bmjsem-2022-001522 3

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Figure 2 Flow chart of the participants. RFC, Runfitcheck.

injury prevention in running (see online supplemental not. The design study is presented in figure 1. Participants
file 2). All groups received their first health monitor who completed at least six of the nine health monitors,
about 2 weeks after completing the baseline question- including the last one, were entered into a draw offering
naire. Runners in both intervention groups (RFC-­a and a possibility to win either one of three running magazine
RFC-­o) received information about Runfitcheck by email subscriptions or one of three sports packages to the value
and were redirected to the Runfitcheck website after of €50.
completing the health monitor.
The control group also received an email with a link
Sample size
to the health monitor but did not receive information
In this study, it was hypothesised that the use of Runfit-
about the Runfitcheck. Additionally, they were only told
check would lead to a reduction of 33% in RRIs. The
that this was a study to get insight into injuries of adult
sample size calculation was based on calculations for
novice runners. For the remainder of the study period,
longitudinal studies with repeated measures.22 To achieve
all groups received an email with a link to the health
80% power with a significance level of 0.05, taking into
monitor every 2 weeks. In the accompanying email of the
account eight repeated measures (every 2 weeks for 4
RFC-­a group, they were stimulated to use the Runfitcheck
months) and a within-­person correlation of 0.3,15 the
by different calls to action and the email containing a
sample size calculation revealed that 98 participants
link to the online intervention.
per study group were needed in this study. Expecting a
After 2 months and at the end of the study, all groups
response rate of 70% and a loss to follow-­up of 10%,15
received a more elaborate questionnaire (T5 and T9,
the sample size was estimated at 150 participants for each
figure 1, online supplemental file 4). Participants were
asked about injury preventive behaviour in the past study group (a total of 450 participants).
2 months. Finally, after 4 months, participants in both
intervention groups were asked questions about their use Data analysis
and view of the Runfitcheck (T9, figure 1). Participants Descriptive characteristics were conducted for the base-
in the control group were asked whether they had heard line variables of the three groups. These baseline variables
about the Runfitcheck and whether they had used it or were analysed for differences between the groups using

4 van der Does H, et al. BMJ Open Sp Ex Med 2023;9:e001522. doi:10.1136/bmjsem-2022-001522

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Table 1 Baseline characteristics of the runners (n=741)
Baseline characteristics RFC-­a (n=252) RFC-­o (n=251) Control (n=238) Total (n=741)
Age, years (%)
 18–24 5 8 8 7
 25–34 25 25 26 26
 35–44 33 27 22 28
 45–54 25 27 27 27
 55–64 9 9 15 11
 65 or older 3 2 2 2
Gender (%)
 Male 34 34 30 33
 Female 66 66 70 67
Height (cm), mean (SD) 174.0 (14.5) 174.4 (11.0) 173.9 (8.5) 174.1 (11.7)
Weight (kg), mean (SD) 73.0 (11.8) 73.0 (12.5) 71.0 (12.2) 72.4 (12.2)
Running experience, months (%)
 None, starting <1 – – –
 <6 6 5 5 6
 6–12 11 9 14 11
 13–18 10 10 11 10
 19–24 11 12 13 12
 >24 61 63 56 60
Running level (%)
 Inexperienced (novice) 6 7 7 7

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 Little experienced 31 30 30 30
 Somewhat experienced 62 63 63 63
 Experienced – – – –
 Very experienced – – –
Running frequency (%)
 Didn’t start yet 1 1 2 2
 Less than once a week 3 3 5 4
 Once a week 11 13 13 12
 Twice a week 37 38 34 36
 Three times a week 42 39 39 40
 Four or more times a week 5 6 7 6
Running minutes each time, mean (SD) 55.2 (31.9) 55.5 (32.4) 54.2 (31.2) 55.0 (31.8)
Injured at baseline (%)
 No 55 56 54 55
 Yes, RRI 29 34 32 32
 Yes, injury, different sport 15 9 13 12
 No answer 1 1 1 1
Severity score baseline, mean (SD) 19.4 (27.1) 17.8 (25.8) 19.7 (26.7) 18.9 (26.5)
RFC-­a, Runfitcheck through an active approach; RFC-­o, Runfitcheck once; RRI, running-­related injury.

the χ2 test for the categorical variables and a one-­way if the missing data were random, the pattern of missing
analysis of variance for the continuous variables. data was analysed in two ways.23 First of all, it was assessed
Runners that only completed the baseline question- whether baseline variables (age, gender, running expe-
naire and runners in the control group that used the rience and running level) were associated with missing
Runfitcheck were excluded from analysis. To determine follow-­
up data by using univariate logistic regression.

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Table 2 Compliance with the study protocol, running exposure and RRI characteristics such as severity score and number of
RRIs displayed per study group
RFC-­a (n=252) RFC-­o (n=251) Control (n=238)
Compliance with the study protocol (%)
 Complete 30 31 30
 Missing 25 25 17
 Dropout 46 44 53
Running exposure
 Duration (min/2 weeks)* 52.9 (23.0) 51.8 (21.1) 53.3 (21.6)
 Frequency (times/2 weeks)* 4 (2) 4 (2) 4 (3)
RRI characteristics
 RRI (n) 70 79 62
 Injury rate† 13.1 15.3 12.6
 Participants with new RRIs (%) 23 26 21
 Time to new RRI (days)‡ 40 (39) 41 (41) 36 (34)
 Time loss (days/2 weeks)* 2.2 (1.6) 2.6 (2.4) 2.2 (1.9)
 Total time loss (days)‡ 8.9 (9.1) 9.0 (7.4) 7.7 (6.8)
Severity score, mean (SD) 63.1 (80.3) 69.5 (81.5) 64.3 (86.5)
*Mean and SD over a 2-­week period.
†Injuries per 1000 running hours.
‡Mean and SD over the total monitoring period.
RFC-­a, Runfitcheck through an active approach; RFC-­o, Runfitcheck once; RRI, running-­related injury.

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Second, the outcome data of the health monitor were one-­off referral to the Runfitcheck (RFC-­o) and 276 to the
related to the outcome of the health monitor preceding control group. Eighty-­seven per cent of the participants
and the one following to see whether these were related, (n=747) completed at least one of the health monitors
also using univariate logistic regression. and were therefore included in the analyses. Six of the
Survival analysis Cox regression was used to assess the participants in the control group used the intervention
differences in time to new RRI between the three groups. (Runfitcheck) and were therefore excluded from the
Significance and the Wald statistic are reported, and the analysis, leaving 741 participants for further analysis. The
HR will be reported when significant. Generalised esti- complete flow of the participants can be found in figure 2.
mating equations (GEE) were used to gain insight into Two-­thirds (67%) of the runners were female; most
the difference in the risk of the occurrence of a new RRI were between 25 and 54 years old (table 1). Sixty per cent
and the development of the severity score between the of the runners had more than 2 years of running experi-
three groups. Furthermore, GEE was used to see if there ence, and a little over 60% assessed their running level
were changes over time (the monitor period) in the occur- as ‘somewhat’ experienced. Most runners ran twice or
rence of new RRIs and/or the severity score and whether thrice a week, averaging 55 min (SD=31.8) per running
these differed between groups. The GEE accounts for session. At baseline, more than half of the runners (55%)
the correlation of repeated outcome measures within had no (running-­related) injury.
subjects over time. Additionally, all these analyses were
Missing data
performed for the group runners who reported no injury
Univariate logistic regression revealed that most baseline
at baseline and to analyse the effect of compliance to the
variables were not statistically predictive of incomplete
Runfitcheck on RRIs and the severity score. These anal-
data. Only the analysis for gender showed that men
yses are presented in online supplemental file 5.
were more likely to have missing data than women (OR
All statistical analyses were performed using IBM SPSS
1.51, 95% CI 1.10 to 2.09, p<0.05). Non-­response on one
(V.25), and significance was accepted at p<0.05.
health monitor predicted non-­response on the following
health monitor. This assumes that the data are missing at
RESULTS
random, which is accounted for in the GEE analysis.
In total, 3862 participants were interested in the study, of
whom 851 were eligible for participation (figure 2). Of Compliance with the study protocol, running exposure and
these eligible participants, 295 were randomly allocated RRI characteristics
to the intervention group with an active approach (RFC-­ After 4 months of follow-­up in all groups, about 30%
a), 280 were allocated to the intervention group with the completed all health monitors (100%), while about half

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Table 3 Effect of Runfitcheck on running-­related injuries using generalised estimating equations
RRI Severity score
Beta OR (95% CI) P value Beta Wald χ2 P value
Group
 Control Reference Reference
 RFC-­o 0.202 1.22 (0.86 to 1.74) 0.260 0.070 0.003 0.954
 RFC-­a 0.013 1.01 (0.71 to 1.45) 0.944 −0.432 0.123 0.725
Linear trend* −0.040 0.96 (0.91 to 1.01) 0.121 −0.669 30.712 0.000
*Adjusted for the intervention group.
RFC-­a, Runfitcheck through an active approach; RFC-­o, Runfitcheck once; RRI, running-­related injury.

of the participants dropped out during the monitor Strengths and weaknesses in relation to other studies
period (table 2). On average, a participant filled out six In a previous study by Kemler et al, positive effects were
health monitors. There was no significant difference found of the Runfitcheck on injury preventive behaviour
between groups in the number of health monitors filled of novice runners.14 The assumption was made that
out (F(2,738)=0.52, p=0.60). increased injury preventive behaviour using the Runfit-
A summary of running exposure and RRI characteris- check would ultimately lead to a decrease in RRIs.
tics is shown in table 2. Around 25% of the participants However, this study did not demonstrate these positive
in the intervention groups reported a new RRI, and 20% effects to prevent RRI.
in the control group (table 2). The injury rate ranged Fokkema et al16 also showed no effect of an online inter-
from 13.1 to 15.3 injuries per 1000 running hours. Time vention programme on RRIs in recreational runners.
to new RRI ranged from 36 up to 41 days. The number While Fokkema et al used a generalised intervention, in
of new RRIs did not significantly differ between groups our study, we gave tailor-­made advice based on running
(F(2,738)=0.61, p=0.55). profiles rather than RRI. However, our approach was

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probably not specific enough to prevent RRIs. In contrast
Effects of the intervention on RRI to the study of Fokkema et al16 and our study, Hespanhol
Cox regression showed no differences in time to the first et al15 did find a preventive effect of their tailor-­made
RRI between the study groups (Wald χ2=0.893, p=0.640). intervention. In their study, advice for recovery and
The GEE analyses showed no difference between the prevention was given directly after notification of an RRI
study groups in the risk of a new RRI nor the severity score responding to the situation. This is a more ‘right on time’
(table 3). During the monitoring period, there was no way for (secondary) injury prevention since it is known
change in the development of RRIs overall and between most people take action the moment something happens
groups. However, the linear trend for the severity score and not before the onset of an injury.15 16
showed a significant decrease in the severity score over Looking at the running population in the other
the monitor period for all participants together (table 3; studies, Fokkema et al16 included adult recreational
linear trend). runners who registered for one of three large running
In additional analyses, the same analyses were events between 5 and 42 195 km. Hespanhol et al15
performed for the group runners who reported no injury studied adult trail runners participating in a recent
at baseline. Furthermore, the effect of visiting the Runfit- trail running event (15–62 km). Trail and recreational
check on RRIs was analysed. These analyses showed no runners are probably more experienced runners,
differences between groups (see online supplemental file while in our study, the participants were expected to be
5). mainly novice runners and probably less experienced
runners. These may need a different approach when
it comes to injury prevention. Novice runners have a
DISCUSSION high injury risk but lack a sense of urgency.24 Fokkema
Principal findings et al and Hespanhol et al showed that runners with an
In this study, we evaluated whether the Runfitcheck RRI were more inclined to participate in the inter-
affected the time until the onset of a new RRI among vention than runners without physical complaints.15 16
adult novice runners. Based on our results, the Runfit- This was confirmed by the recent study of Verhagen
check did not have a protective or harmful effect on the et al,25 which showed that recreational runners do
time until the onset of a new RRI. The time until the not have a conscious will to prevent injuries and use
onset of the first new RRI did not differ between the self-­
regulation to deal with complaints and injury.
study groups, and there was no effect of the Runfitcheck When runners do not have any experience with
on the severity scores. being injured, they might not feel the urge to protect

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themselves against injury. Future research in injury Meaning of the study and future research
prevention for recreational/novice runners should Using a tailor-­made intervention based on a runner’s
consider this. profile was ineffective in preventing RRIs in novice
Another point of discussion is the definition of the runners. Even though this study included just one group
experience level of runners, namely novice, recreational of mainly novice runners, it suggests that preventive
and competitive runners. There is no clear definition research and creating awareness concerning injury is
in the literature, and every study uses different defi- difficult when dealing with novice runners. As suggested
nitions, making a comparison of research outcomes before, the TPB could be used in future studies when
and drawing conclusions difficult.26 27 By reporting the evaluating Runfitcheck. The TPB might explain the vari-
injury incidence in relation to the amount of time spent ance around RRI preventive behaviour and intention and
running, a comparison would be possible; however, rela- may give starting points to create awareness concerning
tively few studies report this.26 Hence, in consultation injuries in more novice/less experienced runners.
with the Royal Dutch Athletics Association, we based the The components of the Runfitcheck are developed
definition mainly on the runners’ feelings. However, to in cooperation with several (running) experts. These
make research outcomes more comparable, an inter- components could be investigated concerning their
national consensus on the definition and/or the way effect on RRI individually. For example, the preventive
of reporting the experience level of runners must be effects of strength exercises can be studied, and proven
reached. This would also translate to better practical effects can be used to prevent RRIs in novice runners.
application by the running community, coaches, phys- Coaches may be able to use the individual exercises in
ical therapists, etc.27 their training programme for novice/less experienced
In this study, an RRI was defined as any physical runners.
complaint sustained by a runner during running, resulting
in the runner quitting the current running activity or not Author affiliations
1
Dutch Consumer Safety Institute, Amsterdam, The Netherlands
being able to start a new one,18 19 including at least 1 day 2
Amsterdam UMC location University of Amsterdam, Department of Orthopedic
of time loss. This definition may have missed some RRIs, Surgery and Sports Medicine, Meibergdreef 9, Amsterdam, The Netherlands
such as runners with iliotibial band (ITB) syndrome, 3
Section Sports Medicine, Faculty of Health Sciences, University of Pretoria,
achilles tendinopathy and patellafemoral pain (PFP) Pretoria, South Africa
4
syndrome (common RRIs). Runners with these inju- Amsterdam Collaboration on Health & Safety in Sports (ACHSS), IOC Research

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Center of Excellence, Amsterdam, The Netherlands
ries rarely quit their current running activity or cannot 5
Amsterdam Movement Sciences, Musculoskeletal Health, Sports, Amsterdam, The
start a new running activity (including at least 1 day of Netherlands
time loss). The definition used in a study impacted the
outcome of the study. For comparability of future studies, Twitter Henrike van der Does @Henrike84, Ellen Kemler @ellenkemler and Vincent
consensus on definitions of runners and RRI is of major Gouttebarge @VGouttebarge
importance. Contributors EK was guarantor and together with HvdD responsible for the
One of the strengths of the study is how the interven- conceptualisation of the idea of the study, data analysis, interpretation of the data
and preperation of the manuscript. EK and VG acquired funding. VG, EK and HvdD
tion is presented. This is based on the wishes and needs of designed the study. EK and HvdD prepared the materials and implemented the
novice runners. Therefore, theoretically, the Runfitcheck study. HvdD collected the data and carried out the data analyses. HvdD drafted the
is expected to be attractive and stimulating enough for manuscript with contribution from EK. VG was responsible for the critical review of
novice runners. However, the results show poor compli- the manuscript. All authors read and approved the final manuscript.

ance with the Runfitcheck in both intervention groups Funding This work was supported by ZonMW (Grant No 536001012), the Dutch
Organisation for Health Research and Development.
(see online supplemental file 5). Further research could
consider using the theory of planned behaviour (TPB) in Competing interests None declared.
evaluating the Runfitcheck since this theory may explain Patient and public involvement Patients and/or the public were involved in the
design, or conduct, or reporting, or dissemination plans of this research. Refer to
half of the variance around RRI preventive behaviour the Methods section for further details.
and intention.28
Patient consent for publication Not applicable.
Finally, the dropout rate in this study was relatively
Ethics approval This study involves human participants and was approved
high (48%) compared with other studies.16 29 However, by the Medical Ethics Review Committee of the Amsterdam University Medical
just 13% of all the participants were excluded from the Centers, location Academic Medical Center (W19_241#19.290, Amsterdam, the
analysis. When the runners completed at least one health Netherlands). Participants gave informed consent to participate in the study before
monitor, data until they dropped out were included in taking part.
the analysis. The dropout rate could (probably partly) be Provenance and peer review Not commissioned; externally peer reviewed.
explained by runners with an injury (temporarily) quit- Data availability statement Data are available upon reasonable request. The
ting running and dropping out of our study, reflected relevant anonymised patient-­level data set analysed during the current study is
available from the corresponding author on reasonable request.
in the significant decrease in the number of new RRIs
Supplemental material This content has been supplied by the author(s). It has
per health monitor over the research period. Previous
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
research has also shown that an injury is one of the main peer-­reviewed. Any opinions or recommendations discussed are solely those
reasons to quit being active.29 of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and

8 van der Does H, et al. BMJ Open Sp Ex Med 2023;9:e001522. doi:10.1136/bmjsem-2022-001522

 Open access

BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2022-001522 on 29 May 2023. Downloaded from http://bmjopensem.bmj.com/ on June 13, 2023 by guest. Protected by
responsibility arising from any reliance placed on the content. Where the content 13 Adriaensens L, Hesselink A, Fabrie M. Effectiveness of an Online
includes any translated material, BMJ does not warrant the accuracy and reliability tailored intervention on determinants and behaviour to prevent
of the translations (including but not limited to local regulations, clinical guidelines, running related sports injuries: a randomised controlled trial. SSEM
terminology, drug names and drug dosages), and is not responsible for any error 2014;62:6–13.
14 Kemler E, Cornelissen MH, Gouttebarge V. The effectiveness of an
and/or omissions arising from translation and adaptation or otherwise. Online intervention in stimulating injury-­preventive behaviour in adult
Open access This is an open access article distributed in accordance with the novice runners. results of a randomised controlled trial. In Review
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which [Preprint] 2020.
permits others to distribute, remix, adapt, build upon this work non-­commercially, 15 Hespanhol LC Jr, van Mechelen W, Verhagen E. Effectiveness
of Online tailored advice to prevent running-­related injuries and
and license their derivative works on different terms, provided the original work is promote preventive behaviour in Dutch trail runners: a pragmatic
properly cited, appropriate credit is given, any changes made indicated, and the randomised controlled trial. Br J Sports Med 2018;52:851–8.
use is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. 16 Fokkema T, de Vos R-­J, van Ochten JM, et al. Online Multifactorial
prevention programme has no effect on the number of running-­
ORCID iDs related injuries: A randomised controlled trial. Br J Sports Med
Henrike van der Does http://orcid.org/0000-0002-8579-4430 2019;53:1479–85.
Ellen Kemler http://orcid.org/0000-0002-3549-7091 17 Kemler E, Gouttebarge V. A tailored advice tool to prevent injuries
Vincent Gouttebarge http://orcid.org/0000-0002-0126-4177 among novice runners: protocol for a randomized controlled trial.
JMIR Res Protoc 2018;7:e187.
18 Fuller CW, Molloy MG, Bagate C, et al. Consensus statement on
injury definitions and data collection procedures for studies of
REFERENCES injuries in Rugby Union. Br J Sports Med 2007;41:328–31.
1 Kemler E, Blokland D, Backx F, et al. Differences in injury risk 19 Bahr R. No injuries, but plenty of pain? on the methodology
and characteristics of injuries between novice and experienced for recording Overuse symptoms in sports. Br J Sports Med
runners over a 4-­year period. The Physician and Sportsmedicine 2009;43:966–72.
2018;46:485–91. 20 Pluim BM, Loeffen FGJ, Clarsen B, et al. A one-­season prospective
2 Videbæk S, Bueno AM, Nielsen RO, et al. Incidence of running-­ study of injuries and illness in elite Junior tennis. Scand J Med Sci
related injuries per 1000 h of running in different types of runners: a Sports 2016;26:564–71.
systematic review and meta-­analysis. Sports Med 2015;45:1017–26. 21 Clarsen B, Rønsen O, Myklebust G, et al. The Oslo sports trauma
3 van derH, Valkenberg H. Cijferrapportage Hardlopen 2014-­2018. research center questionnaire on health problems: A new approach
Amsterdam 2019. to prospective monitoring of illness and injury in elite athletes. Br J
4 Hulteen RM, Smith JJ, Morgan PJ, et al. Global participation in sport Sports Med 2014;48:754–60.
and leisure-­time physical activities: A systematic review and meta-­ 22 Twisk JWR. Applied longitudinal data analysis for epidemiology.
analysis. Preventive Medicine 2017;95:14–25. In: Applied Longtitudinal Data Analysis for Epidemiology. 2nd ed.
5 Verhagen E. Prevention of running-­related injuries in novice runners: Cambridge University Press, 9 May 2013.
are we running on empty Br J Sports Med 2012;46:836–7. 23 Clarsen B, Bahr R, Heymans MW, et al. The prevalence and impact
6 Williams PT. Relationship of running intensity to hypertension, of Overuse injuries in five Norwegian sports: application of a new
hypercholesterolemia, and diabetes. Med Sci Sports Exerc surveillance method. Scand J Med Sci Sports 2015;25:323–30.
2008;40:1740–8. 24 Goossens H. Verslag Focusgroepgesprek RFC 2019. VeiligheidNL.

copyright.
7 van Gent RN, Siem D, van Middelkoop M, et al. Incidence and Amsterdam, 2019.
determinants of lower extremity running injuries in long distance 25 Verhagen E, Warsen M, Silveira Bolling C. I just want to Run - how
runners: A systematic review. Br J Sports Med 2007;41:469–80; recreational runners perceive and deal with injuries. BMJ Open Sport
8 Linton L, Valentin S. Running with injury: A study of UK novice and Exerc Med 2021;7:e001117.
recreational runners and factors associated with running related 26 Kluitenberg B, van Middelkoop M, Diercks R, et al. What are the
injury. J Sci Med Sport 2018;21:1221–5. differences in injury proportions between different populations
9 Buist I, Bredeweg SW, Lemmink KAPM, et al. Predictors of of runners? a systematic review and meta-­analysis. Sports Med
running-­related injuries in novice runners enrolled in a systematic 2015;45:1143–61.
training program: A prospective cohort study. Am J Sports Med 27 Fredette A, Roy JS, Perreault K, et al. The association between
2010;38:273–80. running injuries and training parameters: A systematic review. J Athl
10 Kemler E, Huisstede BMA. Sports-­goal-­oriented runners are more Train 2022;57:650–71.
prone to running-­related injury. Phys Ther Sport 2020:153–8. 28 Hespanhol L, Vallio CS, van Mechelen W, et al. Can we explain
11 Hreljac A. Etiology, prevention, and early intervention of Overuse running-­related injury preventive behavior? A path analysis. Braz J
injuries in runners: A Biomechanical perspective. Phys Med Rehabil Phys Ther 2021;25:601–9.
Clin N Am 2005;16:651–67, 29 Hofstede H, Franke TPC, van Eijk RPA, et al. In training for a
12 Fields KB, Sykes JC, Walker KM, et al. Prevention of running injuries. Marathon: runners and running-­related injury prevention. Phys Ther
Curr Sports Med Rep 2010;9:176–82. Sport 2020;41:80–6.

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