Evaluation of the SCAT 5 tool in the assessment of concussion in Para athletes: a Delphi study

OBJECTIVES

To investigate if the sport concussion assessment tool version 5 (SCAT5) could be suitable for application to Para athletes with a visual impairment, a spinal cord injury, or a limb deficiency.

METHODS

A 16-member expert panel performed a Delphi technique protocol. The first round encompassed an open-ended questionnaire, with round 2 onwards being composed of a series of closed-ended statements requiring each expert's opinion using a five-point Likert scale. A predetermined threshold of 66% was used to decide whether agreement had been reached by the panel.

RESULTS

The Delphi study resulted in a four-round process. After round 1, 92 initial statements were constructed with 91 statements obtaining the targeted level of agreement by round 4. The expert panellist completion rate of the full four-round process was 94%. In the case of athletes with a suspected concussion with either limb deficiencies or spinal cord injuries, the panel agreed that a baseline assessment would be needed on record is ideal before a modified SCAT5 assessment. With respect to visual impairments, it was conceded that some tests were either difficult, infeasible or should be omitted entirely depending on the type of visual impairment.

CONCLUSION

It is proposed that the SCAT5 could be conducted on athletes with limb deficiencies or spinal cord injuries with some minor modifications and by establishing a baseline assessment to form a comparison. However, it cannot be recommended for athletes with visual impairment in its current form. Further research is needed to determine how potential concussions could be more effectively evaluated in athletes with different impairments.

Para sport and anti-doping: a study of Swedish Para athletes' experiences and perceptions

Introduction

A well-functioning anti-doping system relies on being perceived by athletes as effective, fair, and practically feasible to implement. While research has highlighted the views of Olympic athletes on anti-doping over the past decade, the experiences and perceptions of Para athletes have not been extensively explored. The purpose of this study was to examine Swedish elite Para athletes' experiences and perceptions of the policy and practice of the anti-doping system.

Methods

A quantitative cross-sectional approach was used, with a web survey elaborated from a survey with Olympic athletes adjusted for Para athletes with physical, visual, and intellectual impairments. The sample consisted of 66 active Para athletes competing at national or international level (response rate 71%). Data were analyzed using descriptive statistics and differences between subgroups were examined Fisher's exact test. Thematic analysis was employed to analyze open-ended questions.

Results

Most of the respondents expressed a positive outlook on the anti-doping system, advocating for comprehensive efforts. A significant portion (35%) had not received anti-doping education, with those who did reporting increased confidence in avoiding unintentional doping. Despite their elite status, half of the respondents had not undergone doping control. Mistrust regarding the system's effectiveness and fairness was identified, with over half of the participants emphasizing the need for new technical solutions to enhance procedures specifically tailored for Para athletes.

Discussion

The athletes in this study advocate for a Para sports-focused approach in the anti-doping system, emphasizing equal testing opportunities, procedural adjustments for independence and privacy, and increased access to education. The findings illuminate the unique conditions faced by athletes with impairments within the anti-doping system, offering valuable insights for policymaking in the development of anti-doping strategies tailored to Para athletes and their various impairments.

Mental health, sleep, and pain in elite Para athletes and the association with injury and illness-A prospective study

INTRODUCTION

The interest in the health of Para athletes continues to increase. Still, there are few studies that have evaluated health parameters beyond injury and illness in this athlete population.

OBJECTIVE

To assess (1) the weekly proportion of elite Para athletes reporting anxiety/depression, low sleep levels (≤7 hours), and pain over 52 weeks; (2) and to explore whether these health parameters are associated with the risk for a sports injury or illness.

DESIGN

A 52-week prospective study, part of the Sports-related Injury and Illness in Paralympic Sport Study (SRIIPSS).

SETTING

A total of 107 Swedish elite Para athletes with physical, visual, and intellectual impairment participated.

MAIN OUTCOME MEASURES

Data on self-reported anxiety/depression, sleep levels, pain, and injuries/illnesses were collected weekly. Comparisons of these parameters preceding an injury/illness were made using Friedman's analysis of variance (ANOVA).

RESULTS

The proportion of athletes reporting weekly anxiety/depression was 34.1%; 60.9% of athletes reported sleeping ≤7 hours and 49.9% reported pain. In exploratory analyses, there were no significant differences between weeks before an injury for any of the variables. There were significant differences in levels of sleep over the weeks, where sleep levels were significantly higher (>10 hours) 4 weeks prior to an illness (p = .016).

CONCLUSION

This cohort of elite Para athletes reported relatively high levels of anxiety/depression, low sleep levels, and pain, which is a concern. High sleep levels and the risk for illness might be an indication of overtraining, which commonly leads to persistent fatigue and an increased susceptibility to infections. Monitoring of the health of elite Para athletes is recommended to be able to improve performance and health in this population.

The Underlying Mechanisms of Sports Injuries in Paralympic Goalball: A Mixed-Method Study

OBJECTIVE

Data from the Paralympic Games indicate a fluctuating injury incidence in the Paralympic sport goalball, but the mechanisms behind have not been explored. The aims of this study are to (1) quantitatively analyze goalball injuries reported in the London 2012 and Rio 2016 Paralympic Games, (2) qualitatively explain the differences between both games, and (3) qualitatively assess general injury mechanisms and prevention opportunities of injuries in Goalball.

DESIGN

This is a mixed-method study. Injury incidence rates were analyzed from data collected during the 2012 and 2016 Paralympic Games. Then, semistructured interviews of games participants qualitatively explored injury mechanisms and prevention opportunities.

RESULTS

A reduction of injuries occurred from 2012 (incidence rate, 19.5; 95% confidence interval, 12.5-26.5) to 2016 (incidence rate: 5.6; 95% confidence interval, 1.7-9.5). In both games, acute traumatic injuries were most common. Female athletes reported higher rate of injuries compared with males ( P = 0.05). Qualitative data revealed that causes of injuries were collisions, overuse, and poor physical conditioning. The differences between the two games were explained by equipment, environment, and preparations.

CONCLUSIONS

The result from this study indicates that injuries in goalball are multifactorial. Ultimately, the mixed-method data from this study can help the sports context develop prevention measures.

Physical Demands of Tennis Across the Different Court Surfaces, Performance Levels and Sexes: A Systematic Review with Meta-analysis

BACKGROUND

Tennis is a multidirectional high-intensity intermittent sport for male and female individuals played across multiple surfaces. Although several studies have attempted to characterise the physical demands of tennis, a meta-analysis is still lacking.

OBJECTIVE

We aimed to describe and synthesise the physical demands of tennis across the different court surfaces, performance levels and sexes.

METHODS

PubMed, Embase, CINAHL and SPORTDiscus were searched from inception to 19 April, 2022. A backward citation search was conducted for included articles using Scopus. The PECOS framework was used to formulate eligibility criteria.

POPULATION

tennis players of regional, national or international playing levels (juniors and adults).

EXPOSURE

singles match play. Comparison: sex (male/female), court surface (hard, clay, grass).

OUTCOME

duration of play, on-court movement and stroke performance.

STUDY DESIGN

cross-sectional, longitudinal. Pooled means or mean differences with 95% confidence intervals were calculated. A random-effects meta-analysis with robust variance estimation was performed. The measures of heterogeneity were Cochrane Q and 95% prediction intervals. Subgroup analysis was used for different court surfaces.

RESULTS

The literature search generated 7736 references; 64 articles were included for qualitative and 42 for quantitative review. Mean [95% confidence interval] rally duration, strokes per rally and effective playing time on all surfaces were 5.5 s [4.9, 6.3], 4.1 [3.4, 5.0] and 18.6% [15.8, 21.7] for international male players and 6.4 s [5.4, 7.6], 3.9 [2.4, 6.2] and 20% [17.3, 23.3] for international female players. Mean running distances per point, set and match were 9.6 m [7.6, 12.2], 607 m [443, 832] and 2292 m [1767, 2973] (best-of-5) for international male players and 8.2 m [4.4, 15.2], 574 m [373, 883] and 1249 m [767, 2035] for international female players. Mean first- and second-serve speeds were 182 km·h^-1 [178, 187] and 149 km·h^-1 [135, 164] for international male players and 156 km·h^-1 95% confidence interval [151, 161] and 134 km·h^-1 [107, 168] for international female players.

CONCLUSIONS

The findings from this study provide a comprehensive summary of the physical demands of tennis. These results may guide tennis-specific training programmes. We recommend more consistent measuring and reporting of data to enable future meta-analysts to pool meaningful data.

CLINICAL TRIAL REGISTRATION

The protocol for this systematic review was registered a priori at the Open Science Framework (Registration DOI https://doi.org/10.17605/OSF.IO/MDWFY ).

Injury acknowledgement by reduction of sports load in world-leading athletics (track and field) athletes varies with their musculoskeletal health literacy and the socioeconomic environment

Objective

Although injury burden prompts elite athletics (track and field) athletes to engage in injury management, little is known about their health literacy. We investigated musculoskeletal (MS) health literacy in world-leading athletics athletes and associations with prechampionship injury acknowledgement by reduction of training load in different socioeconomic environments.

Methods

Adult and youth athletics athletes (n=1785) preparing for World Championships were invited to complete the Literacy in Musculoskeletal Problems instrument and report acknowledgement of injury by reduction in training load during prechampionship tapering. Their socioeconomic standing was estimated through the Human Development Index of their home country. Demographic differences were examined using χ2tests and determinants of injury acknowledgement assessed using logistic regression.

Results

Complete data were obtained from 780 athletes (43.7%) with 26% demonstrating sufficient MS health literacy, higher in adult (41%) than youth (13%) athletes (p<0.001). Adult athletes at the uppermost socioeconomic level showed higher MS health literacy than athletes at lower socioeconomic levels (p<0.001). At the uppermost socioeconomic level, adult athletes with sufficient MS health literacy had increased likelihood of acknowledging an injury by reduction in training load compared with peers demonstrating insufficient MS health literacy (OR=2.45; 95% CI 1.33–4.53). Athletes at middle socioeconomic levels with sufficient MS health literacy had decreased likelihood for acknowledging an injury during tapering (OR=0.29; 95% CI 0.11–0.78).

Conclusions

The prevalence of sufficient MS health literacy in world-leading athletics athletes is low. Associations between MS health literacy and injury acknowledgement in these athletes vary with the resourcefulness of the socioeconomic environment, implying that health literacy and resources for medical and performance support should be ascertained concurrently.

A cross-sectional study of anxiety and depression caseness in female competitive figure skaters in Sweden

Objectives

Little is known about figure skaters' mental health. This study aimed to describe anxiety and depression caseness (defined as a screening condition qualifying for psychiatric examination) in competitive figure skaters and analyse factors associated with such caseness.

Methods

A cross-sectional study was performed in April 2019 among all competitive figure skaters in the south-eastern region of Sweden (N=400). The primary outcomes were anxiety caseness, measured using the short-form Spielberger State-Trait Anxiety Inventory and depression caseness, measured using the WHO-5 index. Multivariable logistic regression models were employed to determine the association between anxiety caseness and explanatory factors.

Results

In total, 36% (n=142) of the invited skaters participated. Only females (n=137), mean age 12.9 (SD 3.0) years) were selected for analysis. Of the participating skaters, 47% displayed anxiety caseness and 10% depression caseness. Overweight body image perception (OR 5.9; 95% CI 2.0 to 17.6; p=0.001) and older age (OR 1.2; 95% CI 1.1 to 1.4; p=0.005) were associated with anxiety caseness. Skaters reporting no caseness were younger than those reporting only anxiety caseness (mean age difference -1.9 years; 95% CI -3.1 to -0.7; p=0.001) or anxiety and depression caseness (OR -3.5 years; 95% CI -5.6 to -1.5 years; p<0.001).

Conclusion

Anxiety caseness was associated with overweight body image perception and older age in female competitive figure skaters. Older skaters reported generally worse mental health. More research on the mental health of figure skaters is warranted, considering comorbidity and focusing on those needing further assessment and support.

“It gives me a wake up call” ‐ It is time to implement athlete health monitoring within the Para sport context

OBJECTIVES

The aim of this study was to explore elite Para athletes' and coaches' perceptions of experiences of athlete health monitoring.

MATERIALS AND METHODS

This study used a qualitative design, applying a phenomenographical approach. Thirteen athletes and six coaches from two different socioeconomic contexts (the Swedish and South African Paralympic programs) participated. Data were collected through individual interviews focusing on athletes' and coaches' perceptions of experiences of athlete health monitoring within Para sport.

RESULTS

Three main themes were revealed: (i) the benefits of athlete health monitoring, (ii) the importance of implementation and adaptation of athlete health monitoring in the real-world sports context, and (iii) barriers of athlete health monitoring. The perceptions were that regular monitoring can detect injuries early and thereby prevent them from progressing. Several participants highlighted the importance of monitoring factors beyond injury and illness, such as Para sport-specific health issues. Athletes' experiences were that they started to reflect on their own health, which was interpreted as improvement in health literacy. Another perception was that athlete health monitoring only is conducted within the research context and that athletes are not followed up. The perception was that it is the sports federations' responsibility to monitor and provide support when needed. Lastly, data revealed differences in the possibilities of conducting monitoring, which was related to both socioeconomic factors and Para sport.

CONCLUSION

Coaches and athletes see health monitoring as valuable and important in enhancing athlete health. However, to maximize the impact, the monitoring structure should be specific to the context and provide multidisciplinary support when needed.

Association between the level of partial foot amputation and gait: a scoping review with implications for the minimum impairment criteria for wheelchair tennis

OBJECTIVE

This scoping review examines how different levels and types of partial foot amputation affect gait and explores how these findings may affect the minimal impairment criteria for wheelchair tennis.

METHODS

Four databases (PubMed, Embase, CINAHL and SPORTDiscus) were systematically searched in February 2021 for terms related to partial foot amputation and ambulation. The search was updated in February 2022. All study designs investigating gait-related outcomes in individuals with partial foot amputation were included and independently screened by two reviewers based on Arksey and O'Malley's methodological framework and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

RESULTS

Twenty-nine publications with data from 252 participants with partial foot amputation in 25 studies were analysed. Toe amputations were associated with minor gait abnormalities, and great toe amputations caused loss of push-off in a forward and lateral direction. Metatarsophalangeal amputations were associated with loss of stability and decreased gait speed. Ray amputations were associated with decreased gait speed and reduced lower extremity range of motion. Transmetatarsal amputations and more proximal amputations were associated with abnormal gait, substantial loss of power generation across the ankle and impaired mobility.

CONCLUSIONS

Partial foot amputation was associated with various gait changes, depending on the type of amputation. Different levels and types of foot amputation are likely to affect tennis performance. We recommend including first ray, transmetatarsal, Chopart and Lisfranc amputations in the minimum impairment criteria, excluding toe amputations (digits two to five), and we are unsure whether to include or exclude great toe, ray (two to five) and metatarsophalangeal amputations.

TRIAL REGISTRATION

The protocol of this scoping review was previously registered at the Open Science Framework Registry (https://osf.io/8gh9y) and published.

Monitoring mental distress in Para athletes in preparation, during and after the Beijing Paralympic Games 2022: A 22 week prospective mixed-method study

It is common in elite sport to monitor athletes' training load, injuries and illnesses, but mental distress is rarely included. An improved understanding of the epidemiology of mental distress among elite Para athletes and how their coaches perceive such monitoring would allow us to better develop and implement preventive measures. The purpose of this study was therefore to (1) prospectively describe elite Para athletes' mental distress, before, during and after the Beijing Paralympic Games (Paralympics Games 22 = PG22); and to (2) gain a better understanding of if and potentially how awareness of athletes' mental distress changed, through weekly monitoring, and influenced how coachers perceive athletes' mental distress and if they accounted for this before, during and after PG22. A mixed-method study design was used, in which prospective mental distress (depression and anxiety) data were collected weekly from 13 [Swedish] elite Para athletes in preparation, during and after PG22. Data were screened and evaluated weekly by a physiotherapist and a sports psychologist, and coaches also received weekly reports. A focus-group interview with the coaches were conducted post Paralympics to address coaches' awareness about mental distress and athlete health monitoring in Parasport. For data analyses, descriptive statistics was used for the quantitative data and a content analysis was conducted for the qualitative data. The results reveled the following proportion of datapoints indicating symptoms of anxiety and depression: before PG22 (15.8 and 19.1%); during PG22 (47.6 and 38.2%); and after PG22 (0 and 11.8%). The qualitative results indicated that coaches perceived athlete health monitoring as helpful for increasing their awareness of mental distress, and as a useful tool to initiate support for their athletes as well as improving their coaching. In summary, this cohort of elite Para athletes reported a high proportion of mental distress during the Winter Paralympic Games in Beijing. The results also show that it is important and feasible to monitor Para athletes' mental distress to detect and manage early symptoms of mental distress.

Safe and Healthy Para sport project (SHAPE): a study protocol of a complex intervention within Para sport

Elite Para athletes report a high incidence of sports injuries, illnesses and other health issues. Despite this, there are few prevention programmes in Para sport, and many of the existing prevention programmes are not adapted to Para athletes. To improve the success of preventive measures, it has been suggested that sports safety work should facilitate health promotion, including athlete health education. Therefore, the overarching aim of this project is to evaluate an accessible health promotion web platform as part of a complex intervention that aims to improve knowledge of athlete health in Para sport. In this protocol, the development, future implementation and evaluation of the intervention are described. To inform the implementation and use of such interventions, it is recommended to involve end users in the development and implementation process. Therefore, a participatory design process, including athletes and the sports organisation, was used to develop an accessible health promotion web platform. To evaluate this complex intervention, a process evaluation combining quantitative evaluation assessing causal pathways with qualitative methods assessing multifaceted pathways will be used. The primary outcomes are injury/illness incidence, athlete health parameters, health literacy and user behaviour. A cohort of elite Para athletes (n=150) from Sweden and South Africa will be invited to participate. This project will be the first that aims to improve athlete health in Para sport through pragmatic and accessible health promotion. It is a boundary-crossing project that will be conducted in a real-world sport setting, including athletes with different socioeconomic backgrounds.

Vulnerability and stressors on the pathway to depression in a global cohort of young athletics (track and field) athletes

This research set out to identify pathways from vulnerability and stressors to depression in a global population of young athletes. Retrospective data were collected at age 18-19 years from Athletics athletes (n = 1322) originating from Africa, Asia, Europe, Oceania, and the Americas. We hypothesised that sports-related and non-sports-related stressors in interaction with structural vulnerability instigate depression. Path modelling using Maximum likelihood estimation was employed for the data analysis. Depression caseness and predisposition were determined using the WHO-5 instrument. Thirty-six percent of the athletes (n = 480) returned complete data. Eighteen percent of the athletes reported lifetime physical abuse, while 11% reported sexual abuse. Forty-five percent of the athletes had recently sustained an injury. The prevalence of depression caseness was 5.6%. Pathways to depression caseness were observed from female sex (p = 0.037) and injury history (p = 0.035) and to predisposition for depression also through exposure to a patriarchal society (p = 0.046) and physical abuse (p < 0.001). We conclude that depression in a global population of young athletes was as prevalent as previously reported from general populations, and that universal mental health promotion in youth sports should include provision of equal opportunities for female and male participants, injury prevention, and interventions for abuse prevention and victim support.

Preparing for snow-sport events at the Paralympic Games in Beijing in 2022: recommendations and remaining questions

During the 2022 Winter Paralympic Games in Beijing, the Para snow-sport events will be held at high altitudes and in possibly cold conditions while also requiring adjustment to several time zones. Furthermore, the ongoing COVID-19 pandemic may lead to suboptimal preparations. Another concern is the high rate of injuries that have been reported in the Para alpine and snowboard events. In addition to these challenges, Para athletes various impairments may affect both sports-specific demands and athlete health. However, the group of Para snow-sport athletes is an understudied population. Accordingly, this perspective paper summarises current knowledge to consider when preparing for the Paralympic Games in Beijing and point out important unanswered questions. We here focus specifically on how sport-specific demands and impairment-related considerations are influenced by altitude acclimatisation, cold conditions, travel fatigue and jetlag, complications due to the COVID-19 pandemic, and injury prevention and sports safety considerations. As Para athletes with spinal cord injury, limb deficiency, cerebral palsy and visual impairment account for the majority of the Para snow-sport athletes, the focus is mainly on these impairment groups. In brief, we highlight the extra caution required to ensure athlete health, performance and sports safety among Para athletes participating in the snow-sport events in the 2022 Beijing Paralympic Games. Although there is an urgent need for more high-quality research focusing on Para winter athletes, we hope these non-consensus recommendations will help prepare for the 2022 Beijing Paralympic Winter Games.

Blind sports’ blind spot: The global epidemiology of visual impairment against participation trends in elite blind para sport

Background: It remains unknown whether access to elite blind sports opportunities is globally balanced or matches the prevalence of blindness/visual impairment (VI). The primary objective of this study was to determine the rate of elite blind sports participation in each world region registered in the International Blind Sports Federation’s (IBSA) and to assess its association with the global and regional prevalence of blindness/VI. The secondary objective was to determine the association between other covariates, such as age, vision class, and sex, with the number of IBSA-registered athletes from each region.

Methods: A baseline estimate of blindness/VI data was established and used when comparing participation rates to blindness/VI rates. Descriptive statistics were used to describe sports participation and associated co-variates.

Results: Among 123 member countries registered in IBSA, 31 did not have any completed registrations in blind sports, of which 22 had a prevalence of blindness/VI higher than the global average. During the summer season 2019, 738 (29.52%) IBSA athletes were female and 1762 (70.48%) were male.

Conclusions: These results suggest elite blind/VI sport participation is limited independently from blindness/VI prevalence. Increasing blind-friendly sport resources, especially in low-and-middle-income countries (LMICs), would improve the rate of elite sport participation among athletes with blindness/VI.

'The Little Engine That Could': A Qualitative Study of Medical Service Access and Effectiveness among Adolescent Athletics Athletes Competing at the Highest International Level

Little is known about provision of medical services to adolescents prior to participating in international top-level sports. This study aimed to investigate experiences of medical service provision among high-level adolescent athletics (track and field) athletes from three continents. A thematic narrative analysis was applied to data collected from 14 athletes by semi-structured interviews. Although competing at the highest international level, these adolescent athletes had difficulties making sense of symptoms of ill health, especially on their own. With increasing exercise loads, the athletes’ medical support needs had extended beyond the capacity of parents and local communities. As there was no organized transfer of the responsibility for medical support to sports organizations, the athletes often had to manage their health problems by themselves. There were major variations among the adolescent athletes with regards to medical service access and quality. The services used ranged from sophisticated computer-assisted biomechanical analyses to traditional healers. Decreased exercise load was the common sports injury treatment. The results of this study demonstrate how the ethical standards underpinning youth sports as well as the equal provision of medical services to adolescents are challenged across the world. Further research on health service provision to adolescent top-level athletes is warranted.

Incidence of sports-related concussion in elite para athletes - a 52-week prospective study

Objective: To assess the 52-week incidence proportion and incidence rate of sports-related concussion (SRC) among elite Para athletes, and to analyze the injury mechanisms.Method: In total, 70 male and 37 female Swedish elite Para athletes (median age 29 years) with vision, physical and intellectual impairment, weekly self-reported sports-related injuries including concussion in an eHealth application adapted to Para athletes. Descriptive statistics were used to assess the incidence rate and incidence proportion. Chi-square statistics were used to analyze differences in the proportion of SRC.Results: A total of 13 SRC were reported: three athletes each sustained two SRC. The incidence proportion was 9.3% (95% CI 4.8-16.7), and the incidence rate 0.5 SRC/1000 hours (95% CI 0.3-0.9) of sports exposure. Athletes with vision impairment and female athletes reported a significantly higher proportion of SRC. A majority of the injuries (n = 9; 69%) occurred during sport-specific training. The injury mechanisms were collision with object (n = 7; 54%), collision with person (n = 4; 31%), and poor playing field conditions (n = 2; 16%).Conclusion: The incidence of concussion among elite Paralympic athletes is comparable to sports for able-bodied athletes. Athletes with vision impairment and female athletes reported a significantly higher incidence of SRC, and collisions were the most common injury mechanism. These results can form the basis for future preventive research studies.

Determinants of Sports Injury in Young Female Swedish Competitive Figure Skaters

Introduction: Although figure skating attracts several hundred thousand participants worldwide, there is little knowledge about physical health and sports injuries among young skaters. The present study aimed to describe the health status of a geographically defined Swedish population of licensed competitive figure skaters and to examine injury determinants.

Methods: All licensed competitive skaters in the southeastern region of Sweden were in April 2019 invited to participate in a cross-sectional study using an online questionnaire. Multiple binary logistic regression was used for the examination of injury determinants. The primary outcome measure was the 1-year prevalence of a severe sports injury episode (time loss >21 days). The secondary outcome measure was the point prevalence of an ongoing injury. The determinants analyzed were age, skating level, relative energy deficiency indicators, and training habits.

Results: In total, 142 (36%) skaters participated, 137 (96%) girls [mean (SD) age: 12.9 (SD 3.0) years]. Participating boys (n = 5) were excluded from further analysis. The 1-year prevalence of a severe sports injury episode was 31%. The most common injury locations for these injuries were the knee (25%), ankle (20%), and hip/groin (15%). In the multiple model, having sustained a severe injury episode was associated with older age (OR 1.2, 95% CI 1.1–1.4; p = 0.002) and an increased number of skipped meals per week (OR 1.1, 95% CI 1.0–1.3; p = 0.014). The point prevalence of an ongoing injury episode was 19%. The most common locations were the knee (24%), ankle (24%), and foot (24%). Having an ongoing injury episode was associated with older age (OR 1.4, 95% CI 1.2–1.7; p < 0.001) and an increased number of skipped meals per week (OR 1.1, 95% CI 1.0–1.3; p = 0.049).

Conclusion: One-third of young female Swedish competitive figure skaters had sustained a severe injury episode during the past year, and a fifth reported an ongoing episode. Older age and an increased number of skipped meals per week were associated with a sports injury episode. Long-term monotonous physical loads with increasing intensity and insufficient energy intake appear to predispose for injury in young female figure skaters. Further examination of injury determinants among competitive figure skaters is highly warranted.

Lifetime Prevalence of Verbal, Physical, and Sexual Abuses in Young Elite Athletics Athletes

To examine prevalence of verbal, physical, and sexual abuses in young elite athletes, a cross sectional questionnaire-based survey was conducted during the World Athletics under 20 World Championships. This questionnaire aimed at distinguishing between abuses perpetrated in the context of Athletics from those which were unrelated to Athletics. Four hundred and eighty athletes (52.3%, male) from North America, South America, Europe, Africa, Asia, and Oceania took part in the electronic anonymous survey. Outside Athletics setting, no gender difference was found for the prevalence of verbal, physical, and sexual abuses. However, 45 males (18% of the male population) and 34 females (15% of the female population) athletes reported sexual abuse. Asian athletes reported a slightly higher rate of sexual abuse; three quarters of them being non-touching abuses. Inside Athletics setting, no gender difference was found for the prevalence of verbal, physical, and non-touching sexual abuses. However, 58 males (23%) and 47 females (21%) reported verbal abuses. Thirty-one males (12%) and 20 females (9%) reported physical abuses, whereas 30 males (12%) and 17 females (7%) reported sexual abuses. Physical abuses were slightly more frequent in Asia and in Africa and less frequent in South America. Sexual abuses inside Athletics also differed over regions, and were unexpectedly twice more frequent than expected in Asia and slightly less frequent than expected in Europe. Friends and partners were identified as the more frequent (>50%) abusers outside or inside the Athletics settings, whereas outside Athletics and inside Athletics, coaches were identified as sexual abuse perpetrators in 8 and 25% of cases, respectively. The prevalence of verbal, physical, or sexual abuses is high but consistent with what has been reported in United Kingdom, Norway, Canada, and Sweden at national level in recreational or elite athletes. Sexual abuse, including touching or penetrative abuses, occurred significantly more often in male athletes when compared to female athletes. This finding invites healthcare and social workers, and policymakers to also consider the risk of sexual abuse of young male athletes in Athletics. These results also call for longitudinal studies on young elite athletes.

Para sport translation of the IOC consensus on recording and reporting of data for injury and illness in sport

In 2020, the IOC proposed a universal methodology for the recording and reporting of data for injury and illness in sport. Para sport is played by individuals with impairment, and they have a unique set of considerations not captured by these recommendations. Therefore, the aim of this addendum to IOC consensus statement was to guide the Para sport researcher through the complexities and nuances that should be taken into consideration when collecting, registering, reporting and interpreting data regarding Para athlete health. To develop this translation, experts in the field of Para sports medicine and epidemiology conducted a formal consensus development process, which began in March 2020 with the formation of a consensus group that worked over eight phases, incorporating three virtual consensus meetings to finalise the translation. This translation is consistent with the IOC consensus statement, yet provides more detailed Para athlete specific definitions and recommendations on study population, specifically, diagnostic and eligible impairment categorisation and recording of adaptive equipment, and defining and classifying health problems in the context of Para sport. Additionally, recommendations and Para athlete specific examples are described with regards to injury mechanism, mode of onset, injury and illness classification, duration, capturing and reporting exposure and risk. Finally, methods and considerations are provided to cater to the varied needs of athletes with impairment with respect to data collection tools. This harmonisation will allow the science to develop and facilitate a more accurate understanding of injury and illness patterns for tailoring evidence-informed prevention programmes and enabling better planning of medical services for Para sport events.

Concussion in para sport: the first position statement of the Concussion in Para Sport (CIPS) Group

Concussion is a frequent injury in many sports and is also common in para athletes. However, there is a paucity of concussion research related to para sport, and prior International Concussion in Sport (CIS) consensus papers have not substantively addressed this population. To remedy this and to improve concussion care provided to para athletes, the concussion in para sport (CIPS) multidisciplinary expert group was created. This group analysed and discussed in-depth para athlete-specific issues within the established key clinical domains of the current (2017) consensus statement on CIS. Due to the onset of the COVID-19 pandemic, the group held all meetings by video conferencing. The existing Sport Concussion Assessment Tool 5 (SCAT5) for the immediate on-field and office-based off-field assessment of concussion was evaluated as part of this process, to identify any para athlete-specific concerns. Regular preparticipation and periodic health examinations are essential to determine a baseline reference point for concussion symptoms but pose additional challenges for the interpreting clinician. Further considerations for concussion management for the para athlete are required within the remove, rest, reconsider and refer consensus statement framework. Considering return to sport (RTS), the 2017 CIS consensus statement has limitations when considering the RTS of the para athlete. Case-by-case decision making related to RTS following concussion is imperative for para athletes. Additional challenges exist for the evaluation and management of concussion in para athletes. There is a need for greater understanding of existing knowledge gaps and attitudes towards concussion among athlete medical staff, coaches and para athletes. Future research should investigate the use and performance of common assessment tools in the para athlete population to better guide their clinical application and inform potential modifications. Concussion prevention strategies and sport-specific rule changes, such as in Para Alpine Skiing and Cerebral Palsy Football, also should be carefully considered to reduce the occurrence of concussion in para athletes.

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships

Background

Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type.

Design

Cross-sectional web-based survey.

Methods

A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination.

Results

A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation.

Conclusions

The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

Prevalence of Sports-Related Injuries and Illnesses in Paralympic Athletes

BACKGROUND

With increased participation in Paralympic sports, the burden of sports-related injuries and illnesses may increase. However, there is limited knowledge about the epidemiology of sports-related injuries and illnesses in Paralympic sports (SRIIPS).

OBJECTIVE

To describe among Swedish Paralympic athletes the 1-year retrospective period prevalence of severe SRIIPS and the point prevalence of all SRIIPS and to examine differences in prevalence proportions between athletes with different impairments, behaviors, and sport characteristics.

DESIGN

Cross-sectional study.

SETTING

Swedish Paralympic Programme.

PARTICIPANTS

One hundred and four Paralympic athletes with visual, physical, and intellectual impairment.

METHODS

An eHealth application adapted to Paralympic athletes was used to collect self-report data on existing and previous SRIIPS, as well as impairment, behavior, and sport characteristics.

MAIN OUTCOME MEASUREMENTS

One-year retrospective period prevalence and point prevalence.

RESULTS

The period prevalence of severe injuries was 31% (95% CI 23-40) and the point prevalence 32% (95% CI 24-41). The period prevalence of severe illnesses was 14% (95% CI 9-23), and 13% of the athletes (95% CI 8-22) reported a current illness. More severe injuries (P <.05) were reported by athletes aged 18 to 25 years, not using assistive device, having pain during sport, using analgesics, continuing training injured, and feeling guilt when missing exercise. Athletes who reported a previous severe injury, having pain in daily life and during sport, using analgesics, and being upset when unable to exercise had a higher prevalence of current injuries (P <.05). Being female, reporting previous severe illness, using prescribed medication, and feeling anxious/depressed were features associated with ongoing illnesses (P <.05).

CONCLUSION

Paralympic athletes report a high prevalence of SRIIPS. Behavioral and psychological aspects as well as pain and use of medication appear to be associated with the occurrence of SRIIPS. The results imply that factors leading to SRIIPS are complex and call for a broad biopsychosocial approach when developing preventive measures.

LEVEL OF EVIDENCE

III.

mHealth Self-Report Monitoring in Competitive Middle- and Long-Distance Runners: Qualitative Study of Long-Term Use Intentions Using the Technology Acceptance Model

Background

International middle- and long-distance running competitions attract millions of spectators in association with city races, world championships, and Olympic Games. It is therefore a major concern that ill health and pain, as a result of sports overuse, lead to numerous hours of lost training and decreased performance in competitive runners. Despite its potential for sustenance of performance, approval of mHealth self-report monitoring (mHSM) in this group of athletes has not been investigated.

Objective

The objective of our study was to explore individual and situational factors associated with the acceptance of long-term mHSM in competitive runners.

Methods

The study used qualitative research methods with the Technology Acceptance Model as the theoretical foundation. The study population included 20 middle- and long-distance runners competing at national and international levels. Two mHSM apps asking for health and training data from track and marathon runners were created on a platform for web survey development (Briteback AB). Data collection for the technology acceptance analysis was performed via personal interviews before and after a 6-week monitoring period. Preuse interviews investigated experience and knowledge of mHealth monitoring and thoughts on benefits and possible side effects. The postuse interviews addressed usability and usefulness, attitudes toward nonfunctional issues, and intentions to adhere to long-term monitoring. In addition, the runners’ trustworthiness when providing mHSM data was discussed. The interview data were investigated using a deductive thematic analysis.

Results

The mHSM apps were considered technically easy to use. Although the runners read the instructions and entered data effortlessly, some still perceived mHSM as problematic. Concerns were raised about the selection of items for monitoring (eg, recording training load as running distance or time) and about interpretation of concepts (eg, whether subjective well-being should encompass only the running context or daily living on the whole). Usefulness of specific mHSM apps was consequently not appraised on the same bases in different subcategories of runners. Regarding nonfunctional issues, the runners competing at the international level requested detailed control over who in their sports club and national federation should be allowed access to their data; the less competitive runners had no such issues. Notwithstanding, the runners were willing to adhere to long-term mHSM, provided the technology was adjusted to their personal routines and the output was perceived as contributing to running performance.

Conclusions

Adoption of mHSM by competitive runners requires clear definitions of monitoring purpose and populations, repeated in practice tests of monitoring items and terminology, and meticulousness regarding data-sharing routines. Further naturalistic studies of mHSM use in routine sports practice settings are needed with nonfunctional ethical and legal issues included in the evaluation designs.

Transcutaneous oxygen pressure as a predictor for short-term survival in patients with type 2 diabetes and foot ulcers: a comparison with ankle-brachial index and toe blood pressure

AIMS

Ankle-brachial index (ABI) is the most commonly used test when diagnosing peripheral vascular disease and is considered a marker for cardiovascular risk. Transcutaneous oxygen pressure (TcPO₂), a test associated with microvascular function, has in several studies shown better correlation with diabetic foot ulcer (DFU) healing. Whether a low TcPO₂ could be a marker for mortality in the high-risk population of DFU patients has not been evaluated before. The aim of this study was to evaluate the predictive value of TcPO₂ in comparison with ABI and toe blood pressure (TBP) on 1-year mortality in type 2 diabetes patients with DFU.

METHODS

Type 2 diabetes patients aged ≤ 90 years, with one DFU who attended our multidisciplinary DFU-unit during year 2013-2015 and were screened with TcPO₂, ABI and TBP were retrospectively evaluated. One-year mortality was assessed from the national death register in Sweden.

RESULTS

A total of 236 patients (30% women) with a median age of 76 (69-82) years were evaluated in this study. Within 1 year, 14.8% of the patients died. TcPO₂ < 25 mmHg was associated with a higher 1-year mortality compared with TcPO₂ ≥ 25 mmHg (27.7 vs. 11.6%, p = 0.003). TBP and ABI did not significantly influence 1-year mortality. In a Cox regression analysis adjusted for confounders, TcPO₂ was independently predicting 1-year mortality with a hazard ratio for TcPO₂ < 25 mmHg of 2.8 (95% CI 1.34-5.91, p = 0.006).

CONCLUSIONS

This study indicates that a low TcPO₂ is an independent prognostic marker for 1-year mortality among patients with type 2 diabetes and DFU.

An eHealth Application of Self-Reported Sports-Related Injuries and Illnesses in Paralympic Sport: Pilot Feasibility and Usability Study

Background

Sport participation is associated with a risk of sports-related injuries and illnesses, and Paralympic athletes’ additional medical issues can be a challenge to health care providers and medical staff. However, few prospective studies have assessed sports-related injuries and illnesses in Paralympic sport (SRIIPS) over time. Advances in mobile phone technology and networking systems offer novel opportunities to develop innovative eHealth applications for collection of athletes’ self-reports. Using eHealth applications for collection of self-reported SRIIPS is an unexplored area, and before initiation of full-scale research of SRIIPS, the feasibility and usability of such an approach needs to be ascertained.

Objective

The aim of this study was to perform a 4-week pilot study and (1) evaluate the monitoring feasibility and system usability of a novel eHealth application for self-reported SRIIPS and (2) report preliminary data on SRIIPS.

Methods

An eHealth application for routine collection of data from athletes was developed and adapted to Paralympic athletes. A 4-week pilot study was performed where Paralympic athletes (n=28) were asked to weekly self-report sport exposure, training load, general well-being, pain, sleep, anxiety, and possible SRIIPS. The data collection was followed by a poststudy use assessment survey. Quantitative data related to the system use (eg, completed self-reports, missing responses, and errors) were analyzed using descriptive statistics. The qualitative feasibility and usability data provided by the athletes were condensed and categorized using thematic analysis methods.

Results

The weekly response rate was 95%. The athletes were of the opinion that the eHealth application was usable and feasible but stated that it was not fully adapted to Paralympic athletes and their impairments. For example, it was difficult to understand how a new injury or illness should be identified when the impairment was involved. More survey items related to the impairments were requested, as the athletes perceived that injuries and illnesses often occurred because of the impairment. Options for description of multifactorial incidents including an injury, an illness, and the impairment were also insufficient. Few technical issues were encountered, but athletes with visual impairment reported usability difficulties with the speech synthesizer. An incidence rate of 1.8 injuries and 1.7 illnesses per 100 hours of athlete exposure were recorded. The weekly pain prevalence was 56% and the impairment contributed to 20% of the reported incidents.

Conclusions

The novel eHealth-based application for self-reported SRIIPS developed and tested in this pilot study was generally feasible and usable. With some adaptation to accommodate Paralympic athletes’ prerequisites and improved technical support for athletes with visual impairment, this application can be recommended for use in prospective studies of SRIIPS.

Trial Registration

ClinicalTrials.gov NCT02788500; https://clinicaltrials.gov/ct2/show/NCT02788500 (Archived by WebCite at http://www.webcitation.org/6v56OqTeP)

Test-Retest Reliability of Isokinetic Knee Strength Measurements in Children Aged 8 to 10 Years

Background:

Isokinetic dynamometry is a useful tool to objectively assess muscle strength of children and adults in athletic and rehabilitative settings. This study examined test-retest reliability of isokinetic knee strength measurements in children aged 8 to 10 years and defined limits for the minimum difference (MD) in strength that indicates a clinically important change.

Hypothesis:

Isokinetic knee strength measurements (using the Biodex System 4) in children will provide reliable results.

Study Design:

Descriptive laboratory study.

Methods:

In 22 healthy children, 5 maximal concentric (CON) knee extensor (KE) and knee flexor (KF) contractions at 2 angular velocities (60 deg/s and 180 deg/s) and 5 maximal eccentric (ECC) KE/KF contractions at 60 deg/s were assessed 7 days apart. The intraclass correlation coefficient (ICC_2.1) was used to examine relative reliability, and the MD was calculated on the basis of standard error of measurement.

Results:

ICCs for CON KE/KF peak torque measurements were fair to excellent (range, 0.49-0.81). The MD% values for CON KE and KF ranged from 31% to 37% at 60 deg/s and from 34% to 39% at 180 deg/s. ICCs in the ECC mode were good (range, 0.60-0.70), but associated MD% values were high (>50%). There was no systematic error for CON KE/KF and ECC KE strength measurements at 60 deg/s, but systematic error was found for all other measurements.

Conclusion:

The dynamometer provides a reliable analysis of isokinetic CON knee strength measurements at 60 deg/s in children aged 8 to 10 years. Measurements at 180 deg/s and in the ECC mode were not reliable, indicating a need for more familiarization prior to testing.

Clinical Relevance:

The MD values may help clinicians to determine whether a change in knee strength is due to error or intervention.

The Sports-Related Injuries and Illnesses in Paralympic Sport Study (SRIIPSS): a study protocol for a prospective longitudinal study

BACKGROUND

Paralympic sport provides sporting opportunities for athletes with a disability, with the Paralympic Games as the main event. Participation in sport is, however, associated with a significant risk for sustaining injuries and illnesses. Our knowledge of sports-related injuries and illnesses in Paralympic sport is very limited and there are no large-scale epidemiological cohort studies. The purpose here is to present a protocol for a prospective longitudinal study: The Sports-Related Injuries and Illnesses in Paralympic Sport Study (SRIIPSS).

METHODS/DESIGN

An argument-based method for investigation of design problems was used to structure the study protocol. The primary requirement of the protocol is to allow prospective studies over time and include exposure to both training and competition. To reflect the complexity of Paralympic sport with athletes' pre-existing impairments, use of assistive equipment, pain and other and medical issues, it is required that the data collection system is specifically adapted to Paralympic sport. To allow the collection of data, at the same time as there is limited access to coaches and medical personnel, it is advantageous that data can be collected online directly from the athletes. Based on this a self-report athlete monitoring system will be developed, where the athletes can enter data weekly via their mobile phones or lap-tops. Data will be collected from around 100 Swedish Paralympic athletes for approximately 1 year, which will allow us to i) prospectively estimate the annual incidence of sports-related injuries and illnesses and ii) explore risk factors and mechanisms for sustaining sports-related injuries and illnesses based on athlete exposure and training loads.

DISCUSSION

For effective implementation of injury and illness prevention measures, comprehensive epidemiological knowledge is required. This study will be the first prospective longitudinal self-report study of sports-related injuries and illnesses in Paralympic sport over a longer period of time. The results will eventually contribute to the development of evidence-based preventive measures specifically adapted to Paralympic sport in order to provide safe and healthy sport participation. Thereby, the project will be of relevance for Paralympic athletes at all levels and to the Paralympic Movement.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov (Identifier: NCT02788500; Registration date: 22 May 2016).

Heart rate-corrected QT interval prolongation as a prognostic marker for 3-year survival in people with Type 2 diabetes undergoing above-ankle amputation

AIM

To evaluate whether heart rate-corrected QT interval is a plausible prognostic factor for survival after major amputation in people with Type 2 diabetes.

METHODS

All people with Type 2 diabetes aged < 80 years who underwent a major amputation at two hospitals with multidisciplinary diabetic foot teams were evaluated and grouped according to whether their heart rate-corrected QT interval was  ≤  or  > 440 ms.

RESULTS

A total of 70 patients with a median age of 72 years were included in the study. During the 3 years of follow-up, 38 patients (54%) died. Heart rate-corrected QT interval prolongation was present in 51.4% of the patients and was strongly associated with 3-year mortality (73 vs 36%; P < 0.001). In a Cox proportional hazard model, heart rate-corrected QT interval prolongation was the strongest independent risk factor for 3-year mortality [hazard ratio 2.20 (95% CI 1.11-4.38)]. Treatment with metformin seemed to have a protective effect [hazard ratio 0.22 (95% CI 0.05-0.94)].

CONCLUSIONS

The findings of the present study indicate that heart rate-corrected QT interval prolongation is associated with increased mortality in people with Type 2 diabetes undergoing above-ankle amputation.

The impact of metabolic control and QTc prolongation on all-cause mortality in patients with type 2 diabetes and foot ulcers

AIMS/HYPOTHESIS

The increased all-cause mortality in patients with chronic diabetic foot ulcers cannot fully be explained by traditional cardiovascular risk factors. The significance of heart-rate-corrected QT (QTc) prolongation, a finding often seen in these patients, is unknown. Recently, the importance of metabolic control and hypoglycaemia has been discussed. The aim of this study was to evaluate the impact of different HbA1c levels and QTc prolongation on all-cause mortality in the high-risk population of patients with type 2 diabetes mellitus and foot ulcers.

METHODS

All patients with type 2 diabetes, younger than 80 years, visiting our diabetes foot unit, with a foot ulcer duration >4 weeks, were screened for participation. Patients on dialysis were excluded. Patients were grouped according to HbA1c level and QTc time ≤ or > 440 ms.

RESULTS

Patients (n = 214, median age 69.1 years) were grouped according to HbA1c level (HbA1c < 7.5% [<58 mmol/mol] n = 81, 7.5-8.9% [58-74 mmol/mol] n = 70, >8.9% [>74 mmol/mol] n = 63). Baseline characteristics, including use of potential hypoglycaemic drugs, were similar between groups. During the 8 years of follow-up 151 patients died (70.6%) and HbA1c < 7.5% (<58 mmol/mol) was strongly associated with increased mortality. The highest mortality was seen in patients with a combination of HbA1c < 7.5% (<58 mmol/mol) and QTc prolongation, with an 8 year mortality of 92.1% as compared with 48.8% in those with HbA1c < 7.5% (<58 mmol/mol) but without QTc prolongation. CONCLUSION/INTERPRETATIONS: HbA1c < 7.5% (<58 mmol/mol) in a high-risk population of patients with type 2 diabetes and foot ulcers is associated with a significantly higher mortality, particularly in patients with QTc prolongation.