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To analyse the association between pre-participation health status and in-championships injuries in a large dataset from seven international athletics championships, and to determine the health status of athletes during the four weeks before the start of international athletics championships.Prospective cohort study.We used data collected from athletes of national teams with medical staff who participated i) in a pre-participation health survey (retrospective data collection) and ii) in an in-championships injury surveillance (prospective data collection) during seven international athletics championships (2013-2018). We performed a binomial logistic regression with in-championship injury (yes/no) as the dependent variable and sex, age, discipline (explosive/endurance), type of championships (outdoor/indoor) and pre-participation injury complaint (yes/no) and pre-participation illness complaint (yes/no) as independent variables, with odds ratios (OR) and 95% confidence intervals (95% CI).Out of the 1095 athletes included 31.2% reported an injury complaint during the 4 weeks before the championships and 21.6% an illness complaint. The univariate model showed that discipline, type of championships and pre-participation injury complaints (OR = 2.57, 95%CI: 1.66 to 3.97) were significantly associated with in-championships injuries, and the multivariable model showed that type of championships and pre-participation injury complaints (OR = 2.64, 95%CI: 1.60 to 4.36) remained significantly associated with in-championships injuries.Our present study shows that an injury complaint during the four weeks before an international athletics championship significantly increased risk of sustaining an injury during the following championship, which was reported by about one third of athletes with differences between sex and disciplines.

Background: Long-term effects of playing soccer (football) on the brain structure and function of the brain are vividly debated. While some studies showed differences in neurocognitive performance and structural brain changes in retired male players, data on female players are scarce. The present study compares cortical thickness and neurocognitive performance in former high-level female soccer (SOC) and non-contact sport athletes (CON). Methods: 3 T T1-weighted 3D MPRAGE MRI was performed, and vertex-wise cortical thickness was analyzed using FreeSurfer (v. 6.0.0). Neurocognitive performance in seven domains of SOC and CON was assessed. A multivariate linear model was used to analyze interactions with respect to heading frequency and a history of concussion. Results: SOC (n = 15, mean age 38.3 ± 5.1 years) and CON (n = 16, mean age 36.6 ± 5.8 years) had a similar cortical thickness and performed similarly in the neurocognitive tests except for verbal memory and psychomotor speed, where SOC performed significantly worse than CON. Moderate headers had a significantly larger cortical thickness than rare headers in the right inferior parietal region. Visual memory and cortical thickness were positively correlated in the group of frequent headers and negatively correlated in CON, but not in the other header groups. Perspective: In contrast to previous reports in male soccer players, female players did not reveal cortical thinning in comparison with control athletes, whereas neurocognitive profiles of female soccer players might not significantly differ from male athletes. Small sample sizes, subjective header assessment, and the case–control study design require a cautious interpretation.

Objectives It has been claimed that analyses of large datasets from publicly accessible, open-collaborated (“citizen science-based”) online databases may provide additional insight into the epidemiology of injuries in professional football. However, this approach comes with major limitations, raising critical questions about the current trend of utilising citizen science-based data. Therefore, we aimed to determine if citizen science-based health data from a popular online database on professional football players can be used for epidemiological research, i.e. in providing results comparable to other data sources used in previously published studies. Design Retrospective database analysis. Methods Transfermarkt.com (Transfermarkt; Hamburg; Germany) is a publicly accessible online database on various data of professional football players. All information provided in the section “injury history” of football players from the top five European leagues over a period of ten seasons (2009/10–2018/19) were analysed. Frequency, characteristics, and incidence of injuries were reported according to seasons and countries, and results compared with three previously published databases (a scientific injury surveillance, a media-based study, and an insurance database). Results Overall, 21,598 injuries of 11,507 players were analysed from the Transfermarkt.com database. Incidence was 0.63 injuries per player-season (95% CI 0.62 to 0.64) but significant differences between subgroups (countries, years) were found. In comparison to other databases, citizen science-based data was associated with lower injury incidences and higher proportions of severe injuries. Conclusions With few exceptions (e.g., severe injuries), the use of citizen science-based health data on professional football players cannot be recommended at present for epidemiological research.

Background Team-sport players have a particularly high injury risk. Although female sex is considered a risk factor, it is still unknown whether female and male team-sport players, in fact, differ in their injury rates. We aimed to compare injury rates between female and male players by systematically reviewing and meta-analyzing injury surveillance studies of both sexes in order to evaluate sex-specific differences in team-sport injuries. Methods Studies that prospectively collected injury data for high-level female and male players (age ≥16 years) in basketball, field hockey, football (soccer), handball, rugby (union and sevens), and volleyball were included. Two reviewers (AZ and AL) independently assessed study quality and extracted data for overall, match, training, and severe injuries (>28 days’ time loss) as well as data regarding injury locations and types. Incidence rate ratios (IRRs) were pooled in a meta-analysis, and meta-regression analysis was performed when 10 or more studies were available. Results Of 20 studies, 9 studies reported injury data from football, 3 studies from rugby, 3 studies from handball, 1 study from basketball, 1 study from field hockey, 2 studies from volleyball, and 1 study from basketball and field hockey. For overall injuries, the pooled IRR (0.86; 95% confidence interval (95%CI): 0.76−0.98) indicated significantly more injuries in male than in female players. For injury location, the pooled IRR showed higher injury rates in male athletes than in female athletes for upper extremity, hip/groin, thigh, and foot injuries. Female players had a significantly higher rate of anterior cruciate ligament injuries (IRR = 2.15, 95%CI: 1.27−3.62) than male players. No significant sex-specific differences in IRR were found for match, training, severe injuries, concussions, or ankle sprains. Conclusion Our meta-analysis provides evidence for sex-specific differences in the injury rates in team sports. Further epidemiological studies including both sexes in sports other than football are needed in order to strengthen the evidence.

Fixture congestion increases injury risk in football, but how it impacts other sports is unclear. The aim of this study was to identify associations between match density and injury incidence in field hockey players. Injury data from a prospective cohort study of professional and youth players was analysed in two ways. Inter-match intervals were clustered into

OBJECTIVE To assess the mental health and experience of sport-related harassment and abuse of elite aquatic athletes and to analyze it in relation to gender and discipline. DESIGN Cross-sectional study using an anonymous survey. SETTING The FINA World Championships 2019. PARTICIPANTS Registered athletes in the disciplines of swimming, diving, high diving, water polo, artistic swimming, and open water swimming. INTERVENTIONS Athletes completed an online or paper-based questionnaire. MAIN OUTCOME MEASURES The main outcome measures included screening for depression (10-item version of the Center for Epidemiological Studies Depression Scale revised), eating disorders (Brief Eating Disorders in Athletes Questionnaire), the subjective need for psychotherapeutic support, and the experience of sport-related harassment and/or abuse. RESULTS A quarter (24.6%) of the 377 responding athletes were classified as depressed and 2.5% as having an eating disorder. More than 40% of the athletes stated that they wanted or needed psychotherapeutic support. Fifty-one athletes (14.9%) had experienced harassment/abuse in sport themselves, and 31 (9%) had witnessed it in another athlete. The experiences of harassment and abuse ranged from unwanted comments about body or appearance (40.2%) to rewards in sport for sexual favors (2.5%) and rape (0.3%). Athletes who had experienced harassment/abuse in sport themselves had higher average scores for depression and eating disorders, and more of them felt they needed psychotherapeutic support. Up to a third would not talk or report to anybody if they saw or experienced harassment/abuse, and less than 20% would talk to an official for help. CONCLUSION Targeted initiatives are required to address mental health issues and harassment and abuse in sport in the FINA aquatic disciplines.

Objectives To analyse the potential association between in-competition injuries and performance success (determined as “winning a medal”) in combined events during international athletics championships. Methods Newly incurred injuries were prospectively reported daily by the national medical teams and/or by the local organising committee physicians during 18 international athletics championships. Participation, climatic conditions and performance (medals) were collected retrospectively from the internet. Potential association between injury and performance success (win a medal) were analysed using an adjusted stepwise multiple regression and risk indicators presented as Odd Ratios (OR) (95%CI). Then, the proportions of injured competing athletes were descriptively presented among ranked and dropped-out, and medallist and non-medallist athletes. Results A total of 799 athletes competed in combined events during the included 18 championships, of these 134 (16.8%) had at least one injury. An adjusted stepwise multiple regression analysis revealed that in-competition injury was significantly associated with lower odds of winning a medal (OR = 0.45 (95% CI 0.20–0.88)). The proportion of injured athletes was higher among the dropped-out than among the ranked athletes, and among non-medallists than medallists. Design This was a total population design. Conclusions During international athletics championships, being injured during a combined events competition was associated with lower odds of winning a medal. Injury prevention could contribute to improve performance success.

ObjectivesThe primary aim was to describe the characteristics and prevalence of musculoskeletal complaints of a large group of non-professional golfers. Secondary aims were to compare golfers different in (A) skill-level, (B) presence of low back pain (LBP) and (C) performance of prevention exercises.MethodsA sample of 1170 male golfers (mean age 54.98, SD=13.3) were surveyed online on personal and golf-specific characteristics, medical history and complaints in the preceding 7 days. Subgroups (A) with different golfing handicap (0 to 5, >5 to 10, >10), (B) with and without LBP and (C) who performed versus did not perform injury prevention exercises were compared using analysis of variance and χ2test.ResultsThe prevalence and severity of musculoskeletal complaints was similar in everyday life and when playing golf. More than one-third of the golfers (n=436; 37.3%) reported LBP in the preceding 7 days, while other frequently affected body parts were the shoulder and knee. Golfers with different skill level differed in age and most golf-related characteristics but not in prevalence and severity of musculoskeletal complaints. Golfers with and without LBP were similar in almost all variables. Golfers who performed prevention exercises (n=371; 27.1%) were older and had a higher prevalence of complaints.ConclusionThe prevalence and severity of musculoskeletal complaints in golfers were similar to the wider population. It seems that injury prevention exercises were implemented after injury, rather than as primary prevention. Prospective studies looking at the epidemiology of injury, risk factors and interventions are required.

Epidemiological studies of injury in elite and recreational golfers have lacked consistency in methods and definitions employed and this limits comparison of results across studies. In their sports-generic statement, the Consensus Group recruited by the IOC (2020) called for sport-specific consensus statements. On invitation by International Golf Federation, a group of international experts in sport and exercise medicine, golf research and sports injury/illness epidemiology was selected to prepare a golf-specific consensus statement. Methodological stages included literature review and initial drafting, online feedback from the consensus group, revision and second draft, virtual consensus meetings and completion of final version. This consensus statement provides golf-specific recommendations for data collection and research reporting including: (i) injury and illness definitions, and characteristics with golf-specific examples, (ii) definitions of golf-specific exposure measurements and recommendations for the calculation of prevalence and incidence, (iii) injury, illness and exposure report forms for medical staff and for golfers, and (iv) a baseline questionnaire. Implementation of the consensus methodology will enable comparison among golf studies and with other sports. It facilitates analysis of causative factors for injuries and illness in golf, and can also be used to evaluate the effects of prevention programmes to support the health of golfers.

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport-specific or setting-specific consensus statements on sports injury (and, eventually, illness) epidemiology to date. Our objective was to further strengthen consistency in data collection, injury definitions and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension. The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups and a 3-day consensus meeting in October 2019. This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems; severity of health problems; capturing and reporting athlete exposure; expressing risk; burden of health problems; study population characteristics and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE Extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS). The IOC encourages ongoing in- and out-of-competition surveillance programmes and studies to describe injury and illness trends and patterns, understand their causes and develop measures to protect the health of the athlete. Implementation of the methods outlined in this statement will advance consistency in data collection and research reporting. Funding Agencies|International Olympic Committee

Objective:There is an ongoing debate on the potential negative effect of contact sport participation on long-term neurocognitive performance due to inherent exposure to concussive and subconcussive head impacts. The aim of the present study was to investigate whether cognitive ageing is exacerbated in elite soccer players compared to the general population.Method:Neurocognitive performance in 6 domains was compared between 240 elite soccer players and a normative sample from the general population (n = 585) using the computerised test battery CNS Vital Signs. We used two-way factorial ANOVA to analyse the interaction between age groups (15–19, 20–29, 30–39, 40–49 years) and study population (female soccer players vs. norm sample) in their effects on neurocognitive performance.Results:We found no significant interaction effect of age group and study population in five of six test domains. For processing speed, the effect of age was more pronounced in female soccer players (F= 16.89,p= .002). Further, there was a clear main effect of study population on neurocognitive performance with generally better scores in soccer players.Conclusions:Elite female soccer players generally performed better than the norm sample on tests of cognitive function, and further, cognitive ageing effects were similar in elite soccer players and controls in all but one domain. A lifespan approach may facilitate insightful future research regarding questions related to long-term neurocognitive health in contact sport athletes.

Objective To assess athlete's training environment and health problems before the FINA World Championships (WC) (2017) and to analyze the differences between the 6 disciplines, gender, and countries with different medal rankings during the championships. Design Retrospective anonymous questionnaire. Setting FINA WC 2017. Participants Registered aquatic athletes (swimmers, divers, high divers, water polo players, artistic swimmers, open water swimmers). Main outcome measures The outcome measures included the following: training and competition load, availability of support staff, performance of injury prevention exercises, and prevalence of health problems. The independent variables included gender, aquatic discipline, and country group based on medal ranking. Results In the 12 months preceding the Championships, 67% of the athletes reported physical complaints and 41% trained or competed with a diagnosed injury. Only half of the athletes reported that injury prevention exercises were always (29.9%) or often (23.4%) a regular part of their daily training. In the daily training environment, support staff (excluding coach) was not available or available only if the athlete pays in 28.4% (specialized trainer) to 58.9% (sport scientist) of cases. About one-quarter of the athletes rated the support offered by their National Team program as poor or very poor. There were discrepancies in training loads and support staff among the 6 aquatic disciplines. Availability of support staff, athlete's satisfaction with their training environment/support, and regular use of injury prevention exercises were higher in countries that ranked higher in the medal list. Conclusions Injury prevention strategies should be promoted in aquatic sports, with prospective surveillance for the early identification of physical complaints. The facilitation of access to sport-specific experts could improve athlete's health and performance, especially in countries with low medal ranking.

Several international sports federations have implemented a standardized injury reporting system during their championships. However, very few studies have investigated athletes with disabilities during major championships apart from the Paralympic Games. Therefore, the aim of this study was to assess the rate and characteristics of injuries during the Wheelchair Basketball World Championships 2018 (WBWC). This prospective cohort study was conducted during the WBWC held in Hamburg, Germany, from August 16 to August 26, 2018. Physicians or physiotherapists of all 28 participating teams (total 336 players) were asked to report all newly incurred injuries (with location, diagnosis, cause, and estimated duration of absence) daily on a standardized injury report form. Prevalence and incidence rates were calculated. Medical staff of 11 teams (132 players) reported 100 injuries, equivalent to 75.8 per 100 players (95% CI: 60.9-90.7) or 68.9 per 1000 player-days (55.4-82.4). Eight time-loss injuries were reported (6.1 injuries per 100 players [95% CI: 1.9-10.3] or 5.5 injuries per 1000 player-days [1.7-9.3]). More injuries were incurred during matches (n = 68) than during training. Most injuries affected the neck/cervical spine (16%), thoracic spine/upper back (15%), and shoulder (14%). The most frequent diagnosis was muscle spasms (25%), the most frequent cause was overuse (52%). A high rate of non-time-loss injuries compared to Paralympic Games was reported. Future studies should focus on the etiology of muscle spasms and further identify injury mechanisms of traumatic and overuse injuries in wheelchair basketball players to develop adequate preventive measures.

Purpose. Physical activity (PA) can protect from developing mental disorders. Knowledge regarding optimal PA intensity, type, context, and amount for mental health is sparse. this study aims to determine the relationship between leisure-time PA and prevalence of depression and anxiety, and whether associations vary by PA amount, context, intensity, and type. Methods. Overall, 682 recreational athletes (age: M = 33.0 years; SD = 12.4; 53% female) completed a questionnaire on personal characteristics related to their leisure-time PA behaviour, the centre of Epidemiologic Studies Depression Scale (cES-D), and the Generalized Anxiety Disorder (GAD-7) scale. Effect sizes (cohen's d, 2 partial) and power analyses using G*Power were applied. Results. Individuals who met PA recommendations (n = 596) reported lower depression scores (M = 11.69; SD = 8.57) than those who did not meet the recommendations (n = 86; M = 12.88; SD = 8.73). Lowest depression and anxiety scores were observed for indoor team athletes (M = 10.75; SD = 7.66 and M = 2.94; SD = 3.03, respectively), followed by outdoor individual athletes (M = 11.17; SD = 9.41 and M = 3.39; SD = 3.50, respectively). Under specific conditions, high depression scores were noted for vigorous-intensity PA levels (M = 20.5; SD = 4.94). Conclusions. Meeting the WHO PA recommendations (moderate-intensity PA 150 min/week) reduces symptoms of depression and anxiety. However, no linear dose-response relation was observed. No differences were found between in- and outdoor or team and individual sports but between sport disciplines. Prospective research to evaluate the reasons is needed. Refereed/Peer-reviewed

ObjectiveTo assess the mental health and experience of sport-related harassment and abuse of athletes participating in the FINA World Championships 2019, and to analyse it in relation to gender and the aquatic disciplines.DesignCross-sectional study using an anonymous questionnaire.MethodsDuring the Championships, registered athletes (swimmers, divers, high divers, water polo players, artistic swimmers, open-water swimmers) completed a survey including the main outcome measures of depression (CES-D-10), eating disorders (BEDA-Q), the subjective need for psychotherapeutic support, and the experience of harassment and/or abuse in their sports environment.ResultsA quarter of the athletes (n=62, 24.6%) were classified as depressed and more than a third (n=111, 35.0%) as having an eating disorder. More than 40% of the athletes stated that they wanted or needed psychotherapeutic support for mental health problems. Fifty-one athletes (14.9%) had experienced harassment/abuse in sport themselves, and 31 (9%) had witnessed it in another athlete. The experiences of harassment and abuse ranged from unwanted comments about body or appearance (40.2%) to rewards in sport for sexual favours (2.5%) and rape (0.3%). Athletes who had experienced harassment/abuse in sport themselves had higher average scores for depression and eating disorders, and more of them needed psychotherapeutic support. Up to a third would not talk to anybody if they saw or experienced harassment/abuse, and less than 20% would talk to an official for help.ConclusionTargeted initiatives are required to address the burden of mental health issues and harassment and abuse in sport in the FINA aquatic disciplines.

To assess the mental health and experience of sport-related harassment and abuse of elite aquatic athletes and to analyze it in relation to gender and discipline.Cross-sectional study using an anonymous survey.The FINA World Championships 2019.Registered athletes in the disciplines of swimming, diving, high diving, water polo, artistic swimming, and open water swimming.Athletes completed an online or paper-based questionnaire.The main outcome measures included screening for depression (10-item version of the Center for Epidemiological Studies Depression Scale revised), eating disorders (Brief Eating Disorders in Athletes Questionnaire), the subjective need for psychotherapeutic support, and the experience of sport-related harassment and/or abuse.A quarter (24.6%) of the 377 responding athletes were classified as depressed and 2.5% as having an eating disorder. More than 40% of the athletes stated that they wanted or needed psychotherapeutic support. Fifty-one athletes (14.9%) had experienced harassment/abuse in sport themselves, and 31 (9%) had witnessed it in another athlete. The experiences of harassment and abuse ranged from unwanted comments about body or appearance (40.2%) to rewards in sport for sexual favors (2.5%) and rape (0.3%). Athletes who had experienced harassment/abuse in sport themselves had higher average scores for depression and eating disorders, and more of them felt they needed psychotherapeutic support. Up to a third would not talk or report to anybody if they saw or experienced harassment/abuse, and less than 20% would talk to an official for help.Targeted initiatives are required to address mental health issues and harassment and abuse in sport in the FINA aquatic disciplines.

BackgroundRunning is a popular sport with high injury rates. Although risk factors have intensively been investigated, synthesized knowledge about the differences in injury rates of female and male runners is scarce.ObjectiveTo systematically investigate the differences in injury rates and characteristics between female and male runners.MethodsDatabase searches (PubMed, Web of Science, PEDro, SPORTDiscus) were conducted according to PRISMA guidelines using the keywords “running AND injur*”. Prospective studies reporting running related injury rates for both sexes were included. A random-effects meta-analysis was used to pool the risk ratios (RR) for the occurrence of injuries in female vs. male runners. Potential moderators (effect modifiers) were analysed using meta-regression.ResultsAfter removal of duplicates, 12,215 articles were screened. Thirty-eight studies were included and the OR of 31 could be pooled in the quantitative analysis. The overall injury rate was 20.8 (95% CI 19.9–21.7) injuries per 100 female runners and 20.4 (95% CI 19.7–21.1) injuries per 100 male runners. Meta-analysis revealed no differences between sexes for overall injuries reported per 100 runners (RR 0.99, 95% CI 0.90–1.10,n = 24) and per hours or athlete exposure (RR 0.94, 95% CI 0.69–1.27,n = 6). Female sex was associated with a more frequent occurrence of bone stress injury (RR (for males) 0.52, 95% CI 0.36–0.76,n = 5) while male runners had higher risk for Achilles tendinopathies (RR 1. 86, 95% CI 1.25–2.79,n = 2). Meta-regression showed an association between a higher injury risk and competition distances of 10 km and shorter in female runners (RR 1.08, 95% CI 1.00–1.69).ConclusionDifferences between female and male runners in specific injury diagnoses should be considered in the development of individualised and sex-specific prevention and rehabilitation strategies to manage running-related injuries.

International audience; Objective: To analyse the rates of lower limb muscle injuries in athletics disciplines requiring different running velocities during international athletics championships.Design: Prospective total population study.Methods: During 13 international athletics championships (2009–2019) national medical teams and local organizing committee physicians daily reported all newly incurred injuries using the same study design, injury definition and data collection procedures. In-competition lower limb muscle injuries of athletes participating in disciplines involving running (i.e. sprints, hurdles, jumps, combined events, middle distances, long distances, and marathon) were analysed.Results: Among the 12,233 registered athletes, 344 in-competition lower limb muscle injuries were reported (36% of all in-competition injuries). The proportion, incidence rates and injury burden of lower limb muscles injuries differed between disciplines for female and male athletes. The most frequently injured muscle group was hamstring in sprints, hurdles, jumps, combined events and male middle distances runners (43–75%), and posterior lower leg in female middle distances, male long distances, and female marathon runners (44–60%). Hamstring muscles injuries led to the highest burden in all disciplines, except for female middle distance and marathon and male long distance runners. Hamstring muscles injury burden was generally higher in disciplines requiring higher running velocities, and posterior lower leg muscle injuries higher in disciplines requiring lower running velocities.Conclusions: The present study shows discipline-specific injury location in competition context. Our findings suggest that the running velocity could be one of the factors that play a role in the occurrence/location of muscle injuries.

International outdoor athletics championships are typically hosted during the summer season, frequently in hot and humid climatic conditions. Therefore, we analyzed the association between apparent temperature and heat-related illnesses occurrence during international outdoor athletics championships and compared its incidence rates between athletics disciplines. Heat-related illnesses were selected from illness data prospectively collected at seven international outdoor athletics championships between 2009 and 2018 using a standardized methodology. The Universal Thermal Climate Index (UTCI) was calculated as a measure of the apparent temperature based on weather data for each day of the championships. Heat-related illness numbers and (daily) incidence rates were calculated and analyzed in relation to the daily maximum UTCI temperature and between disciplines. During 50 championships days with UTCI temperatures between 15celcius and 37celcius, 132 heat-related illnesses were recorded. Average incidence rate of heat-related illnesses was 11.7 (95%CI 9.7 to 13.7) per 1000 registered athletes. The expected daily incidence rate of heat-related illnesses increased significantly with UTCI temperature (0.12 more illnesses per 1000 registered athletes/degrees C; 95%CI 0.08-0.16) and was found to double from 25 to 35 degrees C UTCI. Race walkers (RR = 45.5, 95%CI 21.6-96.0) and marathon runners (RR = 47.7, 95%CI 23.0-98.8) had higher heat-related illness rates than athletes competing in short-duration disciplines. Higher UTCI temperatures were associated with more heat-related illnesses, with marathon and race walking athletes having higher risk than athletes competing in short-duration disciplines. Heat-related illness prevention strategies should predominantly focus on marathon and race walking events of outdoor athletics championships when high temperatures are forecast.

Background: Identifying factors that contribute to the occurrence of injury is an important step in designing training programs to minimize the risk of injury. However, despite high injury rates, variables contributing to injury in field hockey players remain relatively unexplored. Purpose: To identify factors that may predict injury in professional and youth field hockey players. Study Design: Cohort study; Level of evidence, 2. Method: Professional and youth hockey players completed preseason neuromuscular performance testing and were monitored for injuries, training, and game exposure throughout the subsequent 12-month indoor and outdoor hockey season. Least absolute shrinkage and selection operator analysis was conducted to identify injury risk factors. Receiver operating characteristic curves were then calculated to determine the individual predictive accuracy of the identified variables. Results: A total of 83 players (mean ± SD age, 20.7 ± 4.9 years; 34.9% female) with complete performance, injury, and exposure data were included for data analysis. Almost half of players (44.6%) sustained a time-loss injury during the season, and 73% of these injuries occurred in the lower limb. Playing more games and having an older age, asymmetrical and poor dynamic postural control, and better explosive performance were identified as jointly influencing the risk of injury. When considered individually, number of games played throughout the season was the most accurate predictor of injury risk (area under the curve [AUC] = 0.74; P < .001), while asymmetrical and poor dynamic postural control (AUCs = 0.61-0.65; P = .01-.04) and better explosive athletic performance (AUCs = 0.65-0.67; P < .01) were identified as moderate individual predictors of sustaining a general or lower limb injury. Conclusion: A number of modifiable factors were individually and jointly associated with an increased injury risk in field hockey players, providing initial evidence for the design of targeted and sport-specific training programs to mitigate the risk of injury.

BackgroundAdverse long-term effects of playing football due to repetitive head impact exposure on neurocognition and mental health are controversial. To date, no studies have evaluated such effects in women.AimsTo (1) compare neurocognitive performance, cognitive symptoms and mental health in retired elite female football players (FB) with retired elite female non-contact sport athletes (CON), and to (2) assess whether findings are related to history of concussion and/or heading exposure in FB.MethodsNeurocognitive performance, mental health and cognitive symptoms were assessed using computerised tests (CNS-vital signs), paper pen tests (Category fluency, Trail-Making Test, Digit Span, Paced Auditory Serial Addition Test), questionnaires (Hospital Anxiety and Depression Scale, SF-36v2 Health Survey) and a symptom checklist. Heading exposure and concussion history were self-reported in an online survey and in a clinical interview, respectively. Linear regression was used to analyse the effect of football, concussion and heading exposure on outcomes adjusted for confounders.ResultsFB (n=66) performed similar to CON (n=45) on neurocognitive tests, except for significantly lower scores on verbal memory (mean difference (MD)=−7.038, 95% CI −12.98 to –0.08, p=0.038) and verbal fluency tests (MD=−7.534, 95% CI –13.75 to –0.46, p=0.016). Among FB weaker verbal fluency performance was significantly associated with ≥2 concussions (MD=−10.36, 95% CI –18.48 to –2.83, p=0.017), and weaker verbal memory performance with frequent heading (MD=−9.166, 95% CI –17.59 to –0.123, p=0.041). The depression score differed significantly between study populations, and was significantly associated with frequent heading but not with history of concussion in FB.ConclusionFurther studies should investigate the clinical relevance of our findings and whether the observed associations point to a causal link between repetitive head impacts and verbal memory/fluency or mental health.

ObjectiveTo analyse differences between athletic disciplines in the frequency and characteristics of injuries during international athletics championships.MethodsStudy design, injury definition and data collection procedures were similar during the 14 international championships (2007–2018). National medical teams and local organising committee physicians reported all newly incurred injuries daily on a standardised injury report form. Results were presented as number of injuries and number of injuries per 1000 registered athletes, separately for male and female athletes, and for each discipline.ResultsFrom a total of 8925 male and 7614 female registered athletes, 928 injuries were reported in male and 597 in female athletes. The discipline accounting for the highest proportion of injuries was sprints, for both men (24%) and women (26%). The number of injuries per 1000 registered athletes varied between disciplines for men and women: highest in combined events for male athletes (235 (95% CI 189 to 281)) and female athletes (212 (95% CI 166 to 257)), and lowest for male throwers (47 (95% CI 35 to 59)) and female throwers (32 (95% CI 21 to 43)) and for female race walkers (42 (95% CI 19 to 66)). Injury characteristics varied significantly between disciplines for location, type, cause and severity in male and female athletes. Thigh muscle injuries were the main diagnoses in the disciplines sprints, hurdles, jumps, combined events and race walking, lower leg muscle injuries in marathon running, lower leg skin injury in middle and long distance running, and trunk muscle and lower leg muscle injuries in throws.ConclusionsInjury characteristics differed substantially between disciplines during international athletics championships. Strategies for medical service provision (eg, staff, facilities) during athletics championships should be discipline specific and be prepared for targeting the main injuries in each discipline.

ObjectivesTo determine the incidence and characteristics of hockey (‘field hockey’) injuries over the course of one outdoor and indoor season. Comparisons of female versus male players, outdoor versus indoor season and match versus practice were performed.MethodsFemale and male teams of the first, second, third, regional and youth divisions were recruited among a local hockey association in Northern Germany, and followed over an indoor and an outdoor season. Exposure times and location, type, severity and cause of injuries during practice and matches were documented by the coaches or medical staff and collected weekly. Prevalence and incidence rates were calculated.ResultsOf the 232 players (mean±SD age 20.7±4.7 years, 68.1% male, 31.9% first division), 84 players (36.2%) suffered 108 new injuries during the season. The overall incidence rate was 3.7 injuries per 1000 player hours (95% CI 3.0 to 4.4). The injury incidence was lower in practice (2.7 per 1000 player practice hours, 95% CI 2.0 to 3.3) than in matches (9.7 per 1000 player match hours, 95% CI 6.8 to 12.7), and was similar for female and male players as well as during the outdoor and the indoor season. Most injuries affected the lower limb (thigh, knee and ankle) and occurred without contact (58.3%). Severe injuries (n=34; 31.5%) were predominantly located at the knee and hand/finger.ConclusionHockey players have a high prevalence and incidence of injuries, especially at the lower limb.

OBJECTIVE: The objective of this study was to assess the efficacy of a newly developed warm-up programme ('11+ Kids') regarding its potential to reduce injuries in children's football.METHODS: Children's football teams (under 9 years, under 11 years, and under 13 years age groups) from Switzerland, Germany, the Czech Republic and the Netherlands were invited. Clubs were randomised to an intervention group and a control group, and followed for one season. The intervention group replaced their usual warm-up by '11+ Kids', while the control group warmed up as usual. The primary outcome was the overall risk of football-related injuries. Secondary outcomes were the risks of severe and lower extremity injuries. We calculated hazard ratios using extended Cox models, and performed a compliance analysis.RESULTS: In total, 292,749 h of football exposure of 3895 players were recorded. The mean age of players was 10.8 (standard deviation 1.4) years. During the study period, 374 (intervention group = 139; control group = 235) injuries occurred. The overall injury rate in the intervention group was reduced by 48% compared with the control group (hazard ratio 0.52; 95% confidence interval 0.32-0.86). Severe (74% reduction, hazard ratio 0.26; 95% confidence interval 0.10-0.64) and lower extremity injuries (55% reduction, hazard ratio 0.45; 95% confidence interval 0.24-0.84) were also reduced. Injury incidence decreased with increasing compliance.CONCLUSION: '11+ Kids' is efficacious in reducing injuries in children's football. We observed considerable effects for overall, severe and lower extremity injuries. The programme should be performed at least once per week to profit from an injury preventive effect. However, two sessions per week can be recommended to further increase the protective benefit.TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02222025.

Objective Concussion diagnosis and management in sports largely relies on neurocognitive testing. In the absence of baseline assessment, only norm values of the general population are available for comparison with scores of concussed athletes. To evaluate whether (elite) sport specific norm values are needed, cognitive performance was compared between top-level football players and the general population. Methods Cognitive performance of 425 top-level football players was evaluated using the computerized test battery CNS Vital Signs. Players were split into two age groups (15-19 and 20-29 years) and test results were compared with a norm sample (n = 268) by means of age-standardized scores using Cohen's d effect size statistics. Results The younger age group outperformed the norm sample in all domains, with small to moderate effects on tests of processing speed (d = 0.58, 95% CI = 0.31,0.85), cognitive flexibility (d = 0.27, 95% CI = 0.01,0.53) and psychomotor speed (d = 0.97, 95% CI = 0.69,1.24). In the older age group, no differences were found on four out of six domains; a moderate positive effect was found for psychomotor speed (d = 0.74, 95% CI = 0.54,0.93), a small negative effect for reaction time (d = -0.47, 95% CI = -0.66,-0.28). Relative to the norm, older football players scored lower than younger football players on all test domains. Conclusion Cognitive performance of elite football players may be different from the general population. It is recommended to use football-specific norm scores for comparison with test results of concussed players, and to choose an adequate control group when investigating effects of contact sport on cognition. Studies with older/retired football players are needed to further analyze potential sport-specific age effects.

BackgroundInformation on the prevalence of mental health problems of elite athletes is inconclusive, most probably due to methodological limitations, such as low response rates, heterogeneous samples.AimsTo evaluate the prevalence and risk factors of depression and anxiety symptoms in high-level female football players.MethodsFemale football players of 10 German first league (Bundesliga) and 7 lower league teams were asked to answer a questionnaire on players’ characteristics, the Center of Epidemiologic Studies Depression Scale (CES-D) and the Generalised Anxiety Disorder (GAD-7) scale.ResultsA total of 290 players (184 first and 106 lower league players) took part in the study. The CES-D score indicated mild to moderate symptoms of depression in 48 (16.6%) and severe symptoms in 41 (14.1%) players. The GAD-7 score indicated an at least moderate generalised anxiety disorder in 24 (8.3%) players. The prevalence of depression symptoms and generalised anxiety disorders was similar to the female general population of similar age. However, significantly more second league players reported symptoms of depression than first league players, and thus the prevalence of depression symptoms in second league players was higher than in the general population. Only a third of the 45 (15.7%) players who stated that they currently wanted or needed psychotherapeutic support received it.ConclusionThe prevalence of depression and generalised anxiety symptoms in elite football players is influenced by personal and sport-specific variables. It is important to raise awareness of athletes’ mental health problems in coaches and team physicians, to reduce stigma and to provide low-threshold treatment.

Football (soccer) is very popular among children. Little is known about risk factors for football injuries in children. The aim was to analyze potential injury risk factors in 7- to 12-year-old players. We collected prospective data in Switzerland and the Czech Republic over two seasons. Coaches reported exposure of players (in hours), absence, and injury data via an Internet-based registration system. We analyzed time-to-injury data with extended Cox models accounting for correlations on team- and intra-person levels. We analyzed injury risk in relation to age, sex, playing position, preferred foot, and regarding age-independent body height, body mass, and BMI. Further, we analyzed injury risk in relation to playing surface. In total, 6038 player seasons with 395 295 hours of football exposure were recorded and 417 injuries occurred. Injury risk increased by 46% (Hazard Ratio 1.46 [1.35; 1.58]; P

Zusammenfassung DIAGNOSTIK UND THERAPIE Gehirnerschütterungen im Sport sind in der letzten Zeit häufig in den Medien und Fachzeitschriften diskutiert worden. In den USA haben die Schadenersatzklagen von ehemaligen American-Football-Spielern gegen die NFL und von ehemaligen Eishockeyspielern gegen die NHL sowie der Kinofilm „Erschütternde Wahrheit“ (Originaltitel: „Concussion“) mit Will Smith in der Hauptrolle Aufsehen erregt. In Deutschland führte die Gehirnerschütterung des Fußballnationalspielers Christoph Kramer während des Endspiels der FIFA-Weltmeisterschaft 2014 zu Debatten über den Umgang mit Kopfverletzungen im Sport. Was bei einer Gehirnerschütterung beachtet werden muss, warum eine sorgfältige Diagnostik wichtig ist und welche Therapien bei Gehirnerschütterung hilfreich sind, erklärt das Autorenteam vom Swiss Concussion Center, Zürich.

A decade ago, Blair1 pondered the future of physical activity research, much of which has since come to pass. More recently, a BJSM Blog2 invited readers to consider how their future research would look. Given the increased international focus on reducing injury/illness in athletes, it is timely to consider what research needs to be undertaken and acted on to achieve feasible reductions over the next 10 years. ‘Future Studies’3 or ‘Thought Leadership’ happens when a defined group of experts calls attention to what they think will be important for their field in the future. This is common in social science disciplines (eg, finance) and in scientific areas with major implications for policy development (eg, in climate control/environmental science). It has been less commonly applied in medicine, though it has underpinned discussion in areas like cancer research4 and academic medicine.5 Thought leadership involves big picture thinking and can lead to new ideas for major developments over time. There is evidence that such exercises can significantly shape research agenda and priority setting. This novel approach was applied to Sports and Exercise Medicine through asking a select group of international experts to contribute their priority research directions for the next 10 years. This is intended as a starting point only, to stimulate discussion with, and elicit responses from, the broader community interested in the prevention of injury and illness in athletes. International experts were invited to participate if they had delivered ≥1 keynote addresses at the International Olympic Committee (IOC) World Conferences of Prevention of Injury and Illness in Sport in 2011, 2014 or their precursor conferences organised by the Oslo Sports Trauma Research Centre in 2005 and 2008. Of 21 keynote speakers, 12 contributed their views to this paper. The experts covered a range of disciplines, including clinical sports …

BackgroundIllnesses impair athletes’ participation and performance. The epidemiology of illness in athletics is limited.ObjectiveTo describe the occurrence and characteristics of illnesses during international athletics championships (indoor and outdoor), and to analyse differences with regards to athletes’ sex and participation in explosive and endurance disciplines.MethodsDuring 11 international championships held between 2009 and 2017, physicians from both national medical teams and the local organising committees reported daily on all athlete illnesses using a standardised report form. Illness frequencies, incidence proportions (IPs) and rates (IRs), and relative risks (RR) with 95% CIs were calculated.ResultsDuring the 59 days of the 11 athletics championships, 546 illnesses were recorded in the 12 594 registered athletes equivalent to IP of 43.4 illnesses per 1000 registered athletes (95% CI 39.8 to 46.9) or IR of 1.2 per 1000 registered athlete days (95% CI 1.1 to 1.2). The most frequently reported illnesses were upper respiratory tract infections (18.7%), exercise-induced fatigue/hypotension/collapse (15.4%) and gastroenteritis (13.2%). No myocardial infarction was recorded. A total of 28.8% of illnesses were expected to lead to time loss from sport. The illness IP was similar in male and female athletes, with few differences in illness characteristics. During outdoor championships, the illness IP was higher in endurance than explosive disciplines (RR=1.87; 95% CI 1.58 to 2.23), with a considerably higher IP of exercise-induced illness in endurance disciplines, but a similar upper respiratory tract infection IP in both discipline groups.ConclusionsIllness prevention strategies during international athletics championships should be focused on the most frequent diagnoses in each discipline group.

Illnesses can impair sports participation and performance in athletics training or competition (including major championships).1 Travel, jet lag, changes in climatic/environmental conditions and changes in food habits, in addition to the competition per se, could predispose athletes to illness in major championships context.2–4 During international athletics championships, an incidence of illnesses between 20 and 68 per 1000 registered athletes have been reported.2 3 5 6 However, extended and deeper epidemiological analyses are needed to develop effective illness prevention strategies. Therefore, this study aimed to describe the occurrence and characteristics of illnesses at international athletics championships with regards to sex (male and female athletes), disciplines (explosive and endurance) and championships type (indoor and outdoor). In major athletics championships between 2009 …

ObjectiveTo evaluate a potential reduction in injury related healthcare costs when using the ‘11+ Kids’ injury prevention programme compared with a usual warmup in children’s football.MethodsThis cost effectiveness analysis was based on data collected in a cluster randomised controlled trial over one season from football teams (under-9 to under-13 age groups) in Switzerland. The intervention group (INT) replaced their usual warmup with ‘11+ Kids’, while the control group (CON) warmed up as usual. Injuries, healthcare resource use and football exposure (in hours) were collected prospectively. We calculated the mean injury related costs in Swiss Francs (CHF) per 1000 hours of football. We calculated the cost effectiveness (the direct net healthcare costs divided by the net health effects of the ‘11+ Kids’ intervention) based on the actual data in our study (trial based) and for a countrywide implementation scenario (model based).ResultsCosts per 1000 hours of exposure were CHF228.34 (95% CI 137.45, 335.77) in the INT group and CHF469.00 (95% CI 273.30, 691.11) in the CON group. The cost difference per 1000 hours of exposure was CHF−240.66 (95%CI −406.89, −74.32). A countrywide implementation would reduce healthcare costs in Switzerland by CHF1.48 million per year. 1002 players with a mean age of 10.9 (SD 1.2) years participated. During 76 373 hours of football, 99 injuries occurred.ConclusionThe ‘11+ Kids’ programme reduced the healthcare costs by 51% and was dominant (ie, the INT group had lower costs and a lower injury risk) compared with a usual warmup. This provides a compelling case for widespread implementation.

ObjectiveTo identify changes in International Federations’ priorities and the barriers to implementing athlete and global health initiatives. Results should influence the work of the International Federation medical committees, the IOC and the Association of Summer Olympic International Federation.MethodsThe 28 Summer and 7 Winter International Federations participating in the most recent Olympic Games (2016; 2018) were surveyed to (i) identify the importance of 27 health topics, (ii) assess their progress on implementation health-related programmes and (iii) the barriers to implementation of these programmes. We compared International Federations’ activities in 2016 and 2017.ResultsThe response rate was 83%. Health topics which most International Federations regarded as important and in which the International Federations felt insufficiently active were ‘team physician certification’, ‘prevention of harassment and abuse’, ‘eating disorders/disordered eating’, ‘mental health’ and ‘injury surveillance’. Compared with 2016, there was a decrease in International Federations’ activities in ‘injury surveillance’, ‘nutritional supplements’ and ‘hyperandrogenism’. The main barrier to implementing health-related programmes was ‘International Federation political support/willingness’, followed by ‘knowledge’. ‘Time’ and ‘coach support’ were more often reported than ‘finances’, or ‘IOC or Association of Summer Olympic International Federations partnership’.ConclusionIf International Federations are going to promote health of athletes and global health promotion through physical activity (sport), International Federation leadership must change their focus and provide greater political support for related initiatives. Improving coach and athlete knowledge of the health issues could also facilitate health programme delivery. Time constraints could be mitigated by sharing experiences among the International Federations, Association of Summer Olympic International Federations and the IOC. International Federations should focus on those health-related topics that they identified as being important, yet rate as having insufficient activity.

Background Injury and illness surveillance in the aquatic disciplines has been conducted during the FINA World Championships and Olympic Games. The development of an aquatic-specific injury and illness surveillance system will improve the quality of the data collected and the development of preventive measures. Our ultimate objective is to enhance aquatic athlete health and performance. Objective The objective was to refine the injury and illness surveillance protocols to develop aquatic-specific definitions of injury and illness; define aquatic-specific injury location and causation; better describe overuse injuries; regard pre-existing and recurrent injuries; more accurately define aquatic athlete exposures and develop a protocol to capture out-of-competition aquatic athlete health parameters. Methods FINA compiled an Injury and Illness Surveillance Expert Working Group comprised of international experts to review the scientific literature in the field. A consensus meeting was convened to provide an opportunity for debate, following which recommendations were collated. Results Aquatic-specific injury and illness surveillance protocols covering both the in-competition and out-of-competition time periods were developed. Definitions for all relevant variables were outlined, and documentation forms for athletes and for clinicians were proposed. Recommendations for the implementation of an injury and illness surveillance system for FINA are presented. Conclusion The FINA consensus authors recommend ongoing in-competition and out-of-competition surveillance to determine injury and illness trends over time. The implementation of the definitions and methodology outlined in this paper will improve the accuracy and value of injury and illness surveillance, and provide important information for injury prevention.

Objectives The quality of epidemiological injury data depends on the reliability of reporting to an injury surveillance system. Ascertaining whether all physicians/physiotherapists report the same information for the same injury case is of major interest to determine data validity. The aim of this study was therefore to analyse the data collection reliability through the analysis of the interrater reliability. Design Cross-sectional survey. Methods During the 2016 European Athletics Advanced Athletics Medicine Course in Amsterdam, all national medical teams were asked to complete seven virtual case reports on a standardised injury report form using the same definitions and classifications of injuries as the international athletics championships injury surveillance protocol. The completeness of data and the Fleiss’ kappa coefficients for the inter-rater reliability were calculated for: sex, age, event, circumstance, location, type, assumed cause and estimated time-loss. Results Forty-one team physicians and physiotherapists of national medical teams participated in the study (response rate 89.1%). Data completeness was 96.9%. The Fleiss’ kappa coefficients were: almost perfect for sex (k = 1), injury location (k = 0.991), event (k = 0.953), circumstance (k = 0.942), and age (k = 0.870), moderate for type (k = 0.507), fair for assumed cause (k = 0.394), and poor for estimated time-loss (k = 0.155). Conclusions The injury surveillance system used during international athletics championships provided reliable data for “sex”, “location”, “event”, “circumstance”, and “age”. More caution should be taken for “assumed cause” and “type”, and even more for “estimated time-loss”. This injury surveillance system displays satisfactory data quality (reliable data and high data completeness), and thus, can be recommended as tool to collect epidemiology information on injuries during international athletics championships.

Work and activity-specific fear-avoidance beliefs have been identified as important predictor variables in relation to the development of, and treatment outcome for, chronic low back pain. The objective of this study was to provide a cross-cultural German adaptation of the Fear-Avoidance Beliefs Questionnaire (FABQ) and to investigate its psychometric properties (reliability, validity) and predictive power in a sample of Swiss-German low back pain patients. Questionnaires from 388 operatively and non-operatively treated patients were administered before and 6 months after treatment to assess: socio-demographic data, disability (Roland and Morris), pain severity, fear-avoidance beliefs, depression (ZUNG) and heightened somatic awareness (MSPQ). Complete baseline and follow-up questionnaires were available from 255 participants. The corrected item-total correlations, coefficients of test-retest reliability and internal consistencies of the two scales of the questionnaire were highly satisfactory. In a confirmatory factor analysis (CFA), all items loaded on the appropriate factor with minor loadings on the other. Cross-sectional regression analysis with disability and work loss as the dependent variables yielded results that were highly comparable with those reported for the original version. Prognostic regression analysis replicated the findings for work loss. The cross-cultural German adaptation of the FABQ was very successful and yielded psychometric properties and predictive power of the scales similar to the original version. The inclusion of fear-avoidance beliefs as predictor variables in studies of low back pain is highly recommended, as they appear to have unique predictive power in analyses of disability and work loss.