Health Systems in High-Performance Sport: Key Functions to Protect Health and Optimize Performance in Elite Athletes.

Enabling athletes to achieve peak performances while also maintaining high levels of health is contextually complex. We aim to describe what a 'health system' is and apply the essential functions of stewardship, financing, provision of services and resource generation to an Australian high-performance sport context. We introduce a fifth function that health systems should not detract from athletes' ability to achieve their sports goals. We describe how these functions aim to achieve four overall outcomes of safeguarding the health of the athletes, responding to expectations, providing financial and social protection against the costs of ill health, and efficient use of resources. Lastly, we conclude with key challenges and potential solutions for developing an integrated health system within the overall performance system in high-performance sport.

Youth athletes at Swedish sports high schools with an athletics specialism emphasise environmental support for injury risk management: a focus group study.

In this study, we examined knowledge and understanding of sport-related injuries among youth athletics (track and field) athletes and assessed their needs in managing any health problems. Qualitative data were collected via 12 focus groups with youth athletes (16-19 years) studying at Swedish sports high schools with an athletics specialism. All focus group discussions were audiorecorded and transcribed before being analysed using a thematic analysis approach. Four researchers independently reviewed the transcripts, generated codes and developed themes. Three overarching themes related to the athletes' knowledge and understanding of sport-related injury were developed: (1) awareness of injuries, (2) perception of injuries, and (3) factors contributing to injuries. The youth athletes were typically uncertain about how to acknowledge a sport-related injury. They expressed that knowledge about injuries was obtained in part by reflecting on the lived experiences of their peers. It was also demonstrated that there appears to be a 'culture of acceptance' regarding injury occurrence. In contrast, causes of injuries were viewed as dependent on multiple factors (eg, lack of context-specific knowledge about training practices). Regarding athletes' needs in managing injuries, an additional three themes were developed: (1) creating functioning elite sports environments, (2) application of knowledge and (3) fostering athletes. An apparent lack of structure and organisation related to the school environment was identified as an important issue to review to create opportunities for sustainable athletic development. The study identified areas that can be improved in Swedish sports high schools with an athletic specialism and could be applied in other youth sports contexts. The results of this study guide school stakeholders, alongside the sport governing bodies who have the mandate to influence activities in youth sports contexts, whereby special attention should be directed towards improving the social environment for youth athletes.

Elite lean athletes at sports high schools face multiple risks for mental health concerns and are in need of psychosocial support.

The combined demands on an adolescence in an elite sports high school can negatively affect mental health (eg, stress, burnout, depression, anxiety). Late adolescence is also when elite-striving athletes typically transition from junior-to-senior level programs. In addition, adolescent elite lean sports athletes have an increased risk of suffering from abnormal eating pathology. The purpose of this study was to investigate the perceived psychosocial needs that young, elite-striving lean sports athletes in sports high schools find essential for their sports careers and transition from junior-to-senior level sports. Eight Swedish elite-striving lean sports athletes (2 men and 6 women; median age 17.0 years, range: 16-18 years) participated in this study and sports represented were athletics (n = 1), gymnastics (n = 3), and wrestling (n = 4). Semi-structured interviews were performed, and data was analyzed by thematic analysis. Results showed integration, both in the present situation and for the future, as an overarching theme perceived as essential for a successful elite sports career over time. Three additional themes were also identified: (a) Psychosocial stress (combined performance demands, diminished social life, sports-related body weight demands, taboo talking about eating disorders, injuries), (b) Protective psychosocial factors (social support and psychological safety, communication and coordination school and sports, self-care/health behaviors), and (c) support needs junior-to-senior transition (career advice and mentorship, individualized support). As a result, elite-striving, lean sports athletes attending sports high schools need additional support to excel in their academic and athletic endeavors. Sports developmental programs continue to provide inadequate support before and during the junior-to-senior level transition. Similarly, despite the continued calls for reducing the stigma of mental health, athletes in sports schools still encounter barriers from coaches and peers, making the subject taboo, particularly surrounding eating pathologies.

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 χ2 tests 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.

Universal prevention through a digital health platform reduces injury incidence in youth athletics (track and field): a cluster randomised controlled trial.

OBJECTIVES: To examine whether universal prevention via a digital health platform can reduce the injury incidence in athletics athletes aged 12-15 years and if club size had an influence on the effect of the intervention. METHODS: This was a cluster randomised trial where young athletics athletes were randomised through their club following stratification by club size into intervention (11 clubs; 56 athletes) and control (10 clubs; 79 athletes) groups. The primary endpoint was time from baseline to the first self-reported injury. Intervention group parents and coaches were given access to a website with health information adapted to adolescent athletes and were encouraged to log in and explore its content during 16 weeks. The control group continued training as normal. Training exposure and injury data were self-reported by youths/parents every second week, that is, eight times. The primary endpoint data were analysed using the log-rank test. Cox proportional hazards regression was used to analyse the second study aim with intervention status and club size included in the explanatory models. RESULTS: The proportion of completed training reports was 85% (n=382) in the intervention group and 86% (n=545) in the control group. The injury incidence was significantly lower (HR=0.62; χ2=3.865; p=0.049) in the intervention group. The median time to first injury was 16 weeks in the intervention group and 8 weeks in the control group. An interaction effect between the intervention and stratification factor was observed with a difference in injury risk between athletes in the large clubs in the intervention group versus their peers in the control group (HR 0.491 (95% CI 0.242 to 0.998); p=0.049). CONCLUSIONS: A protective effect against injury through universal access to health information adapted for adolescent athletes was observed in youth athletics athletes. The efficacy of the intervention was stronger in large clubs. TRIAL REGISTRATION NUMBER: NCT03459313.

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.

Design of the performance outcome scoring template (POS-T) with example application on CO2 emissions reduction amongst 36 OECD member countries.

In applied program settings, such as in natural environment control and education, performance evaluation is usually conducted by evaluators considering both self-comparison and comparison with peers. We have developed the performance outcome scoring template (POS-T) for assessments with high face-validity in these settings. POS-T puts achievements of individuals or groups in context, i.e. the resulting performance outcome score (POS) reflects a meaningful measure of performance magnitude with regards to internal and external comparisons. Development of a POS is performed in four steps supported by a statistical framework. Software is supplied for creation of scoring applications in different performance evaluation settings. We demonstrate the POS-T by evaluation of CO2 emissions reduction amongst 36 OECD member countries.

Training in spikes and number of training hours correlate to injury incidence in youth athletics (track and field): A prospective 52-week study.

OBJECTIVES: The aim was to describe the annual incidence and types of musculoskeletal injuries, and to examine factors associated with injury risk. DESIGN: A 52-week prospective study in Swedish youth athletics aged 12-15 years. METHODS: Data on exposure to training and injury were collected from parents/caregivers and youth athletes using a web-survey system. RESULTS: A total of 101 (86%) youth athletes participated. Fifty-four (53%) of the athletes reported one new injury. Girls were at higher risk of sustaining an injury than boys (p = 0.048). Ninety-one percent of the new injuries were non-traumatic and 85% occurred in the lower extremities. Injuries to the front thigh represented 20% of the injuries. Cox proportional hazard regression analyses showed a six-fold increased risk for a first injury for athletes reporting use of spikes and training <6 h every two weeks (hazard ratio, 6.1; 95% confidence interval, 1.2-31.3) compared to athletes training <6 h using no spikes. Athletes training 6 h or more reporting use or no use of spikes had an eight-fold increase injury risk (p < 0.01). CONCLUSIONS: Almost half of the youth athletes experienced a new injury and girls had a higher risk compared to boys. Nine out of ten injuries were related to overuse. An interesting observation was the high incidence of injuries to the quadriceps muscle complex. The study identified a correlation with training hours and an interaction with track spikes and risk of injury that needs further attention.

'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.

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.

Assessing parents, youth athletes and coaches subjective health literacy: A cross-sectional study.

OBJECTIVES: The aim was to describe levels of subjective Health Literacy (HL), and to examine possible differences in prevalence proportions between sexes, age groups and level of educations among youth athletes and their mentors (coaches, parents/caregivers) in Swedish Athletics. DESIGN: Cross-sectional. METHODS: Data on subjective HL were collected using the Swedish Communicative and Critical Health Literacy (S-CCHL) instrument for mentors and for youth the School-Aged Children (HLSAC) instrument. Questions assessing mentors' literacy on sports injury and return to play were also included. RESULTS: The surveys were completed by 159 (91%) mentors and 143 youth athletes (87%). The level of S-CCHL was sufficient in 53% of the mentors. Of youth athletes, 28% reported a high level of HL and the item with least perceived high HL (21%) was critical thinking. Ninety-four percent of the mentors believed that it is quite possible to prevent injuries in athletics and 53% perceived having a very good knowledge about how to prevent injuries. Forty-six percent of the mentors perceived having a very good knowledge of return to sport criteria. CONCLUSIONS: The level of health literacy was low with about half of the mentors and one out of three youth athletes having adequate HL levels. Only half of the mentors stated having a good knowledge of various injury prevention strategies. To reduce health consequences in youth sport and enable talent development more work is needed to understand the facilitators and barriers for the uptake of various health promotion and injury prevention strategies.

Suicidal thoughts (ideation) among elite athletics (track and field) athletes: associations with sports participation, psychological resourcefulness and having been a victim of sexual and/or physical abuse.

OBJECTIVE: To examine associations between suicidal ideation and sexual and physical abuse among active and recently retired elite athletics (track and field) athletes. METHODS: The study population consisted of all athletes (n=402) selected for a Swedish Athletics team between 2011 and 2017. Data on suicidal ideation, suicidal events (estimated through the 1 year non-sports injury prevalence), lifetime abuse experiences, sociodemographics, sense of coherence and coping strategies were collected using a cross-sectional survey. The data were analysed using binary logistic regression with suicidal ideation and non-sports injury as outcomes. RESULTS: 192 athletes (47.8%) returned data. The prevalence of suicidal ideation was 15.6% (men 17.4%; women 14.2%) and the non-sports injury prevalence was 8.0% (men 11.6%; women 5.7%). Among women, suicidal ideation was associated with having been sexually abused (OR 5.94, 95% CI 1.42 to 24.90; p=0.015) and lower sense of coherence (OR 0.90, 95% CI 0.85 to 0.96; p=0.001) (Nagelkerke R2=0.33). Among men, suicidal ideation was only associated with use of behavioural disengagement for coping (OR 1.51, 95% CI 1.18 to 1.95; p=0.001) (R2 =0.25). Among women, non-sports injury prevalence was associated with having been sexually abused (OR 8.61, 95% CI 1.34 to 55.1; p=0.023) and participating in an endurance event (OR 7.37, 95% CI 1.11 to 48.9; p=0.039 (R2 =0.23), while among men, having immigrant parents (OR 5.67, 95% CI 1.31 to 24.5; p=0.020) (R2 =0.11) was associated with injury outside sports. CONCLUSIONS: About one out of six international athletics athletes reported having experienced suicidal ideation. World Athletics and National Olympic Committees need to include suicide prevention in their athlete protection programmes.

Statement on Methods in Sport Injury Research From the First METHODS MATTER Meeting, Copenhagen, 2019.

SYNOPSIS: High-quality sports injury research can facilitate sports injury prevention and treatment. There is scope to improve how our field applies best-practice methods-methods matter (greatly!). The first METHODS MATTER meeting, held in January 2019 in Copenhagen, Denmark, was the forum for an international group of researchers with expertise in research methods to discuss sports injury methods. We discussed important epidemiological and statistical topics within the field of sports injury research. With this opinion document, we provide the main take-home messages that emerged from the meeting. Meeting participants agreed that the definition of sport injury depends on the research question and context. It was considered essential to be explicit about the goal of the research effort and to use frameworks to illustrate the assumptions that underpin measurement and the analytical strategy. Complex systems were discussed to illustrate how potential risk factors can interact in a nonlinear way. This approach is often a useful alternative to identifying single risk factors. Investigating changes in exposure status over time is important when analyzing sport injury etiology, and analyzing recurrent injury, subsequent injury, or injury exacerbation remains challenging. The choice of statistical model should consider the research question, injury measure (eg, prevalence, incidence), type and granularity of injury data (categorical or continuous), and study design. Multidisciplinary collaboration will be a cornerstone for future high-quality sport injury research. Working outside professional silos in a diverse, multidisciplinary team benefits the research process, from the formulation of research questions and designs to the statistical analyses and dissemination of study results in implementation contexts. This article has been copublished in the British Journal of Sports Medicine and the Journal of Orthopaedic & Sports Physical Therapy. J Orthop Sports Phys Ther 2020;50(5):226-233. doi:10.2519/jospt.2020.9876.

Statement on methods in sport injury research from the 1st METHODS MATTER Meeting, Copenhagen, 2019.

High quality sports injury research can facilitate sports injury prevention and treatment. There is scope to improve how our field applies best practice methods-methods matter (greatly!). The 1st METHODS MATTER Meeting, held in January 2019 in Copenhagen, Denmark, was the forum for an international group of researchers with expertise in research methods to discuss sports injury methods. We discussed important epidemiological and statistical topics within the field of sports injury research. With this opinion document, we provide the main take-home messages that emerged from the meeting.

Injuries and illnesses in Swedish Paralympic athletes-A 52-week prospective study of incidence and risk factors.

INTRODUCTION: Sports-related injuries and illnesses in Paralympic sport (SRIIPS) are a concern, but knowledge about the etiology and risk factors is limited. The aim of this study was to describe the annual incidence, type, and severity of injuries and illnesses among Swedish Paralympic athletes and to assess risk factors. METHODS: Swedish Paralympic athletes (n = 107) self-reported SRIIPS every week during 52 weeks using an eHealth application. Incidence proportions (IP) and incidence rates (IR) were used as measures of disease burden. Time-to-event methods (Kaplan-Meier and Cox regression) were used to identify risk factors. RESULTS: The annual IP for injury was 68% and for illness 77%. The injury IR was 6.9/1000 hours and the illness IR 9.3/1000 hours. The median time to injury was 19 weeks (95% CI: 10.5-27.4) and to illness 9 weeks (95% CI: 1.4-16.6). Most injuries occurred during training, and 34% were classified as severe (≥21 days of time loss). An increased injury risk was observed among athletes in team sports (HR 1.88; 95% CI: 1.19-2.99), athletes with a previous severe injury (HR 2.37; 95% CI: 1.47-3.83), and male athletes (HR 1.76; 95% CI: 1.06-2.93). The most common illness type was infection (84%). Athletes in team sports (HR 1.64; 95% CI: 1.05-2.54) and males with a previous illness (HR = 2.13; 95% CI: 1.04-4.36) had a higher illness risk. CONCLUSION: Paralympic athletes report a high incidence of injuries and illnesses over time. This emphasizes the need to develop preventive strategies of SRIIPS and optimize medical services for this heterogeneous athlete population.

Developing web-based health guidance for coaches and parents in child athletics (track and field).

The aim of this study was to develop athletics health guidance (AHG) aimed at supporting coaches and parents involved in organized child athletics by providing practical advice and tools for the management of the most common health problems experienced in athletics by the 12- to 15-year olds. The study used participatory action research (PAR) and an established health service guideline development procedure modified to fit AHG development in child athletics. A sequential process consisting of four steps with associated subgoals was employed. The collected data were structured according to the AHG development steps and analyzed using qualitative methods. The most common health concern identified was injuries related to growth and overuse. No randomized controlled studies investigating injury prevention programs or any existing concepts/guidelines in child athletics were found that could be used in the development of the AHG. A requirements document was instead defined in a nominal group process and used for the AHG development. The areas included in the final AHG were as follows: training youth athletes, growth and puberty, recovery, injury prevention, injuries and illnesses, mental illness, safe sport, and anti-doping. The evidence regarding health issues in child athletics is limited, indicating that actions to support good health in the sport are currently based essentially on best practice. The long-term aim of the AHG and associated website is to systematically create and introduce conditions that can bridge the "know-do gap" and provide coaches and parents with easy-to-access and up-to-date knowledge in the field of child athlete health in athletics.

Running for your life: A qualitative study of champion long-distance runners' strategies to sustain excellence in performance and health.

OBJECTIVES: To investigate champion long-distance runners' strategies for managing injury and illness symptoms and staying well. DESIGN: Qualitative research study. METHODS: Twelve long-distance runners were interviewed immediately after having competed in World Championships finals. Thematic analysis was used to categorise and structure the data. The results were presented as primary themes and overarching constructs representing connections between the primary themes. RESULTS: The champion runners' basic tactic to manage symptoms of ill health was characterized by rapid adjustment of sports load and a strong incentive to learn from experience and professional advice. This tactic was named here educated flexibility. A secondary exigency tactic was associated with reaching short-term goals and a consequential acceptance of health hazards. The runners used economic and other environmental strain to explain use of the exigency tactic. Most champion runners' long-term strategy to stay well included both tactics successfully combined to maintain a performance level assuring a regular income. Avoidance of letting environmental strain and health problems create vicious circles was at the centre of these strategies. CONCLUSIONS: Champion runners' main strategy to stay well and sustain their superiority in performance was characterized by constantly paying attention to symptoms of ill health, listening to medical advice, and not letting environmental strain interfere with adjustment of sports load. Many top-level runners originate from global regions where formal education programs and health insurance plans are poorly regulated and supported. Bio-psychosocial models including empowerment at individual and systems levels should be considered when health services are planned for professional runners.

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.

Health complaints and heat stress prevention strategies during taper as predictors of peaked athletic performance at the 2015 World Athletics Championship in hot conditions.

OBJECTIVES: To investigate whether self-reported health complaints and choice of heat stress prevention strategies during the taper predicted peaking at an athletics championship in hot conditions. DESIGN: Cohort study. METHODS: Data on health and heat stress prevention were collected before the 2015 World Athletics Championship in Beijing, China. Peaking was defined using the athlete's pre-competition ranking and final competition rank. Baseline and endpoint data were fitted into multiple logic regression models. RESULTS: Two hundred forty-five (29%) of 841 eligible athletes participated. Both sprint/power (Odds ratio (OR) 0.33 (95% Confidence interval (CI) 0.11 to 0.94), P=0.038) and endurance/combined events (OR 0.38 (95% CI 0.14 to 1.00), P=0.049) athletes having sustained concern-causing health complaints during the taper were less likely to peak. Endurance/combined events athletes who chose pre-cooling to mitigate heat stress were less likely to peak (OR 0.35 (95% CI 0.15 to 0.80), P=0.013), while sprint/power athletes reporting a sudden-onset injury complaint during the taper displayed increased peaking (OR 4.47 (95% CI 1.28 to 15.59), P=0.019). CONCLUSIONS: Health complaints that caused the athlete concern during the taper were predictive of failure to peak at a major athletics competition. Sprint/power athletes who experienced an acute injury symptom during the taper appeared to benefit from rest. Pre-cooling strategies seem to require further validation during real-world endurance/combined events. It appears that athletics athletes' self-reported health should be monitored during the taper, concerns addressed, and heat stress prevention strategies individually tested before championships in hot conditions.