Year-round injury and illness surveillance in UK summer paralympic sport athletes: 2016-2019.

OBJECTIVE: To identify the priority injuries and illnesses across UK summer Paralympic World Class Programmes (WCP). METHODS: Four years (2016-2019) of electronic medical records from 360 athletes across 17 Paralympic WCP sports were analysed. Methods were based on the 2021 International Paralympic Committee translation of the original 2020 International Olympic Committee consensus statement for epidemiological recording and reporting. This included reporting incidence (count of injury per athlete year) and burden (time loss days per athlete year) of injuries by impairment category. RESULTS: 836 injuries and 453 illnesses were recorded during the surveillance period, accounting for 34 638 and 10 032 time-loss days, respectively. 216 (60%) athletes reported at least one injury, while 171 (47.5%) reported at least one illness. There were 0.9 injuries per athlete year, resulting in a mean injury burden of 38.1 days per athlete year. The lumbar/pelvis, shoulder and thoracic/ribs body region had the greatest incidence whereas the shoulder, lumbar/pelvis and wrist had the greatest injury burden. All impairment categories had shoulder or lumbar/pelvis as the body region with the greatest incidence, however the burden of body areas did not always reflect the incidence. Athletes reported 0.5 illnesses per athlete year, resulting in an average illness burden of 11.3 days per athlete year. The respiratory, gastrointestinal, dermatological and genitourinary organ systems had the greatest illness incidence. CONCLUSIONS: To optimise health and performance in Paralympic sport athletes, system-wide mitigation initiatives should target priority injury problems occurring in the lumbar/pelvis, shoulder, thoracic spine/ribs and wrist. Illness types causing the greatest burden vary with impairment group, and illness mitigation initiatives should consider athlete impairment types in their design, while continuing to note the high incidence of respiratory and gastrointestinal illness across all impairments. Further research should examine associated risk factors and the influence of impairment categorisation.

Year-round longitudinal health surveillance in UK Olympic Summer Sport Athletes 2016-2019.

OBJECTIVES: To identify the priority injury and illness types across UK summer Olympic World Class Programme sports to inform development, implementation and evaluation of associated injury risk mitigation and management initiatives. METHODS: Four years (2016-2019) of electronic medical records of 1247 athletes from 22 sports were analysed and reported using methods based on the 2020 International Olympic Committee consensus statement for epidemiological recording and reporting. RESULTS: 3562 injuries and 1218 illness were recorded, accounting for 146 156 and 27 442 time-loss days. Overall, 814 (65%) athletes reported at least one injury, while 517 (41%) reported at least one illness. There were 1.3 injuries per athlete year resulting in a mean burden of 54.1 days per athlete year. The lumbar/pelvis, knee, ankle and shoulder body regions had the highest incidence and burden. Athletes reported 0.5 illnesses per athlete year, resulting in a mean burden of 10.4 days per athlete year, with most composed of respiratory illness and gastroenteritis. Injuries within sport groups were representative of the injury risk profile for those sports (eg, knee, hand and head injuries had the highest incidence in combat sports), but respiratory illnesses were consistently the greatest problem for each sport group. CONCLUSIONS: To optimise availability for training and performance, systematic risk mitigation and management initiatives should target priority injury problems occurring in the lumbar/pelvis, knee, ankle and shoulder, and respiratory illness. Follow-up analysis should include identification of sport-specific priority health problems and associated risk factors.

Clinical patterns, recovery time and prolonged impact of COVID-19 illness in international athletes: the UK experience.

OBJECTIVES: To report COVID-19 illness pattern, symptom duration and time loss in UK elite athletes. METHODS: Observational, clinical and database review of athletes with symptomatic COVID-19 illness managed within the UK Sports Institutes. Athletes were classified as confirmed (positive SARS-CoV-2 PCR or antibody tests) or probable (consistent clinical features) COVID-19. Clinical presentation was characterised by the predominant symptom focus (eg, upper or lower respiratory illness). Time loss was defined as days unavailable for full sport participation and comparison was made with a 2016-2019 respiratory illness dataset from the same surveillance system. RESULTS: Between 24 February 2020 and 18 January 2021, 147 athletes (25 Paralympic (17%)) with mean (SD) age 24.7 (5.2) years, 37% female, were diagnosed with COVID-19 (76 probable, 71 confirmed). Fatigue was the most prevalent symptom (57%), followed by dry cough (50%) and headache (46%). The median (IQR) symptom duration was 10 (6-17) days but 14% reported symptoms >28 days. Median time loss was 18 (12-30) days, with 27% not fully available >28 days from initial date of infection. This was greater than our historical non-COVID respiratory illness comparator; 6 days, 0-7 days (p<0.001) and 4% unavailable at 28 days. A lower respiratory phenotype (ie, including dyspnoea±chest pain±cough±fever) was present in 18% and associated with a higher relative risk of prolonged symptoms risk ratio 3.0 (95% CI: 1.4 to 6.5) and time loss 2.1 (95% CI: 1.2 to 3.5). CONCLUSIONS: In this cohort, COVID-19 largely resulted in a mild, self-limiting illness. The presence of lower respiratory tract features was associated with prolonged illness and a delayed return to sport.

The benefits of a systematic assessment of respiratory health in illness-susceptible athletes.

Respiratory tract illness is a leading cause of training and in-competition time loss in elite athletes. Asthma is known to be prevalent in athletes, but the coexistence of other respiratory problems in those deemed to be susceptible to respiratory tract illness is unknown. The aim of this study was to apply a comprehensive prospective approach to identify respiratory problems and explore relationships in athletes with heightened respiratory illness susceptibility.UK World Class Performance Programme athletes prospectively completed a systematic review of respiratory health with validated questionnaires and respiratory-focused investigations, including studies of nasal flow, exhaled nitric oxide, spirometry, bronchoprovocation testing and allergy testing.Systematic respiratory health assessment was completed by 122 athletes (55 females, mean±sd age 24±4 years). At least one respiratory health issue, requiring intervention, was identified in 97 (80%) athletes and at least two abnormalities were found in 73 (60%). Sinonasal problems were the most commonly identified problem (49%) and 22% of athletes had a positive indirect bronchoprovocation test. Analysis revealed two respiratory health clusters: 1) asthma, sinus problems and allergy; and 2) laryngeal and breathing pattern dysfunction. Respiratory illness susceptible athletes had 3.6±2.5 episodes in the year prior to assessment and were more likely to have allergy (OR 2.6, 95% CI 1.0-6.5), sinonasal problems (2.6, 1.1-6.0) and symptoms of laryngeal (5.4, 1.8-16.8) and breathing pattern dysfunction (3.9, 1.1-14.0) than nonsusceptible athletes (all p<0.05).A systematic approach to respiratory assessment identifies a high prevalence and coexistence of multiple respiratory problems in illness-susceptible athletes.

Screening Identifies Suboptimal Vaccination Protection in Illness-Susceptible Elite Athletes.

OBJECTIVE: Some groups of elite athletes have an apparent increased susceptibility to respiratory tract infection (RTI) with implications for their health and athletic performance. In this study, we aim to systemically evaluate vaccine response patterns as a potentially efficacious intervention strategy in elite athletes preparing for Olympic competition. DESIGN: Cross-sectional observational study. SETTING: A UK Sport-funded Olympic training program. PATIENTS: One hundred twenty elite athletes and 10 matched healthy controls were studied. A subset of athletes were classified as RTI highly susceptible (n = 22), RTI nonsusceptible (n = 23), and asthmatic (n = 33), with matched controls also recruited (n = 10, 27 ± 3 years). INTERVENTIONS/OUTCOME MEASURE: Serum samples were analysed from participants analysing enzyme-linked immunosorbent assay for Immunoglobulin G (IgG) responses against measles, mumps, rubella, and pneumococcus vaccines. RESULTS: Although a majority of athletes (>90%) had detectable IgG levels against measles and rubella, only 76% had detectable mumps responses, with similar findings apparent in controls. Of those RTI-susceptible and asthmatic athletes, 22% had suboptimal antipneumococcal responses below 30 mg/L. CONCLUSION: A significant proportion of elite athletes preparing for Olympic competition seem to be at risk of mumps infection. In addition, RTI-susceptible and asthmatic athletes exhibit suboptimal pneumococcal antibody responses, highlighting a need for prospective immune screening in athletes to ensure vaccination strategies are effectively delivered.

On average, a professional rugby union player is more likely than not to sustain a concussion after 25 matches.

OBJECTIVES: To investigate concussion injury rates, the likelihood of sustaining concussion relative to the number of rugby union matches and the risk of subsequent injury following concussion. METHODS: A four-season (2012/2013-2015/2016) prospective cohort study of injuries in professional level (club and international) rugby union. Incidence (injuries/1000 player-match-hours), severity (days lost per injury) and number of professional matches conferring a large risk of concussion were determined. The risk of injury following concussion was assessed using a survival model. RESULTS: Concussion incidence increased from 7.9 (95% CI 5.1 to 11.7) to 21.5 injuries/1000 player-match-hours (95% CI 16.4 to 27.6) over the four seasons for combined club and international rugby union. Concussion severity was unchanged over time (median: 9 days). Players were at a greater risk of sustaining a concussion than not after an exposure of 25 matches (95% CI 19 to 32). Injury risk (any injury) was 38% greater (HR 1.38; 95% CI 1.21 to 1.56) following concussion than after a non-concussive injury. Injuries to the head and neck (HR 1.34; 95% CI 1.06 to 1.70), upper limb (HR 1.59; 95% CI 1.19 to 2.12), pelvic region (HR 2.07; 95% CI 1.18 to 3.65) and the lower limb (HR 1.60; 95% CI 1.21 to 2.10) were more likely following concussion than after a non-concussive injury. CONCLUSION: Concussion incidence increased, while severity remained unchanged, during the 4 years of this study. Playing more than 25 matches in the 2015/2016 season meant that sustaining concussion was more likely than not sustaining concussion. The 38% greater injury risk after concussive injury (compared with non-concussive injury) suggests return to play protocols warrant investigation.

Tackling concussion in professional rugby union: a case-control study of tackle-based risk factors and recommendations for primary prevention.

BACKGROUND/AIM: Concussion, the most common injury in professional rugby union, occurs most commonly during the tackle. Thus, we investigated the association between tackle characteristics and concussion. METHODS: 182 video clips of tackles leading to clinically diagnosed concussion and 4619 tackles that did not were coded across three professional rugby union competitions. A variable selection process was undertaken to identify the most important variables for interpretation. A multivariate generalised linear model was used to model the association between retained variables and concussion risk. Magnitude-based inferences provided an interpretation of the real-world relevance of the outcomes. RESULTS: The four retained variables were: accelerating player, tackler speed, head contact type and tackle type. Overall, 70% of concussions occurred to the tackler and 30% to the ball carrier. There was a higher risk of concussion if the tackler accelerated into the tackle (OR: 2.49, 95% CI 1.70 to 3.64) or the tackler was moving at high speed (OR: 2.64, 95% CI 1.92 to 3.63). Head contact with the opposing player's head (OR: 39.9, 95% CI 22.2 to 71.1) resulted in a substantially greater risk of concussion compared with all other head contact locations. CONCLUSIONS: Interventions that reduce the speed and acceleration of the tackler and reduce exposure to head-to-head contact would likely reduce concussion risk in professional rugby union.

Application of the subsequent injury categorisation model for longitudinal injury surveillance in elite rugby and cricket: intersport comparisons and inter-rater reliability of coding.

BACKGROUND: When an athlete has more than one injury over a time period, it is important to determine if these are related to each other or not. The subsequent injury categorisation (SIC) model is a method designed to consider the relationship between an index injury and subsequent injury(ies). OBJECTIVE: The primary aim was to apply SIC to longitudinal injury data from two team sports: rugby union and cricket. The secondary aim was to determine SIC inter-rater reliability. METHODS: Rugby union (time-loss; TL) and cricket (TL and non-time-loss; NTL) injuries sustained between 2011 and 2014 within one international team, respectively, were recorded using international consensus methods. SIC was applied by multiple raters, team clinicians, non-team clinicians, and a sports scientist. Weighted kappa and Cohen's kappa scores were calculated for inter-rater reliability of the rugby union TL injuries and cricket NTL and TL injuries. RESULTS: 67% and 51% of the subsequent injuries in rugby union and cricket respectively were categorised as injuries to a different body part not related to an index injury (SIC code 10). At least moderate agreement (weighted and Cohen kappa ≥0.60) was observed for team clinicians and the non-team clinician for both sports. Including NTL and TL injuries increased agreement between team clinician and non-team clinician, but not between clinician and sports scientist. CONCLUSION: The most common subsequent injury in both sports was an injury to a different body part that was not related to an index injury. The SIC model was generally reliable, with the highest agreement between clinicians working within the same team. Recommendations for future use of SIC are provided based on the proximity of the rater to the team and the raters' level of clinical knowledge.

Playing surface and UK professional rugby union injury risk.

Artificial rugby union playing surface installation is increasing. This prospective cohort study aimed to examine the effect of playing surface on match injury types within 157 players of two UK professional rugby union clubs playing 209 matches (96 on artificial surfaces and 113 on grass) over three seasons. There was no difference in overall injury risk between the two playing surfaces with injury incidence on artificial 80.2 (CI 69.9-91.7) and on grass 81.9 per 1000 match-hours (CI 72.2-92.5), with an incidence rate ratio (RR) of 0.98 (CI 0.82-1.17). There was a higher rate of concussion (RR 0.52, CI 0.34 - 0.78) and chest injuries on grass (RR 0.26 CI 0.07, 0.95), and a higher rate of thigh haematoma (RR 2.25, CI 1.05-4.82) foot injuries (RR 4.12, CI 1.10, 15.40) and injury to players being tackled (RR 1.46, CI 1.00, 2.15) on artificial. Whilst there was no higher injury risk for matches played on artificial versus natural grass surfaces, the higher incidence of concussion and chest injury on grass, and the higher rate of foot injuries on artificial surfaces may be related to tackle and footwear-to-surface interface factors.

Functional polymorphisms in the P2X7 receptor gene are associated with stress fracture injury.

Military recruits and elite athletes are susceptible to stress fracture injuries. Genetic predisposition has been postulated to have a role in their development. The P2X7 receptor (P2X7R) gene, a key regulator of bone remodelling, is a genetic candidate that may contribute to stress fracture predisposition. The aim of this study is to evaluate the putative contribution of P2X7R to stress fracture injury in two separate cohorts, military personnel and elite athletes. In 210 Israeli Defense Forces (IDF) military conscripts, stress fracture injury was diagnosed (n = 43) based on symptoms and a positive bone scan. In a separate cohort of 518 elite athletes, self-reported medical imaging scan-certified stress fracture injuries were recorded (n = 125). Non-stress fracture controls were identified from these cohorts who had a normal bone scan or no history or symptoms of stress fracture injury. Study participants were genotyped for functional SNPs within the P2X7R gene using proprietary fluorescence-based competitive allele-specific PCR assay. Pearson's chi-squared (χ (2)) tests, corrected for multiple comparisons, were used to assess associations in genotype frequencies. The variant allele of P2X7R SNP rs3751143 (Glu496Ala-loss of function) was associated with stress fracture injury, whilst the variant allele of rs1718119 (Ala348Thr-gain of function) was associated with a reduced occurrence of stress fracture injury in military conscripts (P < 0.05). The association of the variant allele of rs3751143 with stress fractures was replicated in elite athletes (P < 0.05), whereas the variant allele of rs1718119 was also associated with reduced multiple stress fracture cases in elite athletes (P < 0.05). The association between independent P2X7R polymorphisms with stress fracture prevalence supports the role of a genetic predisposition in the development of stress fracture injury.

International consensus statement on injury surveillance in cricket: a 2016 update.

Cricket was the first sport to publish recommended methods for injury surveillance in 2005. Since then, there have been changes to the nature of both cricket and injury surveillance. Researchers representing the major cricket playing nations met to propose changes to the previous recommendations, with an agreed voting block of 14. It was decided that 10 of 14 votes (70%) were required to add a new definition element and 11 of 14 (80%) were required to amend a previous definition. In addition to the previously agreed 'Match time-loss' injury, definitions of 'General time-loss', 'Medical presentation', 'Player-reported' and 'Imaging-abnormality' injuries are now provided. Further, new injury incidence units of match injuries per 1000 player days, and annual injuries per 100 players per year are recommended. There was a shift towards recommending a greater number of possible definitions, due to differing contexts and foci of cricket research (eg, professional vs amateur; injury surveillance systems vs specific injury category studies). It is recommended that researchers use and report as many of the definitions as possible to assist both comparisons between studies within cricket and with those from other sports.

Concussed or Not? An Assessment of Concussion Experience and Knowledge Within Elite and Semiprofessional Rugby Union.

OBJECTIVE: The primary aim was to assess experience and knowledge of adult concussion among international, professional and semiprofessional players, coaches, medical staff, and referees within Rugby Union. The secondary aim was to identify preferred education dissemination routes. DESIGN: Questionnaires devised specifically for players, coaches, medical staff, and referees. SETTING AND PARTICIPANTS: A total of 370 players, 44 coaches, 40 medical staff, and 33 referees from within Wales were surveyed. MAIN OUTCOME MEASURES: Knowledge of the signs and symptoms of concussion, return to play guidelines and consequences of concussion were investigated along with experiences of, and attitudes towards, concussion. RESULTS: The respondents had extensive experience of sustaining or witnessing rugby-related concussion. Medical staff had the greatest level of concussion knowledge, with coaches having the least. Players and coaches exhibited a disconnection between being "knocked-out" and practically applying this when managing concussion. Almost half of the players and coaches did not indicate concussion could impair performance. Eighty percent of medical staff had felt pressured to clear a concussed player. Most players (82%), coaches (66%), and referees (64%) incorrectly believed protective equipment prevents concussion. Players and coaches prefer concussion education from medical staff, whereas medical staff and referees prefer such education from governing body Web sites or training courses. CONCLUSIONS: Several role-specific misconceptions and deficiencies in concussion knowledge were identified and should be targeted through education. Medical staff had the highest level of concussion knowledge and were the preferred sources of education for players and coaches. Therefore, they are encouraged to play a greater role in providing concussion education.

Batting head injury in professional cricket: a systematic video analysis of helmet safety characteristics.

BACKGROUND: Batters in cricket are continuing to sustain head and facial injuries despite wearing protective helmets. OBJECTIVE: To gain an understanding of the types and mechanisms of head injuries sustained by batters wearing a helmet. METHODS: Injury type, location and mechanism were categorised via analysis of 35 videos of National or International cricketers sustaining a head injury while batting. RESULTS: 53% of the injuries occurred following ball impact to either the helmet faceguard and peak, or the faceguard alone. Ten injuries (29%) resulted from the ball penetrating the gap between the helmet peak and faceguard. 29% of the injuries involved the ball contacting the face following penetration of the gap between the helmet peak and faceguard. Fractures, lacerations and contusions were the most common injuries associated with face or faceguard impacts while concussion was more commonly associated with impacts to the side or rear of the helmet shell. Many of the injuries described resulted in prolonged or permanent absence from cricket. CONCLUSIONS: Significant head and facial injuries occur in cricket batters despite wearing of helmets. Cricket helmet design and associated National and International Safety Standards should be improved to provide increased protection against head injury related to ball impact to the faceguard and shell of the helmet.

International cricket injury surveillance: a report of five teams competing in the ICC Cricket World Cup 2011.

BACKGROUND: Injury surveillance is the cornerstone of effective injury management. However, to date no studies using recommended methods and involving multiple nations have been conducted within International Cricket. AIM: To conduct injury surveillance across multiple teams during the ICC Cricket World Cup 2011. METHODS: An electronic system, based on the guidelines for injury surveillance in international cricket, was used to record all new injury episodes was used for data collection. RESULTS: Twenty-three time-loss and 97 non-time-loss injuries were recorded. The injury incidence was 3.7/100 player-days (0.7 time-loss and 3.0 non-time-loss) with time-loss incidence being; for match injury 20.1/1000 player-days, bowling injury 3.3/100 bowling days and batting injuries 2.2/10,000 balls faced. Thigh muscle strain and medical illness were the diagnoses with the highest incidence. Fast bowlers, slow bowlers and batters all had a similar injury prevalence of approximately 5%. The bowling delivery stride was the activity that resulted in the greatest lost time. CONCLUSIONS: This is the first study to use recommended injury surveillance guidelines to reporting injury rates across multiple teams at a major cricket tournament. Non-time-loss injury incidence appears relatively high and further study of the effect on performance and progression to subsequent time-loss is required. Fast bowler injury prevalence rates are lower than reported elsewhere, however this may be due to the nature of the tournament and match format, which is likely to impose a lower relative workload. In future, data from all competing teams over all formats of the game (Twenty20, ODI and Tests) needs to be analysed to effectively inform injury prevention research and practice.

The influence of cricket fast bowlers' front leg technique on peak ground reaction forces.

High ground reaction forces during the front foot contact phase of the bowling action are believed to be a major contributor to the high prevalence of lumbar stress fractures in fast bowlers. This study aimed to investigate the influence of front leg technique on peak ground reaction forces during the delivery stride. Three-dimensional kinematic data and ground reaction forces during the front foot contact phase were captured for 20 elite male fast bowlers. Eight kinematic parameters were determined for each performance, describing run-up speed and front leg technique, in addition to peak force and time to peak force in the vertical and horizontal directions. There were substantial variations between bowlers in both peak forces (vertical 6.7 ± 1.4 body weights; horizontal (braking) 4.5 ± 0.8 body weights) and times to peak force (vertical 0.03 ± 0.01 s; horizontal 0.03 ± 0.01 s). These differences were found to be linked to the orientation of the front leg at the instant of front foot contact. In particular, a larger plant angle and a heel strike technique were associated with lower peak forces and longer times to peak force during the front foot contact phase, which may help reduce the likelihood of lower back injuries.

Relationships between fast bowling technique and ball release speed in cricket.

The aim of this study was to identify the key aspects of technique that characterize the fastest bowlers. Kinematic data were collected for 20 elite male fast bowlers with 11 kinematic parameters calculated, describing elements of fast bowling technique that have previously been linked to ball release speed. Four technique variables were identified as being the best predictors of ball release speed, explaining 74% of the observed variation in ball release speed. The results indicate that the fastest bowlers have a quicker run-up and maintain a straighter knee throughout the front foot contact phase. The fastest bowlers were also observed to exhibit larger amounts of upper trunk flexion up to ball release and to delay the onset of arm circumduction. This study identifies those technique variables that best explain the differences in release speeds among fast bowlers. These results are likely to be useful in both the coaching and talent identification of fast bowlers.

Evidence of immunometabolic dysregulation and airway dysbiosis in athletes susceptible to respiratory illness.

BACKGROUND: Respiratory tract infection (RTI) is a leading cause of training and in-competition time-loss in athlete health. The immune factors associated with RTI susceptibility remain unclear. In this study, we prospectively characterise host immune factors in elite athletes exhibiting RTI susceptibility. METHODS: Peripheral blood lymphocyte flow cytometry phenotyping and 16S rRNA microbial sequencing of oropharyngeal swabs was performed in a prospective elite athlete cohort study (n = 121). Mass cytometry, peripheral blood mononuclear cell (PBMC) stimulation and plasma metabolic profiling was performed in age-matched highly-susceptible (HS) athletes (≥4RTI in last 18 months) (n = 22) compared to non-susceptible (NS) (≤1RTI in last 18 months) (n = 23) athletes. Findings were compared to non-athletic healthy controls (HC) (n = 19). FINDINGS: Athletes (n = 121) had a reduced peripheral blood memory T regulatory cell compartment compared to HC (p = 0.02 (95%CI:0.1,1.0)) and reduced upper airway bacterial biomass compared to HC (p = 0.032, effect size r = 0.19). HS athletes (n = 22) had lower circulating memory T regulatory cells compared to NS (n = 23) athletes (p = 0.005 (95%CI:-1.5,-0.15)) and HC (p = 0.002 (95%CI:-1.9,-0.3) with PBMC microbial stimulation assays revealing a T-helper 2 skewed immune response compared to HC. Plasma metabolomic profiling showed differences in sphingolipid pathway metabolites (a class of lipids important in infection and inflammation regulation) in HS compared to NS athletes and HC, with sphingomyelin predictive of RTI infection susceptibility (p = 0.005). INTERPRETATION: Athletes susceptible to RTI have reduced circulating memory T regulatory cells, metabolic dysregulation of the sphingolipid pathway and evidence of upper airway bacterial dysbiosis. FUNDING: This study was funded by the English Institute of Sport (UK).