Interventions to Prevent Sports and Recreation-Related Injuries

Chapter 7 Interventions to Prevent Sports and Recreation-Related Injuries Julie Gilchrist, Gitanjali Saluja, and Stephen W. Marshall 7.1. INTRODUCTION Participation in sports, recreation, and exercise is an important part of a healthy, physically active lifestyle; however, injuries due to sports and recreational activities are a significant public health problem. Injuries can occur as a result of organized sports activities in schools, clubs, or leagues; but many injuries also occur in infor- mal settings, such as sports played in backyards or neighborhoods. In this chapter, we address injuries related to sports, such as basketball, football, and soccer; recreational activities, such as biking, skating, skiing, and playground activities; and exercise and training activities, such as weight training, aerobics, and jogging. Although swimming and other water sports are recreational activities, drowning prevention is addressed in another chapter. Because participants engage in sports, recreation, and exercise mainly for fun and fitness, the risks inherent in these activities may not be recognized, and injury prevention measures are often overlooked. More than 11,000 people receive treatment in U.S. emergency departments (EDs) each day for injuries sustained while participating in recreational activities (Gotsch, Annest, Holmgreen, & Gilchrist, 2002). In addition, many injuries in sports and recreation are not treated in the emergency department but rather in acute care clinics, orthopedic offices, sports medicine clinics, and primary-care providers’ offices. The social and economic costs associated with these injuries are high. An estimated 7 million participants seek medical care each year in the United States for injuries they sustain while participating in sports and recreational activities (Conn, Annest & Gilchrist, 2003). More than 20% of those injured lose at least 1 day of work or school due to their injuries. Participants often cite injuries as a reason that they 117 118 J. Gilchrist et al. stop taking part in potentially beneficial physical activities (Finch, Owen & Price, 2001; Hootman et al., 2003; Koplan, Powell, Sikes, Shirley, & Campbell, 1982). Fur- thermore, some injuries common in these activities such as traumatic brain injuries and knee injuries can have long-term consequences such as epilepsy (Thurman, Alverson, Dunn, Guerrero, & Sniezek, 1999) or premature osteoarthritis (Feller, 2004), respectively. Injury surveillance in the United States suggests that the sports and recreational activities most commonly associated with injuries vary by age but include basketball, bicycling, exercising (e.g., aerobics, jogging, and weight training), football, base- ball/softball, soccer, skating (ice/in-line/roller), snow sports, gymnastics/cheer- leading, playground activities, and horseback riding. It is not currently possible to compare risks across activities because population-based participation estimates (or exposures) are not available. Given the fact that these are popular activities and public health mandates since the 1950’s include promotion of regular exercise, the potential exposure to injury risk associated with these activities is high. Injury risk varies by many factors. Traditionally, these are classified as either intrinsic or extrinsic to the individual. Intrinsic factors are personal qualities or characteristics. Some, such as age and gender, cannot be readily altered; however, others, such as level of fitness and playing skill, can be modified to reduce injury risk. For example, pre-season conditioning programs can improve athlete fitness and reduce injury risks, even in children. Extrinsic risk factors, on the other hand, are risk factors in the environment in which an individual participates. They are common to all participants and can include things such as the risk inherent in each activity, the physical attributes of the environment where the activity takes place, and even the weather. For instance, untethered movable soccer goal posts pose a risk for all players. Many of these risk factors in fitness activities have been identified through studies during military physical training. Table 7.1 presents a summary of common intrinsic and extrinsic risk factors identified by previous authors (Jones, Reynolds, Rock, & Moore, 1993). Unfortunately, the risk factors and injury rates for each activity have not been fully delineated. Information regarding relative risks among different age groups and in different activities is sparse. Basic information on risk and protective factors and effectiveness of prevention programs for many activities is also lacking. Researching sports- and recreation-related injuries and prevention measures can be difficult for a number of reasons. First, the nature of participation varies greatly. For instance, basketball is a very popular activity; it can be highly organized and competitive such as NCAA Division I basketball or played alone or with friends in driveways, playgrounds, or gyms at religious centers and schools. Each level of play has some risks that are similar and some that are different. Second, exposure information to provide adequate denominators is currently lacking. Current ED data systems provide estimates of the number of injuries seen in U.S. hospital EDs; however, without valid population-based information on exposure to sports and recreational activities, meaningful injury rates can not be calculated, and risks cannot be compared across groups or activities. Third, as noted previously, many injuries are not treated in EDs. As many as 40% of medically treated injuries may be seen outside of an ED (Conn et al., 2003; Gotsch et al., 2002). Fourth, the studies that have been conducted have used a wide variety of definitions of injury and exposure to sports/recreation; and as a result, comparisons of risks and rates across studies are difficult. For example, some studies capture any injury that affected participation, even if for only a few minutes, whereas others only capture injuries that required medical care, an ED visit or hospitalization. Finally, sports- and recreation- Interventions to Prevent Sports and Recreation-Related Injuries 119 Table 7.1. Intrinsic and Extrinsic Risk Factors for Musculo- skeletal Injuries Associated with Weight-Bearing Exercise and Activitya Intrinsic Factors Sex Age (extremes) Previous injury Behavioral factors Smoking Previous physical activity/lifestyle (sedentary) Physical fitness Aerobic endurance (low) Muscle endurance (low) Strength (low or imbalanced) Flexibility (extremes or imbalanced) Body composition (extremes) Anatomic abnormalities High arches Bowed legs Leg-length discrepancies Musculoskeletal disease Osteoporosis Arthritis Extrinsic Factors Training parameters (excessive or rapid increase) Duration Frequency Intensity Environmental conditions (extremes or irregular) Terrain Surfacing Weather Equipment (e.g., worn or improperly fitting footwear) aReprinted with permission from Jones et al. (1993). related injury prevention often has been based on anecdotal evidence. Thus many of the interventions used today have not been subjected to rigorous trials and have become entrenched as common practice often without formal scientific evaluation using study designs such as randomized controlled trials. For example, stretching before strenuous exercise has long been encouraged as a means to prevent injury; however, trials and epidemiological studies of pre-exercise stretching have pro- duced inconsistent results regarding any injury prevention effect (MacAuley & Best, 2002; Thacker, Gilchrist, Stroup, & Kimsey, 2004). Consensus by experts in the field can be a valid way to address some injury issues; however, practices resulting from consensus, while potentially beneficial, will not be addressed in this chapter. Despite these challenges, several effective measures have been identified to reduce injury risk. Similar to infectious diseases, the occurrence of an injury is the result of interplay between the host (the participant), the vector or vehicle (the sport or activity), and the environment (both physical and sociocultural) in which the activity takes place. Sleet (1994) described examples of the targeted use of strategies designed to reduce sports injuries related to the host, vector, and environment and how these strategies may overlap. The three types of strategies each target different causative factors in sports injury. The education/behavior change strategies primarily target 120 J. Gilchrist et al. changes in host or individual risk behavior. Policy/enforcement strategies primarily target the environment through changes in laws, policies, regulations, and compli- ance. Engineering/technology strategies primarily target the agent or vector of injury (i.e., the activity) and modify or reduce the amount of energy transferred. An adaptation of this model is presented in Figure 7.1. Categorization of interventions is complex—for instance, a helmet may be engineered to minimize energy transfer during an activity (vector); there may be a rule or law requiring its use (environment); but ultimately, the participant (host) must decide to wear it. Effective or promising strategies have been identified to alter aspects of each of these entities to reduce injury risks in common sports and recreational activities (Table 7.2). However, for many interventions in this area, research either hasn’t been conducted or findings are conflicting, limiting science-based recommendations. The remainder of this chapter addresses example interventions

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