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Abstract
Background Prevention of sport injuries and illnesses is a focus for epidemiological surveillance.
Objectives To record and analyse all sports injuries and illnesses registered during the second Asian Beach Games.
Design A descriptive epidemiological study using the International Olympic Committee Surveillance system to register injuries and illnesses during the second Asian Beach Games.
Methods The second Asian Beach Games hosted 1132 athletes from 43 countries competing in 14 beach sports. All National Olympic Committees' physicians of the participating teams were invited to report all injuries and illnesses. In addition, medical officers at the different Olympic venues and the main Olympic village reported injuries and illnesses treated at the clinics on a daily basis.
Results A total of 177 injuries were reported equating to an incidence rate of 156.4 per 1000 registered athletes. Tent pegging recorded the highest incidence of injuries with 357 per 1000 registered athletes. The most prevalent injuries were in the foot/toe with 14.1% of all reported injuries. The majority of injuries were incurred during competition (75.4%). In addition, the most common mechanism of injury was contact with another athlete (n=42, 23.7%) and combined sudden and gradual overuse contributed to 30% of the total injury burden. Furthermore, 118 illnesses were reported resulting in an incidence rate of 104.2 illnesses per 1000 registered athletes. The most affected system was the respiratory tract (39.1%) with infection being the most common cause (n=33, 38.0%). The incidence of injury and illness differed significantly among the 14 sports.
Conclusion The data indicate that the risk of injury from beach games is sport dependant. This means that any preventive measures have to be tailored for each discipline. Furthermore, the study showed that respiratory infections are the commonest illness in beach sports and therefore, event organisers should focus improving public health measures and hygiene awareness.
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The health and well-being of international athletes is paramount to the International Olympic Committee (IOC) mission. To achieve such target, accumulation of accurate data on injuries and illness incurred during multisport events is a critical step before proposing preventive measures. Systematic surveillance is the gold standard in monitoring trends in injuries and illness over time. It is the most useful tool for the identification of high-risk sports and common mechanisms of injury. According to Van Mechelen et al's four-stages model of injury epidemiology, procuring descriptive data is the essential first step to develop effective and relevant prevention strategies.1
International sporting events are an ideal environment to conduct surveillance injury and illness projects. This is because the targeted population constitute a relatively homogenous group in terms of skills and the study period is defined by the event itself. The first use of systematic surveillance system for sport injuries dated back to 1998, when the Federation Internationale de Football Association started to collect data on injuries incurred in all their competitions.2,–,6 Since then, multiple other sport organisations surveyed their athletes.7,–,9 Furthermore, during the Summer Olympic Games 2004, an accomplished injury-surveillance project was conducted. Based on the experience from this event, the IOC developed a standardised protocol for injury surveillance in multisport events.10 ,11 The IOC system was first tested during the 2008 Beijing Olympic Games.12 It proved to be very effective and reliable in injury surveillance. After that, the IOC system was extended to include the surveillance of illness among athletes' competing in international events and was successfully conducted during the 2010 Winter Olympic Games in Vancouver.13
International multisport tournaments have a positive impact on the global economic and social development and contribute to the achievement of broader targets such as the United Nations Millennium Development Goals. Events such as the Asian Beach Games which is a multisport event regulated by the Olympic Council of Asia is an example of how international sport contribute to social and economic development.14 The first games were held in Bali, Indonesia in 2008. In 2010, the Sultanate of Oman hosted the second games between 8th and 16th of December. The games included athletes from 43 Asian countries who competed in 14 different sports. For beach games, less knowledge on risk of injury and illness exists. The aim of this study was to use the IOC surveillance system to describe the risk of injury and illness occurring during the second Asian Beach Games in Muscat 2010. Furthermore, the study attempted to assess the causes and mechanisms of such injuries and illnesses during the beach games. The results of this study will add to the existing body of knowledge on the risk of injury and illness occurring during multisport events specifically beach sports.
Methods
In this study, we used the injury-surveillance system for multisport events designed by the IOC, of which the detailed protocol has been previously published elsewhere.11 The injury definition and data collection procedures were successfully implemented in the Olympic Games 2008 in Beijing.12 ,13 Subsequently, illnesses were included in the surveillance system and were implemented during the Winter Olympic Games 2010.13 This study included surveillance for both injuries and illnesses.
All physicians or healthcare providers of the participating National Olympic Committees (NOCs) were invited to participate in this study a month before the commencement of the tournament. They were asked to provide a daily report, using the injury report form, of all newly encountered injuries or illnesses. They were also requested to report the absence of injury and illness on a daily bases. The Local Organising Committee (LOC) physicians from the venue and athletes' accommodation clinics reported injuries and illnesses for NOCs without healthcare providers.
A detailed booklet was distributed among all participating teams and LOC physicians with information about the study a month before the commencement of the study. The booklet contained the study design and protocol with IOC definitions of injury and illness and a comprehensive guide on how to use the daily reporting form. Furthermore, the lead researcher presented the details of the study 3 days before the games launch to representatives of all the medical teams of participating NOCs. In order to ensure compliance of all NOCs and local doctors, members of the research team contacted the NOCs and LOCs on daily basis to check the completion of daily reporting forms. Furthermore, all received reporting forms were checked for accuracy and duplication. The research group used the athletes' accreditation numbers as the unique identifiers for each reported case.
Definition of injury and illness
The definition of injury according to the IOC was used.11 ,15 An injury was defined as any musculoskeletal complaint and/or concussion newly incurred due to competition and/or training during the period of the second Asian Beach Games that received medical attention regardless of the consequences with respect to absence from competition or training. This injury definition included four aspects:
All injuries that received medical attention (not only time-loss injuries);
Newly incurred injuries (pre-existing, not fully rehabilitated injuries should not be reported; re-injuries (injuries of the same location and type) should be reported only if the athlete has returned to full participation after the previous injury);
Incompetition or training injuries;
Injuries sustained during the period of the Games (8th to 16th December 2010).
An illness was defined as any physical complaint (not related to injury) newly incurred during the second Asian Beach Games that received medical attention regardless of the consequences with respect to absence from competition or training. This illness definition included three aspects:
All illness that received medical attention (not only those resulting in time loss);
Newly incurred illness (pre-existing and chronic illnesses should not be reported unless the athlete suffers an acute exacerbation);
Illnesses incurred during the period of the second Asian Beach Games (8th to 16th December 2010).
If multiple body parts were injured at the same incident, multiple types of injuries occurred in the same body part, or if different body parts were affected by illnesses, only the most severe injury/illness was reported, however, with several diagnoses.4 ,11
The cause and the context of the injury were reported as per the discretion of the treating physician in consultation with first aid providers first to attend to the injured athlete.
Confidentiality and ethical approval
Strict confidentially was ensured at all times and all collected data were made anonymous and all identifiers were excluded before data analysis. Ethical approval was obtained from the Oman Olympic Committee and the Sultan Qaboos University, College of Medicine and Health Sciences.
Data analysis
All data were statistically processed using SPSS (SPSS for Windows, version 15.0, Chicago, Illinois, USA).
The compliance of the NOCs with the study protocol of reporting (ie, participation rate) was calculated by dividing the number of received injury and illness report forms by the number of expected forms (ie, the number of participating NOCs multiplied by 8 days). If multiple forms were received for the same NOC or same incident, then one form was used for the response rate analysis and the others were excluded after confirmation of duplication.
This study presents descriptive data in the forms of frequencies, proportions and mean values with SD. These data included the athletes' age, frequency and proportions of injuries and illnesses, such as injury type, location, cause, circumstance and severity and affected illness systems with following symptoms, causes and estimated time loss. The method used to calculate the incidence of injuries and illnesses was the number of injuries/illnesses per 1000 registered athletes.
For all other continuous variables, comparisons were analysed using the Student's t test for independent groups. Furthermore, a χ2 test and Fisher exact test were used for all other categorical variables with small numbers. The comparison between male and female rates of injury was expressed using a rate ratio (RR) with corresponding 95% CI and the significance was tested using a z test based on the Poisson model. The level of two-tailored significance was set to be at α=0.05.
Results
Response rate
All the 17 NOCs with medical teams and the 26 venue clinics (including; 17 field clinics and 9 residential clinics) are included in the analysis of response rate. Throughout the 8 days of the second Asian Beach Games, a total number of 301 completed forms were received out of the maximum 344 forms distributed (136 from NOCs and 208 venue and field clinics; response rate 87.5%) (table 1). The venue clinics' doctors reported 57 (26.6%) injuries and 29 (24.6%) illnesses. The response rate from NOCs with less than 30 athletes was low because there were only five small NOCs with healthcare professionals in the team and therefore data reporting is mainly done by LOC doctors.
Response rate and incidence of injuries and illnesses
Injuries
Incidence
Among the 1132 registered athletes (736 males, 396 females), 177 injuries occurred in 167 athletes resulting in an injury incidence of 156.4 per 1000 registered athletes. There were 161 registered athletes who sustained one injury (14.2% of the total registered athletes). There were four athletes with three injuries and two athletes with two injuries each.
The incidence of injuries was higher in female (184.3 injuries per 1000 athlete (95% CI 168.5 to 200.1) than in male athletes (141.6 injuries per 1000 athlete (95% CI 88.2 to 189.0), RR=1.3(1.1 to 1.5), p=0.004). Gender information was missing for five injured athletes. The age was not significantly different between injured athletes and their non-injured counterparts bearing in mind that information on age were missing for 63 injured athletes.
Sport-dependant risk
Table 2 shows the variable injury incidence among different beach sports. In relation to the number of registered athletes, the incidence of injuries was highest for tent pegging, beach kabaddi, beach soccer, beach handball and beach water polo (incidence rate of 357 – 171 per 1000 registered athletes). There was no difference between the highest risk sports in male and female athletes. However, the risk for injury was lowest for water ski, triathlon and bodybuilding (less than 50 injuries per 1000 registered athletes) (table 2).
Injury and illness incidence among different sports
Injury location and type
Overall, foot/toe, thigh and shoulder were the most injured sites with 14.1%, 7.9% and 7.9% of the total reported injuries, respectively. In males, the most common site of injury was knee (6.2%) and in females, the lumbar spine and lower back (7.9%). Sprains (26.6%), lacerations and abrasions (15.3%) and contusions and haematomas (13.0%) were the most common injury types. In beach soccer, 14 out of 37 (37.8%) injuries affected the foot and toe followed by injuries to the thigh (9 out of 37 (24.3%)) (table 3). There were nine reported fractures, three of which were among athletes competing in sepaktakraw. During the games, nine dislocation injuries were reported, three of which were among beach soccer athletes. There was only one concussion reported and this was in beach soccer.
Injury and illness incidence, location, system affected, cause and type
Injury mechanism and context
The three most common mechanisms of injury were as follows: contact with another athlete (n=42, 23.7%), sudden-onset overuse (n=30, 16.9%) and gradual-onset overuse (n=25, 14.1%) (table 3). Information is missing for eight injuries (4.5%). In terms of sports, kabaddi had the highest percentage of all injuries caused by contact trauma 65.0% (n=13). This was followed by handball with 45.5%(n=15) of all injuries were caused by contact with another athlete.
Information on the contexts of injuries was missing for 49 injuries (27.7%). The overall relative risk of sustaining an injury during competition relative to that during training was 3.1 (RR 2.9–4.2, p=0.002). However, the RR was sport dependant as shown in table 4. The RR of injury for sailing was the same in competition and training.
Severity and context of injuries
Time loss due to injury
Of the 177 reported injuries, 130 (73.4%) were reported to result in a time-loss situation for the athlete (table 4). The majority (n=125, 70.6%) were expected to cause loss less than 24 h. However, three fractures and one dislocation were reported to cause a time loss of 3 days or more. Information on time loss was missing for 47 injuries.
Illness
Incidence and distribution
During the 8 days of the second Asian Beach Games, 118 illnesses were reported resulting in an incidence of 104.2 illnesses per 1000 registered athletes.
Overall, there was no significant difference between the incidence of illness among male and female athletes (105 vs 104 per 1000 athletes, p=0.18). Ill and healthy male and female athletes were similar for age (male; 29.9, SD=6.2, female; 29.4, SD=6.0, p=0.12). Illness was highest among beach soccer athletes (n=30, 19.1%) (table 3).
Affected system, symptom, cause and severity
Information was missing for 31 (26.3%) of illnesses. The respiratory system was the most affected with 34 (39.1%) illnesses reported, mostly observed in handball (n=13, 38.2%) and soccer (n=10, 29.4%). Subsequently, the most common cause reported for these illnesses was infection (n=33, 38.0%). The most common symptoms of the illnesses was pain (n=29, 33.3%) and other symptoms (including dehydration, anaphylaxis, dizziness). The most frequent diagnosis was upper respiratory tract infection (pharyngitis, sinusitis, tonsillitis; n=21, 19.4%). A total of 31 illnesses (34.8%) were exercise induced or caused by environmental factors.
Discussion
This study attempted to record and analyse all incurred injuries and illnesses during the second Asian Beach Games in Muscat 2010. To the authors' knowledge, this study is the first to collect data specifically on a multisport beach games international tournament.
The response rate to the study was 87.9% which is comparable to the Summer Olympic Games response rate (88.0%) and slightly lower than that of the Winter Olympic Games (94.2%).12 ,13
The incidence of injuries in the study was 156.4 per 1000 registered athletes and the illness incidence was 104.2 per 1000 registered athletes. Furthermore, 15.5% of the athletes incurred an injury during the games, and 10.4% of the athletes contracted an illness during the tournament time.
If compared with other descriptive studies which used the same IOC surveillance system, then the Asian Beach Games incidence of injury is higher than that reported from the Vancouver Games 2010 (11%)13 and the Summer Olympics in Beijing 2008 (9.6%).12 This observed difference in injury rate is intuitivelydue to the differences in the nature of the played sports themselves. It could also represent an overestimation in the Asian Beach Games due to smaller study size compared with the other two Olympic Games studies. Similarly, the rate of illness during the Asian Beach Games was also relatively higher than the rate of illnesses during the Winter Olympic Games 2010.13 It is important to note that the Beach Games took place in a time of the year with a background of a seasonal rise in the incidence of viral respiratory illnesses and this could have accounted for the higher recorded incidence of illness.
Estimating the risk of injury in different sports is a challenging and confounded task as the biomechanics within each sport differ considerably. In this study, the risk of injury was reported as the total number of injuries/illnesses per registered athletes for each sport/discipline, which is the recommended way of presenting risk of injury during sports.10 The risk of sustaining an injury was highest for tent pegging (35.7%), beach kabaddi (24.1%), beach soccer (23.6%), beach handball (21.2%) and beach water polo (17.1%). All these sports are characterised by high speed and full contact with other players or objects.9 Athletes competing in tent pegging – and other equestrian sports – have been previously shown to have high risk for injuries because of the nature of horse riding and the risk of falls.16 ,17 Beach kabbadi is a relatively new addition to beach games and hence data on injury risk is lacking. The sport itself is characterised by high physical contact between competitors similar to that of wrestling.18 ,19 The injury rate of beach soccer in this study is lower than that reported from soccer games during the Summer Olympic Games (31.5%).12 However, it is important to interpret this with caution as beach soccer has different risk profile to that of outdoor or indoor soccer.20 Beach soccer contributed the most (66.7%) to the total number of foot and toe injuries during the tournament. About half of the total injuries in this study occurred in the lower extremity with sprains, strains and contusions as the main types of injuries during the Asian Beach Games 2010. Furthermore, ankle sprain and strain is the commonest injury reported. It is worth mentioning that concussion is only reported once and this seems very under reported. Concussion is a major concern in sports with great physical contact such as beach soccer and kabbadi. The reasons for under reporting of concussion include athletes not wanting to lose time off field and the lack of awareness about the subtle symptoms of head concussion during sports.21 However, nine fractures were reported, most of them in sports such as handball, sepaktakraw and soccer. This number of fractures was similar with published data on sports injuries from tournaments that included such sports.7 ,12 ,20 ,22 Furthermore, 6.8% of reported injuries affected the clavicle and shoulder which mainly occurred among handball and volleyball players. This is in agreement with reported injury sites from the Summer Olympic Games and international beach volleyball tournaments.9 ,12
Regarding the mechanism of injury, contact with another athlete was the most frequent reported cause of injury (23.7%). This is similar to data reported from the Summer Olympic Games.12 Other causes identified were sudden-onset overuse (16.9%) and gradual-onset overuse (14.1%). This is in agreement with the international literature of multisport events.8 ,12 ,13 ,23 It is important to note that the field of play conditions (as determined by the on-site field doctors) contributed to about 11.9% of total injuries reported. This emphasises that field design is critical in beach sports. However, it is also essential to appreciate that the mechanism of injury is sport dependant and therefore any preventive measures have to be tailored to consider such discrepancy.
The majority of injuries in the Asian Beach Games happened during competition time (75.4%). The risk of sustaining an injury during competition was three times that during training. This is consistent with injuries reported from the Winter Olympic Games, Summer Olympic Games and the 2007 World Athletics Championships using the same surveillance system.23 The Summer Olympic Games study showed that injuries which occurred during competition were different from training injuries.12 However, this aspect was not investigated in our study.
Study limitations and future research
The IOC surveillance system has been shown to be reliable and feasible during multisport events.11 However, this study has some limitations that are important to note. First, the small number of participants might have contributed to an overestimation of the injuries and illnesses incidences. Furthermore, the response rate in such projects is greatly dependent on the availability and participation of team physicians, and the fact that only 17 NOCs (out of 43) had their own physicians, limited the efficiency of injury and illness reporting. This was mostly apparent in the NOCs with less than 30 athletes who had only 19% response rate as only five of these NOCs had their own healthcare professionals. This issue might have caused a reporting bias in the results presented here. The use of video analysis of injuries will give a comprehensive insight into the exact circumstances of the injury and therefore better knowledge for preventive programs design.24 It will also be useful to have basic health parameters (body mass index, previous chronic conditions, previous injuries) for athletes so such confounding factors will be taken into account when analysing injuries during multi-sport events. Collecting such data will allow the development injury risk predictive profile for each athlete in each sport.
The concept of ‘time loss’ is only an estimate by physicians and may not reflect the real time loss. A follow-up of all injured athletes to assess the impact of the injury in term of time loss and return-to-play is ideal but expensive and impracticable to implement.
Implications
Data from this study show that research into beach sports is urgently needed in order to achieve better competing conditions for athletes in such sports. The use of the IOC system appears to be appropriate and should be continued in upcoming Asian Beach Games. However, the issue of reporting bias is still a drawback of the current IOC system and further rigorous reporting ideas are needed to capture all injuries during international tournament. Moreover, it is also essential for future research to collect baseline data to control for possible fitness and physical factors that could confound injury incidence. Finally, the use of technology will enhance data of the circumstances of injuries and therefore provides more comprehensive understanding when designing preventive measures. Furthermore, a follow-up survey of injured athletes will provide some insight into the long-term impact of injuries beyond the time of the tournament. This study shows that injury incidences in beach sports are sport dependant and any preventive measures have to be individually tailored.
Conclusion
At least 15.6% of athletes sustained an injury during the second Asian Beach Games and 10.4% suffered an illness. The sports differ in terms of risks, causes and time loss. Tent pegging had the highest risk of injury due to its nature as a fast-paced game with high physical contact between players. The variable injury risk between different beach sports indicates that any preventive strategies have to be tailored according to the nature and risk. Surveillance systems of injuries and illness during international multisport events should be continued and technology should be incorporated into the surveillance system to enhance the accuracy and quality of data collected. Long-term follow-up of injuries will be essential.
Acknowledgments
The research group would like to express great thanks to Dr M Jegathesan, the chairperson of the Medical Committee, Olympic Council of Asia for his support to this project. Our gratitude goes to all NOCs and local doctors for providing the data. A special thank you to Mr Ahmed Al-Saidi for his help during the data collection.
References
Footnotes
Funding International Olympic Committee.
Competing interests None.
Ethics approval Sultan Qaboos University Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data collected and presented in this study are available to any who may be interested and should contact the lead author.