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Abstract
Background Injury and illness surveillance in the aquatic disciplines has been conducted during the FINA World Championships and Olympic Games. The development of an aquatic-specific injury and illness surveillance system will improve the quality of the data collected and the development of preventive measures. Our ultimate objective is to enhance aquatic athlete health and performance.
Objective The objective was to refine the injury and illness surveillance protocols to develop aquatic-specific definitions of injury and illness; define aquatic-specific injury location and causation; better describe overuse injuries; regard pre-existing and recurrent injuries; more accurately define aquatic athlete exposures and develop a protocol to capture out-of-competition aquatic athlete health parameters.
Methods FINA compiled an Injury and Illness Surveillance Expert Working Group comprised of international experts to review the scientific literature in the field. A consensus meeting was convened to provide an opportunity for debate, following which recommendations were collated.
Results Aquatic-specific injury and illness surveillance protocols covering both the in-competition and out-of-competition time periods were developed. Definitions for all relevant variables were outlined, and documentation forms for athletes and for clinicians were proposed. Recommendations for the implementation of an injury and illness surveillance system for FINA are presented.
Conclusion The FINA consensus authors recommend ongoing in-competition and out-of-competition surveillance to determine injury and illness trends over time. The implementation of the definitions and methodology outlined in this paper will improve the accuracy and value of injury and illness surveillance, and provide important information for injury prevention.
- Injury prevention
- Illness
- Surveillance
- Aquatic sports
- Swimming
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Introduction
Aquatic sport (swimming, diving, water polo, synchronised swimming, open water swimming and high diving), the second largest sport based on the number of athletes at the Olympic Games, is governed by the FINA. Approximately 2500 athletes from 180 countries compete at the FINA World Championships before a cumulative global audience of 4.5 billion. As the custodian of a sport that enjoys global popularity and participation throughout the lifespan, FINA has the responsibility of protecting the health and well-being of its athletes. Its Medical Rules clearly outline: “FINA…should take care that sport is practised without danger to the health of the athletes…To that end, it takes the measures necessary to preserve the health of athletes and to minimise the risks of physical injury and psychological harm.”1
Athlete health protection should be on a methodologically sound injury and illness surveillance model for the accurate collection of data to clearly define the health risks of the specific sport.2–5 Several International Sport Federations have published methods and/or consensus statements for injury and illness surveillance based on the requirements and characteristics of their sport, such as football,6 ,7 cricket,8 rugby,9 ,10 tennis,11 skiing,12 horse racing,13 athletics14 and multisport events.15 These approaches are an important step towards injury and illness prevention.16
Previous injury and illness surveillance in aquatic sports
FINA participated in the 2004 Athens Olympic Games on injury surveillance team sport with its discipline of water polo.17 All aquatic disciplines were included in the injury surveillance during the 2008 Beijing Olympic Games,18 and in the injury and illness surveillance during the 2012 London Olympic Games.19 FINA conducted its first injury and illness surveillance during the 2009 FINA World Championships.20 In 2013, a retrospective survey capturing physical complaints in the 4 weeks prior to the Championships was also implemented to ascertain the magnitude of overuse injuries not captured using the traditional methodology.21 A further FINA project on out-of-competition illness analysed the prevalence of asthma in a large cohort of close to 1500 elite aquatic athletes competing at the Olympic Games and FINA World Championships during the time period of 2004–2009.22
The IOC methodology for injury and illness surveillance15 used for the FINA injury and illness surveillance in Rome20 and Barcelona21 had important limitations for aquatic events with regard to exposure (specifically for swimming relays, open water swimming team, synchronised swimming team and synchronised diving events) and injury location (specifically head injuries in water polo requires further differentiation). More importantly, the IOC surveillance protocol was not designed to capture the true extent of overuse injuries, since it focuses on acute, new-onset injuries during the in-competition time period. However, FINA studies showed that 37.5% of all injuries during the World Championship were caused by overuse,20 and injuries incurred in the out-of-competition period were still present during competition.21 Also, the high prevalence of asthma in the elite swimmer reported by Mountjoy et al22 is not captured in the IOC protocol which only records new-onset illnesses or exacerbations of existing illnesses.22
Consensus meeting objectives
The methodological limitations outlined above demonstrate the need for FINA to refine the in-competition injury and illness surveillance protocols specifically for the aquatics sports and to cover both the in-competition and out-of-competition time periods. The objectives were to:
Develop aquatic-specific definitions of injury and illness;
Specify aquatic-specific injury location and causation;
Better describe overuse injuries;
Regard pre-existing and recurrent injuries;
Develop a protocol and documentation forms to capture out-of-competition health problems of aquatic athletes;
More accurately define aquatic athlete exposures.
Methods
To realise the objectives outlined above, FINA convened an Injury and Illness Surveillance Expert Working Group (FINA consensus group). Participants included a project lead (MM), a scientific lead (AJ), experts in sports injury epidemiology (AJ, BC, IS, BMP), aquatic sports medicine (MM, KK, CvdH, DG, HPD), sport psychiatry (SM) and an athlete representative (PH). Prior to the consensus meeting, relevant topic areas were determined by the project coordinator and scientific lead. Each topic was assigned a lead expert and a secondary participant who were responsible for conducting a literature review and drafting a preliminary summary of the designated topic(s). The topic summaries were collated and circulated for review by all participants prior to the meeting.
The consensus meeting was held at Aspetar in Doha, Qatar, in December 2014. The meeting was moderated by a non-aquatic sport medicine expert (KMK) and recorded in an audio file and transcribed by an administrative assistant. Each topic was presented by the identified lead participant and discussion by all participants ensued. Following discussion, consensus was reached by the participants under the guidance of the moderator. Any discrepancies following discussion were identified in the audio and meeting notes. After the meeting, the participants redrafted their respective topic assignments based on the discussions at the meeting. These new modified scientific summaries along with the audio files and the administrative assistant meeting notes were reviewed, and all data were collated in an initial consensus document draft by the project lead. This initial consensus document was edited by the scientific lead prior to the circulation to all participants for review. All comments were once again collated, and a second consensus document was drafted by the project lead and reviewed by the science lead. This document and subsequent iterations were circulated to all participants for comment and final review.23 Any remaining discrepancies in consensus are notated in this final document.
Consensus recommendations
Definitions of injury and illness
The FINA consensus group reviewed the published injury and illness definitions, and modified the wording as required to ensure aquatic specificity:
Medical condition/health-related incident: “Any physical or psychological complaint or disorder experienced by an athlete, irrespective of the need for medical attention or time loss from training or competing in an aquatic discipline.”14
Injury: “A physical complaint or observable damage to body tissue produced by the transfer of energy experienced or sustained by an athlete during participation in training or competing in an aquatic discipline, regardless of whether it received medical attention or its consequences with respect to impairments in competition or training” (based on refs. 9 ,14).
Illness: “A complaint or disorder experienced by an athlete not related to injury, regardless of whether it received medical attention or its consequences with respect to impairments in training or competing in an aquatic discipline.”14 An illness can be either physical or psychological. A psychological illness can be a response to psychological trauma suffered during sport (ie, abuse, harassment, post-traumatic stress disorder, response to sport injury) or suffered outside of sport (ie, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) diagnoses).
Medical attention: “An injury or illness where a qualified clinician has assessed the athlete's medical condition” (based on refs. 6 ,9 ,11 ,14).
Clinician: FINA has 208 member federations with very different healthcare cultures. Therefore, it would be restrictive to define ‘qualified clinician’ with traditional titles, especially since the same title can mean different things in different regions. The FINA consensus group defines a clinician as “anyone who is involved in the health care of athletes, reviews medical or physiological information, and/or implements an action plan to improve the athlete's health, where health is considered in a broad sense but must be more than just performance enhancement.” Clinicians include, but are not limited to, the team physician, physiotherapist, physiologist, nurse, physician assistant, etc. For example, sport scientists who review lactate results and alter a training programme are not acting as clinicians. However, sport scientists (who are licensed or designated by licensed professionals to act on their behalf) who review blood tests for anaemia and recommend iron are acting as clinicians.
Time loss: “A time-loss injury or illness leads to the athlete being unable to take full part in FINA activities” (based on refs. 6 ,9 ,14). If the athlete misses the rest of the training or competition session but returns for the next training/competition, this should be recorded as a time-loss incident.
Definitions of recurrences, reinjuries and exacerbations
Fuller et al24 were the first to address the definition and classification of recurrences, reinjuries and exacerbations in injury surveillance. Subsequently, Hamilton et al,25 Finch and Cook26 and Shrier et al27 published different definitions and classification systems. The FINA consensus group discussed the different models, and decided to adopt the classification system of Hamilton et al.25 Although the later models26 ,27 appear to have advantages over traditional models, they are only being developed recently, and the FINA consensus group felt it was too early to recommend them for general use.
Index injury: “The first recorded injury in a series of injuries constituting a recurrent condition.”25
Exacerbation: “Injury to same location and of the same type as the index injury, where the index injury has not completely healed.”25
Reinjury: “Injury to same location and of the same type as the index injury, where the index injury has completely healed.”25
Local injury: “Injury to same location but a different type from the index injury.”25
New injury: “Injury to a different location from the index injury.”25
The FINA consensus group recommends that the terms ‘acute’ and ‘chronic’ should generally not be used when describing aquatics injuries, because of their ambiguities, overlap and confusion with ‘traumatic’ and ‘overuse’ injury (which are defined below). Where the context requires them to be used, they should be explicitly defined.
Mechanism or causation of injury
According to van Mechelen et al,2 Meeuwisse and colleagues,3 ,4 and Bahr and Krosshaug,28 clearly defining the injury mechanism may identify future prevention interventions. Mode of onset for sports injuries is typically classified as being either traumatic or overuse. Theoretically, the difference between the two types is the nature of the energy transfer that caused them. For traumatic injuries the energy transfer is instantaneous, whereas for overuse injuries it is accumulated over time.26 Operationally, however, sports injuries are classified based on whether they are linked to a specific, clearly identifiable event such as a fall or a collision (traumatic) or not (overuse).6 ,13 ,14
Traumatic injury: Refers to an injury caused by a single, clearly identifiable energy transfer.9 ,14 The mechanism of a traumatic injury can be further specified in (1) non-contact, (2) contact with another athlete/person and (3) contact with an object or animal (goal post, diving board, lane marker, sea life, water surface from heights). A separate classification of importance in the development of prevention interventions is the determination of the presence of a rule violation as a causative factor.
Overuse injury: Refers to a condition caused by multiple accumulative bouts of energy transfer without a single, identifiable event responsible for the injury.6 ,14
It is important to recognise the potential conflict between the theoretical and operational definitions of overuse injury. The operational definition for overuse is, in effect, made by exclusion and does not consider the actual cause of the injury. Application of this operational definition is normally straight forward, as for most aquatics injuries the presence or absence of an inciting event is easy to determine. However, in certain cases, it may be a challenge. For some overuse injuries, symptom onset can be rapid despite being preceded by a subclinical process of cumulative tissue damage. For example, pain may develop over the course of a single training session, or even instantaneously during a ‘normal’ loading situation, such as when a diver suddenly feels the onset of a back pain in a pars stress fracture.29 In such cases, there is a substantial risk of misclassification. Certain authors have attempted to solve this challenge by sub classifying overuse injuries into those with a rapid onset and those with a gradual onset.15 ,30 ,31 However, even when this is done, the same difficulties arise in differentiating between rapid-onset overuse injuries and acute injuries. In these cases, the injury recorder needs to make a clinical judgement based on the theoretical definition of overuse and acute injuries. In particular, it should be considered whether the energy transfer occurring at the perceived moment of injury was sufficient to damage previously healthy, intact tissue.
Circumstances of injury
The circumstances of injury include the discipline and event (for grouping see below), the classification as training or competition and if the latter, the competition level (ie, heat, semifinals, finals, quarter finals, preliminaries).
Discipline refers to one of the six aquatic sports (swimming, diving, synchronised swimming, open water swimming, water polo and high diving).
Event is defined as “the type of competition activity for which medals are awarded following finals (ie, 400 m free, 50 m breaststroke, 4×200 m medley relay, 10 m Synchro, Duet Technical Routine).”
Competition is defined as “the period during which the athletes participate in an event against athletes from another team/league/ nation that are timed (swimming and open water swimming), judged (synchronized swimming, diving and high diving) or during match play (water polo).”
Training is defined as “physical activities that are aimed at maintaining or improving athletic skills or physical condition.”11 The warm-up/cool-down period before/after a competition should be recorded as training exposure.11
Location, type and diagnosis of injury
Categories for reporting location and type of injury have been published previously.6 ,9 ,11 ,13–15 For water polo, the FINA consensus group recommends to document injury to the face in more detail (see box 1).
Categories for location of injury6,9,11,13–15
▸ Head and trunk
Head, specify: eye, ear, nose, face, dental
Neck/cervical spine
Chest/sternum/ribs
Thoracic spine/upper back
Lumbar spine/lower back
Abdomen
Pelvis/sacrum/buttock
▸ Upper extremity
Shoulder (including clavicle)
Upper arm
Elbow
Forearm
Wrist
Hand
Finger/thumb
▸ Lower extremity
Hip/groin
Thigh
Knee
Lower leg/Achilles tendon
Ankle
Foot/toe
Other
For reporting the type of injury, the FINA consensus group recommends the use of previously published formats14 ,15 for paper-based reports as outlined in box 2, and either the Orchard Sports Injury Classification System (OSICS)32 of the Sport Medicine Diagnostic Coding System (SMDCS)33 for online reporting. The use of an additional free-text box would allow the reporting clinician to add more detail when necessary.
Categories for type of injury14,15,34,35
Concussion (regardless of loss of consciousness)
Fracture (traumatic)
Stress fracture (overuse)
Other bone injuries
Dislocation, subluxation
Tendon rupture
Ligamentous rupture
Sprain (injury of joint and/or ligaments)
Lesion of meniscus or cartilage
Strain/muscle rupture/tear
Contusion/haematoma/bruise
Tendinosis/tendinopathy
Arthritis/synovitis/bursitis
Fasciitis/aponeurosis injury
Impingement
Laceration/abrasion/skin lesion
Dental injury/broken tooth
Nerve injury/spinal cord injury
Muscle cramps or spasm
Growth plate disturbance/avulsion
Other
Diagnosis and cause of illness
In comparison with diagnosis systems for injuries, there is less published on the diagnosis of illnesses in sports medicine.11 ,14 ,36 The FINA consensus group recommends utilisation of the classifications for ‘affected body systems’ and ‘symptoms’ of illness in the aquatic sports (see boxes 3 and 4).
Categories for affected system by illness14,19–21,34,36,37
Upper respiratory tract (nose, sinuses, pharynx, larynx)
Lower respiratory tract (trachea bronchi, lungs)
Gastrointestinal
Cardiovascular
Urogenital/gynaecological
Metabolic/endocrinological
Allergic/immunological
Haematological
Dermatological
Musculoskeletal
Ophthalmological/otological
Dental
Neurological/central nervous system
Psychiatric/psychological
Other
Categories for illness symptoms14,19–21,34,36,37
Pain/ache/soreness
Fever/chills
Nausea, vomiting, diarrhoea
Cough, wheezing, dyspnoea
Shortness of breath
Irregular heartbeat/palpitation
Dehydration/excess sweating
Rash/itch/eczema
Nasal congestion/rhinorrhoea
Dizziness/vertigo
Fainting/syncope
Numbness/weakness/tingling
Fatigue/lack of energy/lethargy
Sleep disturbance
Psychological problems/anxiety/depression
Other
The FINA consensus group recommends the inclusion of aetiology or cause of illness. In particular, it should be reported whether the illness is (1) new onset, recurrent or pre-existing, and (2) communicable versus non-communicable.
The FINA consensus group recommends that a diagnosis be recorded only when provided by a clinician, and that athlete reports should be limited to symptoms and their consequences for training and competition. Both sports medicine-specific coding systems (OSICS32 and SMDCS33) have classification codes for the recording of medical illness in athletes. The OSICS has 301 classification codes for the recording of medical illness as they pertain to athletes (codes # 181–402).32 While it is not feasible to utilise the detail of these coding systems on a paper-based illness reporting form, it is possible to utilise these coding systems in electronic reporting. The principle non-sports medicine-related coding system for disease and injury is the International Classification of Diseases and Injuries (ICD); however, this system is not specific enough for utilisation in sports medicine.38 ,39
Severity of injury and illness
Historically, sports federations have assessed severity in relation to the number of days missed from sport participation,6 ,9 ,11 ,13 ,14 The FINA consensus group recommends this approach in order to facilitate comparison with other sports. However, limitations of this approach in recording the severity of injuries and illnesses that do not lead to time loss are recognised. In particular, the true impact of overuse injuries is underestimated using time loss, as athletes in aquatics and other sports often continue to train and compete with a potential impact on performance despite their existence.21 ,29 ,40
When studies aim to record all injury and illness problems, including those that do not lead to time loss, the use of alternative methods of measuring severity should be considered. For example, a severity score could be based on athletes’ responses to a questionnaire on the consequences of injury and illness on sports participation, training volume, performance and degree of symptoms.40 ,41 The International Classification of Functioning, Disability and Health (ICF) can also be utilised to classify severity.42 Table 1 shows different ways of grading injury/illness severity. Ultimately, the specific method of determining severity should be defined by the research question being asked and always explicitly stated when reporting.
Different methods of defining injury/illness severity
If a time-loss approach is used, the definition of full recovery also needs to be clearly stated.43 Some investigators have used practical solutions such as return to full participation.24 Others have argued that the healing date should be the date the last treatment was applied for an injury27 ,44 because many participants return to full participation while still injured.21 ,29 ,45
Exposure
The underlying principle for assessing exposure is to put the number of injuries and illnesses in context, so that one can compare the risk of injury across sports and time. For out-of-competition studies, the number of athletes included, the duration of the observation period as well as the exposure in training and competition should be recorded. Exposure in training should be documented in hours, whereas exposure in competition should follow the in-competition surveillance system.
The duration of the championship is defined from the time period between and including the first and last day of competition regardless of whether or not the competition for the individual athlete is completed. For in-competition projects, a registered athlete is one who is listed on the official entry list for the competition by the authoritative governing body independent of whether the athlete actually participated in the event.15 To calculate the athlete competition days, the number of registered athletes is to be multiplied by the total number of competition days for the each discipline.21
When calculating starts in aquatics, a discipline-specific approach is required. For individual sports, one sums the number of starts in all heats, rounds, qualifications and finals for all athletes, including athletes who did not finish and were disqualified.15 For water polo, the number of player-matches should be calculated as 2 teams×7 players×the number of matches played.6 ,46 For the remaining non-individual sports such as open water swimming team events, swimming relays, synchronised diving and synchronised swimming events, the number of starts should be calculated by multiplying the number of athletes on a team by the number of entries.21 If an athlete starts in more than one discipline, each start is counted.21
Calculation of incidence and prevalence
The incidence is the number of new occurrences of an injury/illness in relation to the athletes at risk in a given time period. Incidence may be calculated as the number of new injuries/illnesses per 100 athletes,21 per 1000 athletes exposures, or per 1000 athlete-days47 ,48 or per 1000 h of exposure.6 ,7 ,11 ,15 Incidence of training injuries may be reported as per 1000 athlete-days or per 1000 training hours. Incidence of competition injuries may be reported as injuries per 1000 starts15 or per 1000 player-matches6 ,9 or per 1000 player-hours.6 ,15
Prevalence is the proportion of athletes affected by a specific condition at a defined time (point prevalence) or time period (eg, 12-month prevalence, life-time prevalence), and is calculated by dividing the number of athletes with an injury or illness (regardless of the onset time) by the total number of athletes. Prevalence is often useful in cross-sectional studies, and for both long-term conditions and those in which a definite start date is difficult to define, such as overuse injuries.29 ,41 ,45 Some prospective studies with serial measurements of prevalence have reported the average prevalence over the duration of the study or the season.40 ,41 ,45
Athlete characteristics
The FINA consensus group recommends that basic athlete characteristics be recorded for injury and illness surveillance studies in the aquatic sport including age, sex, discipline, event(s) and nationality. Further information, such as years of competitive experience, competition/ training load, underlying health issues and recent time zone changes, might be included depending on the research question.
Grouping of FINA events
Depending on the research question, FINA events can be grouped for ease of comparison. For example, in the FINA study on the prevalence of asthma, the aquatic endurance disciplines of swimming, open water swimming and synchronised swimming were grouped together and compared with the non-endurance discipline of diving.22 Other groupings of disciplines include (1) aesthetic (synchronised swimming, diving, high diving) versus non-aesthetic disciplines (water polo, swimming and open water swimming), and (2) timed events (swimming, open water swimming) versus non-timed event (synchronised swimming, diving and water polo). Within the disciplines themselves, groupings can also occur. For example, in swimming, results can be grouped by stroke type (breast stroke, freestyle, butterfly, back stroke) or by distance (sprint (50+100 m), middle distance (200+400 m), long distance (≥800 m)).
Implementation methods
Who reports?
For in-competition injury and illness surveillance, the FINA consensus group recommends the reporting to be done by a clinician (for definition see above) to capture medical attention and time-loss injuries/illnesses. When the researchers would like to register all injuries (ie, complaints of overuse injuries), athletes reporting on their own medical conditions is desirable. Furthermore, coaches of aquatic athletes can also report athletes’ health problems.
Reporting and recording methods
In addition to the traditional injury and illness surveillance methods conducted with paper-based reporting systems, the digital media offers more options for data collection. Recent studies demonstrate the benefits of SMS texting as a means of reporting injury and/or illness status,50–52 and the completion of online questionnaires of athlete health status.40 ,41 Likewise there are many sports medicine-specific software programmes available to facilitate the efficiency and accuracy of injury and illness surveillance in sports medicine.53 To be effective, electronic injury surveillance programmes should be easy to use, allow data entry at any time and include data validation.
Future recording of medical conditions in the aquatic sports
Given the finding that a high percentage of elite aquatic athletes of all disciplines train and compete with injury,21 and the high prevalence of asthma in swimming,22 the FINA consensus group recommends the prospective monitoring of athletes’ health in all aquatic disciplines throughout the year. Prospective injury and illness surveillance during the in-competition and out-of-competition period may be conducted by the reporting of symptoms/complaints by the athlete, or by the recording of medical conditions by a clinician at predefined regular intervals at least on a weekly basis to minimise recall bias.
Up until now, very few methods have been proposed for the prospective recording of medical conditions that include complaints not leading to absence from sport.11 ,14 ,40 Report forms and questionnaires must be designed to match the objectives of the specific study, however should include the variables outlined above. The Oslo Sports Trauma Research Centre (OSTRC) developed a questionnaire on health problems based on their Overuse Injury Questionnaire,41 and validated it in elite athletes of various sports in Norway including swimming.40 This questionnaire has four key questions that must always be answered by the athlete, as well as subsequent questions that can be modified to suit the project needs. A modified version was developed and implemented by FINA and IAAF in 2013 to assess the presence of physical complaints in the out-of-competition period leading into the World Championships.21 ,54
The FINA consensus group developed for health surveillance in aquatic athletes during in-competition and out-of-competition period, (1) a self-report for aquatic athletes that includes the four initial questions of the OSTRC questionnaire on health problems40 plus detailed information on the injury or illness as outlined above (see online supplementary appendix 1i), as well a similar report form for clinician (see online supplementary appendix 2). The FINA expert working group recommends the use of these forms in the in-competition and out-of-competition period, and encourages validation of these protocols. Electronic versions can be developed and are recommended for use in long-term studies (for a development guide see http://www.ostrc.no/fina).
Conclusions
The FINA consensus authors recommend ongoing in-competition surveillance to determine injury and illness trends over time. Evident by the high prevalence of overuse injuries21 and asthma22 in aquatic athletes, the utilisation of a prospective out-of-competition surveillance system is also recommended. Assessment of risk factors should be included in the injury and illness surveillance projects to facilitate the development of preventive interventions. The implementation of the definitions and methodology outlined in this paper will improve the accuracy and value of injury and illness surveillance programmes in aquatic sports. Ultimately, this should lead to enhanced health and performance of aquatic athletes.
What are the findings?
Aquatic-specific injury and illness definitions are outlined, and categories for documenting details of injuries and illnesses in the aquatic sports are specified.
The registration of exposure and the calculation of incidence/prevalence are described.
Report forms (for athletes and for clinicians) for monitoring injury and illness in the aquatic sports are presented.
There is a need for out of competition injury and illness data to be included in the monitoring of elite aquatic athletes.
How might it impact on clinical practice in the future?
Aquatic injury and illness surveillance programmes will adopt the standardised methodology.
Out-of-competition injury and illness surveillance programmes will be implemented.
Results from studies utilising this protocol will influence prevention interventions to improve aquatic athlete health.
Acknowledgments
The authors would like to acknowledge FINA for its dedication to the protection of the health of the aquatic athlete and for the support of this project. A special thanks you to Johan Lefebvre (FINA), Dr Jim Miller (FINA) and Ania Tarazi (Aspetar) for their assistance with the consensus meeting.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
- Data supplement 1 - Online supplement
- Data supplement 2 - Online supplement
Footnotes
Twitter Follow Hendrik Dijkstra at @DrPaulDijkstra
Contributors MM provided substantial contributions to conception and design, coordination of authors, drafting and revising the manuscript and approval of final version to be published. AJ provided substantial contributions to conception and design, drafting and revising the manuscript and approval of final version to be published. JMA, CvdH, PH and KK contributed to drafting the manuscript and approval of final version to be published. BC and IS provided significant contribution to drafting and revising the manuscript and approval of final version to be published. BMP, SM and DG contributed to drafting and revising the manuscript and approval of final version to be published. HPD was involved in revising the manuscript and approval of final version to be published. KMK was involved in moderating the Consensus Meeting and approval of final version to be published.
Competing Interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
↵i One author (BC) did not agree to the entire design of the online supplementary appendices.