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Preventing Sport and Recreation Injuries

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I Introduction

Ontarians throughout the lifespan are encouraged to participate in sports and recreational activities. Getting and staying active is a great way to have fun and stay healthy. Particularly as concerns grow over ballooning obesity rates, regular exercise is considered to be an important route to health and wellness. At the same time, it's important to realize that sports and recreation are a common source of injury. While public health practitioners wish for people to be active participants in life, they understand it's important they do so in ways that will minimize their risk of injury.

The Ontario Injury Prevention Resource Centre has produced several evidence-based practice synthesis documents to help public health staff and managers, as well as their community partners, as they design, implement and evaluate programs to meet the Ontario Public Health Standards for Prevention of Injury and Substance Misuse.

Sport and Recreation Injuries: Evidence-Based Practice Synthesis is intended for policy makers, health promoters and others with an interest in preventing injuries associated with sports and recreational activities. It is divided into several sections: an overview of the magnitude of injuries resulting from sports and recreational activities; risk factors; and a synthesis of best available evidence for effective practices to reduce injuries from sports and recreation. This article offers highlights of this document.

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II Magnitude of the problem

Every day, Ontarians of all ages engage in various sports and recreational activities. Injuries are common. Recognizing the unique risk factors and the most common injuries among different groups of people is a start to developing targeted prevention techniques to reduce the risk and allow people to participate in and enjoy sports and recreational activities.

The sports and recreational injuries included in the document are limited to those covered by ICD 10 codes (i.e., International Classification of Diseases codes that are the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use.) These include skiing/snowboarding, tobogganing, hockey, football/rugby, soccer, baseball, cycling and water activities involving non-powered watercraft, water skiing and drowning. The following statistics show how common injuries are in sports and recreation.

  1. During 2005 - 2006, sports and recreational injuries led to 127,365 emergency department visits and 2,982 hospitalizations, accounting for more than 9,425 days in hospitals.
  2. Males were responsible for close to 75% of emergency visits and 80% of hospitalizations. The gender disparity was particularly wide at ages 10 - 19.
  3. Injuries to the lower limbs are the most common reason for hospitalization, followed by head injuries, although type of injury varied by age group.
  4. Cause of injury also varied by age group, with most kids under nine and adults over 50 years of age, visiting emergency after a fall from a bicycle. Youth 10 -14 years of age most often went to emergency after a fall involving skates, skis, sport boards or inline skates. Teenagers 15 -19 years were most often hurt colliding with another person during a sport. Adults 20 - 49 were hurt most often after being struck with sports equipment such as a ball or hockey puck.
  5. For people more seriously hurt and thus hospitalized for at least a night, a fall from a bike was the most common reason for children under 15 and adults over 30. For those aged 15 - 29, most were hurt after hitting another person during a sport, such as in hockey, soccer or football/rugby.

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III Risk Factors

Modifiable risk factors to lower the risk of injury - variables over which one has control - include wearing protective gear, learning proper skills and warming up muscles before physical activity. Non-modifiable risk factors include age, gender and family history. Risk factors vary by age and gender.

Risk Factors for Childhood and Adolescent Injury

  • Children's bones, muscles, tendons and ligaments are still growing, which makes them more prone to injury than adults. Differing skill levels and physical size may lead to increased risk of injuries among smaller, less skilled or coordinated children.

Risk Factors for Adults

  • Because they work during the week, some adults squeeze all their physical activity into their weekends and may push themselves too hard, increasing their injury risks. Sudden activity spurts can put stress on the bones and joints of obese and unfit people.
  • Female athletes have increased risks related to fluctuating estrogen levels, structural differences in the knee and thigh muscles and the way they jump, land and twist.

Risk Factors for Older Adults

  • Increased risks for older adults are often due to a lack of compensation for the physical changes of aging. These include deterioration in vision and hearing, agility and mobility and slowed reaction times.

Environmental Risk Factors

Physical, political and social environments also contribute to the risk of injury.

  • Some low-income areas may have poorly maintained parks and fields with holes in the ground, poor lighting or even broken glass or needles. The layout of a physical environment can also have an impact on risk. For example, tobogganing on hills near trees can be risky.
  • The political and social environment includes safety standards regarding sports equipment as well as regulations requiring individuals to wear protective gear.

Violence and Injury

  • Violence can also cause injury in sports and recreational activities. Research suggests violent injuries are typically acquired through competitive, contact sports, such as football, basketball, wrestling and hockey, rather than non-contact sports or activities, such as tennis, baseball, soccer, cross-county, track and swimming.

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IV Evidence-Informed Practice Recommendations

Evidence-informed practices are interventions that have been cited as best practices by researchers who have conducted a systematic review of relevant literature, as was done for this document.

To effectively prevent injuries from sport and recreational activities, it is not enough to implement specific structural or educational interventions. Prevention also involves setting precedents and implementing wider campaigns to achieve success. Thus, it is important to partner with coaches, parents, caregivers and the Ministry of Health Promotion's Sport and Recreation Branch.

Prevention efforts targeted at compliance with the use of protective gear and of modifying physical features of the playing environment have been shown to be effective. Injury prevention efforts, however, should also take into account age-specific initiatives and/or sport specific activities with the active general population, as outlined below.

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1. Children and Adolescents

Parents, caregivers and coaches should be involved to help children make smart choices. Multiple strategies have been found to be effective in reducing the rate of injury, including education, training, equipment and policy change.

Public health practitioners can plan interventions for parents and coaches to increase knowledge about children's injuries and developmental stages. This includes such interventions as educating about playground standards, promoting protective gear, ensuring sport programs have certified athletic trainers and educating to ensure children are not pushed into activities they dislike or are incapable of doing.

Practitioners can also engage key stakeholders and plan interventions to improve standards for injury prevention in sports. A sports injury prevention policy can include such points as grouping young people according to skills, experience and size; ensuring a base level of physical conditioning; promoting fair play and preventing foul play; ensuring pain or injuries are reported to coaches and that injured players are cleared by health professionals before returning to play. It is important to instil good sportsmanship at a young age.

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2. Adults

Again, interventions should focus on education, training, equipment and policy/regulations.

Public health practitioners can plan interventions to educate adults about reducing their risk of injury through such actions as protective gear and proper footwear, training, warming up and cooling down, cross training and following physical activity guidelines.

Practitioners can also plan interventions that improve safety policies and regulations by collaborating with the Ministry of Health Promotion's Sport and Recreation Branch for support, promotion and legislation of athletic standards for adults; collaborating with sports organizations to implement a sports safety promotion program and with physical activity groups to ensure injury prevention messages are incorporated into general messages about physical activity; and advocating for the use of Canadian Standards Association-approved sports and recreation equipment.

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3. Older Adults

The risk of injury for older adults often stems from a lack of compensation for the physical changes that occur gradually and can go almost unnoticed as individuals age. The Centre for Activity and Aging has set up physical activity guidelines, which address aging factors and are designed to reduce the risk of injury. Preventing injury should incorporate the same multi-factorial approach that is taken for fall prevention (as found in the synthesis document on falls across the lifespan).

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V Managing the Risk of Specific Popular Sports

Sports linked to the highest number of injuries have been identified, as follows, along with strategies to reduce injury risks:

  • Hockey: Wearing properly fitted protective gear and ensuring coaches do as well, ensuring adequate physical conditioning, reinforcing following rules and ensuring coaches and officials are certified and qualified, are all techniques to reduce injury.
  • Baseball: Injuries stem from collisions, falls, sliding and overuse. Good physical conditioning, awareness of overuse injuries, wearing the gear and learning proper technique, ensuring playing fields are well maintained and modifying the rules for children, including using softer balls, are all ways to reduce injury risks.
  • Cycling: Properly fitted bicycle helmets protect against head injuries and in Ontario all children under 18 are required to wear helmets. Research suggests it may make sense to mandate helmet use for adults over 18 as well, which also ensures they are positive role models. Helmet giveaways increase their use.
  • Soccer: In addition to training, warm-ups, following rules and wearing appropriate gear as in other sports, soccer goal posts should be properly secured and ball size should be appropriate for the age group.
  • Skiing, Snowboarding, Ice Skating, In-line Skating: Ski bindings should be adjusted by a professional at the beginning of each season, helmets should be promoted, as should other protective gear, participants should be educated to remain on slopes suited to skill level and to build gradually to more advanced runs, skaters should understand the rules of the skating rink and to check that outdoor ice is thick enough to skate on safely.
  • Boating and Waterskiing: Risk of injury is reduced if participants wear personal floatation devices, avoid alcohol, check weather forecasts and get trained in boating and water safety. Water skiers should be trained and a "spotter" should be in the boat.
  • Football/rugby: As with other sports, protective gear, warm-ups, training, avoiding playing through injury and proper physical conditioning, can all reduce injury risks.
  • Tobogganing: Injury risks are lowered if a gently-sloping hill free of potential hazards is chosen, a helmet is worn, the toboggan is in good condition and can be steered and stopped, riders keep scarves or long hair tucked inside coats and sit or kneel facing forward.

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VI Managing the Environmental Risks

Social, physical and political environments are intertwined. Changes applied to one are often felt by the others. Practitioners can promote safe, clean parks and fields and work with local politicians on this issue, collaborate with the community to clean up parks and work to keep community centres open for extended hours.

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VII Implementation and Evaluation  

Implementation and ongoing evaluation at each stage of the injury prevention strategy will maximize effectiveness. An evaluation framework should be put in place that looks at not only the intended outcomes of the program and initiatives but also evaluates each stage of the implementation process.

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VIII Conclusion

This article offers highlights of the Sport and Recreation Injuries: Evidence-Based Practice Synthesis Document. The full document, designed to be of use to public health practitioners and others interested in preventing sports and recreation injuries can be downloaded at www.oninjuryresources.ca. Synthesis documents on alcohol and on falls throughout the lifespan are also available.

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IX References

Ontario Injury Prevention Resource Centre. (2008.) Sport & Recreation Injuries: Evidence-Based Practice Synthesis Document. Toronto, Ontario Injury Prevention Resource Centre, 2008.