Joakim Ekberg

Injury patterns in Swedish elite athletics: annual incidence, injury types and risk factors

Objective To estimate the incidence, type and severity of musculoskeletal injuries in youth and adult elite athletics athletes and to explore risk factors for sustaining injuries. Design Prospective cohort study conducted during a 52-week period. Setting Male and female youth and adult athletics athletes ranked in the top 10 in Sweden (n=292). Results 199 (68%) athletes reported an injury during the study season. Ninety-six per cent of the reported injuries were non-traumatic (associated with overuse). Most injuries (51%) were severe, causing a period of absence from normal training exceeding 3 weeks. Log-rank tests revealed risk differences with regard to athlete category (p=0.046), recent previous injury (>3 weeks time-loss; p=0.039) and training load rank index (TLRI; p=0.019). Cox proportional hazards regression analyses showed that athletes in the third (HR 1.79; 95% CI 1.54 to 2.78) and fourth TLRI quartiles (HR 1.79; 95% CI 1.16 to 2.74) had almost a twofold increased risk of injury compared with their peers in the first quartile and interaction effects between athlete category and previous injury; youth male athletes with a previous serious injury had more than a fourfold increased risk of injury (HR=4.39; 95% CI 2.20 to 8.77) compared with youth females with no previous injury. Conclusions The injury incidence among both youth and adult elite athletics athletes is high. A training load index combing hours and intensity and a history of severe injury the previous year were predictors for injury. Further studies on measures to quantify training content and protocols for safe return to athletics are warranted.

Prevalence of Musculoskeletal Injuries in Swedish Elite Track and Field Athletes

Background: Little is known of injury patterns in track and field (athletics). Injury prevalence has been proposed as the most appropriate measure of the injury rate in sports where athletes are at risk for overuse problems. Purpose: To ascertain 1-year retrospective and current prevalence of injury in elite track and field athletes to help plan injury prevention programs for this sport. Study Design: Descriptive epidemiology study. Methods: Two hundred seventy-eight youth (16 years old) and adult athletes from an eligible study population of 321 athletes were included. Results: The 1-year retrospective injury prevalence was 42.8% (95% confidence interval [CI], 36.9%-49.0%); the point prevalence was 35.4% (95% CI, 29.7%-41.4%). The diagnosis group displaying the highest injury prevalence was inflammation and pain in the gradual onset category (1-year prevalence, 20.9%; 95% CI, 16.2%-26.2%; and point prevalence, 23.2%; 95% CI, 18.4%-28.7%). A strong tendency for higher 1-year prevalence of 16.5% (95% CI, 12.2%-21.4%) than point prevalence of 8.5% (95% CI, 5.5%-12.5%) was recorded for sudden onset injuries in the diagnosis group sprain, strain, and rupture. The body region showing the highest injury prevalence was the knee and lower leg with 15.0% (95% CI, 11.0%-19.8%) 1-year prevalence and 13.7% (95% CI, 9.8%-18.3%) point prevalence, followed by the Achilles tendon, ankle, and foot/toe with 11.7% (95% CI, 8.2%-16.1%) 1-year prevalence and 11.4% (95% CI, 7.9%-15.8%) point prevalence. Conclusion: The injury prevalence is high among Swedish elite track and field athletes. Most of the injuries affect the lower extremities and are associated with a gradual onset. Although it is associated with a potential recall bias, the 1-year retrospective prevalence measure captured more sudden onset injuries than the point prevalence measure. Future prospective studies in track and field are needed to identify groups of athletes at increased risk.

Population-based simulations of influenza pandemics: validity and significance for public health policy

OBJECTIVE To examine the validity and usefulness of pandemic simulations aimed at informing practical decision-making in public health. METHODS We recruited a multidisciplinary group of nine experts to assess a case-study simulation of influenza transmission in a Swedish county. We used a non-statistical nominal group technique to generate evaluations of the plausibility, formal validity (verification) and predictive validity of the simulation. A health-effect assessment structure was used as a framework for data collection. FINDINGS The unpredictability of social order during disasters was not adequately addressed by simulation methods; even minor disruptions of the social order may invalidate key infrastructural assumptions underpinning current pandemic simulation models. Further, a direct relationship between model flexibility and computation time was noted. Consequently, simulation methods cannot, in practice, support integrated modifications of microbiological, epidemiological and spatial submodels or handle multiple parallel scenarios. CONCLUSION The combination of incomplete surveillance data and simulation methods that neglect social dynamics limits the ability of national public health agencies to provide policy-makers and the general public with the critical and timely information needed during a pandemic.

Web 2.0 Systems Supporting Childhood Chronic Disease Management: Design Guidelines Based on Information Behaviour and Social Learning Theories

Self-directed learning denotes that the individual is in command of what should be learned and why it is important. In this study, guidelines for the design of Web 2.0 systems for supporting diabetic adolescents’ every day learning needs are examined in light of theories about information behaviour and social learning. A Web 2.0 system was developed to support a community of practice and social learning structures were created to support building of relations between members on several levels in the community. The features of the system included access to participation in the culture of diabetes management practice, entry to information about the community and about what needs to be learned to be a full practitioner or respected member in the community, and free sharing of information, narratives and experience-based knowledge. After integration with the key elements derived from theories of information behaviour, a preliminary design guideline document was formulated.

Design of a protocol for large-scale epidemiological studies in individual sports: the Swedish Athletics injury study

Background Epidemiological studies have mainly been performed on team sports. The authors set out to develop a protocol for large-scale epidemiological studies of injuries among elite athletics athletes. Methods An argument-based method for investigation of complex design problems was used to structure the collection and analysis of data. Specification of the protocol was preceded by an examination of requirements on injury surveillance in individual sports and iterated drafting of protocol specifications, and followed by formative evaluations. Results The requirements analysis shows that the central demand on the protocol is to allow for detailed epidemiological analyses of overuse injuries, which subsequently requires regular collection of self-reported data from athletes. The resulting study protocol is centred on a web-based weekly athlete e-diary enabling continual collection of individual-level data on exposure and injuries. To be able to interpret the self-reported data on injury events, collection of a wide range of personal baseline data from the athlete, including a psychological profile, is included in the protocol. Conclusions The resulting protocol can be employed in intervention programmes that can prevent suffering among both adult elite and youth talent athletes who have made considerable life investments in their sport.

Meta-narrative analysis of sports injury reporting practices based on the Injury Definitions Concept Framework (IDCF): A review of consensus statements and epidemiological studies in athletics (track and field)

OBJECTIVES Consistency in routines for reporting injury has been a focus of development efforts in sports epidemiology for a long time. To gain an improved understanding of current reporting practices, we applied the Injury Definitions Concept Framework (IDCF) in a review of injury reporting in a subset of the field. DESIGN Meta-narrative review. METHODS An analysis of injury definitions reported in consensus statements for different sports and studies of injury epidemiology in athletics (track and field) published in PubMed between 1980 and 2013 was performed. Separate narratives for each of the three reporting contexts in the IDCF were constructed from the data. RESULTS Six consensus statements and 14 studies reporting on athletics injury epidemiology fulfilled the selection criteria. The narratives on sports performance, clinical examination, and athlete self-report contexts were evenly represented in the eligible studies. The sports performance and athlete self-report narratives covered both professional and community athletes as well as training and competition settings. In the clinical examination narrative, data collection by health service professionals was linked to studies of professional athletes at international championships. CONCLUSIONS From an application of the IDCF in a review of injury reporting in sports epidemiology we observed a parallel usage of reporting contexts in this field of research. The co-existence of reporting methodologies does not necessarily reflect a problematic situation, but only provided that firm precautions are taken when comparing studies performed in the different contexts.

The psychological factor ‘self-blame’ predicts overuse injury among top-level Swedish track and field athletes: a 12-month cohort study

Background Athletes’ psychological characteristics are important for understanding sports injury mechanisms. We examined the relevance of psychological factors in an integrated model of overuse injury risk in athletics/track and field. Methods Swedish track and field athletes (n=278) entering a 12-month injury surveillance in March 2009 were also invited to complete a psychological survey. Simple Cox proportional hazards models were compiled for single explanatory variables. We also tested multiple models for 3 explanatory variable groupings: an epidemiological model without psychological variables, a psychological model excluding epidemiological variables and an integrated (combined) model. Results The integrated multiple model included the maladaptive coping behaviour self-blame (p=0.007; HR 1.32; 95% CI 1.08 to 1.61), and an interaction between athlete category and injury history (p<0.001). Youth female (p=0.034; HR 0.51; 95% CI 0.27 to 0.95) and youth male (p=0.047; HR 0.49; 95% CI 0.24 to 0.99) athletes with no severe injury the previous year were at half the risk of sustaining a new injury compared with the reference group. A training load index entered the epidemiological multiple model, but not the integrated model. Conclusions The coping behaviour self-blame replaced training load in an integrated explanatory model of overuse injury risk in athletes. What seemed to be more strongly related to the likelihood of overuse injury was not the athletics load per se, but, rather, the load applied in situations when the athletes body was in need of rest.

Performance of eHealth Data Sources in Local Influenza Surveillance:A 5-Year Open Cohort Study

Background There is abundant global interest in using syndromic data from population-wide health information systems—referred to as eHealth resources—to improve infectious disease surveillance. Recently, the necessity for these systems to achieve two potentially conflicting requirements has been emphasized. First, they must be evidence-based; second, they must be adjusted for the diversity of populations, lifestyles, and environments. Objective The primary objective was to examine correlations between data from Google Flu Trends (GFT), computer-supported telenursing centers, health service websites, and influenza case rates during seasonal and pandemic influenza outbreaks. The secondary objective was to investigate associations between eHealth data, media coverage, and the interaction between circulating influenza strain(s) and the age-related population immunity. Methods An open cohort design was used for a five-year study in a Swedish county (population 427,000). Syndromic eHealth data were collected from GFT, telenursing call centers, and local health service website visits at page level. Data on mass media coverage of influenza was collected from the major regional newspaper. The performance of eHealth data in surveillance was measured by correlation effect size and time lag to clinically diagnosed influenza cases. Results Local media coverage data and influenza case rates showed correlations with large effect sizes only for the influenza A (A) pH1N1 outbreak in 2009 (r=.74, 95% CI .42-.90; P<.001) and the severe seasonal A H3N2 outbreak in 2011-2012 (r=.79, 95% CI .42-.93; P=.001), with media coverage preceding case rates with one week. Correlations between GFT and influenza case data showed large effect sizes for all outbreaks, the largest being the seasonal A H3N2 outbreak in 2008-2009 (r=.96, 95% CI .88-.99; P<.001). The preceding time lag decreased from two weeks during the first outbreaks to one week from the 2009 A pH1N1 pandemic. Telenursing data and influenza case data showed correlations with large effect sizes for all outbreaks after the seasonal B and A H1 outbreak in 2007-2008, with a time lag decreasing from two weeks for the seasonal A H3N2 outbreak in 2008-2009 (r=.95, 95% CI .82-.98; P<.001) to none for the A p H1N1 outbreak in 2009 (r=.84, 95% CI .62-.94; P<.001). Large effect sizes were also observed between website visits and influenza case data. Conclusions Correlations between the eHealth data and influenza case rates in a Swedish county showed large effect sizes throughout a five-year period, while the time lag between signals in eHealth data and influenza rates changed. Further research is needed on analytic methods for adjusting eHealth surveillance systems to shifts in media coverage and to variations in age-group related immunity between virus strains. The results can be used to inform the development of alert-generating eHealth surveillance systems that can be subject for prospective evaluations in routine public health practice.

Age as a determinant for dissemination of seasonal and pandemic influenza : An open cohort study of influenza outbreaks in Östergötland County, Sweden

An understanding of the occurrence and comparative timing of influenza infections in different age groups is important for developing community response and disease control measures. This study uses data from a Scandinavian county (population 427.000) to investigate whether age was a determinant for being diagnosed with influenza 2005–2010 and to examine if age was associated with case timing during outbreaks. Aggregated demographic data were collected from Statistics Sweden, while influenza case data were collected from a county-wide electronic health record system. A logistic regression analysis was used to explore whether case risk was associated with age and outbreak. An analysis of variance was used to explore whether day for diagnosis was also associated to age and outbreak. The clinical case data were validated against case data from microbiological laboratories during one control year. The proportion of cases from the age groups 10–19 (p<0.001) and 20–29 years old (p<0.01) were found to be larger during the A pH1N1 outbreak in 2009 than during the seasonal outbreaks. An interaction between age and outbreak was observed (p<0.001) indicating a difference in age effects between circulating virus types; this interaction persisted for seasonal outbreaks only (p<0.001). The outbreaks also differed regarding when the age groups received their diagnosis (p<0.001). A post-hoc analysis showed a tendency for the young age groups, in particular the group 10–19 year olds, led outbreaks with influenza type A H1 circulating, while A H3N2 outbreaks displayed little variations in timing. The validation analysis showed a strong correlation (r = 0.625;p<0.001) between the recorded numbers of clinically and microbiologically defined influenza cases. Our findings demonstrate the complexity of age effects underlying the emergence of local influenza outbreaks. Disentangling these effects on the causal pathways will require an integrated information infrastructure for data collection and repeated studies of well-defined communities.

Injury rates and risk-factors associated with eventing: a total cohort study of injury events among adult Swedish eventing athletes

The aim of this study was to examine injury events and risk-factors among Swedish adult eventing athletes. A cross-sectional study design with retrospective recording of 1-year sports-specific exposure and injury data was used. The invited study population consisted of all members of the Swedish Equestrian Federation with eventing as their primary discipline (n = 513). The participation rate was 70.0%. The total 1-year injury prevalence was 26.6%; the specific 1-year prevalence of traumatic injury was 19.3% and of overuse injury 10.9%. The incidence of traumatic injury events was 0.54 injury events/1000 eventing hours (95% confidence interval (CI), 0.35–0.73 injury events/1000 eventing hours) for novices and 0.35 injury events/1000 eventing hours for qualified riders (95% CI, 0.21–0.49 injury events/1000 eventing hours). A total of 27.9% of the traumatic injury events led to severe injuries (causing more than 3 weeks absence from riding). Attitude to risk-taking was the only factor predicting an athlete becoming injured (p = 0.023), and qualification level was the only risk factor for additional injuries among injured riders (p = 0.003). Our results suggest that injury prevention programs in eventing should also give attention to overuse injuries and that care should be taken when eventing athletes are licensed into higher qualification groups.