Preventing recreational sports injuries: practicalities and governance

Robust injury surveillance is the key to understanding and preventing recreational sport injuries

Sport and recreational activities are profoundly important for easing the economic and personal burdens of chronic disease and mental illness. International organisations, including the Centers for Disease Control and Prevention in the United States and the World Health Organization, have mapped both their positive contributions to mental and physical wellbeing and the costs of inactivity.1,2 Sport and recreational activities are also an integral part of society, not least in Australia, where professional sport and outdoor activities contribute significantly to the national identity.

Because of their importance for physical and mental health, government departments of sport in most developed countries are allied with other aspects of cultural development. For example, the division of sport and recreation in Western Australia is part of the Department of Local Government, Sport and Cultural Industries; in the United Kingdom, the Department for Digital, Culture, Media and Sport provides governance for physical activities, including assuring that these activities are fair, safe, and inclusive. These departments, however, do not require that the immediate and long term implications of physical activity, both for the individual and society, should be explored.

As exemplified by four articles published in this issue of the MJA, it is recognised that the true risks and costs to society of recreational activity and sport need to be better understood. The authors’ determination to provide clear evidence and raise awareness of the true risk and economic impact of three recreational activities, each popular in Australia, is clear. Brukner and colleagues3 searched for media reports of fatalities caused by head injuries in cricket over the past 160 years. Fernando and her co-authors4 report an excellent audit of the health care costs to society associated with sport-related emergency department attendances in Victoria, coupled with an analysis of the relative risk and health costs of specific activities, while Prabhakaran and colleagues5 provide a snapshot of some of the dangers for the participants of junior motocross. Franklin and his co-authors6 emphasise the need for education to reduce the number of preventable deaths from an under-appreciated form of drowning.

The four articles highlight some of the governance limitations and the lack of centralised, universal databases that combine to hamper determining injury types, rates, and risks, as well as making measuring the effectiveness of injury prevention initiatives difficult, especially in non-elite level sport. The authors needed to retrieve data with different methods, each relying on assumptions and extrapolations, and their estimates of the incidence and prevalence of the injuries examined may not be accurate. What these vignettes have validated is the need to improve surveillance systems for injuries in recreational activities, so that better education and prevention programs can be developed. The responsibility for these processes will have to be shared by government departments, public health authorities, sports governing bodies, and health insurers.

The report by Prabhakaran and her co-authors5 suggests that no organisational injury surveillance exists in junior motocross, despite the clear risks to the young competitors; that there were 24 visits to hospital among the 340 competitors is unsurprising given the finding by Fernando and colleagues4 that high velocity and motorised sports are generally dangerous in terms of emergency department presentations. It is difficult to determine which risk reduction steps should be undertaken if mechanistic data are not collected (ie, data on the cause and nature of injuries). The social interests associated with motor sport are clear, but evaluation of its impact should assess both its health benefits and whether the ensuing hospital costs should be met by participants through independent insurance.

We need sound epidemiological data on injuries during recreational activities to identify priority injury problems, risk factors, economic and individual costs, and health benefits, as well as to inform injury prevention programs. Valuable lessons can be learned from robust risk management approaches in industry and occupational health, and from centralised, standardised health collection systems, including those of insurance companies and governing bodies in professional sport. Injury surveillance in sport is most effective in countries with centralised collection by national health systems of data on all injuries and fatalities. In Sweden and other Scandinavian countries,7 for example, national health insurance systems collect sufficient details for all claims and medical events to monitor potential causes; in New Zealand, the Accident Compensation Corporation (https://accsportsmart.co.nz) records injury and illness across the country and funds the development of treatment and prevention programs, such as Rugby Smart (https://www.rugbysmart.co.nz).

The article by Fernando and colleagues4 reinforces the potential value of this approach, providing clear information about the most frequent sport-related injuries, as well as preliminary estimates of per participant rates of injury. Ideally, health organisations should work with the national governing bodies of sports to achieve consensus on injury reporting and the impact of prevention strategies.

Many professional sports are now implementing improvements in safety and welfare; current hot topics include head and spinal injuries, mental health,8 cardiac screening, and concussion.9,10 Successful initiatives in the rugby codes and cricket, for example, have been well supported by an occupational health structure that includes medical staff, injury surveillance, and the ability to influence regulations, such as rule modifications, the use of protective equipment, and education on injury risk management.

The head injury problem is not limited to contact sports. In professional cricket, more powerful hitting and shot making, together with greater risk taking, are likely to have contributed to rising rates of concussion and the continued occurrence of cricket-related fatalities. Until recently, cricket helmet design was largely unregulated, allowing flaws that could permit the ball to penetrate face guards and cause serious eye, facial, and dental trauma.11 Robust injury surveillance provided the impetus for revising helmet safety testing standards in the United Kingdom; after their adoption by the International Cricket Council in 2015, this type of injury has almost completely disappeared. Bruckner and colleagues3 similarly argue that improving protective equipment is effective, particularly in preventing traumatic injury. Modifying individual risk factors, such as the training environment, can also be helpful, especially for reducing rates of traumatic injury.

Although widely employed, reductionist injury prevention approaches that target individual risk factors are much less effective in preventing gradual onset injury. Researchers from the Australian Centre for Research into Injury in Sports and its Prevention (ACRISP) recently published a complex systems model of the development and prevention of running-related injuries12 that included interactions between more than 60 factors, including international and national governance, state and local sporting organisations, health care systems and providers, the media, the running environment, and training methods. While the combinations and interactions probably contribute to susceptibility to injury, the Holy Grail of a systems approach — enabling recreational athletes to avoid injury by effectively identifying and managing critical risk factor combinations — seems a long way off.

The articles in this issue of the MJA make it clear that systematic processes for the surveillance of sport-related risks in Australia are inadequate, as are the available data on exposure to risk. Lessons can be learned from occupational health and safety approaches. All industrial environments are now heavily regulated, with compulsory keeping of injury logbooks and investigations of all fatalities; government departments analyse all significant road traffic fatalities and insurance data. Professional sports are increasingly employing similar techniques, but this does not apply to recreational sport.

With sufficient investment, it will be possible to accurately determine both the extent to which active recreation reduces rates of chronic disease and the musculoskeletal and hospitalisation costs of more active lives. What will not be so easy to quantify are psychosocial components related to the community and societal benefits of physical activity. It thus seems incumbent on developed countries to establish robust injury surveillance systems supported by national governing bodies (perhaps tying public funding to data collection and reporting), government departments, and health care providers, including accident and emergency departments, primary care providers, and health insurance companies. If specific mechanistic data are also collected, sporting activities can not only be made safer, but health care costs can be better allocated and health planning more informed.