High incidence of injuries at the Pyeongchang 2018 Paralympic Winter Games: A prospective cohort study of 6804 athlete days

Abstract

Objective
To describe the epidemiology of sports injury at the Pyeongchang 2018 Paralympic Winter Games.

Methods
567 athletes from 49 countries were monitored daily for 12 days over the Pyeongchang 2018 Paralympic Winter Games (6804 athlete days). Injury data were obtained daily from teams with their own medical support (41 teams and 557 athletes) and teams without their own medical support (8 teams and 10 athletes) through two electronic data capturing systems.

Results
112 of 567 athletes (19.8%) reported a total of 142 injuries, with an injury incidence rate (IR) of 20.9 per 1000 athlete days (95% CI 17.4 to 25.0). The highest IR was reported for para snowboard (IR of 40.5 per 1000 athlete days [95% CI 28.5 to 57.5]; p<0.02), particularly in the lower limb and head/face/neck anatomical areas. Across all sports at the Games, acute traumatic injuries (IR of 16.2 per 1000 athlete days [95% CI 13.2 to 19.8]) and injuries to the shoulder/arm/elbow complex (IR of 5.7 per 1000 athlete days [95% CI 4.2 to 7.8]) were most common. However, most injuries (78.9%) did not require time loss.

Conclusion
The new Paralympic Winter Games sport of Para snowboard requires attention to implement actions that will reduce injury risk. The shoulder was the most injured single joint—a consistent finding in elite para sport.

Full text

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DermanW, etal. Br J Sports Med 2019;0:1–6. doi:10.1136/bjsports-2018-100170
High incidence of injuries at the Pyeongchang 2018
Paralympic Winter Games: a prospective cohort study
of 6804 athletedays
Wayne Derman, 1,2 Phoebe Runciman,1,2 Esme Jordaan,3,4 Martin Schwellnus, 5,6
Cheri Blauwet,7 Nick Webborn,8 Jan Lexell,9 Peter van de Vliet,10 James Kissick,11
Jaap Stomphorst,12 Young-Hee Lee,13 Keun-Suh Kim14
Original article
To cite: DermanW,
RuncimanP, JordaanE, etal.
Br J Sports Med Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
bjsports-2018-100170
For numbered affiliations see
end of article.
Correspondence to
Professor Wayne Derman,
Institute of Sport and Exercise
Medicine, Department of
Surgical Sciences, Stellenbosch
University, Cape Town, South
Africa; ewderman@ iafrica. com
Accepted 3 February 2019
© Author(s) (or their
employer(s)) 2019. No
commercial re-use. See rights
and permissions. Published
by BMJ.
ABSTRACT
Objective To describe the epidemiology of sports injury
at the Pyeongchang 2018 Paralympic Winter Games.
Methods 567 athletes from 49 countries were
monitored daily for 12 days over the Pyeongchang 2018
Paralympic Winter Games (6804 athlete days). Injury
data were obtained daily from teams with their own
medical support (41 teams and 557 athletes) and teams
without their own medical support (8 teams and 10
athletes) through two electronic data capturing systems.
Results 112 of 567 athletes (19.8%) reported a total
of 142 injuries, with an injury incidence rate (IR) of 20.9
per 1000 athlete days (95% CI 17.4 to 25.0). The highest
IR was reported for para snowboard (IR of 40.5 per 1000
athlete days [95% CI 28.5 to 57.5]; p<0.02), particularly
in the lower limb and head/face/neck anatomical areas.
Across all sports at the Games, acute traumatic injuries
(IR of 16.2 per 1000 athlete days [95% CI 13.2 to 19.8])
and injuries to the shoulder/arm/elbow complex (IR of
5.7 per 1000 athlete days [95% CI 4.2 to 7.8]) were
most common. However, most injuries (78.9%) did not
require time loss.
Conclusion The new Paralympic Winter Games sport of
Para snowboard requires attention to implement actions
that will reduce injury risk. The shoulder was the most
injured single joint—a consistent finding in elite para
sport.
INTRODUCTION
Given the increase in health surveillance research
in the sporting arena, the International Paralympic
Committee (IPC) seeks to preserve the health of the
para athlete in several ways including high-quality
epidemiological research on injury and illness in the
Paralympic Games.1–5 Web-based studies began at
the London 2012 Summer Paralympic Games1 and
have continued at the Rio 20165 Summer Games
and at Paralympic Winter Games at the Sochi 20144
and Pyeongchang 2018 Games. These studies
are the first epidemiological descriptions of the
incidence of injury per 1000 athlete days in para
athletes in a winter setting and build on previous
work initiated from the Salt Lake 2002 Paralympic
Winter Games.6 7
The injury incidence rate (IR) reported in the
web-based studies represents training and competi-
tion related injuries recorded in a cohort of athletes
during the precompetition and competition period
of a Paralympic Games and expressed per 1000
athlete days. The overall IR of the 12-day Sochi
2014 Paralympic Winter Games was 26.5 injuries
per 1000 athlete days (95% CI 22.7 to 30.8).4 The
combined sports of para alpine skiing and para
snowboard (a subdiscipline of para alpine skiing at
the Sochi Games) had a higher rate of injury (IR of
41.1 [95% CI 33.7 to 49.6], p=0.0001) compared
with all other sport categories. Subsequent analysis
indicates an individual IR of 43.8 (95% CI 35.0 to
54.9) for para alpine skiing and an IR of 30.3 (95%
CI 17.7 to 52.0) for para snowboard). At the Sochi
Games, although injuries to the upper body (IR of
8.5 [95% CI 6.4 to 11.1]) and lower body (IR of
8.4 [95% CI 6.3 to 10.9]) were similar, injuries
in the shoulder region were most common (IR of
6.4 [95% CI 4.6 to 8.6]). Additionally, the IR of
acute traumatic injuries (IR of 17.8 [95% CI 14.7
to 21.4]) was higher than acute on chronic injuries
(IR of 3.8 [95% CI 2.5 to 5.6]) and chronic overuse
injuries (IR of 4.9 [95% CI 3.3 to 6.9]).4
It is important that longitudinal investigations
remain ongoing with repeated measures at multiple
Games to identify which areas of para athlete
health require attention, intervention and further
monitoring.8 Thus, subsequent studies are required
in order to further elucidate the patterns of injury
observed in the Paralympic Games setting.
The objective of the present study was to docu-
ment the incidence of injuries sustained at the
Pyeongchang 2018 Paralympic Winter Games. This
study aimed to report overall injury IR, injury IR
per sport (specifically to determine the baseline
injury IR in the new sport of para snowboard),
type of injury and anatomical areas affected by the
injury in both the precompetition and competition
period of the Games. These data will help identify
risk factors for injuries in the Winter Games setting
and help guide injury education and prevention
programmes.
METHODS
This descriptive study was a component of a larger
ongoing prospective epidemiological study of injury
in both Summer and Winter Paralympic Games and
was conducted during the 3-day precompetition
period and 9-day competition period of the Pyeo-
ngchang 2018 Paralympic Winter Games. Athletes
participated in five categories of sports: para
alpine skiing, para snowboard, para Nordic skiing
(combining para cross-country skiing and para
biathlon), para ice hockey and wheelchair curling.
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Original article
Participants
The current study was conducted by members of the IPC’s
Medical Committee. Consent was provided by all athletes for
the use of deidentified medical data gathered during the Games.
The web-based injury and injury surveillance system
(WEB-IISS) was used to record injuries by physicians of teams
who had their own medical support at the Games. This system
has been used successfully at the London 2012, Sochi 2014 and
Rio 2016 Paralympic Games.1 4 5 A more detailed description of
the WEB-IISS can be found in the previous literature.4 Daily use
of the WEB-IISS was enhanced by education provided to teams
participating at the Games. Introductory information about the
study was provided prior to the Games via email to all National
Paralympic Committee’s (NPC) chefs de mission (n=49).
Further communication was sent to all teams who had their own
medical support at the Games (n=41). A medical briefing was
held during the precompetition period where team physicians
were provided with detailed information about the study and
individualised training sessions on using the WEB-IISS. Daily
data entry compliance was also incentivised by the provision of
a basic tablet computer (Samsung, Seoul, Korea) to each partic-
ipating country that had medical support at the Games, which
team physicians could use for data entry. Countries with accom-
panying medical staff who had less than five athletes in their team
reported their data through the same secure, password-protected
portal via either personal computers or computers available in
the athlete village.
The Pyeongchang Local Organising Committee of the Games
customised surveillance system in the medical polyclinic venues
was used by teams who did not have accompanying medical staff
(n=8), as well as WEB-IISS covered athletes who chose to use
polyclinic services. This system was used to capture all admis-
sions to peripheral hospitals, radiology services and all medical
and pharmacy encounters. It was also used to record specialist
services at both the central polyclinic and medical support at
the venues at the Games. After the close of the Games, these
data were delinked and processed to remove duplicate entries
and data from non-athletes. We excluded radiology, physio-
therapy, non-ophthalmological eye examinations (optometry) or
orthopaedic bracing visits to the polyclinic during this time. The
remaining data were then integrated into the WEB-IISS injury
master spreadsheet for analysis. Thus, the present study consti-
tutes all injuries presented to team physicians and local policlinic
staff during the 12 day Games period of the Pyeongchang 2018
Paralympic Winter Games.
Definition of injury
The general definition accepted for reporting an injury was
described as ‘any athlete experiencing an injury that required
medical attention, regardless of the consequences with respect
to absence from competition or training’. An injury was defined
as ‘any newly acquired injury as well as exacerbations of pre-ex-
isting injury that occurred during training and/or competition of
the Games period of the Pyeongchang 2018 Paralympic Winter
Games’. Acute traumatic, acute on chronic and chronic injuries
were reported. An acute traumatic injury was defined as ‘an
injury that was caused by an acute precipitating traumatic event’.
An acute on chronic injury was defined as ‘an acute injury in an
athlete with symptoms of a chronic injury in the same anatom-
ical area’. A chronic (overuse) injury was defined as ‘an injury
that developed over days, weeks or months and was not associ-
ated with any acute precipitating event’.4
Calculation of athlete days
Team size was determined using the list of all accredited athletes
participating at the Games published by the IPC prior to the
Games. This was to ensure that all team sizes (both WEB-IISS
and polyclinic monitored athletes) came from the same source
and were seen to be reliable data. Athlete days were calculated by
multiplying the total term days (3 day precompetition and 9-day
competition period) multiplied by team size as published by the
IPC. These data constituted denominator data for the calcula-
tion of injury IR. The provision of accurate denominator data
is critical to correct analysis and reporting of the epidemiology
of injury in this international multisport setting, with multiple
teams.
Calculation of the injury proportion and IR
Injury proportion was calculated as the percentage of athletes
who sustained one or more injuries during the Games period.
The injury IR was calculated as injuries per 1000 athlete days.
The number of athlete days was reported separately by sport, age
group and sex. The IR per 1000 athlete days was reported for
all injuries as well as injuries in different sports and anatomical
areas. The percentage of athletes reporting an injury was calcu-
lated as the number of athletes with an injury divided by the total
number of athletes competing in the relevant sub group, multi-
plied by 100. Where athletes incurred multiple injuries during
the total Games period, each of these were reported as distinct
injuries.
Calculation of time loss
Time loss as a result of injury was estimated by the team physi-
cian at the time of reporting the injury. They were then able to
log into the system at a later stage and modify the entry to repre-
sent the actual days lost by the athlete.
Time loss data were only available for injuries logged on the
WEB-IISS. Thus, the time loss data represented 557 athletes
(98.2%) who had their own medical support (6684 athlete days).
Statistical analysis of the data
All data (WEB-IISS and polyclinic datasets) were in the form of
counts (ie, the number of injuries each athlete reported). Results
for impairment data were reported via total number of injuries
(%) only since the impairment data of all the athletes partici-
pating at the Games was not available. Some athletes partici-
pated in more than one sport and/or more than one event; the
primary sport of the athlete was used in the analysis. Where
some athletes incurred multiple injuries during the total Games
period, each of these were reported as distinct injuries. Further-
more, if an athlete sustained a two-part injury, the injuries were
classified as distinct injuries. Descriptive statistical analyses were
reported, including number of athletes participating in five cate-
gories of sport (para alpine skiing, para snowboard, para Nordic
skiing [combining para cross-country skiing and para biathlon],
para ice hockey and wheelchair curling), by age (12–25 years,
26–34 years and 35–75 years) and sex (male or female), number
of reported injuries and number and percentage of athletes with
an injury. Generalised linear Poisson regression modelling (SAS
V.9.4) was used to model the number of reported injuries overall,
as well as the number of injuries for anatomical areas affected by
the injury and were corrected for overdispersion and included
the independent variables of interest. Unadjusted injury IRs were
reported per 1000 athlete days (including 95% CIs). Incidence
of injury was reported by sex, age group, type of sport and
anatomical area affected by the injury.
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DermanW, etal. Br J Sports Med 2019;0:1–6. doi:10.1136/bjsports-2018-100170
Original article
RESULTS
Participants
A total of 567 athletes (433 men and 134 women), represented
49 countries at the Games (6804 athletes days). Five hundred
and fifty-seven athletes from 41 countries (98.2% of all athletes,
6684 athlete days) had their own medical support, and 10
athletes from eight countries (120 athlete days) used the local
polyclinic medical facilities. Some athletes were monitored on
the WEB-IISS and also chose to use polyclinic services; however,
in instances where the same injury was reported, only WEB-IISS
encounters were included given that they offered greater detail
regarding the clinical characteristics of each injury.
The mean (±SD) age of all athletes in this study was 32.1±10.3
years (range 15–67 years). Table 1 presents the total numbers
of athletes, sex and age distribution in five categories of sports,
namely para alpine skiing, para snowboard, para Nordic skiing
(combining para cross country skiing and para biathlon), Para ice
hockey and wheelchair curling.
Incidence of injury by sport
The total number of injuries, as well as injuries reported in five cate-
gories of sports are presented in table 2. A total of 142 injuries (114
WEB-IISS and 28 polyclinic) were recorded in 112 athletes during the
12-day Games period, thus 19.8% (injury proportion) of all athletes
sustained one or more injuries at the Games. This represented an IR
of 20.9 injuries per 1000 athlete days (95% CI 17.4 to 25.0). There
were more new injuries reported (n=118; IR of 17.3 [95% CI 14.2
to 21.1]) than recurrent injuries (n=24; IR of 3.5 [95% CI 2.4 to
5.2]). Twenty-eight athletes sustained separate injuries on different
days of competition, and one athlete sustained a multilocation injury.
There was a higher IR of injury recorded for para snowboard (IR
of 40.5 [95% CI 28.5 to 57.5], p<0.02) than all other sports cate-
gories combined. The most cited mechanisms of sport-related acute
injury as reported by team physicians for para snowboard athletes
included: (1) the athlete being out of control, (2) technique faults,
(3) technical difficulties or (4) not knowing how the injury occurred.
The sport of wheelchair curling had a lower IR of injury (IR of 6.9
[95% CI 2.7 to 17.6], p<0.01) compared with para alpine skiing,
para snowboard and para ice hockey but not para Nordic skiing.
Incidence of injury by sex and age group
Table 3 presents the incidence of injury by sex and age group.
There were no significant differences in the injury IRs between
men and women and between age groups.
Incidence of injury in the precompetition (3 days) and
competition period (9 days)
There were 33 injuries recorded in 31 athletes (IR of 19.4 [95%
CI 13.6 to 27.6]) during the precompetition period, and 109
injuries recorded in 95 athletes (IR of 21.4 [95% CI 17.4 to
26.3]) during the competition period of the Pyeongchang 2018
Paralympic Winter Games (table 4). There was no significant
difference in the injury IR between these two periods.
Incidence of injury by anatomical area
The anatomical areas affected by injury are presented in table 5.
The upper limb (IR of 7.9 [95% CI 6.1 to 10.3]) and lower limb
(IR of 7.1 [95% CI 5.2 to 9.54]) had a similar IR of injury. The
shoulder/upper arm/elbow complex had the highest IR of injury
(IR of 5.7 [95% CI 4.2 to 7.8]), followed by the head/neck/face
complex (IR of 4.3 [95% CI 2.9 to 6.2]) and the wrist/hand/
finger complex (IR of 2.2 [95% CI 1.3 to 3.6]).
Injuries to the shoulder/upper arm/elbow complex were
highest in the following sports: para ice hockey (n=21; 56% of
all injuries), para Nordic skiing (n=13; 50% of all injuries) and
para alpine skiing (n=13; 30% of all injuries).
Incidence of injuries by onset
Table 6 presents the number and rate of injuries by onset of
injury, namely acute traumatic injury, acute on chronic injury
and chronic overuse injury. There were more acute traumatic
injuries (IR of 16.2 [95% CI 13.2 to 19.8]; p<0.05) than acute
on chronic (IR of 1.5 [95% CI 0.8 to 2.7]) and chronic overuse
(IR of 3.2 [95% CI 2.1 to 5.0]) injuries.
Injury by impairment
Table 7 depicts the impairment profiles of 93 athletes with
injuries, whose data were captured on the WEB-IISS. Injuries
Table 1 Number of athletes participating in each sport at the Pyeongchang 2018 Paralympic Winter Games
Sport All athletes Men Women Age 13–25 years Age 26–35 years Age 36–75 years
All 567 433 134 161 216 190
Para alpine skiing 141 101 40 59 53 29
Para snowboard 72 58 14 20 30 22
Para Nordic skiing 159 100 59 52 73 34
Para ice hockey 135 134 1 29 52 54
Wheelchair curling 60 40 20 1 8 51
Table 2 Incidence of injury by sport for athletes competing at the Pyeongchang 2018 Paralympic Winter Games
Sport
Total number
of injuries
Number of athletes
with an injury
Total number of
athletes competing
Total number
of athlete days
Percentage of athletes
with an injury (%)
Injury incidence rate: injuries/1000
athlete days (95% CI)
All 142 112 567 6804 19.8 20.9 (17.4 to 25.0)
Para snowboard 35 24 72 864 33.3 40.5 (28.5 to 57.5)*
Para alpine skiing 39 30 141 1692 21.3 23.1 (16.5 to 32.1)
Para ice hockey 37 29 135 1620 21.5 22.8 (16.2 to 32.1)
Para Nordic skiing 26 24 159 1908 15.1 13.6 (9.1 to 20.5)
Wheelchair curling 5 5 60 720 8.3 6.9 (2.7 to 17.6)†
*Higher than all other sport categories (p<0.02).
‡Lower than para snowboard, para alpine skiing and para ice hockey but not para Nordic skiing (p<0.01).
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Original article
provided by the polyclinic did not provide impairment details
of the injured athletes. There were 50 injuries (53.8%) recorded
in athletes with limb deficiency, followed by 25 injuries (26.9%)
recorded in athletes with spinal cord injury.
Time loss as a result of injury
Of the injuries reported using the WEB-IISS during the Games
period, 21.1% (24 out of 114 injuries) required one or more
days of exclusion from training or competition, while 78.9% of
athletes reporting an injury on the WEB-IISS required no time
loss from training or competition. There were three injuries
that were classified as moderately serious (8–28 days lost due to
injury) and three injuries classified as serious (28 days–6 months
lost), according to the consensus statement on time loss injuries
in athletics (table 8).9
DISCUSSION
The present study represents a significant addition to the litera-
ture regarding the incidence of injuries per 1000 athlete days in
athletes competing at the Paralympic Winter Games and docu-
ments the incidence of injury in five categories of sport during
the Pyeongchang 2018 Games.
Para snowboard: more injuries than all other sports combined
The first important finding was that the new winter sport of
para snowboard had a higher rate of injury (IR of 40.5 [95%
CI 28.5 to 57.5]; p<0.02) than all other sports. Injuries to the
anatomical areas of the lower limb (n=15; 42% of total inju-
ries; p<0.01) and head/neck/face (n=14; 40% of total injuries;
p<0.01) constituted more than 80% of the injuries among para
snowboard athletes monitored using the WEB-IISS. This finding
extends our knowledge of injuries in able-bodied athletes partic-
ipating in snowboarding, where higher rates of injury were
reported following the inclusion of the discipline into existing
winter sport programmes. The most common injuries reported
in these studies included head and knee injuries and indicates a
similar pattern of injuries as a result of snowboarding in both
able-bodied and para athletes.10–18
Acute traumatic injuries were the most commonly reported inju-
ries at these Games (IR of 16.2 [95% CI 13.2 to 19.8])1 4 5 and
also constituted the majority of injuries reported in para snowboard
athletes (82% of all snowboard injuries). The mechanisms of acute
sport-related acute injury on the WEB-IISS for para snowboard
athletes were: the athlete being out of control, technique faults,
technical difficulties or not knowing how the injury occurred. It is
interesting to note that the most severe serious injury (6 months) was
acquired during a para snowboard training run, in the lower half
of the course, where the athlete suffered an acute anterior cruciate
knee ligament injury that required surgery (table 8). Yet, the vast
majority of para snowboard injuries were only medical attention
injuries (including many lacerations and contusions) that did not
lead to any time loss.
Although the incidence of injury was reported for para snow-
board at the Sochi 2014 Games, this was combined with para
alpine skiing given that in 2014, para snowboard was organised
as a subsdiscipline within World Para Alpine Skiing (45 athletes;
IR of 30.3 [95% CI 17.7 to 52.0]). It was however listed as an
individual sport at the Pyeongchang 2018 Games. Thus, this
study is the first to fully describe injuries acquired during this
sport in a Paralympic Winter Games setting. As this may reflect
the relative inexperience of the competitors compared with the
other well-established winter para sports, it is suggested that
education and safety programmes are considered within this
sport going forward.
We believe it is important to contextualise injury as reported
in this paper, especially with respect to severity. A percentage of
78.9 of all injuries sustained in these Games did not require time
away from training or competition, indicating that these injuries
are not as clinically significant as those injuries that resulted in
the athlete to be unable to compete/train in their sport. Although
there was a significantly higher unadjusted IR of injury in para
snowboard in this study, further studies investigating significant
time loss injuries in isolation are required.
Shoulder injuries remain common in para athletes
The second important finding was the high incidence of injury in
the shoulder/arm/elbow complex (39 injuries; IR of 5.7 [95% CI
4.2 to 7.8]), with 27 of these injuries reported for the shoulder
joint. The shoulder joint has been highlighted in both the
summer and winter setting for athletes with impairment, mainly
for wheelchair users who use their upper body to perform both
their sport and activities of daily living.1 4 5 19–22 In the current
study, sports in which athletes used their arms for power and
stability during high-speed propulsion, namely para ice hockey
Table 3 Incidence of injury by sex and age group for athletes competing at the Pyeongchang 2018 Paralympic Winter Games
Sex/age group
Total number
of injuries
Number of athletes
with an injury
Total number of
athletes competing
Total number of
athlete days
Percentage of athletes
with an injury (%)
Injury incidence rate: injuries/1000
athlete days (95% CI)
All 142 112 567 6804 19.8 20.9 (17.4 to 25.0)
Men 103 82 433 5196 18.9 19.8 (16.0 to 24.5)
Women 39 30 134 1608 22.4 24.3 (17.2 to 34.3)
Age 13–25 years 34 27 161 1932 16.8 17.6 (12.2 to 25.5)
Age 26–35 years 60 47 216 2592 21.8 23.2 (17.5 to 30.6)
Age 36–75 years 48 38 190 2280 20.0 21.2 (15.4 to 28.8)
Table 4 Incidence of injury in the precompetition and competition periods for athletes competing at the Pyeongchang 2018 Paralympic Winter
Games
Period
Total number
of injuries
Number of athletes
with an injury
Total number of
athletes competing
Total number of
athlete days
Percentage of athletes
with an injury (%)
Injury incidence rate: injuries/1000
athlete days (95% CI)
All 142 112 567 6804 19.8 20.9 (17.4 to 25.0)
Precompetition 33 31 567 1701 5.5 19.4 (13.6 to 27.6)
Competition 109 95 567 5103 16.8 21.4 (17.4 to 26.3)
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(n=21; 56% of all injuries), para Nordic skiing (n=13; 50% of
all injuries) and para alpine skiing (n=13; 30% of all injuries)
had a higher number of reported injuries in this area.
The IPC Medical Committee is committed to investigating
shoulder injuries in athletes competing in para athletics and para
powerlifting events in an effort to determine the true extent of
the problem facing athletes who use wheelchairs. It is apparent
that this challenge is present in many sporting events (other than
in the sports mentioned above) in which athletes with lower limb
impairment compete (ie, para winter sports). It is therefore indi-
cated that all sports with a high risk for shoulder injuries require
further investigation and subsequent intervention.
Intervention programme in para alpine skiing
The third important finding was the reduction in injuries
reported in the sport of para alpine skiing from the Sochi 2014
Games (IR of 43.8 [95% CI 35.0 to 54.9]) to the Pyeongchang
2018 Games (IR of 23.1 [95% CI 16.5 to 32.1]). It is hypoth-
esised that this reduction was due, in part, to the improved
environmental conditions in Pyeongchang (mean temperature:
−2°C) compared with Sochi (mean temperature: 9°C) and also
to accelerated interventions made by the IPC and World Para
Alpine Skiing federation in an effort to decrease the injury load
in this sport.23 24 At the Sochi Games, modifiable risk factors
for sustaining an injury in para alpine skiing were identi-
fied, including: (1) course design, (2) number of training runs
permitted on the course and (3) the command and control struc-
ture between the technical and medical staff. At the Pyeongc-
hang Games, the Technical Committee implemented a series of
changes to mitigate the risk of injury, including: (1) redesigning
the course, (2) increasing the number of training runs, (3) having
the ability to change event start times and (4) the development
of a snow contingency plan. Education opportunities were also
made available to all NPC medical and technical staff to increase
the awareness and management of para alpine injuries in this
setting.23 The incidence of injuries sustained during the Games’
decreased from an IR of 43.8 (95% CI 35.0 to 54.9) injuries per
1000 athlete days in Sochi 2014 to 23.1 (95% CI 16.5 to 32.1)
injuries per 1000 athlete days in Pyeongchang 2018.
Strengths and limitations of the study
A strength of the current study was that the data collection
system was upgraded prior to these Games, so that medical offi-
cers could alter the number of days lost after the initial logging
of the illness or injury. This facility was kept open for alterations
Table 5 Incidence of injury in each anatomical area for athletes
competing at the Pyeongchang 2018 Paralympic Winter Games
Anatomical area
Total
number
of
injuries
Number of
athletes
with an
injury
Percentage
of athletes
with an
injury (%)
Injury incidence rate:
injuries/1000 athlete
days (95% CI)
All 142 112 19.8 20.9 (17.4 to 25.0)
Upper limb 54 52 9.2 7.9 (6.1 to 10.3)
Shoulder/arm/elbow 39 38 6.7 5.7 (4.2 to 7.8)
Wrist/hand/finger 15 15 2.6 2.2 (1.3 to 3.6)
Lower limb* 48 43 7.6 7.1 (5.2 to 9.5)
Knee 11 10 1.8 1.6 (0.9 to 3.1)
Ankle/foot/toe 13 12 2.1 1.9 (1.1 to 3.4)
Lower leg 7 7 1.2 1.0 (0.5 to 2.1)
Thigh/stump 10 10 1.8 1.5 (0.8 to 2.7)
Hip/groin/pelvis 7 7 1.2 1.0 (0.4 to 2.4)
Head/face/neck†‡ 29 27 4.8 4.3 (2.9 to 6.2)
Spine 6 6 1.1 0.9 (0.4 to 2.0)
Chest/trunk/abdomen 5 5 0.9 0.7 (0.3 to 1.8)
*Fifteen of these injuries occurred in para snowboard (p<0.01).
†Fourteen of these injuries occurred in para snowboard (p<0.01).
‡Four of these injuries were concussions, as reported by team physicians. These included
two in para alpine skiing and two in para ice hockey.
Table 6 Incidence of injury by onset (chronicity) for athletes
competing at the Pyeongchang 2018 Paralympic Winter Games
Type of injury
Total
number of
injuries
Number of
athletes with
an injury
Percentage of
athletes with
an injury
Injury incidence
rate: injuries/1000
athlete days
(95% CI)
All 142 112 19.8 20.9 (17.4 to 25.0)
Acute traumatic 110 91 16.0 16.2 (13.2 to 19.8)*
Acute on
chronic
10 10 1.8 1.5 (0.8 to 2.7)
Chronic overuse 22 21 3.7 3.2 (2.1 to 5.0)
*Higher than all other onsets (p<0.05).
Table 7 A description of the impairment types of the 93 athletes
with an injury on the WEB-IISS at the Pyeongchang 2018 Paralympic
Winter Games
Impairment type
Number of
athletes with
an injury
Percentage of injured
athletes in each
impairment type (%)
All 93 100
Limb deficiency (amputation, dysmelia
and congenital deformity)
50 53.8
Spinal cord injury 25 26.9
Visual impairment 8 8.6
Central neurologic injury (cerebral
palsy, traumatic brain injury, stroke and
other neurological impairments)
6 6.5
Les autres 0 0
Unknown 4 4.3
WEB-IISS, web-based injury and injury surveillance system.
Table 8 A description of the moderately serious (8–28 days) and
serious (28 days–6 months) time loss injuries recorded on the WEB-IISS
at the Pyeongchang 2018 Paralympic Winter Games
Time lost due
to injury
Onset, anatomical area and
mechanism of injury
Sport (event) in which
the injury occurred
Moderately severe injury (8–28 days lost)
20 days Acute knee anterior cruciate ligament
injury, movement fault during
training.
Para alpine skiing (in gym
training session).
21 days Acute shoulder dislocation injury,
athlete was out of control.
Para snowboard (banked
slalom).
21 days Acute ankle lateral ligament sprain
and head/facial fractures, athlete
twisted an extremity.
Para snowboard
(snowboard cross).
Severe injury (28 days-6 months lost)
35 days Acute wrist and hand avulsion
fracture, sledge contact with another
sledge.
Para ice hockey (play-off
match).
60 days Acute shoulder fractures and neck
whiplash injury, pole hooked a gate/
bar.
Para alpine skiing (giant
slalom, lower half of
course).
6 months Acute knee anterior cruciate ligament
injury, athlete landed a jump poorly.
Para snowboard (testing
jump).
WEB-IISS, web-based injury and injury surveillance system.
on 22 February 2019 by guest. Protected by copyright.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2018-100170 on 22 February 2019. Downloaded from

6DermanW, etal. Br J Sports Med 2019;0:1–6. doi:10.1136/bjsports-2018-100170
Original article
to the time loss data to be made by the team physicians for a
period of 2 weeks following the conclusion of the Games.
A limitation was that two electronic sources were used for
data collection (WEB-IISS and polyclinic entries). We suggest
that all athletes be covered on the WEB-IISS at future editions
of the Games or that the local organising committee system be
expanded to include the same variables as the WEB-IISS, in
particular number of days lost and mechanism of injury. There
were a relatively small total number of injuries in this study,
which limits our abilities to perform complex multivariate statis-
tical analysis.
What are the findings?
►The new sport of para snowboard had a higher incidence rate
of injury than all other sports, indicating the need for injury
intervention and prevention programmes in the sport.
►The shoulder joint was the most commonly affected
anatomical area—specificallyin sports where the arms were
used for power and stability during high-speed propulsion.
►There were fewer injuries at the Pyeongchang 2018 Games
than the Sochi 2014 Games in the sport of Para alpine
skiing. We feel injuries were fewer because of favourable
environmental conditions and the injury prevention
programme implemented by the International Paralympic
Committee and World Para Alpine Skiing.
How might it impact on clinical practice in the future?
►Sporting organisations, coaches and athletes can use these
data to identify the anatomical areas and sports with high
risk for injury in a Winter Games setting for athletes with
impairment.
►Our methods for the capturing and analysing the incidence
of injury in athletes with impairment in a Winter Paralympic
Games setting provide a basis for future studies at upcoming
Paralympic Games.
Author affiliations
1Institute of Sport and Exercise Medicine, Department of Surgical Sciences,
Stellenbosch University, Cape Town, South Africa
2International Olympic Committee Research Centre, Cape Town, South Africa
3Biostatistics Unit, Medical Research Council, Parow, South Africa
4Statistics and Population Studies Department, University of the Western Cape,
Bellville, South Africa
5Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences,
University of Pretoria, Pretoria, South Africa
6IOC Research Centre, South Africa, Pretoria, South Africa
7Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation
Hospital and Brigham and Women’s Hospital, Harvard Medical School, Boston,
Massachusetts, USA
8Centre for Sport and Exercise Science and Medicine (SESAME), University of
Brighton, Eastbourne, UK
9Department of Neuroscience, Rehabilitation Medicine, Uppsala Universitet, Uppsala,
Sweden
10Medical and Scientific Department, International Paralympic Committee, Bonn,
Germany
11Carleton University Sport Medicine Clinic, Department of Family Medicine,
University of Ottowa, Ottowa, Canada
12Department of Sports Medicine, Isala Klinieken, Zwolle, The Netherlands
13Rehabilitation Medicine, Wonju College of Medicine, Yonsei University, Wonju,
Seoul, The Republic of Korea
14Yonsei Institute of Sports Science and Exercise Medicine, Yonsei University,
Seodaemun-gu, Seoul, The Republic of Korea
Acknowledgements This study was approved and supported by the International
Paralympic Committee. The authors would like to thank the Pyeongchang Local
Organising Committee of the Games POCOG staff, as well as the National
Paralympic Committee medical staff, whose input was pivotal to the success of this
study.
Contributors All authors have contributed to the development, application and
write up of the current study. Each author has completed a Conflicts of Interest form.
Funding Funding for this study was provided by the IOC Research Centre South
Africa grant and International Paralympic Committee research support.
Competing interests All authors have declared competing interests.
Patient consent for publication Not required.
Ethics approval Ethics board approval for this study was granted by the Research
Ethics Committees of the University of Brighton (FREGS/ES/12/11) and Stellenbosch
University (N16/05/067).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No data are available.
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