The role of International Sport Federations in the protection of the athlete's health and promotion of sport for health of the general population

Health promoting sports federations: theoretical foundations and guidelines

Background

Researchers and policy-makers have highlighted that the potential for organized sports to promote health has been underexploited. Sports clubs have limited capacity to promote health due to their voluntary nature and have called for support from their national sports federations. The present article provides guidelines, based on the theoretical principles of health promoting sports clubs and an analysis of practical tools and proven strategies, to support national sports federations to invest in health promotion (HP).

Methods

A qualitative iterative study was undertaken, based on five 2-h meetings of a group of 15 international researchers in HP in sports clubs. Notes and minutes from meetings, as well as shared outputs were analyzed based on the health promoting sports club framework.

Results

Guidelines developed for national sports federations to promote health includes a definition of a health promoting sports federation (HPSF), a description of how the settings-based approach to HP adapts to national sports federations, as well as practical applications of health promoting sports club's intervention strategies. The analysis of existing tools also demonstrated that most tools are centered on a single dimension of health (social, mental, physical, spiritual or community), and often on a specific health topic. Furthermore, they do not cover HP as a continuous long-lasting process, but are generally short-term programs. The HPSF clarifies theoretical concepts, their practical implementation via case studies and outlines intervention components and tools useful for sports federations in their implementation of HP.

Conclusion

The guidelines developed in this study are intended to facilitate national sports federations to acknowledge/understand, reinforce/underpin and foster current and further investment in HP.

Study of an Anti-Doping Education Program in Spanish Sports Sciences Students

Doping continues to be one of the biggest risks to the credibility of elite sports, and its practice remains widespread among athletes despite improved controls. Athletes' support personnel could be key to preventing doping behavior. In this sense, anti-doping education for this population appears as a possible strategy to reduce doping behaviors in elite sport, but these programs must be evaluated and designed based on scientific evidence. The aim of this research is to explore the impact of an anti-doping education program about substances perceived efficacy, ill-health short- and long-term effects, and the morality of doping substance use in Spanish sports sciences students.

METHOD

A total of 145 students of Physical Activity and Sport Sciences (PASS) from different Spanish universities who took an online anti-doping educational course of the Spanish Anti-Doping Commission (CELAD) answered a questionnaire on their perceptions about doping before, after, and four months later.

RESULTS

The results show that the course reduced students' ignorance about the effects of substances on performance and health and increased their moral judgment and feelings against doping.

DISCUSSION

The results are in line with previous research that showed that the moral stance against doping can be improved through educational programs.

CONCLUSION

Online educational interventions can be effective in reducing doping behavior, so their future implementation among ASP can be an effective strategy to reduce doping behavior.

The Significance of Oral Inflammation in Elite Sports: A Narrative Review

Recently, there has been intense discussion about sports dentistry and potential interactions between oral health and athletes' performance. This narrative review aims to provide a comprehensive overview of the available literature about oral inflammation in sports. For this purpose, it presents the most common types of oral inflammation (gingivitis, periodontitis, pericoronitis, apical periodontitis), and their prevalence in athletes. Both the impact of oral inflammation on performance and causes for oral inflammation in athletes are discussed by presenting current literature. Finally, international recommendations for dental care in sports are presented. Several studies stated a high prevalence of oral inflammation in athletes, especially of gingivitis (58-97%) and periodontitis (41%). Also, many athletes report oral pain (17-30%) and a negative impact of oral health on training (3-9%). Besides this, a systemic impact of oral inflammation is discussed: In periodontitis patients, blood parameters and physical fitness are changed. In athletes, associations between muscle injuries and poor oral health are reported. There are deficits in oral health behavior. Furthermore, systemic changes due to physical stress could influence oral tissues. Overall, complex bidirectional interactions between competitive sports and oral inflammation are possible. Regular dental examinations and prevention strategies should be implemented in sports.

Differences in career longevity before and after implementation of the Women's Tennis Association Tour Age Eligibility Rule and Player Development Programmes: a 25-year study

OBJECTIVES

To assess differences in career longevity, as a potential marker of athlete well-being, before and after the 1995 implementation of the Women's Tennis Association (WTA) Age Eligibility Rule (AER) and Player Development Programmes (PDP), which focused on organisational, physical and psychosocial education, skill building and support for adolescent athletes (≤17 years).

METHODS

Career longevity data were collected through 2019 on adolescent players who began professional tournament play between 1970 and 2014 and reached a WTA singles ranking of 1-150 for a minimum of 1 week during their careers. Players were separated into pre-AER/PDP and post-AER/PDP groups, consisting of those who played their first professional events (FPE) before or after 1 January 1995. Measures of career longevity included career duration and premature retirement.

RESULTS

Eight-hundred and eleven players were included in this study (51% pre-AER/PDP). The median career duration was 14.2 years for the post-AER/PDP group compared with 12.1 years for the pre-AER/PDP group (p<0.001). Moreover, post-AER/PDP players had higher probabilities of 10-year and 15-year careers compared with pre-AER/PDP players. After adjusting for age at FPE, athletes in the pre-AER/PDP group had an increased risk of shorter career duration (HR 1.55; 95% CI 1.31 to 1.83) and increased odds of premature retirement (OR 5.39; 95% CI 2.28 to 12.75) than athletes in the post-AER/PDP group.

CONCLUSIONS

Adolescent athletes participating on the WTA after the combined AER/PDP initiative had longer career durations, higher probabilities of 10-year and 15-year careers, and decreased risk of premature retirement compared with those participating prior to AER/PDP. Organisational practices that encompass both education and competition regulation can positively affect career longevity related to improving athlete well-being.

"I'd got self-destruction down to a fine art": a qualitative exploration of relative energy deficiency in sport (RED-S) in endurance athletes

Relative Energy Deficiency in Sport (RED-S) is a syndrome of impaired health and performance that occurs as a result of low energy availability (LEA). Whilst many health effects associated with RED-S have been widely studied from a physiological perspective, further research exploring the psychological antecedents and consequences of the syndrome is required. Therefore, the aim of this study was to qualitatively explore athlete experiences of RED-S. Twelve endurance athletes (female n= 10, male n= 2; M age = 28.33 years) reporting past or current experiences of RED-S, associated with periods of LEA, took part in semi-structured interviews designed to explore: contexts and mechanisms underpinning the onset of RED-S; the subjective experience of RED-S; and contexts and mechanisms influencing "recovery" from RED-S. Regardless of how RED-S was initiated, all athletes experienced a multitude of physiological impairments, accompanied by significant psychological distress. This paper contributes novel understanding of the complex interplay between physiological and psychological components of RED-S from the perspective of information-rich cases. The findings suggest that system-wide educational prevention and awareness interventions are vital for athletes and support personnel, such as coaches, parents, dieticians, psychologists, and sports medicine staff.

Short-term recovery of physical activity and knee function after an acute knee injury

Objectives

To describe self-reported knee function, participation in physical activity and the number of knee surgeries at 3 and 6 months following acute knee injury.

Methods

Prospective cohort study. Participants, aged 15–40 years with an acute knee injury sustained no more than 6 weeks prior to inclusion, were recruited. There were 279 participants with ACL injury and 101 participants with other acute knee injuries included. Follow-up questionnaires were sent at 3 and 6 months after injury. Demographic information, activity participation, International Knee Documentation Committee subjective knee form (IKDC-SKF) and the Single Assessment Numeric Evaluation (SANE) score were collected. Additional knee injuries were obtained from self-report and medical charts.

Results

The IKDC-SKF, SANE and physical activity participation were reduced at 3-month and 6-month follow-up. The number of participants who achieved health-promoting physical activity levels was reduced by 50% at 6-month follow-up compared with before injury. Seventeen per cent of participants with ACL injury and 41% of participants with other acute knee injuries had returned to their preinjury physical activity at 6 months. Participants with ACL injury reported worse knee function, lower physical activity participation and had more surgeries (128 surgeries, including 109 ACL-reconstructions) compared with participants with other acute knee injuries (six surgeries).

Conclusion

Acute knee injuries, including ACL injuries, affected self-reported knee function and physical activity participation for at least 6 months after index injury. More research is needed to understand how best to help people with acute knee injuries return to physical activity and achieve satisfactory knee function.

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships

Background

Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type.

Design

Cross-sectional web-based survey.

Methods

A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination.

Results

A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation.

Conclusions

The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

Health promotion by International Olympic Sport Federations: priorities and barriers

Objective

To identify changes in International Federations’ priorities and the barriers to implementing athlete and global health initiatives. Results should influence the work of the International Federation medical committees, the IOC and the Association of Summer Olympic International Federation.

Methods

The 28 Summer and 7 Winter International Federations participating in the most recent Olympic Games (2016; 2018) were surveyed to (i) identify the importance of 27 health topics, (ii) assess their progress on implementation health-related programmes and (iii) the barriers to implementation of these programmes. We compared International Federations’ activities in 2016 and 2017.

Results

The response rate was 83%. Health topics which most International Federations regarded as important and in which the International Federations felt insufficiently active were ‘team physician certification’, ‘prevention of harassment and abuse’, ‘eating disorders/disordered eating’, ‘mental health’ and ‘injury surveillance’. Compared with 2016, there was a decrease in International Federations’ activities in ‘injury surveillance’, ‘nutritional supplements’ and ‘hyperandrogenism’. The main barrier to implementing health-related programmes was ‘International Federation political support/willingness’, followed by ‘knowledge’. ‘Time’ and ‘coach support’ were more often reported than ‘finances’, or ‘IOC or Association of Summer Olympic International Federations partnership’.

Conclusion

If International Federations are going to promote health of athletes and global health promotion through physical activity (sport), International Federation leadership must change their focus and provide greater political support for related initiatives. Improving coach and athlete knowledge of the health issues could also facilitate health programme delivery. Time constraints could be mitigated by sharing experiences among the International Federations, Association of Summer Olympic International Federations and the IOC. International Federations should focus on those health-related topics that they identified as being important, yet rate as having insufficient activity.

Performance of the BMJ learning training modules for ECG interpretation in athletes

To assess the accuracy of interpreting the athlete’s ECG both pre and post a series of online training modules among a range of healthcare professionals. 10 512 healthcare professionals from 138 different nations commenced the online course. These were primarily doctors (43%), nurses (18.4%) and other healthcare professionals (3.9%). The users came from 102 different specialities, with General Practice/Family Medicine (24.5%), Cardiology (10.6%), Emergency Medicine (8.7%) and Sports Medicine (6.6%) predominating. Among the 2023 users who completed both the pre-course and post-course test, there was an overall improvement of 15.3% (95% CI 13.9% to 16.6%; p<0.001). 930 completed all four other modules, and these users fared significantly better (18.7% increase; 95% CI 17.3 to 20.0) than those completing no additional modules (11.7% increase; 95% CI 3.3 to 17.7, p=0.036). Demographic analysis showed that while the starting pre-test scores varied significantly between profession/specialty groups (57.8%–82.6%), post-test scores were largely consistent (80.8%–84.6%). Although users showed the most improvement when interpreting primary electrical diseases (12.4% increase), it was also an area of notable weakness compared with the modules of normal training-related findings and cardiomyopathies. With the evolving criteria for ECG interpretation eliciting ever improving levels of specificity and sensitivity in the detection of conditions associated with sudden cardiac death among athletes, training is required to ensure the infrastructure and personnel is in place to uphold these standards. The BMJ Learning course presented is a valuable first step and demonstrates that such an online tool can be effective in aiding ECG interpretation among healthcare professionals globally.

Quality of life among individuals with rugby-related spinal cord injuries in South Africa: a descriptive cross-sectional study

OBJECTIVES

Rugby-related spinal cord injuries (SCIs) are rare but life altering and traumatic events. Little is known about the long-term consequences and outcomes of players who have sustained these injuries. This study investigated current quality of life (QoL) and factors associated with QoL, among individuals with rugby-related SCI in South Africa, by using the International Classification of Functioning, Disability and Health (ICF) framework.

DESIGN

Descriptive cross-sectional study.

SETTING

Rugby-related SCI population of South Africa, as captured in the BokSmart/Chris Burger Petro Jackson Players' Fund database.

PARTICIPANTS

Ninety (n=90) of the 102 eligible players on the database agreed to participate in the study.

MAIN OUTCOME MEASURE

The relationship between QoL, as measured with the WHO Quality of Life questionnaire (WHOQOL-BREF) and specific independent variables (demographic information, level of independence and participation in various activities and life roles) was investigated. Variables that were significantly associated with QoL in bivariate analyses were included in multiple linear regression analyses.

RESULTS

The mean score and SD of the WHOQOL-BREF was 15.1±2.3 arbitrary units. Participation (an ICF framework construct) and income were significantly associated with overall QoL (p<0.001). Participation was the only variable significantly associated with all QoL subdomains (p<0.001). Additionally, number of health concerns, type of healthcare (public vs private) and level of education were significantly associated with various QoL domains (p<0.001).

CONCLUSIONS

On average, these individuals with rugby-related SCI presented with higher QoL scores than other comparable SCI studies. However, lower levels of participation and income, certain levels of education, increased health concerns and use of public healthcare were associated with lower levels of QoL. Sporting bodies have a responsibility to optimise player welfare, by acting on the modifiable factors associated with QoL.

Impact of Health Authority Control Measures Aimed at Reducing the Illicit Use of Anabolic-Androgenic Steroids

OBJECTIVE

To evaluate two interventions on anabolic-androgenic-steroids (AAS) dispensation in retail pharmacies.

MATERIAL AND METHODS

The study was conducted in a north-western region of Spain. Data were the AAS supplied by wholesale drug distributors to retail pharmacies over a period of 102 months. It is designed as an ecological time-series study; the dependent variables were daily defined doses per 1,000 inhabitants per day of each drug. The two interventions evaluated were: (1) an inspection program intended for those retail pharmacies where there was an irregular dispensation and (2) a regulation put forth forcing these pharmacies to carry out additional registers. The medications studied were stanozolol, nandrolone, methenolone, testosterone and mesterolone.

RESULTS

The pre-intervention use of AAS displayed a rising trend. There was an immediate reduction of 30.56% after the first intervention, and a further reduction of 35.25% after the second. There was a seasonal pattern of use in the pre-intervention period, pointing to an increased demand at the end of spring and beginning of summer. The most abused drugs were stanozolol and nandrolone.

CONCLUSION

The health actions were very effective, in that they brought about a sharp reduction in the illicit use of AAS. These interventions could be applied to other drugs in which abuse were detected.

HEALTH INITIATIVES IN NATIONAL PAN-AMERICAN SWIMMING FEDERATIONS

ABSTRACT Introduction: National Swimming Federations (NFs) supervise a large number of athletes and have the duty to protect their health that implies also the opportunity to improve public health. Objective: 1) To determine if the health professionals, the priorities, activities, and researches of the Pan-American NFs are focused on protecting athletes’ health and promoting the health of the population in general. 2) To determine if the FINA rules, projects and programs are applied. Method: A cross-sectional descriptive survey was carried out among the 45 Pan-American NFs requesting information on the profile of the health professionals (dimension 1; D1), on programs, activities and research to promote health measures (dimension 2; D2), and on the importance of Pan-American NFs for the health of athletes and for the promotion of health in society in general (dimension 3; D3). We performed a similarity study according to the Rogers-Tanimoto coefficient (D1 and D2) and the chi-squared test (χ²) (D3). Results: Thirty NFs answered the survey (response rate: 66.6%). For each dimension, the NFs were classified into five groups (A, B, C, D, E). Among the NFs, 33.3% have physicians and 33.3% have physical therapists. In each of the dimensions, Group A accounted for the majority of NFs but their results were lower. The groups with the highest rates in each dimension contained a maximum of two NFs. The health of the elite athletes was ranked as the fourth most important issue. The health of the recreational athletes and the health of the general population had the lowest priority. Drowning prevention programs were the most common. Conclusions: Pan-American NFs have few medical resources and only a few have injury prevention programs for elite athletes. There is a need to improve health promotion programs to achieve relevant social outcomes.

Health promotion through sport: international sport federations’ priorities, actions and opportunities

Objective

To identify areas of priority and activity for international sportsfederations (IFs) with respect to athlete health and safety, and global health. Results serve to direct the work of the Association of Summer Olympic IF Medical and Scientific Consultative Group, the International Olympic Committee and to influence IFs’ planning and priorities.

Methods

The 28 IFs participating in the Summer Olympic Games (2016) were asked to rank the relative importance of 11 health-related topics and to report their activities or research initiatives on 27 identified topics using an electronic survey. A comparison with a similar survey (2012) was made.

Results

The response rate was 100%. In general, the ‘fight against doping’ had the highest priority followed by ‘image as a safe sport’. The topics with the lowest importance ratings were ‘increasing the number of elite athletes’, and ‘health of the general population’. Despite ranking ‘health of your athletes,’ as a top priority, IFs are not addressing all aspects of athlete health. In comparison with 2012, there was a significant decrease in priority for IFs is ‘health of the general population’.

Conclusion

Despite the widespread knowledge of the importance of the promotion of physical activity (sport) on global health, the decreasing priority and programming of the IFs on physical activity promotion is concerning. Although IFs have prioritised the protection of the health of elite athletes, there are gaps in programming demonstrating that IFs are missing important areas of athlete health. Improving recreational athlete health programming could also benefit population health as well as improve IF fan base and sport participation.

Research priorities of international sporting federations and the IOC research centres

BACKGROUND/AIM

To be fully effective, the prevention of injury in sport and promotion of athlete's health needs to be both targeted and underpinned by scientific evidence. This study aimed to identify the research priorities of International Sporting Federation (ISFs) compared to the current research focus of the International Olympic Committee Research Centres (IOC-RCs).

METHODS

Online survey of ISF Medical Chairpersons (n=22, 69% response) and IOC-RC Directors (n=7, 78% response). Open-ended responses relating to injury/illness priorities and specific athlete targets were thematically coded. Ratings were given of the need for different research types according to the Translating Research into Injury Prevention Practice (TRIPP) Framework stages. Results are presented as the frequency of ISFs and IOC-RCs separately.

RESULTS

Both ISFs and IOC-RFs prioritised research into concussion (27%, 72%, respectively), competitive overuse (23%, 43%) and youth (41%, 43%). The ISFs also ranked catastrophic injuries (14%), environmental factors (18%), elite athletes (18%) and Paralympic athletes (14%) as important. The IOC-RCs gave higher priority to preventing respiratory illness (43%), long-term health consequences of injury (43%) and recreational athletes (43%). There was a trend towards ISFs valuing TRIPP stage 5/6 research more highly and for the IOC-RCs to value TRIPP stage 1/2 research.

CONCLUSIONS

There are clear opportunities to better link the priorities and actions of the ISFs and IOC-RCs, to ensure more effective practice-policy-research partnerships for the benefit of all athletes. Setting a mutually-agreed research agenda will require further active engagement between researchers and broader ISF representatives.

Predictors of doping intentions, susceptibility, and behaviour of elite athletes: a meta-analytic review

Research in doping has focused on potential intervention strategies, increasingly targeting predicting factors. Yet, findings are inconsistent, mostly athlete-centred and explain only limited variances in behaviour. This critical review aims to (a) summarize studies that identified predictors of doping intentions, susceptibility, and behaviour in elite athletes and to (b) analyse in how far previous research included aspects beyond athlete-centred approaches, such as context and sporting culture. We reviewed 14 studies that focused on elite athletes. Situational temptation, attitudes, and subjective norms seem to be strong predicting variables of doping intentions (r ≥ 0.50), but intention was no predictor for behaviour. Attitudes were a significant predictor for both, doping susceptibility (r = 0.47) and behaviour (r = 0.30). Most of the predictors are athlete-centred and ignore macro-level factors that might help to explain how certain individual traits impact on the decision making process. The findings from this review call for a critical discussion of whether current doping-prevention research needs to take new directions. We propose future research to bridge findings of psychologists and sociologists, as it appears that doping behaviour cannot be explained by ignoring the one or the other. Impacts of sporting culture that have been identified in qualitative approaches need to be integrated in future quantitative approaches to test for its external validity. Inclusion of both, micro- and macro level factors may enable an integrative prevention program that creates a sporting culture without doping.

Injury and illness in aquatic sport: how high is the risk? A comparison of results from three FINA World Championships

BACKGROUND

Epidemiological information on injury/illness is required to develop effective injury prevention strategies.

AIM

To assess the frequency and characteristics of injuries/illnesses (1) in the 4 weeks prior to and (2) during the Fédération Internationale de Natation (FINA) World Championships 2015 compared with 2013 and 2009.

METHOD

(1) Athletes answered a retrospective questionnaire, and (2) the medical staff reported injuries/illnesses prospectively during the championships.

RESULTS

(1) A quarter of responding athletes reported symptoms in the 4 weeks prior to the championships. More than half of all affected athletes presented with substantial severity, 80% took medication, 70% had overuse injuries and 30% did not modify their training regime despite symptoms. At the start of the championships, 70% of affected participants were still symptomatic. (2) During the championships, injury and illness incidence was 12.9 per 100 athletes. The most common injuries were shoulder sprains (5.7%) and muscle cramps of the lower back (5.7%). The most common illnesses were infections of the respiratory (33.9%) and gastrointestinal tract (23.5%). Risk factors included discipline and age, but not gender. Incidence was highest in athletes competing in high diving (HD), water polo (WP) and diving (DIV) for injuries, and WP and swimming (SW) for illnesses. The significantly higher incidence of injuries and illnesses at the FINA World Championships 2015 compared with 2013 and 2009 was most probably due to a similarly improved response rate of the medical staff.

CONCLUSIONS

In aquatic sports, surveillance and health promotion should focus on prevention of out-of-competition overuse injuries and athlete education.

Methodological quality of the injury surveillance system used in international athletics championships

OBJECTIVES

Incidence and prevalence data obtained from injury surveillance studies could be biased by the response rate as well as by the completeness and quality of the reports. It therefore appears crucial to analyse the quality of the injury surveillance system itself and thereby validate the quality of the data. This study aimed to analyse the quality of and compliance with the injury surveillance system implemented during international athletics championships.

DESIGN

Prospective, epidemiological study.

METHODS

The national medical teams and the local organising committee physicians daily reported all injuries on a standardised injury report form during 14 international athletics championships from 2007 to 2015. The quality of the injury surveillance system was analysed following the guidelines laid down by the Centre for Disease Control and Prevention.

RESULTS

On average 41.7±17.4% (mean±standard deviation) of all registered countries participated in the injury surveillance project, accounting for a coverage of athletes of 79.5±10.2% of all registered athletes. Their medical staff returned 89.2±8.4% of the expected injury report forms (information is missing for one championship). The completeness of injury data provided by medical teams and local organising committee physicians averaged 95.8±6.5%. National medical teams reported 60.6±16.6% of all injuries, and local organising committee physicians 28.7±15.0% whereas 10.6±6.5% of injuries were reported by both.

CONCLUSIONS

The injury surveillance system used during international athletics championships provided good national medical team participation, coverage of athletes, response rate, and completeness of reports. These parameters should be systematically reported for injury surveillance studies to show the quality of the study.

Cricket fast bowling workload patterns as risk factors for tendon, muscle, bone and joint injuries

OBJECTIVE

To assess workload-related risk factors for injuries to particular tissue types in cricket fast bowlers.

DESIGN

235 fast bowlers who bowled in 14600 player innings over a period of 15 years were followed in a prospective cohort risk factor study to compare overs bowled in each match (including preceding workload patterns) and injury risk in the 3-4 weeks subsequent to the match. Injuries were categorised according to the affected tissue type as either: bone stress, tendon injuries, muscle strain or joint injuries. Workload risk factors were examined using binomial logistic regression multivariate analysis, with a forward stepwise procedure requiring a significance of <0.05.

RESULTS

High acute match workload and high previous season workload were risk factors for tendon injuries, but high medium term (3-month workload) was protective. For bone stress injuries, high medium term workload and low career workload were risk factors. For joint injuries, high previous season and career workload were risk factors. There was little relationship between muscle injury and workload although high previous season workload was slightly protective.

CONCLUSIONS

The level of injury risk for some tissue types varies in response to preceding fast bowling workload, with tendon injuries most affected by workload patterns. Workload planning may need to be individualised, depending on individual susceptibility to various injury types. This study supports the theory that tendons are at lowest risk with consistent workloads and susceptible to injury with sudden upgrades in workload. Gradual upgrades are recommended, particularly at the start of a bowler's career to reduce the risk of bone stress injury.

Oral health of elite athletes and association with performance: a systematic review

Background

We aimed to systematically review the epidemiology of oral disease and trauma in the elite athlete population and to investigate the impact of oral health on sporting performance.

Methods

Authors searched Ovid MEDLINE (1950 to October 2013), Ovid EMBASE (1980 to October 2013), EBSCO SPORTDiscus (up to October 2013) and OpenGrey (http://www.opengrey.eu). No date or language restrictions were applied. Papers were included if they evaluated the oral health of professional athletes. The methodological quality of papers was evaluated using a modification of the Newcastle-Ottawa scale.

Results

The literature search led to 9858 potentially relevant citations. Following a set of predefined exclusion criteria, 34 studies remained. Twenty-six studies reported on dental trauma, which ranged in prevalence from 14% to 47% varying by sport and country. Sixteen studies considered the oral health of athletes and reported high prevalence of oral diseases: dental caries 15–75%, dental erosion 36–85%, periodontal disease 15%. In four studies, a range between 5% and 18% of athletes reported negative impact of oral health or trauma on performance. The methodological quality of included studies was generally low.

Conclusions

Within the limits of the review, oral health of athletes is poor. We hypothesise that poor oral health associates with self-reported performance; however, this needs to be tested. Further studies on representative samples of athletes are needed to assess the size of the problem of poor oral health as well as to investigate the possible impact on performance using objective measures of performance.