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Risky opinions

29 Jul, 15 | by Sheree Bekker

“If you are a parent, you know that kids love to keep making circles” ~ Takaharu Tezuka

This charming Ted Talk from architect Takaharu Tezuka captured my imagination. It beautifully illustrates how architecture can positively influence physical activity levels – and we all have heard that sitting is the new smoking – however, I could not help but notice the take-away message that we are left with:

“My point is don’t control them, don’t protect them too much, and they need to tumble sometimes. They need to get some injury. And that makes them learn how to live in this world. I think architecture is capable of changing this world, and people’s lives. And this is one of the attempts to change the lives of children”

So, can child injury prevention include healthy risk promotion? A special feature in Injury Prevention explored this very question. This piece takes the reader on an interesting journey from the developmental benefits of risky play (via parenting and societal perceptions of risk, playground safety standards and children’s play space design, bubble-wrapped recreation, the public policy perspective, risk-benefit assessment, the state of the evidence) through towards calling for a culture of reasonableness: 

“The challenge is to broaden the focus and commit to a child-centric approach—one that includes not only the mitigation of injury but also optimal child development, which necessitates exposure to competence-appropriate risky play in a hazard-free play space”

This has been an ongoing conversation (as hinted at in the Ted Talk): Are our school playgrounds being wrapped in cotton wool?

Of course, there are varying stances on risk within the injury prevention world. Recently, Barry Pless posted his own opinion right here on the Injury Prevention blog in The Safety Hysteric Speaks Again, stating that:

“In some circles I am regarded as an injury prevention fascist, safety hysteric, protect the children fanatic, a wuss, or worse. This has come about because I consistently push for more prevention and less risk taking. I am not at all convinced that risk-taking is good for child development, as some would have us believe. Nor am I convinced that having a serious injury with possible life-long (if not life-threatening) consequences builds character, or whatever”

It seems that this topic is a can of worms, and one which many researchers are (rightly?) wary of engaging in outside of carefully crafted research papers. Our opinions are carefully kept out of the public eye – however social media is rapidly has changed this. A large element of the advocacy that I wrote about last week applies here: why allow others to own the conversation that we, as injury prevention researchers, have all the tools to constructively address?

Our opinions can, and should, be fluid and in flux – and certainly differing too – this is the very nature of advancing our life’s work. Fostering an open and ongoing conversation remains necessary to that very nature of our work, and is one which I believe we should all be partaking in more often.

So, any thoughts?


A walking aid can be a sign of an active senior

26 Jul, 15 | by Klara Johansson

I recently got back from vacation with some of my extended family, a really cool group of people between the ages of two and 92. At age 92, my grandmother still goes for long walks every day (that’s her in the picture below, in the pink jacket, with my mom and brother).

promenad o digitalis edit

Prevention of injury and promotion of physical activity are two issues that can have mutual benefits but can also appear to be in conflict, as has been discussed in recent blog posts about sports safety. Nowhere does this seem more complex to me than the elderly population. Old age is often accompanied by reduced balance and brittle bones, increasing the risk – and the fear – of falls and fractures. Physical activity thus becomes more of a hassle and a hazard. But of course – physical activity also contributes to maintained bone density, even at moderate levels of physical activity (and can improve balance and muscle strength). In addition, there are of course numerous other health benefits to physical activity, including positive effects on mental health and cognitive ability. Regular exercise is recommended as a component of falls prevention in elderly. The authors of a meta-review note that walking seems to be the least efficient part of those programs, but that walking at a moderate pace (avoiding fast walking) still is valuable both as a component of falls prevention and for other health issues, as long as the walking can be done in a safe way.

This is not my area of expertise, but I’m interested because of Gran’s story. I have her permission to share this story and the photos – she says she is happy to share, if it can help others. If any of you readers are working in this field, please comment and let me know if I have missed or misunderstood anything important about this issue!

My Gran is very healthy for a 92-year old, and moves around with ease and a straight back. But three years ago, she had heart surgery. For a long time before the surgery, she had spells of fainting in public, something she remembers vividly. Once, she fell off the stairs of the bus and onto the sidewalk. (Thankfully with no serious injury, which she attributes to her habit of doing Chi Gong every morning, but that’s another story.) Despite this, she had been reluctant to start using walking aids, since she didn’t actually have any walking difficulties and didn’t want to seem more infirm than she was. (I haven’t found any research on this, but by experience I would think this is a common attitude. If you know of any research, please let us know!)

After surgery, she was at first weak-kneed and still afraid of losing her balance, but was encouraged by doctors to engage in regular physical activity. Feeling that she owed them to do her best, since they had chanced a heart surgery on an 89-year old, she accepted the walker-rollator*, the most common walking aid in Sweden, for using on walks (in addition to engaging in other, scheduled exercise activities). She has never regretted that decision, and is very fond of her walking aid, and the freedom and safety it gives her.


Gran and her rollator now go for long walks every day. She has learned to walk with a straight back also with the rollator – placing both hands on the handles, which are adjusted to her height. She even gets compliments from strangers on how beautifully straight-backed she walks with the rollator. She is no longer afraid of falling, and has a high confidence in her own walking fitness and independence. She insists on her daily walks, feeling that if she fails them, her health will suffer.

Gran’s rollator, as most Swedish rollators, has four wheels, hand brakes, a basket at the front lower end and a little “bench” to sit on.

On the little basket she can carry home the groceries – or bring an extra jacket for herself or for a grandchild. When she gets tired, she finds a spot off to the side, applies the brakes and sits on the bench for a while. Thus, she also decreases the risk of falling from fatigue. At home, she walks with one of her best friends, at least one hour per day, and when they get tired, they sit down on their rollators and talk over a cup of coffee – which they bring in a thermos in the rollator’s basket. During vacation, she walks alone or with children, grandchildren and great-grandchildren. For Gran, the rollator is her enabler of these walks, and she praises the benefits of the rollator and encourages others in her situation to start using one.

A walking aid is often seen as a sign of age or infirmity. But a study shows that for people over 75, walking with a rollator can be considered moderate to high intensity physical activity, enough to improve aerobic fitness. Thus, I see the walker-rollator as a sign of an active – and safe – senior.


* I was unsure what the correct term in English is, but after a quick scan of the Internet I think a walker-rollator is the best term for the four-wheel walker.

All photos are taken by me, and published with permission of family members who are in the photos.

A potential “home run” for Little League Elbow Prevention? Check!

22 Jul, 15 | by dbui


Major League Baseball season is now in full swing. As an Australian, I was only properly introduced to Baseball earlier this year on my medical elective, and I’ve quickly come to love “America’s Game”. But of course the major league players of today didn’t get there overnight, they’ve thrown thousands of pitches, spent hours in batting cages and years of their youth at training.

Its this repetitive training that becomes an issue, particularly in the paediatric population. This has become such a problem that terms such as Little League Elbow, have been coined in the medical literature, to refer to elbow problems related to the stress of repetitive throwing.

Known risk factors for injury include pitch count and biomechanics (Fleising and Andrews, 2012; Olsen et al, 2006). Specific parameters include throwing more than 80 pitches per appearance ( 3.85-fold increase), pitching for more than 8 months per year (5.05-fold increase), pitching in more than 100 competition innings in a calender year (3.5-fold increase) and worryingly, throwing frequently when arm was fatigued (36.18-fold increase).  Poor technique aka biomechanics is due to a number of social factors including less mastery by individuals and competitive pressure, and is exacerbated by more compliant connective tissue, open growth plates, and underdeveloped muscles in youth players.

As such, many Baseball organisations and Sports Physicians recommend prevention measures to prevent these injuries in developing players. These preventative guidelines for include restriction of the amount of pitching, avoiding pitching through fatigue or pain, and secondary prevention which includes education of coaches, parents and children to enable early diagnosis and management.

However, guidelines are only as good as their compliance, and studies have demonstrated that few coaches follow these guidelines regularly, with only 43% of US coaches correctly answering pitch count and rest periods and only 28% of Japanese coaches complying with similar regulations in Japan. Of course, a number of sociocultural factors are at play here, as these recommendations are often at odds with the competitive nature of sport. On a secondary level, whilst regular medical evaluation has been found to be effective in #injuryprevention in the big leagues, medical supervision is not available in the majority of non-professional, little league, youth baseball clubs. It is therefore difficult for these problems to be picked up early.

Researchers in Japan have come up with an interesting secondary prevention idea, seen in the 2015 Orthopaedic Journal of Sports Medicine (Yukutake et al. 2015). Through multivariate analysis, they have come up with a 6-item checklist that screens for elbow injury in Little League (sensitivity, 0.717; specificity, 0.771). This simple idea is easy to implement, freely available and requires little-to-no medical expertise.

6-item scale (Yukutake et al. 2015)

criteria 6 point

Importantly, they have designed this screening tool so that it can be easily used by parents, a powerful tool in paediatric injury prevention. “When parents are aware their child is at risk for elbow injury, they can monitor pitch counts themselves and encourage coaches to apply the limits for strictly”. They can also arrange for earlier medical intervention if needed.

It got me thinking; could this type of validated screening become commonplace in other sports?

The end result may be healthier junior players, earlier intervention, prolongation of their playing careers and ultimately, a healthier society. Sounds like a win-win-win to me!

Let us know your thoughts below, or on twitter! @IP_BMJ or @David_Bui_

On sharks and media advocacy

22 Jul, 15 | by Sheree Bekker

This week saw some of the most dramatic footage yet of a near-miss ‘shark attack’ on a surfer. Interestingly, this incident will be picked up on – not only by marine biologists and conservationists – but by sports injury prevention researchers too. It can easily be re-framed as a near-miss, potentially catastrophic injury in a sporting contest.

As with all such dramatic events, this incident generated sensationalist media headlines. Whilst this can shine a much-needed spotlight on injury issues that should be spoken about more openly, such as domestic violence, it can also be a significant barrier to public education about prevention. Sensationalism does not usually tally with rational scientific evidence.

I recently attended a presentation where this same problem was discussed in relation to concussion: 

This clearly dovetails with the issue of language used around such incidents. Some marine biologists and conservationists take issue with the phrase ‘shark attack’, preferring to name such incidents ‘unintentional human-shark interactions’ – in much the same way as many injury prevention researchers take issue with the word ‘accident’ and prefer to use the term ‘unintentional incident’ (see: How members of the public interpret the word accident‘It was a freak accident’: an analysis of the labelling of injury events in the US press, and BMJ bans “accidents”).

To what extent can and should we, as injury prevention researchers, harness the potential of the media to advocate for correct use of language around injuries, and ultimately influence attitudes, perceptions and behaviours?

I recently re-tweeted this excellent take from Ross Tucker:

  1. Scientists need to take more ownership of the wider communication and translation of knowledge. Otherwise they are only doing half their job.
  2. This means they must pay attention, and work on, understanding how people want to receive complex messages, and learn how to deliver them.
  3. It’s difficult only because research is often not purpose-driven enough, with a clear need. Communicating without relevance is impossible.
  4. Why hope that your life’s work will make a broader impact thanks to someone else (assuming you want this), when you can own it yourself?
  5. Failing to do this leaves doors open for misrepresentation of science.
  6. That said, we aren’t marketers or salespeople. Balance between accuracy and appeal is tricky. Being relevant does not trump being right.
  7. Find even one way to make our work understandable or ‘sticky’. You won’t be selling your soul, you’ll just expand your influence.

It certainly is better to be looked over, than overlooked.

If you are texting you are not driving

20 Jul, 15 | by jsantaella

Texting while driving is ... (f/13, 1/50 sec, 48mm)

There is increasing concern about the risk associated with distracted driving
 and more specifically with the manipulation of cell/smartphones while driving. Adolescents are a population at high risk given that approximately 50% of youth age 16 and older (U.S. data) admits texting/e-mailing while driving in the past-month.

A recent study by Klauer et al., Distracted Driving and Risk of Road Crashes among Novice and Experienced Drivers, shows how performing secondary tasks while driving increases the risk of crashing. Particularly among novice adolescent drivers (aged 16), the odds of crashing or nearly crashing greatly increased if drivers were sending or receiving text messages, reaching for a cell phone or dialing a cell phone (four, seven and eightfold risk increments, respectively). Other secondary tasks, such as reaching for another object other than cell phone, looking at roadside object and eating, were also associated with greater risk of crashing. The authors also found that, among novice adolescent drivers, the proportion of distracted driving tasks increased over time, suggesting that as drivers become confident in their driving they may relax their attitudes towards multitasking.

Reducing the prevalence of distracted driving surely requires a continuous effort from multiple organizations but also the engagement of active community members. In this regard, the U.S. department of transportation in April 2015 launched the National Driving Awareness Month, an initiative aiming at increasing awareness and promoting stronger regulations and enforcement programs. This effort also incorporated a specific component targeting adolescents that provided videos and reports on the risk associated with texting and driving, stories of teens involved in texting and driving events, tips to reduce the risk, and information on the changes in state regulations.

State texting laws targeting teens have been previously associated with an 11% decrease in traffic fatalities among adolescents. It is expected that the new efforts targeting multiple components will also translate in an important shift towards reduction in the acceptability of multitasking while driving, and in consequence on the prevalence of this behavior and the rate of injuries related to it.

*Helpful comments from Andres Villaveces

A Gap in Gun Violence Injury Prevention Data in the United States

17 Jul, 15 | by aelkhatib

Do guns make people safer? Do comprehensive back ground checks limit gun violence in the United States? Which gun violence or firearm safety interventions work in our states? What effect do right-to-carry laws have on our communities?

Nine years ago, the Centers for Disease Control and Prevention (CDC) was on the forefront of trying to answer these questions to make meaningful changes and enact policies to prevent injury related to firearms and gun violence.

Last month, the United States House of Representatives Appropriations Committee voted to reject amendment (19-32) from Congresswoman Nita Lowey that would have allowed the CDC to study whether there was an association between firearm ownership and gun violence.  This isn’t something new. This ban has been enacted since 1996, when the National Rifle Association (NRA) accused the CDC of lobbying gun control. The NRA then helped a Representative to lobby Congress to cut funding from the CDC budget in the exact amount it had dedicated to gun violence and firearm safety research the previous year ($2.6 million).

Although the funding was eventually restored (although continually decreased), research as to the effect of firearm safety and gun violence on public health has essentially been eliminated. Researchers are discouraged from specializing in firearm safety or gun violence due to the fact there isn’t enough funding to support research.

Databases, such as the National Violent Death Reporting System (NVDRS), record the causes of all violent deaths; including firearm-related injury and death. However, there are some limitations: this data is voluntarily reported by only 32 states within the United States; incidents which contained missing data elements (i.e. – lacking information on demographics, weapon type, or circumstances regarding the incident) are omitted from the database; and only incidents which have been reported to the police are reflected in this database.

Needless to say, there is a general lack of data and information regarding injury prevention from firearms and gun violence in the United States. Unfortunately, I don’t have an answer, but I thought I might reflect on this.

Feel free to share your comments!

BokSmart: 5 questions with Dr James Brown

15 Jul, 15 | by Sheree Bekker

Untitled Haiku Deck2

A study in the June 2015, Volume 21, Issue 3 of Injury Prevention, The BokSmart intervention programme is associated with improvements in injury prevention behaviours of rugby union players: an ecological cross-sectional study comes to us from researchers based in South Africa. This research assessed whether player behaviour improved since the launch of the BokSmart nationwide injury prevention programme for rugby union.

One of the authors on this paper, Dr James Brown, kindly agreed to answer a few questions on this work for this blog post. James is a Post-Doctoral Fellow for BokSmart and the Chris Burger Petro Jackson Players’ Fund at the Division of Exercise Science and Sports Medicine, University of Cape Town.

1) Tell us about BokSmart. What is it and why is it important?

BokSmart is a nationwide injury prevention program for rugby in South Africa. It is based on the successful New Zealand program, RugbySmart, and is a joint initiative of the national rugby federation of South Africa – the South African Rugby Union (SARU) – and the Chris Burger Petro Jackson Players’ Fund. Mainly through extensive coach and referee education, the program attempts to reduce all injuries, but specifically catastrophic (permanently disabling) injuries in players. Preventing injuries is particularly important in rugby as it is a collision sport with a higher risk of injury than most other sports and because it is particularly popular in South Africa with an estimated 400-500,000 players.

2) I know that you are active on Twitter (follow James @jamesbrown06), so what is the main message of this research in 140 characters or less?

Injury-preventing behaviours of rugby players have improved since the launch of the @BokSmart nationwide injury prevention program in South Africa in 2008

3) What are the implications of the findings of this study for readers of Injury Prevention?

The success of any intervention is reliant, in part, on the intervention’s ability to influence the behaviour of the intervention target. Thus, it was important to the BokSmart implementers to assess if there was a change in player injury-preventing behaviour. While we could not exclude other potential influences on these players’ behaviour in this ecological study, it is a positive sign that most of the behaviours improved in this five year period, particularly the behaviours that were targeted by the intervention’s implementers.

4) This research focuses on player behaviour, why is this an important component of an injury prevention programme?

Besides what is mentioned above, this study was also an important comparison to New Zealand’s evaluation of RugbySmart, as BokSmart used a very similar questionnaire to assess their players’ behaviours.

5) Tell us more about Rugby Science 

Starting the website was an attempt to deliver some of the plethora of useful, practical scientific research that exists in rugby to the end-user. A colleague, Dr Sharief Hendricks, and I were involved in rugby at both a research and practical level as coaches/players a couple of years ago. We both had experiences a number of coaches, parents and players who asked us questions that had already been answered in the form of scientific publications. From research that Dr Hendricks had conducted, it was obvious that it would be unlikely that coaches would read any scientific publication, so we hoped this might bridge that gap.

James and I would be happy to keep this conversation going either on the comments of this blog, or over on Twitter. Feel free to contact him directly via these Rugby Science contact details.

Thank you for your insight James!

Athletic Injury Rates during Ramadan

10 Jul, 15 | by aelkhatib

Ramadan began on June 18th and will likely end on July 19 this year. For those who don’t know, Ramadan is the ninth month of the Islamic lunar calendar. Muslims believe this month to be when the first verse of the Quran was revealed to the Prophet Muhammad. As an act of devotion and self-control, Muslims intermittently fast from eating, drinking, smoking, and sexual relations between sunrise and sunset.

In 2012, the Summer Olympics in London overlapped with the month of Ramadan. Last year, the 2014 FIFA World Cup in Brazil overlapped with Ramadan for the first time 1986. This year, Ramadan overlaps with three major soccer tournaments: the 2015 FIFA Women’s World Cup in Canada, Copa America in Chile, and CONCACAF Gold Cup in North America. For many Muslim athletes, such as Mesut Ozil, Karim Benzema, and Paul Pogba, this poses a challenge for training and competition.

It is suggested that Muslim athletes may be at greater risk of physical injury while fasting during the month of Ramadan due to: hypohydration, increased perception of fatigue, glycogen depletion, altered carbohydrate intake, and sleep phase shift.

There is not much data about injury rates in Muslim athletes during the month of Ramadan. Though, a pilot study, which investigated the injury rate of a Tunisian, professional soccer team over two competitive seasons, found no significant difference between the general rate of injury between fasting and non-fasting players. However, there was a significant increase of non-contact and overuse injury rates for fasting players during Ramadan. (Injury rate was calculated as the ratio of the number of injuries per hour of exposure and expressed as the rate per 1000 hours). During these two competitive seasons, the non-contact and overuse injuries among fasting players included: muscle spasms/contractures, muscle strains, and tendinosis.

Another study, which investigated the injury risk of 527 professional soccer players in Qatar, observed no significant difference of incidence in total, match, or training injuries during Ramadan or non-Ramadan periods. However, there was an increased incidence of match injury observed in non-fasting players; this difference was maintained for 2 months following the month of Ramadan.

Despite what one might intuit, previous research indicates that elite or professional athletes are sufficiently able to maintain athletic performance and cognitive function during Ramadan – if their training schedule, nutrient intake, hydration intake, and sleep patterns are appropriately managed.

With this in mind, it is highly recommended for coaches, athletic trainers, sports dietitians, and other team managers to be involved in the management of their fasting athletes. Training schedules, cultural background, and fitness level of players should be taken into consideration when determining interventions to reduce the risk of injury related to fasting-induced fatigue, nutrition, and hydration.


P.S . — Ramadan Kareem!

Data viz: adolescent injury and mental health

10 Jul, 15 | by Klara Johansson

I’m addicted to interactive visualisations of data, when they are well-made, informative and easy to use. One that I’ve returned to repeatedly is the “GBD 2010 Heat Map“, which ranks causes of deaths and DALY’s globally. The graph is based on the Global Burden of Diseases, Injuries and Risk factors Study, an impressive project that aspires to quantify mortality and morbidity globally. (Needless to say, the uncertainty intervals are wider for countries lacking comprehensive mortality registration… but it is especially for those settings that this project is invaluable!)
It’s a quite simple graph, but the beauty lies in how easy it is to shift between the measures, groups and countries/regions you are interested in. NB: The picture below is just a static image showing only the age groups I selected for this blog post, go to the live graph to explore other options than those shown here.

One thing that stands out very clearly in this graph is something we are already aware of: that injury prevention is an urgent issue among adolescents and young adults. Of the top ten causes of death worldwide in the ages 15-19 and ages 20-24, injuries rank as first (road injuries), second (self-inflicted), third (violence), fifth/ninth (drowning) and ninth/tenth (burns).

If we would change* the measure shown to YLD – years lived with disability – the main cause of morbidity for those aged 15-24 is depression; other mental health problems such as anxiety, conduct disorder and substance abuse are also among the top ten (see the graphs for ages 15-19 and ages 20-24 ).
These two issues – injuries and mental health – are not unrelated. Of course, mental health problems are strongly related to suicide and self-harm. But a recent article in Injury Prevention by McDonald, Sommers & Fargo also highlights the complex interrelations between mental health problems and risky driving, a complexity that seems particularly prominent among adolescents and young adults compared to adults. The article is based on a sample of youth and adults who are high-risk drivers, and shows, for the younger group, several significant pathways from depression and conduct behavior to various aspect of risky driving. (Similar results have been demonstrated earlier for example by our own Bridie Scott-Parker, a short report here in Injury prevention, and a path analysis in British Journal of Psychology.)
Thus, to some extent, mental health promotion and injury prevention need to go hand in hand, maybe especially among adolescents.


* In the live graph, select the measure you want by using controls in the top panel. Here you can also select age groups, male/female/total and countries/regions. Selecting regions can be a bit tricky, which I find to be the main drawback of this graph.

Firearms in the house and risk of suicide

8 Jul, 15 | by jsantaella

Suicide is an important form of external-cause mortality. The World Health Organization estimates that every 40 seconds a person commits suicide in the world. Given that a high proportion of suicides happen impulsively it makes sense that limiting the easy access to lethal means of suicide, such as firearms, during the suicidal crisis, could help to reduce the occurrence of suicides.

The recent work of Barber and Miller – Reducing a Suicidal Person’s Access to Lethal Means of Suicide -
A Research Agenda, provides an interesting review of studies with evidence supporting the link between firearm ownership and suicide risk. This is a particularly important area of research in the U.S. given the fact that most suicides are committed using firearms, firearms are one of the most lethal methods, and also because firearms are highly accessible and cognitively acceptable in U.S. culture. In their review, the authors provide evidence from different individual and ecological studies that consistently show an association between firearm ownership and higher risk of dying by suicide. The authors also present evidence from studies showing that among firearm households there is lower risk of suicides when firearms are stored unloaded, locked, and separately from ammunition. In addition, the review shows information from studies suggesting that personal factors, that could influence both the likelihood of buying a firearm and of committing suicide, are not likely to be explaining the firearms-suicide risk connection, given that people living in homes with firearms are no more likely to screen positive for psychopathology or suicidal ideation, or to report suicide attempts, than those living in homes without firearms.

Given the evidence, it is possible that alternative solutions may be effective. For example, raising awareness about the increased risk of suicide when there is a firearm in the home is key especially during critical times. Simultaneously providing information on available services (e.g. counseling available through hotlines or apps in mobile phones) may be effective, at least in part, in counteracting the current U.S. scenario in which approximately 19,000 individuals commit suicide using firearms every year.

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