Article Text

Original research
Epidemiology of adverse events related to sports among community people: a scoping review
  1. Akihiro Hirata1,2,
  2. Yoshinobu Saito3,4,
  3. Manabu Nakamura2,
  4. Yasuaki Muramatsu2,
  5. Kento Tabira2,
  6. Kanako Kikuchi2,
  7. Tomoki Manabe2,
  8. Kentaro Oka2,
  9. Mizuki Sato2,
  10. Yuko Oguma2,5
  1. 1 Research Fellow, Japan Society for the Promotion of Science, Chiyoda-ku, Tokyo, Japan
  2. 2 Graduate School of Health Management, Keio University, Fujisawa, Kanagawa, Japan
  3. 3 Faculty of Sport Management, Nippon Sport Science University, Yokohama, Tokyo, Japan
  4. 4 Graduate School of Physical Education, Health and Sport Studies, Nippon Sport Science University, Yokohama, Kanagawa, Japan
  5. 5 Sports Medicine Research Center, Keio University, Yokohama, Kanagawa, Japan
  1. Correspondence to Dr Yuko Oguma; yoguma{at}keio.jp

Abstract

Objectives Numerous reports have described injuries and illnesses in competitive athletes, but studies on leisure-time physical activity and associated adverse events in the general population have not been adequately reviewed. This study aimed to summarise the previous findings on this topic.

Design Scoping review.

Data sources PubMed and Ichushi-Web for articles in English and Japanese, respectively (13 April 2023).

Eligibility criteria for selecting studies Articles on adverse events related to sports performed by ‘individuals and groups active in the community’ were included, whereas those on elite athletes, exercise therapy and rehabilitation, and school sports were excluded. Terms related to physical activity, exercise, sports and adverse events were used for the search strategies.

Results The literature search yielded 67 eligible articles. Most articles were from the USA, Japan and Australia. Running, scuba diving, rugby and soccer were the most commonly reported sports. Adults were the most common age category in the samples. The most commonly reported adverse events were injuries; only 10 articles reported diseases. 13 longitudinal studies reported the frequency of adverse events based on the number of events/participants×exposure.

Conclusion Adverse events such as sports trauma, disability and certain diseases occur sometimes during sporting activities by residents; however, the articles identified in this review showed biases related to the countries and regions where they were published and the sports disciplines and types of adverse events reported, and articles reporting the frequency of adverse events were also limited. This highlights the need for more high-quality observational studies on diverse populations in the future.

  • SPORTS MEDICINE
  • PUBLIC HEALTH
  • Safety
  • EPIDEMIOLOGY

Data availability statement

No data are available.

http://creativecommons.org/licenses/by-nc/4.0/

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The search strategy was developed in consultation with librarians at the Shinanomachi Media Center, Keio University Libraries.

  • It focuses on the sports activities that individuals in the general population engage in and is also unique in that it is an overarching survey that does not limit the type of sport or adverse events.

  • We used only two databases; therefore, it is possible that some relevant papers were missed.

  • Due to the nature of scoping reviews, it was not possible to evaluate the quality of the individual articles.

Introduction

The WHO defines physical activity as any bodily movement that is produced using skeletal muscles and requires energy expenditure.1 Physical activity has a variety of health benefits, and physical activity promotion efforts are, therefore, being promoted by several governments.2 Physical activity broadly includes occupational, transportation-related and domestic activities, as well as leisure activities, which comprise exercise, sports and unstructured recreation. According to the WHO Global Action Plan on Physical Activity 2018–2030, leisure-time physical activity (LTPA) includes walking, cycling, sports and recreational activities such as dance, yoga and tai chi.2

Nevertheless, notwithstanding their undeniable advantages, adverse events such as sports-related injuries and illnesses and even sudden death have been reported with participation in these activities. The actual occurrence of adverse events has even been systematically organised for competitive sports for athletes and exercise therapy for the sick, and there have been many studies on sports injuries and illnesses in international competitions, including the Olympic and Paralympic Games.3 4 Systematic reviews focusing on specific sports such as soccer5 and basketball,6 major sports injuries such as ankle sprains7 and concussions,8 and adverse events during exercise therapy for patients recovering from various illnesses have also been conducted.9

However, reports on such adverse events during regular sporting activities by individuals in the general population are much more limited. Particularly in Japan, where the rate of ageing is increasing faster than in other countries,10 promoting physical activity in a safe and secure manner is becoming more and more important. The sports practised by residents are diverse, and the complete picture of the adverse events related to these activities is unclear. Currently, many developed countries have an ageing population and will face the same demographic challenges as Japan. It would, therefore, be helpful to understand the situation in Japan for every country, which has a highly ageing population compared with other countries. Therefore, it is necessary to understand the currently available evidence and identify the gaps in the literature.

Accordingly, this study aimed to provide a scoping review of epidemiological papers on adverse events associated with LTPA practised by residents to organise previous findings in an exploratory manner, understand the current scenario in this context and identify potential avenues for future research.

Methods

For the purpose of this scoping review of the literature on adverse events occurring during sporting activities by residents, sports were defined as LTPA including walking, cycling and recreation. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysesextension for Scoping Reviews statement (PRISMA-ScR).11

Search strategy and study identification

The search strategy was developed in consultation with librarians at the Shinanomachi Media Center, Keio University Libraries (January–March 2023). One researcher (AH) searched the database on 13 April, 2023. As this review was conducted in an exploratory manner, two major databases with articles on adverse events related to sports activities by residents were used—PubMed for the English-language literature search and Ichushi-Web for the Japanese-language literature search. The database-specific search strategies and the number of papers identified are listed in online supplemental table 1.

Supplemental material

The search results were exported to Microsoft Excel and checked for duplicates. As the primary screening, titles and abstracts were reviewed to exclude papers that did not meet the acceptance criteria of this study (AH). As the secondary screening, pairs of researchers (from MN, YM, KT, KK, TM, KO and MS) reviewed the full text of the selected papers. In case of any disagreement between two researchers regarding whether or not to include an article, a third researcher (YO and YS) reviewed the full text. The number of inclusions and exclusions at each screening stage is presented in figure 1. The reasons for exclusion were cited only during the full-text screening stage. After each stage, the reviewers resolved any conflicts through discussion, and progress to the next screening stage was made only after 100% agreement was reached. The same process was applied during the data extraction stage.

Figure 1

Study selection flow chart.

Inclusion criteria

The PCC (P: population or participants, C: concept, C: context) framework12 was used for defining the inclusion criteria for this study. ‘Residents’ defined as ‘individuals living or working in the community’ were designated as the ‘participants’, and professional athletes and similar elite athletes were therefore excluded. The ‘concept’ was sports-related adverse events, defined as sports injuries, illnesses, deaths or other accidents associated with any sport. ‘Context’ was defined as sporting activities that were voluntarily conducted by local communities, sports facilities or individuals. Articles on exercise therapy and rehabilitation for recovery from injury or disease, exercise interventions such as care prevention classes, competitive sports in schools and physical activities in the classroom were excluded.

Exclusion criteria

  1. Non-English/non-Japanese articles.

  2. Conference proceedings or abstracts.

  3. Case reports, review articles and commentaries.

  4. Systematic, scoping, narrative and umbrella reviews.

  5. Dissertations.

  6. Consensus statements.

Data extraction

The following data were extracted from the included papers and collated independently by researchers in a predetermined tabular format.

  1. Study description: authors, year of publication.

  2. Description of the included subjects: country, sample size, age, sex ratios and sports description.

  3. Study methods: study design, measurement methods.

  4. Outcome measures: nature of adverse events, major adverse events and frequency of occurrence (person/exposure: frequency calculated based on time and number of events).

These findings are presented as a narrative summary and were tabulated to discern the trends in the literature. Sample sizes were classified into five categories: 1–100, 101–1000, 1001–10 000, 10 001–100 000 and >100 001. Age was categorised based on representative values and ranges reported in individual papers as follows—children and adolescents: age 5–17 years, adults: age 18–64 years and older adults: age ≥65 years). Adverse events were categorised as injury, death, disease, cardiac arrest or accident. The quality (bias) and level of evidence of each study were not evaluated.

Patient and public involvement

None.

Results

The search strategy identified 4341 articles for consideration. These included three articles in English13–15 and two in Japanese16 17 related to this study that had been previously identified in a manual search. After screening the titles, abstracts and text, 67 articles were considered eligible for inclusion (online supplemental table 2).

Sample descriptors

The publication years ranged from 1982 to 2023, with most reports published in 2020 (8 articles), 2019 (6 articles), and 2010 and 2014 (5 articles each). Most reports were from the USA, Japan, Australia, the Netherlands and New Zealand (15, 12, 9, 5 and 4 articles, respectively). All three studies conducted in more than one region included the USA. Of the 12 studies conducted in Japan, 8 were included in the Japanese-language database and 4 were included in English-language database.18–21

The individual studies had a minimum sample size of 36 residents22 and a maximum sample size of 14 483 636 residents.16 Based on the sample size categories (1–100: 10 articles, 101–1000: 25 articles, 1001–10 000: 13 articles, 10 001–100 000: 3 articles and ≥100 001: 6 articles), the category with the most articles was the 101–1000 residents category. The sample size was not specified in 10 articles.15 23–31

The individual study samples covered a wide range of ages. Adults were the most common age category (n=46), followed by children and adolescents (n=22); the other articles covered multiple age categories. The age range of the sample was unknown in case of eight articles.16 26–28 30–33 Individuals with chronic illnesses or disabilities were not identified in the included articles. All the included study participants were male in six articles26 34–38 and female in four articles.17 39–41 The sex ratio was not reported in 16 articles.

In terms of sports disciplines in the individual study samples, 51 articles considered a single discipline and 16 considered multiple disciplines. The highest number of single-discipline reports were for running (seven articles), scuba diving (six articles), rugby and soccer (four articles each), surfing and netball (three articles each).

The study design in all articles was an observational study. 29 were retrospective studies that used existing adverse event reports or databases, 21 were prospective studies with follow-up of new adverse events and 17 were cross-sectional studies that investigated the prevalence and past experience of adverse events at a given point in time using questionnaires or other means. Outcomes were recorded by using questionnaires in 27 articles, adverse event report forms in 26 articles, existing databases in 9 articles, interviews in 3 articles and a combination of questionnaires and interviews in 2 articles.

Adverse events descriptors

In terms of the outcomes reported in individual studies, most articles reported injuries (55 articles), followed by death (12 articles), diseases (10 articles), cardiac arrest and accidents (1 article each). Nine articles reported on more than one outcome.

Injuries to the motor organs were the primary injury reported. Additionally, contusions, head trauma, wounds and concussions were also reported.

The sports in articles reporting deaths were cycling,42 skiing/snowboarding,43 diving (scuba diving, breath-hold diving and snorkelling25 27 44–46), rugby,26 mountaineering,31 wilderness recreation,47 multiple sports/recreation24 and aerosports (paragliding, hang-gliding and speed flying).48

50% of articles report a disease reported on barotrauma/decompression illness due to scuba diving.18 20 49–51 Heatstroke, stroke and heart failure during cycling,52 wilderness recreation,47 exercising in the gym16 17 and golf30 were the other diseases reported.

Frequency of adverse events

Of the 67 articles included in this review, 13 (9 prospective and 4 retrospective studies) reported the frequency of adverse events based on the number of occurrences/participants×exposures (online supplemental table 3).

The frequency of adverse events was indicated by 1000 person-hours in 4 articles papers,19 38 53 54 1000 person-days in 2 articles33 47 and 1000 person-exposures in 3 articles.36 55 56 Other articles reported the frequency of adverse events in terms of 1 000 000 person-days,43 1 person-year,20 100 person-exposures57 and 1000 person-exposures (ski runs).58 The sample subjects and sports events reported for 1000 person-hours were rugby for adults,38 rugby for children and adolescents,53 Australian football/field hockey/basketball/netball for adults,54 and soccer for children and adolescents.19

Discussion

This scoping review of observational studies analysed original articles reporting adverse events associated with any sport that residents engaged in. Articles were retrieved from English and Japanese databases to ascertain the current situation in various countries as well as in Japan.

Since 2000, several guidelines for documenting sports injuries have been published, that is, 2006 for soccer,59 2007 for rugby60 and 2008 for the International Olympic Committee.61 Our results show that the number of individual articles on the reviewed topic has been increasing since the 2010s. Moreover, of the 67 articles included in this review, 47 were published after 2010, indicating that there has been a considerable increase in interest in sports safety, as well as in sporting events conducted by residents, in the last two decades.

In terms of the countries and regions where the studies were conducted, most were conducted in the USA (15 articles), Japan (12 articles) and Australia (9 articles). In terms of study design, 29 were retrospective studies, 21 were prospective studies and 17 were cross-sectional studies. The outcome measures were most frequently reported in questionnaires (27 articles) and reports (26 articles). However, the influence of language barriers due to the setting of this study and the involvement of countries where contact sports with a high incidence of sports trauma, such as American football, Australian football, rugby and lacrosse, are often played seem important. Thus, the social and cultural context of each country with regard to sport should be considered in interpreting the study’s results.62

The sample sizes of the individual studies ranged from 36 to 14 483 636. The category with the largest number of reports was 101–1000 subjects (25 articles), and thus studies with relatively large sample sizes were incorporated. However, there were 10 articles in which the sample size was not specified and 16 in which the sex ratio was unknown, indicating that an accurate description of the target population in this research area remains an issue to be addressed. The target populations of the studies analysed in this study predominantly comprised adults <65 years, children or adolescent age groups. The risks related to sporting activities are expected to be higher in older adults than in younger adults. However, only two articles in this study included older adults aged 65 or more. The results of this study indicate that many existing reports in this research area are centred on the injury. Therefore, reports on adverse events triggered by medical disorders and falls that are expected to occur in older adults are needed.

The sports disciplines included in this review were mostly running, rugby and soccer. Running is the most popular high-intensity physical activity worldwide, and the WHO recommendation that people run more frequently may have influenced these results.2 In rugby and soccer, the guidelines for sports trauma, injury and disease surveillance existed prior to those for other sports disciplines.59 60 Consequently, there may be a better environment for conducting epidemiological studies in rugby and soccer than that in other sports disciplines. One of the unique features of this study was the large number of reports on several types of diving. All reported adverse event outcomes were related to barotrauma/decompression illness. We speculate that the specificity of this condition may have led to many studies.

In a survey on sports trauma and injury, the number of cases was underestimated and severity was overestimated when recorded prospectively by physicians for 1 year and when recorded retrospectively by athletes based on their recollection for the past year.63 Therefore, an accumulation of high-quality prospective papers is needed to accurately identify adverse events during physical activity. However, only 21 of the studies (30%) included in this review were prospective studies. To prospectively study, the various physical activities performed by residents, it is necessary to record and accumulate information on activity status (exposure) and occurrence of adverse events on a consistent basis.

The most commonly reported adverse events were injuries (n=56), including sports injuries and disorders, skin wounds and contusions. Twelve articles reporting fatalities were also identified. Articles with death as an outcome were most common for diving (n=5) while the others were on sports disciplines where high-energy trauma could occur, such as mountaineering, aerosports and rugby. Sudden cardiac death is a serious accident during sports,64 but only five articles in this review reported sudden cardiogenic death or disease occurring during sports, excluding the articles on barotrauma/decompression illness in diving. These articles papers reported the incidence of heatstroke, ailment, stroke and heart failure.16 17 30 47 52 The subjects and types of sports in these papers included only reports on gym exercise for adults,16 17 golf,30 cycling for adults52 and wilderness recreation for children and adolescents and adults.47 Therefore, future studies should clarify whether sudden cardiogenic death and disease that develops or worsens as a result of sports activities are indeed as uncommon as our findings indicate.

The articles included in this review were primarily longitudinal studies, with 13 articles on the frequency of adverse events based on the number of occurrences/participants×exposure. These articles were from the USA (five articles), Australia (three articles) and Japan (two articles). Of these 13 articles, 10 evaluated reports that documented adverse events. Therefore, to measure and analyse adverse events during sports more accurately, it is important to establish a system to record and longitudinally analyse the adverse events during routine sports activities.

Strengths and limitations

This scoping review is the first review article in this research area. It focuses on the sports activities that individuals in the general population engage in, and is also unique in that it is an overarching survey that does not limit the type of sport or adverse events. Athletes and patients undergoing exercise therapy were excluded, and efforts were made to capture the actual status of sports played by residents as far as possible.

Nevertheless, this review had several limitations. First, we used only two databases, and therefore, it is possible that some relevant papers were missed. This was mainly because we were unaware of how many papers had been published on this topic, and therefore, conducted this review in an exploratory manner. Second, most of the included papers were from the USA, Japan and Australia, and thus this review may not reflect the situation in other regions. Third, there was bias in the sports categories in the included articles. We hope that further studies on other types of sports activities will be conducted in the future. It is desirable to accumulate high-quality prospective studies in this area and conduct more systematic reviews in the future. Finally, due to the nature of scoping reviews, it was not possible to evaluate the quality of the individual articles.

Suggestions

The results of this review offer several suggestions for sports-related field and epidemiological studies in resident populations. The first is to describe the attributes of the participants more accurately, as several included studies did not specify several basic participant attributes. Second, there is a need for a standard classification for participant age. In this scoping review, the categories used in the WHO guidelines were used as a reference for classification; however, they need to be more commonly used by researchers. Third, a standard classification scheme is required for categorising the sports and adverse events as well—the various adverse events that can potentially occur while playing sports must be systematically summarised. Fourth, a system should be established for routinely reporting activities and adverse events at the actual sites where residents perform these activities. Many of the studies in this scoping review were questionnaire based, cross-sectional or retrospective. However, prospective longitudinal studies are required to ensure high-quality descriptive epidemiological data. It has been reported that the sequential estimation of causes and implementation of countermeasures based on the understanding of the current situation are important for preventing sports injuries.65 Therefore, monitoring of adverse events is important from the viewpoint of safety management.

Conclusions

Adverse events, including sports injuries and disorders and certain diseases, were found to occur during sports activities in residents. However, the articles identified in this review were characterised by biases with regard to the countries and regions where the studies were conducted, the sports disciplines and the types of adverse events reported. Moreover, only a few studies reported the frequency of adverse events. These may be due to the fact that sports played in a region have a wide variety of subjects and sports disciplines, making it difficult to capture the actual situation. Considering these factors, more high-quality observational studies in more diverse populations are needed.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Acknowledgments

The authors thank Ms. Asako Nishizaki (Librarian; Shinanomachi Media Center, Keio University Libraries) for assistance with developing the search strategies used in this review. We would like to thank Editage (www.editage.jp) for English language editing.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors AH was responsible for setting the research questions, planning and conducting the literature search, title and abstract screening, drafting. MN, YM, KT, KK, TM, KO, and MS conducted the screening, extracted data from the relevant articles, reviewed the manuscript for the most relevant papers, and contributed to the writing of the Results and Discussion sections. YO and YS were responsible for setting the research questions, providing advice regarding data extraction elements, and editing and revising the manuscript prior to submission. All the authors have reviewed the final manuscript and approved its submission.

  • Funding This work was supported by JSPS KAKENHI (grant number JP23KJ1892) and the MHLW Programme (grant number 22FA1004).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.