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Francesco Feletti, MD1,2

1Local Health Trust of Romagna, Department of Diagnostic Imaging S. Maria delle Croci Hospital, Ravenna, Italy

2Department of Electronics, Information and Bioengineering, Politecnico di Milano University, Milan, Italy

DIFFICULTIES & METHODS IN EXTREME SPORTS MEDICINE

RESEARCH

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TABLE OF CONTENTS

1.MOTIVATION

2.METHODS

3.EXTREME ENVIRONMENTS Number of variables

4.EXTREME PERFORMANCE

5.TECHNOLOGY

6.SPORT-SPECIFIC ASPECTS Assessment parameters Terminology Design of the studies Limitations of the studies Possible solutions

7.NON-COLLABORATION Cultural habits Legal implications Solutions

8.CONCLUSIONS

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1.MOTIVATION

Extreme sports medical research encounters many difficulties and requires special methods.

•Some measurements may be particularly complex and it may be difficult to acquire data in remote and adverse environments.

•The assessment parameters and methods adopted in traditional sports may not be adequate for many extreme sports due to the many variables involved and the intermittent nature of these sports.

•Participants in extreme sports may be reluctant to take part in medical research because of their cultural conditioning.

3Feletti F, et al. Extreme Sports Medicine, Springer 2016.

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This lecture is a report of my own experience in this field and also includes some examples

from existing literature.

2.METHODS

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3.EXTREME ENVIRONMENTS

Which are the main difficulties in medical research in extreme sports? The first thing that springs to mind is environment-related problems.

•It may be difficult to acquire data in remote areas due to the difficulties in transporting the equipment.

•Specific problems may be encountered, such as how to protect the equipment in salt water.

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•In extreme sports many environment-related variables (e.g. wind and waves) play an important role, they are difficult to measure, hard to predict and they often interact in different ways.

•In the case of wind, for example, it may be useful to measure a mean value, but the wind speed range is also important since the wind changes continuously and a single gust may cause an incident.

•Wind may also affect other parameters such as waves and the relationship between wind and wave height may be influenced by several factors including the depth of the sea, or features of the seabed, etc.

As a consequence all these elements and factors and how they interact must be considered.

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3.EXTREME ENVIRONMENTS Number of variables

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However extreme sports are not only about extreme environments. Measurement-taking may encounter other problems, because of the true

nature of these sports.

•Athletes may be under pressure and this could cause bias in the measurements.

•Any interference with the athletes' actions, may affect their performance which may have required a lot of money, time and training.

•Taking measurements could be dangerous: try to imagine the effects of measuring equipment mounted on a wingsuit during proximity flight.

4.EXTREME PERFORMANCE

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Photo©courtesy of Red Bull Content Pool/Michael Clark

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•Technology may provide solutions.

•Sometimes the required technology is not available and it needs to be developed.

5.TECHNOLOGY

Phot

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f M

. Va

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Valsecchi measured whole body vibration in kitesurfing using a purposely designed measurement system; of course, he had to make the devices waterproof. Valsecchi M, PoliTESI, 2016.

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•In their study “How dangerous is BASE jumping?” Soreide et al, reviewed records of 20,850 jumps from 1995 to 2005 at the Kjerag massif in the Lysefjorden (Rogaland county, Stavanger) on the south-western coast of Norway.

•However, this location, despite being a world-renowned site for legal BASE jumping, it would not be representative of BASE jumping as a whole.

•In fact, the Kjerag jumping zone is relatively forgiving, being a 1,000m high cliff (about 3,300 feet) that allows jumpers to reach high airspeeds, stabilize their body position and move away from the wall before opening the canopy, with a clear landing area.

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Being highly technical, these sports may present specific variables which may play an important role and the researcher must be

aware of them and take them into account.

Mei-Dan O, et al. Wilderness Environ Med, 2013.

6.SPORT-SPECIFIC ASPECTS

Soreide K et al, J Trauma, 2007.

Mei-Dan O. Adventure and Extreme Sports Injuries 2013.

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6.SPORT-SPECIFIC ASPECTS Assessment parameters

•Another aspect is that assessment parameters adopted in traditional sports may not be adequate for many extreme sports.

•For instance, the injury rate appraisal in terms of hours practiced may not be completely accurate since many of these sports are intermittent - the time in the field is not necessarily spent in action.

SUPing in Cape Verde. Surfing is a typical intermittent sport. (Photo: Claudio Marosa; courtesy of Springer, Feletti F (Ed) Extreme Sports Medicine 2016).10/22

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•While in traditional sports the injury rate is evaluated in terms of n. of injuries/1,000 hours of sport exposure, in some extreme sports different solutions are required - for example injuries/10,000 skydives or injuries/1,000 BASE jumps. Barrows TH and Mills T. J Emerg Med 2005.

Mei-Dan O et al, Clin J Sport Med 2012.

6.SPORT-SPECIFIC ASPECTS Assessment parameters

Photo©courtesy of Red Bull Content Pool/Michael Clark

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6.SPORT-SPECIFIC ASPECTS Terminology

The use of “accident” and “incident” • In many industries, government agencies, legal and scientific fields,

the term "accident" is not used, or its use is debated, because it could imply that the event was unavoidable (i.e. a chance occurrence or an “act of God") and therefore could not be prevented.

• However, in some extreme sports (e.g. aerial extreme sports, climbing, etc..) “accident” and “incident” are both currently used to mean different feature events with the aim to highlight such aspects that may practically affect risk management:

• “accident” is often preferred for an event which actually results in unpleasant consequences such as material damages, injuries, illnesses or death;

• “incident” more generically refers to an event which affects or may affect people’s safety, near misses included

• The possibility of using the term “accident”, should be considered in extreme sports medicine.

Davis et al, BMJ, 2001. Pless and Hagel, J Epidemiol Community Health, 2005. Pubmed search, April 2016.

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We have said that extreme sports are intermittent activities. And in fact many surfers or kite-surfers spend their lives on a beach waiting for enough

wind or surf. However a researcher probably can’t do the same.

•This is one of the reasons why studies on injuries in extreme sports are often retrospective or are based on self-reported data, or data collected by non-medical personnel.

6.SPORT-SPECIFIC ASPECTS Design of the studies

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•Retrospective studies are mainly prone to recall bias, potentially leading to incorrect conclusions about epidemiology.

•Data collected by non-medical personnel may be inaccurate both in terms of evaluation and classification.

•However, establishing a different system to collect medical data in these sports is particularly problematic due to the large number of intermittent participants, the fact that they practice in many different locations, and again only in specific weather conditions.

6.SPORT-SPECIFIC ASPECTS Limitations of the studies

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•A thorough understanding of the sports is essential.

•A decision could be taken to study a specific subdiscipline of the sport, a specific setting or a specific event.

6.SPORT-SPECIFIC ASPECTS Possible solutions

Italian Kitebuggying- Championship, Monte Petrano (PU), Italy

Photo©ExtremeSportMed 15/22

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•Sports participants may be reluctant to take part in medical research because of their cultural habits.

•The fact is that some groups of extreme sports athletes don’t like to speak about injuries out of a sort of superstition since they are aware of the dangers of their sport.

7.NON-COLLABORATION

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•Sometimes this is true. •This is not evidence-based. •Sometimes, however, participants are not aware of their sport's pitfalls.

A common reaction when you try to involve extreme sports participant in medical research is:

“Your research is not necessary: I know exactly the risks of this sport, I can tell you them, so you can

publish them and save your time!”

7.NON-COLLABORATION Cultural habits

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•Another reason which makes extreme sports medical research difficult is that some sports have legal implications.

•For example BASE jumpers rarely obtain permission to perform their jumps from objects such as: tall buildings, towers, antennas, etc.

•Participants may fear that analyzing the dangers of their sport may lead to new legal limitations.

7.NON-COLLABORATION Legal implications

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Here, the best solution, is to be directly involved in the sport or to be assisted by somebody who is closely

involved in this world such as a highly respected figure.

7.NON-COLLABORATION Solutions

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“Researching extreme sports requires thorough understanding of the activities, preferably from

within, which also makes it easier to approach the right population and get their will and approval to

collect and analyze unique data”.

Mei-Dan O, Carmont MR. Adventure and Extreme Sports Injuries. Epidemiology, Treatment, Rehabiltation, Prevention Springer 2013, Introduction; xi-xii.

7.CONCLUSIONS

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Thanks for your attention!

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REFERENCES

ACKNOWLEDGEMENTS Special thanks to Michael Clark/Red Bull Content Pool and Springer for allowing

me to use their photos.

1. Davis RM, Pless B. BMJ bans “accidents” Accidents are not unpredictable BMJ 2001; 322 :1320. doi: 10.1136/jech.2003.017715 PMCID: PMC1733021.

2. Feletti F. Introduction. In Feletti F (Ed), Extreme Sports Medicine, Springer 2016.

3. Mei-Dan O, Carmont MR. Adventure and Extreme Sports Injuries. Epidemiology, Treatment, Rehabiltation, Prevention Springer 2013, Introduction; xi-xii.

4. Mei-Dan O, Carmont MR, Monasterio E. The Epidemiology of Severe and Catastrophic Injuries in BASE Jumping. Clin J Sport Med 2012;22:262–267.

5. Mei-Dan O, Monasterio E, Carmont M, Westman A. Fatalities in wingsuit BASE jumping. Wilderness Environ Med. 2013; 24(4): 321-7. doi: 10.1016/j.wem.2013.06.010.

6. Pless IB, Hagel BE. Injury prevention: a glossary of terms J Epidemiol Community Health. 2005 Mar;59(3):182-5.

7. PubMed. US National Library of Medicine National Institutes of Health. http://www.ncbi.nlm.nih.gov/pubmed?term=(Accident%5BTitle%5D)%20AND%20(%222015%22%5BDate%20-%20Completion%5D%20%3A%20%223000%22%5BDate%20-%20Completion%5D) (Accessed on 5 April 2016).

8. Soreide K, Ellingsen CL, Knutson V. How dangerous is BASE jumping? An analysis of adverse events in 20,850 jumps from the Kjerag Massif, Norway. J Trauma. 2007;62(5): 1113-7.

9. Valsecchi M. Whole body vibration in kitesurfing. PoliTESI. http://hdl.handle.net/10589/8162.