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Sport participation is associated with a risk of sports-related injuries and illnesses, and Paralympic athletes’ additional medical issues can be a challenge to health care providers and medical staff. However, few prospective studies have assessed sports-related injuries and illnesses in Paralympic sport (SRIIPS) over time. Advances in mobile phone technology and networking systems offer novel opportunities to develop innovative eHealth applications for collection of athletes’ self-reports. Using eHealth applications for collection of self-reported SRIIPS is an unexplored area, and before initiation of full-scale research of SRIIPS, the feasibility and usability of such an approach needs to be ascertained.
The aim of this study was to perform a 4-week pilot study and (1) evaluate the monitoring feasibility and system usability of a novel eHealth application for self-reported SRIIPS and (2) report preliminary data on SRIIPS.
An eHealth application for routine collection of data from athletes was developed and adapted to Paralympic athletes. A 4-week pilot study was performed where Paralympic athletes (n=28) were asked to weekly self-report sport exposure, training load, general well-being, pain, sleep, anxiety, and possible SRIIPS. The data collection was followed by a poststudy use assessment survey. Quantitative data related to the system use (eg, completed self-reports, missing responses, and errors) were analyzed using descriptive statistics. The qualitative feasibility and usability data provided by the athletes were condensed and categorized using thematic analysis methods.
The weekly response rate was 95%. The athletes were of the opinion that the eHealth application was usable and feasible but stated that it was not fully adapted to Paralympic athletes and their impairments. For example, it was difficult to understand how a new injury or illness should be identified when the impairment was involved. More survey items related to the impairments were requested, as the athletes perceived that injuries and illnesses often occurred because of the impairment. Options for description of multifactorial incidents including an injury, an illness, and the impairment were also insufficient. Few technical issues were encountered, but athletes with visual impairment reported usability difficulties with the speech synthesizer. An incidence rate of 1.8 injuries and 1.7 illnesses per 100 hours of athlete exposure were recorded. The weekly pain prevalence was 56% and the impairment contributed to 20% of the reported incidents.
The novel eHealth-based application for self-reported SRIIPS developed and tested in this pilot study was generally feasible and usable. With some adaptation to accommodate Paralympic athletes’ prerequisites and improved technical support for athletes with visual impairment, this application can be recommended for use in prospective studies of SRIIPS.
ClinicalTrials.gov NCT02788500; https://clinicaltrials.gov/ct2/show/NCT02788500 (Archived by WebCite at http://www.webcitation.org/6v56OqTeP)
Paralympic sport continues to grow and attracts athletes from all around the world. However, participation in Paralympic sport is, like all sport, associated with a risk of sports-related injuries and illnesses, and Paralympic athletes’ additional medical issues are challenging to health care providers and medical staff [
Knowledge of sports-related injuries and illnesses in Paralympic sport (SRIIPS) is limited, and few prospective studies have assessed SRIIPS over time [
To allow data collection over longer periods of time and in heteregenous populations, athlete monitoring through self-reports is an established method of observing athletes’ health, including both sports-related injuries and illnesses [
By collecting data electronically, self-reports can be used with minimal memory bias and constitute real-time personalized data [
For successful implementation of an application, it is important to consider methodological and practical challenges [
The aim of this study was to perform a 4-week pilot study and (1) evaluate the monitoring feasibility and system usability of a novel eHealth application for longitudinal epidemiological research on self-reported SRIIPS and (2) report preliminary data on SRIIPS.
The purpose of the eHealth monitoring is to enable Paralympic athletes to self-report SRIIPS, exposure to sport, and general health parameters in an e-diary. For the data collection, the Briteback survey tool was used. This tool is integrated with software built on team communication research. The tool allows researchers to construct specific surveys, which are sent automatically as Web links in emails and text messages. The surveys are adapted to computers, tablets, and mobile phones, and participants can choose how to enter their data. Automated system-generated statistics are provided immediately after reporting of data.
The prototype eHealth application was developed and adapted to Paralympic athletes based on a theoretical foundation of existing research within sports medicine [
To evaluate a Web tool as feasible and usable for users with disabilities, the WCAG 2.0 guidelines require it to be perceivable, operable, understandable, and robust for all categories of users [
The final weekly e-diary consisted of 12 questions for athletes to respond to pertaining to the following topics:
Participation in normal training
Exposure to sport (sessions)
Exposure to sport (hours)
Exposure to competition
Rate of perceived exertion
Use of analgesics
General well-being
Sleep
Anxiety
Pain
New injury
New illness
Depending on responses, subquestions related to reported SRIIPS could also appear.
A pilot study cohort stratified to represent the different impairments, genders, and sports was selected in June 2016 from the Swedish Paralympic Program. The following inclusion criteria, adopted from the study protocol [
Survey design and technology formulated for use among able-bodied athletes need adaptations to Paralympic athletes with a broad range of impairments. (A) Visually impaired athlete using speech synthesizing technology adapted to the eHealth application, (B) Wheelchair basketball player with individual training behavior often without coach and medical staff, (C) Athlete often traveling using the eHealth application in her training environment, (D) Athlete with cerebral palsy and tetraplegia using a joystick to navigate the eHealth application.
The study followed the ethical principles for medical research involving human subjects per the World Medical Association Declaration of Helsinki and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and is registered at ClinicalTrials.gov [NCT02788500]. The entire study was approved by the Regional Ethical Review Board in Lund, Sweden (Dnr 2016/169). Participation in the study was voluntary, and informed written consent was collected from all participants.
Feasibility studies enable researchers to assess if a study design and preliminary results can be shaped into relevant findings and future interventions. It is necessary to pursue a feasibility study if (1) there are few previously published studies in the research area, (2) a specific intervention is used, and (3) the study population requires unique consideration of the method.
Feasibility can be referred to as the ability of users to adopt a new system in daily procedures with focus on the questions: Can it work? Does it work? and Will it work? Important aspects of feasibility in this study were acceptability (Is the application suitable?), demand (Is the application likely to be used?), practicality (Can the application be used outside the intervention?), adaptation (Will the application work for this population?), integration (Can the application be integrated in an existing system?), expansion (Can the application be expanded?), and implementation (Can the application be successfully delivered to the participants?) [
Usability is a characteristic of quality in use, according to the International Organization for Standardization [
The Fit between Individuals, Task, and Technology (FITT) framework of information technology (IT) adoption was used to structure and present the data on feasibility and usability goals (
Feasibility and usability goals structured according to the Fit between Individuals, Task, and Technology framework and the Post-Study System Usability Questionnaire.
Conceptual framework and measure | Data source | ||
Demographics (gender, age, sport, impairment) | Athlete information | ||
Fit to individual | PSSUQa |
||
Fit into daily routines | PSSUQ |
||
Fit into Paralympic sport | PSSUQ |
||
Efficiency | PSSUQ |
||
Effectiveness | PSSUQ | ||
Learnability | PSSUQ | ||
Satisfaction | PSSUQ | ||
Error recovery | Reported and detected errors |
aPSSUQ: Post-Study System Usability Questionnaire.
Injury:
Any new musculoskeletal pain, feeling, or injury that causes changes in normal training or competition to the mode, duration, intensity, or frequency, regardless of whether or not time is lost from training or competition
Illness:
Any new illness or psychological complaint that causes changes in normal training or competition to the mode, duration, intensity, or frequency, regardless of whether or not time is lost from training or competition
For example, IT adoption in an athletic environment may depend on the fit between the attributes of the individual user (ie, motivation, experience, computer anxiety), attributes of the technology (ie, functionality, usability), and attributes of the task (ie, complexity, task, organization).
A 4-week SRIIPS pilot study was performed with an integrated poststudy feasibility and usability assessment [
Quantitative data related to demographics, system use, completed self-reports, number of reported incidents, missing answers, and system errors were analyzed using descriptive statistical methods.
The qualitative feasibility and usability data were condensed and categorized using a thematic analysis method. Thematic analysis is a flexible method for identifying, analyzing, and reporting patterns within various data sets (eg, texts, webpages, and interviews). The method provides rich and detailed information that is associated with the specific research question [
Data on SRIIPS collected during the 4-week period were analyzed using basic descriptive statistics. The incidence rates were calculated as the number of new incidents divided by total athlete exposure hours (per 1000 hours of sport participation) [
A total of 1643 self-reports, 1354 weekly e-diary reports, and 289 responses to follow-up questions were collected. The average weekly response rate was 95%. A total of 37 instances of missing data were noted in the weekly e-diary reports; 28 were observed among athletes with visual impairment, 7 from athletes with physical impairment, and 2 from athletes with intellectual impairment. Questions concerning pain, anxiety, and training load generally had a high response rate (96% to 100%). The questions with most missing answers (n=11) were about general well-being with horizontally displayed check boxes. The follow-up questions, for example, concerning SRIIPS symptoms, diagnosis, and injury severity, had on average 1 to 2 missing answers every week; 11 of these were from athletes with visual impairment and 2 from athletes with physical impairment. A total of 21 athletes, 8 with visual impairment, 12 with physical impairment, and 1 with intellectual impairment, provided complete postuse feasibility and usability data. Two technical errors related to the system and the speech synthesizer were reported by athletes with visual impairment. No system use errors occurred. Almost three-quarters (15/21, 71%) of the athletes reported that it was easy to complete the task. About three-quarters (16/21, 76%) of the athletes found it easy to define a new illness, and 52% (11/21) found it easy to define a new injury. About three-quarters (15/21, 76%) of the athletes reported that it was easy to use the closure form, and 62% (13/21) reported that the application was adapted to Paralympic sport. Most (18/21, 86%) of the athletes were satisfied with the experience of performing the task, and 90% (19/21) found it important to perform this study.
A summary of the thematic analysis is presented in
The athletes’ opinion was that some parts of the eHealth application were not fully adapted to Paralympic athletes. For example, the athletes found it difficult to know how to define and identify a new injury or illness, especially when their impairment was involved. In addition, more survey items related to an impairment were requested, as the perception was that some incidents occurred because of the impairments. The athletes also found it important to be able to report all new injuries and illnesses (ie, also injuries that had not been sustained during sports participation).
Summary of the thematic analysis of the Paralympic athletes’ feasibility and usability evaluation of the eHealth application.
Theme | Code | Meaning unit |
Health monitoring in Paralympic sport | Feasibility to Paralympic athletes | The application is not specifically adapted to Paralympic sport |
It is difficult to define a new SRIIPSa | ||
Some injuries occur because of the impairment | ||
Survey design | Complex incidents | It is difficult to report several injuries or illnesses |
Insufficient description of multifactorial incidents | ||
More free text alternatives and multiple check box alternatives would be good | ||
Impairment diversity and usability | Usability to visually impaired athletes | It is not trouble-free to use a screen reader |
Horizontal questions do not work with VoiceOver | ||
It is easier to use free text alternatives | ||
Longitudinal eHealth monitoring | Sustainability | It is easy to understand and follow the weekly e-diary |
The terminology used is intelligible | ||
It is important that this kind of study is conducted |
aSRIIPS: sports-related injuries and illnesses in Paralympic sport.
Identified issues were also related to the survey design and were associated with the reporting of complex incidents using the survey design originally developed for able-bodied athletes. For example, if an athlete wanted to report 2 new injuries in the weekly report, they did not easily understand how to accomplish this task.
The perception was also that there were insufficient options for describing multifactorial incidents including an injury, an illness, and the impairment. To improve the design, the athletes asked for opportunities to better describe their incidents through free text or more multiple check box alternatives.
Athletes with visual impairment had usability difficulties with tasks involving a visual analog scale and horizontal reply alternatives due to a technical problem with the connection between their speech synthesizer and the eHealth application. Some athletes with visual impairment chose instead to write free text at the end of the questionnaire or not leave a response at all. The questions using vertically displayed response alternatives worked well for the athletes with visual impairment. Athletes with physical impairment or intellectual impairment did not report any functionality problems.
The athletes stated that the use of the eHealth application was feasible and could be extended to longer periods of time. They perceived that it was easy to understand and use the application. Most of the athletes were of the opinion that the terminology was comprehensible and that it was easy to understand which dates and week they should report. A majority also stated that it is important that health monitoring is performed.
One athlete dropped out during the study period; thus, 4-week data were available from 27 athletes. A total of 10 athletes (37%) reported anxiety, 15 (56%) reported pain, and 9 (33%) reported use of analgesics weekly. The median self-rated general well-being score was 4 (1-7). The average time spent on training each week was 7.6 hours. The median weekly rated perceived exertion was 6 (1-10). In total, 15 new injuries (reported by 12 athletes) and 14 new illnesses (reported by 12 athletes) were reported, giving an incidence rate of 1.8 injuries per 100 hours and 1.7 illnesses per 100 hours of athlete exposure, respectively. For 71% (5/7) of the injuries and 60% (6/10) of the illnesses, the athlete reported a higher mean training load than the week before. Tissue inflammation and pain (10/15, 67%) and upper respiratory tract infections (9/14, 64%) were the most common preliminary causes. A total of 80% (12/15) of the injuries were related to overuse, 66% (10/15) of the injuries were reported from athletes with visual impairment, and 57% (8/14) of illnesses were reported from wheelchair athletes. The typical injury severity was 1 to 3 days of time loss of training and 2.6 missed training sessions for illnesses. In 20% (3/15) of the injuries and 21% (3/14) of the illnesses, the impairment was perceived to be involved in the cause.
Advances in eHealth technology for athlete self-reporting and monitoring [
A critical conceptual issue related to feasibility and the fit between the individual, task, and technology was how to define and report new SRIIPS, especially when the impairment was involved. The athletes perceived that the eHealth application was not fully adapted, as some SRIIPS may occur because of the impairment. This observation corroborates the reports from a recent qualitative study where Paralympic athletes perceived that their impairments played an important role in the etiology of SRIIPS [
Regarding usability efficiency, the athletes described that there were not enough options for description of multifactorial incidents including injuries, illnesses, and impairments. The construction of questions and terminology has previously been reported to be a main issue identified by athletes, and athletes are more willing to complete surveillance systems if they can recognize themselves in the questions asked [
Another usability design issue related to task completion was the human-computer error of the audible feedback system used by the athletes with visual impairment. Even though there have been developments of touch screen devices, many are still inaccessible to visually impaired users who often adopt error recovery compensatory strategies [
Possible explanations for the high response rate are the short study period and system usability adaptation for easy use on mobile phones and other platforms. A restriction in athlete monitoring using self-reports is the workload assigned to the athlete, implying that collection of as little and as relevant data as possible is important in long-term surveillance [
The athletes were of the opinion that the application was easy to understand and could be extended to longer periods of time. Thus, we considered the application to be feasible for Paralympic athletes and believe that it can be adopted in their daily procedures with regard to the ability of the users [
Only 2 similar studies within Paralympic sport have included athlete exposure based on time [
Only a handful of studies have assessed the incidence of illnesses among Paralympic athletes. Studies at the Paralympics Games indicate that illness rates are similar to injury rates [
A strength of this study is the detailed preparatory work undertaken to develop the eHealth application and specifically adapt it to Paralympic athletes with visual impairment, physical impairment, and intellectual impairment. Another strength is the subsequent evaluation and correction of feasibility and usability indicators of the monitoring system before the start of full-scale long-term studies. A limitation is that we only evaluated poststudy reported feasibility and usability issues and that the qualitative analysis included only written answers and no interviews. Another limitation is that the pilot study period was relatively short, and it is therefore not possible to distinguish long-term results and response rates. A larger study sample including athletes from all Paralympic sports may also have provided further insights into the feasibility and usability of this novel eHealth application.
The novel eHealth-based application for self-reported SRIIPS developed and tested in this pilot study was generally feasible and usable. With some adaptation to accommodate Paralympic athletes’ prerequisites and improved technical support for athletes with visual impairment, this application can be recommended for use in prospective studies of SRIIPS. This will advance our knowledge of the incidence and risk factors of SRIIPS and facilitate the development of evidence-based prevention measures adapted to Paralympic sport.
Fit between Individuals, Task, and Technology
information technology
Post-Study System Usability Questionnaire
sports-related injuries and illnesses in Paralympic sport
Strengthening the Reporting of Observational Studies in Epidemiology
Web Content Accessibility Guidelines
The authors wish to thank all the Paralympic athletes participating in the study. We also thank Parasport Sweden and the Swedish Paralympic Committee for endorsing this study, and Johan Åberg, CEO at Briteback, for technical support during the study period.
KF and JL conceptualized the project. KF, JJ, ÖD, TT, and JL contributed to the design of the study, drafting of the manuscript, and review of the final manuscript. All authors read and approved the final manuscript.
None declared.