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On-line version ISSN 1806-9940
Rev Bras Med Esporte vol.10 no.1 Niterói Jan./Feb. 2004
Lesiones deportivas en el atletismo: comparacion entre las informaciones obtenidas en historias clinicas y consultas de la morbilidad referida
Carlos Marcelo PastreI; Guaracy Carvalho FilhoII; Henrique Luiz MonteiroIII; Jayme Netto JúniorIV; Carlos Roberto PadovaniV
Mestre, Depto. de Fisioterapia das Faculdades Adamantinenses Integradas; Faculdade
de Educação Física Unoeste Presidente Prudente; Fisioterapeuta
da Seleção Brasileira de Atletismo
IIProfessor Doutor, Depto. de Ortopedia e Traumatologia, FAMERP, São José do Rio Preto
IIIProfessor Doutor, Depto. de Educação Física, Faculdade de Ciências, Unesp Bauru
IVProfessor Mestre, Depto. de Fisioterapia, Faculdade de Ciências e Tecnologia, Unesp Presidente Prudente; Doutorando em Ciências da Saúde Famerp; Técnico da Seleção Brasileira de Atletismo
VProfessor Titular, Depto. Bioestatística, Instituto de Biociências, Unesp Botucatu
To understand sports injuries is necessary to quantify and associate them with specific risks factors from sports. Although, formal records about sports injuries are rare overcoat in Brazilian track and field athletes where few clubs have health care service. This fact could not be a problem, because public health researchers adapt with epidemiological methods, like report inquires morbidity, to collect data. From this fault of control about sports injuries records and the facility to have information together athletes, the aim of this study was to collect information about sports injuries, reported by high performance athletes, going back until eight months and compare them with their records. Twenty-five athletes were analyzed (sixteen men and nine women), age 25.7 ± 4.4 (years), height 1.74 ± 0.10 (m), weight 70.4 ± 13.15 (kg) and time of practice 8.38 ± 4.06 (years). Two physiotherapists were trained separately to collect information about sports injuries, one in records and another with the athletes in interview. The binomial proportion test by agreement was used to compare the information with 95% of confidence. After analyzed the agreement between that two collect forms, that variables values were within the limits of confidence established for statistics tests with the following values: 88.33% to the variables injury tip and injury mechanism or high of symptoms, 90% to the variable quality of return to the sports practice and 91.67% to the variables anatomical place and period of training. There was high rate of agreement between collected information, showing reported morbidity inquire efficiency in collect data about sports injuries.
Key words: Track and field. Sports injuries. Morbidity inquires.
Para comprender las lesiones deportivas (LD) es necesario cuantificarlas, asociandolas a factores causales particulares al esporte. Aún así, faltan registros sobre estas patologías en las instituciones deportivas, sobretodo en el atletismo brasileño, donde pocos son los clubes que poseen servicios de asistencia de la salud. La ausencia de tales registros, estudios en el área de Salud Pública, se utilizan otros recursos epidemiológicos para colectas, tales como las consultas de morbilidad referida. A partir de esta escasez de información y de la facilidad de obtención de datos junto a los propios atletas, se objetivó, para esta pesquisa, levantar informaciones sobre las LD referidas por los atletas de alto rendimento, retrocediendo ocho meses, y comparándolas con los registros de historias clínicas. Por lo tanto, fueron tomados veinticinco atletas de elite, dieciseis de género masculino y nueve del femenino, con edades de 25,7 ± 4,4 años, altura de 1,74 ± 0,10 m, peso 70,4 ± 13,15 kg e tiempo médio de entrenamiento de 8,38 ± 4,06 años. Dos fisioterapeutas fueron entrenados separadamente para recolectar información sobre LD. Uno de ellos en historias clinicas y el otro de los propios atletas a través de entrevistas (Interrogatorio de Morbidade Referida - IMR). El estudio de concordancia de respuestas para las dos formas de colecta fué realizado por el test de proporción binomial, estabeleciendose límites de 95% de confianza para la concordancia. Los resultados mostraron que en todas las variables estudiadas los valores estaban dentro de los límites de confianza estabelecidos para los tests estadísticos, siendo: 88,33% para las variables tipo de lesión o agravio y mecanismo de lesión o aumento de los síntomas, 90% para la variable calidad del reintegro a las actividades deportivas el 91,67% para las variables local anatómico y período de entrenamiento. Se concluye por lo tanto, que ha habido una elevada tasa de concordancia entre las informaciones recogidas, mostrando así, la eficacia del IMR para la recolecta de informaciones sobre lesiones deportivas para la población investigada.
Palabras clave: Atletismo. Lesiones deportivas. Interrogatorios de morbilidad referida.
Track and field is different from the other sports modalities by attempting several biomechanical gestures due to its variety of events. The constant exposition to risk factors and consequent injuries occurrence due to its practice warns for the necessity of quantifying lesions associated to this sport in order to control and also to avoid them, enabling not only the performance improvement, but also the maintenance of the athlete's health.
In the public health context, the quantification of diseases is performed by means of epidemiological resources, which use strategies adequate to each research possibility1, where two groups of methods are presented: 1) routine records of attendance such as the clinical records that, when well organized and standardized, become an excellent and reliable instrument for morbidity studies; 2) reported morbidity inquires (RMI), where the injured athlete reports his lesion himself, going back a given period of time, being often used for injuries recordings, where no clinical evaluations or additional examinations are required2.
However, reviews on the subject have warn for the difficulty of making comparisons between results of those inquires and of ratifying its validity, especially due to the absence of definitions standardizations and employed methods. Thus, the type of health harm related to the remembrance and to the morbidity report is worthy of emphasis.
Allusive matters regarding the benign affections, common accidents, complaints and non-expressive symptoms are limited to short and recent periods: two weeks are the period selected by many researchers. Data on serious accidents or internment rather include longer intervals, commonly going back 12 months1,2.
Usually, the epidemiological inquires are used when the existing information are inadequate or insufficient in virtuousness, among other factors, of improper or insufficient notifications3,4 what, indeed, occurs in the sportive context, especially in Brazil.
Thus, with the objective of investigating the frequency of specific sports lesions in our environment, inquires or forms towards sports modalities or several physical practices were developed5-10. In this way, an instrument used in public health was included in the sports in order to describe and to characterize specific injuries, however, yet with no agreement regarding the time of the lesion installation until the interview report as a determinant factor to the remembrance. Specifically regarding this last aspect, the use of the RMI as a collecting instrument, going back to periods of time longer than two weeks, seems to be contradictory.
Hahn11 verified in his study, that signs or symptoms in the knee articulations of athletes were concordantly remembered between periods from one week up to one year. Pinheiro et al.12, identified information disagreements regarding osteo-muscular symptoms in bank clerks, related to different periods of time, shorter or longer.
Despite the researchers' effort, the records on sports lesions occurrence, even in high performance sports, besides not standardized, are restricted. There is a great difficulty on the access to information on athletes and their lesions, resulting in a lack of control about the current situation of injuries installation to the health of those involved in sports activities, according to findings of Chalmers13. Without this adequate control, the difficulties on the prevention and the possibilities for lesions installation are both higher, including track and field.
In this work, it was verified the difficulty of generating information on Sports Injuries(51), especially in track and field, as well as the lack of protocols in that purpose. The training centers spread all over the country, do not dispose of any type of injuries record. Different situation is observed in the Prudentina Track and field Association (PAA), which counts on systematic records of sports injuries during all season, enabling comparison between different collect forms.
To have knowledge about the period of time in which the athlete is able to remember the lesion, as well as the possibility for the application of a RMI, going back such time, may serve as aid for training centers that have no systematic records, besides other health professionals related to sports in general, to be able to collect data about sports injuries.
Due to the doubt about the athletes' remembrance time on their sports lesions, it was understood as convenient to perform an investigation on the application of a RMI, as an attempt of obtaining data on injuries occurring in this modality.
Thus, the objective of this study is to survey information of high-performance athletes, going back eight months through RMI and to compare them to clinical records.
CASUISTIC AND METHOD
1. Nature and population of the study
The research's data were obtained from interviews and files containing SI information occurred during one training season and track and field meetings, what characterizes this study as being of transversal type. However, as reported information address to facts already occurred, a retro-analytical component is also inserted, as described by Pereira2, where multiple variables were analyzed.
Twenty-five athletes from the Prudentina Track and field Association (PAA) were analyzed, sixteen male (64%) and nine female (36%). All are track and field runners, specialists in power and velocity competitions, who train in the National Center of Track and field Training, at Presidente Prudente - SP, Brazil.
Besides the experience time in sports practice and the participation on the Training National Center, it is worthy mentioning that all athletes analyzed have already participated on important competitions in the national or international fields in the modality studied.
2. Description of the reported morbidity inquire (RMI) and variables involved
The RMI was composed by a questionnaire used as data collecting instrument, elaborated by means of a closed model, initially containing personal data with regard to the athletes such as: genus, age, weight, height and time of training.
For the attainment of information regarding SI, questions about the type of lesion, anatomical place, mechanism and training period were added, besides the information regarding the return to the regular physical activities based on the experience of other authors who have already worked with similar instruments7,8,10. In order to facilitate the attainment of information and its further organization, all items related to the variables researched were numerically classified. The RMI model and its classification are presented on figure 1.
In this study, SI is considered as any pain or muscular-skeleton affection resulting from sportive trainings or competitions, sufficient to cause alterations on the regular training, either in type, duration, intensity or frequency14.
The matter regarding the type of lesion aimed to identify, as epidemiological studies of reported morbidity, the injury noticed by the athlete, regardless the clinical diagnosis. The lesion anatomical place counted on an illustrative figure of the human body, with the purpose of facilitating the athlete's identification.
The mechanisms for the lesion installation or the increase of signs and symptoms were investigated aiming to know the occurrence moment of the reported SI. Now, the training period in which the lesion occurred revealed the specific phase of the training in the season, the lesion was observed, where the following periods are considered: basic, specific and competitive. Finally, the return to activities was presented with the purpose of observing the return to the regular sportive practice, in other words, without any training alterations, occurred with or without the presence of symptoms.
3. Field procedures
Two physiotherapists who received identical questionnaires were trained separately to collect information about sports injuries suffered by athletes during the last season of trainings and competitions (eight months). One of them obtained data from personal interview using specific form, therefore, characterized as RMI. The other one, using the same form, attempted to fill it out based on records from the PAA health sector, covering the period relative to the same season. Those procedures are described on literature as procedures used to perform morbidity studies within a population or institution1-3.
It is worthy elucidating that the information contained in the PAA records are retroactive until 4 days from the athlete's exposition to the sports injury and are complemented with information obtained from the technical commission and from the team's health sector, while RMIs bring information of up to 8 months preceding the research, only regarding to the injured athlete.
4. Statistical procedures
The SI records were considered as gold standard for being recorded shortly after the event and for counting on the identification of lesion signs and symptoms, which enabled to characterize more clearly history, nature, situational cause and procedures adopted for the control and treatment of the injury.
The study of responses agreement on both collect forms (records and inquires) considering type of lesion, anatomical place, lesion mechanism or symptom increase, training period and quality of return to activities was performed using the binomial proportion test by agreement and the limit of 95% of confidence was established15.
5. Legal aspects of the research
The participation of the population investigated was given by means of reading, comprehension and written authorization of a term for clear and free permission, which was approved together with the original project for this research by the Research and Ethics Committee from the Medical School of São José do Rio Preto - SP, Brazil.
On table 1, one verifies, besides the SI frequency distributions, according to the means of data attainment, the information agreement values and the proportion test with the respective intervals of confidence. The muscular injuries were the most observed in both the records and the inquires and the tendinopathy also presented high rate in both collect forms, where the information agreement value showed proportion test significant for p < 0.0001.
The frequencies distributions of injured anatomical places, as well as the agreement values for this variable, are presented on table 2. The lower members were the most injured, regardless the collect forms, with emphasis to the thigh, ankle/foot and leg calf; in this case, the agreement level was of 91.67%.
The lesion mechanism or the increase of signs and reported symptoms is presented on table 3. The speed running is a moment where most injuries occur in both records and inquires with only one disagreement. The high jumps are also worthy of emphasis, once besides presenting high rates, also showed total information agreement.
The table 4 regards to the variable training period, where an agreement of 91.67% is observed in the reported information, when compared to the records, emphasizing the basic and specific periods as the selected for SI installation.
The table 5 presents data regarding the quality of return to regular activities, in other words, whether return occurred with or without signs or symptoms associated to SI. It was verified that the return to training for the group studied, occurred with higher frequency, still with presence of signs and symptoms and that the information agreement for this variable was of 90% with p < 0.0001.
When investigating SI, one notices the lack of agreement between researchers in the conceptual field. Such fact must always be recalled in discussions on the subject, once the disagreements make the analysis between similar studies difficult, in other words, discussions involving populations of athletes5,7,8.
The SI in this research, as observed in other researches, were presented with high rates, what lead us to agree with the affirmation of Laurino et al.9, who concluded that track and field may be considered as a high risk sport for the appearance of SI, in his study. Besides the training load itself, other factors such as age, genus, modality, time of training and precocious specialization seem to contribute for its installation.
Among the SI most observed, the tendinopathy and the muscular distension stand out, which are also observed as the most frequent in studies of Shiffer16 and D'Souza17, involving track and field. Those lesions showed to be marking for the athletes who participate on this research.
Another injury observed in this study was the periostitis, involving 11.67% from the total, disregarding, however, injuries caused by stress, different from what was observed in the research of Bennell and Crossley14, where such occurrence, involving track and field modality, was the most observed. The main reason suggested for such variations involves intrinsic and extrinsic characteristics, particular of each situation, such as surface of sportive practice, weather, specialty and the sports training itself and its adaptive characteristics18.
From the conceptual point of view, the word periostitis has also generated subsidies for discussion: initially, all athletes referred to this injury as "shinbone injury". Indeed, this word is used systematically by many people involved with track and field, replacing the expression tibial stress syndrome. Thus, reports considering the installation of "shinbone injury" were reviewed, being related to a more adequate terminology proposed for the study and disregarding the specificity of the anatomical place for the injury. Thus, the "shinbone injury", representing the tibial stress syndrome was replaced into the definition considered for the periostitis installation.
With the analysis of results, particularities were observed in three injuries: constriction, myalgia and unspecified chronic neuralgia. During the data collecting, it was observed that some athletes that reported to be suffering from constrictions, in fact presented signs and symptoms of myalgia.
The confirmation of the mistake by the interviewed was given through writings on records and through observations of the technical commission that established what actually occurred. Such fact explains the situation presented in the results, pointing out a disagreement regarding the highest rate of reported constrictions in inquires written on reports, and also the low agreement with regard to the myalgia, when reports and inquires were compared.
In cases of unspecified chronic neuralgias, the justification for the account of their high disagreement rate involves their own unspecificity. In other words, signs and symptoms poorly defined, non-specific and also of lower importance are unlikely to be remembered.
Generally, the injuries verified in this research showed coherence with other studies9,10,14.
With regard to the preference places for lesions installation, one noticed that they are found in other investigations within populations of athletes, which researched the physical compromising originated from the mentioned sportive practice9,10,14,16. Such fact may be explained by the higher demand applied to the lower members when compared to other regions, above all by dealing about athletes specialized in speed and muscular explosion competitions.
When disagreeing values are discussed for this variable, comments on the athlete's behavior are needed, about his act of reporting the anatomical place of the lesion. In many cases, the non-remembrance of injuries occurred to thigh region, knee and to the ankle/foot complex was justified, due to amount of injuries in these places.
The SIs occur in all physical preparation phases of athletes. However, the highest prevalence of installation was observed in the specific period. It is worthy recalling that this is the longest interval among the other three analyzed. 55% from the total of lesions were registered on records and 48.33% of information on inquires.
D'Souza17, in a study with track and field athletes of different competition levels, observed that most lesions occur at the training period (60%) and 20% at the competition period. Although the division of SIs into training periods is coherent with our research, the proportions are different. Only 8.33% of injuries were recorded in competitions within the modality. This fact should be valorized, above all by the characteristics of the training level of each individual, in this study, only high performance athletes.
The main reported or registered activities responsible for the highest number of injuries were the activities that require speed and muscular explosion with 41.67% and 40% in records and inquires, respectively. This fact was confirmed by several authors, who identified the activities that require explosive movements as the activities that most injure, regarding track and field9,10. This situation may be explained especially by the excessive biomechanical requirements, either of articulations or of muscular groups involved in such mechanism19.
The return to the regular physical activities was presented mostly in the presence of signs and symptoms. 81.67% of lesions were registered in records and 75% of lesions registered in inquires. We observed a higher disagreement rate between instruments in the symptomatic return, if compared to the asymptomatic return. Thus, the information collected seem to disagree from the affirmations of Pereira2, about the most marking injuries to the individuals. However, it is worthy recalling that the total number of symptomatic returns to the sportive practice was higher than the asymptomatic returns and, this way, it has a higher probability of disagreement.
The investigation results, generally showed to be conflicting with findings of Pinheiro et al.12, who tested agreement levels in osteo-muscular symptoms reports in 7 days and 12 months before the application of an interview. It was verified that only in one region of the body, the shoulders, the agreement between findings occurred. However, the sample was composed of bank clerks, what could explain such results.
Hahn11 verified the validity of the self-report knee symptoms among athletes and concluded that weekly questionnaires could be replaced by yearly ones, due to the disagreement level found in his responses. Those statements confirm the results of this research regarding the interval period of the injury installation and report in inquires.
When analyzing the researches abstracts from Hahn11 and Pinheiro et al.12 and comparing their results to results of this study, one notices that the populations investigated inform, through RMI, the muscular-skeletal lesions occurred, where such injuries seem to be more marking to individuals who need the locomotive device in perfect conditions in order to perform their work duties, fact observed in high-performance athletes.
Based on results found, it was also observed that it is possible to use RMI with time interval going back eight months after the SI installation with relative accuracy, as an instrument of data collecting for scientific research purposes, involving high-performance athletes, especially SI which signs and symptoms showed to be remarkable.
Those statements are in agreement with Girotto et al.7 and Netto Jr.10 who used similar instrument arguing the importance of SI for high-performance athletes in order to collect information going back long periods since the injury installation until the moment of the interview.
From the survey and comparison of information suggested as objective of this research, it was verified that a high rate of agreement between all information surveyed occurred, showing the efficiency of the Reported Morbidity Inquire as instrument of information collecting about sportive lesions for the population investigated.
All the authors declared there is not any potential conflict of interests regarding this article.
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Carlos Marcelo Pastre
Rua Fernão Dias, 950
19023-280 Presidente Prudente, SP, Brazil
2nd version received in 7/12/03
Approved in 12/1/04