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Para Sport & Paralympic Sport Section

Injury and Illness Surveillance in Elite Para Athletes

An Urgent Need for Suitable Illness Prevention Strategies

Hirschmüller, Anja MD, PhD; Fassbender, Katharina MD; Kubosch, Johanna MD, PhD; Leonhart, Rainer PhD; Steffen, Kathrin PhD

Author Information
American Journal of Physical Medicine & Rehabilitation: February 2021 - Volume 100 - Issue 2 - p 173-180
doi: 10.1097/PHM.0000000000001501


What Is Known

  • Epidemiology of injuries and illnesses during Paralympic Games have been extensively studied.
  • Incidence and prevalence of injuries and illnesses among elite Para athletes are higher than among their able-bodied pairs, and their injuries and illnesses often have more serious consequences.
  • Prospective monitoring data of Para athletes are lacking.

What Is New

  • At any given time, 28% elite-level German Para athletes reported health problems, and 12% experienced substantial health problems.
  • Paraplegic athletes reported an overall higher weekly prevalence of health problems compared with nonparaplegic athletes.
  • For a health team, illnesses seem more important to handle than injuries; however, illnesses were more severe and resulted in more time loss days, whereas injuries showed longer durations.
  • The Oslo Sports Trauma Research Center Questionnaire on Health Problems questionnaire is a suitable method for injury and illness surveillance in Para athletes with a high satisfaction rate from the athlete side.

Injuries and illnesses among Paralympic athletes have been extensively studied during Paralympic Games with incidence rates (IRs) ranging between 10 and 19 illnesses1–4 and 10 and 27 injuries per 1000 athlete days.5–8 Comparably, longitudinal studies on these athletes’ health outside competition settings are still sparse,9 although continuous health monitoring all year round recently has been defined as a major future research goal to prevent injuries and illnesses in sports and exercise communities.10

Early identification and intervention are of significant importance for Para athletes, as (1) the incidence and prevalence of injuries and illnesses among elite Para athletes is higher than among their able-bodied pairs11 and (2) their injuries and illnesses often have more serious consequences.9,11,12 A 1-yr retrospective recording of sports-related injuries and illnesses among 104 Swedish Paralympian athletes revealed a weekly prevalence of severe injuries and illnesses of 31% and 14%, respectively, defined as absence from training and competition for 3 wks or longer.9 The literature addressing injury and illness risk specifically related to paraplegic athletes highlights common health problems to the urinary and gastrointestinal organ systems13,14 and to shoulder overuse injuries.5,15

Several studies in able-bodied elite athletes have shown that injury and illness rates are considerably high in the weeks before major sport events, thereby likely affecting optimal performance at what often is defined as an athlete’s seasonal goal.16 Concurrently, it is concluded that athlete health monitoring should focus on the prevention of out-of-competition medical issues and athlete education. In addition, load management and prevention of health problems are of paramount importance for athletes with impairments, especially during the critical weeks up to and around major events.17

We therefore implemented an injury and illness surveillance system in elite-level German Para athletes allowing for continuous monitoring of their health problems. The aim of this prospective 29-wk cohort study was to describe the weekly prevalence and incidence of acute and overuse injuries and of illnesses in the German Paralympic Team across paraplegic and nonparaplegic athletes, preparing for the Rio 2016 Summer Paralympic Games.


In January 2016, we identified all candidate athletes preparing for the 2016 Rio de Janeiro Summer Paralympic Games through the German National Paralympic Program, and the total number of athletes qualified for the purpose of this study was 178. The medical coordinator of the National Paralympic committee and team physicians responsible for the clinical care of the Paralympic athletes provided their athletes with detailed information about the proposed study. We obtained written informed consent from all athletes and from parents of those younger than 18 yrs (inclusion criteria >16 yrs). Athletes had to confirm their physical and technical abilities to weekly respond to the health monitoring tool through an open-source electronic platform for scientific questionnaires ( All athletes were provided external help (e.g., relatives, coach, project coordinator) to complete the form, if needed. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines (see Supplemental Checklist, Supplemental Digital Content 1, and has been conducted after obtaining approval from the local university’s ethics committee (Approval 522/15) according to the Declaration of Helsinki.

Data Collection Procedures

We applied the validated German version of the Oslo Sports Trauma Research Center Questionnaire on Health Problems (OSTRC-H).18,19 Every Sunday, the system generated a web link that was sent to all athletes via e-mail. A reminder was sent out 2 days later if the athlete still had not responded. The OSTRC-H consists of four graded key questions about sports participation, training volume, performance, and health problems experienced during the previous 7 days.20 For any health problems, athletes were asked to provide information on the number of training/competition days lost because of the problem and whether they have received medical attention for it. If the athlete had experienced more than one health problem during the preceding week, the questionnaire was repeated. Those problems, which lead to moderate or severe reduction in training volume, moderate or severe reduction in sports performance, or complete inability to participate in sport were then defined as substantial health problems.20 The German version of the OSTRC-H questionnaire also requested an answer to the athlete’s weekly training volume.18

Classification, Definition, and Diagnosis of Reported Health Problems

Health problems were classified in accordance with the International Olympic Committee surveillance system.21 Disorders of the musculoskeletal system as well as concussions were classified as injuries and further subcategorized into acute (onset linked to a specific injury event) and overuse injuries (no specific injury event), whereas disorders of other body system were classified as illnesses. In case of any reported medical problems, the project coordinators, all of whom were final year medical student (KF) and medical doctors (AH, JK), contacted the athlete for further clinical follow-up. Depending on the severity of the medical problem and the home residence of the athlete, the case was diagnosed either by telephone, e-mail contact, or face-to face consultation.22 If necessary, we referred the athletes to further medical support, who could be their general practitioner or a medical specialist.

Evaluation of the Athletes’ Acceptance With the Surveillance Program

At the end of monitoring period, we asked all athletes to complete a questionnaire on their satisfaction with the project, about their perceived benefit from the monitoring as well as criticisms and suggestions for further improvements. In the second part of the questionnaire, we asked them to judge the quality of the medical support they were offered before and during the project as well as whether the project had an effect on the realization of their seasonal goals.

Data Analyses and Statistics

We integrated all weekly data into an EXCEL database (Microsoft Excel 2018, Windows). Athletes’ demographic information (age, sex, sports, and impairment) was obtained from the registry of the German national Paralympic Committee. Data were analyzed with SPSS 21 (IBM, Windows).

To describe the health risk among the participating athletes during the 29 wks of data collection, and across paraplegic and nonparaplegic athletes, we calculated the weekly prevalence for all health problems combined and separately for illnesses, acute, and overuse injuries. These data were calculated by the number of athletes reporting any form of health problem divided by the number of returned questionnaires. As secondary outcome measures, we calculated IRs as the number of injuries/illnesses per 1000 athlete days.

We calculated athletes’ weekly response rates based on the number of returned questionnaires divided by the number of participating athletes and as an exposure measure, athlete days, as the sum of returned questionnaires multiplied by 7. We reported the burden of health problems as the sum of reported lost training days and as cumulative severity score. A severity score was calculated based on the 4 graded initial questions, ranging from 0 to 100, where “100” represents the worst outcome, and the cumulative severity score represents the sum of the weekly reported severity score for each of the cases.

We calculated 95% confidence intervals (CI) of rate ratios (RR) for the number of injuries and illnesses between paraplegic and nonparaplegic athletes by conducting a simple Poisson model, assuming constant hazard. We present data descriptively with frequencies and proportions, and with means and standard deviations (SD), prevalence and incidence data as means and RRs with 95% CI. We regarded 2-tailed P values of less than 0.05 as significant.


A total of 72 of the initial cohort of 178 candidate athletes (40%) agreed to participate, and 58 (81%) of those stayed in the project during 29 wks. Of the 14 athletes who decided to withdraw from the monitoring program, nine did not qualify for the Rio Games, one athlete reported of too much traveling without having reliable Internet access, and four athletes did not specify their reasons for withdrawal.

The 58 athletes, comprising the final cohort, represented five impairment groups (visual impairment, spinal cord injury, intellectual impairment, limb deficiency, cerebral palsy/upper motor neuron deficiency) and 10 sports: paracycling (n = 18), wheelchair basketball (n = 12), swimming (n = 8), shooting (n = 6), athletics (n = 5), table-tennis (n = 4), equestrian (n = 2), and canoeing, rowing, wheelchair rugby (n = 1 each).

Athletes were subcategorized into “paraplegic “(n = 19) and “nonparaplegic” (n = 39), and sports varied across impairment groups. The athletes’ demographics, weekly training volume, and training days lost after a health problem are summarized in Table 1. Training volume differed considerably across sports. Although athletes competing in swimming had a weekly training volume of 20.2 ± 10.1 hrs, athletes from shooting, wheelchair rugby, and canoeing reported a lower weekly volumes (11.3 ± 5.1, 10.3 ± 5.3, 7.0 ± 3.7) hrs/wk, respectively. Paraplegic athletes (mean 13.3 ± 6.8 hrs) reported similar weekly training volume compared with nonparaplegic athletes (mean = 16.1 ± 7.5 hrs; mean difference = −2.8; 95% CI = −3.8 to 0.4; P = 0.060).

TABLE 1 - Distribution of paraplegic (n = 19) and nonparaplegic athletes (n = 39) to sports, their weekly response rates, athlete days, and training volume
Paraplegic (n = 19) Nonparaplegic (n = 39) All (N = 58)
Age, mean ± SD 41.5 ± 10.1 33.4 ± 11.1 36.1 ± 11.4
Weekly response rate, mean ± SD, % 92.9 ± 8.0 92.3 ± 8.8 92.5 ± 8.5
Athlete days, n 3591 7336 10,927
 Para cycling 5 13 18
 Swimming 0 8 8
 Wheelchair basketball 7 5 12
 Athletics 1 4 5
 Table tennis 1 3 4
 Para equestrian 0 2 2
 Para canoe 1 0 1
 Para rowing 0 1 1
 Wheelchair rugby 1 0 1
 Shooting 3 3 6
Weekly training volume, mean ± SD, hr 13.3 ± 6.8 16.1 ± 7.5 15.2 ± 7.4

Weekly Prevalence of Health Problems

With an on average weekly response rate of 92.5 ± 8.5%, we recorded a total of 177 health problems in 51 athletes, resulting in 94 illnesses, 52 overuse, and 31 acute injuries.

At any given time over the 29 wks, 28% of our athletes reported health problems (95% CI = 26% to 30%), and 12% (11% to 14%) experienced substantial health problems. Divided into health problems, overuse injuries accounted for a mean weekly prevalence of 13% (11% to 15%) illnesses of 11% (9% to 13%), and acute injuries of 5% (4% to 6%). The mean prevalence of health problems varied between sex, with female and male athletes reporting of 33% and 24%, respectively (P < 0.001).

Although the overall prevalence of health problems diminished over the surveillance period of 29 wks, the prevalence of substantial health problems did not change (Fig. 1). Based on the means of the first and final 5 wks of data collection, the prevalence of health problems in general reduced by 20.9 ± 4.1% (P < 0.001) and of illnesses by 16.1 ± 2.9% (P < 0.001), whereas the prevalence of overuse (5.7 ± 3.1%, P = 0.187) and acute injuries (0.1 ± 2.0%, P = 0.99) stayed constant.

Weekly prevalence of all health problems and substantial health problems for paraplegic (n = 19) and nonparaplegic (n = 39) elite German Para athletes.

For 29 wks, the weekly prevalence of all health problems differed significantly between paraplegic (33%, 29% to 37%) and nonparaplegic athletes (26%, 23% to 29%; P = 0.007; Fig. 1).

Incidence Rates of Health Problems

The overall IR of health problems per 1000 athlete days was 16.2 (95% CI = 14.0 to 18.8). This number could be divided into IRs of 8.6 (95% CI = 7.0 to 10.5) illnesses, 4.8 (95% CI = 3.6 to 6.2) overuse injuries, and 2.8 (95% CI = 2.0 to 4.0) acute injuries per 1000 athlete days, respectively (Table 2).

TABLE 2 - Incidence rates and RRs/mean differences ± 95% CI, and number of athletes affected for illnesses, acute and overuse injuries, average duration, weekly severity score, cumulative severity score, and time loss days for their respective health issues
Paraplegic (n = 19) Nonparaplegic (n = 39) RR/Mean Difference (95% CI) All (N = 58)
 Incidence, n 37 57 94
 Incidence rate 10.3 (7.5 to 14.2) 7.6 (6.0 to 10.1) 0.8 (0.5 to 1.1) 8.6 (7.0 to 10.5)
 Duration, wk 1.7 (1.3 to 2.1) 2.4 (1.4 to 3.3) −0.7 (−1.9 to 0.5) 2.1 (1.5 to 2.7)
 Weekly severity score 47.4 (39.4 to 55.4) 41.7 (34.6 to 48.8) 5.7 (−5.0 to 16.5) 44.3 (39.0 to 49.6)
 Cumulative severity score 78.2 (55.2 to 101.2) 83.1 (57.5 to 108.6) −4.9 (−41.2 to 31.5) 81.9 (64.1 to 99.7)
 Time loss days, n 2.8 (1.5 to 4.1) 3.5 (2.2 to 4.9) −0.7 (−2.7 to 1.3) 3.3 (2.3 to 4.3)
Acute injuries
 Incidence, n 13 19 31
 Incidence rate 3.6 (2.1 to 6.2) 2.6 (1.7 to 4.1) 0.7 (0.4 to 1.4) 2.8 (2.0 to 4.0)
 Duration, wk 2.6 (−0.2 to 5.4) 2.5 (1.2 to 3.9) 0.1 (−2.7 to 2.9) 2.6 (1.2 to 2.9)
 Weekly severity score 40.9 (27.4 to 56.3) 29.4 (20.2 to 38.5) 11.1 (−4.2 to 26.4) 34.8 (27.1 to 42.6)
 Cumulative severity score 78.4 (21.4 to 135.4) 75.1 (33.7 to 116.5) 3.3 (−62.5 to 69.1) 76.6 (44.5 to 108.8)
 Time loss days, n 1.4 (0.2 to 2.6) 1.8 (0.4 to 3.2) −0.4 (−2.2 to 1.5) 1.6 (0.7 to 2.5)
Overuse Injuries
 Incidence, n 18 34 52
 Incidence rate 5.0 (3.2 to 8.0) 4.6 (3.3 to 6.5) 0.9 (0.5 to 1.6) 4.8 (3.6 to 6.2)
 Duration, wk 4.5 (1.1 to 7.8) 5.7 (3.3 to 8.1) −1.2 (−5.3 to 2.8) 5.3 (3.3 to 7.2)
 Weekly severity score 22.9 (15.0 to 31.5) 29.0 (24.0 to 33.9) −6.1 (−15.1 to 3.0) 26.8 (22.4 to 31.2)
 Cumulative severity score 123.5 (14.0 to 233.1) 117.2 (69.1 to 165.3) 6.4 (−94.5 to 107.2) 119.5 (71.4 to 167.5)
 Time loss days, n 4.0 (0.3 to 7.8) 2.1 (0.5 to 3.9) 1.8 (−1.7 to 5.3) 2.9 (1.2 to 4.5)

Paraplegic athletes had an IR of 10.3 illnesses (95% CI = 7.5 to 14.2) per 1000 athlete days, whereas nonparaplegic athletes reported rates of 7.6 illnesses (95% CI = 6.0 to 10.1) per 1000 athlete days (RR = 0.8 (95% CI = 0.5 to 1.1); Table 3). Incidence rates for overuse injuries in paraplegic athletes were 5.0 (95% CI = 3.2 to 8.0) versus 4.6 (95% CI = 3.3 to 5.6) in nonparaplegic and for acute injuries 3.6 (95% CI = 2.1 to 6.2) versus 2.6 (95% CI = 1.7 to 4.1), respectively (Table 2).

TABLE 3 - Incidences rates and RRs (RR ± 95% CI) for affected illnesses systems and injury locations for paraplegic (n = 19) and nonparaplegic athletes (n = 39)
Paraplegic (n = 19) Nonparaplegic (n = 39)
n IR (95% CI) n IR (95% CI) RR (95% CI)
 Upper airway 13 3.6 (2.1 to 6.2) 34 4.6 (3.3 to 6.5) 1.3 (0.7 to 2.4)
 Gastrointestinal 9 2.5 (1.3 to 4.8) 4 0.5 (0.2 to 1.5) 0.2 (0.1 to 0.7)*
 Urological 7 1.9 (0.3 to 4.1) (7 finger/hand injuries) 4 0.5 (0.2 to 1.5) 0.3 (0.1 to 1.0)*
 Gynecological 0 1 0.1 (0 to 1.0)
 Skin related 0 2 0.3 (0.1 to 1.1)
 Other infectiology 1 0.3 (0 to 2.0) 1 0.1 (0 to 1.0) 0.5 (0 to 7.8)
 Headache/memory/vertigo 6 1.7 (0.8 to 3.7) 3 0.4 (0.1 to 1.3) 0.2 (0.1 to 1.0)*
 Earache 0 3 0.4 (0.1 to 1.3)
 Psychiatric/psychological 0 2 0.3 (0.1 to 1.1)
 Symptoms of the underlying illness 0 1 0.1 (0 to 1.0)
 Other 1 0.3 (0 to 2.0) 2 0.3 (0.1 to 1.1) 1.0 (0.1 to 10.8)
Total 37 10.3 (7.5 to 14.2) 57 7.6 (6.0 to 10.1) 0.8 (0.5 to 1.1)
 Head 1 0.3 (0 to 2.0) 1 0.1 (0 to 1.0) 0.5 (0 to 7.8)
 Shoulder/chest 11 3.1 (1.7 to 5.5) 16 2.2 (1.3 to 3.6) 0.7 (0.3 to 1.5)
 Upper arm 0 1 0.1 (0 to 1.0)
 Elbow 3 0.8 (0.3 to 2.6) 5 0.7 (0.3 to 1.6) 0.8 (0.2 to 3.4)
 Finger/hand 7 1.9 (0.9 to 4.1) 4 0.5 (0.2 to 1.5) 0.3 (0.1 to 1.0)*
 Cervical spine 1 0.3 (0 to 2.0) 2 0.3 (0.1 to 1.1) 1.0 (0.1 to 10.8)
 Thoracic spine 3 0.8 (0.3 to 2.6) 1 0.1 (0 to 1.0) 0.2 (0 to 1.6)
 Lumbar spine 1 0.3 (0 to 2.0) 2 0.3 (0.1 to 1.1) 1.0 (0.1 to 10.8)
 Sacroiliac joint 2 0.6 (0.1 to 2.2) 1 0.1 (0 to 1.0) 2.0 (0.2 to 17.5)
 Hip/groin 1 0.3 (0 to 2.0) 2 0.3 (0.1 to 1.1) 1.0 (0.1 to 10.8)
 Thigh/gluteal 1 0.3 (0 to 2.0) 4 0.5 (0.2 to 1.5) 0.7 (0.1 to 23.4)
 Knee 0 4 0.5 (0.2 to 1.5)
 Lower leg/ankle 0 5 0.7 (0.3 to 1.6)
 Foot/toe 0 2 0.3 (0.1 to 1.1)
 Lower limb 0 1 0.1 (0 to 1.0)
 Stump 0 2 0.3 (0.1 to 1.1)
Total 31 8.6 (6.1 to 12.3) 53 7.2 (5.5 to 9.5) 0.8 (0.5 to 1.3)
*Significant group differences.

Burden of Health Problems—Time Loss and Injury/Illness Severity Score

With 10.927 athlete days recorded, we measured a total of 486 lost training days during the study period: 306 days (63%) because of illnesses, 149 days (31%) because of overuse injuries, and 31 days (6%) because of acute injuries, respectively. Illnesses and injuries were both associated with a mean time loss of 3 days. Looking at the cohort as a whole, illnesses showed higher severity scores than injuries (P < 0.001), whereas injuries resulted in longer duration (P = 0.002), with the highest cumulative severity score for overuse injuries (P > 0.05). There were no significant differences for paraplegic and nonparaplegic athletes with respect to days of time loss from training/competition and cumulative severity scores resulting from acute or overuse injuries or illnesses (Table 2).

Injuries and Illnesses According to Paraplegic and Nonparaplegic Athletes

The IR for upper respiratory tract infections was high for both paraplegic and nonparaplegic athletes with an IR of 3.6 (95% CI = 2.1 to 6.2) versus 4.6 (3.3 to 6.5). For paraplegic athletes, higher IRs were found for gastroenterological problems, urinary tract infections, as well as neurological problems (e.g., headache, vertigo). In addition, there was a significant higher IRs for finger/hand injuries in paraplegic athletes compared with nonparaplegic athletes (Table 3).

Evaluation of the Athletes’ Acceptance With the Surveillance Program

Two-thirds of the athletes (n = 48, 66.7%) responded to the evaluation questionnaire at the end of the monitoring program. Concerning the benefit of the project, 20 athletes perceived that the project “increases medical safety for myself.” Another 20 athletes claimed “benefit for future Games and future generations,” whereas 13 athletes judged the program as having “no benefit.”

When asked for their satisfaction with their medical support, 80% of the athletes reported to be “satisfied” (27%) or “very satisfied” (52%) with the medical support they got during the project compared with only 66%, before the project. Athletes proposed to add psychological aspects to the questionnaire as well as a method to fill out the questionnaire without Internet connection.

As points of criticism, it was listed that the questionnaire could only be completed with an Internet connection, which is not always available as well as that psychological aspects are not addressed in the questionnaire.


So far, little research on sports injury and illness epidemiology has been conducted among Para athletes compared with the able-bodied athlete population. This is the first prospective longitudinal study on injury and illnesses surveillance of elite-level Para athletes with clinically validated follow-ups of reported health problems. A total of 58 athletes participated in a health monitoring program and were followed for 29 consecutive weeks when preparing for and competing in the 2016 Rio de Janeiro Paralympic Games.

At any given time, almost 1 in 3 (28%) of these athletes reported health problems and 12% experienced substantial health problems. Injury and illness IRs varied from 2.8 to 8.6 cases per 1000 athlete days.

Not surprisingly, paraplegic had a higher weekly prevalence of health problems than nonparaplegic athletes, as well as higher IRs for certain injury and illness types.

Weekly Prevalence and Incidence Rates of Health Problems

The observed weekly prevalence of overall health problems (28%) was comparable with the retrospectively collected point prevalence of injuries and illnesses among Swedish Paralympic athletes (32% for injuries, 14% for illnesses).9 However, point prevalence of the German athletes were 46% for paraplegic and 32% for nonparaplegic athletes during their first week of data collection (Fig. 1). In an attempt to compare severe health issues between these two elite cohorts, the overall weekly prevalence of substantial health problems was lower among the German athletes (12%) compared with a period prevalence of severe injuries (31%) and severe illnesses (14%) among the Swedish Para athletes. In the Swedish team, “severity” was defined by “experiencing time loss for a minimum of 3 wks.”9 Differences within the cohorts, composition of sports and impairment groups, definitions, and design (prospectively vs retrospectively) should also cause awareness when comparing these two cohorts with respect to health risk.

The present weekly prevalence of health problems was also lower than that reported from able-bodied Olympic19 and young elite high school cohorts,23–25 all having applied the same methodology to continuously track athletes’ health (the OSTRC-H questionnaire). A generally higher prevalence of acute injuries in able-bodied athletes compared with Para athletes may explain these differences.

Looking at injury IRs, these were lower among the German Para athletes than those rates recorded in Paralympic Summer Games.6,8,26 These findings, however, were not surprising, considering the composition of the German cohort with respect to their sports. Although sports with high injury IRs in Paralympic Summer Games are football 5- and 7-a-side, rugby, wheelchair fencing, and judo,6 these sports were not represented among the German athletes included in this monitoring.

Illness and Injury Incidence Rates According to Impairment Group

Respiratory tract, gastrointestinal, and urinary tract infections were the most commonly reported illnesses. Paraplegic athletes, in specific, revealed a risk and should be regularly instructed with regard to urinary tract infections and gastrointestinal symptoms, as perineal hygiene, frequent bladder emptying, and hand sanitizing before catheterization. In addition, an annual urologic examination by an urologist experienced in paraplegic patients should be considered.13 Furthermore, some authors recommend regular urinary testing during major competitions to mitigate these health problems.13 Athletes should also be meticulously instructed in hygienic measures and infection prevention possibilities to avoid spreading of infectious diseases. Such measures should include the use of disinfectants and nasal showers, sneezing into the elbow instead of the hands, and avoiding hand shaking—especially to other team mates and stuff, media, etc.14,17,27 In the London 2012 and Rio 2016 Paralympic Games, athletes with SCI had the highest risk for new illnesses compared with other impairment types.3,11 In addition, the importance of sleeping and recovery time for the immune system should be communicated with the athletes and coaches.27,28

By observing a substantial risk for shoulder injuries, specifically among wheelchair athletes, this longitudinal monitoring supports the results of short-term surveillances showing high rates of shoulder injuries in Paralympic athletes.6,26 Shoulder prevention programs should therefore be the first goal when implementing prevention programs for wheelchair athletes.15 In this context, screening on subacromial impingement syndrome and rotator cuff injuries as well as sport specific problems (athletes shoulder/GIRD) should be assessed in the sports medical check-ups.29,30

Burden of Health Problems—Time Loss and Injury/Illness Severity Score

Illnesses had higher IRs and mean severity scores than injuries and were resulting in longer time lost from sport. These findings were in line with data from young elite high school athletes where illnesses represented the highest median weekly severity score.23 However, among these able-bodied athletes, illnesses lasted of generally shorter duration than injuries,23 which again is contrasting to what is observed among German Para athletes. For many Para athletes, illnesses, for example, urinary or upper respiratory infections, are often part of their underlying medical conditions. In addition, data on associating training load to illness risk are presently lacking in Para athletes.14

There were no significant differences for paraplegic and nonparaplegic athletes with respect to days of time loss from training/competition and severity scores resulting from injuries or illnesses, which was surprising considering the underlying medical conditions associated with comorbidities seen in many paraplegic athletes (14).

Strengths and Limitations/Methodological Considerations

The present data collection represents the first prospective long-term surveillance program of high-level German Para athletes, demonstrating the effectiveness of a health safety net with early interventions. Although the initial cohort of 72 athletes diminished to 58 over the surveillance period, this number provides valuable information on the health problems in high-level summer Para athletes preparing for Paralympic Games. These data can form a guidance in the clinical preparation for the Paralympic Games in Tokyo 2020.

Not being qualified for the 2016 Rio Paralympic Games was the main cause for athlete’s withdrawal from the program. However, the response rate of the remaining participants was as high as 93%, showing a good adherence and acceptance of the project. Another strength of this investigation to underpin its acceptance was the athletes’ high satisfaction reported in the final evaluation questionnaire. In addition, involved team physicians rated the additional information they got from the OSTRC-H questionnaire on their athletes’ medical conditions and training load as meaningful and worth spending time on.

External validity needs to be mentioned as one of the limitations of this study. Only one-third of the eligible athletes participated in the study, and 14 athletes withdrew during the study, which may restrict the generalizability to other elite Para athletes. In line with the above, project support from the national federations was varying in the German Para sport movement, which again was reflected by the fact that some sports achieved higher athlete participation rates than others. The current findings should encourage to further implement this monitoring program at all levels of stakeholders (athlete, coach, medical team, sport governing body), to expand the cohort to all German Para athletes, and thereby to improve the medical service.

The low participation rate (33%) was mainly due to the way of recruitment. Because of the European data protection rules, the eligible athletes had to be invited by the national federation. As soon as the athlete accepted the invitation, the project coordinator contacted the athlete and provided information and consent forms. However, if the importance of our study was not brought close to athletes from the federation’s side, it was likely that the corresponding request to participate was not of high priority for the athlete or lost among other demands of being a high-level athletes (e.g., as commitments to the training and competition schedules, sponsors, and antidoping declarations).

Another limitation to the methodology was the fact that the web-based reporting system currently is not accessible without Internet access and not barrier free. Visual impaired athletes had difficulties in independently completing the questionnaire, and intercellularly impaired athletes might not have fully understood the project information given, although additional help was provided to all athletes at any given time, if needed.

Practical Implications and Future Plans

The protection of the health of the athlete should be the core objective of any clinical profession dealing with athlete care. Given the fact that the acceptance of the participating athletes, coaches, and medical staff was very high, this monitoring program is to be continued to optimize medical support and communication strategies in German Paralympic sport and to evaluate the effects of health preventive measures.

As a main result of this project, the continuous monitoring of the athletes’ health showed a marked reduction in reported health problems throughout the monitoring period. This reduction in weekly prevalence could be attributed to an improved medical support with a short reaction time from the medical staff. However, fewer reported health issues during the 29 wks could also be the result of an underreporting of minor symptoms over time. Athletes might have considered the reporting of the same symptoms every week or of symptoms that did not need further attention (e.g., a running nose) as nonbeneficial. Other reasons for a decreasing reporting over time could be, for example, adaptation to higher training loads over time and time of the year. The monitoring started in early spring, which because of its climate could have resulted in a higher reporting of upper respiratory tract infections and colds.

The OSTRC-H has been shown to be a suitable method for injury and illness surveillance in German Para athletes. With these athlete training and competing across the world, we required the platform to be easily accessible worldwide to achieve high compliance from and a recognizable benefit for the athlete. The project showed the monitoring program feasible in a Paralympic setting and over a time frame, as long as 29 wks. Still speculative, the monitoring program could apply to other sports as well as to leisure time Para athletes with a lower medical support.

Monitoring programs, including early interventions, will contribute to reduce the risk of overtraining, injuries, and illnesses and consequently help athletes stay healthy and achieve their best performance.18−20,28 The second version of our German OSTRC-H questionnaire will contain the validated Patient Health Questionnaire-4 questionnaire to address psychological aspects31 and will also be assessable via a smartphone application allowing for offline availability.


At any given time, 28% of elite-level German Para athletes reported health problems, and 12% experienced substantial health problems. Paraplegic athletes had a higher weekly prevalence of health problems than nonparaplegic athletes, but the two groups did not differ with respect to the burden of risk. For a health team, illnesses seem to be even more important than injuries to handle. The OSTRC-H is a suitable method for injury and illness surveillance in Para athletes, and athletes expressed a high satisfaction with the monitoring program.


The authors thank the German National Paralympic Committee, especially Mrs. Solveig Konrad and Mr. Denis Schneider for promoting the project and contacting the athletes, the trainers, and the team doctors. The authors furthermore thank all team physicians being involved in the project for their cooperation, their help in data collection, and their support of the athletes. The authors are also grateful to Dr Ben Clarsen for his support in data management and statistical analysis as well as all to the participating athletes for diligently completing the questionnaires.


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Paralympic Athletes; Surveillance; Injury; Illness; Paraplegic; Para athlete

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