Comprehensive periodic health evaluations of 454 Norwegian Paralympic and Olympic athletes over 8 years: what did we learn?

OBJECTIVE: A periodic health evaluation (PHE) is a comprehensive and multidisciplinary investigation of athlete health widely used in elite sport, but its contents and benefits can be questioned. This study aimed to determine the prevalence of conditions identified by a PHE among Paralympic and Olympic athletes over four consecutive Games cycles from Rio de Janeiro 2016 to Beijing 2022 and to assess the benefits and potential pitfalls of a comprehensive PHE programme in detecting existing injuries, illnesses and other health issues. METHODS: We collected extensive health history and clinical examination data on elite athletes: medical history, ECG, blood pressure, blood samples, spirometry, musculoskeletal health, cognitive function, mental health and compliance with public health programmes. RESULTS: The final cohort included 87 Paralympic and 367 Olympic athletes, representing 565 PHE cycles. Musculoskeletal problems and unspecified pain, infections and allergies were the most frequent health issues. High blood pressure was the most prevalent cardiovascular finding, and vitamin D deficiency the most common laboratory abnormality. Most athletes complied with the public childhood vaccination programmes, but fewer with recommended cancer screening. Follow-up of health issues was variable. CONCLUSION: Our PHE programme identified musculoskeletal problems, infections, allergies, elevated blood pressure and vitamin D deficiency as common health conditions. Longitudinal follow-up of health conditions identified during screening and improved compliance with public health and cancer screening programmes is needed to determine the true benefits of athlete care prompted by the PHE.

Injury and illness among Norwegian Olympic athletes during preparation for five consecutive Summer and Winter Games.

OBJECTIVE: To describe the patterns of health problems among Norwegian Olympic candidates during their preparations for five consecutive Olympic Games (London 2012, Sochi 2014, Rio de Janeiro 2016, PyeongChang 2018 and Tokyo 2020). METHODS: This was a descriptive epidemiological study using the Oslo Sports Trauma Research Center Questionnaire on Health Problems to collect data on all self-reported health problems from Norwegian Olympic candidate athletes for 12-18 months prior to each Olympic Games. Team physicians and physiotherapists followed up the athlete reports, providing clinical care and classifying reported problems according to the International Olympic Committee 2020 consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sport. RESULTS: Between 2011 and 2020, 533 athletes were included in the Norwegian Olympic team monitoring programme, with a 78% response to the weekly questionnaire. During this time, athletes reported 2922 health problems, including 1409 illnesses (48%), 886 overuse injuries (repetitive mechanism, 30%) and 627 acute injuries (traumatic mechanism, 21%). Diagnostic codes were recorded for 2829 (97%) of health problems. Athletes reported, on average, 5.9 new health problems per year (95% CI: 5.6 to 6.1), including 1.3 acute injuries (CI: 1.2 to 1.4), 1.7 overuse injuries (CI: 1.6 to 1.9) and 2.9 illnesses (CI: 2.7 to 3.0). Each year, female and male athletes lost an average of 40 and 26 days of training and competition due to health problems, respectively. The diagnoses with the highest health burden were anterior cruciate ligament rupture, respiratory infection, lumbar pain and patellar tendinopathy. CONCLUSION: The injury burden was particularly high among female athletes and in team sports, whereas endurance sports had the greatest burden of illness. Our data provide a compelling argument for prioritising medical care and investing in prevention programmes not just during the Olympic Games, but also the preparation period.

High prevalence of low bone mineral density but normal trabecular bone score in Norwegian elite Para athletes.

Background: Low bone mineral density (BMD) increases the risk of bone stress injuries (BSI) and is one of several clinical concerns in Para athlete sports medicine. However, whether bone microarchitecture is altered in Para athletes is not known. Objective: We aimed to investigate BMD, bone microarchitecture and incidence of bone stress injuries in Norwegian elite Para athletes. Design: In this cross-sectional study in Para athletes, Dual energy x-ray absorptiometry (iDXA, Lunar, GE Health Care) derived areal BMD, trabecular bone score (TBS), a surrogate marker for bone microarchitecture, and body composition (body weight (BW), lean body mass (LBM), fat mass (FM), fat percentage) were investigated and compared between ambulant and non-ambulant athletes. Also, the association between BMD, TBS and body composition variables was investigated. Incidence of BSI was assessed with a questionnaire and confirmed by a sports physician in a clinical interview. BMD Z-score <-1 was defined as low and ≤-2 as osteoporotic. TBS ≥ 1.31 was normal, 1.23-1.31 intermediate and <1.23 low. Results: Among 38 athletes (26 ± 6 yrs, 14 females), BMD Z-score was low in 19 athletes, and osteoporotic in 11 athletes' lumbar spine (LS) or femoral neck (FN). BMD was lower in non-ambulant vs. ambulant athletes both in LS (1.13 ± 0.19 vs. 1.25 ± 0.14 g/cm2, p = 0.030) and FN (0.90 ± 0.15 vs. 1.07 ± 0.16 g/cm2, p = 0.003). TBS was normal for all athletes. BMD Z-score in LS was positively associated with TBS (r = 0.408, p = 0.013), body weight (r = 0.326, p = 0.046) and lean body mass (r = 0.414, p = 0.010), but not with fat mass or fat percentage. None of the athletes reported any BSI. Conclusions: Half of the Norwegian elite Para athletes had low BMD, and 29% had BMD Z-score <-2 suggesting osteoporosis. Non-ambulant athletes were more prone to low BMD than ambulant athletes. However, despite high prevalence of low BMD, TBS was normal in all athletes, and BSI was absent in this young population.

Health-related quality of life in young Norwegian survivors of out-of-hospital cardiac arrest related to pre-arrest exercise habits.

Aim: To compare health-related quality of life (HRQoL) in young survivors of out-of-hospital cardiac arrest (OHCA) in Norway with an age and sex-matched reference population and to assess the associations between exercise volume prior to OHCA and HRQoL after. Methods: We present data from survivors aged 18-50 years registered with OHCA in the Norwegian Cardiac Arrest Registry between January 1st 2015 and December 31st 2017. Survivors were invited to answer two questionnaires; (1) the Short Form 36 (SF-36) Health Survey Version 1, and (2) about exercise habits prior to OHCA. Respondents were randomly matched 1:1 for age and sex with a reference population (data were available from the Norwegian Centre for Research Data). Results: Of the 175 survivors invited, 95 (54%) responded, median age was 44 (range 35-48) years, 26 (27%) females. Valid results for SF-36 were available for 91 survivors, of whom 87 reported pre-OHCA exercise-volume. Prior to OHCA, 21 did no regular exercise, 44 exercised 1-4 hours/week and 22 exercised ≥5 hours/week. Compared to the reference population survivors had significantly (p < 0.01) poorer SF-36 scores for scales relating to physical- and mental health. SF-36 scale scores were similar in survivors who did and did not exercise regularly. Within the regular exercisers, survivors reporting ≥5 hours of exercise/week had better SF-36 scores than those exercising less. Conclusion: Poorer HRQoL in survivors compared to the reference population should prompt us to explore how treatment and rehabilitation could be improved and adapted. More exercise before OHCA favoured better HRQoL after, which aligns well with the recognised positive association between HRQoL and physical activity in general.

A 3-year population-based study of exercise-related sudden cardiac arrest among 12- to 50-year-old Norwegians.

INTRODUCTION: Regular exercise is associated with reduced risk of cardiovascular disease. Paradoxically, an increased risk of sudden cardiac arrest (SCA) is documented during or immediately after exercise and in athletes compared to the nonathletic population. Our objective was to identify, through multiple sources, the total number of exercise-related versus non-exercise-related SCA in the young population in Norway. METHODS: We collected primary data from the prospective Norwegian Cardiac Arrest Registry (NorCAR) for all patients aged 12-50 suffering SCA of presumed cardiac cause from 2015 to 2017. We collected secondary data about prior physical activity and the SCA, through questionnaires. We searched media reports for SCA incidents in sports. Exercise-related SCA is defined as SCA during or <1 h after exercise. RESULTS: Overall, 624 patients, median age 43 years, were included from NorCAR. Two thirds (393) replied to the study invitation, of whom 236 answered the questionnaires: 95 survivors and 141 next of kin. The media search resulted in 18 relevant hits. With a multiple source approach, we identified 63 cases of exercise-related SCA, equivalent to an incidence of 0.8/100 000 person-years, versus 7.8/100 000 person-years of non-exercise-related SCA. Among those who answered (n = 236), almost two thirds (59%) exercised regularly, most commonly (45%) 1-4 h/week. Endurance exercise (38%) was the most prevalent type of regular exercise and the most common activity during exercise-related SCA (53%). CONCLUSION: The burden of exercise-related SCA was low (0.8 per 100 000 person-years) and ten times lower than non-exercise-related SCA in the young population in Norway.

The aftermath of surviving a sudden cardiac arrest for young exercisers - a qualitative study in Norway.

BACKGROUND: When surviving a sudden cardiac arrest (SCA), physical, cognitive, and emotional effects of surviving may be present for months or years. The survivors' family and colleagues are also highly affected by the incident. There is little knowledge about experiences of surviving SCA in individuals who prior to the incident were young and reported to exercise regularly. Consequently, the aim of this study was to explore the aftermath of surviving a SCA in young, regular exercisers. METHODS: The study had a qualitative design, conducting in-depth individual interviews with SCA survivors < 50 years of age reporting to exercise ≥ 5 h/week and/or who suffered SCA during or less than 60 min after exercise. The data were analysed using systematic text condensation in-line with recommendations from Malterud. RESULTS: 18 of 31 eligible participants were included in the study. Through analysis we identified 'Establishing a new everyday life' as superordinate category, with subordinate categories a) being part of my surroundings, b) expecting normality but facing a new reality and c) lucky to be alive! CONCLUSION: This study adds knowledge about young and regular exercisers' experiences after surviving a SCA. The obligations of everyday life in young survivors of SCA often imply a high work load and complex tasks, e.g. due to being in the beginning of their career or even still studying. Healthcare personnel, as well as the society, need to acknowledge that although lucky to be alive and apparently well-functioning, young survivors of SCA may have persistent challenges that cause frustration and reduced quality of life.

Experiences of cardiac arrest survivors among young exercisers in Norway: A qualitative study.

Aim: To explore how young exercisers experience surviving sudden cardiac arrest (SCA), focusing on interpretation of warning signs and experiences with the healthcare system. Methods: The study had a qualitative design, and data was collected using individual, semi-structured interviews. Inclusion criteria were SCA survivors aged 18-50 years old who reported at least five hours of exercise/week prior to SCA, or who suffered SCA during or ≤60 min after exercise. Results: 18 interviews were performed (4 females), age range 19-49 years old. Analysis identified the themes [1] neglected warning signs, [2] fluctuating between gratitude and criticism and [3] one size does not fit all. When young exercisers experienced symptoms such as fainting, chest pain, arrythmia, shortness of breath and fatigue, these were often ignored by either the participants, healthcare personnel or both. SCA survivors were grateful to the healthcare system and for the efforts made by healthcare personnel, but experienced a mismatch between what patients needed and could utilize, and what they actually received regarding both information and individualised services. Being young exercisers, the participants reported to have individual needs, but treatment and rehabilitation were not adapted and were mainly targeted to rehabilitation of older patients. Conclusion: Patients and healthcare personnel should be aware of cardiac related symptoms and warning signs for SCA, and these should be properly assessed in the population of young exercisers. SCA survivors need useful and repeated information. The needs of SCA survivors among young exercisers require individualisation of services.

Illness and injury among Norwegian Para athletes over five consecutive Paralympic Summer and Winter Games cycles: prevailing high illness burden on the road from 2012 to 2020.

OBJECTIVE: To describe the illness and injury pattern of Norwegian Para athletes over five consecutive Paralympic Summer and Winter Games cycles and to identify which health problems should be targeted in risk management plans with respect to impairment types. METHODS: We monitored athletes from 12 to 18 months prior to each Game using a weekly online questionnaire (Oslo Sports Trauma Research Center-H2 (OSTRC-H2)). We asked them to report all health problems they had experienced in the preceding 7 days, irrespective of their consequences on their sports participation or performance and whether they had sought medical attention. RESULTS: Between 2011 and 2020, 94 candidate athletes were included in this monitoring programme and prepared to represent Norway; of these, 66 (71%) were finally selected for multiple Paralympic Games. The overall response rate to the weekly questionnaires was 87%. At any given time during the five observation cycles, 37% of the athletes (95% CI 36% to 38%) reported having at least one health problem. Athletes with neurological impairments (n=51) lost 10 days per year due to respiratory problems (95% CI 9 to 11) compared with 9 days (8-10) among those with musculoskeletal impairments (n=37). Gastrointestinal problems caused a time loss of on average 4 days per year in athletes with neurological impairments versus 1 day in athletes with musculoskeletal impairments (mean difference 2.7 days, 2.1-3.3). Musculoskeletal injuries generated a high burden for both athlete groups, in particular, to the elbow, shoulder and lumbosacral regions. CONCLUSION: At any given time, nearly two out of five elite Norwegian Para athletes reported at least one health problem. Respiratory tract and other infections; gastrointestinal problems, injuries to the shoulder, elbow and lumbosacral regions represented the greatest health burden. Our findings can help guide the allocation of clinical resources, which should include a broad network of medical specialists, together with dieticians and physiotherapists, to meet the health challenges in Para athletes.

Methods, challenges and benefits of a health monitoring programme for Norwegian Olympic and Paralympic athletes: the road from London 2012 to Tokyo 2020.

OBJECTIVE: To describe the implementation of a health monitoring programme for Norwegian Paralympic and Olympic candidates over five consecutive Olympic and Paralympic Games cycles (London 2012, Sochi 2014, Rio de Janeiro 2016, PyeongChang 2018 and Tokyo 2020). METHODS: Athletes were monitored for 12-18 months preparing for the games using a weekly online questionnaire (OSTRC-H2) with follow-up by physicians and physiotherapists, who provided clinical care and classified reported problems. RESULTS: Between 2011 and 2020, 533 Olympic and 95 Paralympic athletes were included in the monitoring programme, with an overall response of 79% to the weekly questionnaire and a total observation period of 30 826 athlete weeks. During this time, 3770 health problems were reported, with a diagnosis rate of 97%. The average prevalence of health problems at any given time was 32% among Olympic athletes and 37% among Paralympic athletes. Acute traumatic injuries represented the greatest burden for Olympic team sport athletes, and illnesses represented the greatest burden for Olympic endurance and Paralympic athletes. On average, Olympic athletes lost 27 days and Paralympic athletes lost 33 days of training per year due to health problems. CONCLUSION: Conducting long-term health monitoring of Olympic and Paralympic athletes is challenging, particularly because athletes travel frequently and often relate to many medical providers. This programme has been implemented and improved within Team Norway for five Olympic and Paralympic cycles and during this time we believe it has helped protect our athletes' health.

Cardiovascular incidents in male professional football players with negative preparticipation cardiac screening results: an 8-year follow-up.

BACKGROUND: Preparticipation cardiac screening of athletes aims to detect cardiovascular disease at an early stage to prevent sudden cardiac arrests and deaths. Few studies have described the cardiovascular outcomes in athletes classified as negative on screening. OBJECTIVE: To identify cardiovascular incidents in a cohort of male professional football players who were cleared to play after a negative screening result. METHODS: This is a retrospective 8-year follow-up study of 595 professional male football players in Norway who underwent preparticipation cardiac screening by experienced cardiologists, including electrocardiography (ECG) and echocardiography, in 2008. We performed a media search to identify sudden cardiovascular incidents between January 2008 and February 2016. Incidents were cross-checked with medical records. RESULTS: Six of the 595 players (1%), all classified as negative on cardiac screening, experienced severe cardiovascular incidents during follow-up. Retrospective review revealed abnormal ECG findings in one case, not recognised at the time of screening. Three players suffered a sudden cardiac arrest (all resuscitated successfully), one a myocardial infarction, one a transient ischaemic attack and one atrial flutter. Three of the players ignored chest pain, paresis, dyspnoea or near-syncope, two completed a match with symptoms before seeking medical assistance, one player's symptoms were misinterpreted and received inappropriate treatment initially, and two players were discharged from hospital without proper follow-up, despite having serious cardiovascular symptoms. CONCLUSIONS: A comprehensive preparticipation cardiac screening did not identify a subset of 6 of 595 players who experienced subsequent cardiovascular incidents as being at risk. It is important to remind athletes that a normal cardiac screening exam does not protect against all cardiac diseases. Timely reporting of symptoms is essential.

[Cardiac screening of young athletes]. / Hjertescreening av unge idrettsutøvere.

BACKGROUND: Young athletes are at an increased risk of sudden cardiac death compared to others. Cardiac screening has been proposed to prevent deaths. We wished to review the evidence for cardiac screening of young athletes. METHOD: We have conducted a literature search in PubMed on sudden cardiac death in young athletes, using a combination of search terms related to screening, incidence, cost efficiency and recommendations, supplemented by secondary references and articles from our own archive. RESULTS: Published studies utilise a variety of definitions of athlete and sudden death, and some studies also include cardiac arrest with subsequent successful resuscitation. Retrospective studies, often based on media searches, remain the most common form. The cause of death is not invariably determined by an autopsy. Recommendations in favour of screening are based on studies of limited quality and on the personal, often regional, experiences of experts. INTERPRETATION: The differences in study methods result in uncertain incidence figures. The estimates of cost efficiency are therefore questionable. To improve the quality of knowledge, standardised methods need to be devised, ideally also including a register of cardiac arrest in children and young people. To date, we have insufficient knowledge to recommend mandatory cardiac screening with ECG in Norway. Should this be introduced, it should be differentiated according to gender, type of sport and competition level. Cost efficiency could probably be improved with the aid of standardised questionnaires and a standardised interpretation of ECG among athletes.

High ambulatory blood pressure in male professional football players.

BACKGROUND: No data exist on ambulatory blood pressure (ABP) in athletes. OBJECTIVES: To identify ABP and examine recommended follow-up of high office blood pressure (OBP) in male professional football players and secondary study indicators of sympathetic activity. METHODS: Players with high OBP (cases) from a previous screening of 594 players (n=28) were matched for age and ethnicity with players with optimal OBP (controls). High ABP was defined as a mean of ≥135/85 mm Hg during daytime and ≥120/75 mm Hg during night-time. The players replied to questions regarding follow-up of high OBP. High night-time ABP and lack of nocturnal dip (≤10% decline in average BP) were taken as indicators of increased sympathetic activity. RESULTS: 26 cases and 26 controls, mean age 28±4 years, were included. 15 (58%) of the cases had sustained hypertension and 11 (42%) white coat hypertension. Among the controls, 17 (65%) had normotension and 9 (35%) masked hypertension. ABP during night-time was high in 23 (88%) of the cases and in 16 (64%) of the controls, and nocturnal dip was absent in 9 (35%) and 11 (42%), respectively. 10 (38%) of the cases had no follow-up of high OBP. CONCLUSIONS: More than one-third of the players with optimal OBP had masked hypertension during daytime and more than half of all players had high ABP during night-time, which are novel findings in athletes. Together with the reduced nocturnal dip, this might indicate increased sympathetic activity. Follow-up of high OBP after preparticipation screening is random and should be organised.

[Use of glucosamine does not reduce the need for other pain-relieving drugs]. / Glukosaminbruk reduserer ikke behovet for analgetika.

BACKGROUND: Since 2004, glucosamine has been available as a prescription drug for symptomatic treatment of mild to moderate osteoarthritis. The aim of this study was to characterize glucosamine utilization patterns, and patients' concomitant use of other analgesics, as well as the prescribers' medical specialty. MATERIAL AND METHODS: We searched the Norwegian Prescription Database for all glucosamine prescriptions dispensed during the years 2004, 2005 and 2006, and prescriptions for analgesics with codeine, and non-steroidal anti-inflammatory drugs (NSAIDs) reimbursed for arthrosis for the same patients. RESULTS: In the three-year period, 91,107 patients received 297,558 prescriptions for glucosamine-corresponding to a total cost for patients of 70 mill. NOK. 86 % of patients were more than 50 years old, 69 % were women. Among physicians with a known specialty, 84 % of prescribers were specialists in general practice. 33.3 % of patients used glucosamine all three years. Among the patients who used glucosamine regularly 19 % were prescribed NSAIDs, while 22 % of them used analgesics containing codeine. Patients who started taking glucosamine did not reduce their use of analgetics containing codeine. A positive correlation was seen between use of glucosamine and use of NSAIDs. INTERPRETATION: Glucosamine use is not associated with use of less other pain-relieving drugs. This may reflect insufficient clinical effect of glucosamine.