Injuries to individuals participating in mountain and
wilderness sports: a thematic review
(Short title: Mountain and wilderness sports injuries)
Alasdair Mort, PhD, and David Godden, MD
Authors’ affiliation: Centre for Rural Health, University of Aberdeen, Scotland, UK
Word count (abstract): 241
Word count (text portion): 2,492
Corresponding author:
Alasdair Mort, PhD
Centre for Rural Health, University of Aberdeen
Centre for Health Science
Inverness IV2 3JH
Scotland, UK
E-mail: a.mort@abdn.ac.uk
Telephone: +0044 (0)1463 255 886 Fax: +0044 (0) 1463 255 800
Acknowledgements:
This research was funded by the University of Aberdeen Sixth Century Fund and by
Highlands and Islands Enterprise (Inverness and East Highland)
Abstract
Objective: to summarise evidence on injuries occurring in individuals participating in
mountain and wilderness sports.
Data sources: SCOPUS, ISI Web of Knowledge, SPORTDiscus, OVID Safety and
Health, Index to Theses, COPAC, and SportScotland e-library. Search term: (mountain*
or wilderness or adventure or climb* or (hill walk*)) AND (accident* or injur* or
rescue*) AND (epidemiolog* or statistic* or pattern* or survey*). Search period: 1987
to 2010.
Study selection: A total of 2,034 articles were identified. The full text of 137 articles
was retrieved. 50 articles met inclusion criteria – mountain and wilderness; nonmotorised, leisure time, outdoor activities; non-fatal injury. Skiing and snowboarding
articles were excluded.
Data extraction: Study design was classified using the ‘STOX’ hierarchy of evidence.
Study quality was rated independently by two reviewers.
Data synthesis: All studies were observational. Twenty-one (42%) were longitudinal,
20 (40 %) were cross sectional surveys, and nine were cohort studies. A majority of
casualties were aged 20-39 years. There was a clear male majority, 70-89% in most
studies. 5-10 % of casualties sustained severe injuries – less than 10% were admitted to
hospital. Casualties sustained an average of 1.2-2.8 injuries (most > 1.6), which mainly
affected the soft-tissues; between 2 - 38% were fractures. Up to 90 % of injuries were to
the extremities.
Conclusions: The majority of mountain and wilderness sports injuries are minor to
moderate. However, some casualties have life-threatening medical problems, which
may have long-term implications for return to sport and general well-being.
Key words: mountain, wilderness, injury
INTRODUCTION
Health promotion strategies challenge obesogenic lifestyles by encouraging
individuals to be more physically active. For example, the American College of Sports
Medicine and American Medical Association endorse the “Exercise is Medicine™”
programme (exerciseismedicine.org). Strategies for increasing exercise levels include
the promotion of the great outdoors.1 In 2010, there were just over 281 million
recreation visits to US National Parks, involving around one and a quarter billion hours
of recreation time.2 Evidence indicates that some areas have seen an increase in
recreation visits,3 and visits to some US national parks are expected to increase with
climate change.4,5
Participation in some high-energy, outdoor sporting disciplines has increased.
For example, the number of mountaineers attempting to summit Mount McKinley
(Denali National Park, US) rose from 659 in 1980 to 1,223 in 2010 (peak of 1,340 in
2005).6 Also, the number of persons visiting a purpose-built Scottish mountain bike
centre rose by 55 % from 2002 to 2003.7 Activities similar to these are now widely
available to the general population through improved access, increased provision of
courses and expert guides, and lower cost equipment hire, amongst other factors.
However, these activities can be hazardous and occasionally result in fatality.8
There is clearly an important trade-off between the physical and psychological
benefits of participating in mountain and wilderness sports and the risk of experiencing
injury, which may have long-term consequences. The objective of this review is to
summarise the spectrum of injuries occurring in individuals participating in mountain
and wilderness sports. The findings are of relevance for clinicians who may treat
participants and for groups developing safety messages.
METHODS
Review Design and Inclusion and Exclusion criteria
We defined mountain and wilderness sports as active, competitive or noncompetitive outdoor pursuits taking place in non-urban environments. This includes, but
is not exclusive to, upland areas, moorland, deserts and forests. We did not define
‘mountain’ by a particular altitude, or ‘wilderness’ by distance from a population of a
specific size. This definition reflected the wider use of this terminology (e.g. ‘mountain
biking’ is usually not defined by a particular altitude or gradient).
A thematic design was selected in order to classify injuries by mountain and
wilderness sport. Inclusion and exclusion criteria are defined in Table 1. Expressions of
opinion and case studies/series were excluded to minimise bias. No restrictions were
placed upon country of origin, although only full-text articles in English were included.
Articles published pre-1987 were excluded in order that the review reflected
predominantly ‘modern’ sports practices. Also, pilot searches indicated that the majority
of relevant articles were published from 1987 onwards.
Articles describing injuries resulting from skiing (of any type) and
snowboarding were excluded. Skier and snowboarder injury data are well-represented in
the research literature.9-11 Also, mechanisms for recording participation data are in
place; most skiers and snowboarders require lift passes, facilitating case finding and
incidence studies. There are also publications dedicated specifically to this field. Other
mountain and wilderness sports injury epidemiology on the other hand has been
described as, “…the pursuit of infrequent phenomena”.12
Literature Search
Nine electronic databases were searched; SCOPUS, ISI Web of Knowledge,
SPORTDiscus, OVID Safety and Health, Index to Theses, COPAC, and the
SportScotland e-library. The search term employed was; (Mountain* OR Wilderness
OR Adventure OR Cave OR Caving OR Climb* OR (Hill walk*)) AND (Accident* OR
Injur* OR Rescue*) AND (Epidemiolog* OR Statistic* OR Pattern* OR Survey*). The
keyword string was shortened for selected databases. Three journals with direct
relevance were hand-searched; Wilderness and Environmental Medicine (pre-1995,
Journal of Wilderness Medicine), High Altitude Medicine and Biology and the
Emergency Medicine Journal.
Figure 1 displays a flowchart of the search strategy. The initial search identified
a total of 2,034 potential articles, which was reduced to 1,667 after excluding articles
published pre-1987 and those in languages other than English. An additional 52 articles
were identified through hand-searching and searching grey literature. The full text of
142 articles was selected, 137 of which were successfully retrieved and reviewed
independently by the authors. The authors came to agreement on a final list of 50
articles.
Evidence Classification
The design of included studies was categorised according to STOX
methodology (Table 2).13 STOX was originally developed for classifying evidence in
cross-disciplinary research; as such it is more inclusive than other systems, referring to
evidence ‘type’ rather than strength. STOX also features several levels for observational
designs.
Quality Assessment
The quality of included studies was appraised so that each piece of evidence was
given appropriate weighting in the review. A new matrix was developed which included
a total of 11 quality items; no gold-standard matrix for appraising observational studies
existed.14 Each item was assigned to one of three categories; the categories were: ‘A’ –
criteria met in full; ‘B’ – criteria met in part; and ‘C’ – criteria not met. This was
preferred to numerical scoring, which can be confusing as different scales apply
different weights to key methodologic domains.15
The authors critically appraised each article independently. Inter-rater agreement
was calculated using the Kappa coefficient.16,17 The authors then reviewed their
appraisals and discussed any discrepancies, to reach agreement on refined appraisal
criteria. Agreement was reached on 79.8 % of quality items – disagreement was
restricted to either A-B (11.6 %) or B-C (10.9 %) error. The resulting Kappa score was
0.64, indicating substantial agreement above chance alone, and this was considered
sufficient to progress to data extraction.
Data Extraction and Synthesis
Relevant data from each article were extracted into an Excel (Mircosoft®,
Redmond, Washington, US) spreadsheet for summary and comparison purposes.
Articles were arranged thematically by mountain and wilderness sport discipline, then
by evidence type. Data synthesis was solely narrative - a meta-analysis of study data
would have been inappropriate considering the substantial variation in study design.
RESULTS
Description of included studies
The 50 included studies were grouped into four mountain and wilderness sport
categories: mountaineering, rock climbing, trekking/hiking; mountain biking; adventure
racing; casualties from other sports. All studies were observational; the majority were
longitudinal analyses (n=21, 42 %) or cross-sectional surveys (n=20, 40 %). The
remaining nine articles described cohort studies (18 %). Twenty-one studies (42 %)
derived from the United States, ten (20 %) from the UK. Nine studies examined
European data (5 Austrian). The remaining ten articles included data from New
Zealand, Australia, Nepal, Brazil and Canada. Among all included articles, from the 11
quality items assessed, the mean number of ‘A’ ratings was 7, the mean number of ‘B’
ratings was 1.1, and ‘C’ ratings 2.9. Table 3 summarises data from individual studies.
Demographics
Casualty mean age was most often between 30 and 39 years followed by 20-29
years although individual casualty age could be considerably older or younger (range: 7
to 73 years). All studies reported a male majority, ranging from 53.3 % to 91.2 % (most
commonly 70 %-89 %).
Injury severity
Nine studies classified injury severity using recognised clinical scoring systems.
Eight studies reported an Injury Severity Score (ISS), which uses the body part-specific
Abbreviated Injury Score (AIS) as its basis.18,19 ISS ranges from a minimum score of 0,
indicating no injury, to a maximum of 75 – a score of 75 is given automatically if any
body part has an AIS of 6. One study reported injury severity according to the scale
developed by the American National Advisory Committee for Aeronautics (NACA),
which ranges from 0 (no injury or illness) to VII (death on scene).20
Mean ISS ranged from 2.9 to 6.2 indicating that mountain and wilderness sports
injuries were mostly minor to moderate. However, there were some more serious
injuries – individual casualty ISS ranged from 1 to 41. Approximately 5-10 % of
injuries were reported severe in nature, although studies applied different ISS thresholds
for ‘severe injury’ (from ISS 13 to 15). The one mean NACA reported was 3.4 (NACA
III = severe, but not life-threatening disease or injury; acute intervention necessary;
NACA IV = development of vital (life-threatening) danger possible). Generally, less
than 10 % of casualties treated at definitive care were admitted for further treatment,
although 60 % were admitted in one study,28 an exception to the majority of data.
Between 1.5 % and 5.6 % of casualties were treated in intensive care. Mean length of
hospital stay was three weeks or less, but ranged up to five months for individual
casualties. Between 25 % and 73 % (majority ≤ 50 %) of survey respondents sought
treatment from a range of healthcare practitioners including emergency room staff,
family physicians and physiotherapists. The proportion of casualties requiring surgical
management ranged from 0 % up to 66 % of those with ISS > 12 admitted to one
trauma centre.
Injuries sustained
The mean number of injuries sustained by individuals ranged from 1.2 to 2.8,
although eight out of the nine studies that included this statistic reported ≥ 1.6 injuries.
The proportion of casualties sustaining multiple injuries ranged from 11 % to 60 %
(majority < 50 %). Mountain and wilderness sports injuries mostly affected the softtissues - abrasions, lacerations and contusions were experienced by up to three quarters
of individuals injured. Sprains and strains were also reported, some of which were
chronic problems associated with excessive training. Within studies, the proportion of
fracture managed ranged from 2 % to 38.2 % (Figure 2). However, when expressed by
body part injured, the proportion of fracture could be far greater – for example, one
study reported that 90.5 % of spinal injuries involved fracture.28 Some evidence from
mountain biking indicated that females were more likely to sustain fracture than
males.43
Body part(s) injured
Up to 90 % of injuries affected the extremities. The proportion of lower
extremity injury was broadly similar across mountain and wilderness sport themes
(range: 17.7 % to 54 %; majority 20 % to 40 %) (Figure 3). There was the suggestion
that mountaineering and rock climbing resulted in less lower extremity injury overall. A
majority of hiking/trekking studies reported a preponderance of lower extremity and
back injury.39-42 In contrast, there was much variation in the proportion of upper
extremity injury (range: 6 % to 70 %; majority 10 % to 50 %) (Figure 4), some of which
could be accounted for by methodological differences. For example, surveys of rock
climbers tended to report more upper extremity injury than longitudinal studies.35,38
The proportion of head injury ranged from 6 % to 29 % (majority 10% to 20%).
Around 10 % of injuries affected the face, while injuries to the torso accounted for less
than 20 % of problems (commonly < 10 %) - injuries affected the chest more than the
abdomen. Generally less than 10 % of injuries affected the spine or back, although up to
27 % of climbers who fell more than 2m and 49 % of paragliders suffered spinal
injury.31,66
Risk factors for injury
Rock climbers sustained a majority of acute injury through falling then landing
in a feet- or side-first position.29,30,34 Falls resulting in injury tended to occur on routes
of lower difficulty.30,35 In mountaineering, injury severity following falls was influenced
more by the nature of the climbing surface than by fall height per se – travelling on
mixed terrain (rock and snow/ice) was particularly hazardous.33,34 Injured hikers were
often ill-prepared (e.g. wearing inappropriate footwear, poor navigation skills).26,33,39,41
Mountain bikers tended to sustain injuries when travelling downhill and after losing
control.43,44,46,56,58 Forward falls over the handlebars were associated with greater
injury.44,52 Some collisions and mechanical failure, particularly in the downhill event,
were also noted. Adventure racers were more susceptible to injury if they were
inexperienced, and also if competitors had pre-existing injuries.62 Disciplines conducted
on foot were associated with more injury.62,64
DISCUSSION
Individuals participating in mountain and wilderness sports sustained a diverse
range of injuries. The majority were minor to moderate complaints that were either self-
treated or required minimal management. However, more serious injuries were noted,
some of which were potentially life-threatening and required sophisticated management.
These injuries may have involved a lengthy process of rehabilitation, impacting upon
individuals’ ability to work, return to sport and overall quality of life; this applies to
persons treated as inpatients or outpatients.71,72 Considerable financial costs have been
reported from related activities. For example, over 15,000 individuals sustaining
‘adventure tourism’ injuries in New Zealand, including some injuries from mountain
and wilderness sports, submitted claims totalling over 15.5 million NZ$ in one year
between July 2003 and June 2004 (median claim cost – 98.6 NZ$) – injuries from
mountain biking accounted for the fourth highest number of claims.73
There is evidence to indicate that the nature of mountain and wilderness sports
injury may be altered by changes in equipment design. For example, Nehoda and coworkers reported the incidence of central liver injury to mountain bikers in Austria
using a particular type of bar-end.49 The number of individuals with liver injuries
dropped dramatically when this equipment was removed from the market. Such
interaction-type injuries have also been associated with clipless pedal systems, where
the rider is unable to release himself in adequate time and is injured by the bike itself. 74
The modification of existing sporting disciplines may also introduce unique injury
‘sets’. For example, the development of the shorter, faster, more aggressive event of
downhill mountain biking resulted in a significantly higher injury rate (per period of
riding time) compared with cross-country riders – evidence suggested that downhill
riders experienced more face/head/neck injury and more fractures, and were more likely
to be treated in emergency rooms.44 It seems likely that this trend of invention will
continue and clinicians should remain alert to subtle changes in injury mechanism and
type.
LIMITATIONS
There were some limitations to this review. There was considerable variation in
the volume and type of data recorded by individual studies. For example, several
systems were employed to classify injury type, severity and body part(s). Only a
minority of studies were higher quality cohort studies - the majority were longitudinal
analyses and cross-sectional surveys. Included cross-sectional surveys were open to
recall and selection bias –75 also, injuries were self-reported, not physician diagnosed.
Most cross-sectional surveys reported the demographics of all survey respondents,
including individuals without injury. Finally, grouping mountaineering, rock climbing
and hiking/trekking into a single theme may have restricted the analysis of individual
disciplines.
SUMMARY AND RECOMMENDATIONS
Mountain and wilderness sports injuries were in the main minor to moderate,
although a minority of life-threatening problems were reported. It is likely that some of
these injuries will have been associated with long-term sequelae, requiring prolonged
rehabilitation. There are several evidence gaps that should be addressed in future
studies. More robust methods for calculating mountain and wilderness sports injury
rates should be explored – rates are sometimes based upon estimates of participation,
inferred from other statistics such as the number of nights spent in mountain huts.76
Techniques employed to record skiing and snowboarding participation may have
application in other activities. The potential for participant education and modification
of outdoor clothing and equipment to reduce injuries should be further explored.
Finally, where injuries have taken place, future research should explore the
rehabilitation load that such patients exert on out-of-hospital healthcare services.
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Tables Key:
Table 1. Inclusion and exclusion criteria – Column heads: ‘Inclusion criteria’
‘Exclusion criteria’
Table 2. STOX evidence classification system
8
– Column heads: ‘Evidence type’
‘STOX classification’ ‘Description’
Table 3a. Summary of included studies – Column heads: ‘Study’ ‘Mountain and
wilderness sport’ ‘Setting’ ‘Period of data collection’ ‘Injury incidence/ survey
response’ ‘Demographics’ ‘Body part(s) injured’ ‘Injury type, severity and mechanism’
Table 3b. Mountain biking – Column heads: ‘Study’ ‘Setting’ ‘Period of data
collection’ ‘Injury incidence/ survey response’ ‘Demographics’ ‘Body part(s) injured’
‘Injury type, severity and mechanism’
Table 3c. Adventure racing – Column heads: ‘Study’ ‘Setting’ ‘Period of data
collection’ ‘Injury incidence/ survey response’ ‘Demographics’ ‘Body part(s) injured’
‘Injury type, severity and mechanism’
Table 3d. Casualties from other mountain and wilderness sports – Column heads:
‘Study’ ‘Mountain and wilderness sport’ ‘Setting’ ‘Period of data collection’ ‘Injury
incidence/ survey response’ ‘Demographics’ ‘Body part(s) injured’ ‘Injury type,
severity and mechanism’
Figure Key:
Figure 1. Search strategy
Figure 2. Proportion of injury involving fracture. * indicates study of a competitive
event. ** spinal injury only
Figure 3. Proportion of injury affecting the lower extremities. * indicates study of
a competitive event
Figure 4. Proportion of injury affecting the upper extremities. * indicates study of
a competitive event