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390 ClarsenB, etal. Br J Sports Med 2020;54:390–396. doi:10.1136/bjsports-2019-101337
Improved reporting of overuse injuries and health
problems in sport: an update of the Oslo Sport
Trauma Research Centerquestionnaires
Benjamin Clarsen ,1 Roald Bahr,1 Grethe Myklebust,1 Stig Haugsboe Andersson,1
Sean Iain Docking ,2 Michael Drew,3 Caroline F Finch ,4
Lauren Victoria Fortington ,4 Joar Harøy ,1 Karim M Khan ,5 Bill Moreau,6,7
Isabel S Moore ,8 Merete Møller,9 Dustin Nabhan ,1,10
Rasmus Oestergaard Nielsen ,11 Kati Pasanen ,12,13 Martin Schwellnus,14
Torbjørn Soligard ,15 Evert Verhagen 16
Consensus statement
To cite: ClarsenB,
BahrR, MyklebustG,
etal. Br J Sports Med
2020;54:390–396.
For numbered affiliations see
end of article.
Correspondence to
Dr Benjamin Clarsen,
Department of Sports Medicine,
Norwegian School of Sport
Sciences, Oslo Sports Trauma
Research Center, Oslo 0806,
Norway; ben. clarsen@ nih. no
Accepted 28 January 2020
Published Online First
14February2020
© Author(s) (or their
employer(s)) 2020. No
commercial re- use. See rights
and permissions. Published
by BMJ.
ABSTRACT
In 2013, the Oslo Sports Trauma Research Center
Overuse Injury Questionnaire (OSTRC- O) was developed
to record the magnitude, symptoms and consequences
of overuse injuries in sport. Shortly afterwards, a
modified version of the OSTRC- O was developed to
capture all types of injuries and illnesses—The Oslo
Sports Trauma Research Center Questionnaire on
Health Problems (OSTRC- H). Since then, users from
a range of research and clinical environments have
identified areas in which these questionnaires may
be improved. Therefore, the structure and content of
the questionnaires was reviewed by an international
panel consisting of the original developers, other user
groups and experts in sports epidemiology and applied
statistical methodology. Following a review panel
meeting in October 2017, several changes were made to
the questionnaires, including minor wording alterations,
changes to the content of one question and the addition
of questionnaire logic. In this paper, we present the
updated versions of the questionnaires (OSTRC- O2 and
OSTRC- H2), assess the likely impact of the updates on
future data collection and discuss practical issues related
to application of the questionnaires. We believe this
update will improve respondent adherence and improve
the quality of collected data.
INTRODUCTION
The Oslo Sports Trauma Research Center (OSTRC)
Overuse Injury Questionnaire was developed
to address challenges which arise when using
traditional sports injury surveillance methods to
document the epidemiology of overuse injuries.1
Traditionally, most injury surveillance studies used
time loss from sport as the primary criterion for
defining the occurrence of injury and the duration of
time lost as a surrogate measure of injury severity.2
This approach underestimates the full impact of
overuse injuries because athletes with an overuse
injury can often continue to train and compete
despite persistent injury- associated symptoms and
limitations.3 The OSTRC Overuse Injury Question-
naire contains four domains which seek to evaluate
the consequences of overuse injuries on athletes: (1)
sports participation, (2) training volume, (3) sports
performance and (4) pain (table 1, first column). By
administering the questionnaire at regular intervals
(eg, weekly), clinicians and researchers are able to
monitor how the consequences of overuse injury
change over time.
The OSTRC Overuse Injury Questionnaire
was initially developed to collect information on
overuse injuries in specific, predefined, anatom-
ical areas. However, it quickly became apparent
that the approach was not only suited to recording
overuse injuries—athletes may also continue to
participate after sustaining acute injuries or while
suffering illness.4 Therefore, a modified version
of the overuse injury questionnaire was developed
that allowed athletes to record all types of health
problems—the OSTRC Questionnaire on Health
Problems.5 In this version, the four key questions
referred to all types of health problems (table 2,
first column), and if an athlete reported a problem,
he/she then had to provide additional information
such as the type of problem and its location or main
symptoms.5
The OSTRC overuse injury and health prob-
lems questionnaires have been widely cited and
adopted in sports injury research since their initial
publications in 2013 and 2014. A citation search
performed in March 2019 using Thompson- Reuters
Web of Science database identified 254 citations of
the questionnaires, including 59 and 14 studies that
used the overuse injury and health problem ques-
tionnaires, respectively, to collect data.
In addition to its research applications, the
OSTRC health problems questionnaire has also
gained popularity as a clinical monitoring tool to
evaluate health trends and ensure timely care to
athletes in a range of elite sports organisations.
Users include, among others, the Norwegian, US,
Australian and Dutch Olympic programmes and
the Norwegian, US, Dutch and German Paralympic
programmes.
Due to this successful uptake, user groups from a
range of research and clinical environments gained
experience using the OSTRC questionnaires and
identified several issues requiring consideration. To
address these issues, which ranged from wording
clarification to data analysis principles, the original
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Consensus statement
Table 1 Original and updated versions of the OSTRC- O questionnaire, with changes highlighted in red
The OSTRC- O
Original version (OSTRC- O)Updated version (OSTRC- O2)
Please answer all questions regardless of whether or not you have problems with your
knees. Select the alternative that is most appropriate for you, and in the case that you
are unsure, try to give an answer as best you can anyway.
Please answer all questions regardless of whether or not you have problems in
your(insert anatomical location here, eg, knees). Select the alternative that is most
appropriate for you, and in the case that you are unsure, try to answer as best you can
anyway.
The term ‘knee problems’ refers to pain, ache, stiffness, swelling, instability/giving way,
locking or other complaints related to one or both knees.
The term ‘(location) problems’ refers to (insert common symptoms or injury
consequences here, eg, pain, ache, stiffness, clicking/catching, swelling, instability/giving
way, locking)or other complaints related to your (location).
Question 1 Question 1—Participation
Have you had any difficulties participating in normal training and competition due to
knee problems during the past week?
Have you had any difficulties participating in training and competition due to (location)
problems during the past 7 days?
a. Full participation without knee problems a. Full participation without (location) problems
b. Full participation, but with knee problems b. Full participation, but with (location) problems
c. Reduced participation due to knee problems c. Reduced participation due to (location) problems
d. Cannot participate due to knee problems d. Could not participate due to (location) problems
Question 2 Question 2—Modified training/competition
To what extent have you reduced you training volume due to knee problems during the
past week?
To what extent have you modified your training or competition due to (location)
problems during the past 7 days?
a. No reduction a. No modification
b. To a minor extent b. To a minor extent
c. To a moderate extent c. To a moderate extent
d. To a major extent d. To a major extent
e. Cannot participate at all
Question 3 Question 3—Performance
To what extent have knee problems affected your performance during the past week? To what extent have (location) problems affected your performance during the past 7
days?
a. No effect a. No effect
b. To a minor extent b. To a minor extent
c. To a moderate extent c. To a moderate extent
d. To a major extent d. To a major extent
e. Cannot participate at all
Question 4 Question 4—Pain
To what extent have you experienced knee pain related to your sport during the past
week?
To what extent have you experienced (location) pain related to your sport during the
past 7 days?
a. No pain a. No pain
b. Mild pain b. Mild pain
c. Moderate pain c. Moderate pain
d. Severe pain d. Severe pain
OSTRC- O, Oslo Sports Trauma Research Center Overuse Injury Questionnaire.
developers of the questionnaire initiated a review process in
August 2017 that included consulting with an international
panel of researchers and clinicians who represented key user
groups. The process included a review panel meeting in Oslo on
3 and 4 October 2017.
In this paper, we summarise the topics discussed during the
meeting and introduce several changes to the wording, structure
and logic of the original questionnaires. We also analyse new and
previously collected data to illustrate the impact of the changes.
We refer to the OSTRC Overuse Injury Questionnaire and
OSTRC Questionnaire on Health Problems collectively as the
OSTRC questionnaires except where it is necessary to specify one
in particular. In those cases, we use the abbreviation OSTRC- O
and OSTRC- H.6 We use the suffix ‘2’ to specify the updated
versions of the questionnaires (ie, OSTRC- O2 and OSTRC- H2).
QUESTIONNAIRE REVIEW PROCEDURE
Review panel members were identified by the primary author (BC)
based on their experience using the OSTRC questionnaires for
research or clinical purposes or their expertise in epidemiological
and applied statistics methodology in the sports medicine context.
Prior to the meeting, the primary author had informal discussions
with all panel members to establish the meeting agenda. Panel
members who were unable to attend the meeting (n=5) provided a
written summary of their positions on each agenda item. Following
the meeting, a detailed summary was distributed to the entire panel,
including the proposed changes to the questionnaire wording,
logic and response categories. The panel agreed unanimously on
all changes and contributed as authors of this manuscript.
CHANGES TO THE OSTRC QUESTIONNAIRES
We considered each of the four key OSTRC questions in detail
and discussed the need for changes to the wording, logic and
response categories. Proposed changes were categorised as minor
or more substantial. A more substantial change was defined as one
where the panel agreed that such a change required validation.
Minor (inconsequential) wording changes
The panel noted several areas of ambiguity and inconsistency
between questions in the original questionnaires and agreed to
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392 ClarsenB, etal. Br J Sports Med 2020;54:390–396. doi:10.1136/bjsports-2019-101337
Consensus statement
Table 2 Original and updated versions of the OSTRC- H questionnaire, with changes highlighted in red
The OSTRC- H
Original version (OSTRC- H)Updated version (OSTRC- H2)
Please answer all questions regardless of whether or not you have experienced health
problems in the past week. Select the alternative that is most appropriate for you, and in
the case that you are unsure, try to give an answer as best you can anyway.
Please answer all questions regardless of whether or not you have experienced health
problems in the past 7 days. Select the alternative that is most appropriate for you, and
in the case that you are unsure, try to answer as best you can anyway.
If you have several illness or injury problems, please refer to the one that has been your
worst problem this week. You will have a chance to register other problems at the end of
the questionnaire.
A health problem is any condition that you consider to be a reduction in your normal
state of full health, irrespective of its consequences on your sports participation or
performance, or whether you have sought medical attention. This may include, but is not
limited to, injury, illness, pain or mental health conditions.
If you have several health problems, please begin by recording your worst problem in
the past 7 days. You will have a chance to register other problems at the end of the
questionnaire.
Question 1 Question 1—Participation
Have you had any difficulties participating in normal training and competition due to
injury, illness or other health problems during the past week?
Have you had any difficulties participating in training and competition due to injury,
illness or other health problems during the past 7 days?
a. Full participation without health problems a. Full participation without health problems
b. Full participation, but with injury/illness b. Full participation, but with a health problem
c. Reduced participation due to injury/illness c. Reduced participation due to a health problem
d. Cannot participate due to injury/illness d. Could not participate due to a health problem
Question 2 Question 2—Modified training/competition
To what extent have you reduced you training volume due to injury, illness or other
health problems during the past week?
To what extent have you modified your training or competition due to injury, illness or
other health problems during the past 7 days?
a. No reduction a. No modification
b. To a minor extent b. To a minor extent
c. To a moderate extent c. To a moderate extent
d. To a major extent d. To a major extent
e. Cannot participate at all
Question 3 Question 3—Performance
To what extent has injury, illness or other health problems affected your performance
during the past week?
To what extent has injury, illness or other health problems affected your performance
during the past 7 days?
a. No effect a. No effect
b. To a minor extent b. To a minor extent
c. To a moderate extent c. To a moderate extent
d. To a major extent d. To a major extent
e. Cannot participate at all
Question 4 Question 4—Symptoms
To what extent have you experienced symptoms/health complaints during the past
week?
To what extent have you experienced symptoms/health complaints during the past 7
days?
a. No symptoms/health complaints a. No symptoms/health complaints
b. To a mild extent b. To a mild extent
c. To a moderate extent c. To a moderate extent
d. To a severe extent d. To a severe extent
OSTRC- H, Oslo Sports Trauma Research Center Questionnaire on Health Problems.
make minor changes to the questionnaire instructions and to the
wording of all four questions. These changes included replacing
‘the past week’ with ‘the past 7 days’, replacing ‘cannot’ with
‘could not’ and adding titles to differentiate the questions
(tables 1 and 2, second columns).
In the OSTRC- H2, we replaced ‘injury/illness’ with ‘health
problem’ in the instructions, questions and response categories.
In the OSTRC- H2 instructions, we included the following defi-
nition of health problem: ‘A health problem is any condition that
you consider to be a reduction in your normal state of full health,
irrespective of its consequences on your sports participation or
performance, or whether you have sought medical attention. This
may include, but is not limited to, injury, illness, pain or mental
health conditions.’
This definition is consistent with the International Olympic
Committee consensus statement on methods for recording and
reporting epidemiological data on injury and illness in sports.7
The original OSTRC- O was published using only the knee,
shoulder and low back as example areas. However, some
readers appear to have misinterpreted this as meaning that the
OSTRC- O is a specific knee, shoulder and low back question-
naire. Therefore, we made minor changes to the OSTRC- O
template to clarify that the questionnaire is applicable to any
anatomical region (table 1, second column).
More substantial changes
We recognised that reducing training volume is only one way in
which an athlete can modify their normal sports participation in
response to a health problem. The original question may have
missed other common modifications such as reduced intensity,
changes in the type of training (eg, cycling instead of running)
or changing roles in a team (tactical/positional). To address this,
we changed the wording of question 2; instead of asking about
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Consensus statement
Table 3 Comparison between the responses to the old and new
wording of question 2
New wording
Training or competition modification
2a 2b 2c 2d 2e
Old
wording
Training
reduction
2a 52 15 2 0 0
2b 11 14 1 0 0
2c 0 1 2 0 0
2d 0 1 1 9 0
2e 0 0 0 1 8
Data were collected from 90 athletes over 13 weeks; a total of 596 questionnaire
responses were collected, of which 118 included a health problem.
Column and row headings 2a–e represent response categories to question 2 as
shown in (tables1 and 2).
In this analysis, we did not apply gatekeeper logic and thus included a fifth
response category (could not participate at all) to the new question.
Table 4 Comparison of the number of injuries and illnesses identified
when gatekeeper logic is and is not applied to question 1
No logic Gatekeeper logic
Difference
(%)
All problems
Injuries 3460 3045 12.0
Illnesses 1857 1574 15.2
Substantial problems
Injuries 1245 1236 0.7
Illnesses 1049 1024 2.4
Time loss problems*
Injuries 1295 1244 3.9
Illnesses 1251 1171 6.4
Data are based on a convenience sample of 13 888 OSTRC- H responses from elite
Norwegian athletes.
*Identified using an additional question that asked respondents how many days
they were unable to train or compete due to that health problem in the past 7 days.
the extent to which an athlete has reduced their training volume,
the revised question asks about the extent to which athletes have
modified their training or competition. To align with this change,
the word ‘normal’ was removed from question 1.
Athletes may answer differently when asked about modi-
fied training or competition, compared with reduced training
volume. To assess the consequences of the change in wording,
for a period of 13 weeks, we included both questions simul-
taneously in the ongoing registry of three Dutch National
Olympic programmes (ie, water polo, equestrian sports and
baseball); these programmes, included 90 athletes familiar
with the OSTRC- H. To assess the level of agreement between
responses to both questions, we calculated Cohen’s kappa using
equal weights (table 3). The kappa coefficient was 0.55 which
suggests substantial differences. However, the main inconsisten-
cies between versions 1 and 2 occurred for the least severe health
problems (ie, those with little or no consequences on training).
These differences were consistent with our reasoning to modify
the questioning.
Changes to questionnaire logic and answer categories
As questions 2–4 are only relevant for athletes who have a health
problem and continue to participate in training and competition,
we propose a new ‘gatekeeper’ logic that can be applied to ques-
tion 1. Using this logic:
►If an athlete selects the first answer option ‘full participation
without health problems’, all further questions are redun-
dant. In this case, a total severity score of 0 is assigned and
the questionnaire is complete.
►If an athlete selects the fourth answer option ‘could not
participate due to a health problem’, questions 2–4 are
redundant. In this case, a total severity score of 100 is
assigned. The athlete continues directly to additional ques-
tions researchers may apply to the questionnaire classify the
reported health problem.
This logic will reduce unnecessary responder burden by
ensuring athletes only receive questions relevant to their current
health state. However, it is important to note that in the past,
when respondents were expected to complete all four key ques-
tions, their responses were not always consistent. For example,
an athlete may have reported ‘reduced participation due to a
health problem’ in question 1, then ‘cannot participate at all’ in
question 2 or 3. Consequently, for consistency and clarity, we
removed the response category ‘cannot participate at all’ from
questions 2 and 3. We recommend that for these questions, the
values to calculate the severity score are aligned with question 1
and 4 (ie, A=0, B=8, C=17, D=25) (readers are directed to Ref.
1 for a full explanation of the OSTRC severity score).
Consequences of changing the questionnaire logic and answer
categories
By applying gatekeeper logic, we eliminate the opportunity for
athletes to report ‘full participation without health problems’ in
question 1 and then (inconsistently) report the existence of a
health problem in the subsequent questions. The revised ques-
tionnaire is, therefore, likely to reduce the number of health
problems identified.
To estimate the extent to which this occurs, we calculated the
number of health problems identified when gatekeeper logic
was and was not applied, using a convenience sample of 13 888
OSTRC- H responses from elite Norwegian athletes. As shown
in table 4, approximately 13% of the total number of cases were
missed when gatekeeper logic was used. However, the missing
cases were almost all of minor severity, given that 98.5% of
substantial problems were still captured using gatekeeper logic.
Additional questions
The OSTRC questionnaire is a tool to capture and monitor
health problems longitudinally in athletic populations.
Following the four key questions, additional questions must be
used to classify health problems and provide additional infor-
mation to researchers or clinicians. We did not attempt to make
recommendations on these follow- up questions, for a number of
reasons. First, the questions used to classify health problems (eg,
injured body part, injury type) should follow consensus- based
recommendations.7 Second, the level of detail that is necessary
and/or feasible to collect will vary between clinical and research
settings. For example:
►Collecting free- text (qualitative) information about a health
problem, or knowing exactly who is aware of it, may be
unnecessary in research studies where investigators do not
need to provide clinical responses based on athlete responses.
However, this information can be valuable when clinicians
use the questionnaire in a practical athlete- monitoring
context.
►For some research questions, such as those investigating rela-
tionships between load and injury or those related to subse-
quent injuries, knowing the exact date of injury or symptom
onset may be extremely important.
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Consensus statement
►It may be relevant to record whether the athlete has not been
able to participate due to other reasons than health prob-
lems, such as holidays, work or school commitments.
►Users cannot calculate the exact number of time- loss days
from the four key questions alone. A follow- up question is
needed to collect this information accurately.
Users should, therefore, customise additional questions of the
OSTRC questionnaires to suit their research and/or clinical needs
and should categorise data according to international classifica-
tion standards, such as the IOC consensus statement on methods
for recording and reporting epidemiological data on injury and
illness in sports.7 Conversely, we recommend that users retain
the exact wording and scoring of the four key questions to facil-
itate data interpretation, comparison and pooling.
DISCUSSION
In addition to reviewing the content and structure of the OSTRC
questionnaires, the expert group discussed a range of general
issues related to the questionnaire use, outcome measures, anal-
ysis methods and the need for consistent scientific reporting.
Our aim was not to reach consensus on all topics, but to high-
light areas that users may want clarified, share lessons learnt and
to identify areas needing further research.
Are two questionnaires necessary?
As the OSTRC- H is designed to record all types of health prob-
lems, it may appear to negate the need for the OSTRC- O, which
is limited to recording overuse injuries in predefined anatom-
ical areas. However, previous research has shown that question-
naires asking athletes about specific injury types capture a greater
number of problems in that location than when generalised
questions are used.8 Therefore, the OSTRC- O may be preferable
in studies that focus on overuse injuries to one specific injury
location, particularly when collecting data for risk factor studies
and randomised controlled trials.9–11 In these cases, competing
risks should be considered in the statistical analyses to reduce
the risk of bias.12
Distribution frequency
As the questionnaire refers to the previous 7 days, weekly distri-
bution of the questionnaire is necessary to capture every health
problem. However, for certain research questions, it may be
acceptable to distribute the questionnaire less frequently, such
as every second week9 10 13 or every month.14 If investigators or
clinicians choose this approach, some short- duration cases may
not be recorded, but outcome measures will still be comparable
to data collected weekly.1 5 We highlight, however, that to limit
recall bias,15 even if the questionnaire is distributed infrequently
(eg, only once a month), the questions should still refer to ‘the
past 7 days’.
In elite sports, it is becoming increasingly common to collect
training- related data from athletes every day. In this case, daily
monitoring of health status using a modified version of the
OSTRC- H is also feasible. This may be clinically valuable if
athletes have sufficiently intensive medical coverage and may
allow for greater accuracy in the collected data. However, data
collected daily may not be directly comparable to those collected
weekly. This approach will also increase the demand on the
athletes, and response rates and accuracy may decline over time.
Outcome measures and analytical approaches
Traditional epidemiological constructs, such as injury and illness
incidence, prevalence and severity can be obtained using the
OSTRC questionnaires with some basic additional questions on
exposure and time loss. In addition, because the OSTRC ques-
tionnaires provide details on the consequences and symptoms
of health problems, a range of other outcome measures can also
be presented. The severity score and substantial health problems
are two novel outcomes proposed with the original OSTRC
questionnaires. These measures may be valuable for clinical use;
however, as they are yet to be fully validated, researchers must
consider their limitations.
The severity score falls between 0 (full participation without
health problem) and 100 (no participation at all) and is calcu-
lated based on the athlete’s responses on the four OSTRC
questions. This score allows the visualisation of changes in the
consequences of health problems over time for an athlete, which
can be valuable for coaches, athletes and clinicians. However,
using the severity score appropriately in analyses can be prob-
lematic. Although the severity score has previously been anal-
ysed as a continuous outcome variable, we emphasise that it
does not satisfy the basic requirements of a continuous measure
(eg, equal interval between possible scores). In effect, therefore,
the severity score represents an ordinal- scale variable with 25
possible outcomes, not 100. Recent publications highlight the
analytical benefits of representing various ‘states’ of an athlete’s
health on an ordinal scale.16 Unfortunately, for this approach to
be feasible with small samples (as is normally the case in sports
medicine research), the number of potential states needs to be
far fewer than 25 to reduce the risk of sparse data bias.17 Using
the time- varying nature of the OSTRC questionnaires outcomes
in advanced multistate models is an area requiring further devel-
opment and validation.
Of particular note is the longitudinal nature of the data regis-
tered with the OSTRC questionnaires. Longitudinal approaches
provide opportunities to explore the risks and prognoses of
health problems over time and account for correlated data. Such
analyses are of special interest for elite athletic populations that,
in general, are smaller in number but tend to experience multiple
events (injuries and/or illnesses). When considering longitudinal
analytical methods, users should be aware of the inherent chal-
lenges of these methods, including (i) missing data, (ii) time-
varying exposures, outcomes, confounders, effect- measure
modifiers and mediators, (iii) recurrent/subsequent events and
(iv) competing risks.16 18 19
Factors that may promote athletes to adopt the OSTRC
questionnaires
As shown in our citation analysis, multiple authors have
employed the OSTRC questionnaires since the first publica-
tion in 2013.1 This suggests that the questionnaires represent
versatile and functional tools for both research and clinical use.
In many cases, studies have reported high response rates from
athletes. However, the questionnaires have not always been
successfully adopted by athletes.20 21 In our experience and based
on recent research,21 factors that are crucial to obtaining high
response rates in the clinical setting include providing feedback
to respondents, timely follow- up by clinicians when a health
problem is reported and personal interaction with athletes to
motivate them. Similar factors influence the implementation of
sports injury surveillance practices outside clinical settings.22
We recognised that to encourage adoption of the ques-
tionnaire, its name should be relevant and recognisable to
respondents. Although researchers should report the official
questionnaire titles and abbreviations (OSTRC- O2 and OSTRC-
H2) in scientific communications, it is not necessary to use the
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ClarsenB, etal. Br J Sports Med 2020;54:390–396. doi:10.1136/bjsports-2019-101337
Consensus statement
What is already known on this topic
►The Oslo Sports Trauma Research Center questionnaires were
developed to address challenges in recording the full extent
of sports- related health problems using standard sports injury
data collection methods.
►The questionnaires have been widely adopted in sports injury
research and in clinical health monitoring programmes by a
range of elite sports organisations.
►Due to this successful uptake, a range of questionnaire-
related issues requiring clarification or modification have
been identified.
What this study adds
►This manuscript proposes specific changes to the wording,
structure and logic of the Oslo Sports Trauma Research Center
(OSTRC) questionnaires and discusses the likely impact of the
proposed changes on collected data.
– Updated versions of the questionnaires (OSTRC- O2 and
OSTRC- H2) are provided.
– A range of general issues related to questionnaire use,
outcome measures, analysis methods and implementation
success are discussed, alongside areas needing further
research.
official titles when delivering the questionnaire to respondents.
Instead, we encourage users to rename the questionnaires to suit
their purpose and context (eg, The Norwegian Olympic Team
Health Report).
Importantly, this paper presents updates to the OSTRC ques-
tionnaires, so they provide greater clarity and consistency in the
questions themselves. We also hope to ensure easier navigation
using the gatekeeper logic. We believe that these changes will
provide a better experience for the respondents and, in turn,
maximise their adherence.
Subjectivity and context specificity
Completion of the OSTRC questionnaires requires a high level
of subjectivity. Questions ask for the athletes’ perceptions of the
consequences that a health problem has on their participation
and performance, as well as their perceived symptoms. These
perceptions are dependent on contextual factors such as athlete
experience, level of sports, type of sport and time of season.23 24
This means that data collected from different cohorts of athletes
will not necessarily be comparable. We encourage further
research to explore the psychometric properties of the OSTRC
questionnaires across different contexts and populations.
When the questionnaires are applied to contexts beyond adult
sports (eg, among children, athletes with disability, performing
artists and in occupational settings), the wording should be
adjusted. We recommend an expert- based approach to ensure
sound principles behind such adjustments, as we employed in
this update. Any future adaptations of the questionnaire should
undergo psychometric testing and validation.
CONCLUSION
Users from a range of sports research and clinical environments
have gained experience using the OSTRC questionnaires and
have identified areas in which they could be improved. In this
paper, to provide greater clarity and consistency of questioning,
we present changes to the wording, structure and logic of the
original OSTRC questionnaires. We believe that these changes
will improve athletes’ experience when completing the question-
naires and also improve the quality of collected data.
Author affiliations
1Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo Sports
Trauma Research Center, Oslo, Norway
2LASEM Research Centre, La Trobe University, Bundoora, Victoria, Australia
3Athlete Availability Program, Australian Institute of Sport, Canberra, Australian
Capital Territory, Australia
4Exercise Medicine Research Institute, School of Medical and Health Sciences, Edith
Cowan University, Perth, Western Australia, Australia
5Family Practice & Kinesiology, The University of British Columbia, Vancouver, British
Columbia, Canada
6Southern California University of Health Sciences, Whittier, California, USA
7University of Western States, Portland, Oregon, USA
8School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
9Institute of Sports Science and Clinical Biomechanics, University of Southern
Denmark, Odense, Syddanmark, Denmark
10Sports Medicine Division, United States Olympic Committee, Colorado Springs,
Colorado, USA
11Department of Public Health, Aarhus University, Aarhus, Denmark
12Sport Injury Prevention Research Centre (SIPRC), Faculty of Kinesiology, University
of Calgary, Calgary, Alberta, Canada
13Tampere Research Center of Sport Medicine, UKK Instituutti, Tampere, Finland
14Sports, Exercise, Medicine and Lifestyle Research Institute (SEMLI), University of
Pretoria, Pretoria, South Africa
15Medical and Scientific Department, International Olympic Committee, Lausanne,
Switzerland
16Department of Public and Occupational Health, Amsterdam University Medical
Centres, Amsterdam, Noord- Holland, The Netherlands
Twitter Benjamin Clarsen @benclarsen, Stig Haugsboe Andersson @
stighandersson, Sean Iain Docking @SIDocking, Michael Drew @_mickdrew,
Caroline F Finch @CarolineFinch, Lauren Victoria Fortington @LFortington,
Joar Harøy @JHaroey, Isabel S Moore @IzzyMoorePhD, Merete Møller @
Merete_Moller, Dustin Nabhan @nabhansportsmed, Rasmus Oestergaard Nielsen
@RUNSAFE_Rasmus, Torbjørn Soligard @TSoligard and Evert Verhagen @
Evertverhagen
Acknowledgements The Oslo Sports Trauma Research Center has been
established at the Norwegian School of Sport Sciences through generous grants from
the Royal Norwegian Ministry of Culture, the South- Eastern Norway Regional Health
Authority, the International Olympic Committee, the Norwegian Olympic Committee
& Confederation of Sport and Norsk Tipping AS. CFF, LVF and MD are members of
the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) at
Edith Cowan University. ACRISP is one of the International Research Centres for the
Prevention of Injury and Protection of Athlete Health supported by the International
Olympic Committee.
Contributors All authors were involved in the questionnaire review process,
provided editorial input to the text and approved the final manuscript. BC and EV
drafted the manuscript and performed the analyses. SHA performed the citation
search.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon request.
ORCID iDs
BenjaminClarsen http:// orcid. org/ 0000- 0003- 3713- 8938
Sean IainDocking http:// orcid. org/ 0000- 0001- 7051- 7548
Caroline FFinch http:// orcid. org/ 0000- 0003- 1711- 1930
Lauren VictoriaFortington http:// orcid. org/ 0000- 0003- 2760- 9249
JoarHarøy http:// orcid. org/ 0000- 0002- 0475- 637X
Karim MKhan http:// orcid. org/ 0000- 0002- 9976- 0258
Isabel SMoore http:// orcid. org/ 0000- 0002- 4746- 3390
DustinNabhan http:// orcid. org/ 0000- 0002- 1244- 515X
Rasmus OestergaardNielsen http:// orcid. org/ 0000- 0001- 5757- 1806
KatiPasanen http:// orcid. org/ 0000- 0002- 0427- 2877
TorbjørnSoligard http:// orcid. org/ 0000- 0001- 8863- 4574
EvertVerhagen http:// orcid. org/ 0000- 0001- 9227- 8234
Protected by copyright. on March 26, 2020 at University of Cape Town Libraries.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2019-101337 on 14 February 2020. Downloaded from
396 ClarsenB, etal. Br J Sports Med 2020;54:390–396. doi:10.1136/bjsports-2019-101337
Consensus statement
REFERENCES
1 Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for
the registration of overuse injuries in sports injury epidemiology: the Oslo sports
trauma research centre (OSTRC) overuse injury questionnaire. Br J Sports Med
2013;47:495–502.
2 Fuller CW, Ekstrand J, Junge A, etal. Consensus statement on injury definitions and
data collection procedures in studies of football (soccer) injuries. Br J Sports Med
2006;40:193–201.
3 Bahr R. No injuries, but plenty of pain? on the methodology for recording overuse
symptoms in sports. Br J Sports Med 2009;43:966–72.
4 Hammond LE, Lilley JM, Pope GD, etal. The impact of playing in matches while
injured on injury surveillance findings in professional football. Scand J Med Sci Sports
2014;24:e195–200.
5 Clarsen B, Rønsen O, Myklebust G, etal. The Oslo sports trauma research center
questionnaire on health problems: a new approach to prospective monitoring of
illness and injury in elite athletes. Br J Sports Med 2014;48:754–60.
6 Jorgensen JE, Rathleff CR, Rathleff MS, etal. Danish translation and validation of the
Oslo sports trauma research centre questionnaires on overuse injuries and health
problems. Scand J Med Sci Sports 2016;26:1391–7.
7 Bahr R, Clarsen B, Derman W. International Olympic Committee consensus statement:
methods for recording and reporting of epidemiological data on injury and illness in
sport including STROBE extension for sport Injury and illness surveillance (STROBE-
SIIS)). Br J Sports Med 2020;54:372–89.
8 Clarsen B, Krosshaug T, Bahr R. Overuse injuries in professional road cyclists. Am J
Sports Med 2010;38:2494–501.
9 Andersson SH, Bahr R, Clarsen B, etal. Risk factors for overuse shoulder injuries
in a mixed- sex cohort of 329 elite handball players: previous findings could not be
confirmed. Br J Sports Med 2018;52:1191–8.
10 Andersson SH, Bahr R, Clarsen B, etal. Preventing overuse shoulder injuries among
throwing athletes: a cluster- randomised controlled trial in 660 elite handball players.
Br J Sports Med 2017;51:1073–80.
11 Harøy J, Clarsen B, Thorborg K, etal. Groin problems in male soccer players are more
common than previously reported. Am J Sports Med 2017;45:1304–8.
12 Andersen PK, Geskus RB, de Witte T, etal. Competing risks in epidemiology:
possibilities and pitfalls. Int J Epidemiol 2012;41:861–70.
13 Clarsen B, Bahr R, Andersson SH, etal. Reduced glenohumeral rotation, external
rotation weakness and scapular dyskinesis are risk factors for shoulder injuries
among elite male handball players: a prospective cohort study. Br J Sports Med
2014;48:1327–33.
14 Pluim BM, Clarsen B, Verhagen E. Injury rates in recreational tennis players do not
differ between different playing surfaces. Br J Sports Med 2018;52:611–5.
15 Valuri G, Stevenson M, Finch C, etal. The validity of a four week self- recall of sports
injuries. Inj Prev 2005;11:135–7.
16 Nielsen RO, Bertelsen ML, Ramskov D, etal. Time- to- event analysis for sports injury
research Part 2: time- varying outcomes. Br J Sports Med 2019;53:70–8.
17 Greenland S, Mansournia MA, Altman DG. Sparse data bias: a problem hiding in plain
sight. BMJ 2016;352:i1981.
18 Nielsen RO, Bertelsen ML, Ramskov D, etal. Time- to- event analysis for sports injury
research Part 1: time- varying exposures. Br J Sports Med 2019;53:61–8.
19 Ullah S, Gabbett TJ, Finch CF. Statistical modelling for recurrent events: an application
to sports injuries. Br J Sports Med 2014;48:1287–93.
20 Bromley S, Drew M, Talpey S, etal. Collecting health and exposure data in Australian
Olympic combat sports: feasibility study utilizing an electronic system. JMIR Hum
Factors 2018;5:e27.
21 Barboza SD, Bolling CS, Nauta J, etal. Acceptability and perceptions of end- users
towards an online sports- health surveillance system. BMJ Open Sport Exerc Med
2017;3:e000275.
22 Ekegren CL, Donaldson A, Gabbe BJ, etal. Implementing injury surveillance systems
alongside injury prevention programs: evaluation of an online surveillance system in a
community setting. Inj Epidemiol 2014;1:19.
23 Bolling C, Delfino Barboza S, van Mechelen W, etal. How elite athletes, coaches, and
physiotherapists perceive a sports injury. Transl Sports Med 2019;2:17–23.
24 Bolling C, van Mechelen W, Pasman HR, etal. Context matters: revisiting the first step
of the ’sequence of prevention’ of sports injuries. Sports Med 2018;48:2227–34.
Protected by copyright. on March 26, 2020 at University of Cape Town Libraries.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2019-101337 on 14 February 2020. Downloaded from
