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ApuntsMedEsport.2014;49(184):123---138

www.apunts/org

REVIEW

Association

between

injury

and

quality

of

life

in

athletes:

A

systematic

review,

1980---2013

Natália

Boneti

Moreira

a,∗

,

Gislaine

Cristina

Vagetti

b

,

Valdomiro

de

Oliveira

c

,

Wagner

de

Campos

c

aPhysiotherapyDepartment,FaculdadeDomBosco,Curitiba,Brazil

bMusicTherapyDepartment,UniversidadeEstadualdoParaná,Curitiba,Brazil cPhysicalEducationDepartment,UniversidadeFederaldoParaná,Curitiba,Brazil

Received28January2014;accepted16June2014

Availableonline17July2014

KEYWORDS

Qualityoflife; Review; Athletes;

Woundsandinjuries; Athleticinjuries; Sports

Abstract Despitethebenefitsofparticipationinsports,italsoentailsarisksituationforthe occurrence ofinjuriesatany levelofperformance.These injuriescan affectboth physical and psychologicalaspects,and consequently,generate asignificantdeclinein performance and/orlackofparticipation,whichmayaffecttheirqualityoflife.Thepresentstudyaimsto systematicallyreviewinformationregardingtheassociationofinjurywithdomainsofquality oflife (QoL)inadult athletes andtoidentifythe mostcommonly usedinstruments forthe measurementofinjuryandQoLinadultathletespublishedbetween1980and2013.Searches wereperformedusingfivedatabases(MEDLINE/PubMed,WebofScience,SPORTDiscus,PsycINFO andLILACS)andthereferencescitedinretrievedarticles.Fromthesearch,only12articles mettheinclusioncriteriaandwereretrievedandexamined.Differentquestionnaireswithout standardizationareusedtoassesstheinjuryofathletes.FortheassessmentofQoL,moststudies usedtheSF-36.Theevaluationofthedirectionoftheassociationbetweeninjuryanddomainsof QoLdemonstratedthatmoststudiesincludedinthisreviewshowedhighpercentagesofnegative associationinthelifesatisfactiondomain(100%),followed bybodilypain(71.4%),physical componentscore(75%),physicalfunctioning,physical,vitality,socialfunctioning(66.7%each), mentalhealth(62.5%),andgeneralhealthdomains(57.1%).Inconclusion,inadultathletes, moststudiesdemonstratedanegativeassociationbetweeninjuryandQoLdomains,especially inthephysicalandsocialaspects.However,theassociationbetweeninjuryandQoLdomains needsfurtherinvestigation.

© 2014ConsellCatalà de l’Esport.Generalitat deCatalunya. Publishedby ElsevierEspaña, S.L.U.Allrightsreserved.

Correspondingauthor.

E-mailaddress:nataliaboneti@hotmail.com(N.B.Moreira). http://dx.doi.org/10.1016/j.apunts.2014.06.003

1886-6581/©2014ConsellCatalàdel’Esport.GeneralitatdeCatalunya.PublishedbyElsevierEspaña,S.L.U.Allrightsreserved.

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124 N.B.Moreiraetal. PALABRASCLAVE Calidaddevida; Revisión; Atletas; Heridasylesiones; Heridasatléticas; Deportes

Asociaciónentrelesiónycalidaddevidaenlosatletas:Unarevisiónsistemática, 1980-2013

Resumen A pesar de los beneficios de participar en la vida deportiva, ello entra˜na una situaciónderiesgodebidoalaocurrenciadelesionesacualquierniveldedesempe˜no.Dichas lesionespuedenafectartantoalosaspectosfísicoscomopsicológicos,ygenerarportantoun descensosignificativodeldesempe˜noy/ounafaltadeparticipación,loquepuedeafectarasu vezalacalidaddevida.Elpresenteestudiotrataderevisarsistemáticamentelainformación relativaalaasociaciónentrelaslesionesylosámbitosdelacalidaddevidaenatletasadultos, asícomoidentificarlosinstrumentosmáscomúnmenteutilizadosenlamedicióndelaslesiones ylacalidaddevidaendichosatletas,enartículospublicadosentre1980y2013.Lasbúsquedas serealizaronutilizandocincobasesdedatos(MEDLINE/PubMed,WebofScience,SPORTDiscus, PsycINFOyLILACS)ylasreferenciascitadasenartículosrecuperados.Deentrelabúsqueda realizada,sólo12artículoscumplieronloscriteriosdeinclusión,yfueronrecuperadosy exam-inados.Sehanutilizadodiferentescuestionariosnoestandarizadosparaevaluarlaslesionesde losatletas.Paraevaluarlacalidaddevida,muchosestudiosutilizaronelSF-36.Laevaluaciónde ladireccióndelaasociaciónentrelesiónyámbitosdelacalidaddevidademostróquemuchos estudiosincluidosenestarevisiónreflejaronelevadosporcentajesdeasociaciónnegativaenel ámbitodelasatisfaccióndevida(100%),seguidodelosámbitosdedolorcorporal(71,4%), pun-tuacióndecomponentesfísicos(75%),funcionamientofísico,vitalidadfísica,funcionamiento social(66,7%cadauno),saludmental(62,5%),ysaludgeneral(57,1%).Enconclusión,enatletas adultos,muchosestudiosdemostraronunaasociaciónnegativaentrelesionesyámbitosdela calidaddevida,especialmenteenlosaspectosfísicosysociales.Sinembargo,laasociación entrelesiónyámbitosdelacalidaddevidaprecisaunainvestigaciónadicional.

©2014ConsellCatalà del’Esport.GeneralitatdeCatalunya.PublicadoporElsevierEspaña, S.L.U.Todoslosderechosreservados.

Introduction

Sports practice is widespread all over the world,1

demonstratingastrongpositiveinfluenceinhealthfor prac-titionersrelatedtophysicalaspects;e.g.,cardiorespiratory improvements2---6andpsychologicalaspects,e.g.,stressand

anxiety reduction.7,8 Despite these benefits, participation

insportsalsoentailsarisksituationfortheoccurrenceof injuries at any level of performance.6,9,10 This framework

has been shown to be more exacerbated in athletes, as wellasthosewhoexhaustivelyexercise,9asthereisgreater

exposuretoextrinsicandintrinsicfactors.Amongthe extrin-sicfactors,thetrainingcharacteristicsandthetypeofthe activityarehighlighted;theintrinsicfactorsareassociated withthebiological(e.g.sex,age),biomechanical(e.g. flex-ibilityandmusclestrength)andpsychosocialcharacteristics (e.g.motivationandexperience).11,12

Participationinsportsbetweenathletesinvolvesan ele-vated physical requirement that can provoke an organic adjustmentprocessthatcanhaveanegativeeffectonbody withahighpotentialforimbalanceinmuscleandbone struc-turesresultingininjuries.13 Theseinjuriescanaffectboth

physicalandpsychologicalaspects,andconsequently, gen-erate a significant decline in performance and/or lack of participationwhichmayaffecttheirqualityoflife.

Qualityoflife(QoL)isdefinedasanindividual’s percep-tionofhisorherpositioninlifeinthesocioculturalcontext andinrelationtohisorhergoals,expectations,standards andconcerns.14Thisconceptismultidimensionalthatallows

fortheanalysisofseveraldimensions15,16whichinturn,can

alsobereferredtoasgeneralQoLorhealthrelatedquality oflife(HRQoL).TheQoLconceptisbasedonthedefinition thatencompassesasenseofwell-beingandhappiness, with-outreferencetohealthproblemsordisorders.Ontheother hand, HRQoL is part of a multidimensionalapproach that considersphysical,mentalandsocial-relatedsymptoms,as wellaslimitationsthatarecausedbyillness.17

Evidence supports the association between injury and QoL in athletes, however this relation is not fully estab-lishedyet.1,18Otherstudieshavebeendonespecificallywith

QoLinolderadults,19,20orinnon-athletes21,22 andwithout

evaluatingtherelationtoinjuries.Furthermore,other stud-iesinvestigatedonly theinstrumentsusedtoevaluatethe injuryandQoL,whichistheirvalidityandreliabilitywithout evaluatingtheassociationbetweenthevariables.23---25

Suchevidencewillprovideanoverviewoftheinfluence of the injuryin the differentdomainsof QoL in athletes, andwillalsoidentifygapsintheliteratureforthe develop-ment of newresearch, aswell direction and planningfor injury prevention and rehabilitation allowing for a faster returnwithmajorqualityandminorresidualinjuryeffects for thispopulation,prioritizingahealthyreturntosports. Withthesefactsinmind,thepresentstudyaimsto systemat-icallyreviewinformationregardingtheassociationofinjury withdomainsof QoLin adult athletesand toidentifythe most commonlyusedinstruments for themeasurement of injury and QoL in adult athletes publishedbetween 1980 and2013.

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Associationbetweeninjuryandqualityoflifeinathletes 125

Methods

The literature searchwas performed inApril 2013on the MEDLINE/PubMed,WebofScience,SPORTDiscus,PsycINFO andLILACSelectronicdatabases.Thesearchwaslimitedto articlesthatwerepublishedbetweenJanuary1980andApril 2013,andarticlesthatwerepublishedinPortuguese,English andSpanishwereconsidered.AcombinationofMedical Sub-jectHeadings(MeSH),‘‘DescritoresdeCiênciasdaSaúde’’

(DeCS;fortermsinPortuguese)andtextwordswereusedto generatethelistofcitations.Thesearchprocesswas con-structedspecificallyfor each databaseandnolimitswere usedinthesesearches.Thekeytermswereusedtosearch inMEDLINE/PubMedandLILACSandbytopicintheWebof Science,SPORTDiscusandPsycINFO.

Oursearchstrategywasbasedonacombinationoffour search parameters: injury,quality of life, population and age group. The keywords for injury (wounds and injuries ORinjur*ORathleticinjur*), qualityoflife(qualityoflife ORpersonalsatisfactionORhealthstatusORwellbeingOR healthrelatedqualityoflife),population (athlet*OR ath-letic*ORsport*ORsportsmedicine)andagegroup(adult* ORagedORelderlyORyoungadult*ORmiddleaged)were usedincombinationtolocatepotentiallyrelevantstudies. TheBooleanoperator‘‘AND’’wasusedtocombinethefour groupsinthesearch.Thetruncationsymbolsforeach spe-cificdatabase(e.g.,*or#)wereusedtocapture allsuffix variationsofarootword.

Articleswereselectedin accordancewithasystematic method. All of the selection processes and article eval-uations were conducted in pairs (N.B.M; G.C.V.), and if there wasdisagreement between reviewers onthe inclu-sion and exclusion criteria, the article in question was specificallydiscussed until afinal consensuswasreached. An initial analysis was performed based on the titles of themanuscripts, andasecond evaluation wascarriedout basedontheabstractsofallarticlesthatmettheinclusion criteriaor couldnotbeclearlyruled out.Afterexamining the abstracts, all of the selected articles were retrieved andsubsequentlyexaminedusingtheestablishedinclusion criteria.Amanualsearchofthebibliographiesofselected articleswasalsoperformed,andtheprincipalauthorsofthe manuscriptswere contactedtoidentifyother publications thatmettheinclusioncriteria.

Inclusionandexclusioncriteria

The followinginclusion criteriawereconsidered: (i) origi-nalarticlespublishedinpeer-reviewedjournalsthataimed totest for an association between injury and domainsof QoL,(ii)studiespublishedbetweenJanuary1980andApril 2013; (iii) samples with athletes aged 17 years or older or samples witha meanage in thisage group; (iv) cross-sectionalandfollow-upstudies;and(v)teamorindividual sports.

Theinjuryassessmentincluded:Self-assessmentofinjury andtheevaluation bytheteamorthopedist andinternist. For the QoL assessment, we decided that the search for studiesshouldnotbelimitedtothosethatusedageneric instrument to assess QoL (e.g., WHOQoL-100 or SF-36) because it could exclude important studies that examine

theassociationbetweenPAanddomainsofQoL.Therefore, weincludedstudiesthatutilizedself-reportedQoL question-naires,inventoriesandwellbeingscaleswhichcontainedthe QoLor HRQoL domains(well-being, lifesatisfaction, self-ratedhealth),andthedomainsthatcompriseQoLorHRQoL (physical,psychological,social,cultural,mentaland spiri-tualdomains).14,26---28

Articles were excluded if they assessed athletes in adapted sport activities, for example wheelchair sports, becausethis category has different conditionsof training andgamewhencomparedtounadjustedsports.

Qualityassessmentofthestudies

Twoindependent reviewers (N.B.M; G.C.V.)evaluatedthe qualityof the studies using the Strengthening the Repor-ting of Observational Studies in Epidemiology (STROBE) checklist.29 The checklist contains 22 items and contains

recommendationsaboutwhatshouldbeincludedforamore accurateandcompletedescriptionofobservationalstudies. Allofthequestionswerecodedaszero(representingpoor quality)orone(representingadequatequality).Study qual-ityscorescouldrangefromzeroto22pointsmeaningthat thehigherthescore,thebetterthemethodologicalquality ofthestudy.Intheeventofdifferencesinarticleevaluations betweenthetworeviewers,thearticlewasreassesseduntil theyreachedanagreement.Thestudieswereclassifiedin threegroupsaccordingtotheirmethodologicalquality.For thispurpose, eachstudy’smethodologicalscorewas com-paredto the maximum score in STROBE (22 points): this strategyderivedhighquality(≥70%totalscore),moderate quality(50---69% total score), and low quality (<50% total score)studies30(seeTable1).

Directionoftheassociationbetweeninjuryand QoL

Anevaluationwasperformedtodeterminethedirectionof theassociationbetween injuryanddomainsofQoL inthe reviewedstudies.Forthisevaluation,significantresultsof associationbetweeninjuryandQoLdomainswereused.The percentagesofthestudiesaccordingtothedirectionofthe association were calculated. In orderto provide a better understanding,percentagesweregroupedintothree cate-gories:(a)negative(−):studies withnegativeassociation betweeninjuryandQoL;(b)zero(0):studieswithouta sig-nificantassociationbetweeninjuryandQoL;and(c)positive (+):studieswithapositiveassociationbetweeninjuryand QoL(seeTable2).

Table2‘‘Summaryoftheassociationofinjuryand dif-ferent aspects of QoL’’ had the purpose of identifying a commonQoLdomain,independentlyoftheinstrumentused toassesstheQoL.TheQoLdomainsweregroupedintothe sameclass,asfollows:MentalHealth:Stress,31Anxietyand

Depression32;GeneralHealth:PerceivedHealth32;Physical componentscore: Health Index32 and Knee Specific

Qual-ityofLife33;PhysicalFunctioning:UsualactivitiesandSelf

care.32

(4)

126

N.B.

Moreira

et

al.

Table1 Summaryofthestudiesregardingtheassociationbetweeninjuryandqualityoflifeinathletesdescribedbyresearchdesign.

Author Pointsofquality

assessment (%/classifica-tion)

Country/dateof collect

Sample;age Sportscategory Measurementof injury Measurementof qualityoflife Adjustment variables Mainfindings Cross-sectionalstudies Kleiberetal., 198736 13points (59/moderated)

Notreported 426men;not

reported Basketballand football Questionnaire developedfor thestudyto assessthe historyofinjury LifeSatisfaction Index-A

None Theformerathleteswhoseinjuries

terminatedtheirathleticcareerduring

theirfinalyearhadsignificantlylower

lifesatisfactionscoresthandidthose

whosecareerswerenotinterruptedby

injury(meanitemscoreforinjury=2.80

comparedto2.94fornoninjury,

p=.021);

Beinginjuredmightalsoreduce

subsequentinformalinvolvementin

sportandaffectlifesatisfactionasa

result. Turneretal., 200032 19points (95/high) United Kingdom/Not reported 284men;mean age56.1±11.8 years Football Self-assessment ofosteoarthritis (OA)

EuroQol(EQ-5D) Ageorother

morbidity

RespondentswithOAscoredsignificantly

lower(p<0.05)onhealthindexof

EQ-5Dutility(0.58±0.31vs.0.81±0.19)

andperceivedhealthratingscalesthan

respondentswithoutOA(Current

health=56.4±25.6vs.70.4±20.0;

futurehealth=60.2±23.3vs.

75.2±19.3),indicatingpoorer

subjectivehealthintheformergroup;

Asignificantlyhigher(p<0.001,all

df=1)proportionofrespondentswithOA

reportedproblemsoneachofthefive

EQ-5Dprofiledimensions:pain(x2=31.04),

mobility(x2=59.27),usualactivities

(x2=46.18),selfcare(x2=10.93),and

anxiety/depression(x2=10.48);

Insummary,theresultssuggestthat

respondentswhoreportedthattheyhad

beendiagnosedwithOAhavea

significantlylowerHRQoLthanpeers

withnodiagnosisofOA.Theimpactof

OAwasmostpronouncedinperceived

physicaldimensionsofHRQoLsuchas

painandmobility.However,thedisease

alsohadanoticeablepsychosocial

impact.

(5)

Association between injury and quality of life in athletes 127 Table1 (Continued)

Author Pointsofquality

assessment (%/classifica-tion)

Country/dateof collect

Sample;age Sportscategory Measurementof injury Measurementof qualityoflife Adjustment variables Mainfindings Mcallister etal.,200138 19points (95/high)

Notreported 562subjects

(333men,229 women); between18and 24years(mean age19.6years) Baseball, softball,track and cross-country, swimming, diving,water polo,tennis, golf,football, basketball, volleyball, soccer,and gymnastics Questionnaire developedfor thestudyto assessthe currentinjury HRQoLand domainsof SF-36 Classificationof injury (‘‘mild’’=minimal ornoeffecton participation, practice,or play; ‘‘serious’’= significant effecton participation, practice,or playorthose thatresultedin theathlete’s inability)

TherewasatrendfordecreasedSF-36

componentscoresandsummaryscores

withincreasedinjuryseverityinboth

menandwomenathletes;

Seriousinjurywasapredictoroflower

scoreswhencomparedwiththe

noninjuredathletes(p<0.05)inthe

Mentalcomponentsummaryscale

(men=48±2.1vs.52±0.5;

Women=50±1.9vs.52±0.5),physical

componentsummaryscale

(men=44±2.2vs.54±0.4;

women=47±1.3vs.54±0.5),andall

eightcomponentSF-36scores(physical

function:men=85±4.5vs.94±1.2, women=88±3.5vs.96±1.2;role physical:men=47±9.6vs.96±1.0, women=73±7.7vs.91±2.0;role emotional:men=73±9.2vs.94±1.2, women=75±8.0vs.93±1.8;bodily

pain:men=52±5.0vs.84±1.1;mental

health:men=71±2.7vs.80±1.0, women=76±2.8vs.79±1.0;vitality: men=59±4.3vs.69±1.1, women=64±2.8vs.68±1.1;social function:men=70±5.6vs.88±1.2, women=74±5.0vs.87±1.6;general health:men=72±4.2vs.81±1.1; women=74±3.7vs.79±1.3);

Mildinjurywaspredictiveoflowerscores

whencomparedwiththenoninjured

athletes(p<0.05)inthephysical

componentsummary(men=50±0.8vs.

54±0.4;women=50±1.1vs.54±0.5),

rolephysical(men=82±3.7vs.96±1.0;

women=83±4.6vs.91±2.0),bodily

pain(men=69±2.5vs.81±1.1;

women=68±3.5vs.82±1.4),social

function(men=82±3.2vs.88±1.2;

women=82±3.0vs.87±1.6),and

generalhealth(men=72±2.6vs.

81±1.1;women=74±2.5vs.79±1.3);

Injurywasfoundtohaveastrongly

negativeeffectonalleightoftheSF-36

componentscoresaswellasonthe

physicalandmentalcomponent

summaryscores.

(6)

128 N.B. Moreira et al. Table1 (Continued)

Author Pointsofquality

assessment (%/classifica-tion)

Country/dateof collect

Sample;age Sportscategory Measurementof injury Measurementof qualityoflife Adjustment variables Mainfindings Mcallister etal.,200339 17points (77/high)

Notreported 66subjects;

between18and 24years Football, basketball, soccer, gymnastics,

trackandfield,

skiing,baseball, andtennis Self-assessment oftheinjury HRQoLand domainsof SF-36

None Therewerenostatisticallysignificant

differences(p>0.05)betweentheanterior

cruciateligamentinjurygroupandthe

uninjuredgroupinthecomponentand

summaryscoresoftheSF-36(physical

function=91±13.3vs.93.3±8.5;role physical=96.2±11vs.94.6±19.5;role emotional=91.9±23.6vs.93.9±19.4; socialfunction=92.4±10.3vs.91.2±15.7; bodilypain=86.9±14.9vs.80.5±17.8; mentalhealth=79.5±13.6vs.82.5±9.3; vitality=67.8±15.2vs.66.5±17.6;general health=83±13.6vs.84.3±14.3;physical componentscore=54.5±5.5vs.53.5±5.6;

mentalcomponentscore=52.7±7.8vs.

53.5±6.7);

Insummary,qualityoflifeofelitecollegiate

athleteswhosustainedananteriorcruciate

ligamentinjurywasnotsignificantly

differentfromthatoftheiruninjured

teammates. Guskiewicz etal.,200734 19points (95/high) Not reported/2001 2552men;mean age53.8±13.4 years Football Previous concussionwas basedonthe player’s retrospective Recallofinjury events Component scoresofSF-36

Age,yearssince

retirement, numberofyears played,physical component scoreonthe SF-36,and diagnosed comorbidities Including osteoarthritis, coronaryheart disease,stroke, cancer,and diabetes

Therewasanassociationbetweenrecurrent

concussionanddiagnosisofdepression

(x2=71.21,df=2,p<0.005),witha

significanttestforlineartrend(x2=63.76,

df=1,p<0.005)suggestingthatthe

prevalenceincreasesinalinearfashionwith

increasingconcussionhistory.Thus,retired

playersreportingahistoryofthreeormore

previousconcussionswerethreetimesmore

likely(prevalenceratioof3.06;95%CI:2.29,

4.08)tobediagnosedwithdepression,and

thosewithahistoryofoneortwoprevious

concussionswere1.5timesmorelikely

(prevalenceratioof1.48;95%CI:1.08,2.02)

tohavebeendiagnosedwithdepression,

relativetoretireeswithnoconcussion

history;

Aftertheadjustmentforconfounding

variablesonlyasmallreductioninthe

prevalenceratioswasobserved(2.58;95%

CI:1.90,3.55and1.39;95%CI:1.03,1.96,

respectively),suggestingthatthesignificant

associationbetweenconcussionhistoryand

diagnosisofdepressionwasnotattributable

toconfoundingbythesefactors;

Thefindingssuggestthatprofessional

footballplayerswithahistoryofthreeor

moreconcussionsareatasignificantly

greaterriskforhavingdepressiveepisodes

laterinlifecomparedwiththoseplayers

withnohistoryofconcussion.

(7)

Association between injury and quality of life in athletes 129 Table1 (Continued)

Author Pointsofquality

assessment (%/classifica-tion)

Country/dateof collect

Sample;age Sportscategory Measurementof injury Measurementof qualityoflife Adjustment variables Mainfindings Irgensetal., 200735 20points (91/high) Norway/March 2004 230men; between40and 59yearsofage (meanage 52±6.7years) Diver Questionnaire developedfor thestudyto assessthe historyofinjury (decompression sickness) HRQoLand domainsof SF-36 Concussionor headinjury, other neurological disorderand psychological problemsin

diverswithand

without decompression sickness

Diverswithahistoryofdecompression

sicknessreportedconsiderablylowerscores

forallscales(p<0.001)thandiverswithno

historyofdecompressionsickness

(physical=62±32vs.88±32;bodily pain=56±30vs.72±30;general health=48±26vs.72±25;vitality=49±27 vs.70±27;socialfunctioning=61±36vs. 84±36;emotional=73±31vs.91±30; Mentalhealth=71±23vs.84±22);

Thelineartrendsremainedafteradjustment

forconfoundingvariablesforalldomainsof

HRQoL(p<0.05);

Thestudydemonstratedadecreasingtrend

forallscalesofSF-36whencomparingthe

scoresindiverswithnoreported

decompressionsickness.

Nicholas

etal.,200740

19points

(95/high)

Notreported 36men;mean

age62±3years

Football Theinjury

statusofthe playerswas recordedbythe team orthopedistand internist Component scoresofSF-36

None SF-36physicalhealthscoreswere21%lower

inplayerswhoreportedhavingarthritis

(p<0.01)andbackpain(p<0.05)compared

withtheotherplayers.Physicalhealth

scoreswere19%abovenormalforplayers

withoutarthritis(p<0.01)andnotdifferent

fromnormalforplayerswitharthritis(6%

lower,p<0.6).Physicalhealthscoreswere

11%abovenormalforplayerswithoutback

pain(p<0.05)andtendedtobebelow

normalforplayerswhoreportedhavingback

pain(12%lower,p=0.12).Thecombination

ofarthritisandbackpainappearedtohavea

compoundingeffectonphysicalhealth

scores;

Mentalhealthscoreswere53.1±8.9vs.

53.3±6.4forplayerswithandwithout

arthritis(p=0.95)and51.7±8.7vs.

54.0±7.8forplayerswithandwithout

chroniclowbackpain(p=0.42);

Physicalandmentalhealthscoreswerenot

differentbetweenthe16playerswithno

significantinjuryhistoryin1969(physical

healthscore,45.5±13.6;mentalhealth

score,53.4±7.8)comparedwiththe20

playerswhohadsignificantpreviousinjuries

(physicalhealthscore,50.1±9.7,p=0.24;

mentalhealthscore,53.1±8.4,p=0.92);

Insummary,thecombinationofarthritisand

backpainappearedtohaveacompounding

effectonphysicalhealthscores.Mental

healthscoreswereunaffectedbythe

presenceorabsenceofanyofthereported

medicalproblems.

(8)

130 N.B. Moreira et al. Table1 (Continued)

Author Pointsofquality

assessment (%/classifica-tion)

Country/dateof collect

Sample;age Sportscategory Measurementof injury Measurementof qualityoflife Adjustment variables Mainfindings Huffman etal.,200841 18points (82/high) USA, Canada/seasons 2005---2006and 2006---2007 696subjects (409male,287 female); between17and 23yearsofage (meanage18.5 years) Crew,lacrosse, fencing, wrestling, baseball, Softball, swim-ming/diving, volleyball,field hockey,golf, basketball, tennis, cross-country/track, squash,soccer, andgymnastics Questionnaire developedfor thestudyto assessthe historyofinjury Domainsof SF-36

None Athleteswithnohistoryofinjuryscored

significantlyhigher(p<0.05)thanathletes

whoreportedanypreviousinjuryintermsof

allhealthdomains(Physical

functioning=98.6±7.0vs.97.3±8.3; physical=96.2±15.2vs.92.9±20.1;bodily pain=88.8±15.0vs.80.2±19.3;general health=86.3±12.7vs.83.3±13.6; vitality=70.7±13.9vs.67.8±13.7;social functioning=96.3±9.9vs.92.9±13.4; mentalhealth=83.4±10.0vs.81.6±11.1);

exceptrolelimitationsduetoemotional

problems(98.1±10.3vs.95.8±16.8);this

latterdifferenceapproached,butdidnot

reach,significance(p=0.057);

Insummary,amongathleteswhoarecleared

forparticipation,anyhistoryofinjury----even

remoteminorinjuriesinsomecases----hasa

detrimentaleffectonanathlete’sperceived

healthstatus.

Kuehletal.,

201037

18points

(82/high)

Notreported 302subjects

(210male,92 female);mean age19.8±2 years Football, lacrosse, women’ssoccer, softball, baseball, volleyball, wrestling,water polo,swimming, andtennis Ademographic formincluding concussion history HRQoLand domainsof SF-36 Numberof concussion(0 group=No concussion;1---2 group=1---2 concussion;3+ group=≥3 concussion)

Significantdifferencesbetweengroupswere

notedonthebodilypain,socialfunctioning,

andvitalitysubscalesoftheSF-36(p<0.05).

Pairwisetestsrevealedthatthe3+grouphad

significantlylowerscoresforbodilypain

(48.07±8.88)comparedwiththe1---2group

(52.07±7.74;U(1)=1363.0,z=−2.5)and

the0group(53.50±8.32;U(1)=2158.0,

z=−3.7).The3+grouphadsignificantly

lowerscoresonsocialfunctioning

(48.47±9.43)thanthe1---2group

(51.55±7.31;U(1)=1433.5,z=−2.2)and

the0group(51.86±8.03;U(1)=2461.5,

z=−3.0]andhadlowerscoresonvitality

(52.40±8.40)thanthe0group

(55.92±8.35;U(1)=2506.5,z=−2.6);

Asignificantnegativecorrelationwasfound

betweenthebodilypain(rs=−0.204;

r2=0.042),socialfunctioning(r

s=−0.139;

r2=0.019),andvitality(r

s=−0.165;

r2=0.027)subscales,withthelowerHRQoL

scoresassociatedwiththegroupswhohad

moreself-reportedconcussions.Allother

subscalecorrelationswerenotsignificant;

Significantcorrelationssuggesta

dose---responserelationshipwherethegroups

withhighernumbersofprevious

sport-relatedconcussionareassociatedwith

lowerHRQoL,andmayhavenegative

consequencesoncertaindomainsofHRQoL

incollegiateathletes.

(9)

Association between injury and quality of life in athletes 131 Table1 (Continued)

Author Pointsofquality

assessment (%/classifica-tion)

Country/dateof collect

Sample;age Sportscategory Measurementof injury Measurementof qualityoflife Adjustment variables Mainfindings Malinauskas, 201031 18points (82/high)

Notreported 123subjects(69

male,54 female); between18---25 yearsofage (meanage 21.22±1.28 years) Basketball, football,track andfield, easternmartial arts,volleyball, andgymnastics Ademographic questionnaire provided additional information abouttheir injury Satisfaction

withLifeScale

(SWLS) Classificationof injury(‘‘minor’’ or‘‘severe’’ basedonthe numberofdays lostto participationin theathlete’s sport)

Thereweresignificantdifferences(p<0.001)

withthemajorinjuriesgrouphavingtheless

lifesatisfaction(16.50±5.98;t=5.11)when

comparedwiththeminorinjuriesgroup

(22.17±6.21);

Thelevelofinjuryoftheparticipantswas

foundtoberelatedtolifesatisfaction,in

summary,participantswithamajorinjury

hadtheleastlifesatisfaction.

Follow-upstudies VonPorat etal.,200433 19points (95/high) Sweden/1986---2000 1986=344men, 2000=154men; between30and 56years(mean ageof38years)

Soccer Diseasespecific

kneeinjuryand

osteoarthritis

outcomescore

(KOOS)

Domainsof

SF-36

None Theinjuredplayersreportedsignificantly

worseoutcomeinkneespecificqualityof

life(60±24.6,95%IC56.2---63.9vs.

92±13.5,95%CI88.6---95.7)andintheSF-36

subscalesphysicalfunctioning(84.5±14.5,

95%CI82.1---86.8vs.93.1±15.4,95%CI

92.1---94.1)androlephysical(81.4±30.9,

95%CI76.5---86.4vs.88.5±26.7,95%CI

86.7---90.2)comparedwithSwedishmenaged

35---44.However,inthesubscalessocial

functioning(93.6±13.9,95%CI91.3---95.8vs.

89.5±20.0,95%IC88.2---90.8)andmental

health(86.4±12.9,95%CI84.4---88.5vs.

82.2±18.6,95%CI81.0---83.4)theplayers

scoredsignificantlyhigherthanthe

referencegroup;

Theinjuryandtheosteoarthritis,

irrespectiveofthetreatmentprovidedto

thesepatients,oftenresultinkneerelated

symptomsthatseverelyaffecttheknee

relatedqualityoflifebymiddleage.

(10)

132 N.B. Moreira et al. Table1 (Continued)

Author Pointsofquality

assessment (%/classifica-tion)

Country/dateof collect

Sample;age Sportscategory Measurementof injury Measurementof qualityoflife Adjustment variables Mainfindings

Kerretal.42 19points

(95/high) Not reported/2001---2010 899men;mean age62±10.9 years Football Previous concussionwas basedonthe player’s retrospective Recallofinjury events Component scoresofSF-36

None Thecomparisonofphysicalhealthcomposite

scores(PCS)bychangeinself-report

concussionhistoryofformerprofessional

footballplayersin2001and2010showedin

thegreaternumberreportedthescore45.5

(95%CI44.2---46.7)and42(95%CI40.7---43.3),

andinthesamenumberreportedthescore

was46.7(95%CI45.8---47.6)and44.1(95%IC

43.2---45);andthecomparisonofmental

healthcompositescores(MCS)in2001and

2010showedinthegreaternumberreported

thescore53.4(95%CI52.3---54.6)and49.8

(95%IC48.4---51.2),andinthesamenumber

reportedthescorewas53(95%CI52.2---53.8)

and51.4(95%CI50.5---52.3);

WhenthechangeinPCSandMCSscoresfrom

2001to2010wascomparedbychangein

self-reportconcussionhistory,thegreater

number-reportedgroupreportedlower

averagePCSandMCSscoresinthe2010than

thesame-numberreportedgroup(PCS:

t=−2.1,p=0.011;MCS:t=−2.0,p=0.045).

Furthermore,thegreater-number-reported

grouphadagreateraveragedropinMCS

scorefrom2001to2010,relativetothe

same-number-reportedgroup(t=−2.7,

p=0.008).Curiously,thegreater-number

reportedgrouptendedtohaveagreater

averagedropinPCSfrom2001to2010than

thesame-numberreportedgroup(t=−1.1,

p=0.277);

Furthermore,increasesinconcussion

reportingwereassociatedwithdeclinesin

SF-36PCSandMCS,suggestingapossible

relationshipbetweenconcussionreporting

andchangesinhealthstatus.

Abbreviations:HRQoL:HealthRelatedQualityofLife,OA:OsteoarthritisandCI:ConfidenceInterval.

Assessingthequalityofarticles:ItwasusedthechecklistofObservationalStudiesinEpidemiology-STROBE(Elmetal.,2007),forcross-sectionalandfollow-upstudies(withscoresfrom 0to22points).

Injuryassessinginstruments:

Kneeinjuryandosteoarthritisoutcomescore(KOOS):isa42itemselfadministeredquestionnairebasedontheWOMACosteoarthritisindex(Bellamyetal.,1988),provenvalidforsubjects withanteriorcruciateligamentinjuryandearlyosteoarthritiscoveringfiveseparatedimensions:pain,symptoms,activitiesofdailyliving,sportandrecreationfunction,andkneerelated qualityoflife.

InstrumentsassessingQoL:

SF-36:ShortForm-36isashortenedversionoftheMOSquestionnairecomprising36itemscoveringeightcomponents(domains):functionalcapacity,physicalaspects,pain,generalhealth, vitality,social,emotionalaspects,mentalhealth.

LifeSatisfactionIndexA:composedoftenitemsthatexaminethelifesatisfactionandwell-beingoverthelifecourse. TheSatisfactionwithlifescale(SWLS):composedoffiveitemsthatseektoestimatetheoveralllifesatisfaction.

EuroQol(EQ-5D):EuropeanQualityofLifeisaquestionnairethatmeasuresthehealth-relatedqualityoflifecoveringfivedomains:mobility,self-care,usualactivities,pain/discomfort, andanxiety/depression.

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Associationbetweeninjuryandqualityoflifeinathletes 133

Table2 SummaryoftheassociationofinjuryanddifferentaspectsofQualityofLife(QoL). DomainsofQoL Totalof

studies

Directionofassociationwithinjury(thenumbers arethestudyreferencenumber)

%total

Negativea Zerob Positivec

C F C F F

Lifesatisfaction 2 31,36 100.0

Bodilypain 7 32,35,37,38,41 39 33 71.4

Physicalcomponentscore 8 32,34,38,40 33,42 37 75

Physicalfunctioning 6 32,38,41 33 37,39 66.7 Physical 6 35,38,41 33 37,39 66.7 Vitality 6 35,37,38,41 39 33 66.7 Socialfunctioning 6 35,37,38,41 39 33 66.7 Mentalhealth 8 31,32,35,38,41 37,39 33 62.5 Generalhealth 7 32,35,38,41 37,39 33 57.1

Mentalcomponentscore 6 34,38 42 37,39,40 50.0

Emotional 6 35,38 37,39,41 33 33.3

a Negative(−):StudieswithnegativeassociationbetweeninjuryandQoL. b Zero(0):StudieswithoutasignificantassociationbetweeninjuryandQoL.

c Positive(+):StudieswithapositiveassociationbetweeninjuryandQoL.C---cross-sectionalstudies;F---follow-upstudies. StudiesthathadthepurposetoidentifyacommonQoLdomain,independentlyoftheinstrumentusedtoassesstheQoL,weregrouped intothesameclassoftheevidencesummary,asfollows:Mentalhealth:stress,31anxietyanddepression32;GeneralHealth:perceived health32;Physicalcomponentscore:HealthIndex32 andKneeSpecificQualityofLife33;Physicalfunctioning:usualactivitiesandself care.32

Results

Theliteraturesearchyielded615potentiallyrelevant arti-cles. After reading the titles, 288 articles were selected on the basis of the inclusion criteria. The 288 abstracts werereviewed and40 articleswere selectedfor full text review.Of these,71.43% were excluded for thefollowing reasons:11studies(36.7%)didnotpresentQoLasan out-come,ninestudies(30%)didnotpresentthedesigncriteria (cross-sectionalorfollow-upstudies),sixstudies(20%)did notconsistofathletes,andfourstudies(13.3%)didnotmeet thesamplecriteria(≥17years).Twoadditionalstudieswere obtainedfromthereferencesearch.Therefore,12studies werereviewed(Fig.1).

Of the 12 studies included, ten (83.3%) were cross-sectional studies31,32,34---41 and two(16.7%) werefollow-up

studies.33,42 Most studies did not include the survey

year (58.33%),31,32,36---40 and five (41.67%) were conducted

between2001and2010.34,35,38,39,41Allofthecharacteristics

andmainresultsofthestudiescanbeobservedindetailin

Table1ofthisreview.

The mean age of the participants of the studies ranged between 18.541 and 62 years.40,42 Most

stud-ies (58.33%) only included men32---36,40,42 and five studies

(41.67%) included both genders.31,37---39,41 Sixstudies (50%)

evaluatedmore than one sportcategory,31,36---39,41 and the

majoritywereincludedinthecollectivesportcategory fore-mostwithfootball,31,32,34,36---40,42followedbysoccer,33,37---39,41

basketball,31,36,38,39,41volleyball,31,37,38,41baseball37---39,41and

softball.37,38,41 Intheindividualsportcategory,the

major-ityofthestudiesincludedtennis,37---39,41gymnastics,31,38,39,41

trackandfield,31,38,39andswimmingcategories.37,38,41

Somestudiesonlyclassifiedtheinjuryseverity31,38while

othersdidnotclassifyorreportthetypeofinjury.36,41The

majorityreportedthetypeofinjury(66.67%),andthemore commonlyevaluatedwastheconcussion,34,37,42followedby

the anteriorcruciate ligamentinjury,33,39 osteoarthritis,32

and decompression sickness.35 Only one study evaluated

more than one injured structure, including knee, back, shoulderandankleinjuries.40

Qualityofstudies

Noneofthestudiesachievedamaximumscore(22points) on the STROBE checklist,29 and the scores ranged from

2035 to 13 points.36 Of the cross-sectional studies, four

studies32,34,38,40obtained19pointsandfourstudies31,37,39,41

obtained the minimumscore (17 points, see Table 1). Of thefollow-upstudies,allobtained19pointsontheSTROBE checklist.33,42Basedontheproposedcutoffpoints,3091.67%

ofthestudieswereclassifiedashighquality,andonlyone study(8.33%)wasmoderatequality.36

EvaluationofinjuryandQoL

In 11 studies (91.67%), the history of the injury was obtainedthrough self-assessmentmethods. In these stud-ies,aquestionnairedevelopedfor thestudy wasthemost frequently used (83.33%) to evaluate the history of the injury.31,32,34---39,41,42 One study33 used the Disease specific

kneeinjury andosteoarthritis outcomescore (KOOS),and onlyonestudy40usedadirectmeasureoftheinjuryprovided

fromtheevaluationofanorthopedist.

The most widely used questionnaire to assess QoL (75%)wastheShortForm-36(SF-36),33---35,37---42 followedby

the Life Satisfaction Index-A,36 European Quality of Life

is a questionnaire (EuroQol),32 and the Satisfaction with

(12)

134 N.B.Moreiraetal. 615 references founda PubMed / MEDLINE – 388 (63.09%) Web of Science – 100 (16.26%) SPORTDiscus – 81 (13.17%) PsycoINFO – 42 (6.83%) LILACS –4 (0.65%) 327 (53.17%) references excluded

after reading the titles

288 (46.83%) references selected to

read abstracts

40 (13.89%) references selected for reading the

full text

12 (28.57%)manuscripts were selected: 10 cross-sectional studies (83.3%)

2 follow-up studies (16.7%) 2 articles extracted

from the reference lists of selected manuscriptsb,c

248 (86.11%) references excluded after reading the

summaries for having no relation with the aim of the

study

30 (71.43%) references excluded for not meeting the

eligibility criteria: - 11 references (36.7%) do not present QoLas an

outcome - 9 references (30%) do not presented the design criteria (Cross-sectional or Follow-up

studies) - 6 references (20%) do not consist of athletes

- 4 references (13.3%) do not meet the sample

criteria (=17 years)

Figure1 Flowchartofthestudyselectionprocess.aTheoverlappedreferenceswereexcluded.bMcAllisteretal.(2003).cTurner

etal.(2000).

life scale (SWLS).31 Due to the variability of injury and

QoL assessment tools, it was not possible to perform a meta-analysis.

Characteristicsofcross-sectionalstudies

Ofthe10cross-sectionalstudies,seven(70%)didnotreport thecountrythat conductedtheresearch.31,34,36---40Each of

theother studiesincluded thefollowing countries:United Kingdom,32Norway,35 USAandCanada.41

Ofthese,onlyone40usedadirectmeasureofinjury

(eval-uationofanorthopedist)whiletheremainderofthestudies (90%)usedself-assessmentoftheinjury.31,32,34---39,41To

eval-uate the QoL, themajority of the studies (70%)used the SF-36,34,35,37---41one studyusedthe LifeSatisfaction

Index-A,36 onestudyusedtheEuroQol,32 andonestudyusedthe

SWLS.31 OfthestudiesthatusedtheSF-36toevaluatethe

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Associationbetweeninjuryandqualityoflifeinathletes 135 athletes’QoL,fivestudiesusedthedomainsofQoL35,37---39,41

andtwostudiesusedthecomponentscoreofQoL.34,40

The majority of the studies (40%) used variance analysis,35,36,39,41 threestudies (30%) usedregression31,34,38

andcovarianceanalysis.32,37,40Sixstudies(60%)used

statis-ticalapproachesthatallowed fortheinclusionofpossible confounding variables.31,32,34,35,37,38 The most commonly

usedvariableswereclassification/numberofinjuries,age, andothercomorbidities.Formoredetailsaboutthestudies, seeTable1.

Characteristicsofthefollow-upstudies

Of the two follow-up studies, one was performed in Sweden,33 and one did not report the countrywhere the

studywasperformed.42

Amongthefollow-upstudies,VonPoratetal.33evaluated

theathletesforthefirsttimein1986andthesecondtime in2000,andusedtheKOOStoassesstheinjuryofthe ath-letes.Kerretal.(2012)evaluatedtheathletesforthefirst timein2000andthesecondtimein2010,anduseda pre-viousconcussionbasedontheplayer’sretrospectiverecall of injury events. Both studies usedthe SF-36to evaluate theathletes’QoL,butone33 usedthedomainsofSF-36and

other42 usedthecomponentscoresofSF-36.

Allthefollow-upstudies34,42usedthevariancemodelin

the data analysis,and did not includeconfounding varia-blesintothemodel.Formoredetailsaboutthestudies,see

Table1.

Summaryofevidencefortheassociationbetween

injuryandQoL

Table2summarizesthemainresultsregardingthe associa-tionbetweeninjuryanddomainsofQoL.Themajorityofthe studiesusedtheSF-36toevaluateQoL;inthisway,themost commonly evaluated domainswere mentalhealth, physi-calcomponentscore,bodilypain,generalhealth,physical functioning, physical, vitality, social functioning, mental componentscoreandemotional.

The evaluation of the direction of the association between injury and domains of QoL revealed that most studiesincludedinthisreviewshowedhighpercentagesof negativeassociationinthelifesatisfactiondomain(100%), followedbybodilypain(71.4%),physicalcomponentscore

(75%),physicalfunctioning,physical,vitality,social func-tioning(66.7%each),mentalhealth(62.5%),generalhealth

domains(57.1%).Furthermore,domainswithlow percent-agesofnegativeassociationincludedthementalcomponent score(50%), andemotional domain (33.3%) (seeTable 2). Theconsistencyofthestudieswasnotevaluatedduetoits design(cross-sectionalandfollow-up).

Discussion

TheliteraturehasshowedanincreasinginterestintheQoL ofathletes,18,43---46however,therearefewstudiesthat

asso-ciate QoL with injuries in this population. The reviewed studies1,18 did not use a systematic search in the

litera-turewhich mayhavelimitedor inadequatelydirectedthe resultsandconclusion.Additionally,thesestudies1,18didnot

identifythedirectionoftheassociationbetweeninjuryand QoLwiththeathletes.Thus,itbecomesevidentthatthere is a lack of a systematic review study that examines the associationbetweeninjuryandQoLinadultathletes.

Accordingtothesearchperformed inthisstudy,it was possible to note an increase in research after 2007. This evolution can be related withthe development and pop-ularityof thenewinstruments basedontheself-reported health status and which can be applied in a variety of diseases andinjuries.41 Furthermore, the high prevalence

of sports injuries and the possibility of generating nega-tiveeffectsonathlete’shealthhasdrawntheattentionof researchers.34,37,40

Moststudies includedin thisreview did notreportthe locationof theresearch31,34,36---40,42 whichmadeit

impossi-bletoconcludeiftherewasaconcentrationofstudiesina particularcountryorlocation.Regardingthegenderofthe sample,moststudiesevaluatedonlymen.32---36,40,42Thisfact

canbeexplainedbysportsparticipationinwhichmenhave ahighernumberofparticipants;although,women’s partic-ipationhasincreasedoverthelasttwodecades,ithasnot reachedthemalecontingentyet.47

Anothernotedfact withtheanalysisoftheresults was the variety of sports categories evaluated in the same study31,36---39,41whichexhibitsadvantagesanddisadvantages.

The advantage is related to the possibility of explaining thepossibleaspectsthatinfluenceathletes’QoLinseveral sportscategories,becauseaspecificpreventiveapproachto theathletesmightbedifficultbecauseeachsportscategory hasparticularitiesandspecificsportsgesturesandtraining methods. Thus, the individual search and analysis of the sportscategoriesbecomesimportantinordertocreatean interventionwithgreaterspecificity.

Even with the sports category analysis, most stud-ies evaluate the collective category,31---34,36---42 especially

football.31,32,36---40,42Footballispopularworldwidebothasa

spectacleandasaformofrecreationalexerciseandinvolves majorsources of investment.Moreover, it is a sport with highspeed contact anda high incidenceof injuries32 and

due to these factors, there is growing scientific interest asevidencedbytheincreasingnumberofstudieswiththis category.However,allsportspresentariskofinjury demon-stratingtheneedformorestudiesinothersportscategory. This review shows some variability among the studies regardinghowinjuryismeasured,withinstrumentswithout validityandreliability.31,32,34---39,41,42 This fact draws

atten-tion because the inadequate assessment for injuries can generate bias in epidemiologic studies when the propor-tionof events recalled is associated withthe health end pointsof interest,suchasdepression orQoL.Associations observedinthesestudiesmaybespuriousifathletesdifferin theirknowledgeandrecognitionofinjurysymptomatology, resulting in inadequate associations with health status.42

Thus,thestandardizationofinjuryassessmentinstruments is essential for future research because, in addition to avoidingmisinterpretation,itwouldfacilitatethe compar-isonbetweenstudies, amplifyingtheprofessionals’ action involvedwiththeperformanceofathletes.

Unlike the injury assessment, QoL assessment showed uniformityinthequestionnairesusedforevaluation.Among thestudies included inthis review, the most widely used instrumentformeasuringQoLwastheSF-36.33---35,37---42

(14)

136 N.B.Moreiraetal. SF-36is a generic instrumentto assessHRQoL andhas

been translated into several languages and validated for severalcultures.Thisquestionnairecontains36itemsthat aredividedintoeightscalesandcanalsobegroupedinto

physicalandmentalcomponents.48InBrazil,theinstrument

wastranslatedandvalidatedbyCiconellietal.49

Addition-ally,theinstrumentallowsforthe measurementofhealth dimensionsandcanassesstheimpactofdiseaseandthe ben-efitsoftreatment.Itisalsoagoodpredictorofmortality.50

Thereis evidence tosuggest that the physical and bodily painsubscalesoftheSF-36maybeusedtofollow-up mus-culoskeletalconditions,whichwouldjustifyitswidespread usetoevaluatetheinfluenceofinjuriesonHRQoL.51

Regardingthe associationbetween theinjury andQoL, most studies analyzed in this review showed negative results,inotherwords,theinjuredathletesreportedlower QoLscores,rangingaccordingtotheQoLdomains.The phys-icaldomainsassessanylimitationcausedbyphysicalhealth problems,andlowerscoresindicatethepatient’ssensethat physicalhealthisassociatedwithworkproblemsor perfor-manceofotherdailyactivities.48Essentiallyevaluatingthe

conceptofdisability,itisdefinedastheinabilityofa per-sontofulfillhisorherdesiredornecessarysocialorpersonal roles.52

Theseassociationssuggestthattheinjuryhasanegative influenceonthephysicalandsocialaspectsofathletes’QoL. This fact can be explained by the physical consequences causedbyinjurythatgeneratemajorimpactontheathletes’ activities;amongthem,we canmentionthepainwhichis thefirstsymptomoftheinjuryandcomprisesthebodilypain domain.32

Another example is the physical limitation caused by theinjury,suchasdifficultymovingindependentlyand per-formingdailyactivities,comprisingphysicalfunctioningand physicaldomains,andthecombinationofsuchdomains com-prise the physical component score (physical functioning, physicalandbodilypain).Jointly,highlevelsofpaincanbe debilitatingandmaycontributetolowersocialfunctioning andvitality,37whichwouldexplainthenegativeassociation

betweeninjuryandsocialfunctioningandvitalitydomains. Moreover,lower scores in the social domainshow that injuriesdonotaffect only athletes’physical aspects.The social domainis designedto assess theeffect of physical healthoremotionalproblemsontheindividual’sabilityto participateinsocialactivities,48whichisoftenneglectedin

theindividual’sassessment.Thus,theindividual’sapproach evaluation,containingtheuniqueneedsofeachindividual, takinginto consideration allthe aspectsrelated toinjury andpersonalrelationships,allowforanoverallfocusofthe prospects,notneglectingissuesaffectingthewell-beingof athletes.53

The studiesincludedin thisreviewsuggeststhatinjury affectsinalessaggressivewaythemental andemotional aspectsofathletes’QoL,aswellastheirhealthperception orthecontributionforworkproblemsanddailyactivities, asa result of emotional problems. These findings can be explainedbythereportoftheevaluatedathletesregarding thetypeofinjuriesin thisreview,andjointly,tothefact thattheseathletesdidnothavetodealwiththeseinjuries foralongperiodtoaffecttheirQoL.Inotherwords,most oftheinjuredathletes wereprobablystillparticipatingin theirsport,tosomeextent,thereforelimitingtheeffectof

significantchangesin mentalandemotionaldomains.This informationpointstotheneedtoassessthewithdrawaltime fromactivity due tosports injury,so inthis way, preven-tiveinterventionscouldbeestimatedinefficiencyandnew methodscouldbeimplemented,generatingongoingbenefits forathletes,andconfirmorrefusethishypothesis.

Briefly,basedonthisreview,itwaspossibletoobserve that injury wasnegativelyassociated withadult athletes’ QoL, rangingaccording toQoL domains. Regarding practi-calapplicabilityoftheseapproaches,suchinformationwill helptoestablishandemphasizetheneedforpreventionand awareness programs about the circumstances surrounding theinjuriesinmastersathletes.

Reductiononathlete’sQoLperceptionduetoinjuriescan generatenegativethinking, andis arisk factorfor dimin-ishedfeelingsofself-esteem,increasedmooddisturbance, depression, anger, confusion, and fatigue, and decreased sportsperformanceorevenwithdrawfromsport.54Constant

reviewofaspectsrelatedtoinjuryandathlete’sQoL percep-tioncanbeaddressedinacomprehensivemanner,avoiding longrecoveryperiods,alwayspayingattentiontotheimpact causedbysportsinjuriesthatgoesbeyondmomentary phys-icallimitations,butalsoitsroleintheperceptionofQoLin bothaspectsofphysicalasmentalhealth.However, infor-mation is stilllimited andscarce demonstrating theneed forstudieswithstandardizedassessmentsofinjury, further-more,controllingfor possibleconfoundingvariables(e.g., presenceof anothercomorbidities orabsenceinthesport due to injury) in the statistics model to help results be broaderandmorereliable.

Limitationsofthestudy

Thisreviewhadsomelimitationsthatshouldbehighlighted. Thefirstlimitationrelatesnotonlytothisreviewbutalsoto moststudiesincludedinit:theuseofquestionnairesto eval-uate theinjuryamongathletes. Manystudiesdidnottest thevalidityofthequestionnaires.Thus,therealprevalence ratesmaybedifferentthanthosefoundinthesestudies.

Asecondlimitationisrelatedtothepossibilitythatsome studies were not included in this review. The electronic searchwaslimitedtostudiespublishedbetween1980and 2013inthefollowingdatabases:MEDLINE/PubMed,Webof Science,SPORTDiscus, PsycINFO andLILACS. It is possible thatrelevantstudies publishedpriortothatperiodandin otherdatabasesaremissing.Thesearchforstudieswasalso limited to peer-reviewed literature, sounpublished data, theses,dissertationsandinstitutionalpositionpaperswere notincluded.Itisimportanttoemphasizethatthestudyof theassociation betweeninjury andQoLis atopicof rela-tivelyrecentinterest,asthemaininstrumentsforassessing QoL were only developed in the 1990s. Therefore, it is believedthatthemostimportantstudiesthatexaminethe associationbetweeninjuryandQoLpublishedinthisperiod aresummarizedinthisreview.

Conclusion

Thissystematicreviewrevealedthattherearefewstudies that have sought toinvestigatethe influence ofinjury on QoLinadultathletes.Differentquestionnairesareusedto

(15)

Associationbetweeninjuryandqualityoflifeinathletes 137 assesstheinjuryofathletesandmostofthemwerecreated

bytheauthorsthemselvesanddonotpresentastandardized assessment.FortheassessmentofQoL, moststudiesused theSF-36.TheassociationbetweeninjuryandQoLshowed a negative relationship and above 65% in 7 domains (life satisfaction, bodilypain,physical componentscore, phys-icalfunctioning,physical,vitality,andsocial functioning), andbetween62.5and33.3%in4domains(mentalhealth, generalhealth, mentalcomponent score,andemotional). These results show thatthe injury negatively affectsQoL forathletes,especiallyinphysicalandsocialaspects.

Studies assessing the injury in a standardized way and approaching individualizedsportcategoriesareneeded so morereliable andspecificcomparisonscan bemade.Also mediating factorssuch aspracticetimeand sporting ges-ture, aswell as confounding factors such as comorbidity orabsenceinthesportduetoinjury,shouldbetakeninto considerationinfuturestudies.

Conflict

of

interest

Authorsdeclarethattheydon’thaveanyconflictof inter-ests.

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