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Earlier studies of ski injury indicated that youths were at increased risk of injury, that males were most likely to injure the head or face, and that females were most likely to injure the knee.
To obtain information about safety knowledge and risk behaviour that might contribute to injury among young skiers and snow-boarders.
Survey of knowledge and behaviour in injured and noninjured cohorts.
Blackcomb Mountain, Whistler, British Columbia.
A total of 863 noninjured and 118 injured skiers and snowboarders aged five to 17 years using Blackcomb during 1993/94.
Skier Knowledge Inventory Questionnaire.
The injured cohort had less knowledge of the Skiers Responsibility Code. In both groups, almost half had had no lessons, 31% had had bindings adjusted by nonprofessionals and chair lift safety bars were used one ride in four by children age 13 to 17 years. The injuried cohort wore helmets slightly less often. Both groups regularly skied through the trees (60% to 70%), and one-thirds had skied on closed runs. Excessive speed was identified as the major cause of injury. Skiers did not recognize jumping as contributing to injury.
Lack of knowledge of safety rules was more prevalent among the injured cohort. Skiing without due care – including skiing through tress, skiing on closed runs, skiing with excessive speed and jumping, particularly by snowboarders – were identified as potential causes of injury.
Des études antérieures sur les blessures en ski révèlent que les jeunes courent un risque accru de blessures et que les garçons sont plus susceptibles de se blesser à la tête ou au visage tandis que les filles risquent davantage de se blesser aux genoux.
Obtenir des renseignements sur les connaissances de la sécurité et les comportements à risque qui peuvent contribuer aux blessures chez les jeunes skieurs et planchistes.
Sondage des connaissances et des comportements d’une cohorte blessée et non blessée.
Blackcomb Mountain, Whistler, Colombie-Britannique.
Un total de 863 skieurs et planchistes non blessés et de 118 skieurs et planchistes blessés âgés de 5 à 17 ans qui se sont rendus à Blackcomb en 1993–1994.
Questionnaire de l’inventaire des connaissances des skieurs.
La cohorte blessée connaissait moins le code de responsabilité des skieurs. Dans les deux groupes, presque la moitié n’avait pas suivi de cours, 31 % d’entre eux avaient fait ajuster leurs fixations par des non-professionnels et s’ils avaient de 13 à 17 ans, ils utilisaient les barres de sécurité des télésièges une fois sur quatre. Ils portaient des casques un peu moins souvent. Les deux groupes skiaient régulièrement dans les sous-bois, et 20 % avaient skié sur des pistes fermées. Une vitesse excessive était identifiée comme la principale cause de blessures. Les skieurs ne considéraient pas les sauts comme facteur contributif des blessures.
Le manque de connaissance des règles de sécurité était plus prévalent chez la cohorte blessée. La pratique du ski sans les précautions nécessaires, dont le ski dans les sous-bois, le ski sur des pistes fermées, le ski à une vitesse excessive et les sauts, surtout chez les planchistes, ont été identifiés comme des causes possibles de blessures.
Downhill skiing and snowboarding are popular outdoor recreational activities. Unfortunately, as with all sporting activities, injuries occur and, in some instances, cause long term disability or death. While skiing and snowboarding are not considered to be activities with particularly high rates of injury, data collected from Blackcomb Mountain, Whistler, British Columbia (1), indicate:
These figures are particularly relevant because they are based on data from an entire ski season and actual denominator/population data obtained from the computerized lift-ticket data maintained by Blackcomb Mountain. Other investigators have estimated the number of skiers using the hill, have based injury rates on a partial season or upon patients seen at nearby clinics or hospitals, rather than ski patrol reports of all injuries on the mountain.
Because these data raise concerns about the number of injuries, their nature and the population at risk, we conducted a study to obtain information about the knowledge and behaviour of young skiers and snowboarders that might contribute to injury and to identify factors that physicians could use in injury prevention initiatives.
This study was approved by the Clinical Research Screening Committee for Human Subjects at the University of British Columbia. Because there was no pre-existing instrument, a questionnaire assessing ski behaviour and ski knowledge (Skier’s Knowledge Inventory or [SKI] Questionnaire) was developed. Appropriate questions and multiple choice answers were developed by a panel that included ski patrollers, physicians, ski instructors, skiers, parents and youth. The SKI questionnaire was tested with children of staff members and then with 25 recreational and competitive skiers at a local ski club to ensure construct validity. Based on feedback from these people, questions were modified for clarification, and at parent’s request, questions concerning drug and alcohol use were deleted. The final questionnaire incorporated 43 multiple choice questions and four open-ended questions. Reliability and validity testing were not completed because the data were used as individual responses rather than scored to arrive at scales or single values. The SKI questionnaire was administered to two groups, injured skiers and a noninjured cohort, all under the age of 18 years.
The injured cohort was identified through injury reports maintained by the Blackcomb Ski Patrol. Injury reports are used for injuries that require referral to a physician for treatment. Treatment for most of these injuries is provided at a family physician-run clinic at the base of the mountain. Data fields on the injury reports include age, sex, skier ability (self-report), equipment status (owned, rented or borrowed), snow conditions, weather conditions, time of day, self-reported cause of the incident (from a list of options) and a description of the injury as determined by the ski patroller at the time. The quality of the medical data collected by the ski patrol is highly reliable because all of the members have industrial first aid certification, many have paramedic training and some are physicians.
Packages containing the consent form and questionnaire were mailed at the end of the season to parents of a convenience sample of 200 injured youth aged five to 17 years who had been referred by the ski patrol for physician care. Nonresponders were reminded via a telephone call, and, if requested, a second package was sent.
A cohort of noninjured youth aged five to 17 years was recruited by one investigator on 30 skiing days at various times (weekends, weekdays, spring break) during March and April. A letter containing a consent form was given to parents of families using the restaurant at mid-mountain at lunch times on a series of weekends, weekdays and school holidays chosen at random. Children whose families consented completed the questionnaire immediately, and content was checked at the time to avoid incomplete data.
Analysis of the data was conducted using Systat 5.2 (Systat, Illinois) and QuattroPro (Corel Corporation Ltd). Questionnaire items were content coded and expressed as percentages.
Responses were received from 118 in the injured cohort (59%), and 863 uninjured subjects were recruited from 900 approached (more than 95% participation). The age distributions of the injured and uninjured cohorts were similar, although there was a higher percentage of 16- and 17-year-olds in the injured cohort compared with the uninjured cohort (r2=0.60 for percentages among those under age 16 years). The injured sample had 64 males (54%) and the uninjured cohort had 489 male respondents (57%).
The uninjured and injured groups had similar perceptions of their ability, style of skiing, speed (20% described themselves as fast skiers), degree of control (47% and 38%, respectively, felt they skied “in control”) and incidence of skiing recklessly (0% versus 1.5%) or when scared (2% versus 4%). About 16% of each group described themselves as “daring”. Excessive speed was viewed by both groups as likely being the major cause of ski injuries (50% in each group), with skiing terrain above one’s ability as the second most frequent cause (18%), followed by collision (12% in the uninjured and 8% in the injured cohorts). Blind jumping was not seen to be a significant problem by either group (4% and 2%).
The Skier’s Responsibility Code (Table 3) is a set of six ‘rules of the road’ for skiers derived from the Alpine Responsibility Code. Among the injured group, 25% had never heard of the code, compared with 31% of the uninjured group. Of those who had heard of the code, 50% of both groups could not list the six main points. Twenty per cent of both cohorts did not know who had the right of way when skiing down a slope. Six per cent of the uninjured and 10% of the injured cohort incorrectly identified the meaning of a blue square as the designation of the difficulty of a run (P<0.0001, binomial distribution).
Twenty-seven per cent of the uninjured group and 20.5% of those injured had had two to nine lessons in the previous year; 44% of the uninjured and 56% of the injured had had no lessons. In the uninjured group, parents were identified as the primary providers of ski safety instruction by those age 12 years or under, and ski instructors were cited by those age 13 to 17 years. In the injured group, ski instructors were seen as the primary providers of information in all age groups except age birth to six years. Ski instructors and ski patrollers were identified as the individuals who would be listened to most regarding safety. The injured group were half as likely as the uninjured group to take this information from parents, and neither group indicated that they would listen to school teachers regarding ski safety.
Some common skiing practices can be deemed ‘unsafe’, including skiing through trees, skiing closed areas, failing to use the safety bar on chair lifts, failure to wear a helmet, jumping and having bindings adjusted by people other than trained technicians. Among both cohorts, 60% to 70% skied through the trees at least one run daily, and one-third had skied on closed runs. Among those over 13 years of age, chair lift safety bars were used about half as often as by those under age 12 years (25% versus 50%), and helmets were rarely worn regularly. Injured children in the 13- to 17-year-old age group reported less helmet use than those in the uninjured sample (Table 4). Jumping contributes to injury, particularly spinal injury, but as reported above, is not considered by young people to be a significant problem. Thirty-one per cent of both groups had had binding adjustments made by individuals other than ski shop technicians.
The overall incidence of injury in our population was consistent with previous reports, as is the high incidence of injury found in young people (2) and the fact that the head/face, knee and shoulder are the most frequent sites of injury (2–5).
The results of this survey of skier knowledge and behaviour provide important information for physicians trying to identify strategies to influence behaviour among young skiers and snowboarders. However, we recognize the limitation of these data and that our results are likely affected by several factors that we were unable to control including the following. The uninjured cohort was skiing with their parents (unavoidable because of the ethical requirement to obtain parental informed consent on the mountain at recruitment). In contrast, the injured cohort may not have been skiing with their parents (this information was not elicited), although the parent may have been involved in completing the mailed questionnaire. The presence of parents may have affected the child’s responses or had an influence on the type of youth recruited to the uninjured cohort. For this reason, we have not called this group a control group.
We do not have denominator data for the distribution of skiers by sex or for skiers versus snowboarders from the lift-ticket data, and, therefore, cannot comment on the injury incidence by sex or by activity.
We do not have data on helmet use among those who sustained head injuries. This is a question is currently being addressed in another study.
The 59% return rate from the injured cohort may have resulted from the decision to mail all the questionnaires at the end of the season rather than closer to the time of injury.
Our data indicate that important elements of knowledge are lacking, including knowledge of the safety code, colour coding of run severity and potential risks associated with jumping. In addition, behaviours (skiing out of bounds, skiing through trees, not wearing a helmet, not using lift safety bars and binding adjustment by amateurs) that increase the chance or potential severity of injury are common.
The authors are grateful for the assistance given by Blackcomb Mountain throughout the period of data collection, and for financial support for aspects of this research provided by SafeStart, the Injury Prevention Program at British Columbia’s Children’s Hospital, sponsored by the Royal Bank.