Musculoskeletal Pain Among E-sport Athletes
Conditions: Musculoskeletal Pain
Sponsor: University College of Northern Denmark

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Musculoskeletal pain among E-sport athletes 
Protocol version 1.0, date 26-03-2019 
Background 
Musculoskeletal (MSK) pain and injuries are common in endurance sports where athletes are required to 
perform at high intensity for an extended period of time  (1). In the short term, MSK pain may significantly 
impair the athletes’ performance, which can lead to unwanted time-off from practice and competitive 
tournaments (1). Ultimately, MSK pain may lead to complete withdrawal from sports and physical activity 
and long-term health issues (1–3) . Previous studies found an association between training load, MSK pain 
and performance. These results indicate that an athlete may experience MSK pain or get injured from both 
too low and to high training loads (1,4).  
Electronic sport (E-sport) also known as competitive gaming is defined by Hamari and Sjöblom as “a form of 
sports where the primary aspects of the sport are facilitated by electronic systems; the input of players and 
teams as well as the output of the E-sport system are mediated by human-computer interference” (5). The 
expected yearly growth-rate of E-sport is estimated to be 25% and approximately 190 million people 
around the world are actively involved in E-sport (6,7). E-sport also encompass structured tournaments 
which offer millions in prizemoney for the winning team (6,8). Furthermore, the tournaments are often 
streamed lived through the internet, so that the hundreds of millions of spectators from all over the world 
can follow their favourite teams in action (5,6). At present it is debated whether or not E-sport should be 
regarded as an actual sport instead of an recreational activity (8). The lack of physical activity and bodily 
movement is today the strongest argument against recognizing E-sport as sports (8). Nevertheless, the 
international demand for recognition is growing, and acceptance of E-sport as an actual sport may be 
inevitable (8). There is only few data on MSK pain in E-sport, however a small study with 65 participants 
found that 41% suffered from back or neck pain and more than 1 in 3 had pain related to the wrist (9). E-
sport athletes have to perform for an extended period of time, similar to athletes from traditional 
endurance sport. As such, MSK pain in E-sport may be associated with training load like it is seen in other 
sports (4). Overall, MSK pain in E-sport could be an unrecognised issue. To provide healthcare professionals 
with and optimal starting point for managing these issues, there is a need for well-conducted studies on the 
prevalence of MSK pain among E-sport athletes. In addition, it is highly relevant to investigate if training 
loads related to E-sport and physical activity levels are different among athletes with MSK pain compared 
to athletes without MSK pain.  
 

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Aims 
The aims of this questionnaire-based cross-sectional study are to; I) investigate the prevalence of MSK pain 
in E-sport athletes, II) assess if training loads among athletes with MSK pain are different from athletes 
without MSK pain, III) investigate if physical activity levels among athletes with MSK pain are different from 
athletes without MSK pain and IIII) descriptively present data on participant characteristics, sleep patterns, 
physical activity levels and utilization of healthcare professionals and pain medication. It is hypothesised 
that E-sport athletes with MSK pain have a higher training load compared to athletes without MSK pain. 
Moreover, it is hypothesised that E-sport athletes with MSK pain have a lower level of physical activity 
compared to athletes without MSK pain. 
Method 
This project will be conducted at the Department of Physiotherapy at UCN, Aalborg, Denmark and the 
protocol will be developed from The Strengthening the Reporting of Observational Studies in Epidemiology 
(STROBE) Statement (10). The project will in addition be pre-registered on www.Clinicaltrials.gov, prior to 
enrolment of the first participant. Participants will be provided with oral and written information regarding 
the study, before providing written informed consent.  
Recruitment 
We aim to recruit 200 E-sport athletes between 15 and 35 years of age. We estimate that 200 athletes will 
be an appropriate sample to investigate the prevalence of MSK pain within the E-sport community. The 
rational for the age-range is based on numbers from DGI which is a national organization in Denmark which 
aim to strengthen the community-based sport clubs and associations (11).  Approximately 60% of the E-
sports athletes registered with DGI are between the ages of 15 and 35 (12).  Athletes will be recruited from 
community-based and/or professional E-sport clubs and teams. Moreover, educational institutions who 
offer their students the opportunity to participate in E-sport will be contacted as well and invited to 
participate. Educational institutions and E-sport clubs and teams in Denmark will be identified through 
web-based searches and through the authors’ network. Initial contact will be established through e-mail or 
via telephone. Members from the research group will subsequently visit clubs, teams and educational 
institutions who initially shows an interest for the project. At this occasion the members of the research 
group will give a short presentation of the project, answer questions regarding the project and distribute 
the questionnaire to those athletes who wants to participate. 
 
 

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Distribution of questionnaires 
Prior to initiation of the study, the questionnaire will be pilot tested and evaluated regarding time to 
complete, relevance and comprehensibility. After the following optimization, the questionnaire will be 
distributed for all participating athletes as an online survey.  
Eligibility criteria 
E-sport athletes from Denmark between the age of 15 and 35, who are participating actively in E-Sport 
through a club and/or team based in the community, at an educational institution or in a private 
organization are eligible for enrolment. In addition, eligible athletes are required to participate in E-sport 
through a computer-based game. As such, athletes who primarily compete through other medias or 
consoles are not eligible for participation.  
Participant information and outcome  
Information regarding MSK pain, utilization of healthcare professionals and pain medicine, physical activity 
levels, E-sport related training load and sleep patterns will be obtained through this questionnaire-based 
study. 
Participant characteristics 
Enrolled athletes will be asked to provide; name, e-mail, phone number, age, gender, height, weight, 
educational level, smoking status, where they participate in E-Sport (e.g. community-based or educational 
institution), which league they are affiliated with (e.g. DGI-league or ESD-league) and which is their primary 
game (e.g. Counter Strike: Global Offensive, Fortnite or PlayerUnknown’s Battleground). 
Musculoskeletal pain 
The primary outcome for the study will be if the athletes have had any MSK pain during the previous week. 
The answer to the primary outcome will be dichotomized (yes/no). Participants will also be asked about the 
location and number of pain sites. If the athlete has pain at more than one site, they will be asked to state 
at which site they experience their primary pain complaint. In relation to the site of the primary pain 
complaint, the athletes are asked to state the worst pain intensity they have experienced during the 
previous week. Pain intensity will be assessed with an 11-point numeric pain rating scale (0=no pain; 
10=worst possible pain). The athletes will in addition be asked about pain frequency (daily, weekly, several 
times per week, monthly, rarely). To investigate the level of pain interference, athletes will be asked if their 
MSK pain affect their ability to engage in E-sport. 
 

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Eye fatigue 
Within a group of E-sport athletes, one study found that 52% reported eye fatigue (9). As such, we are also 
interested in investigating if the included athletes experience eye fatigue in relation to E-sport 
participation. 
Training load related to E-sport 
Athletes will be asked how many hours per week they spend on structured E-sport with is defined as 
training with a coach being present. In addition, they are asked how many hours per week they train 
without a coach present (e.g. when they are at home). Time spend on training without a coach present will 
be defined as unstructured training. The total E-sport related training load will be assessed by combining 
the number of hours the athletes engage in structured and unstructured E-Sport. 
Healthcare utilization 
In order to investigate care-seeking behaviour regarding MSK pain within the study population, the athletes 
will be asked if they have had any treatment from a healthcare professional during the previous 3 months 
for MSK pain. In addition, participants will be asked if they currently use any pain medication, which type of 
medication they use and how frequent. The athletes are also asked to describe the reason for using pain 
medicine. 
Level of physical activity 
Physical activity levels will be assessed with the Danish version of the International Physical Activity 
Questionnaire (IPAQ) short form. This survey is comprised of 7 items which assess time spend on physical 
activity at vigorous and moderate intensity, walking and sitting during the previous 7 days. 
Sleep patterns 
To assess sleep patterns the athletes will be asked how many hours they sleep during the night. In order to 
investigate the quality of sleep the athletes will be asked if they  experience trouble falling asleep, if their 
sleep is interrupted during the night and if they feel tired in the morning. This approach has been used 
previously to investigate sleep patterns (3).  
Data analysis 
The prevalence of MSK pain within the study population will be presented in absolute numbers and as 
percentage values. To investigate if E-sport related training loads differ among athletes with and without 
MSK pain we will use total E-sport related training load (N hours spend on structured E-sport + N hours 
spend on unstructured E-sport). An independent sample t-test will be applied for this comparison if data 
are normally distributed. To assess if physical activity levels are different among athletes with and without 

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MSK pain we will use the responses from the IPAQ short form. For this comparison we will use an 
independent sample t-test or the Wilcoxon rank-sum test. Participant characteristics, distribution and 
number of MSK pain sites, utilization of health professionals and pain medicine, physical activity levels, 
training loads and sleep patterns will be presented descriptively. The data will be presented with means, 
standard deviations and 95% confidence intervals. Non-parametric data will be presented with absolute 
numbers and as percentage values, medians and range. 
Ethics 
Prior to undertaking the study, approval was sought from the local ethics committee in the Northern part 
of Jutland in Denmark, however according to Danish law (Bekendtgørelse af lov om videnskabsetisk 
behandling af sundhedsvidenskabelige forskningsprojekter §14 stk. 2) no ethical approval is need. 
Data proception 
This study will adhere to the Helsinki declaration and person data will be collected and stored in 
accordance with the General Data Protection Regulation (GDPR).  
Perspective 
Arguably, staying pain – and injury free while participating in sports is the most optimal way to become a 
top-level athlete (8). The same logic could be applicable for E-sport athletes. As such, it is possible that 
highly engaged E-sport athletes will sustain injuries or experience MSK pain because of their choice of 
recreational activity. However, data on MSK pain among E-sport athletes is lacking. The national federation 
of E-sport in Denmark, eSport Denmark, was established in 2007 and is working towards branding, 
developing and expanding E-sport to the Danish population (13). Moreover, E-sport Denmark is 
collaboration with DGI to help establish community-based E-sport clubs and teams all over Denmark (14). 
As such, we are witnessing a paradigm shift where players organise themselves in teams and engaging in 
training sessions with coaches at a physical location. As the awareness and interest for participating in E-
sport is on the rise, there is a need to collect data on the health status among E-sport athletes, in order to 
provide healthcare professional with the right tool and knowledge to help E-sport athletes to stay active 
within their sport. 
 
 
 

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References 
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