Accepted Manuscript
Title page
Regular Article
Title: Assessment of adverse events and near-misses during voluntary community-driven
sports activities by community residents: A cross-sectional study
Author(s): Akihiro Hirata1, 2, 3 Yuko Oguma2, 3,*, Takeshi Hashimoto2, 3Affiliation(s): 1Research Fellow of Japan Society for the Promotion of Science, 2Sports
Medicine Research Center, Keio University, 3Graduate School of Health Management, Keio
University

Mailing address(es): Akihiro Hirata: akihirohirata@keio.jp, Yuko Oguma: yoguma@keio.jp,
Takeshi Hashimoto: hashimotot@keio.jp

Number of Figures: 1

Number of Tables: 6

Running Title: Adverse events and near-misses in community sports

1Corresponding Author:
Yuko Oguma
Sports Medicine Research Center, Keio University, Graduate School of Health Management,
Keio University,
Phone: +81-(0)45-566-1090
Fax: +81-(0)45-566-1067
E-mail address: yoguma@keio.jp2

Abstract
Although physical activities have many health benefits, adverse events and near-misses, suchas injuries and falls, can occur during these activities. This study aimed to assess theoccurrence of adverse events and near-misses during sports activities conductedindependently by community residents. A survey questionnaire was sent via the internet to theleaders or directors of sports organizations at six public sports centers or associations. In total,
108 individuals answered the survey, with 60% male and 40% female respondents.
Individuals aged 50–69 years accounted for 60% of the total number of respondents. All
respondents were asked about their experiences of adverse events and near-misses within thepast three years: the reports of these incidents were obtained using the recall method.
Duplicate adverse events and near-misses were identified based on the sports discipline; timeof occurrence; and sex and age of person involved to determine if there were duplicate
reports. Most of the respondents' activities as staff were performed once a month, with eachactivity lasting 1–2 h. Forty-five adverse events were reported, including 26 injuries, 13 falls,
and 6 others (such as heat stroke, vertigo, and presyncope). Twenty-four near-misses werereported, including 12 near-collisions with people or objects, five near falls, and seven otherincidents. We found that approximately 30% of the respondents experienced adverse events,suggesting the need for documentation of adverse events, implementation of safety measures,and proper safety education for operating staff.
3

Keywords
athletic injuries, accidental falls, ankle sprain, heat stroke, recreation

4

タイトル
地域住民が主体的に実施するスポーツ活動中の有害事象やヒヤリハットの評価：横断的研究

著者
平田昂大 1, 2, 3 、小熊祐子 2, 3,*、橋本健史 2, 3

所属
1

日本学術振興会特別研究員、 2 慶應義塾大学スポーツ医学研究センター、 3 慶應義塾大学大学院健康マネジメント研究科

要旨
身体活動・運動は、健康上の利点が数多くある一方で活動中には傷害や転倒などの有害事象およびヒヤリハットが発生している。本研究では、地域住民が主体的に実施する身体活動・運動中に発生した有害事象およびヒヤリハットの発生状況を明らかにすることを目的とした。調査方法は、6 つの公共スポーツ団体・公共スポーツセンタ
ーの運動指導者または運動支援者を対象にオンラインアンケートを実施した。オンラ
インアンケートでは、過去 3 年間以内の有害事象・非谷内ハットについての経験を尋ね、想起法を用いて報告を得た。報告された有害事象・ヒヤリハットについては、ス
5

ポーツ種目、発生時期、関係者の性別・年齢をもとに重複報告がないかどうか確認した。オンラインアンケートの回答者は 108 名で、男性 60％、女性 40％であった。50-69
歳の回答者が全体の 60％を占めた。回答者の運動指導者・運動支援者としての活動
は、ほとんどが月 1 回、1 回の活動時間は 1-2 時間で、有害事象は 45 件報告された。
有害事象の内訳は、けが 26 件、転倒 13 件、その他（熱中症、めまい、意識障害など）
6 件であった。また、ヒヤリハットは 24 件報告され、その内訳は、人や物と衝突しそうになった 12 件、転倒しそうになった 5 件、その他 7 件だった。この結果から、回答者の約 30％が有害事象を経験していることがわかり、有害事象の記録を残す、
安全対策の実施、運営スタッフへの適切な安全教育の必要性が示唆された。

キーワード
スポーツ外傷・障害、転倒、足関節捻挫、熱中症、レクリエーション

61

Introduction

2

The benefits of physical activity are numerous. The physical activity guidelines1,2 reported

3

positive effects of regular and moderate-intensity physical activity on mortality,4

cerebrovascular and coronary artery disease, hypertension, stroke, osteoporosis, type 2

5diabetes mellitus, metabolic syndrome, obesity, some types of cancer, depression, cognitive

6

functions, and falls.

7

On the other hand, musculoskeletal injuries, cardiovascular events, and sudden death have8

been noted during these physical activities.2 Reports of adverse events during sports activities

9

included those involving athletes3-5 and relatively high-intensity exercise, such as

10international athletic competitions.6-8 They also included adverse events involving exercise

11

therapy at medical institutions,9,10 those involving local residents such as students,11,12 and12large-scale events such as marathons.13-15 There have been reports on assessing adverse

13

events during independent sports activities. In studies involving athletes, the frequency of

14

occurrence was presented as the number of athletic injuries per activity day or hour. However,15

reports focusing on local residents are limited to school classes, extracurricular club activities,

16

and large-scale events. This may be because local residents engage in a wide variety of sports

17

activities as they gather together voluntarily and daily, making it difficult to accurately assess18

the status of their activities. Therefore, the actual status of injuries, accidents, and other19

adverse events during sports activities that were voluntarily and routinely done by local
7

20

community gatherings is unknown.

21

Regarding safety measures at sports sites, athletes and exercise therapy providers often have a22

full medical system for pre-exercise medical checkups and adverse events during activities

23

due to their nature. However, in sports activities in group gatherings voluntarily conducted by

24

local residents, it can be expected that medical systems might be insufficient. In addition, it is25

necessary to understand the actual situation and take safety measures accordingly, because it26

is assumed that there would be people who exercise with underlying diseases and a history of27

exercise injury.

28

There are several adverse effects that might occur during physical activity aside from the29

effects on the physical and mental health of the person involved. According to health30

behavior science, it has been pointed out that injuries and poor physical condition during31

physical activity can be the cause of slips (one-shot interruptions16), lapses (short-term

32

interruptions), and relapses (long-term interruptions17) of exercise habits.18 From a33socioeconomic perspective, a study conducted in 2012 in the Netherlands reported that the34

indirect costs of medical expenses and lost productivity due to sports-related injuries were the35third largest cost factor after household and traffic accidents.19

36

Sakae Ward, Yokohama City has been certified as a Safe Community, which is an

37

international certification since October 2013. Safe Community is a program in which

38

communities take to prevent accidents and injuries through cross-sectoral collaboration,
8

39

based on the idea that fatal accidents and injuries can be prevented by identifying their causes.

40

The certification is granted after an assessment based on the indicators presented by the

41

International Non-Governmental Organization (NGO) Safe Communities Certification Center

42(formerly World Health Organization [WHO] Collaborating Centre on Community Safety

43

Promotion). In Sakae Ward, subcommittees have been established for eight themes: (i) child44

safety, (ii) sports safety, (iii) traffic safety, (iv) child abuse prevention, (v) safety for the45elderly, (vi) disaster safety, (vii) suicide prevention, and (viii) crime prevention. In addition,46

the injury surveillance subcommittee has been collecting data through specialized measures.20

47

The authors, commissioned by Sakae Ward, Yokohama City, have been cooperated with the48

Taskforce Committee for Sports Safety, Sakae Ward Safe Community, Yokohama City, to49

investigate adverse events and implementing safety measures during voluntary sports

50

activities by Sakae Ward residents since 2019. Therefore, this study aimed to evaluate the51

occurrence and trends of adverse events and near-misses during community-driven physical52

and sports activities in groups that were voluntarily conducted by Sakae Ward residents. This53

evaluation was based on a questionnaire survey conducted by the Taskforce Committee for

54

Sports Safety, Sakae Ward Safe Community, Yokohama City.

55
56

Methods

57

This is a descriptive epidemiological study that analyzed data from an online questionnaire.
9

58
59

Participants

60

The questionnaire targeted leaders and directors who were active in the member

61

organizations of the Taskforce Committee for Sports Safety, Sakae Ward Safe Community,

62

Yokohama City. The leader mainly conducts sports coaching and on-site management, while63

the director mainly supports the leader. The member organizations were the following: Sakae

64

Ward Sports Association, Sakae Ward Sports Promotion Committee, Sakae Ward Youth

65

Instructors Council, Sakae Ward Sawayaka Sports Promotion Committee, Nonprofit

66

organization (NPO) Sakae Sports Club, and Sakae Sports Center.

67

The research team analyzed the data provided by Sakae Ward from the results of

68

questionnaires administered to the survey participants. The 108 respondents who completed69

the survey were included in the study. Figure 1 summarizes the process for selecting analysis

70

adverse events and near misses. This study was conducted upon the approval of the Ethical71

Review Committee of Sports Medicine Research Center at Keio University (approval

72

number: 2020-03).

73

Fig. 1. Flowchart of selecting analysis adverse events and near misses

74
75

Questionnaire76

The online questionnaire form, created using Yokohama City electronic application system,10

77

was sent by e-mail through the Taskforce Committee for Sports Safety, Sakae Ward Safe

78

Community, Yokohama City. The response period was from November 2020 to January 2021.

79

The questions were designed to ask about experiences of adverse events and near-misses

80

during sports activities within the past 3 years.

81

There were three main questions. The first question was about the personal attributes of the82

respondents (leaders and directors): organization, age, gender, sports discipline, exercise

83

teaching experience, qualifications held, frequency of activities as leader/director, and84

number of people taught per session. The second question was about experience of adverse

85

events: presence or absence of occurrence, circumstances at the time of occurrence, response

86

after the occurrence, age, gender, and sports discipline of the person concerned. The third

87

question was about near-misses: presence or absence of occurrence, circumstances of88

occurrence, age, sex, and sports discipline of the person concerned. Details of these survey

89

items are given in Appendix Table 1. For those survey targets who were not familiar with the90

online questionnaire, Sakae Ward Office staff interviewed them by phone and entered91

responses on their behalf. After excluding personal information, the survey results were92

received by a research team at the Sports Medicine Research Center, Keio University, for data

93

analysis. Note that sports activities in this study include physical activities such as walking

94

and recreational activities such as athletic events. With reference to the definition used in the95

Japanese report21, adverse events were defined as any unfavorable events, such as accidents,11

96

injuries, or illnesses that occurred to participants physically or mentally during exercise or97

physical activity. Furthermore, near-misses were defined as incidents that did not cause

98

physical or mental harm to participants, but caused a "near-miss" or "aha" experience for99

instructors or supporters in the field of practice.21

100
101

Statistical analysis

102

Data were described in terms of frequency (%) for nominal scale data, and χ² test or Fisher's

103

exact probability test was performed as necessary. Proportional scale data, such as years of104

experience, were expressed as medians (interquartile range). The number of adverse event

105

occurrences per 10 activities and per 1000 activity h were obtained by calculating the number

106

of activities (times/month), activity h (hours/hour), and number of people/activity (persons/h)107

based on the activities of the leader/director who reported the adverse event. The

108

questionnaire results were analyzed using IBM SPSS Statistics ver. 27 (IBM, Chicago, IL).

109
110

Results

111

Attributes of survey respondents (leaders and directors)

112

A questionnaire survey addressed leaders and directors who were active in the member

113

organizations of the Taskforce Committee for Sports Safety, Sakae Ward Safe Community,

114

Yokohama City. As a result, 108 respondents were recruited. Sixty-five (60.2%) respondents
12

115

were men and 43 (39.8%) were women. The age distribution of the respondents was 31

116(28.7%) in their 50–59 of age and 35 (32.4%) in their 60–69, showing that the respondents in

117

this survey were relatively older adults. In terms of the positions of the respondents, the118

leaders who were mainly involved in teaching and on-site management accounted for 60.2%

119(39 men [36.1%] and 26 women [24.1%]) in 65 cases. The directors who were mainly120

involved in supporting leaders accounted for 38.0% (25 men [23.1%] and 16 women

121[14.8%]) in 41 cases. Moreover, the number of respondents who were in their 60s accounted

122

for 32.4% (35), and 2 (2%) athletes and were in other fields. Recreation, including athletic

123

event, was the most common sports practiced by the survey respondents (16 cases [14.8%]),124

followed by badminton (13 cases [12%]) (Table 1).

125

Table 1. Attributes of the respondents to the online questionnaire by sex and age

126
127

Regarding the respondents' experience in attending seminars on guidance and support for

128

sports activities (including lifesaving seminars), 87 respondents (80.6%) answered that they129

had attended such seminars. Of these, 54 respondents (50.0%) had attended less than once a

130

year, 30 (27.7%) had attended approximately once a year, and three (2.7%) had attended131

more than once a year. Fifty-seven respondents (52.8%) held some type of certification, with132

35 respondents (32.4%) indicating that they held certifications that included lifesaving

133

training (first-aid lifesavers; health and exercise instructors; and lifesaving training
13

134

certificates provided by the Japanese Red Cross Society and the fire department). The other135

22 cases (20.3%) held instructor certifications in the respective sports disciplines.

136

The median activity history as a leader and director of the respondents was 10.0 (5.0–20.0)

137

years in men and 11.5 (3.3–20.0) years in women. The frequency of activity was 1.0 (1.0–4.0)

138

times/month in men and 4.0 (2.0–8.8) times/month in women. The duration of activity was

139

2.0 (2.0–3.0) hours/time in men and 2.0 (1.3–2.0) hours/time in women. In addition, the140number of participants per activity was 20.0 (15.0–30.0) in men and 19.0 (14.0–33.0) in

141

women (Table 2). More than 100 participants responded that they participated in recreation,

142

Sawayaka Sports (Boccia etc.), badminton, and walking.

143

Table 2. Activities of the respondents to the online questionnaire

144
145

Adverse events

146

Of the 108 survey respondents, there were 45 reports of adverse events over the past 3 years,

147

from which, two reports were obtained from 11 respondents. By sports discipline, eight cases

148(17.7%) were reported in soccer, seven (15.5%) in recreation, and six (13.3%) in softball.

149

Among men, eight cases (17.7%) were reported in soccer, seven (15.5%) in recreation, and150

six (13.3%) in softball. Among women, four cases (8.8%) were reported in volleyball (Table

151

3). Adverse events included "injury" in 26 cases (57.8%), "fall" in 13 cases (28.9%), and152"other" in six (13.3%). In terms of response after an adverse event, all cases were handled in
14

153

some way, and there were no cases in which the initial response to an adverse event could not154

be made. Of the 45 adverse events, four cases (8.9%) (two injuries, one fall, and one other)

155

were transported to emergency rooms and 10 cases (22.2%) (nine injuries and one fall) to156

hospitals.

157

Table 3. Number of adverse events stratified by sports discipline, sex, and age

158

Considering the possibility that differences in the background of the leaders/directors

159

according to their experience in attending courses and their qualifications may have affected160

reporting adverse events, a χ² test was conducted. The results showed no statistically161

significant differences (experience in training courses p = 0.80, qualifications p = 0.21).

162

The overall number of adverse events was 0.07 occurrences per 10 activities and 0.75

163

occurrences per 1,000 h of activity. Recreation was the sports with the highest number of164

incidents per number of activities, with 0.49 incidents per 10 activities. Table tennis was the165

sports with the highest number of incidents per activity hour, with 4.17 incidents per 1,000

166

activity h (Table 4).

167

All tendon injuries involved the Achilles tendon, with two occurring in men aged 40–49 and168

three in women aged 50–59. Among sports adverse events, three cases occurred in volleyball,169

one in badminton, and one in soccer. Ankle sprains occurred in one case each in soccer

170

among male and female participants younger than 10 years, one in volleyball among women171

aged 50–59 years, and one in table tennis among women aged 60–69 years. Concussions and
15

172

chest and back contusions occurred during soccer, with a small number of occurrences.

173

However, concussions occurred in children under 10 years of age playing soccer. Contusions

174

mostly involved the chest and back in children under 10 years of age playing soccer.

175

Table 4. Frequency of adverse events by sports discipline (calculated values)

176
177

Injuries

178

Regarding the 26 injuries classified as "injury" in the adverse event category, the lower leg

179

was the most common site of injury in eight cases, followed by the ankle/foot in four, and the180

wrist/hand in four. In terms of the classification of "injury" based on a diagnostic name, there

181

were six cases of sprains, five of tendon injuries, four of fractures, and four of separated flesh.

182

Considering diagnoses, Achilles tendon injuries and ankle sprains occurred most frequently in

183

five and four cases, respectively (Table 5).

184

Table 5: Body part and type of injuries

185
186

Falls

187

Among the events classified as "falls" in the adverse event category, 11 occurred during

188

sports activities and two during transportation; six occurred in the 70–79 age group and one

189in the 80–89 age group, with 53.8% of falls occurring in the 70–79 age group or older (Table

190

6).
16

191

Table 6. Detailed circumstances of the fall cases

192
193

Near-misses

194

Regarding occurrence of near-misses over the past 3 years, 24 near-misses were reported,

195

from which, one respondent reported two cases. The 24 near-misses were categorized into 12

196

cases of near collision with person-to-person or person-to-object, five cases of near fall, and197

seven other cases, based on a close examination of the events descriptions. The other seven198

cases included three cases of near fall head-first to the floor during gymnastics, one case of

199

an arrow from a person's head hitting the glasses worn during Kyudo (Japanese archery).

200

These seven cases also included one case of performing an action different from the program

201

without following the instructions. They also comprised one case of a participant with202

chronic illness and one case of a junior high school student throwing a metal ball into the203

middle of a crowd during petanque.

204

Fisher's exact probability and χ² tests were performed to determine the possibility that the205

reporting of near-misses might have been affected by the experience of leaders and directors

206

in attending training courses and by the presence or absence of their qualifications. The

207

results showed no statistically significant differences (experience in attending training

208

courses, p = 1.00; qualifications, p = 0.24).

209
17

210

Discussion

211

This study was conducted using data from a survey targeting leaders and directors in Sakae

212

Ward in 2020 as part of Safe Community, using a cross-sectoral collaboration program to213

prevent accidents and injuries. It aimed to evaluate adverse events and near-misses during

214

sports activities in groups. The results of this study provided an indication of the occurrence

215

and frequency of adverse events and near-misses during physical and sports activities in

216

groups, which were performed voluntarily and routinely by local residents.

217
218

Attributes of survey respondents

219

The survey respondents comprised of 60% leaders and 40% directors. The age groups were220

50–59 (30%) and 60–69 (30%) years of age, and more than half of the respondents were in221

the 60–69 age group or older. This may be due to the fact that Sakae Ward has 31.3% of the222

total population aged 65 and above, making it the most aged ward among the 18 wards of223

Yokohama City. Recreation and badminton accounted for 15% and 12%, respectively, of the224

sports the respondents performed.

225

The median length of time in which the respondents had been active was 10 years, and 80.6%

226

of respondents had attended courses related to their sporting activities. More than half of the227

respondents had certifications related to sports activities. However, only 32.4% of them had

228

certifications including lifesaving courses. Given that sports-related sudden deaths have been
18

229

reported in surveys conducted in the general population in France22, it is suggested that all

230

instructors and support personnel need to be trained in cardiopulmonary resuscitation (CPR).

231

It has been reported that the emergency action plan (EAP) should be rehearsed at least once a232

year, and should specify responses to various types of adverse events that may occur and233

appropriate emergency transportation routes.23 Although the training status of safety234

management during sports activities among leaders and directors could affect the accuracy of235

reporting adverse events and near-misses, no statistically significant difference was found in236

this study. This may be related to the longer activity history of the participants in this study.

237

The median duration of each activity was 2 h in both men and women, and the number of238

participants per activity was about 20 in both men and women.

239
240

Analysis of adverse events

241

Of the 108 survey respondents, approximately 30% reported experiencing adverse events.

242

The adverse events were classified as 26 injuries, 13 falls, and six others.

243

In a report on injuries during sports activities, Kamada et al.11 surveyed Japanese students244(12–18 years) and reported that the injuries occurred most commonly in the lower extremities245(15.4%). In addition, a systematic review24 of epidemiological studies of sports injuries

246

including ankle sprains reported that ankle sprains were a major injury in many sports

247

disciplines. In this study, 57.7% of the injuries occurred in the lower extremities (the
19

248

ankle/foot, lower leg, knee, thigh, and hip), with ankle sprains accounting for 4 of 26 injuries

249(15.3%). This suggests that many injuries occurred in the lower limbs in voluntary exercise

250

by Sakae Ward residents, and that the main injury was likely to be an ankle sprain, which is251

consistent with the findings of previous studies. According to the National Athletic Trainers'

252

Association position statement25, prevention of ankle sprains and their recurrence requires the253

use of taping/supporters, a comprehensive approach with emphasis on balance and254neuromuscular control. It is recommended to continue rehabilitation for at least 3 months, to255

strengthen and improve the peri-ankle, hip extensor, and abductor muscle groups, and to256

reduce ankle dorsiflexion range of motion limitation. It is also important to include an257

appropriate warm-up prior to the main exercise, such as the warm-up program for injury

258

prevention represented by the FIFA11+26 published by the Federation Internationale de259

Football Association.

260

Regarding post-injury response, rest, ice, compression, and elevation (RICE) treatment, is261

widely known as a common response in sports settings, and icing has been shown to be262

effective in reducing post-injury pain.27 Considering lower extremity injuries, especially263

ankle sprains, which are expected to occur more frequently, preventive training, warm-up

264

before main exercise, and measures at the time of injury should be taken as necessary.

265

A descriptive epidemiological study using data from the National Database of Health266

Insurance Claims and Specific Health Checkups of Japan28 reported that 44% of Achilles
20

267

tendon ruptures occurred in patients aged 40–59 years. In this study, all cases of Achilles

268

tendon injuries occurred in the 40-49 and 50-59 age groups. Achilles tendon injuries are269

thought to be caused by tendon degeneration and uncoordinated muscle activity.29 It has been270

reported that even in trained athletes, exercise intensity with a ratio of the last week's

271

cumulative load (acute load) to the last four weeks' cumulative load (chronic load) (Acute272

Chronic Workload Ratio [ACWR]) of 0.8 to 1.3 minimizes the risk of injury. However, an

273

ACWR above 1.5 is reported to be in the danger zone.30,31 Therefore, we suggest that rapid

274

exercise and exercise intensity that is too high is a risk for injury, and that daily physical275

activity and exercise can prevent inappropriate muscle contraction and improper movement.

276

On the other hand, one concussion and one chest contusion in participants under 10 years of277

age that could result in a commotio cordis were identified in soccer, with a small number of278

reports. Concussions are caused by direct or indirect external trauma to the head. Since the279

symptoms and recovery process of concussion vary from one individual to another, the return280

to competition must be halted for a while until symptoms are evaluated.32 In particular, in281

young athletes, the return-to-play process should be more conservative, taking into account282

the effects on the developing brain damage.32 Commotio cordis is the second most common

283

cause of sudden cardiac death in young athletes33, and measures such as installation of284

Automated External Defibrillators (AED), CPR training, and the development of EAPs

285

should be considered.
21

286

Thirteen adverse events classified as falls were reported: 11 during sports activities and two

287

during transportation. The two cases that occurred during transportation included a case of a288

man aged 80–89 years who fell at the entrance of an archery range, and the other case was289

that of a male participant aged 10 years or younger slipped and fell while running. Seven of290

the 13 falls (53.8%) occurred in participants aged 70–79 years or older. Risk factors for falls

291

include age over 80 years, history of previous falls, poor balance, muscle weakness, poor

292

vision, and medication use.34 Therefore, we suggest that falls can be prevented through daily

293

health checks such a blood pressure, a body temperature measurement, and hearing about age,294

history of falls, and implementation of multi-component exercises35 that have been shown to295

be effective in preventing falls. Furthermore, it is also important to consider environmental

296

factors such as poor floor conditions, inappropriate shoes and clothing, and too much dark

297

lighting in the activity area.

298

Four out of six (67%) of the other adverse events were suspected to be heat stroke, since all299

cases occurred between July and September, which are the summer months in Japan. A study

300

analyzing data on emergency medical evacuations for heat stroke in Fukuoka City, Japan,

301

indicated that the older adults aged 70–79 years or older were most susceptible to heat302

stroke.36 In this study, three out of four suspected heat stroke cases (75%) were in the 70–79

303

age group. According to the American College of Sports Medicine consensus statement37,

304

prehospital management of heat stroke should include early recognition. The importance of
22

305

the following three measures is demonstrated: (i) early recognition, (ii) immediate cooling,306

and (iii) transport to a medical facility. In this study, the response to all four cases of307

suspected heat stroke was observation (including transfer to a cooler location and308

rehydration), clearly indicating the need for on-site training in the initial assessment of heat309

stroke, ice and ice baths for cooling the body, and preparation of a list of medical facilities to310

which the patient could be transported.

311

The frequency of adverse events calculated in this study was 0.07 per 10 activities and 0.75

312

per 1,000 h of activity. Recreation was the sports activities with the highest number of313

occurrences per number of activities, with one adverse event occurring in every 20 activities.

314

The sports with the highest number of incidents per activity hour was table tennis, with one

315

incident per 250 h of activity. Studies reporting adverse events during sports activities

316

performed by community residents are limited. However, a prospective cohort study38

317

conducted in Finland reported 1.2 walking injuries per 1,000 h of activity based on data318

collected through interviews. Compared to the present study, the number of injuries was 0.63

319

per 1,000 h, which was approximately half of the result yielded in the previous study. In

320

activities other than walking, the number of adverse events in the present study is estimated321

to be lower than that in the study by Parkkari et al.38 This may be due to differences in study

322

methods, demographic attributes of participants, and intensity of sports activities. It should323

also be noted that the number of occurrences in this study was calculated based on the
23

324

activities of instructors and supporters who reported adverse events that may be far from the325

true number of occurrences. However, the information on the frequency of adverse events

326

revealed in this study may be useful for the prevention and countermeasures of adverse

327

events during physical activity.

328
329

Analysis of near-misses

330

Approximately 30% of the respondents reported near-miss experiences. A close examination

331of the 24 near-misses reported in this study revealed that 12 involved near-collisions between

332

person-to-person or person-to-object, five involved near falls, and seven involved others that333

occurred during gymnastics. There are games that always have the potential for collisions and334

falls, such as contact between a baseball batter and an infielder or a fall during gymnastics.

335

Therefore, it is important to provide safe technical instruction and create an environment that336

prevents accidents related to the characteristics of the game. In addition, there were some337

cases that required improvement in participant management and reminders during exercise,338

such as when participants did not follow the leader's instructions, a participant had a chronic339

illness, or a participant threw a petanque ball into the presence of others. Since

340

leaders/directors have a duty of care for safety, it is important for them to thoroughly explain341

and check the safety of participants prior to their participation in exercise. Medical screening342

by physicians prior to participation in ultramarathon events has been reported to be effective
24

343

in preventing adverse events.13 However, it is not realistic for all community residents to be344

checked by a physician prior to sports activities in their daily activities. Therefore, we suggest

345

that it would be important for leaders/directors and participants themselves to confirm

346

screening prior to exercise participation, such as using the Physical Activity Readiness

347

Questionnaire.39

348
349

Limitations

350

This study might be affected by recall bias because the adverse events and near-misses that351

occurred in the past 3 years were surveyed by questionnaire. In fact, the number of adverse

352

events and near-misses reported was higher in 2019 and 2020. Furthermore, in 2020, due to353

the worldwide pandemic of novel coronavirus infection (COVID-19), a state of emergency354

was declared in Japan. The Japanese government called on the public to refrain from going355

out from April 7 to May 31 in Sakae Ward, Yokohama City. Even after the state of emergency356

was declared, there were restrictions on the use of public sports facilities from the summer to357

the fall of 2020. Therefore, the number of activities in 2020 was likely lower than in previous

358

years. Third, this study was conducted only in Sakae Ward. In addition, sports leaders and359

directors belonging to the six organizations that make up the Taskforce Committee for Sports

360

Safety, Sakae Ward Safe Community, Yokohama City were the participants of this study,361

whereas the current status of physical activity conducted by organizations other than these or
25

362

by individuals remains unknown. Selection bias may have influenced the results. Thus, there

363

might be limitations to the generalizability and representativeness of this study. However,364

there are 13 cities in Japan that have received Safe Community certification40, and it is365

expected that similar initiatives are being conducted in other municipalities. We suggest that366

researchers can contribute to the creation of a safe and secure environment for physical367

activity and exercise for local residents by getting involved in surveys and initiatives that368

local governments are proactively implementing.

369
370

Conclusion

371

This study investigated the occurrence of adverse events and near-misses during372

community-driven group sports activity in Sakae Ward. The results revealed the attributes

373

and activities of the leaders and directors involved in the management of sports activities.

374

The adverse events included "injuries," "falls," and "others" such as heat stroke. The

375

near-misses revealed situations that could have become adverse events. Although the376frequency of adverse events and near-misses in this study was low, the fact that377

approximately 30% of the survey respondents experienced adverse events suggests the need378

for documentation of adverse events, implementation of safety measures, and proper safety379

education for operating staff. Preventive measures should be taken against the risks

380

highlighted in the results of this study, and an EAP should be prepared in the event of an
26

381

incident.

382
383

Acknowledgements384

We would like to express our gratitude to Sakae Ward, Yokohama City for their cooperation385

in this study. This study was conducted in response to data provided by the "Project for the386

Promotion of Measures to Prevent Injuries and Accidents During Exercise" conducted by387

Sakae Ward, Yokohama City.

388
389

Conflict of Interests

390

The authors declare that there are no conflicts of interests.

391
392

Author Contributions

393

AH and YO designed the study. AH analyzed the data and drafted the manuscript. YO and394

TH edited and revised the manuscript. All authors approved the final version of the395

manuscript for submission.

396

Data Statement: The datasets generated and analyzed during the current study are available

397

from the corresponding author on reasonable request.

27

398

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Sakae Ward Safe Community Promotion Council, Taskforce Committee for Sports Safety
Online questionnaire: November 2020 to January 2021
Taskforce Committee for Sports Safety Members (Leaders / Directors)- Sakae Ward Sports Association- Sakae Ward Sports Promotion Committee- Sakae Ward Youth Instructors Council- NPO Sakae Sports Club
- Sakae Sports Center- Sakae Ward Sawayaka Sports Promotion Committee

Respondents: 108

Adverse events: 33- Cases of injury: 21- Falls: 8- Others: 4

IncludeNear-misses: 38- Cases of near collisions: 12- Near falls: 5- Others: 21 (including 12 adverse events)→ - Cases of injury: 5- Falls: 5- Others: 2

Added to adverse events: 12- Cases of injury: 5- Falls: 5- Others: 2
2 cases not considered as near-misses
ExcludeDon't remember the specifics: 1
Clothes and luggage got wet from rain: 1
Excluded because specific circumstances were
unknown.

Object of analysis

Object of analysis

Adverse events: 45

Near misses: 24- Cases of injury: 26- Falls: 13- Others: 6
NPO: Nonprofit organization
Fig. 1: Flowchart for selecting analysis adverse events and near misses- Cases of near collisions : 12
- Near falls: 5- Others: 7

Table 1: Attributes of the respondents to the online questionnaire by sex and age
Male, n (%)
Age

20-29

30-39

40-49

1 (0.9)4 (3.7)4 (3.7)50-59

Female, n (%)

60-69

70-79

80-89

Total

8 (7.4)13 (12.0)

11 (10.2)

2 (1.9)39 (36.1)

7 (6.5)9 (8.3)3 (2.8)1 (0.9)25 (23.1)

20-29

30-39

40-49

50-59

3 (2.8)2 (1.9)7 (6.5)2 (1.9)9 (8.3)

60-69

70-79

80-89

Total

9 (8.3)4 (3.7)1 (0.9)26 (24.1)

3 (2.8)1 (0.9)0' (0.0)

16 (14.8)

Position
LeaderDirector

1 (0.9)OtheraTotal

1 (0.9)1 (0.9)1 (0.9)1 (0.9)1 (0.9)1 (0.9)1 (0.9)8 (7.4)15 (13.9)23 (21.3)

14 (13.0)

3 (2.8)65 (60.2)

1 (0.9)4 (3.7)1 (0.9)1 (0.9)3 (2.8)9 (8.3)7 (6.5)9 (8.3)2 (1.9)32 (23.1)

1 (0.9)1 (0.9)4 (3.7)16 (14.8)

12 (11.1)

5 (4.6)

1 (0.9)43 (39.8)

5 (4.6)6 (5.6)3 (2.8)1 (0.9)17 (15.7)8 (7.4)3 (2.8)2 (1.9)Organization
Sakae Ward Sports Association
Sakae Ward Sports Promotion Committee

1 (0.9)1 (0.9)

Sakae Ward Youth Instructors Council

2 (1.9)5 (4.6)9 (8.3)

Sakae Ward Sawayaka Sports Promotion Committee

2 (1.9)1 (0.9)7 (6.5)1 (0.9)

Sakae Sports Center

2 (1.9)1 (0.9)0 (0.0)10 (9.3)

1 (0.9)1 (0.9)2 (1.9)2 (1.9)2 (1.9)1 (0.9)3 (2.8)0 (0.0)0 (0.0)1 (0.9)1 (0.9)8 (7.4)15 (13.9)23 (21.3)

Recreation (Athletic meeting etc.)

2 (1.8)4 (3.7)8 (7.4)

Badminton

1 (0.9)2 (1.8)1 (0.9)14 (13.0)

20 (18.5)

2 (1.9)OtherbTotal

4 (3.7)18 (16.7)

2 (1.9)NPO Sakae Sports Club

3 (2.8)3 (2.8)65 (60.2)

1 (0.9)1 (0.9)1 (0.9)4 (3.7)4 (3.7)16 (14.8)

12 (11.1)

5 (4.6)

1 (0.9)43 (39.8)

1 (0.9)1 (0.9)2 (1.8)4 (3.7)2 (1.8)7 (6.4)SportsTable tennis

1 (0.9)14 (12.9)
1 (0.9)1 (0.9)2 (1.8)1 (0.9)2 (1.8)7 (6.4)Gymnastics

1 (0.9)Sawayaka Sports (Boccia etc.)

1 (0.9)1 (0.9)2 (1.8)3 (2.7)

Baseball

2 (1.8)1 (0.9)1 (0.9)1 (0.9)Soccer1 (0.9)3 (2.7)1 (0.9)

Soft tennis

3 (2.7)

Softball

3 (2.7)

Volleyball

5 (4.6)

1 (0.9)1 (0.9)1 (0.9)4 (3.7)2 (1.8)3 (2.7)1 (0.9)7 (6.4)6 (5.5)1 (0.9)1 (0.9)1 (0.9)6 (5.5)0 (0.0)5 (4.6)0 (0.0)3 (2.7)1 (0.9)1 (0.9)1 (0.9)4 (3.7)0 (0.0)1 (0.9)0 (0.0)3 (2.7)1 (0.9)4 (3.7)

Walking

1 (0.9)2 (1.8)1 (0.9)Dance sports

0 (0.0)1 (0.9)1 (0.9)1 (0.9)1 (0.9)1 (0.9)3 (2.7)

Kyudo (Japanese archery)

2 (1.8)2 (1.8)0 (0.0)Kendo

1 (0.9)1 (0.9)0 (0.0)Tennis1 (0.9)1 (0.9)0 (0.0)1 (0.9)0 (0.0)Gateball

1 (0.9)Ttug of war

1 (0.9)1 (0.9)0 (0.0)Bowling

1 (0.9)1 (0.9)0 (0.0)1 (0.9)0 (0.0)1 (0.9)0 (0.0)Target bird golf

1 (0.9)Powerlifting

1 (0.9)Otherc1 (0.9)Total

1 (0.9)1 (0.9)1 (0.9)2 (1.8)2 (1.8)8 (7.4)15 (13.8)

23 (21.2）

6 (5.5)14 (12.9)

3 (2.7)65 (60.1)

1 (0.9)2 (1.8)1 (0.9)3 (2.7)3 (2.7)1 (0.9)4 (3.7)4 (3.7)15 (13.8)

12 (11.1)

5 (4.6)a: Other (2): participant, athlete, b: Other (1): Neighborhood association (Tai Chi), c: Others (16): Yoga, athletics, yachting, petanque, golf, event support, preventive care exercise, Pilates, infant physical education, tai chi, aerobics, etc.
The empty cells represent 0 (0%).

10 (9.2)
1 (0.9)42 (38.8)

Table 2: Activities of the respondents to the online questionnaire
Male
Activity history (years)

Female10.0 (5.0 - 20.0)

11.5 (3.3 - 20.0)

Activity frequency (times/month)

1.0 (1.0 - 4.0)

4.0 (2.0 - 8.8)

Activity duration (hours/session)

2.0 (2.0 - 3.0)

2.0 (1.3 - 2.0)

20.0 (15.0 - 30.0)

19.0 (14.0 - 33.8)

Number of participants (persons/session)Median (interquartile range), Respondents: Leader, Director, Other (participant, athlete)
Activity history: Number of years of exercise teaching experience
Activity frequency: Approximate number of activities per month
Activity duration: Approximate duration per activity
Number of participants: Approximate number of persons per sports activity

Table 3: Number of adverse events by sport discipline, sex, and age
Male, n (%)
Age

-9

10-19

Soccer3 (6.6)3 (6.6)

Recreation (Sports Day etc.)

1 (2.2)

20-29

30-39

40-49

50-59

Female, n (%)
60-69

70-79

80-89

Unknown

Total

-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80-89

Unknown

Total

Sports2 (4.4)

Softball

1 (2.2)1 (2.2)1 (2.2)3 (6.6)

1 (2.2)2 (4.4)3 (6.6)

Soft tennis

2 (4.4)Volleyball
1 (2.2)

Badminton

7 (15.5)

0 (0.0)6 (13.3)

0 (0.0)2 (4.4)1 (2.2)

Baseball

2 (4.4)

Kyudo (Japanese archery)

1 (2.2)

Target bird golf

1 (2.2)Other

1 (2.2)4 (8.8)5 (11.1)

0 (0.0)0 (0.0)8 (17.7)

0 (0.0)3 (6.6)6 (13.3)

4 (8.8)4 (8.8)1 (2.2)6 (13.3)

1 (2.2)1 (2.2)1 (2.2)1 (2.2)2 (4.4)2 (4.4)3 (6.6)2 (4.4)

Table tennis

The empty cells represent 0 (0%).

0 (0.0)0 (0.0)Walking

Total

8 (17.7)

1 (2.2)2 (4.4)1 (2.2)1 (2.2)1 (2.2)2 (4.4)1 (2.2)2 (4.4)0 (0.0)1 (2.2)0 (0.0)1 (2.2)0 (0.0)1 (2.2)1 (2.2)33 (73.3)

1 (2.2)1 (2.2)0 (0.0)0 (0.0)0 (0.0)1 (2.2)5 (11.1)

1 (2.2)4 (8.8)0 (0.0)0 (0.0)12 (26.6)

Table 4: Frequency of adverse events by sports discipline (calculated values)
Number ofAdverseNumber of

Average

Number ofactivities

Number ofoccurrences

activity time

Total activity

occurrences

eventsRespondents(activities

activities

per 10(hours pertime over 3

per 1,000(cases)(persons)

per month)over 3 years

activities

activity)

years

hours

Soccer

8

5

46

1,656

0.05

2.6

21,5280.37

Recreation (Athletic meeting etc.)

7

4

4

144

0.49

3.8

2,160

3.24

Softball

6

4

11

396

0.15

2.8

4,356

1.38

Walking

4

3

16

576

0.07

3.7

6,336

0.63

Volleyball

4

2

28

1,008

0.04

2.0

4,032

0.99

Soft tennis

4

3

16

576

0.07

3.7

6,336

0.63

Table tennis

3

2

5

180

0.17

2.0

720

4.17

Badminton

3

3

10

360

0.08

5.0

5,400

0.56

Baseball

2

2

18

648

0.03

6.0

7,776

0.26

Target bird golf

1

1

12

432

0.02

2.0

864

1.16

Kyudo (Japanese archery)

1

1

4

144

0.07

2.0

288

3.47

Other

2

2

2

72

0.28

2.0

288

6.94

All

45

32

172

6,192

0.07

3.2

60,0840.75

Number of activities over 3 years = Number of reported activities (activities per month) *12 months *3 years
Number of occurrences per 10 activities = (number of adverse events/ number of activities over 3 years) *10
Average activity time (hours per activity) =[Sum of each activity time (hours per activity) reported in the same sport discipline]/ [number of reports inthe same sport discipline]
Total activity time over 3 years = reported activity time (hours per activity) *number of activities over 3 years
Number of occurrences per 1,000 hours = (number of adverse events/ total activity time over 3 years) *1,000

Table 5: Body part and type of injuries, n (%)
SprainLower leg
Foot joint/sufficient

4 (15.4)

Hand joints/hands

1 (3.9)Tendon injury

Bone fractures

Muscle injury

5 (19.3)

1 (3.9)2 (7.7)Chronic injury

Concussion

Skin Injuries

BruisesTotal
8 (30.8)
4 (15.4)

2 (7.7)Elbow

1 (3.9)Head/Face

2 (7.7)
1 (3.9)Front Wrist

4 (15.4)

1 (3.9)3 (11.6)2 (7.7)

1 (3.9)1 (3.9)1 (3.9)Chest/Back

1 (3.9)1 (3.9)Femoral joint

1 (3.9)1 (3.9)Thighs1 (3.9)1 (3.9)Knee

1 (3.9)Total

6 (23.1)

The empty cells represent 0 (0%).

1 (3.9)5 (19.3)

4 (15.4)

4 (15.4)

1 (3.9)1 (3.9)2 (7.7)

3 (11.6)

26 (100)

Table 6: Detailed circumstances of the fall cases
Sex

Age

SportsPlace

Details

1 Male40-49

Recreation

Schoolyard

Stumbled over uneven ground.

2 Male40-49

SoftballBaseball ground

Fell over while picking up the ball.

3 Male40-49

SoftballBaseball ground

Fell while running for a base.

4 Male40-49

Recreation

Schoolyard

Fell down just before passing the baton in a relay race.

5 Male70-79

Walking

Road

Stumbled over a step.

6 Male70-79

Soft tennis

Tennis court

Fell forward while chasing a ball.

7 Male70-79

Soft tennis

Tennis court

Fell down while picking up a short ball.

8 Female 70-79

Soft tennis

Tennis court

Fell backwards while trying to hit the ball.

9 Male70-79

Recreation

Parks/sports fields

Slipped and fell while running.

10 Male70-79

Recreation

Parks/sports fields

Fell while running in the parent participation event at the Sports Day.

11 MaleUnknown Recreation

Schoolyard

Fell while running.

12 Male-9

Badminton

Building entrance

Slipped on the floor while running and fell.

13 Male80-89

Kyudo (Japanese archery)

Building entrance

Tripped and fell on a step in a doorway.

[Appendix Table 1] Questionnaire items
Question Item

Response Method

Questions about responders (Leader and Director)
1 Age

Selective

10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-99, others

2 Sex

Selective

Male, Female
Sakae Ward Sports Association, Sakae Ward Sports Promotion Committee,

3 Organization

Selective

Sakae Ward Youth Instructors Council, NPO Sakae Sports Club, Sakae Sports
Center, Sakae Ward Sawayaka Sports Promotion Committee

4 Activity Location

Descriptive
Kendo, Kyudo (Japanese archery), Baseball, Volleyball, Table tennis, Tennis,
Soft tennis, Badminton, Softball, Karate, Gymnastics, Basketball, Walking,

5 Sports discipline

Selective

Soccer, Gateball, Tug of war, Bowling, Target bird golf, Dance sports,
Powerlifting, Recreation (Athletic event etc.), Sawayaka Sports (boccia etc.),
Other

6
7

Position:
Leader/Director*
History of Activities as
Leader/Director

8 Qualifications
9
10

Experience of attending
seminarsFrequency of Activities as
Leader/Director

Selective

Leader, Director, Other

Descriptive Number (year)
Descriptive
Selective

No experience, less than once a year, about once a year, More than once a
year, Other

Descriptive Number (times/month)

11 Activity time

Descriptive Number (hours/time)

12 Number of participants

Descriptive Number (persons/time)

Questions about adverse events
13

Occurrence and type of

Selective

Not occurring, Fall, Chest pain, Aggravation of chronic disease, Injury, Other

14 Year

Selective

2017, 2018, 2019, 2020, Don't remember

15 Month

Selective

16 Sex

Selective

Male, Female

17 AgeSelective-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-99, Unknown

adverse events

January, February, March, April, May, June, July, August, September, October,
November, December, don’t remember

Kendo, Kyudo (Japanese archery), Baseball, Volleyball, Table tennis, Tennis,
Soft tennis, Badminton, Softball, Karate, Gymnastics, Basketball, Walking,
18 Sports discipline

Selective

Soccer, Gateball, Tug of war, Bowling, Target bird golf, Dance sports,
Powerlifting, Recreation (Athletic event etc.), Sawayaka Sports (boccia etc.),
Other

19 Location

Selective

20 Response at the time

Selective

Gymnasium, Soccer field, Baseball field, Tennis court, Training gym, Other
grounds, Park, Other
No treatment, Observation (recovery/improvement with rest), On-the-spot firstaid, Hospital visit, Emergency transport, Other

21 Details of response
22

Situation at the time of
the fallDescriptive
Descriptive
Head/face, neck, chest/back, abdomen/back, hip joint, thigh, knee joint, lower

23 Part of injury

Selective

leg, foot joint/foot, shoulder joint, upper arm, elbow joint, forearm, forearm,joint/part

24 Name of injury

Descriptive

25 Situation at time of injury

Descriptive

26 Another case

Descriptive(Name of disease)

Questions about near-misses
27

Occurrence and year ofnear- misses

Selective

Not occurring, 2017, 2018, 2019, 2020, Don't remember
January, February, March, April, May, June, July, August, September, October,

28 Month

Selective

29 Sex

Selective

Male, Female

30 AgeSelective-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-99, Unknown

November, December, don’t remember

Kendo, Kyudo (Japanese archery), Baseball, Volleyball, Table tennis, Tennis,
Soft tennis, Badminton, Softball, Karate, Gymnastics, Basketball, Walking,
31 Sports discipline

Selective

Soccer, Gateball,Tug of war, Bowling, Target bird golf, Dance sports,
Powerlifting, Recreation (Athletic event etc.), Sawayaka Sports (boccia etc.),
Other

32 Location
33

Details of the near-missincident

34 Another case

Selective

Gymnasium, Soccer field, Baseball field, Tennis court, Training gym, Other
grounds, Park, Other

Descriptive
Descriptive*Leader: a person who mainly conducts sports coaching and on-site management; Director: a person who mainly supports theleader