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In this cross-sectional study, we invited players from the highest ice hockey leagues for females [Swedish Women’s Hockey League (SWHL)] and men (Swedish Hockey League [SHL], HockeyAllsveskan [HA]) in Sweden to respond to an online survey. SWHL players participate in another prospective study and provided separate informed consent. Players from the SHL and HA provided their informed consent anonymously before answering the online survey. The Swedish ethics review authority approved the study protocol (Dnr 2022–02668-01). We wrote the manuscript with consideration to the Strengthening the Reporting of Observational Studies in epidemiology (STROBE) guidelines [15].
Participants and recruitment
Ice hockey players in the SWHL (10 teams) as well as SHL (14 teams) and HA (14 teams) were invited to participate in the study. SWHL players were recruited within an ongoing prospective study investigating injuries and health problems in the league. The SWHL management provided us with contact information for all players who received direct e-mail invitations with two reminders between end of August and beginning of September 2022. Hence, the sampling frame for female players included the total target population at the time of recruitment. For male players we relied on voluntary response sampling by indirectly inviting them via official league managements and club’s medical teams between September and October 2022. They received a public link via email and were provided with a QR-code for the survey in their locker rooms.
Data collection
Data were collected online through respondent-surveys for female players and anonymous surveys for male players. Players provided demographic information and reported general conditions for playing ice hockey (occupation besides ice hockey, family situation, medical support), perceived stress and information regarding injuries during the previous season.
Description of general conditions for playing ice hockey
We collected information about general conditions for playing ice hockey by asking questions about occupational obligations besides playing ice hockey, living- and family conditions, as well as available medical support. Players reported whether their primary occupation is playing ice hockey or if they have other occupational duties such as work or studies. Players also reported if they live by themselves or together with their parents, partners, or children. Finally, we asked a series of questions about the medical support available to players during games, matches, and outside of the sport.
Measurement of perceived stress
Perceived Stress Scale (PSS-10) was used to assess perceived stress during the previous season, and current level of perceived stress was assessed by single item stress question (SISQ). PSS-10 consists of 10 items that measure the degree to which life is/has been perceived as unpredictable, uncontrollable, and overloading. These 10 items are answered on a 5-point Likert scale (0–4) and summarized as a total score ranging from 0 (no perceived stress) to 40 (highest degree of perceived stress). PSS-10 is a valid and reliable measure [16] that has been validated in the Swedish language [17]. SISQ, a single item formulated “Stress means a situation in which a person feels tense, restless, nervous, or anxious or is unable to sleep at night because his/her mind is troubled all the time. Do you feel this kind of stress these days?” is a valid way to measure current stress in survey-research [18,19,20]. SISQ is answered on a 5-point Likert scale ranging from 1 (no perceived stress) to 5 (highest degree of perceived stress).
Measurement of past season injury
An injury was defined as self-reported “injury or pain” during the past season in one of the following 8 anatomical areas: Head/face/neck, shoulder, elbow/wrist/hand, lower back, pelvis/hip/groin, thigh, knee, and lower leg/ankle/foot. The anatomical areas were chosen based on previous publications describing injury occurrence in ice hockey players [21]. If players indicated an injury in one of these areas (Yes/No), they were provided with the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O). OSTRC-O was developed to register overuse injuries [22] but can be applied on both acute and overuse injuries. The questionnaire measures the (1) impact an injury has on a player’s ability to train and play games, (2) potential reductions in training volume and (3) performance due to the injury as well as (4) pain during sport participation. OSTRC-O was modified by asking players to report injuries occurring during the past season. Players then answered some follow-up questions regarding onset of the injury and duration of potential time loss from ice hockey (total inability to participate in training or match, measured in weeks).
Data management
The burden of each injury was calculated based on the four OSTRC-O items response alternatives, as a severity score [22] ranging from 0 (full participation without health problem) to 100 (highest impact; no participation). Participants who reported no injury/problem were rated with score 0. A total severity score for all injuries during previous season was computed by summarising the severity score for each anatomical area. Injuries characterized by at least one of the following three OSTRC-O responses were defined as “substantial injuries”: (1) moderate or severe reduction in training volume; (2) moderate or severe affected performance; and (3) inability to participate. Injuries characterized by a score of more than 0 in at least one of the 4 OSTRC-O questions without fulfilling criteria to be substantial were defined as “non-substantial injuries”. Players were categorised into either “No”, “Non-substantial” (any injury, but non-substantial) or “Substantial” injury during previous season. SISQ responses were also categorized into low (response options: “not at all stressed” and “just a little stressed”) medium (response option: “stressed to some extent”) and high (response options: “quite stressed” and “very much stressed”).
Statistical analysis
Spearman correlation was applied for analyses of association between the injury severity score and perceived stress level (PSS) during previous season and current stress level (SISQ) in total group and stratified by sex. The non-parametric correlation was chosen due to skewed distribution of total severity sum of injuries during previous season, and the ordinal five categorical response scale for SISQ. Comparisons of perceived stress during previous season (PSS score) were compared with independent samples t-test between female and male players, and with Analysis of Variance (ANOVA) between injury groups (no, non-substantial, or severe injury) during previous season. The parametric test was used since the PSS score showed a normal/symmetric distribution. Current stress level was compared between sex with Kendall’s tau-B test for the 3 categorical SISQ outcome. For the full Likert scale of current stress level (SISQ), the comparison was performed with Mann-Whitney U test between sex and Kruskal Wallis between injury groups (no, non-substantial or substantial injury during previous season). The non-parametric tests were used due to the single ordinal/Likert scale which was not normally distributed. If omnibus ANOVA or Kruskal Wallis test showed significance, post hoc pairwise comparisons (LSD/Dunn, not Bonferroni-adjusted) were performed. Comparison of stress levels (PSS and SISQ full Likert scale) between injury groups were also performed stratified by sex. All analyses were performed in IBM Statistical Package for Social Sciences SPSS (version 27).
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