Research Summary: Aquatic Spinal Cord Injuries

RESEARCH 

This is a meta-analysis of 33 original studies on diving safety in open water and swimming pool settings between 1980 to date, plus several meta-analyses focused on exploring the aetiology of diving incidents. Articles are presented in order of recency. 

 

Qiu, Z., Veiga, S., Lorenzo, A., Kibele, A. and Navarro, E. 2021. Differences in the key parameters of the individual versus relay swimming starts. Sports Biomechanics. pp. 1-13. 

A study of 12 elite-level swimmers aged 16-17 years old was asked to perform 2 x 25 m sprints using front crawl in the relay and non-relay start formats. Relay swimmers spent longer on the block, had a higher flight path and reached a greater distance than non-relay start formats. Swimmers spent less time submerged to reach maximum water depth and resurface when performing a relay start. Very large correlations were seen between take-off height and entry distance. 

 

Yilmaz, M., Ikizoglu, E., Arslan, M., Ozgiray, E., Caliskan, K. and Erbayraktar, R. 2021. An overview of spinal injuries due to dive or fall into shallow water. Our long-term, double-centre experience from the Aegean Coast. Emergency Medicine International. pp.1-7. 

A retrospective study of hospital records for 39 patients between 2012-2019 with a spinal injury following a dive or fall into shallow water. 36 injured persons were male, with 3 being female. The average age was 31.59, with a range of 14-92 years. 29 persons required surgery. Comorbidities were detected in 9 persons and included hyperthyroidism and diabetes. 5 persons had extracervical injuries such as lacerations to the head, chest, or limbs. One person died as a result of a post-operative cardiac arrest. Injury at the C5 or C6 level accounted for 27 cases. Gymnastics, horseback riding, skiing and mountain climbing all had higher prevalence rates for spinal injuries than diving into the water. 

 

Murphy, K. 2020. Negligence and premise liability in instruction of a racing dive in competitive swimming. Journal of Physical Education, Recreation & Dance. 91(3), pp.55-58. 

A review of the Olivia Khan case (a USA case from California) in which the 14-year-old was instructed to dive into shallow water at a competition event despite her protest that she was fearful of diving into shallow water, she had never swum competitively before, she had joined the swim team only one month prior, and she had never received any instruction in diving into shallow water. She performed two successful dives, but on the third, she broke her neck. Olivia had taken part in two previous swim meets where she had participated as the first swimmer in the relay, where she was permitted to start in the water. Olivia was given several assurances by her coach that she would not be required to dive into shallow water at the event. 

The defendant argued that he had taught Olivia to dive several times in the deep end of the pool and at least once in the shallow end. A coaching assistant could not recall any instances where Olivia had been asked to dive into shallow water. On two occasions, the coaching assistant observed Olivia dive too deep whilst using the deep water. 

The Court at first instance dismissed her claim by issuing summary judgment. The Court was of the view that the risk of diving into shallow water was apparent to all at the event and that restricting dives into shallow water would substantial impair participation in the activity of diving at gala events. The Court took the view that Olivia voluntarily accepted this risk in agreeing to take part in the event. The appellate court affirmed the view of the court at first instance. The court felt that changing the order of Olivia's position in the relay was part of challenging students and was fundamental to the coaching of students in sports. The court found that the broken promise and change to the performance of a shallow water dive was not the cause of her injury. The court agreed that the risk was apparent to all at the event. 

The Supreme Court reversed the appellate court's ruling and remanded the case back to a full trial. The Court focussed on the absence of receiving training in the performance of a shallow racing dive, the defendant's prior knowledge of Olivia's fear of shallow dives, the defendant's broken promise that Olivia could start in the water, and the threat made by the coach to Olivia that if she did not dive, she could not take part in the event as the key aspects of a valid claim. If Olivia assumed the risk of diving into shallow water by practising a new skill, she also assumed the risk that she may not be deemed competent to perform that skill by her coach. The failure of the court at first instance to hear the testimony of an expert witness with 40 years of experience in the customary sequence for teaching diving was incorrect; the Court should have heard this evidence. 

 

Siedlecki, Z., Nowak, K. and Sniegocki, M. 2020. Diving-related cervical spine injuries. A systematic review, treatment, and educational approach. Journal of Physical Education and Sport. 20(6), pp.3684-3690. 

A study of 18 hospitalizations with spinal cord injuries caused by diving into the water in Poland between 2015-2020. All 18 cases involved males. The injury level was C7 in 2 cases, C6 in 10 cases, C5 in 3 cases, and C4 in 1 case. 2 cases involved under 18s, 5 cases involved 18-21-year-olds, 7 cases 22-30-year-olds, and 4 cases involved those 30+ years. 15 cases involved intoxication by alcohol. 11 cases involved lakes, 5 cases rivers, and 2 cases garden pools. Full fitness recovery was achieved in only 22% of cases.  

 

Kozlowski, J. 2019. Shallow water diving injury contributory negligence defence. Parks & Recreation. pp.30-37. 

A review of the US case of Core v North Carolina Division of Parks and Recreation [2018] N.C. App. LEX-IS 1040, involved James Core, who dived into Lake Waccamaw and hit his head on the bottom resulting in spinal injury. 

 

Manz, W., Greenshields, J., Wright, B., Goss, C. and Skutnik, B. 2019. Head depth and head speed during competitive backstroke ledge starts. International Journal of Aquatic Research and Education. 12(1), pp.1-16. 

A study of 61 high-school swimmer backstroke dive entries into a 1.53-metre starting end depth. The maximum head speed for 93% of entries exceeded 0.6 m/s, and 29% of entries exceeded 1.2 m/s. No difference in maximum head depth between using or not using a backstroke ledge was observed. 

 

Barbara-Bataller, E., Mendez-Suarez, J., Aleman-Sanchez, C., Sanchez-Enriquez, J. and Sosa-Henriquez, M. 2017. Spinal cord injuries resulting from diving accidents in the Canary Islands. Nuerocirugia. 28(4), pp.183-189. 

A retrospective study of 264 patients admitted to a Spinal Cord Injury Unit in the Canary Islands between 2000 and 2014 was analyzed. 23 (8.7%) were caused by diving into shallow water.

• 56% took place between 2000-2005, 17% between 2006-2010 and 26% between 2011 and 2014.
• 34.7% of the patients were tourists, and the rest were residents of the Canary Islands.
• 80% were single, 63% lived with their parents, and 20% lived with a partner.
• 41% were employed, and 23.5% were unemployed. 35.3% were students. 
• August accounted for 30.4% of incidents, with March 13%, July 13% and November 13%.
• 39% occurred on a Friday. 
• Only 8.7% of cases involved intoxication via alcohol. Six persons (26.1%) had taken illicit drugs. 
• 43.5% dived into the sea, 39.1% after jumping into the water from the beach and 17.4% after diving into swimming pools. 
• 60.9% of cases had an injury level at C5 followed by 13% at C4 and C6, respectively. 
• 5 were under 18, 13 were under 30, and 10 were 30 or over. 

 

Chan, C., Eng, J., Tator, C., Krassioukov and The Spinal Injury Research Evidence Team. 2016. Epidemiology of sport-related spinal cord injuries. A systematic review. The Journal of Spinal Cord Medicine. 39(3), pp.255-266. 

A meta-analysis of 54 spinal injury studies across 25 countries between 1980 and 2015. The sport causing the greatest number of spinal injuries in most countries was diving, ranging from 7.7% in Germany to 64.9% in China, with a mean of 35.3%. 

 

Williams, D. and Odin, L. 2016. Board diving regulations in public swimming pools and risk of injury. Risk Analysis. 36(6), pp.1251-1262. 

There are thought to be 98 swimming pools in the UK with swimming pool diving facilities accessible to the public. The study involved a survey of 20 pool managers of swimming pools in the UK with diving facilities. 228,905 persons per year were estimated to have visited the swimming pools involved in the study. The diving facilities were open to the public for an average of 18.65 of 77.27 hours of total pool opening time per week. The number of types of dive permitted in public sessions was, on average, 2.4 of 5 available types included within the survey. The number of incidents per 100,000 pool visitors was estimated to be 0.63.  

In a second study, 22 experienced club-level masters platform and springboard divers were compared against 22 undergraduates with no diving experience. The average age of the divers was 26.54 years for the club divers and 23.18 for the undergraduate control group.  A set of survey questions was provided to both groups. Experienced divers generally perceived the risk of diving and using a swimming pool to be lower than the undergraduate control group. 

 

Cornett, A., White, J., Wright, B. and Stager, J. 2014. Competitive swim start safety. International Journal of Aquatic Research and Education. 8(2), pp.115-142. 

A series of seven experiments investigating swim start safety. 

• A study of 211 dives involving two groups of swimmers; under 10s and those 15 years and over. Water depth was 2.29 metres at the starting end. The maximum head depth and head velocity were greatest (0.76 m v 0.63 m) in the 15 year+ category.
• In a second study, filming shifted to a pool with a water depth of 1.22 metres, where 471 dives were analyzed. The results were similar (0.56 m v. 0.6 m).
• A third experiment involved 11 collegiate swimmers performing competitive starts in those three different water depths: 1.52 m, 2.13 m, and 3.66 m. Water depth was found not to influence head velocity and maximum head depth.
• A fourth experiment involved two groups of swimmers: those with less than 1-year and those with more than 1-year of competitive experience. Results found that both groups of swimmers, when asked to perform a shallower dive, performed a shallower dive. 
• A fifth experiment involved the swimmers from the second study. Swimmers asked to perform a shallow start performed a significantly shallower start than those who were asked to perform a normal diving entry.  
• A sixth experiment involved swimmers asked to perform three competitive diving starts from three starting heights: 0.21 m, 0.46 m, and 0.76m. The maximum head depth and velocity were significantly greater from the poolside and the starting block than the intermediate height. 
• A seventh experiment involved a survey of race start instruction given by US swim coaches, which received 471 responses. Only 21.7 % of respondents used a dive progression protocol from a professional organization. 89.8% relied on a mental checklist when designing dive progression training. 

 

Cornett, A. and Stager, J. 2014. Minimum water depth rules for competitive swim starts. International Journal of Aquatic Research and Education. 8, pp.288-294. 

A meta-analysis of four published studies involving competitive swimming racing starts was analysed. 

 

Chan-Seng, E., Perrin, F., Segnarbieux, F. and Lonjon, N. 2013. Cervical spine injuries from diving accident. A 10-year retrospective descriptive study on 64 patients. Orthopaedics & Traumatology. Surgery & Research. 99, pp.607-613. 

A retrospective study of 64 diving spinal injury cases in France between 2000-2010. This equalled 9.5% of all spinal injury cases reported during that period. 54 (84%) occurred in inland or coastal waters as compared to 15% in private swimming pools. 95% of traumas occurred to male participants. 3 patients drowned following submersion. 59 (93%) cases occurred between April and August, with the peak in July (20 cases) and August (27 cases). 52 (82%) persons returned to their work or studies following the incident. 

 

Moran, K. and Webber, J. 2013. Surfing requiring first aid in New Zealand, 2007-2012. International Journal of Aquatic Research and Education. 7(3), pp.192-203. 

In a retrospective analysis of 8,437 incidents requiring first aid by surf lifeguards in New Zealand between 2007-2012, 16% involved surfing. 68% were male and 31% female. 43% were aged between 16-30 years, with children between 11-15 years accounting for 25%. Europeans were overrepresented (85% vs. 62% of the New Zealand population). 59.2% involved a laceration, 15.2% involved bruising, 7% involved a marine sting, and other injuries comprised 13% of the 1,150 incidents where the nature of the injury was known. Only 15.9% of incidents resulted in a referral to a doctor, and 4.4% of incidents were admitted to the hospital from the beach. The head/neck/eyes accounted for 31.7%, the foot/toes/ankle 22.9%, lower limbs 18.6%, and upper limbs accounting for 15% of cases. Only 11 spinal injuries were reported (c.1% of cases). 50% of surfing incidents involved the person being struck by their own board and 5.8% by another persons board. 21.2% of surfing injuries involved contact with the ocean floor. 

 

Cornett, A., Naganobori, H. and Stager, J. 2012. Intra-individual head depth variability during the competitive swim start. International Journal of Aquatic Research and Education. 6(4), pp.350-363. 

A study of 22 persons from the US who performed five competitive starts from a starting block in water 3.66 metres deep. The average age of swimmers was 17.1 ± 4.4 years. The range of values intra-individual variability is quite large in a competitive sample. Intra-individual variability is positively correlated with the average depth of the racing starts. 

 

Cornett, A., White, J., Wright, B. and Stager, J. 2012. Teaching competitive racing starts. Practices and opinions of professional swim coaches. International Journal of Aquatic Research and Education. 6(2), pp.156-170. 

Survey results from 471 swim coach views on safe diving practices were analyzed. 74.4% of coaches reported that a swimmer should be able to dive before teaching them to perform a competitive start. 78.3% of coaches said the progression they used to teach diving was personally designed, the rest using a recognized approach from a professional body. 30.5% of coaches began teaching diving from a block at 6 years or under and 38.7% at 7-8 years. Fear was reported in 47.6% of cases as the most challenging aspect coaches reported having to overcome for dives into shallow water. 

 

Amorim, E., Vetter, H., Mascarenhas, L., Gomes, E., Carvalho, J. and Gomes, J. 2011. Spine trauma due to diving. Main features and short-term neurological outcome. Spinal Cord. 49, pp.206-210. 

A retrospective study of 1,324 spinal injury patients admitted to a hospital in Brazil between 14 and 65 years old between 1991 and 2006. 140 incidents involved spinal cord injuries from jumping or diving into the water. 92.1% were male. 63% were between 15-29 years old. 49.3% of cases occurred in the summer months between December and March. 42.1% involved an injury at the C5 level and 19.3% at the C6 level. 

 

Boran, S., Lenehan, B., Street, J., McCormack, D. and Poynton, A. 2011. A 10-year review of sports-related spinal injuries. Irish Journal of Medical Science. 180, pp.859-863. 

A review of 196 sport-related spinal injuries admitted to the hospital between 1993 and 2003. 145 (28 involving diving) incidents involved males and 51 (2 involving diving) incidents involved females. Only one incident involved a jet ski; a female who was 21 years old. The average age of injured persons was 30.2 years, with the range between 14-72 years. Incidents increased in prevalence in the summer months of July, August and September. Diving accounted for 15.3% of injuries, the majority of these occurring abroad and being repatriated home. Over 90% of incidents resulted in damage to the cervical spine, with C6 being the most common level. 43% of incidents required surgery. There was a similar representation of those who had dived into swimming pools against those who had dived into the sea. Excess alcohol consumption was a factor in 64% of cases.  60% of total injuries occurred in the under 35s. 

 

Cornett, A., White, J., Wright, B., Willmott, A. and Stager, J. 2011. Block height influences the head depth of competitive racing starts. International Journal of Aquatic Research and Education. 5(2), pp. 174-186.

In a study of 11 collegiate swimmers in the USA with a mean age of 20.1 years, a standing height of 1.79 metres, and a mass of 74.5 kilograms took part in an experimental test in a diving pit with a 3.66-metre water depth. All swimmers performed a competitive start from each of the 0.21 metres, 0.46 metres and 0.76-metre blocks. The only instruction to swimmers was to perform their typical racing start. A video of each dive was recorded against a backdrop aluminium frame to assist with the measurement of trajectory. 

Three measurements were taken: maximum head depth, head speed at maximum head depth, and distance from the wall at maximum head depth. There was no significant correlation between maximum head depth, head speed or distance and block height. 

 

Cornett, A., White, J., Wright, B., Wilmott, A. and Stager, J. 2011. Racing start safety. Head depth and head speed during competitive backstroke starts. International Journal of Aquatic Research and Education. 5(4), pp.389-401. 

A study of 122 dives involving participants aged 6-16 years. Some participants were recorded multiple times, as the event involved racing starts for freestyle and backstroke events. The starting water depth was 1.22 metres. As age increased, so did maximum head depth. Maximum head speed increased broadly in line with the age of swimmers. The distance from the wall broadly increased with the age of swimmers. 

 

Cornett, A., White, J., Wright, B., Wilmott, A. and Stager, J. 2011. Racing start safety. Head depth and head speed during competitive swim starts into a water depth of 2.29m. International Journal of Aquatic Research and Education. 5(1), pp.14-31. 

A study of 211 dives involving 99 male and 112 female swimmers from the USA between 6-22 years was observed performing a racing start in the swimming pool. A track start and a grab start were compared. The maximum depth achieved by boys was generally greater than girls of the same age. Freestyle and butterfly racing starts generally achieved greater water depths and distance from the wall than breaststroke starts. Head speed at maximum depth was generally faster for breaststroke starts than freestyle or butterfly. The maximum head depth and distance from the wall, in general, was greater in deeper water than in shallower water, indicating the adjustment divers made for the water depth. Maximum head speed was faster in shallower water. Maximum head speed exceeded 3.4 m/s in 21.5% of cases and 1.9 m/s in 96% of cases within the over 15s category. 

 

Carll, K., Park, A. and Tortolani, J. 2010. Epidemiology of catastrophic spine injuries in High School, College, and professional sports. Seminar in Spine Surgery. 22, pp.158-172. 

A short US meta-analysis of swimming and diving spinal injury cases. 

 

Collier, T., Jones, M. and Murray, H. 2010. Skimboarding. A new cause of water sport spinal cord injury. Spinal Cord. 48, pp.349-351. 

A case series involving three skimboarders in the USA. Case 1 involved a 17-year-old male and advanced skimboarder who hit his head on the ocean floor. Case 2 involved a 23-year-old skimboarder who was flipped by a wave and hit his head on the ocean floor. Case 3 involved a 19-year-old male who fell from his skimboard and hit his head on the ocean floor. The development of more extreme manoeuvres in skimboarding and its growing popularity are thought to be behind the increase in spinal injury cases. The key difference from surfing is that the manoeuvres are practised in shallow water as the waves break. 

 

Vlok, A., Petersen, I., Dunn, R. and Stander, J. 2010. Shallow-water spinal injuries - devastating but preventable. South African Medical Journal. 100, pp.682-684. 

A study of 46 spinal injury patients admitted to a South African hospital between 2003 and 2009. 

• 57% of injuries occurred during school holidays
• 91% were male
• The average age at the time of injury was 23 years
• 37% involved alcohol consumption
• 20 patients were injured in the sea, 13 in swimming pools, 7 in rivers and 4 in tidal pools. In 2 cases, the location was not documented. 

 

Blitvich, J., McElroy, K. and Blanksby, B. 2009. Home swimming pool design to improve diving safety. International Journal of Aquatic Research and Education. 3(3), pp.302-314. 

A study into the engineering and design factors that can contribute to home swimming pool safety in Australia between 1999 and 2008. Interviews with home swimming pool installation companies took place. Average water depth ranged from 0.9-2.0 metres. No pool manufacturers included water depth indicators. 

 

Ye, C., Sun, T., Li, J. and Zhang, F. 2009. Pattern of sports- and recreation-related spinal cord injuries in Beijing. Spinal Cord. 47, pp.857-860. 

A retrospective study of patients from six institutions in Beijing admitted between 1993 and 2006 with spinal cord lesions resulting from sports and recreation activities. 57 cases were analysed; 37 were involved in water sports, and 20 were in other incidents. The age of persons ranged from 5-58 years old, with a mean age of 24.49. 44 were male and 13 female. 34 injuries were from diving into shallow water in a public swimming pool. 5 shallow water diving cases involved alcohol consumption but none involved illicit substances. 19 water sports cases presented an injury level at C4, 7 at C5, and 5 at C6. The number of water sports decreased from 23 to 14 between 1993-1999 and 2000-2006 whilst in other areas the trend was an increase in prevalence. 

A meta-analysis around the issue of diving is also included. 

 

Barss, P., Djerrari, H., Leduc, B., Lepage, Y. and Dionne, C. 2008. Risk factors and prevention for spinal cord injury from diving in swimming pools and natural sites in Quebec, Canada. A 44-year study. Accident Analysis and Prevention. 40, pp.788-797. 

A retrospective study of 171 individuals admitted to two hospitals in Canada between 1961-1994 with a spinal cord injury from diving into shallow water. 8 died shortly following their injuries. 87 individuals participated in the study. 45 involved incidents in swimming pools and 44 in open water. 

• 60% were under 24, 85% were under 35 years old, 95% were under 45 years old
• 33% had training in water safety compared with 56% who had taken swimming lessons
• 37% were aware of the risk of a head-first collision with the pool bottom prior to their incident. 
• 31% had some university education
• 47% self-reported alcohol as a relevant factor in the incident
• In 37% of cases, the injury occurred on the first dive
• 79% of dives took place in water less than 1.4 metres deep
• 16% of pool incident respondents occurred from a diving board and 9% from high locations not intended for diving
• 76% of pool incident respondents said the pool bottom was visible
• 12 (63%) incidents occurred on the up-slope of the pool bottom. 
• 87% of pool incidents occurred at a home pool
• 62% of pool incidents occurred at a friend's house

 

Gurkanlar, D., Yucel, E. and Altinors, N. 2008. Cervical spine injuries in aquaparks. Clinical Journal of Sports Medicine. 18, pp.464-466. 

A series of four case reports from spinal injuries on waterslides in Turkey in 2007. Case report 1 involved a 31-year-old man who descended a waterslide headfirst, sustaining a C7 burst fracture and damage to his C6 and C7 intervertebral discs. Case report 2 involved a 26-year-old man who descended a waterslide headfirst, sustaining a C5 burst fracture and C4-5 posttraumatic intervertebral disc herniation. Case report 3 was of a 30-year-old man who descended a waterslide head first, sustaining a C6-7 posttraumatic intervertebral disc herniation and C7 hypoesthesia.  Case 4 was of a 47-year-old man who dived into shallow water sustaining C6-7 dislocation and C6-7 posttraumatic intervertebral disc herniation. 

 

Heinicke, S. and Tator, C. 2008. Chapter 11 Diving in Tator, H. 2008. Catastrophic injuries in Sports and Recreation. Causes and Prevention. A Canadian Study. 1st edition, University of Toronto Press, Toronto.  

A study of 105 spinal injury cases in Canada resulting from diving during four survey years: 1986; 1989; 1992, and 1995. 93 incidents involved males and 12 incidents females. 5 incidents involving males resulted in a fatality, with death caused in 3 of those incidents by drowning. Facial injuries were rare, being reported in only 1 case. Fracture or dislocation occurred in 88 cases. Diving was the most common cause of spinal injury in Ontario. 

 

Moran, K. 2008. Taking the plunge. Diving risk practices and perceptions of New Zealand youth. Health Promotion Journal of Australia. 19(1), pp.68-71. 

Diving surveys returned by 2,202 school students aged 16-19 years were analyzed. 33% reported they had dived head first into water of an unknown depth, including 40% of males and 24% of females. Maori and Pacific Islands youths were twice as likely as European, Asian or other ethnicities to report having dived into water of an unknown depth. 29% reported having seen friends dive into shallow water, including 28% of males and 17% of females. 26% agreed/strongly agreed that diving into shallow water was acceptable if you knew how to dive. 

 

Benjanuvatra, N., Edmunds, K. and Blanksby, B. 2007. Jumping abilities and swimming grab-start performances in elite and recreational swimmers. International Journal of Aquatic Research and Education. 1(3), pp.231-241. 

A study of 9 elite Australian competitive swimmers (all female) and 7 regularly trained recreational swimmers (all female) took part in two testing sessions. The first was a jumping trial that took place in a gait laboratory. The second was a grab start test recorded at an aquatics centre. Jumps were performed with bare feet and hands by the individual's side to simulate the pool environment. Participants in the grab trial were instructed to perform a grab start followed by a sprint of 25 metres. 

Elite swimmers were significantly faster in their grab start performance to 5 metres and 15 metres. The elite group generated significantly greater horizontal impulses and shallower takeoff angles than the recreational group. The jumping trial results did not correlate significantly with the takeoff velocities for the grab starts, they did correlate strongly and significantly with the time taken to reach 5 metres. The time to 5 m results also correlated strongly with jump height results from the jumping trial. 

 

Korres, D., Benetos, I., Themistocleous, G., Mavrogenis, A., Nikolakakos, L. and Liantis, P. 2006. Diving injuries of the cervical spine in amateur divers. The Spine Journal. 6, pp.44-49. 

A retrospective analysis of 20 diving spinal injury patients in Greece over a 34-year period between 1970-2004. 19 males and 1 female. Diving cases accounted for 2.6% of all admitted spinal injury cases. The mean age was 23 years, with a range between 16-47 years. All admissions were made between May and September. 4 cases involved under 18s, 6 cases involved 18-21-year-olds, 4 cases 22-30-year-olds, and 3 cases involved those 30+ years.  

 

Aito, S., Andrea, M. and Werhagen, L. 2005. Spinal cord injuries due to diving accidents. Spinal Cord. 43, pp.109-116. 

A retrospective study of 1,784 spinal injury patients registered in a database held by the Spinal Unit of Florence in Italy between 1978 and 2002. 65 patients experienced a spinal injury from diving into shallow water. 49% of shallow water diving incidents involved people from other regions or countries. 72% of swimming pool cases occurred between July and August. 56% of pool incident fractures were at the C5 level, 15% at the C6 level, and 11% at the C7 level. 

 

Chalmers, D. and Morrison. 2003. Epidemiology of non-submersion injuries in aquatic sporting and recreational activities. Sports Medicine. 33, pp.745-770. 

A meta-analysis of non-submersion injuries in aquatic sport and recreational activities, including spinal injuries. 

 

Smith, E., Paulsen, C. and Wiklund, M. 2003. Review of spinal cord injury statistics related to diving and diving board use. American Institutes for Research AIR project 01858. pp.1-17. 

A meta-analysis of spinal cord injury prevalence and aetiology in the USA. 

 

Bhide, V., Edmonds, V. and Tator, C. 2000. Prevention of spinal cord injuries caused by diving. Evaluation of the distribution and usage of a diving safety video in high schools. Injury Prevention. 6, pp.154-156. 

A questionnaire was sent to the heads of physical education departments of 92 public secondary schools in the Toronto region asking about their use of the Sudden Impact diving safety video in the 1994-5 school year. 59 schools replied to the questionnaire. 47 were aware of the Sudden Impact video, and 45 reported that they had received a copy. 40 of the schools that had received a copy used it in the 1994-5 academic year. The video was shown on average six times per school. In total, 6,793 saw the video, which amounted to 16% of the total number of students within those schools in which the video was used. Only 46% used the accompanying Leaders Guide to facilitate classroom discussion or teacher preparation.  

 

Blitvich, J., McElroy, G., Blanksby, B. and Douglas, G. 1999. Characteristics of 'low risk' and 'high risk' dives by young adults. Risk reduction in spinal cord injury. Spinal Cord. 37, pp.553-559.

A study of 95 undergraduate students in Australia completed a questionnaire about their swimming and diving background prior to performing 3 or 4 commonly used dives. The four dives involved: two from deck level, one from a 0.75-metre block, and 34 participants volunteered to undertake a running dive entry with a 2-metre run up.  Cameras were positioned to record the dives, and subsequent treading water or length swim as instructed. 

An increase in dive velocity correlated with an increase in the maximum distance, water depth, flight distance, and angle of the dive. 60 participants indicated that they had been taught by a professional to swim, whilst only 17 reported they had been taught to dive by a professional. 52 participants reported partaking in 11 or more swimming lessons taught by a qualified person. 79 participants reported their dive ability was between average and very good on a scale of 1-5. Starting blocks and running dives increased the distance achieved at maximum water depth and the angle of entry.

It is suggested that being told to surface quickly following the dive would help reduce the maximum water depth reached with the dive. Increasing flight distance also reduced the maximum water depth reached with the dive. 23 divers fully retracted their arms prior to reaching maximum water depth, leaving the head exposed. Velocity at maximum depth was determined for 316 dives performed and ranged between 0.61 m/s to 3.1 m/s. Impact at 0.6 m/s can dislocate the cervical spine, whilst impact at 1 m/s is sufficient to crush the cervical spine. 14 dives resulted in a flight distance of over 5 metres, with the longest trajectory being 5.9 metres. 

 

Blanksby, B., Wearne, F., Elliott, B. and Blitvich, J. 1997. Aetiology and occurrence of diving injuries. A review of diving safety. Sports Medicine. 23(4), pp.228-246. 

A meta-analysis of diving safety covers the distribution of injuries across the globe in various water bodies, including the sea and swimming pools. A comprehensive, albeit 30-year-old review of dive speed, water depths, and swimming pool design are investigated. 

 

DeVivo, M. and Sekar, P. 1997. Prevention of spinal cord injuries that occur in swimming pools. Spinal Cord. 35, pp.509-515. 

A retrospective study of 1,106 diving injuries recorded on the National Spinal Cord Injury Statistical Centre database in the USA since 1973 by one of the 13 active SCI centres was analyzed. It has been estimated that approximately 15% of all SCI cases are recorded on the database. 341 incidents occurred in swimming pools and 631 in open water. 134 occurred in unknown locations. 196 of those that occurred in swimming pools returned the survey. 

• The average age at the time of injury was 24 years old
• 86% were men
• 95% were white
• 70% had never married
• Only 7% were college graduates
• 34.4% had been students, and 11.7 % had been unemployed at the time of injury
• 64% of swimming pool cases involved below-ground swimming pools. 
• 86.7% occurred in private residential pools
• 57.2% occurred at a water depth below 1.2 metres. 
• Depth indicators were absent in 74.9% of cases and warning signs in 87.4% of cases. 
• There was no lifeguard on duty in 93.8% of cases.
• Alcohol was involved in 48.9% of cases. 
• 46.1% of cases occurred at pool parties. 
• Other people were present in 97.4% of cases. 
• In 44% of cases, it was the person's first visit to that pool.
• In 27.8% of cases, it was the person's first dive into that pool. 
• In 69.7% of cases, an ordinary flat dive was performed prior to the injury. 
• 52.1% of injuries occurred during daylight hours, 37.1% at nighttime, and 10.8% at dusk. 
• Artificial lighting was not present in 52.8% of cases. 
• 82% of injuries occurred in June, July and August during warmer outdoor temperatures and longer daylight hours. 
• 51% of incidents occurred on a Saturday or Sunday, whereas only 38.6% of all injuries on the database occurred on these days. 
• 35% involved a C5 level injury, 26.8% a C6, and 12.4% a C7.  

 

Price, C., Makintubee, S., Herdon, W. and Istre, G. 1994. Epidemiology of Traumatic spinal cord injury and acute hospitalization and rehabilitation charges for spinal cord injuries in Oklahoma, 1988-1990. American Journal of Epidemiology. 139(1), pp.37-47. 

A study of 376 hospitalizations in the US between 1988-1990. Diving accounted for 172 (46%) of spinal injuries. 13 of 44 cases where alcohol levels were assessed reported intoxication by alcohol as relevant to the aetiology of the incident. 

 

Soloman, K. 1993. Swimming pool risks: How do they compare to other accidental risks? RAND Corporation, pp.1-88. 

A meta-analysis of swimming pool incident, including spinal cord injury, prevalence and aetiology in the USA. 

 

Green, B., Gabrielsen, A., Hall, W. and O'Heir, J. 1980. Analysis of swimming pool accidents resulting in spinal cord injury. Paraplegia. 18, pp.94-100. 

A retrospective study of 72 swimming pool cases occurring prior to 1976 in the USA.

• 64 cases resulted in spinal injury. 57 resulted in tetraplegia. Injury at C5 and C6 accounted for 42 cases. 
• 5 incidents resulted from unintentional acts.
• 59 persons were removed improperly from the water, 55 being removed by a person with no training in rescue techniques.
• 37 persons reported having no formal swimming or diving instruction and claimed to be self-taught.
• 46 persons were unfamiliar with the swimming pool in which the incident occurred.
• 69 reported receiving no verbal or seeing any written warnings of the dangers relating to pool activities prior to the incident.
• Diving into water 1.2 metres or less accounted for 38 cases. 6 incidents involved a head-first entry from a waterslide into water 1 metre deep or less.
• 9 incidents involved the use of springboards
• 9 incidents involved inadequate artificial lighting around the pool at night. 
• 54 cases, there was no constant poolside supervision. There was an absence of safety markings on the pool bottom in 43 cases, depth markings in 35 cases, and no diving signs in 45 cases. 
• 29 incidents involved persons between 13-18 years old. 15 incidents involved persons between 19-24 years old.
• 49 incidents involved people between 1.6-1.8 metres tall, with 12 incidents involving those over 1.9 metres tall.

 

Steinbruck, K. and Paeslack, V. 1980. Analysis of 139 spinal cord injuries due to accidents in water sports. Paraplegia. 18, pp.86-93. 

A study of 2,587 spinal-injury cases (212 sport-related) as recorded by hospital records between 1967 and 1978 in Germany.  131 were classified as diving injuries, with the remaining 8 from watersports. 129 cases resulted in tetraplegia and only 2 in paraplegia. 5 cases involved diving from a height, whilst 3 cases resulted from scuba diving. Injury at the C5 and C6 accounted for 99 diving cases. 11 under 15s and 54 16-20 year-olds were reported within the diving cases. The number under 25 years old totalled 99 diving cases. 125 were men and 5 women. 106 incidents involved diving into man-made lakes or gravel pits. A short blackout immediately following impact with the bottom was reported in several cases. 

  

 Citation. Jacklin, D. 2022. Research summary: Aquatic Spinal Cord Injuries. Water Incident Research Hub, 23 July.