Intrinsic Predictors of Injury on a Multi-day Wilderness Event for Adolescents and Adult Leaders

Abstract

Wilderness recreation has become increasingly popular in the US over the last few decades; with adolescents and young adults making up 20% of participants. While outdoor recreation has many benefits, there is also risk of injury. It is hypothesized that certain intrinsic and lifestyle factors impact risk of injury; stress, age, and pre-existing psychological conditions. There were 48 adolescents, 21 adults, and 3 unclassified individuals enrolled for a total of 72 healthy individuals of varying fitness levels. They pulled handcarts for 22 miles in Utah’s high plains for what is known as Pioneer Trek. This is a multi-day optional experience for youth to participate in to gain an appreciation of what the early Utah settlers accomplished when they crossed the plains. A survey was given to identify pre-existing conditions and education was provided for prevention of common injuries and dehydration. The medical team saw patients as needed and charted the type and frequency of injury. Logistic regression was performed using pre-existing conditions, injury type and frequency. Older age and low feelings of stress were associated with reducing the odds of injury (Age OR = .898, stress OR = .017). We also found that individuals with pre-existing psychological conditions were more likely to incur an injury (OR = 4.90 P = .07). Our study showed that age, psychological condition, and experiencing sensations of stress impact the risk of injury. Thus, these factors should be taken into consideration to prevent injuries in wilderness activities.

“Participants who did not experience stress in their lives are 98% less likely to be injured compared to the odds for individuals who do experience stress.”

Introduction

Wilderness recreation has become increasingly popular In the United States over the last few decades; with an estimated 160.7 million people participating in outdoor adventure activities in 2021. Adolescents and young adults are increasingly engaged, making up about 20% of participants. In fact, young adults and youth were twice as likely to describe themselves as outdoor fanatics compared to their adult counterparts. ¹ The rise in youth participation has led to a number of multi-day outdoor excursions available. The American Camp Association reported that 14 million youth are enrolled in summer camps. ² The National Study of Youth and Religion also reported that 40% of US teens have been to at least one summer camp run by a religious organization. ³

These outdoor adventure camps allow youth to strengthen their connection with nature^4,5 as well as meet developmental needs. Not only that, but these camps can help exemplify positive youth development; fostering an environment of empowerment, positive experiences, and helping youth develop life skills. ⁶ Garst et. al. showed that youth engaging in outdoor adventure camps were able to escape social pressures and have increased peer interaction. ⁷ Overall, outdoor activities have been shown to maintain physical and mental well-being, as well as overall life satisfaction. ⁸ While these activities have multiple lifestyle benefits, they may also lead to injury.^9,10

The purpose of this paper is to define intrinsic and lifestyle risk factors which may predict an injury free wilderness experience on a strenuous multi-day event. Risk factors for injury can be broken up into two categories: intrinsic and extrinsic. This study will focus on intrinsic factors, which are individual, often nonmodifiable biological or psychological factors that can predispose a person to injury; such as life stress, age, and pre-existing psychological conditions. ¹¹ In our cross-sectional study, we aim to understand the relationship between these intrinsic factors and injuries sustained during a guided, multi-day wilderness event for adolescents.

Methods

IRB was approved by Weber State University. All participants of Pioneer Trek of the Riverdale Utah Stake from the Church of Jesus Christ of Latter-Day Saints (Pioneer Trek) were invited to participate in this study, 72 participants joined. Pioneer Trek was a 3-day event that involved adolescents aged 14-18 and adult leaders, pulling handcarts for 22 miles through the high plains in Utah near Utah Lake. It is an optional event for youth to participate in to gain an appreciation of what the early Utah settlers accomplished. A pre-event survey, Supplemental Figure 1, was given to identify pre-existing conditions and education was provided for prevention of common injuries and dehydration. When presenting the pre-event survey, a consent form was given to and signed by parents of the participants under 18. During Pioneer Trek, 238 patient encounters were documented with name, subjective symptoms, objective findings, and disposition (assessment and plan). Of note, not all patient encounters were documented due to staffing shortages. All reported symptoms were divided into one of 10 categories: allergies, dehydration, dermatologic, epistaxis, gastrointestinal, headache, musculoskeletal, ophthalmologic, psychiatric, or other. Of the 238 patient encounters, only data from the 72 participants who filled out the pre-event survey were used. The data were anonymized and statistical analysis was performed.

Statistical Analysis

The analysis was performed using the R-studio programming language © 2009-2022 RStudio (V.4.1.1), Inc. (Boston, MA, USA). The packages used in the analysis were: “leaps” (V.3.1) and “dplyr” (V.1.0.7). The ten unique injury types were consolidated to be one variable determining if an individual experienced an injury. The prediction of injury was determined using logistic regression for multiple logistic regression. The response variable in the model is if a participant was injured or not at any point during the trek. The model has slightly fewer observations than the full data set because some participants declined to answer one or more questions from the survey. Backwards elimination was used to remove variables from the models to obtain the most significant variables. The odds ratio reported how likely an injury would occur for the given variable. A 95% confidence interval was performed to determine the variability of the odds ratio.

Results

Demographics for the 72 participants of this study are shown in Table 1. A listing of pre-existing conditions is shown in Table 2, demonstrating that 67 individuals felt stress and 12 individuals had pre-existing psychological conditions, such as depression or clinical anxiety. Table 3 lists the number of patients seen with a condition that falls under each category.

Table 1.

Participant Demographics.

# of Participants	Age (average, SD)	Gender	Height (inches)	Weight (lbs)	Pre-Psychologic
72	Average: 24.49 SD: 15.22	Female: 29 Male: 37 Other: 6	Average: 68.97 SD: 3.18	Average: 165.47 SD: 59.09	Average: .18 SD: .64

Table 2.

Pre-Existing Conditions.

	Yes/Meets Condition	No/Does Not Meet Condition	No Response	Total (Row)
Stress (Yes)	64	5	3	72
Pre-psychologic conditions (Yes)	6	63	3	72

Table 3.

Reported Injuries On Pioneer Trek.

Reported Injury Type	Frequency
Allergies	6
Dehydration	9
Dermatologic	19
Epistaxis	1
Gastrointestinal	1
Headache	6
Musculoskeletal	5
Ophthalmologic	9
Other	3
Psychiatric	3

Note: These numbers show how many times an injury was reported. For example, we saw 9 participants for ophthalmologic complaints, however some of them we saw more than once. One participant with epistaxis seen for 10 patient encounters is counted as 1. The number reflects the unique patients that we saw and documented with these conditions, not patient visits.

Based on the logistic regression analysis (Table 4) the odds an individual experiences an injury is 10% less likely for each year added to their age. The confidence interval suggests the odds of not having an injury could be as low as 5% to as high as 19% more likely.

Table 4.

Logistic Regression Analysis for SumOfAll Injuries (Physical Predictors) (Yes/No). OR denotes the odds ratio of injury to no injury.

N = 69	OR	95% CI: Lower-Upper	P-Value
Age	.89	.81-.95	.4%
Prepsych	4.90	1.31-65.87	7% a
Stress (Yes)	.017	.0001-.40	3%

^aNote: Pre-psychiatric conditions were calculated as the chance that they would not have an injury or in other words, that they would remain healthy. It was included because the authors’ clinical judgment suggests this was an important factor for further research and consideration which should be included and further evaluated in other studies. In addition the P-value is also suggestive of this conclusion.

The odds of having an injury for an individual that has pre-psychological conditions are about 390% more likely to be injured for each additional pre-psychological condition. Based on the confidence interval this can range from 558% to 131% more likely.

The odds that an individual will have an injury when an individual does not experience stress is 98% less likely for an individual that does experience stress. The odds of having an injury for an individual that experiences stress can vary between 60% more to 99.9% more for an individual that does not experience stress.

Discussion

Age

We saw that patients were 10% less likely to get injured for every year added to their age. This could be due to better awareness of their bodies, or greater knowledge of injury prevention. These results are not consistent with previous research that shows patients with increased age typically have accumulated damage to their bodies and often have pre-existing illnesses leading to increase in injury.^12,13 These inconsistencies could be because our study mainly focused on adolescents and young adults of similar ages. An alternative hypothesis is that adults may have a heightened awareness, greater wisdom and more life experience in the outdoor elements than adolescents who have also lived somewhat sheltered through the COVID-19 pandemic. In addition, the adults that participated in Pioneer Trek were volunteers assigned to assist the youth and knew it was a strenuous activity, they had more life experience and had fewer pre-existing psychological conditions. Consequently, the adolescent group that participated in Pioneer Trek consisted of a melting pot that contained high-level athletes and individuals with more sedentary lifestyles and pre-existing psychological conditions, which may contribute to the discrepancy in our findings.

Pre-existing Psychological Conditions

In this study, we found that participants with pre-existing psychological conditions were more likely to experience an acute injury; with an odds ratio showing that for each additional pre-existing condition an individual is 390% more likely to be injured. Similar results have been reported in previous studies. Behrang and associates found that individuals with psychiatric disorders were 1.6 times more likely to get injured than their counterparts. ¹⁴ It has been shown that a lack of perseverance is associated with depression. ¹⁵ Furthermore, grit is associated with lower levels of depression. ¹⁶ These findings could explain why patients who didn’t have pre-existing psychological conditions were less prone to injury.

For example, there was a mother and daughter with known pre-existing psychological conditions who became overheated and physically exhausted on the first day. They frequently visited the medical tent for water and to take a break from hiking. Ultimately, they decided to go home and discontinue their experience after that first day. This is in contrast to one adolescent male who “twisted his knee” during the first 30 minutes of the trek and was unable to continue hiking, after seeking medical attention and cleared after a focused examination, he made the decision that he would continue on for the next 3 days. Subsequent check-ins with this patient revealed that his pain decreased every day so that his knee didn’t bother him on the subsequent days. He exhibited mental fortitude which likely was the enabling factor in allowing him to complete the Pioneer Trek.

Feeling Stressed

Participants who did not experience stress in their lives are 98% less likely to be injured compared to the odds for individuals who do experience stress. Showing that physical and psychological stressors can lead to a significant increase in injury risk. The association between stress and injuries sustained is in agreement with previous studies. Studies of collegiate dancers found associations between injury frequency and stress throughout the school year. ¹⁷ Williams and Anderson also outlined a stress-strain model of stress injury, ¹⁸ in which they proposed that when an athlete experiences a stressful situation, factors such as history of stressors, coping mechanisms, and personality traits contribute to their injury. Athletes with high stressors undergo a stress response entailing of: shorter attention span, easy distractibility, and higher levels of muscle tension. This response leads to an increased risk of injury. This model could be an explanation on why the participants who felt more stress had an increased risk of injury. Due to the relative paucity of the literature in non-athletic populations, we needed to compare this group to athletes.

On the other hand, patients with a possibly stronger mental resolve and perseverance were hardly ever admitted to the medical team. This is consistent with previous findings in elite athletes, where mental health is inseparable from physical health. ¹⁹ Whether that is because they simply persevered through their injuries or were protected from acute injuries because of their mental state of mind, the result is that they experienced significantly fewer documented injuries. While our study population did not consist purely of elite athletes cited in the mentioned study, there are limited studies done on mental health in relation to physical health in the average adolescent.

This study demonstrates that young age, pre-existing psychological conditions, and stress are positively correlated with injury rates. Such a connection was suggested by the recent “call to action” ²⁰ and is potentially highlighted by the bidirectional relationship between mental health and lifestyle. While age is an unmodifiable variable, we do possess tools in lifestyle medicine to help reduce stress and hopefully provide patients with more control over their psychological condition. These tools include the six pillars of lifestyle medicine; whole food plant predominant eating pattern, adequate physical activity, restful sleep, psychological well-being/stress management, positive social engagement, and avoiding risky substances. If physicians do not feel adequate to provide stress management advice, then referral to a therapist or coach as part of a team may be advisable. Future implications include improved risk assessment and prognostication in advance of wilderness events for youths, as these events are becoming much more common.

Potential Connection to a New Unified Theory of Lifestyle Medicine

As discussed in a recent article by Dean Ornish, “a new unified theory of lifestyle medicine,” ²¹ many of the origins, biological mechanisms, and pathways are not as different as they may seem between acute and chronic diseases. As observed in this study, patients with pre-existing psychological conditions were significantly more likely to become injured than their peers without psychological conditions. One might posit that a pre-existing psychological condition might “share many origins, biological mechanisms, and pathways” with physical conditions. There is a growing body of evidence demonstrating connections between psychological and physical conditions, such as one study suggesting a mechanistic link between type 2 diabetes and depression. ²² This, as with Dr. Ornish’s theory, comes back to inflammation and the implication of pro-inflammatory cytokines creating the environment to potentiate both type 2 diabetes and depression.

As we look at the acute conditions that were evaluated on pioneer trek, we see that the root cause or association with many of them is inflammation; allergies, ²³ dehydration, ²⁴ dermatologic (blisters), ²⁵ epistaxis, ²⁶ gastrointestinal (functional dyspepsia), ²⁷ headache, ²⁸ musculoskeletal ²⁹ conditions, ophthalmologic (extraocular foreign bodies, ³⁰ e.g., dust particles), psychiatric ³¹ conditions. This inflammation, peripheral or neurologic, may very well overflow into other areas of the body if the local inflammatory response is unable to be controlled locally. This inflammatory dysregulation is a likely culprit, with a likely source being a pre-existing psychological condition. As this cerebral inflammation becomes dysregulated and is propagated throughout various tissues, there will potentially be unintended effects at distant locations. These consequences can show up in various forms and as pathologic changes; they are rooted in inflammation.

This inflammation theory is suggested through experiences during this trek with the previously mentioned participants; a mother and daughter with pre-existing psychological conditions, and the teenage boy with an injured knee. The mother and daughter both had pre-existing neurological conditions, likely with concomitant inflammation which could have become uncontrolled and turned into peripheral inflammation. This peripheral inflammation could be expressed as injuries, fatigue, or weakness; making this experience much less enjoyable and unsustainable with the inflammation being perpetuated inside the body due to an ongoing inflammatory process. Contrariwise, perhaps the teenage boy also had initiated an inflammatory response in his knee, but it was not perpetuated by an uncontrolled inflammatory reaction in the brain, but rather remained locally controlled.

This explanation gives us a mechanistic framework whereby we can place other types of injuries in the context of inflammation. In our situation, it has placed mental fortitude as a chemical response to inflammation. Perhaps it was not up to the teenage boy or the mother and daughter how they handled their pioneer trek experience, but rather it was the inflammation present in their bodies and if it was allowed to get out of control which determined whether or not one has a safe and successful wilderness activity.

Limitations

This study used proper research techniques; however, there are some limitations. While our survey to gather pre-adventure information was analyzed anonymously, our target audience was adolescents and, although a faithful and honest audience, they may not have taken this survey as seriously. Participants also could have felt uncomfortable and answered untruthfully. The sample selection did not include everyone who came to see us due to the fact that some participants filled out the questionnaire beforehand. In the future, we will have a tablet and have the patients fill out the questionnaire on the spot so we could include everyone.

Our survey also only asked to quantify how often someone felt stress, and we could have also had our participants rate their stress, which we will have them do in future studies. While some variables are “rare” in the population, based on the appropriate P-value values, these variables are important for the logistic regression model and the outcome variable. Comparing logistic regression models AIC values without the input variables that occur less frequently in the population drops the AIC value considerably. In terms of data gathering another limitation within our results is that we did not separate results between adults and adolescents. In order to have statistical significance and have a large enough sample population, we left the populations combined. There is also the possibility that individuals experienced injury, but did not report it to the medical staff. Finally, there were occasional participant visits where charting was not performed due being short staffed during our busy times. There was no bias made on patient characteristics or complaints.

Conclusion

Overall, this study indicates an association between intrinsic factors of injury in adolescents and young adults during an outdoor wilderness adventure. Having a pre-existing psychological condition, feelings of stress, and age all impact the risk of injury. Thus, these factors should be taken into consideration in preparation for wilderness activities. Lifestyle medicine strategies may be used as an injury prevention strategy.

ORCID iD

Scott Moore https://orcid.org/0000-0002-1548-8462