Clodagh Toomey, PT, PhD

Version 1

evidence-based injury prevention practices into the daily lives of those at risk, those who care for them,

and those with a mandate for public health and safety in British Columbia.

Author: Clodagh Toomey

Editors: Sarah A Richmond, Amanda Black

Reproduction, in its original form, is permitted for background use for private study, education instruction

and research, provided appropriate credit is given to the BC Injury Research and Prevention Unit. Citation

in editorial copy, for newsprint, radio and television is permitted. The material may not be reproduced for

commercial use or profit, promotion, resale, or publication in whole or in part without written permission

from the BC Injury Research and Prevention Unit.

Fax: (604) 875-3569

Website: www.injuryresearch.bc.ca

Suggested Citation:

Toomey C, Black A, Richmond SA, Pike I, Babul S. Evidence Summary: Diving and High-Diving. Active &

Safe Central. BC Injury Research and Prevention Unit: Vancouver, BC; 2018.

Available at http://activesafe.ca/.

springboard at a measured height, usually involving some form of acrobatics before water entry.

accounted for large proportions of injuries in men’s and women’s diving (32.0% and 16.2%,

respectively) (Kerr et al., 2015).

In addition to competitive diving, non-competitive or unstructured diving is a recreational

activity and can take place in many settings. Inadequate knowledge of water depth or

surroundings can pose significant injury risk. Incidence/prevalence data for injury in recreational

diving is often limited to occurrence of fatal spinal cord injury (SCI). Occurrence of non-fatal

injury in private swimming pools, oceans, rivers and lakes are rarely reported. In a systematic

review of all sport participants worldwide, the proportion of SCI in diving related to all-sport SCI

was 35.3% (range 7.7-64.9%) (Chan, Eng, Tator, & Krassioukov, 2016). This was the highest

while almost all SCI related to diving occur in private or residential swimming pools (87%) (Toth

et al., 2005).

Competitive Diving

The analysis of risk and protective factors for competitive diving is limited to one study

investigating lower back pain in elite junior divers ages 12-17 years. The univariate results of this

study suggest that there may be an increased risk of lower back pain with increasing age in junior

male and female divers and with decreased shoulder flexibility in junior male divers (Narita et al.,

2014). These results show that limited shoulder rotation width in males could lead to lumbar

hyperextension when adjusting for the angle of water entry, increasing the risk of lower back

included consumption of alcohol (3.4% of all SCIs in Japan were sport-related under the influence

of alcohol, while 30% of sport-related SCIs were under the influence of alcohol in the US) (Chan

et al., 2016), presence of a pool party, water depth <1.2m, absence of a lifeguard on duty, non-

competitive standard, reduced risk perception, poor lighting, hidden objects, lack of depth

markings or warnings and a lack of adequate design/legislation (Cusimano, Mascarenhas, &

Manoranjan, 2008; Toth et al., 2005). Protective factors for spinal cord injury are related to

diving technique and include diving with maximised flight distance and a low entry angle with a

steering technique. Head and neck injury is reduced when the hands are held together, thumbs

locked and arms extended beyond the head (Cusimano et al., 2008). In recreational diving, the

magnitude of effect of reported risk and protective factors is unknown.

for competitive diving. A literature review (Cusimano et al., 2008) in 2008 descriptively evaluated

interventions for the prevention of spinal cord injury in diving with a number of highlighted

programmes.

With regards to engineering and design of pools, the American Red Cross Swimming and

Diving guidelines in 1992 required a minimum depth of water below the tip of the diving board in

a standard public pool of 9 ft. No incidence of SCI was reported in Olympic sized public pools that

meet these criteria. Most diving related SCI (DSCI) occur in residential pools where the maximum

depth is less than 9 feet (Cusimano et al., 2008).

Education is seen as an important strategy for injury prevention in diving and a number of

education programs (see resources) on diving safety have been implemented in North America

In public diving facilities, more restrictive regulation on dive forms was not associated

with a decrease in injuries (p = 0.93) (Williams & Odin, 2016). Risk was perceived to be lower for

those with experience, and people with experience, favoured less regulation (Williams & Odin,

2016). An intervention (seven 10-minute sessions) to improve diving skill in inexperienced divers

was successful in significantly reducing diving depth (with lesser entry angles, improved

hand/arm placement, greater flight distance and steering-up manoeuvre) in different dive types,

20 months later (Blitvich, McElroy, & Blanksby, 2000). This intervention shows promise in

reducing injury risk in recreational divers that dive in the same pool environment, but may not

reduce the risk of serious injury when diving in oceans, lakes, rivers, etc. Future efforts should be

in recreational diving, primarily aimed at school children. In an assessment and evaluation of

primary prevention in spinal cord injury (Sandin & Klaas, 2013), it was found that a school-

distributed educational video, Sudden Impact (Think First), was only viewed by an average of 16%

of students in each school (Bhide, Edmonds, & Tator, 2000). There was little change in attitude

and no consistent change in knowledge or behaviours as a result of the Think First program in

high school students.

Access or exposure to the program can be a significant barrier to program effectiveness

for many prevention programs, particularly those that do not own the distribution channels for

their work. In general, prevention programs (from non-diving-related sources) with multimodal

interviewed 120 children ages 7-10 years. This study evaluated the “no diving” warning signs for

shallow water. Children understood that breaking your neck results in limitations in mobility and

can occur from diving, but they did not anticipate that such an injury was likely to occur

(Morrongiello et al., 2016). This study further highlighted that children having diving experience,

biased their perceptions of injury susceptibility. Finally, Morrongiello et al. (2016) recommend