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From the safety net to the injury prevention web: applying systems thinking to unravel injury prevention challenges and opportunities in Cirque du Soleil
  1. Caroline Bolling1,
  2. Jay Mellette2,
  3. H Roeline Pasman1,
  4. Willem van Mechelen1,3,4,5,
  5. Evert Verhagen1,3
  1. 1 Amsterdam Collaboration for Health & Safety in Sports, Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
  2. 2 Vegas Golden Knights, National Hockey League, Las Vegas, Nevada, USA
  3. 3 UCT/MRC Research Unit for Exercise Science and Sports Medicine (ESSM), Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
  4. 4 School of Public Health, Physiotherapy and Population Sciences, University College Dublin, Dublin, Ireland
  5. 5 School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
  1. Correspondence to Dr Caroline Bolling; carolbolling{at}


Objective We undertook this qualitative study within an international circus company—Cirque du Soleil—to explore the narrative of artists and the artistic team in regards to injuries and their prevention and to describe the prevention of injuries from a systems thinking lens.

Methods Focus groups (FG) with artists and semistructured individual interviews with the artistic team were conducted in six selected shows. The structure of the interviews and FGs concerned the themes: ‘injury’, ‘injury-related factors’ and ‘injury prevention’. Data were analysed through comparative data analysis based on Grounded Theory. Concept mapping and systems thinking approaches were used to design a map of participants’ views on how to prevent injuries.

Results Injury was mainly described based on performance limitation. The factors mostly mentioned to be related to injury occurrence were physical load factors. Many of these factors were said to be connected and to influence each other. Injury prevention was mapped as a multilevel system, composed by artist-related factors (eg, technique and life style) and extrinsic factors (eg, touring conditions and equipment) that integrate different strategies and stakeholders.

Conclusion Our study reinforces the importance of multilevel injury prevention approaches with shared responsibility and open communication among stakeholders.

  • prevention
  • injuries
  • qualitative
  • elite performance

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  • Contributors CB developed the reasoning for this paper and drafted the first version. JM, EV, WvM and HRP contributed intellectually and provided feedback on various drafts.

  • Funding CB is a PhD candidate supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico–CNPq, Brazil, grant number 202242/2015-3. No other sources of funding were used to assist in the preparation of this article.

  • Competing interests CB and JM are former employees of Cirque du Soleil. EV is a consultant of Cirque du Soleil.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by VU University Medical Center Ethics Committee, Amsterdam, the Netherlands; protocol METc FWA00017598.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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