Para sport translation of the IOC consensus on recording and reporting of data for injury and illness in sport

In 2020, the IOC proposed a universal methodology for the recording and reporting of data for injury and illness in sport. Para sport is played by individuals with impairment, and they have a unique set of considerations not captured by these recommendations. Therefore, the aim of this addendum to IOC consensus statement was to guide the Para sport researcher through the complexities and nuances that should be taken into consideration when collecting, registering, reporting and interpreting data regarding Para athlete health. To develop this translation, experts in the field of Para sports medicine and epidemiology conducted a formal consensus development process, which began in March 2020 with the formation of a consensus group that worked over eight phases, incorporating three virtual consensus meetings to finalise the translation. This translation is consistent with the IOC consensus statement, yet provides more detailed Para athlete specific definitions and recommendations on study population, specifically, diagnostic and eligible impairment categorisation and recording of adaptive equipment, and defining and classifying health problems in the context of Para sport. Additionally, recommendations and Para athlete specific examples are described with regards to injury mechanism, mode of onset, injury and illness classification, duration, capturing and reporting exposure and risk. Finally, methods and considerations are provided to cater to the varied needs of athletes with impairment with respect to data collection tools. This harmonisation will allow the science to develop and facilitate a more accurate understanding of injury and illness patterns for tailoring evidence-informed prevention programmes and enabling better planning of medical services for Para sport events.

Risk Factors for Illness-related Medical Encounters during Cycling: A Study in 102,251 Race Starters-SAFER XI

PURPOSE

There are limited data on risk factors associated with illness-related medical encounters (illME) in cycling events. The aim of this study was to determine risk factors associated with illME in mass community-based endurance cycling events.

METHODS

This is a retrospective cross-sectional study in the Cape Town Cycle Tour (109 km), South Africa, with 102,251 race starters. All medical encounters for 3 yr were recorded by race medical doctors and nurses. illME were grouped into common illnesses by final diagnosis. A Poisson regression model was used to determine whether specific risk factors (age, sex, cycling speed, and average individual cyclist wet-bulb globe temperature [aiWBGT]) are associated with illME, serious and life-threatening or death ME, and specific common illME.

RESULTS

Independent risk factors associated with all illME during an endurance cycling event were slow cycling speed (P = 0.009) and higher aiWBGT (P < 0.001). Risk factors associated with serious and life-threatening or death ME were older age (P = 0.007) and slower cycling speed (P = 0.016). Risk factors associated with specific common illME were fluid and electrolyte disorders (females, older age, and higher aiWBGT) and cardiovascular illness (older age).

CONCLUSION

Females, older age, slower cycling speed, and higher aiWBGT were associated with illME in endurance cycling. These data could be used to design and implement future prevention programs for illME in mass community-based endurance cycling events.

High Prevalence of Non-Communicable Diseases Risk Factors in 36,074 South African Financial Sector Employees: A Cross-Sectional Study

OBJECTIVE

To determine the prevalence of non-communicable disease (NCD) risk factors, total NCD risk category and 10-year risk for cardiovascular diseases (CVD) in financial sector employees.

METHODS

This descriptive observational cross-sectional analysis, data from 36,074 employees was analysed. NCD risk factor data was obtained from health risk assessments that included a questionnaire and clinical measures. The 10-year risk for CVD was calculated using the Framingham non-laboratory based equation.

RESULTS

Inadequate fruit and vegetable intake (89.3%), insufficient physical activity (77.4%), and being overweight (66.8%) were the most prevalent risk factors. Women had significantly higher prevalence ratios for central obesity (2.28; P < 0.001), insufficient physical activity (1.21; P < 0.001), hypercholesterolaemia (1.15; P < 0.001), and overweight (1.08; P < 0.001) compared with men.

CONCLUSION

A more concerted effort is required to provide employees with appropriate tools and education at the workplace to decrease and manage NCDs.

Delphi developed syllabus for the medical specialty of sport and exercise medicine: part 2

Training in the medical specialty of sport and exercise medicine (SEM) is available in many, but not all countries. In 2015, an independent Delphi group, the International Syllabus in Sport and Exercise Medicine Group (ISSEMG), was formed to create a basic syllabus for this medical specialty. The group provided the first part of this syllabus, by identifying 11 domains and a total of 80 general learning areas for the specialty, in December 2017. The next step in this process, and the aim of this paper was to determine the specific learning areas for each of the 80 general learning areas. A group of 26 physicians with a range of primary medical specialty qualifications including, Sport and Exercise Medicine, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. SEM, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. The hierarchical syllabus developed by the ISSEMG provides a useful resource in the planning, development and delivery of specialist training programmes in the medical specialty of SEM.

Women, older age, faster cycling speed and increased wind speeds are independent risk factors for acute injury-related medical encounters during a 109 km mass community-based participation cycling event: a 3-year study in 102251 race starters—SAFER XII

Background

There are limited data on acute injury-related medical encounters (injuries) in endurance cycling events.

Objective

To determine the risk factors for injuries during a mass community-based endurance cycling event.

Design

Retrospective, cross-sectional study.

Setting

Cape Town Cycle Tour (109 km), South Africa.

Participants

102 251 race starters.

Methods

All injuries for 3 years were recorded by race medical doctors and nurses. Injuries were grouped into main anatomical area of injury, and a Poisson regression model was used to determine the risk factors associated with injuries.

Results

The four injury risk factors associated with all injuries during an endurance cycling event were sex (women vs men, p<0.0001), older age (p=0.0005), faster cycling speed (p<0.0001) and higher average individualised Wind Speed (aiWindSpeed, p<0.0001). The only risk factor for serious/life-threatening injuries was women (p=0.0413). For specific main anatomical areas: head/neck (women), upper limb (women, older age, faster cyclists), trunk (women, higher aiWindSpeed), and lower limb (higher aiWindSpeed).

Conclusion

Women, older age, faster cycling speed and higher aiWindSpeed were all risk factors for acute injuries during a mass community-based endurance cycling event. These risk factors should help inform race organisers and medical teams on race day to ensure the best medical care is given, and effective acute injury prevention programmes are disseminated.

Pre-race screening and stratification predicts adverse events-A 4-year study in 29585 ultra-marathon entrants, SAFER X

BACKGROUND

Pre-race screening and risk stratification in recreational endurance runners may predict adverse events (AEs) during a race.

AIM

To determine if pre-race screening and risk stratification predict AEs during a race.

METHODS

A total of 29 585 participants (Male 71.1%, average age = 42.1 years; Female 28.9%, average age = 40.2 years) at the Two Oceans ultra-marathon races (56 km) completed a pre-race medical screening questionnaire and were risk stratified into four pre-specified groups [very high risk (VHR; existing cardiovascular disease-CVD:3.2%), high risk (HR; risk factors for CVD:10.5%), intermediate risk (IR; existing other chronic disease, medication use or injury:53.3%), and low risk (LR:33.0%)]. Race starters, finishers, and medical encounters (ME) were recorded. Did-not-start (DNS) rate (per 1000 entrants that did-not-start), did-not-finish (DNF) rate (per 1000 starters that did-not-finish), AE rate [per 1000 starters that either DNF or had an ME], and ME rate (per 1000 starters with an ME) were compared across risk categories.

RESULTS

Adverse events were significantly higher (per 1000 starters; 95%CI) in the VHR (68.9; 52.4-89.9:P = .0407) compared with the LR (51.3; 46.5-56.7). The DNS rate was significantly different between the IR (190.3; 184.0-196.9) and LR (207.4; 199.2-216.0: P = .0011). DNF rates were not different in the VHR (56.4; 41.9-75.9) compared to LR (44.2; 39.7-49.1: P = .1295), and ME rate was also not different between risk categories, however, VHR (12.9; 7.0-23.9) was approaching significance compared to LR (6.9; 5.2-9.1: P = .0662).

CONCLUSION

Pre-race medical screening and risk stratification may identify athletes at higher risk of AEs. Further studies should be performed in larger cohorts to clarify the role of pre-race medical screening in reducing AEs in endurance runners.

International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport-specific or setting-specific consensus statements on sports injury (and, eventually, illness) epidemiology to date. Our objective was to further strengthen consistency in data collection, injury definitions and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension. The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups and a 3-day consensus meeting in October 2019. This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems; severity of health problems; capturing and reporting athlete exposure; expressing risk; burden of health problems; study population characteristics and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE Extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS). The IOC encourages ongoing in- and out-of-competition surveillance programmes and studies to describe injury and illness trends and patterns, understand their causes and develop measures to protect the health of the athlete. Implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.

Sport Medicine Diagnostic Coding System (SMDCS) and the Orchard Sports Injury and Illness Classification System (OSIICS): revised 2020 consensus versions

Coding in sports medicine generally uses sports-specific coding systems rather than the International Classification of Diseases (ICD), because of superior applicability to the profile of injury and illness presentations in sport. New categories for coding were agreed on in the 'International Olympic Committee (IOC) consensus statement: Methods for recording and reporting of epidemiological data on injury and illness in sports 2020.' We explain the process for determining the new categories and update both the Sport Medicine Diagnostic Coding System (SMDCS) and the Orchard Sports Injury and Illness Classification System (OSIICS) with new versions that operationalise the new consensus categories. The author group included members from an expert group attending the IOC consensus conference. The primary authors of the SMDCS (WM) and OSIICS (JO) produced new versions that were then agreed on by the remaining authors using expert consensus methodology. The SMDCS and OSIICS systems have been adjusted and confirmed through a consensus process to align with the IOC consensus statement to facilitate translation between the two systems. Problematic areas for defining body part categories included the groin and ankle regions. For illness codes, in contrast to the ICD, we elected to have a taxonomy of 'organ system/region' (eg, cardiovascular and respiratory), followed by an 'aetiology/pathology' (eg, environmental, infectious disease and allergy). Companion data files have been produced that provide translations between the coding systems. The similar structure of coding underpinning the OSIICS and SMDCS systems aligns the new versions of these systems with the IOC consensus statement and also facilitates easier translation between the two systems. These coding systems are freely available to the sport and exercise research community.

Improved reporting of overuse injuries and health problems in sport: an update of the Oslo Sport Trauma Research Center questionnaires

In 2013, the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O) was developed to record the magnitude, symptoms and consequences of overuse injuries in sport. Shortly afterwards, a modified version of the OSTRC-O was developed to capture all types of injuries and illnesses-The Oslo Sports Trauma Research Center Questionnaire on Health Problems (OSTRC-H). Since then, users from a range of research and clinical environments have identified areas in which these questionnaires may be improved. Therefore, the structure and content of the questionnaires was reviewed by an international panel consisting of the original developers, other user groups and experts in sports epidemiology and applied statistical methodology. Following a review panel meeting in October 2017, several changes were made to the questionnaires, including minor wording alterations, changes to the content of one question and the addition of questionnaire logic. In this paper, we present the updated versions of the questionnaires (OSTRC-O2 and OSTRC-H2), assess the likely impact of the updates on future data collection and discuss practical issues related to application of the questionnaires. We believe this update will improve respondent adherence and improve the quality of collected data.

International Olympic Committee Consensus Statement: Methods for Recording and Reporting of Epidemiological Data on Injury and Illness in Sports 2020 (Including the STROBE Extension for Sports Injury and Illness Surveillance (STROBE-SIIS))

BACKGROUND

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport- or setting-specific consensus statements on sports injury (and, eventually, illnesses) epidemiology to date.

OBJECTIVE

To further strengthen consistency in data collection, injury definitions, and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension.

STUDY DESIGN

Consensus statement of the International Olympic Committee (IOC).

METHODS

The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups, and a 3-day consensus meeting in October 2019.

RESULTS

This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems, severity of health problems, capturing and reporting athlete exposure, expressing risk, burden of health problems, study population characteristics, and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS).

CONCLUSION

The IOC encourages ongoing in- and out-of-competition surveillance programs and studies to describe injury and illness trends and patterns, understand their causes, and develop measures to protect the health of the athlete. The implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.

Medical encounters, cardiac arrests and deaths during a 109 km community-based mass-participation cycling event: a 3-year study in 102 251 race starters-SAFER IX

BACKGROUND

There are few data on medical encounters, including deaths during mass-participation cycling events.

OBJECTIVE

To determine the incidence and nature of medical encounters during a community-based mass-participation cycling event.

DESIGN

Cross-sectional study across three annual events.

SETTING

2012-2014 Cape Town Cycle Tour (109 km), South Africa.

PARTICIPANTS

102 251 race starters (male=80 354, female=21 897).

METHODS

Medical encounters (moderate, serious life-threatening, sudden cardiac arrest/death), using the 2019 international consensus definitions, were recorded on race day for 3 years as incidence rates (IR per 1000 starters; 95% CI). Overall illness-related (by organ system) or injury-related (by anatomical region) encounters, and severity were recorded.

RESULTS

We recorded 539 medical encounters (IR 5.3; 4.8 to 5.7). The IR was 3.2 for injuries (2.9 to 3.6), 2.1 for illnesses (1.0 to 2.4) and 0.5 for serious life-threatening medical encounters (0.4 to 0.7). In the 3-year study, we encountered three cardiac arrests and one death (2.9 and 1.0 per 100 000 starters, respectively). Injury IRs included upper limb (1.9; 1.6 to 2.1), lower limb (1.0; 0.8 to 1.0) and head/neck (0.8; 0.6 to 1.0). Illness IRs included fluid/electrolyte abnormalities (0.6; 0.5 to 0.8) and the cardiovascular system (0.5; 0.4 to 0.6).

CONCLUSION

In a 109 km community-based mass-participation cycling event, medical encounters (moderate to severe) occurred in about 1 in 200 cyclists. Injury-related (1/300 cyclists) encounters were higher than illness-related medical encounters (1 in about 500). Serious life-threatening medical encounters occurred in 1/2000 cyclists. These data allow race organisers to anticipate the medical services required and the approximate extent of demand.

Team illness prevention strategy (TIPS) is associated with a 59% reduction in acute illness during the Super Rugby tournament: a control–intervention study over 7 seasons involving 126 850 player days

Objectives

To determine whether a team illness prevention strategy (TIPS) would reduce the incidence of acute illness during the Super Rugby tournament.

Methods

We studied 1340 male professional rugby union player seasons from six South African teams that participated in the Super Rugby tournament (2010–2016). Medical staff recorded all illnesses daily (126 850 player days) in a 3-year control (C: 2010–2012; 47 553 player days) and a 4-year intervention (I: 2013–2016; 79 297 player days) period. A five-element TIPS was implemented in the I period, following agreement by consensus. Incidence rate (IR: per 1000 player days; 95% CI) of all acute illnesses, illness by main organ system, infectious illness and illness burden (days lost due to illness per 1000 player days) were compared between C and I period.

Results

The IR of acute illness was significantly lower in the I (5.5: 4.7 to 6.4) versus the C period (13.2: 9.7 to 18.0) (p<0.001). The IR of respiratory (C=8.6: 6.3 to 11.7; I=3.8: 3.3 to 4.3) (p<0.0001), digestive (C=2.5: 1.8 to 3.6; I=1.1: 0.8 to 1.4) (p<0.001), skin and subcutaneous tissue illness (C=0.7: 0.4 to 1.4; I=0.3: 0.2 to 0.5) (p=0.0238), all infections (C=8.4: 5.9 to 11.9; I=4.3: 3.7 to 4.9) (p<0.001) and illness burden (C=9.2: 6.8 to 12.5; I=5.7: 4.1 to 7.8) (p=0.0314) were significantly lower in the I versus the C period.

Conclusion

A TIPS during the Super Rugby tournament was associated with a lower incidence of all acute illnesses (59%), infectious illness (49%) and illness burden (39%). Our findings may have important clinical implications for other travelling team sport settings.

Medical encounters (including injury and illness) at mass community-based endurance sports events: an international consensus statement on definitions and methods of data recording and reporting

Mass participation endurance sports events are popular but a large number of participants are older and may be at risk of medical complications during events. Medical encounters (defined fully in the statement) include those traditionally considered 'musculoskeletal' (eg, strains) and those due to 'illness' (eg, cardiac, respiratory, endocrine). The rate of sudden death during mass endurance events (running, cycling and triathlon) is between 0.4 and 3.3 per 100 000 entrants. The rate of other serious medical encounters (eg, exertional heat stroke, hyponatraemia) is rarely reported; in runners it can be up to 100 times higher than that of sudden death, that is, between 16 and 155 per 100 000 race entrants. This consensus statement has two goals. It (1) defines terms for injury and illness-related medical encounters, severity and timing of medical encounters, and diagnostic categories of medical encounters, and (2) describes the methods for recording data at mass participation endurance sports events and reporting results to authorities and for publication. This unifying consensus statement will allow data from various events to be compared and aggregated. This will inform athlete/patient management, and thus make endurance events safer.

High incidence of injuries at the Pyeongchang 2018 Paralympic Winter Games: a prospective cohort study of 6804 athlete days

Objective

To describe the epidemiology of sports injury at the Pyeongchang 2018 Paralympic Winter Games.

Methods

567 athletes from 49 countries were monitored daily for 12 days over the Pyeongchang 2018 Paralympic Winter Games (6804 athlete days). Injury data were obtained daily from teams with their own medical support (41 teams and 557 athletes) and teams without their own medical support (8 teams and 10 athletes) through two electronic data capturing systems.

Results

112 of 567 athletes (19.8%) reported a total of 142 injuries, with an injury incidence rate (IR) of 20.9 per 1000 athlete days (95% CI 17.4 to 25.0). The highest IR was reported for para snowboard (IR of 40.5 per 1000 athlete days [95% CI 28.5 to 57.5]; p<0.02), particularly in the lower limb and head/face/neck anatomical areas. Across all sports at the Games, acute traumatic injuries (IR of 16.2 per 1000 athlete days [95% CI 13.2 to 19.8]) and injuries to the shoulder/arm/elbow complex (IR of 5.7 per 1000 athlete days [95% CI 4.2 to 7.8]) were most common. However, most injuries (78.9%) did not require time loss.

Conclusion

The new Paralympic Winter Games sport of Para snowboard requires attention to implement actions that will reduce injury risk. The shoulder was the most injured single joint—a consistent finding in elite para sport.

Incidence rate and burden of illness at the Pyeongchang 2018 Paralympic Winter Games

Objective

To describe the incidence rate (IR) and illness burden (IB) at the Pyeongchang 2018 Paralympic Winter Games.

Methods

A total of 567 athletes from 49 countries were monitored for 12 days over the Pyeongchang 2018 Games (6804 athlete days). Illness data were obtained daily from teams with (41 teams, 557 athletes) and teams without (8 teams, 10 athletes) their own medical support, through electronic data capturing systems.

Results

There were 87 illnesses reported, with an illness IR of 12.8 illnesses per 1000 athlete days (95% CI 10.2 to 16.0) and IB of 6.8 days lost per 1000 athlete days (95% CI 3.4 to 13.5). The highest IR was reported for Para snowboard (IR of 19.7 [95% CI 12.0 to 32.2]). Illnesses in the respiratory system (IR of 4.1 [95% CI 2.9 to 5.9]; IB of 1.4 [95% CI 0.6 to 3.0]), skin and subcutaneous system (IR of 2.5 [95% CI 1.5 to 4.1]; IB of 0.6 [95% CI 0.1 to 2.9]), and eye and ocular adnexa (IR of 1.6 [95% CI 0.9 to 3.1]; IB of 0.5 [95% CI 0.1 to 3.3]) were the most common.

Conclusion

This is the first study to report both the IR and IB in this setting. There was a high IR of illness in the new sport of Para snowboard. The respiratory system had both the highest IR and IB.

Illness Among Paralympic Athletes: Epidemiology, Risk Markers, and Preventative Strategies

Paralympic athletes have unique preexisting medical conditions that predispose them to increased risk of illness, but data are limited to studies conducted during the last 3 Paralympic Games. This article reviews the epidemiology of illness (risk, patterns, and predictors) in Paralympic athletes and provides practical guidelines for illness prevention. The incidence rate of illness (per 1000 athlete-days) in Paralympic athletes is high in Summer (10.0-13.2) and Winter (18.7) Paralympic Games. The authors propose general and specific guidelines on preventative strategies regarding illness in these athletes.

Prerace medical screening and education reduce medical encounters in distance road races: SAFER VIII study in 153 208 race starters

Objectives

To examine the efficacy and feasibility of an online prerace medical screening and educational intervention programme for reducing medical complications in long-distance races.

Methods

This was an 8-year observational study of medical encounter rates among 153 208 Two Oceans race starters (21.1 and 56 km) in South Africa. After the first 4-year control (CON) period, we introduced an online prerace medical screening (based on European pre-exercise screening guidelines) and an automated educational intervention programme. We compared the incidence of medical encounters (per 1000 starters; all and serious life threatening) in the CON versus the 4-year intervention (INT) period.

Results

In comparison to the CON period (2008–2011: 65 865 starters), the INT period (2012–2015: 87 343 starters) had a significantly lower incidence (adjusted for age group, sex, race distance) of all medical encounters by 29% (CON=8.6 (7.9–9.4); INT=6.1 (5.6–6.7), p<0.0001), in the 21.1 km race by 19% (CON=5.1 (4.4–5.9); INT=4.1 (3.6–4.8), p=0.0356) and in the 56 km race by 39% (CON=14.6 (13.1–16.3); INT=9.0 (7.9–10.1), p<0.0001). Serious life-threatening encounters were significantly reduced by 64% (CON=0.6 (0.5–0.9); INT=0.2 (0.1–0.4); p=0.0003) (adjusted for age group and sex). Registration numbers increased in the INT period (CON=81 345; INT=106 743) and overall % race starters were similar in the CON versus INT period. Wet-bulb globe temperature was similar in the CON and INT periods.

Conclusion

All medical encounters and serious life-threatening encounters were significantly lower after the introduction of a prescreening and educational intervention programme, and the programme was feasible.

Leisure athletes at risk of medical complications: outcomes of pre-participation screening among 15,778 endurance runners - SAFER VII

OBJECTIVE

International guidelines for pre-participation screening of masters/leisure athletes to identify those that require medical assessment exist, but have not been implemented in mass-community based sports events. We determined the prevalence of runners who, according to these guidelines, would require a medical assessment before participating in a distance running event.

METHODS

Participants of the 2012 Two Oceans races (21.1 and 56 km) in South Africa (n = 15,778) completed an online pre-race medical screening questionnaire using European pre-participation screening guidelines. We determined the prevalence of runners that would require a pre-race medical assessment, based on risk factors, symptoms, and disease.

RESULTS

The pre-participation "self assessment of risk" screening identified 4,941 runners (31.3%; 95% CI 30.6-32.0) that would need to undergo a full pre-participation medical assessment prior to running, if the current pre-participation screening guidelines are applied. Although musculoskeletal complaints and prescription medication use were the main triggers for a medical assessment, 16.8% (n = 2657) runners should undergo medical evaluation for suspected cardiac disease based on the questionnaire results: 3.4% (n = 538) reporting existing CVD (very high risk) and 13.4% (n = 2119) reporting multiple CVD risk factors (high risk). Other possible risk factors were reported as follows: history of chronic diseases (respiratory = 13.1%, gastro-intestinal = 4.3%, nervous system = 3.8%, metabolic/endocrine = 3.5%, allergies = 13.9%); chronic prescription medication = 14.8%, used medication before or during races = 15.6%; past history of collapse during a race = 1.4%.

CONCLUSIONS

Current guidelines identified that > 30% runners would require a full medical assessment before race participation - mainly linked to runners reporting musculoskeletal conditions. We suggest a revision of guidelines and propose that pre-race screening should be considered to identify runners with a "very high," "high," and "intermediate risk" for medical complications during exercise. Pre-race screening and educational intervention could be implemented to reduce medical complications during exercise.

Return to Play After Infectious Disease

Acute illnesses are of significant concern for the health and performance of athletes. Sports medicine physicians face the challenge of promoting sufficient recovery and responding to the demands of the coaches and athletes. This chapter presents the evidence behind the risk factors for acute illness in athletes, the negative consequences of sports participation during illness and the recommendations for safe sports participation.

Risk factors for infection and illness may be intrinsic (e.g. postexercise suppression of the immune system, recent acute illness, female gender) and extrinsic (e.g. training load, nutrition, resting periods).

Fever during illness contributes to systemic symptoms such as headache and myalgia but also to dehydration, muscle breakdown and reduction in cardiometabolic function. The consequences of exercise during illnesses may be aggravation of illness, loss of muscle strength and endurance, cardiac complications, transmission of infection to others, neurological dysfunctions including coordination problems, rhabdomyolysis and in the worst case sudden death.

Recommendations for safe return to sport include clearance of infection allowing full recovery and thereafter gradual progress of exercise volume combined with monitoring of remaining symptoms of illness. Different actions can be taken to prevent acquiring, aggravating and spreading of infections by the athlete (e.g. hygiene, physical contact, covering of the body, sharing of equipment, nutrition), the coaches (e.g. individualised plan of training, competition, nutrition, recovery and recovery measures) and the physicians (monitor and implement illness prevention, identify and arrange for high-risk athletes, educate athletes and staff).