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Despite significant prevention efforts, the numbers of physically inactive individuals, chronic illnesses, exhaustion syndromes and sick leaves are increasing. A still unresolved problem with exercise promotion is the low participation of sedentary persons. This collective term covers heterogeneous subgroups. Their engagement with movement campaigns and resistance to change are influenced by numerous factors. Our aim was to analyse survey data on health, performance, lifestyle habits and the approachability to physical activity campaigns obtained from the Germany-wide ActIv survey. From 2888 study participants aged 50-60 years, 668 persons were categorised into the subgroups "never-athletes", "sports-dropouts", "always-athletes" and "sports-beginners". Large and significant group differences were found for BMI, assessment of quality of life, health and fitness, risk factors and health problems. In total, 42.5% of "never-athletes" and 32.5% of "sports-dropouts" did not state any barriers to sport. There are substantial disparities between the non-athlete groups in terms of their motivation to exercise. In contrast, there are comparatively minor differences in motivation between "sports-dropouts" and "sports-beginners", whose health and fitness are the primary motivators for sport. Our analyses suggest that (i) negative health and performance trends cannot be compensated for by appeals for voluntary participation in exercise programmes and (ii) powerful incentive systems are required.

Sports medicine is a medical specialty that supports the performance of professional and amateur athletes while maintaining their health. Sports medicine professionals need to ensure the safe participation of athletes in sports activities achieved through a periodical preparticipation evaluation (PPE) and a regular medical monitoring of the athletes' health in accordance with the latest recommendations regarding health condition and medical history, physical working capacity, training period and programme, recovery, nutrition, use of supplements, injuries prevention and safe return to play. In order to harmonise these national variations in the content and application of the PPE, the EFSMA Scientific and Educational Commission proposes a 'gold standard' for elite athletes across Europe. Important objectives of PPE are early detection and prevention of severe complications during sports activities both in leisure time and competitive sports. The PPE should entail the following diagnostic components: health status, anthropometry, functional and exercise capacity. It is of utmost importance to develop and implement preventive strategies such as the PPE. Besides monitoring the health status of athletes, the PPE plays an important role in the selection process, bringing valuable information for coaches and supporting a personalised treatment approach. Screening of athletes through a standardised digital PPE could be beneficial for a better understanding of the impact of long-term physical activity. Furthermore, PPE leads the scientific community to a way of working closer together in the interest of the athletes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Sport is historically designated by the binary categorization of male and female that conflicts with modern society. Sport's governing bodies should consider reviewing rules determining the eligibility of athletes in the female category as there may be lasting advantages of previously high testosterone concentrations for transwomen athletes and currently high testosterone concentrations in differences in sex development (DSD) athletes. The use of serum testosterone concentrations to regulate the inclusion of such athletes into the elite female category is currently the objective biomarker that is supported by most available scientific literature, but it has limitations due to the lack of sports performance data before, during or after testosterone suppression. Innovative research studies are needed to identify other biomarkers of testosterone sensitivity/responsiveness, including molecular tools to determine the functional status of androgen receptors. The scientific community also needs to conduct longitudinal studies with specific control groups to generate the biological and sports performance data for individual sports to inform the fair inclusion or exclusion of these athletes. Eligibility of each athlete to a sport-specific policy needs to be based on peer-reviewed scientific evidence made available to policymakers from all scientific communities. However, even the most evidence-based regulations are unlikely to eliminate all differences in performance between cisgender women with and without DSD and transwomen athletes. Any remaining advantage held by transwomen or DSD women could be considered as part of the athlete's unique makeup.

In an effort to reduce transmission and number of infections of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) virus, governments and official bodies around the world have produced guidelines on the use of face masks and face coverings. While there is a growing body of recommendations for healthcare professionals and the wider population to use facial protection in "enclosed spaces" where minimal distancing from other individuals is not possible, there is a dearth of clear guidelines for individuals undertaking exercise and sporting activity. The present viewpoint aims to propose recommendations for face coverings while exercising during the COVID-19 pandemic that consider physical distancing, the environment, the density of active cases associated with the specific sports activity, and the practical use of face coverings in order to reduce potential viral transmission. Recommendations are provided on the basis of very limited available evidence in conjunction with the extensive collective clinical experience of the authors and acknowledging the need to consider the likelihood of the presence of the SARS-CoV-2 in the general population. We recommend that face coverings should be used in any environment considered to be of a high or moderate transmission risk, where tolerated and after individual risk assessment. In addition, as national caseloads fluctuate, individual sporting bodies should consider up to date guidance on the use of face coverings during sport and exercise, alongside other preventative measures.

Competing Interests: Competing interests: None declared.

In this viewpoint we make specific recommendations that can assist and make the return to sport/exercise as safe as possible for all those impacted - from the recreational athlete to the elite athlete. We acknowledge that there are varying rules and regulations around the world, not to mention the varying philosophies and numerous schools of thought as it relates to return to sport/exercise and we have been cognisant of this in our recommendations. Despite the varying rules and circumstances around the world, we believe it is essential to provide some helpful and consistent guidance for return to training and sport for sport and exercise physicians around the world at this most difficult time. The present viewpoint provides practical and medical recommendations on the resumption to sport process., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Bicycle and treadmill exercise tests are used in sports medicine and occupational medicine to detect latent disease, to monitor treatment, and to measure patients' physical performance ability and reserve. In this review, we describe the indications, contraindications, and manner of performance of these tests, along with the variables tested, criteria for evaluation, (sub)maximal stress, and the factors that affect these tests, including age, sex, and medications., Methods: This review is based on pertinent articles retrieved by a selective literature search and on the ergometry guidelines of four medical specialty societies., Results: The proper performance of ergometric stress tests calls for preparation and monitoring by qualified staff as well as standardized testing conditions. Ergometric studies are indispensable as a clinical diagnostic method for the early recognition of disease, for follow-up over time, and for individual counseling. The patient's maximal achievable performance is a predictor of morbidity and mortality. Among the variables that can be measured in the submaximal performance range, the respiratory rate, heart rate, and lactate performance curves are more accurate prognostic predictors than the so-called threshold values (physical working capacity, anaerobic-aerobic threshold). Ergometric stress tests can be used to detect (among other conditions) latent hypertension, pulmonary diseases (e.g., exertional asthma), pabnormal ECG changes, and cardiovascular disorders (e.g., ischemia, arrhythmia, congestive heart failure). The ergometric findings are influenced by the choice of stress-inducing protocol. They provide important information for the planning and monitoring of exercise training and for the treatment of persons suffering from diverse physical conditions, as well as for leisure-time athletes. They are less suit- able for use in the design of training programs for high-performance athletes., Conclusion: Ergometric stress tests provide important data in clinical and preventive medicine. The findings are often difficult to interpret because of the wide range of normal findings, the use of different stress-inducing protocols, and the lack of gen- erally accepted reference values. The establishment of a nationwide fitness and health registry for ergometric data would be very helpful for the individualized inter- pretation of test findings and for the monitoring of exercise training and therapy.

Atrial fibrillation (AF) is the most common heart arrhythmia, the risk of which typically increases with age. This condition is commonly associated with major cardiovascular diseases and structural heart damage, while it is rarely observed in healthy young people. However, increasing evidence indicates that paroxysmal AF can also onset in young or middle-aged and otherwise healthy endurance athletes (e.g., cyclists, runners and cross-country skiers). Here we review the topic of AF associated with strenuous endurance exercise (SEE), for example cycling, running and cross-country skiing, especially at a competitive level, and we propose the definition of a new syndrome based on the accumulating data in the literature: SEE-related AF under the acronym of 'PAFIYAMA' ('paroxysmal AF in young and middle-aged athletes'). Special emphasis is given to the proper differentiation of PAFIYAMA from 'classical AF' regarding pathophysiology, diagnosis and medical management., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Competing Interests: The authors have no conflicts of interest to declare.

Guidelines for cardiovascular prevention need to be regularly revised and updated. With respect to physical activity and exercise, many studies with practical relevance have been published in recent years. They are concerned with the evidence of physical activity for prevention of many diseases and the spectrum of indications for applying physical activity for prevention, therapy and rehabilitation. Training recommendations have been developed for the prevention of various diseases according to the FITT rule, which stands for frequency, intensity, time (of session) and type of sports followed by a progression in the amount of training. Recent publications show that moderate exercise with an increase in regular activity (e.g. 10,000 steps per day) is a sufficient approach for risk reduction in many diseases. An as yet unresolved problem is the best approach for effective motivation for physical exercise. The prescription of exercise is an important approach for improving the motivation for physical activity; however, prescribing exercise needs basic knowledge in sports physiology and proper training recommendations. Furthermore, population-based interventions for physical activity are urgently needed to implement more physical activity in the daily routine. The current ESC guidelines provide a great deal of new information to be implemented in the prevention in primary care; however, with regard to physical activity, more comprehensive biological data of physical activity should be presented in order to improve physician's knowledge, thus enhancing the fight against inactivity and sedentary lifestyles as one of the most significant risk factors.

Background: The impact of high exercise loads on a previously healthy heart remains controversial. We examined the consequences of decades of strenuous endurance exercise at the highest competition level on heart dimensions and volumes as well as on serum biomarkers of cardiac fibrosis/remodeling., Methods and Results: We compared echocardiographic measurements and serum biomarkers of cardiac fibrosis/remodeling [troponin I, galectin-3, matrix metallopeptidase-2 and -9, N-terminal pro-brain natriuretic peptide, carboxy-terminal propeptide of type I procollagen, and soluble suppressor of tumorigenicity-2 (sST-2)/interleukin(IL)-1R4] in 53 male athletes [11 former professional ('elite') and 42 amateur-level ('sub-elite') cyclists or runners, aged 40-70years] and 18 aged-matched controls. A subset of 15 subjects (5 controls, 3 sub-elite and 7 elite athletes) also underwent cardiac magnetic resonance imaging (cMRI). Elite and sub-elite athletes had greater echocardiography-determined left ventricular myocardial mass indexed to body surface area than controls (113±22, 115.2±23.1 and 94.8±21g/m(2), respectively, p=0.008 for group effect), with similar results for left (50.5±4.4, 48.2±4.3 and 46.4±5.2mm, p=0.008) and right (38.6±3.8, 41.1±5.5 and 34.7±4.3mm, p<0.001) ventricular end-diastolic diameter, and cMRI-determined left atrial volume indexed to body surface area (62.7±8.1, 56.4±16.0 and 39.0±14.1ml/m(2), p=0.026). Two athletes showed a non-coronary pattern of small, fibrotic left ventricular patches detected by late gadolinium enhancement. No group effect was noted for biomarkers., Conclusions: Regardless of their competition level at a younger age, veteran endurance athletes showed an overall healthy, non-pathological pattern of cardiac remodeling. Nonetheless, the physiopathology of the ventricular fibrotic patches detected warrants further investigation., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Although low- to moderate-intensity exercise has well-known cardiovascular benefits, it has been increasingly suggested that prolonged strenuous endurance exercise (SEE) could have potential deleterious cardiac effects. In effect, the term 'cardiac overuse injury' (or 'over-exercise') has been recently reported to group all the possible deleterious cardiac consequences of repeated exposure to SEE or 'over-exercise'. In this article, we provide a balanced overview of the current state of knowledge regarding the 'pros' and 'cons' of SEE from a cardiological point of view.

Introduction: There has been a long standing controversy on the role of a resting electrocardiogram (ECG) in the preparticipation examination of athletes, as well as in children and adolescents, in leisure time and competitive athletes. Besides other arguments, this was due to the limited validity, which led to false positive and false negative findings., Methods: Recent studies from different research groups yielded a significant improvement in establishing ECG criteria in athletes to discriminate normal from abnormal or pathological findings in athletes. This is additionally supported and improved by a software-based ECG device considering the new Seattle criteria. These new criteria from the Seattle conference reliably discriminate normal from abnormal findings. Frequent ECG findings in athletes, especially in those engaged in endurance sports are sinus bradycardia, atrioventricular (AV) block and signs of left ventricular hypertrophy., Results: Abnormal findings are related to structural left ventricular alterations due to cardiomyopathy, mainly hypertrophic with or without outflow tract obstruction, arrhythmogenic right ventricular cardiomyopathy (ARVC) and dilated cardiomyopathy. The ECG findings suggestive of electrical conductance disorders are observed in channelopathies, Wolff-Parkinson-White (WPW) syndrome supraventricular arrhythmias or disturbances of cardiac conduction. The main diseases are long or short QT syndrome, Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia. Atrial fibrillation, mostly paroxysmal, is also now more frequently observed especially in middle aged endurance athletes., Conclusion: Interpretation of ECG in young and older athletes requires in-depth knowledge in cardiology and sports medicine. The interpretation can only be carried out by considering medical history, clinical examination and ethnicity. Profound and long-term experience of athlete's ECG interpretation is required to protect athletes and to prevent cardiac emergencies.

: While the preparticipation physical evaluation (PPE) is widely accepted, its usage and content are not standardized. Implementation is affected by cost, access, level of participation, participant age/sex, and local/regional/national mandate. Preparticipation physical evaluation screening costs are generally borne by the athlete, family, or club. Screening involves generally agreed-upon questions based on expert opinion and tested over decades of use. No large-scale prospective controlled tracking programs have examined PPE outcomes. While the panel did not reach consensus on electrocardiogram (ECG) screening as a routine part of PPE, all agreed that a history and physical exam focusing on cardiac risk is essential, and an ECG should be used where risk is increased. The many areas of consensus should help the American College of Sports Medicine and Fédération Internationale du Médicine du Sport in developing a universally accepted PPE. An electronic PPE, using human-centered design, would be comprehensive, would provide a database given that PPE is mandatory in many locations, would simplify PPE administration, would allow remote access to clinical data, and would provide the much-needed data for prospective studies in this area.

While the preparticipation physical evaluation (PPE) is widely accepted, its usage and content are not standardized. Implementation is affected by cost, access, level of participation, participant age/sex, and local/regional/national mandate. PPE screening costs are generally borne by the athlete, family, or club. Screening involves generally agreed-upon questions based on expert opinion and tested over decades of use. No large-scale prospective controlled tracking programs have examined PPE outcomes. While the panel did not reach consensus on electrocardiogram screening as a routine part of PPE, all agreed that a history and physical exam focusing on cardiac risk is essential, and an ECG should be used where risk is increased. The many areas of consensus should help the American College of Sports Medicine and the Fédération Internationale du Médicine du Sport in developing a universally accepted PPE. An electronic PPE, using human-centered design, would be comprehensive, would provide a database given that PPE is mandatory in many locations, would simplify PPE administration, would allow remote access to clinical data, and would provide the much-needed data for prospective studies in this area.

A sedentary lifestyle has been shown to have negative effects on morbidity and mortality. In contrast, a large number of prospective cohort studies on the effects of regular physical activity demonstrated positive effects. Therefore, physical training is today an essential part of prevention and therapy in internal medicine. This review is based on literature research in meta-analysis and review papers. Regular physical exercise or training is a significant and evidence-based part of prevention and therapy of diseases such as heart, cardiovascular and lung diseases, diabetes mellitus, renal disease and cancer. Evidence of training effects is mostly high grade. Physical activity or exercise training is indicated in many diseases as medicine--similar as a drug. It is applied after acute treatment as a component of the standard drug therapy. There is a non-linear dose-response effect, psychological aspects and some side-effects need to be considered.In conclusion, physical exercise acts as a highly efficient drug, and should be used in many diseases. Training recommendations refer to the kind, the duration, the intensity, the frequency and the increase of training., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Controversy surrounds the cardiac effects of competitive sports and the athlete's heart. In this review, we present and discuss the main cardiological findings in competitive athletes., Method: Selective review of pertinent literature retrieved by a search with the keywords "athlete's heart," "ECG," "echocardiography," "endurance exercise," "longevity," and others., Results: Regular exercise leads to functional and structural adaptations that improve cardiac function. Athlete's heart, which develops rarely, is a typical finding in endurance athletes. This condition is characterized by physiological, harmonically eccentric hypertrophy of all cardiac chambers. The athlete's ECG can be used to distinguish physiological, training-related changes from pathological training-unrelated changes. The athlete's heart function is normal at rest and increases appropriately during exercise. The cardiac markers troponin and B-type natriuretic peptide are within the normal range in healthy athletes at rest, but can temporarily be mildly elevated after exhausting endurance-exercise, without evidence of myocardial damage. The epidemiological data suggest that participation in competitive sports increases life expectancy., Conclusion: Competitive exercise does not induce cardiac damage in individuals with healthy hearts, but does induce physiological functional and structural cardiac adaptations which have positive effects on life expectancy.

Introduction: The health and physical fitness of adolescents and young adults are important not just to the individuals concerned, but also to society as a whole. Many studies from many different countries have dealt with the prevalence of overweight, the risk factors for it, and the morbidity it causes, but no more than a few have addressed the effects of unhealthy lifestyles on physical fitness. In this study, we show that young adults' physical performance depends on the number of risk factors they possess. We also compare the young adults' physical performance with that of adolescents aged 10 to 17., Methods: We obtained cross-sectional data on the weight, smoking status, athletic activity, time to run 1 km, and ability to perform a chin-up on a horizontal bar of 8048 subjects aged 10 to 25. The young adults were divided into groups depending on the number of risk factors they possessed from the following list: overweight, smoking, and lack of exercise., Results: 28.4% of the men and 35.4% of the women aged 18 to 25 had none of these risk factors and exhibited the best physical performance. The more risk factors were present, the worse physical performance became. The 24- and 25-year-olds performed at the same level as the 14- and 15-year-olds., Discussion: Unhealthy lifestyles can impair physical fitness even before any chronic disease arises. Possession of even a single risk factor is associated with significantly worse performance. Unless comprehensive and effective interventions are introduced in school and at work, the further cementation and worsening of unhealthy lifestyles will be hard to stop.

The number of sedentary young adults has dramatically increased in past decades, and sedentary lifestyles are adopted at an increasingly earlier age. Little is known about barriers or predictors to (re)initiate regular physical activity in this group. The purpose of the study is to (a) identify subgroups in nonathletes differing in their amenability to physical exercise, (b) to analyze them for differences in barriers and intention to exercise, and (c) compare importance of sports during youth in nonathletes to trained peers. Using a health and fitness questionnaire 589 nonathletes were queried in the cross-sectional survey and compared with 270 trained peers. Athletic abstainers (A), lower (L), and higher (H) motivated nonathletes were separated based on previous engagement in sports. Of the nonathletes, 54.7% reported only 1 barrier to exercise. Although this feature was most prominent in H (71.5%), the other groups showed significantly more barriers and a broader distribution. Similar characteristics but minor differences were observed for perceived importance of sports during youth. The most significant differences between athletes and nonathletes emerged enquiring the attitude and activity of the parents. The majority of nonathletes (72.8%) indicate their intention to exercise in the future. Their intention differed significantly in H (88.1%), L (76.1%), and A (59.1%). However, there are good reasons to doubt that most of those intending nonathletes will actually become physically active. Even in the analyzed narrow age range of men different motivated groups of nonathletes were found. Because of the differences in receptiveness and approachability health promotion policies may not only consider the often recommended tailored interventions but also carefully designed incentive programs.

Regular physical activity is now recognized as an important and very effective step to prevent many diseases, especially those of the cardiovascular system. Many studies within the last 20 years have also shown that exercise capacity or fitness is an important prognostic factor in healthy subjects and patients with cardiovascular diseases for both mortality and morbidity. Physical fitness, which is mainly determined by regular physical activity or training, can be analyzed by maximal exercise testing using the treadmill or cycle ergometry. In addition, fitness is also based on genetic factors. There are some methodological criticisms concerning self-reported questionnaires of physical activity, MET (metabolic equivalent) calculations and exhaustion during maximal voluntary stress testing. However, the results of both approaches are valid and reliable for daily use. Accordingly, every physician regardless of his or her discipline should encourage all patients at every visit to follow a healthy lifestyle, including regular exercise and physical activity. This also applies to older patients, who especially benefit from exercise and physical activity.

A sedentary lifestyle or physical inactivity is recognized as an important risk factor for cardiovascular diseases. Regular physical activity improves muscular function, cardiac function, and metabolic syndrome-related disorders. Leisure time physical activity reduces all-cause mortality by 22-34% and cardiovascular mortality by 27-35%. These data have been shown in many prospective cohort studies and published in four large meta-analyses with more than 800,000 participants (evidence IA). The risk reduction is somewhat more pronounced in the elderly and in women (IB). In addition to reduced mortality, physical activity also improves cardiopulmonary function and quality of life (IB). This also holds true for coronary artery disease, cardiac failure, and arterial hypertension with high-grade evidence (IA). Furthermore, evidence has been shown a risk reduction in stroke, development of cognitive dysfunction, and intermittent claudication. Training recommendations for physical activity have reached high-grade evidence (IA). Therefore, regular physical activity is one of the most important components of a healthy lifestyle. All physicians should ask their patients at all clinic and office visits about physical activity and recommend activity for prevention and therapy.

Background: Physical performance often declines in middle age, but it is unclear to what extent this is due to biological aging. It can be difficult to determine whether such physical changes are truly age-related, as they might alternatively be explained as the negative consequences of a sedentary lifestyle., Methods: We assessed the endurance of a physically active subgroup of the population by performing an age- and sex-stratified analysis of over 900,000 running times of marathon and half-marathon participants aged 20 to 79. We also analyzed the responses of 13,171 marathon and half-marathon runners to a questionnaire about sports, lifestyle, and health., Results: No significant age-related decline in performance appears before age 55. Moreover, only a moderate decline is seen thereafter; in fact, 25% of the 65- to 69-year-old runners were faster than 50% of the 20- to 54-year-old runners. Our survey also revealed that more than 25% of the 50- to 69-year-old runners had started their marathon training only in the past 5 years., Conclusion: Performance losses in middle age are mainly due to a sedentary lifestyle, rather than biological aging. The large contingent of older "newcomers" among marathon runners demonstrates that, even at an advanced age, non-athletes can achieve high levels of performance through regular training.

Background: There is current debate on the appropriate type and extent of medical testing for amateur and hobby athletes before they engage in sports. In particular, views diverge on the value of an ECG at rest., Methods: We selectively searched the Medline and Embase databases for relevant publications that appeared from 1990 to 2008. The most pertinent ones are discussed here along with current reviews and guidelines that give recommendations on pre-participation testing for amateur athletes., Results: History-taking and physical examination are standard around the world. The American guidelines on pre-participation examination do not recommend an ECG at rest, yet the guidelines for most European countries explicitly recommend it. No prospective cohort studies have been performed to date that might provide high-grade evidence (class and level) to support this practice. We discuss the pros and cons of an ECG at rest and also present the guideline recommendations on exercise-ECG testing for amateur athletes over age 40., Conclusion: In accordance with the current European recommendations, and in consideration of the risks of athletic activity, we recommend that all persons participating in sports should undergo a pre-participation examination that includes an ECG at rest. Although primary-prevention campaigns advise physically inactive persons to get regular exercise, prospective studies are still lacking as a basis for recommendations in this group.