Pre-participation evaluation of recreational and competitive athletes – A systematic review of guidelines and consensus statements

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The goal of this systematic review was to aggregate evidence- and consensus-based recommendations for the PPE of recreational or competitive athletes as preparation for developing a German guideline on this subject. Methods : Five databases, including MEDLINE, were searched in August 2022. Searches on the websites of relevant guideline organisations and specialty medical associations were also performed, complemented by citation screening. We included guidelines/consensus statements with recommendations for PPE of adult recreational athletes or competitive athletes of any age, both without chronic illness. We extracted and synthesised data in a structured manner and appraised quality using selected domains of the AGREE-II tool. Results : From the 6611 records found, we included 35 documents. Overall, the quality of the included documents was low. Seven documents (20%) made recommendations on the entire PPE process, while the remainder focussed on cardiovascular screening (16/35, 45.7%) or other topics. We extracted 305 recommendations. Of these, 11.8% (36/305) applied to recreational athletes, while the remaining 88.2% (269/305) applied to athletes in organised or competitive sports. A total of 12.8% (39/305) of recommendations were directly linked to evidence from primary studies. Conclusion : Many recommendations exist for PPE, but only a few are evidence based. The lack of primary studies evaluating the effects of screening on health outcomes may have led to this lack of evidence-based guidelines and contributed to poor rigour in guideline development. Future guidelines/consensus statements require a more robust evidence base, and reporting should improve. Registration: PROSPERO CRD42022355112 Consensus guideline physical activity pre-participation examination pre-participation screening recommendations sports medical screening Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Summary box Pre-participation evaluation aims to prevent possible harm during sports and later damage caused by exertion High-quality evidence for the effect of pre-participation evaluation on patient-relevant outcomes is lacking Recommendations in current guidelines and consensus statements are mostly consensus-based and focus on competitive athletes In the absence of clear benefits of certain evaluation components, choosing the best option depends on how individuals value the benefits and risks involved; shared decision-making should be the norm 1 Introduction Regular physical activity and sports can promote health and, in the long term, reduce the risk of premature death [ 1 ]. However, the 2019/2020 Current Health in Germany (‘Gesundheit in Deutschland aktuell’, GEDA) study by the Robert Koch Institute showed that only 23.3% of women and 29.4% of men are physically active at the recommended level [ 2 ]. Similarly, Bennie and Wiesner found that only 15.0% of adult Europeans met the recommendations for aerobic activity and muscle-strengthening exercises in the years 2013 and 2014 [ 3 ]. The COVID-19 pandemic led to a further decrease in time spent on moderate to vigorous physical activity during lockdown [ 4 – 6 ]. Despite the health-promoting effects of regular physical activity, performing sports can be related to health risks like cardiac arrest or arrhythmias. Maron referred to this phenomenon as the ‘paradox of exercise’ [ 7 ]. Sports-related health risks can affect athletes at any level. The incidence and prevalence of sports-related cardiac arrest differ among populations and regions [ 8 ]. For example, Berdowski et al. reported an incidence of 3.0 and 0.3 cases per 1 million people per year for people aged > 35 years and ≤ 35 years, respectively, in North Holland (Netherlands) [ 9 ]. Karam et al. reported an incidence of 7.0 per 1 million inhabitants per year for adults aged 18–75 years in the Greater Paris area (France) [ 10 ]. These differences in incidence may be attributed to the varying risk factors across populations. For example, the risk of sports-related cardiovascular incidents increases exponentially in people older than 35 years [ 9 , 11 ]. Injuries are an additional risk of sports participation. A systematic review (SR) that Al-Qahtani et al. [ 12 ] conducted showed that the prevalence of sports-related injuries in adolescent athletes ranges from 34–65%. Risk factors for injury include the type of sports and training practices. Prevention of such injuries avoids not only their direct consequences (e.g. required treatment and absence from school or work) but also potential long-term physical constraints or sequelae. Pre-participation evaluation (PPE) is a preventive health examination used in sports medicine that may help people to start or resume physical activity safely by identifying those at an increased risk of adverse events during exercise. Its aims are to reduce the adverse effects of physical activity and prevent any subsequent damage caused by exertion. According to Whitfield et al., up to 95.5% of Americans > 40 years of age are eligible for PPE [ 13 , 14 ]. For participants in official sports competitions, such as squad athletes, PPE is often a standard procedure [ 15 ]. However, there is a debate over which anamnestic and diagnostic assessments should be used for PPE of competitive and recreational athletes [ 11 ]. Limited evidence for the effects of PPE on patient-relevant health outcomes, as well as methodological challenges for conducting high-quality studies, have contributed to this debate [ 16 ]. Therefore, current PPE recommendations and clinical practice seem to rely mostly on clinical expertise. With this SR, we aimed to aggregate and appraise evidence- and consensus-based recommendations for PPE. We used the findings of this SR to develop a new German consensus-based guideline for PPE of recreational athletes [ 17 ]. 2 Methods We performed this SR according to the methods pre-defined in a protocol registered in PROSPERO (CRD42022355112). We reported the SR according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 [ 18 ] and the Implementing PRISMA in Exercise, Rehabilitation, Sports Medicine and Sports Science (PERSiST) guidance [ 19 ]. We contacted the authors of the included documents only for full text retrieval. 2.1 Population, intervention, control and outcome questions and eligibility criteria The SR included evidence- or consensus-based guidelines and consensus statements about the PPE of apparently healthy adults and athletes of all ages (both groups with and without disabilities). It did not include guidelines or consensus statements targeting people with chronic diseases, such as cardiovascular disease or diabetes mellitus. The primary outcomes were the prevention or reduction of fatal events during sports and the possible sequelae of participation in individual sports. We included documents published in English and German. Expired documents and recommendations for countries outside the World Health Organisation (WHO) mortality stratum A [ 20 ] were ineligible. All pre-defined eligibility criteria are presented in Table 1 . [Insert Table 1 here] Table 1 Pre-defined eligibility criteria Inclusion Exclusion Population • healthy adults with or without disabilities • competitive athletes of any age with or without disabilities • primary population with known non-communicable chronic diseases, such as cardiovascular disease or diabetes mellitus Intervention • medical history • anthropometric measurements • cardiometabolic or internal medicine examinations • orthopaedic examinations • additional tests or diagnostic procedures from related disciplines • diagnostic interventions specific to sports for which there is a separate fitness examination (e.g. diving, flying) Comparison • usual care • other anamnestic or diagnostic parameters Outcome • prevention or reduction of exercise-induced (fatal) events during sports participation • prevention or reduction of possible sequelae of sports or exertion • diagnostic test accuracy measures Study type • evidence-based and/or consensus-based guidelines and recommendations • expired documents • documents published before 2012 Setting • WHO mortality stratum A countries • published by professional medical societies, guideline organisations, public or government-led organisations (e.g. the military) or expert groups appointed by such societies or organisations Language • English, German Other • duplicates • multiple publications without additional information 2.2 Literature search We systematically searched for literature on MEDLINE (PubMed), Trip Database, the National Institutes of Health (NIH) Library, the Guidelines International Network’s (GIN) International Guidelines Library, and ECRI Guideline Trust’s guideline repositories. We used automation tools (Word Frequency Analyzer, SearchRefinery [ 21 ]) to facilitate the development of the MEDLINE search strategy and adapted the strategy to the syntax of each database. Searches contained index and free text terms for population, intervention and study type, as applicable. We performed database searches in August 2022, with 1 January 2012 as the start date. We chose this start date because around 50% of guidelines are out of date within five years [ 22 , 23 ]. Therefore, any guideline older than 10 years was presumably outdated. No restrictions of language or publication status were applied at the search stage. In addition, we performed structured hand searches on the websites of the following specialty medical associations and guideline organisations: American College of Sports Medicine, British Association of Sport & Exercise Medicine, Canadian Academy of Sport and Exercise Medicine, Sports Medicine Australia, European Federation of Sports Medicine Associations, Canadian Medical Association Infobase of Clinical Practice Guidelines, Australian National Health and Medical Research Council, National Institute for Health and Care Excellence, New Zealand Guidelines Group via the Ministry of Health New Zealand and VA/DoD Clinical Practice Guidelines. We performed website searches in August and October 2022. The full search strategies, including search dates, are provided as Supplementary Information (Supplement I). 2.3 Document selection We exported all records found via MEDLINE to Endnote (Endnote, Version: 20 [Software]. Clarivate, Boston, Massachusetts, USA. https://endnote.com/ ) and removed duplicates. All records found via websites and other databases were exported to Microsoft Excel (2016). We performed document selection according to pre-defined eligibility criteria (Table 1 ). We then screened the titles and abstracts of all MEDLINE records using the web tool Rayyan [ 24 ]. The other records were screened in Excel based on their titles. We obtained the full texts of all records deemed potentially relevant for full text screening. Notably, two independent researchers (AW, KG) performed all screening steps. We discussed differences until a consensus was reached. If a consensus could not be reached via such discussions, we consulted clinical experts (AH, CJ). In addition, we performed a backward citation search via Scopus, including all eligible documents that were found via the database and website searches and that were available on Scopus. The identification of references was facilitated using Scopus, and deduplication was performed via Endnote. The screening process was identical to that used for the MEDLINE records (AW, NK). 2.4 Quality appraisal We appraised the quality of included documents using two selected domains from the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool [ 25 ]. The tool comprises six domains, namely, 1) Scope and Purpose, 2) Stakeholder Involvement, 3) Rigour of Development, 4) Clarity of Presentation, 5) Applicability and 6) Editorial Independence. Due to resource restrictions, we limited the quality appraisal to domains 3 and 6, which were the most relevant for our purposes. Domain 3 consists of eight items, while domain 6 consists of two items. Two independent researchers (AW, KG, NK) rated each item on a seven-point Likert scale (higher scores mean higher quality). Depending on the scores per individual item and rater, each domain could achieve a score of 0–100%. Two independent researchers (AW, KG) pilot-tested the quality appraisal process using six included documents. Of those, we chose three documents based on heterogeneous characteristics (e.g. content and structure) and three other documents at random. We compared and discussed the appraisal of the pilot sample to agree on specific appraisal criteria, ensure consistency and reduce systematic differences. An additional researcher (NK) joined the team later and performed pilot testing using a sample of four documents. Two researchers (AW, NK) performed all further ratings independently. Afterwards, they discussed deviations of two or more points per item to identify and correct systematic differences in appraisals, as necessary. We calculated the mean scores per document and per domain. For each quality appraisal item, we calculated median scores across documents and the corresponding ranges. 2.5 Data extraction and data items We extracted data into a form (Microsoft Excel, 2016) that we developed for this review. We piloted the form during two sessions, each using three of the documents that we previously selected for the pilot quality appraisal. Two researchers (AW, KG) performed both piloting sessions independently then modified and expanded the data extraction form based on the consensus they reached. Two additional researchers (FS, NK) joined the team later and performed pilot testing using samples of three and four documents, respectively. One of the four researchers (AW, FS, KG, NK) involved extracted data into the piloted form, and a second verified data extraction. We discussed differences until a consensus was reached, including a third researcher as necessary. Extracted data included information about the guideline or consensus statement; population, intervention, control and outcome (PICO) elements; and recommendations. We extracted recommendations labelled as such and recommendation-like sentences from the main document text. A list of all data extraction items can be found on PROSPERO. 2.6 Levels of evidence and strength of recommendations For recommendations that were directly linked to literature in the original publications, we extracted the corresponding references and obtained their full texts. We assigned a level of evidence (LoE) for primary studies or SRs based on their full texts, according to the Oxford 2011 Levels of Evidence [ 26 ]. Two researchers (NK, KG) independently assessed the first 20 references then sought a consensus. One researcher (NK) completed all further assignments. When doubts arose, a second researcher (KG) was consulted. We did not assign LoEs to narrative review, commentary or guideline (without SR) references. We extracted the grade or strength of the recommendation when available. For recommendations labelled as such but that did not have an assigned strength of recommendation or linked evidence, we assigned a level C according to the strength of recommendation taxonomy (SORT), which uses a scale from A (strongest) to C (weakest) [ 27 ]. For recommendation-like sentences that were extracted from the text, we complemented the SORT with an additional level (–) (Table 2 ). [Insert Table 2 here] Table 2 Expanded strength of recommendation taxonomy [ 27 ] Strength of recommendation Definition A Recommendation based on consistent and good-quality patient-oriented evidence* B Recommendation based on inconsistent or limited-quality patient-oriented evidence* C Recommendation based on consensus, usual practice, opinion, disease-oriented evidence* or case series for studies of diagnosis, treatment, prevention or screening – Statement in the text * Patient-oriented evidence measures outcomes that matter to the patient: morbidity, mortality, symptom improvement, cost reduction and quality of life. Disease-oriented evidence measures intermediate, physiologic or surrogate end points that may or may not reflect improvements in patient outcomes (e.g. blood pressure, blood chemistry, physiologic function, pathologic findings). 2.7 Statistical analysis We calculated values and percentages for the nominal data on the characteristics of included documents and recommendations. For calculations, we used Microsoft Excel (2016). 2.8 Synthesis of documents and recommendations We synthesised data using a structured, narrative format. We presented the metadata of the included documents using tabulation. We also grouped extracted recommendations according to their clinical topics (e.g. cardiology, anthropometrics) and provided short summaries for each. We prepared supplementary tables containing all recommendations extracted (including data on the population and type and strength of the recommendation, as well as the LoE of the underlying primary studies). 2.9 Deviations from the protocol For the systematic literature search, we planned to conduct forward and backward citation screening. However, due to a high inclusion rate and limited resources, we omitted the forward citation screening. We pre-defined several outcomes and measures of effect to extract. Due to an unexpectedly high number of recommendations, we decided to focus on recommendations for the type and scope of PPE. We did not systematically extract recommendations for interventions for training, nutrition or other topics, nor for follow-up evaluations. 3 Results The systematic searches yielded 6611 records, and the document selection process is depicted in Fig. 1 . After removing duplicates, expired documents and documents published before 2012, we screened 3959 titles and abstracts then assessed the eligibility of 298 full texts. Finally, we included 35 guidelines and consensus statements 1 published in 43 reports [ 28 – 70 ]. A list of references that were excluded based on the full text, including the primary reason for exclusion, can be found in the Supplementary Information (Supplement II). 3.1 Characteristics of included documents Included documents were published between 2012 and 2022. Most were from the USA, but several other geographic contexts were also represented. The target population was mainly composed of athletes, but other levels of sports participation were also addressed. In terms of the health topic, close to half of the documents focussed on cardiology (see Fig. 2 ). An overview of the characteristics of included documents is provided in Table 3 . Table 3 Characteristics and quality appraisal of included documents ID, ref. Title Publishing organisation Country, year Population AGREE II by domain 3 6 AAFP 2016 [ 28 ] Selected Issues in Injury and Illness Prevention and the Team Physician: A Consensus Statement Unclear (several) USA, 2016 athletes 4% 0% AAFP 2017 [ 29 ] Female Athlete Issues for the Team Physician: A Consensus Statement – 2017 Update American Academy for Family Physicians USA, 2017 female athletes, pregnant athletes 7% 0% AAP 2019 [ 31 ] Preparticipation Physical Evaluation, 5th Edition American Academy of Pediatrics USA, 2019 athletes in organised sports or vigorous physical activities 14% 0% ACOG 2020 [ 30 ] Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804 American College of Obstetricians and Gynecologists USA, 2020 pregnant women 7% 17% ACPM 2013 [ 54 ] Screening for Sudden Cardiac Death Before Participation in High School and Collegiate Sports: American College of Preventive Medicine Position Statement on Preventive Practice American College of Preventive Medicine USA, 2013 high school and college athletes 10% 25% ACSM 2019 [ 38 ] Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Round Table American College of Sports Medicine USA, 2019 cancer survivors 24% 50% ACSM 2021 [ 32 ] ACSM’s Guidelines for Exercise Testing and Prescription, 11th Edition American College of Sports Medicine USA, 2021 general population (including pregnant women and cancer survivors) 11% 0% AEPC 2017 [ 48 ] Cardiovascular Pre-participation evaluation in Young Athletes: Recommendations of the Association of European Paediatric Cardiology Association of European Paediatric Cardiology Europe, 2017 young athletes 13% 75% AHA ACC 2015 [ 36 , 57 , 58 ] Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities: Preamble, Principles, and General Considerations; Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes; Task Force 6: Hypertension: A Scientific Statement from the American Heart Association and American College of Cardiology American Heart Association, American College of Cardiology USA, 2015 general population, participants in organised sports, athletes 41% 33% AMSSM 2017 [ 45 ] AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions American Medical Society for Sports Medicine USA, 2017 athletes 20% 25% AMSSM 2017 (ECG) [ 46 ] International Criteria for Electrocardiographic Interpretation in Athletes: Consensus Statement Unclear (several) World, 2017 athletes 20% 46% AMSSM 2020 [ 41 ] Mental Health Issues and Psychological Factors in Athletes: Detection, Management, Effect on Performance and Prevention: American Medical Society for Sports Medicine Position Statement – Executive Summary American Medical Society for Sports Medicine USA, 2020 athletes 24% 71% ASE 2020 [ 33 ] Recommendations on the Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes: A Report from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance American Society of Echocardiography USA, 2020 young athletes 19% 21% BSE CRY 2018 [ 64 ] A Guideline Update for the Practice of Echocardiography in the Cardiac Screening of Sports Participants: A Joint Policy Statement from the British Society of Echocardiography and Cardiac Risk in the Young British Society of Echocardiography and Cardiac Risk in the Young UK, 2018 young athletes 9% 71% CASEM 2020 [ 69 ] Physical Activity Prescription: A Critical Opportunity to Address a Modifiable Risk Factor for the Prevention and Management of Chronic Disease: A Position Statement by the Canadian Academy of Sport and Exercise Medicine Canadian Academy of Sport and Exercise Medicine World, 2020 general population 8% 21% CCS CHRS 2019 [ 52 ] Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes Canadian Cardiovascular Society, Canadian Heart Rhythm Society Canada, 2019 athletes 42% 54% COCIS 2021 [ 34 , 35 , 44 ] Italian Cardiological Guidelines for Sports Eligibility in Athletes with Heart Disease: Part 1; Part 2; Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in Athletes with Heart Disease: Update 2020 Italian Society of Sports Cardiology and the Italian Sports Medicine Federation Italy, 2021 athletes 8% 0% EA4SD 2020 [ 67 ] The European Association for Sports Dentistry, Academy for Sports Dentistry, European College of Sports and Exercise Physicians Consensus Statement on Sports Dentistry Integration in Sports Medicine European Association for Sports Dentistry Europe/ USA, 2020 athletes of all levels 7% 21% EAPC EACVI 2018 [ 49 , 65 ] The Multi-modality Cardiac Imaging Approach to the Athlete's Heart: An Expert Consensus of the European Association of Cardiovascular Imaging; European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) Joint Position Statement: Recommendations for the Indication and Interpretation of Cardiovascular Imaging in the Evaluation of the Athlete's Heart European Association of Cardiovascular Imaging Europe, 2018 athletes, elite athletes 10% 21% EFSMA 2015 [ 53 ] The Pre-participation Examination in Sports: EFSMA Statement on ECG for Pre-participation Examination European Federation of Sports Medicine Associations Europe, 2015 recreational to elite athletes 14% 21% EFSMA 2021 [ 51 ] Preparticipation Medical Evaluation for Elite Athletes: EFSMA Recommendations on Standardised Preparticipation Evaluation Form in European Countries European Federation of Sports Medicine Associations Europe, 2021 elite athletes 8% 33% EHRA EACPR 2017 [ 59 ] Pre-participation Cardiovascular Evaluation for Athletic Participants to Prevent Sudden Death: Position Paper from the EHRA and the EACPR, Branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE European Heart Rhythm Association, European Association for Cardiovascular Prevention and Rehabilitation Europe, 2017 athletes 14% 13% ESC 2021 [ 66 ] 2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease European Society of Cardiology Europe, 2021 general population (including cancer survivors), athletes 41% 63% ESC 2022 [ 70 ] 2022 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death European Society of Cardiology Europe, 2022 middle aged and older individuals, athletes 32% 75% FATC 2014 [ 43 ] 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Female Athlete Triad Coalition USA, 2014 female athletes 15% 21% FMATC 2021 [ 47 , 62 ] The Male Athlete Triad – A Consensus Statement from the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis; Part II: Diagnosis, Treatment, and Return-To-Play Female and Male Athlete Triad Coalition USA, 2021 male athletes 14% 21% FSC 2019 [ 55 , 56 ] French Society of Cardiology Guidelines on Exercise Tests (Part 1): Methods and Interpretation; (Part 2): Indications for Exercise Tests in Cardiac Diseases French Society of Cardiology France, 2019 athletes 17% 71% IOC 2013 [ 68 ] How to Minimise the Health Risks to Athletes Who Compete in Weight-sensitive Sports Review and Position Statement on Behalf of the Ad Hoc Research Working Group on Body Composition, Health and Performance, Under the Auspices of the IOC Medical Commission International Olympic Committee World, 2013 athletes in weight-sensitive sports 7% 42% IOC 2017 [ 37 ] Exercise and Pregnancy in Recreational and Elite Athletes: 2016/2017 Evidence Summary from the IOC Expert Group Meeting, Lausanne. Part 5. Recommendations for Health Professionals and Active Women International Olympic Committee World, 2017 pregnant and postpartum recreational and elite athletes 6% 75% IOC 2018 [ 60 , 61 ] The IOC Consensus Statement: Beyond the Female Athlete Triad – Relative Energy Deficiency in Sport (RED-S); International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update International Olympic Committee World, 2018 athletes 7% 42% NATA 2012 [ 40 ] National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports National Athletic Trainers’ Association USA, 2012 participants in organised sports 15% 0% NATA 2013 [ 39 ] The Inter-association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-practices Recommendations Unclear (several) North America, 2013 secondary school athletes 8% 0% NATA 2014 [ 42 ] National Athletic Trainers' Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions National Athletic Trainers’ Association USA, 2014 participants in organised sports 17% 0% NATA 2015 [ 63 ] Inter-association Recommendations for Developing a Plan to Recognize and Refer Student-athletes with Psychological Concerns at the Secondary School Level: A Consensus Statement Unclear (several) USA, 2015 secondary school athletes 13% 0% NCAA 2016 [ 50 ] Inter-association Consensus Statement on Cardiovascular Care of College Student-athletes National Collegiate Athletic Association USA, 2016 college athletes 10% 42% 3.2 Quality of included documents Overall, the quality of the documents was low for both domains selected for appraisal. The quality appraisal for domain 3, ‘Rigour of Development’, resulted in a median score of 13% (range 4–42%). Domain 6, ‘Editorial Independence’, was rated with a median score of 21% (range 0–75%). Figure 3 depicts the results per document and domain. The detailed quality assessments with reasons are provided as Supplementary Information (Supplement III). 3.3 Key results We extracted 305 recommendations. Of these, 11.8% (36/305) referred to recreational athletes, while 88.2% (269/305) addressed organised sports and/or competitive athletes. The recommendations referred to various topics (Fig. 4 ). We provide an overview of all recommendations that we extracted, grouped by topic, as Supplementary Information (Supplement IV). Additionally, the full data extraction form is provided as Supplement V. A total of 12.8% (39/305) of recommendations were directly linked to evidence from 57 primary studies. The LoEs for those primary studies were distributed as follows: 5.3% (5/57) at LoE1, 21.1% (12/57) at LoE2, 29.8% (17/57) at LoE3 and 43.9% (25/57) at LoE4. In 266 of the 305 recommendations (87.2%), there was no direct link to evidence from primary studies. The strengths of the recommendations according to the SORT were as follows: 1.3% of recommendations (4/305) were rated A, 4.6% (14/305) were rated B and 24.3% (74/305) were rated C. Of the 305 recommendations, 213 (69.8%) were extracted from the text and not explicitly labelled as recommendations by the authors (Fig. 5 ). 3.3.1 Administration For recreational athletes, we did not identify any recommendations related to PPE administration. Standardisation of PPE was recommended for organised sports and competitive athletes, including (digital) standardised questionnaires and forms [ 31 , 36 , 42 , 45 , 51 , 57 ]. Furthermore, it was recommended that PPE be performed in time to allow for additional evaluations as necessary [ 31 , 42 , 45 ]. Some organisations recommended a complete PPE every two to three years and/or if the level of participation changes, complemented by yearly history taking [ 31 , 42 , 48 ]. In the USA, the American Academy of Pediatrics (AAP) prefered individual examinations [ 31 ], while the National Athletic Trainers’ Association (NATA) considered individual and station-based examinations to be equivalent [ 42 ]. It was emphasised that previous examination results should be made available to the examiner and that further examinations and specialists need to be accessible [ 31 , 33 ]. 3.3.2 Indications for pre-participation evaluation For recreational athletes, the American College of Sports Medicine (ACSM) recommended in 2021 that the need for PPE should be determined in advance [ 32 ] by consulting qualified sports or health professionals or by using the Physical Avidity Readiness Questionnaire Plus (PAR-Q+) [ 71 ]. An international collaboration of organisations did not recommend PPE for people who intend to be physically active at light to moderate intensity [ 69 ]. In the USA, pregnant women were recommended to undergo PPE to identify possible contraindications to sports during pregnancy [ 30 , 32 , 37 ]. Some organisations also recommended PPE for specific populations of cancer survivors, e.g. those with comorbidities or metastatic disease [ 32 , 38 ]. 3.3.3 Scope and test selection For recreational athletes, the ACSM [ 32 ] in 2021 recommended laboratory testing ‘depending on individual risk factors, signs, and symptoms’. According to the 2019 AAP recommendations [ 31 ], screening tests for organised sports and competitive athletes also depend on findings from the medical history and physical evaluation. In the context of elite athletes, the European Federation of Sports Medicine Associations (EFSMA) [ 51 ] recommended thorough PPE, including diverse laboratory and imaging diagnostics, in 2021. For athletes with disabilities, it was recommended that problems typically related to the disability in question should be monitored [ 31 ]. 3.3.4 Medical and family history In the USA and Europe, thorough medical and family history taking was recommended, regardless of the level of participation [ 32 , 42 , 51 ]. This could include past diagnoses or medical procedures, results of physical examinations and laboratory testing, symptoms, illnesses, medications, recreational substance consumption (e.g. alcohol or tobacco), training and work history [ 32 , 51 ]. There were additional recommendations for specific topics pertinent to athletes with disabilities, e.g. renal problems, devices or assistive equipment, catheterisation, self-care and mobility [ 31 ]. For cancer survivors, comorbidities had to be considered, as well as whether the cancer treatment increased the risk of fractures, cardiovascular events, neuropathies or musculoskeletal disorders [ 32 ]. 3.3.5 Physical examination Several components of a physical examination can be included in PPE. These components may be related to anthropometrics, internal medicine, neurology, orthopaedics, dermatology, urology, gynaecology, ophthalmology, dentistry, psychiatry or nutrition. Some organisations suggested mandatory physical examinations for the population of interest. These could be supplemented based on the findings of their medical and family history [ 31 , 42 ]. In pregnant and postpartum women, a supplemental nutritional assessment and an assessment of contraindications were recommended [ 29 ]. For athletes with disabilities, it was recommended to examine the skin for harm due to friction, shearing or pressure from a wheelchair or other assistive devices and to check bladder catheters [ 31 ]. 3.3.6 Anthropometrics All recommendations for anthropometrics applied to organised sports and competitive athletes. In 2019, the AAP [ 31 ] recommended measuring height, weight and BMI (considering the higher muscle mass of some athletes) to diagnose underweight and overweight. In children, growth curves were recommended to be used [ 31 ]. For European elite athletes, the EFSMA [ 51 ] complemented these measures with somatoscopy and other body measurements, as well as mobility and strength, in their 2021 recommendations. 3.3.7 Nutrition We did not identify any nutrition-related recommendations for recreational athletes. All recommendations addressed organised sports and competitive athletes. These were related to energy-balanced eating, as well as disordered eating and eating disorders (DE/ED). It was recommended to include DE/ED in routine assessments [ 29 , 41 , 60 , 68 ]. The International Olympic Committee (IOC) provided a risk assessment model for this context [ 60 ]. If DE/ED is suspected, an ‘Anthropometric, Biochemical, Clinical, Dietary and Environmental (ABCDE) Assessment’ was recommended for further investigation [ 60 ]. Other screening tools mentioned by the American Academy for Family Physicians (AAFP) in 2017 [ 29 ] were SCOFF questions [ 72 ], Eating Disorder Inventory (EDI) [ 73 ] and Low Energy Availability in Females Questionnaire (LEAF-Q) [ 74 ]. For elite athletes, the EFSMA [ 51 ] specifically recommended a comprehensive nutritional assessment in 2021. 3.3.8 Male and female athlete triads For female participants in organised sports and competitive athletes, screening for a triad is recommended as part of PPE in the USA [ 29 , 43 ]. For male athletes, targeted screening questions were also recommended [ 47 , 62 ]. Screening for triads should begin at school age and should include a medication history (particularly hormones) [ 43 ]. Any identified element of the female athlete triad (underweight, amenorrhea or decreased bone density) should prompt further investigation for the presence of the other elements [ 31 , 43 ]. Further investigation was recommended for abnormal menstruation [ 42 ] or underweight [ 31 ]. European guidelines and consensus documents did not address the male or female athlete triad, however. 3.3.9 Heat and hydration History questions about heat illness and risk factors, including fluid intake, training intensity, acclimatisation and screening for the sickle cell trait, were recommended for competitive athletes and in organised sports in the USA [ 28 , 31 , 40 , 42 ]. 3.3.10 Internal medicine In general, cardiologic recommendations included a cardiac medical and family history and a physical examination for all athletes. Recommendations for further cardiologic investigations (e.g. electrocardiography [ECG]) varied according to participation level, age and other risk factors, as well as region (e.g. USA vs Europe). For example, in 2021, the European Society of Cardiology (ESC) [ 66 ] recommended stratifying cardiologic assessments for people > 35 years of age according to their individual cardiovascular risk, which should be evaluated using the SCORE2 instrument [ 75 ]. According to the ACSM recommendations of 2019 [ 38 ], all cancer survivors should be screened for cardiovascular disease and receive a cardiopulmonary exercise test, if deemed necessary. The ESC [ 66 ] recommended in 2021 that cancer survivors who received cardiotoxic therapeutics should undergo echocardiography before exercising at high intensity. In the context of organised sports and competitive athletes, recommendations for ECG as a baseline cardiologic examination were inconsistent. In Europe, a 12-lead ECG was generally recommended [ 44 , 48 , 53 , 64 ]. In North America, a positive (family) history and/or physical examination was sometimes required [ 39 , 52 , 54 ] and, in some cases, a decision was made depending on resources [ 33 ], or a shared decision-making approach was chosen [ 45 ]. Further cardiologic recommendations addressed the interpretation of cardiac imaging in athletes, which can be found in the Supplementary Information (Supplement IV). In the context of pneumological screening, no specific recommendations could be identified for recreational athletes. For organised sports in the USA, a thorough history taking and physical examination were recommended when asthma is suspected [ 40 ]. Except in the 2021 EFSMA recommendations for elite athletes [ 51 ], specific blood and urine tests were not routinely recommended but could be considered depending on risk factors and findings from medical history and physical examinations [ 31 , 42 ]. 3.3.11 Orthopaedics We did not identify any orthopaedic recommendations for recreational athletes. For organised sports and athletes of all levels, it was recommended to start with a history of injuries and surgeries, as well as a physical examination [ 31 , 42 , 51 ]. The results of these examinations could then be used to determine whether further diagnostic assessments were necessary [ 31 , 42 , 51 ]. For female athletes, particular attention should be paid to risks for anterior cruciate ligament injuries, patellofemoral pain and musculoskeletal deficits [ 29 ]. Recommendations for athletes with disabilities included an examination of the stability, flexibility and strength of stressed and frequently injured sites [ 31 ]. 3.3.12 Neurology There were no neurological recommendations for recreational athletes. For organised sports and elite athletes, a thorough neurological examination was recommended for athletes with a history of concussion, seizures, cervical stenosis or spinal cord injury [ 42 , 51 ]. The AAFP [ 28 ] recommended in 2016 that all athletes undergo a neurological and cervical spine examination to prevent cervical spine injuries. According to the AAP recommendations of 2019 [ 31 ], athletes with physical impairments should receive a complete neurological assessment. In the same year, the ACSM [ 38 ] recommended an assessment of balance and mobility for older cancer survivors and those who received neurotoxic chemotherapy. 3.3.13 Psychiatry Specific screening recommendations for psychiatric issues were not available for recreational athletes. For participants in organised sports and athletes, it was recommended to supplement medical history taking with questions about mental health [ 31 , 42 , 63 ]. 3.3.14 Advice to participants As part of PPE, some organisations recommended counselling sports participants about health risks and preventive measures [ 31 , 45 , 48 ]. For recreational athletes, the ACSM [ 32 ] recommended in 2021 that “pregnant women should be educated on the warning signs for when to stop exercise”. 3.3.15 Clearance In its 2019 recommendations, the AAP [ 31 ] provided a list of key questions practitioners should consider (Box 1). Box 1. American Academy of Pediatrics’ recommendations for sports participation clearance [ 31 ] Does participation put the athlete at risk for illness or injury above the inherent hazards of the activity? Does participation increase the risk of injury or illness for other participants? Will treatment of the underlying condition allow safe participation (medication, rehabilitation, bracing and padding)? Can limited participation be allowed while treatment or evaluation is completed? If medical eligibility is denied for certain sports because of medical or safety concerns, can the athlete safely participate in other activities or sports? Moreover, cardiovascular abnormalities should be further evaluated before starting or continuing high-intensity exercise [ 31 ]. Further details were provided in specialist guidelines for cardiovascular disease in athletes, but these were beyond the scope of this review. In the case of athlete triads or relative energy deficiency in sport (RED-S), the use of risk assessment tools was recommended to guide clearance decisions [ 47 , 60 , 62 ]. For athletes with disabilities, inclusion should be the primary consideration, along with safety issues [ 31 ]. [1] These are henceforth referred to as ‘documents’. 4 Discussion This review identified numerous recommendations for performing PPE in sports medicine. Most of them were directed at participants in organised sports or competitive athletes, while fewer recommendations addressed PPE of recreational athletes. These were also often limited to specific subgroups, such as pregnant women or cancer survivors, and did not cover important topics that affect injury prevention, such as orthopaedics or nutrition [ 76 , 77 ]. Most organisations agreed that essential components of PPE include thorough medical and family history taking and a physical examination in all populations. Several organisations recommended a stepwise approach to PPE in which follow-up questions and examinations are chosen based on the results of the mandatory history taking and physical evaluations [ 31 , 42 ]. Varying and sometimes even contradictory recommendations existed for blood and urine testing, exercise stress testing and imaging, especially in the context of cardiovascular PPE. An example is the controversial use of ECG in North American versus European organisations. In North America, the use of ECG screening is more restricted than in Europe and is usually dependent on specific conditions (e.g. risk factors identified by medical or family history) [ 33 , 39 , 44 , 45 , 48 , 52 – 54 , 64 ]. Only a few recommendations were based on evidence; most recommendations seemed to be derived largely from expert experience and consensus. This is not surprising, as robust evidence for the positive effects of PPE on patient-relevant health outcomes is scarce [ 52 , 78 ]. The lack of evidence and reliance on consensus probably contributed to the heterogeneity among recommendations from different organisations and regions. Methodological and organisational challenges in the design and conduct of screening trials also suggest that prospective high-quality studies will continue to be limited [ 79 – 81 ]. The lack of evidence on which to base recommendations was the main driver for the poor ratings of the included documents in the ‘Rigour of Development’ domain of the AGREE II tool. This is consistent with the findings of Riding et al., who systematically reviewed guidelines for cardiovascular PPE [ 82 ]. Riding et al. found that ‘Rigour of Development’ scored lower than any of the other AGREE II domains. According to the authors, the poor-quality appraisal scores of guidelines in preventive sports medicine are attributable more to the limitations in this area of research than to the rigour applied by the guideline groups [ 82 ]. In addition to limited underlying evidence, we perceived poor reporting to be another concern. Both AGREE II domains were given lower ratings due to the lack of available information on guideline methodology, funding and conflict of interest management. Therefore, the use of standardised methods and guidance for the development and reporting of guidelines (e.g. the Reporting Items for practice Guidelines in HealThcare) [ 83 ] is desirable. The lack of solid evidence equally applies to the potential harms of PPE [ 79 ], which need to be discussed to provide a balanced overview. One such harm was proposed to be psychological distress in athletes caused by true-positive or false-positive results [ 79 ]. Hill et al. conducted an SR of the psychological distress of athletes caused by cardiovascular PPE [ 84 ]. While their study showed that PPE generally caused only minimal or no psychological distress to athletes and made them feel safer, a few athletes with true-positive findings did experience distress. According to the authors, this may have been related to follow-up evaluations, sports restrictions or disqualifications [ 84 ]. However, psychological distress affecting a minority of people screened can be justified if positive health outcomes are likely achieved through PPE and appropriate follow-up measures. The decisions surrounding which components to include in PPE may be seen as health decisions, for which evidence for the superiority of one intervention (to screen) over another (not to screen) is either not available or does not allow for differentiation [ 85 ]. In this context, the best choice depends on how individuals value the risks and benefits of the interventions, and shared decision-making about the scope of PPE should be the norm. Despite the uncertainties associated with its benefits and harms, PPE may be a tool for ensuring that current health problems are managed appropriately and for determining whether a person is medically able to engage in a particular sport [ 86 ]. 4.1 Implications of the research More robust evidence for the effects of PPE on health outcomes is needed. Studies on preventive health examinations that aim to collect patient-relevant outcomes face particular methodological challenges associated with randomisation, large sample sizes and long-term follow-up [ 87 ]. Large cluster-randomised trials [ 88 , 89 ], registry-based studies or national cohorts may be the best approach to obtain robust evidence in this context. This might include population-based registries for fatal events or sports-related injuries, analysis of data from health insurance providers or the prospective collection and evaluation of data on preventive health examinations, including follow-up examinations. 4.2 Limitations This SR had several limitations. First, we included only documents published in English and German, so potentially relevant documents published in other languages were not included. Second, many recommendations were extracted directly from the text, as not all documents included recommendations labelled as such. We felt it was important to include these documents and extract recommendations from the text due to their coverage of highly relevant topics and their language suggesting that recommendations were being provided. To mitigate the subjectivity of this process, we performed thorough quality assurance of extractions. Third, due to resource restrictions, we applied only domains 3 and 6 of the AGREE II tool to quality appraisal and were unable to provide information about the other domains. However, these domains contain the most informative items for assessing the underlying methods and evidence used to develop recommendations, as well as the potential effects of funding or conflicts of interest. In a survey of guideline and AGREE II users, these domains had the strongest influence on the overall assessment of guideline quality and recommendations for use [ 90 ]. 5 Conclusion Our review identified recommendations for most components of PPE, ranging from indications and scope to individual diagnostic tests. They helped to define the scope of and clinical questions for the PPE guideline currently being developed in Germany. Most recommendations identified in this review addressed competitive athletes, so there is a need for a comprehensive set of recommendations for individuals who exercise in a recreational setting. Recommendations for the components of PPE were heterogeneous across organisations and geographic regions and were rarely based on evidence from comparative studies. Therefore, more robust evidence for the effects of PPE on health outcomes, e.g. from large cluster-randomised trials or cohort and registry studies, is needed. Reporting should be improved for future guidelines and consensus statements, both the potential benefits and harms of PPE should be considered and the preferences of the target population should be taken into account. Abbreviations ABCDE Anthropometric, Biochemical, Clinical, Dietary and Environmental (Assessment) AAFP American Academy of Family Physicians AAP American Academy of Pediatrics AAOS American Academy of Orthopaedic Surgeons AAPMR American Academy of Physical Medicine and Rehabilitation AASP Association of Applied Sport Psychiatry ACC American College of Cardiology ACC SECLC American College of Cardiology Sports and Exercise Cardiology Leadership Council ACEP American College of Emergency Physicians ACOG American College of Obstreticians and Gynecologists ACS American Cancer Society ACLM American College of Lifestyle Medicine ACRM American Congress of Rehabilitation Medicine ACSM American College of Sports Medicine ACSEP Australasian College of Sports and Exercise Physicians AEPC AEPC AGREE Appraisal of Guidelines for Research and Evaluation AHA American Heart Association AIS Australian Institute of Sport AMSSM American Medical Society for Sports Medicine AOASM American Osteopathic Academy of Sports Medicine AOSSM American Orthopaedic Society for Sports Medicine APA American Psychological Association (Division 47: Exercise and Sport Psychology) APHRS Asia Pacific Heart Rhythm Society APTA American Physical Therapy Association ASCA American School Counselor Association ASD Academy for Sports Dentistry ASE American Society of Echocardiography ASSMP Austrian Society of Sports Medicine and Prevention BASEM British Association for Sports and Exercise Medicine BSE CRY British Society of Echocardiography and Cardiac Risk in the Young CACHN Community and Athletic Cardiovascular Health Network CARF Commission on Accreditation of Rehabilitation Facilities CASEM Canadian Academy of Sport and Exercise Medicine CATA Canadian Athletic Therapists Association CATS College Athletic Trainers’ Society CCS Canadian Cardiovascular Society CDC Centers for Disease Control CHRS Canadian Heart Rhythm Society CIHR Canadian Institute of Health Research COC Canadian Olympic Committee COPSI Canadian Olympic and Paralympic Sport Institute Network CPC Canadian Paralympic Committee CSCCA Collegiate Strength and Conditioning Coaches Association CSEP Canadian Society for Exercise Physiology CSI Canadian Sport Institute DVGS Deutscher Verband für Gesundheitssport und Sporttherapie EA4SD European Association for Sports Dentistry EACPR European Association for Cardiovascular Prevention and Rehabilitation EACVI European Association of Cardiovascular Imaging ECG electrocardiography ECSEP European College of Sports and Exercise Physicians EDI Eating Disorder Inventory EFSMA European Federation of Sports Medicine Associations EHRA European Heart Rhythm Association EAPC European Association of Preventive Cardiology ESC European Society of Cardiology ESSA Exercise and Sports Science Australia FATC Female Athlete Triad Coalition FMATC Female and Male Athlete Triad Coalition FIFA Fédération Internationale de Football Association GIN Guidelines International Network HRS Heart Rhythm Society HSF Heart and Stroke Foundation IAEHC Italian Association of Extra-hospital Cardiologists IAIHC Italian Association of In-hospital Cardiologists ICISF International Critical Incident Stress Foundation IOC International Olympic Committee ISC Italian Society of Cardiology ISSP International Society of Sports Psychiatry LASECS LASECS LEAF-Q Low Energy Availability in Females Questionnaire LoE Level of Evidence NAIAAA National Interscholastic Athletic Administrators Association NASMPA Norwegian Association of Sports Medicine and Physical Activity NATA National Athletic Trainers’ Association NCAA National Collegiate Athletics Association NCCN National Comprehensive Cancer Network NCI National Cancer Institute NCSF National Council on Strength and Fitness NFHS National Federation of State High School Associations NIH National Institutes of Health NSCA National Strength and Conditioning Association PAR-Q+ Physical Activity Readiness Questionnaire Plus PERSiST implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science PICO Population, Intervention, Comparison, Outcome PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses PPE pre-participation evaluation RDSPT Royal Dutch Society for Physical Therapy RED-S Relative Energy Deficiency in Sports SASMA South African Sports Medicine Association SBC-DERC Brazilian Society of Cardiology – Department of Exercise and Rehabilitation SBM Society for Behavioral Medicine SCCT Society of Cardiovascular Computed Tomography SCG Sports Cardiology Group SCMR Society for Cardiovascular Magnetic Resonance SCOFF SCOFF SDA Sports Doctors Australia SGS Schweizerische Gesellschaft für Sportmedizin SORT Strength of Recommendations Taxonomy SR Systematic Review SSC Spanish Society of Cardiology SSESM Swedish Society of Exercise and Sports Medicine WHO World Health Organization Declarations Acknowledgements We would like to thank Ms Irma Hellbrecht for retrieving full texts. Authors’ contributions Supervision: KG, JB; study design and protocol development: KG, JB, AW, CJ, AH; literature search: AW, KG; document selection: AW, KG, NK, CJ, AH; quality appraisal: AW, NK, KG; data extraction: AW, NK, KG, FS; level-of-evidence assessment: NK, KG; statistical analysis and narrative synthesis: KG, AW; writing the first draft of the manuscript: AW; revisions of the manuscript for important intellectual content: KG, JB, NK, AW, FS, CJ, AH; final approval of the manuscript: KG, JB, NK, AW, FS, CJ, AH. Funding This SR was funded by the “Deutsche Gesellschaft für Sportmedizin und Prävention e. V.“, a non-profit organisation. Competing interests AW, NK, JB, FS, CJ, KG and AH have no competing interests. Ethics approval and consent to participate Not applicable Patient consent for publication Not applicable Data availability All data are available within the paper or its supplements References Lear SA, Hu W, Rangarajan S, Gasevic D, Leong D, Iqbal R, et al. 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Riding NR, Dorobantu D-M, Williams CA, Stuart G, Fritsch P, Wilson MG, et al. Protecting the stars of tomorrow: do international cardiovascular preparticipation screening policies account for the paediatric athlete? A systematic review and quality appraisal. Br J Sports Med. 2023;57(6):371–80. 10.1136/bjsports-2022-105659 . Chen Y, Yang K, Marušic A, Qaseem A, Meerpohl JJ, Flottorp S, et al. A Reporting Tool for Practice Guidelines in Health Care: The RIGHT Statement. Ann Intern Med. 2017;166(2):128–32. 10.7326/m16-1565 . Epub 20161122. Hill B, Grubic N, Williamson M, Phelan DM, Baggish AL, Dorian P, et al. Does cardiovascular preparticipation screening cause psychological distress in athletes? A systematic review. Br J Sports Med. 2023;57(3):172–8. 10.1136/bjsports-2022-105918 . Elwyn G, Frosch D, Rollnick S. Dual equipoise shared decision making: definitions for decision and behaviour support interventions. Implement Sci. 2009;4:75. 10.1186/1748-5908-4-75 . Epub 20091118. Ljungqvist A, Jenoure PJ, Engebretsen L, Alonso JM, Bahr R, Clough AF et al. The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes, March 2009. Clin J Sport Med. 2009;19(5):347 – 65. 10.1097/JSM.0b013e3181b7332c . PubMed PMID: 19741306. Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, et al. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ. 2008;336(7653):1106–10. 10.1136/bmj.39500.677199.AE . PubMed PMID: 18483053; PubMed Central PMCID: PMCPMC2386626. Bjerregaard AL, Dalsgaard EM, Bruun NH, Norman K, Witte DR, Stovring H, et al. Effectiveness of the population-based 'check your health preventive programme' conducted in a primary care setting: a pragmatic randomised controlled trial. J Epidemiol Community Health. 2022;76(1):24–31. 10.1136/jech-2021-216581 . Epub 20210618. Maindal HT, Støvring H, Sandbaek A. 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Supplementary Files SupplementISearchStrategies.pdf I search strategies SupplementIIListofExcludedReports.xlsx II list of excluded reports SupplementIIIDetailedQualityAppraisal.xlsx III detailed quality appraisal SupplementIVRecommendations.pdf IV recommendations SupplementVDataextractionform.xlsx V filled data extraction form Cite Share Download PDF Status: Published Journal Publication published 05 Apr, 2025 Read the published version in Sports Medicine-Open → Version 1 posted Reviewers agreed at journal 09 May, 2024 Reviewers invited by journal 21 Mar, 2024 Editor assigned by journal 14 Mar, 2024 First submitted to journal 14 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4099744","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":282197637,"identity":"7b863457-63d8-41af-9877-906f19516d37","order_by":0,"name":"Alina 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04:39:17","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":726377,"visible":true,"origin":"","legend":"\u003cp\u003eIV recommendations\u003c/p\u003e","description":"","filename":"SupplementIVRecommendations.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4099744/v1/6c84caed8f6aecb80d81484e.pdf"},{"id":53360528,"identity":"0601d920-1c4f-487a-a779-f9aa17eb395c","added_by":"auto","created_at":"2024-03-25 04:39:17","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":157519,"visible":true,"origin":"","legend":"\u003cp\u003eV filled data extraction form\u003c/p\u003e","description":"","filename":"SupplementVDataextractionform.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4099744/v1/d22f7d279c8d8e30b937f865.xlsx"}],"financialInterests":"","formattedTitle":"Pre-participation evaluation of recreational and competitive athletes – A systematic review of guidelines and consensus statements","fulltext":[{"header":"Summary box","content":"\u003cul\u003e\n \u003cli\u003ePre-participation evaluation aims \u0026nbsp;to prevent possible harm during sports and later damage caused by exertion\u003c/li\u003e\n \u003cli\u003eHigh-quality evidence for the effect of pre-participation evaluation on patient-relevant outcomes is lacking\u003c/li\u003e\n \u003cli\u003eRecommendations in current guidelines and consensus statements are mostly consensus-based and focus on competitive athletes\u003c/li\u003e\n \u003cli\u003eIn the absence of clear benefits of certain evaluation components, choosing the best option depends on how individuals value the benefits and risks involved; shared decision-making should be the norm\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1 Introduction","content":"\u003cp\u003eRegular physical activity and sports can promote health and, in the long term, reduce the risk of premature death [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the 2019/2020 Current Health in Germany (\u0026lsquo;Gesundheit in Deutschland aktuell\u0026rsquo;, GEDA) study by the Robert Koch Institute showed that only 23.3% of women and 29.4% of men are physically active at the recommended level [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Similarly, Bennie and Wiesner found that only 15.0% of adult Europeans met the recommendations for aerobic activity and muscle-strengthening exercises in the years 2013 and 2014 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The COVID-19 pandemic led to a further decrease in time spent on moderate to vigorous physical activity during lockdown [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the health-promoting effects of regular physical activity, performing sports can be related to health risks like cardiac arrest or arrhythmias. Maron referred to this phenomenon as the \u0026lsquo;paradox of exercise\u0026rsquo; [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Sports-related health risks can affect athletes at any level. The incidence and prevalence of sports-related cardiac arrest differ among populations and regions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For example, Berdowski et al. reported an incidence of 3.0 and 0.3 cases per 1\u0026nbsp;million people per year for people aged\u0026thinsp;\u0026gt;\u0026thinsp;35 years and \u0026le;\u0026thinsp;35 years, respectively, in North Holland (Netherlands) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Karam et al. reported an incidence of 7.0 per 1\u0026nbsp;million inhabitants per year for adults aged 18\u0026ndash;75 years in the Greater Paris area (France) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These differences in incidence may be attributed to the varying risk factors across populations. For example, the risk of sports-related cardiovascular incidents increases exponentially in people older than 35 years [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInjuries are an additional risk of sports participation. A systematic review (SR) that Al-Qahtani et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] conducted showed that the prevalence of sports-related injuries in adolescent athletes ranges from 34\u0026ndash;65%. Risk factors for injury include the type of sports and training practices. Prevention of such injuries avoids not only their direct consequences (e.g. required treatment and absence from school or work) but also potential long-term physical constraints or sequelae.\u003c/p\u003e \u003cp\u003ePre-participation evaluation (PPE) is a preventive health examination used in sports medicine that may help people to start or resume physical activity safely by identifying those at an increased risk of adverse events during exercise. Its aims are to reduce the adverse effects of physical activity and prevent any subsequent damage caused by exertion. According to Whitfield et al., up to 95.5% of Americans\u0026thinsp;\u0026gt;\u0026thinsp;40 years of age are eligible for PPE [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For participants in official sports competitions, such as squad athletes, PPE is often a standard procedure [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, there is a debate over which anamnestic and diagnostic assessments should be used for PPE of competitive and recreational athletes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Limited evidence for the effects of PPE on patient-relevant health outcomes, as well as methodological challenges for conducting high-quality studies, have contributed to this debate [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, current PPE recommendations and clinical practice seem to rely mostly on clinical expertise.\u003c/p\u003e \u003cp\u003eWith this SR, we aimed to aggregate and appraise evidence- and consensus-based recommendations for PPE. We used the findings of this SR to develop a new German consensus-based guideline for PPE of recreational athletes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003eWe performed this SR according to the methods pre-defined in a protocol registered in PROSPERO (CRD42022355112). We reported the SR according to the \u003cem\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/em\u003e (PRISMA) 2020 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and the \u003cem\u003eImplementing PRISMA in Exercise, Rehabilitation, Sports Medicine and Sports Science\u003c/em\u003e (PERSiST) guidance [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. We contacted the authors of the included documents only for full text retrieval.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Population, intervention, control and outcome questions and eligibility criteria\u003c/h2\u003e \u003cp\u003e The SR included evidence- or consensus-based guidelines and consensus statements about the PPE of apparently healthy adults and athletes of all ages (both groups with and without disabilities). It did not include guidelines or consensus statements targeting people with chronic diseases, such as cardiovascular disease or diabetes mellitus. The primary outcomes were the prevention or reduction of fatal events during sports and the possible sequelae of participation in individual sports. We included documents published in English and German. Expired documents and recommendations for countries outside the World Health Organisation (WHO) mortality stratum A [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] were ineligible. All pre-defined eligibility criteria are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-defined eligibility criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePopulation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; healthy adults with or without disabilities\u003c/p\u003e \u003cp\u003e\u0026bull; competitive athletes of any age with or without disabilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; primary population with known non-communicable chronic diseases, such as cardiovascular disease or diabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; medical history\u003c/p\u003e \u003cp\u003e\u0026bull; anthropometric measurements\u003c/p\u003e \u003cp\u003e\u0026bull; cardiometabolic or internal medicine examinations\u003c/p\u003e \u003cp\u003e\u0026bull; orthopaedic examinations\u003c/p\u003e \u003cp\u003e\u0026bull; additional tests or diagnostic procedures from related disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; diagnostic interventions specific to sports for which there is a separate fitness examination (e.g. diving, flying)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComparison\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; usual care\u003c/p\u003e \u003cp\u003e\u0026bull; other anamnestic or diagnostic parameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; prevention or reduction of exercise-induced (fatal) events during sports participation\u003c/p\u003e \u003cp\u003e\u0026bull; prevention or reduction of possible sequelae of sports or exertion\u003c/p\u003e \u003cp\u003e\u0026bull; diagnostic test accuracy measures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStudy type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; evidence-based and/or consensus-based guidelines and recommendations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; expired documents\u003c/p\u003e \u003cp\u003e\u0026bull; documents published before 2012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSetting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; WHO mortality stratum A countries\u003c/p\u003e \u003cp\u003e\u0026bull; published by professional medical societies, guideline organisations, public or government-led organisations (e.g. the military) or expert groups appointed by such societies or organisations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLanguage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; English, German\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; duplicates\u003c/p\u003e \u003cp\u003e\u0026bull; multiple publications without additional information\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Literature search\u003c/h2\u003e \u003cp\u003e We systematically searched for literature on MEDLINE (PubMed), Trip Database, the National Institutes of Health (NIH) Library, the Guidelines International Network\u0026rsquo;s (GIN) International Guidelines Library, and ECRI Guideline Trust\u0026rsquo;s guideline repositories. We used automation tools (Word Frequency Analyzer, SearchRefinery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]) to facilitate the development of the MEDLINE search strategy and adapted the strategy to the syntax of each database. Searches contained index and free text terms for population, intervention and study type, as applicable. We performed database searches in August 2022, with 1 January 2012 as the start date. We chose this start date because around 50% of guidelines are out of date within five years [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, any guideline older than 10 years was presumably outdated. No restrictions of language or publication status were applied at the search stage.\u003c/p\u003e \u003cp\u003eIn addition, we performed structured hand searches on the websites of the following specialty medical associations and guideline organisations: American College of Sports Medicine, British Association of Sport \u0026amp; Exercise Medicine, Canadian Academy of Sport and Exercise Medicine, Sports Medicine Australia, European Federation of Sports Medicine Associations, Canadian Medical Association Infobase of Clinical Practice Guidelines, Australian National Health and Medical Research Council, National Institute for Health and Care Excellence, New Zealand Guidelines Group via the Ministry of Health New Zealand and VA/DoD Clinical Practice Guidelines. We performed website searches in August and October 2022.\u003c/p\u003e \u003cp\u003eThe full search strategies, including search dates, are provided as Supplementary Information (Supplement I).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Document selection\u003c/h2\u003e \u003cp\u003eWe exported all records found via MEDLINE to Endnote (Endnote, Version: 20 [Software]. Clarivate, Boston, Massachusetts, USA. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://endnote.com/\u003c/span\u003e\u003cspan address=\"https://endnote.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) and removed duplicates. All records found via websites and other databases were exported to Microsoft Excel (2016). We performed document selection according to pre-defined eligibility criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We then screened the titles and abstracts of all MEDLINE records using the web tool Rayyan [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The other records were screened in Excel based on their titles. We obtained the full texts of all records deemed potentially relevant for full text screening. Notably, two independent researchers (AW, KG) performed all screening steps. We discussed differences until a consensus was reached. If a consensus could not be reached via such discussions, we consulted clinical experts (AH, CJ).\u003c/p\u003e \u003cp\u003eIn addition, we performed a backward citation search via Scopus, including all eligible documents that were found via the database and website searches and that were available on Scopus. The identification of references was facilitated using Scopus, and deduplication was performed via Endnote. The screening process was identical to that used for the MEDLINE records (AW, NK).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Quality appraisal\u003c/h2\u003e \u003cp\u003eWe appraised the quality of included documents using two selected domains from the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The tool comprises six domains, namely, 1) Scope and Purpose, 2) Stakeholder Involvement, 3) Rigour of Development, 4) Clarity of Presentation, 5) Applicability and 6) Editorial Independence. Due to resource restrictions, we limited the quality appraisal to domains 3 and 6, which were the most relevant for our purposes. Domain 3 consists of eight items, while domain 6 consists of two items. Two independent researchers (AW, KG, NK) rated each item on a seven-point Likert scale (higher scores mean higher quality). Depending on the scores per individual item and rater, each domain could achieve a score of 0\u0026ndash;100%.\u003c/p\u003e \u003cp\u003eTwo independent researchers (AW, KG) pilot-tested the quality appraisal process using six included documents. Of those, we chose three documents based on heterogeneous characteristics (e.g. content and structure) and three other documents at random. We compared and discussed the appraisal of the pilot sample to agree on specific appraisal criteria, ensure consistency and reduce systematic differences. An additional researcher (NK) joined the team later and performed pilot testing using a sample of four documents.\u003c/p\u003e \u003cp\u003eTwo researchers (AW, NK) performed all further ratings independently. Afterwards, they discussed deviations of two or more points per item to identify and correct systematic differences in appraisals, as necessary. We calculated the mean scores per document and per domain. For each quality appraisal item, we calculated median scores across documents and the corresponding ranges.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data extraction and data items\u003c/h2\u003e \u003cp\u003e We extracted data into a form (Microsoft Excel, 2016) that we developed for this review. We piloted the form during two sessions, each using three of the documents that we previously selected for the pilot quality appraisal. Two researchers (AW, KG) performed both piloting sessions independently then modified and expanded the data extraction form based on the consensus they reached. Two additional researchers (FS, NK) joined the team later and performed pilot testing using samples of three and four documents, respectively.\u003c/p\u003e \u003cp\u003eOne of the four researchers (AW, FS, KG, NK) involved extracted data into the piloted form, and a second verified data extraction. We discussed differences until a consensus was reached, including a third researcher as necessary. Extracted data included information about the guideline or consensus statement; population, intervention, control and outcome (PICO) elements; and recommendations. We extracted recommendations labelled as such and recommendation-like sentences from the main document text. A list of all data extraction items can be found on PROSPERO.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Levels of evidence and strength of recommendations\u003c/h2\u003e \u003cp\u003eFor recommendations that were directly linked to literature in the original publications, we extracted the corresponding references and obtained their full texts. We assigned a level of evidence (LoE) for primary studies or SRs based on their full texts, according to the \u003cem\u003eOxford 2011 Levels of Evidence\u003c/em\u003e [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Two researchers (NK, KG) independently assessed the first 20 references then sought a consensus. One researcher (NK) completed all further assignments. When doubts arose, a second researcher (KG) was consulted. We did not assign LoEs to narrative review, commentary or guideline (without SR) references.\u003c/p\u003e \u003cp\u003eWe extracted the grade or strength of the recommendation when available. For recommendations labelled as such but that did not have an assigned strength of recommendation or linked evidence, we assigned a level C according to the strength of recommendation taxonomy (SORT), which uses a scale from A (strongest) to C (weakest) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For recommendation-like sentences that were extracted from the text, we complemented the SORT with an additional level (\u0026ndash;) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExpanded strength of recommendation taxonomy [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrength of recommendation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecommendation based on consistent and good-quality patient-oriented evidence*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecommendation based on inconsistent or limited-quality patient-oriented evidence*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecommendation based on consensus, usual practice, opinion, disease-oriented evidence* or case series for studies of diagnosis, treatment, prevention or screening\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026ndash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStatement in the text\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Patient-oriented evidence measures outcomes that matter to the patient: morbidity, mortality, symptom improvement, cost reduction and quality of life. Disease-oriented evidence measures intermediate, physiologic or surrogate end points that may or may not reflect improvements in patient outcomes (e.g. blood pressure, blood chemistry, physiologic function, pathologic findings).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Statistical analysis\u003c/h2\u003e \u003cp\u003eWe calculated values and percentages for the nominal data on the characteristics of included documents and recommendations. For calculations, we used Microsoft Excel (2016).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Synthesis of documents and recommendations\u003c/h2\u003e \u003cp\u003eWe synthesised data using a structured, narrative format. We presented the metadata of the included documents using tabulation. We also grouped extracted recommendations according to their clinical topics (e.g. cardiology, anthropometrics) and provided short summaries for each. We prepared supplementary tables containing all recommendations extracted (including data on the population and type and strength of the recommendation, as well as the LoE of the underlying primary studies).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.9 Deviations from the protocol\u003c/h2\u003e \u003cp\u003eFor the systematic literature search, we planned to conduct forward and backward citation screening. However, due to a high inclusion rate and limited resources, we omitted the forward citation screening.\u003c/p\u003e \u003cp\u003eWe pre-defined several outcomes and measures of effect to extract. Due to an unexpectedly high number of recommendations, we decided to focus on recommendations for the type and scope of PPE. We did not systematically extract recommendations for interventions for training, nutrition or other topics, nor for follow-up evaluations.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eThe systematic searches yielded 6611 records, and the document selection process is depicted in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. After removing duplicates, expired documents and documents published before 2012, we screened 3959 titles and abstracts then assessed the eligibility of 298 full texts. Finally, we included 35 guidelines and consensus statements\u003ca id=\"#FNLinkFn1\" class=\"FNLink\" href=\"#Fn1\"\u003e1\u003c/a\u003e published in 43 reports [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e]. A list of references that were excluded based on the full text, including the primary reason for exclusion, can be found in the Supplementary Information (Supplement II).\u003c/p\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Characteristics of included documents\u003c/h2\u003e\n \u003cp\u003eIncluded documents were published between 2012 and 2022. Most were from the USA, but several other geographic contexts were also represented. The target population was mainly composed of athletes, but other levels of sports participation were also addressed. In terms of the health topic, close to half of the documents focussed on cardiology (see Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). An overview of the characteristics of included documents is provided in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics and quality appraisal of included documents\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eID, ref.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTitle\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003ePublishing organisation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCountry, year\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAGREE II by domain\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"1\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAAFP 2016 [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eSelected Issues in Injury and Illness Prevention and the Team Physician: A Consensus Statement\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eUnclear (several)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAAFP 2017 [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFemale Athlete Issues for the Team Physician: A Consensus Statement \u0026ndash; 2017 Update\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican Academy for Family Physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efemale athletes, pregnant athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAAP 2019 [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePreparticipation Physical Evaluation, 5th Edition\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican Academy of Pediatrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes in organised sports or vigorous physical activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACOG 2020 [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePhysical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican College of Obstetricians and Gynecologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epregnant women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACPM 2013 [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eScreening for Sudden Cardiac Death Before Participation in High School and Collegiate Sports: American College of Preventive Medicine Position Statement on Preventive Practice\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican College of Preventive Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ehigh school and college athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACSM 2019 [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eExercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Round Table\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican College of Sports Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecancer survivors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACSM 2021 [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eACSM\u0026rsquo;s Guidelines for Exercise Testing and Prescription, 11th Edition\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican College of Sports Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral population (including pregnant women and cancer survivors)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAEPC 2017 [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCardiovascular Pre-participation evaluation in Young Athletes: Recommendations of the Association of European Paediatric Cardiology\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAssociation of European Paediatric Cardiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope, 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eyoung athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAHA ACC 2015 [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e58\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eEligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities: Preamble, Principles, and General Considerations; Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes; Task Force 6: Hypertension: A Scientific Statement from the American Heart Association and American College of Cardiology\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican Heart Association, American College of Cardiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral population, participants in organised sports, athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAMSSM 2017 [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAmerican Medical Society for Sports Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAMSSM 2017 (ECG) [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eInternational Criteria for Electrocardiographic Interpretation in 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the Young\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUK, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eyoung athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCASEM 2020 [\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePhysical Activity Prescription: A Critical Opportunity to Address a Modifiable Risk Factor for the Prevention and Management of Chronic Disease: A Position Statement by the Canadian Academy of Sport and Exercise Medicine\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eCanadian Academy of Sport and Exercise Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorld, 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCCS CHRS 2019 [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCanadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eCanadian Cardiovascular Society, Canadian Heart Rhythm Society\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCanada, 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e54%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOCIS 2021 [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eItalian Cardiological Guidelines for Sports Eligibility in Athletes with Heart Disease: Part 1; Part 2; Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in Athletes with Heart Disease: Update 2020\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eItalian Society of Sports Cardiology and the Italian Sports Medicine Federation\u003c/p\u003e\n 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2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes of all levels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEAPC EACVI 2018 [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e65\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThe Multi-modality Cardiac Imaging Approach to the Athlete\u0026apos;s Heart: An Expert Consensus of the European Association of Cardiovascular Imaging; European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) Joint Position Statement: Recommendations for the Indication and Interpretation of Cardiovascular Imaging in the Evaluation of the Athlete\u0026apos;s Heart\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEuropean Association of Cardiovascular Imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes, elite athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEFSMA 2015 [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThe Pre-participation Examination in Sports: EFSMA Statement on ECG for Pre-participation Examination\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEuropean Federation of Sports Medicine Associations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope, 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erecreational to elite athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEFSMA 2021 [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePreparticipation Medical Evaluation for Elite Athletes: EFSMA Recommendations on Standardised Preparticipation Evaluation Form in European Countries\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEuropean Federation of Sports Medicine Associations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope, 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eelite athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEHRA EACPR 2017 [\u003cspan class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePre-participation Cardiovascular Evaluation for Athletic Participants to Prevent Sudden Death: Position Paper from the EHRA and the EACPR, Branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEuropean Heart Rhythm Association, European Association for Cardiovascular Prevention and Rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope, 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e13%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eESC 2021 [\u003cspan class=\"CitationRef\"\u003e66\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEuropean Society of Cardiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope, 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral population (including cancer survivors), athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eESC 2022 [\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e2022 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEuropean Society of Cardiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope, 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emiddle aged and older individuals, athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFATC 2014 [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eFemale Athlete Triad Coalition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efemale athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFMATC 2021 [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e62\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThe Male Athlete Triad \u0026ndash; A Consensus Statement from the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis; Part II: Diagnosis, Treatment, and Return-To-Play\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eFemale and Male Athlete Triad Coalition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emale athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFSC 2019 [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFrench Society of Cardiology Guidelines on Exercise Tests (Part 1): Methods and Interpretation; (Part 2): Indications for Exercise Tests in Cardiac Diseases\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eFrench Society of Cardiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFrance, 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIOC 2013 [\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eHow to Minimise the Health Risks to Athletes Who Compete in Weight-sensitive Sports Review and Position Statement on Behalf of the Ad Hoc Research Working Group on Body Composition, Health and Performance, Under the Auspices of the IOC Medical Commission\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eInternational Olympic Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorld, 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes in weight-sensitive sports\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIOC 2017 [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eExercise and Pregnancy in Recreational and Elite Athletes: 2016/2017 Evidence Summary from the IOC Expert Group Meeting, Lausanne. Part 5. Recommendations for Health Professionals and Active Women\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eInternational Olympic Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorld, 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epregnant and postpartum recreational and elite athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIOC 2018 [\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e61\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThe IOC Consensus Statement: Beyond the Female Athlete Triad \u0026ndash; Relative Energy Deficiency in Sport (RED-S); International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eInternational Olympic Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorld, 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eathletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNATA 2012 [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNational Athletic Trainers\u0026apos; Association Position Statement: Preventing Sudden Death in Sports\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNational Athletic Trainers\u0026rsquo; Association\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eparticipants in organised sports\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNATA 2013 [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThe Inter-association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-practices Recommendations\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eUnclear (several)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth America, 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esecondary school athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNATA 2014 [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNational Athletic Trainers\u0026apos; Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNational Athletic Trainers\u0026rsquo; Association\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eparticipants in organised sports\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNATA 2015 [\u003cspan class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eInter-association Recommendations for Developing a Plan to Recognize and Refer Student-athletes with Psychological Concerns at the Secondary School Level: A Consensus Statement\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eUnclear (several)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esecondary school athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNCAA 2016 [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eInter-association Consensus Statement on Cardiovascular Care of College Student-athletes\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNational Collegiate Athletic Association\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecollege athletes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Quality of included documents\u003c/h2\u003e\n \u003cp\u003eOverall, the quality of the documents was low for both domains selected for appraisal. The quality appraisal for domain 3, \u0026lsquo;Rigour of Development\u0026rsquo;, resulted in a median score of 13% (range 4\u0026ndash;42%). Domain 6, \u0026lsquo;Editorial Independence\u0026rsquo;, was rated with a median score of 21% (range 0\u0026ndash;75%).\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e depicts the results per document and domain. The detailed quality assessments with reasons are provided as Supplementary Information (Supplement III).\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Key results\u003c/h2\u003e\n \u003cp\u003eWe extracted 305 recommendations. Of these, 11.8% (36/305) referred to recreational athletes, while 88.2% (269/305) addressed organised sports and/or competitive athletes. The recommendations referred to various topics (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). We provide an overview of all recommendations that we extracted, grouped by topic, as Supplementary Information (Supplement IV). Additionally, the full data extraction form is provided as Supplement V.\u003c/p\u003e\n \u003cp\u003eA total of 12.8% (39/305) of recommendations were directly linked to evidence from 57 primary studies. The LoEs for those primary studies were distributed as follows: 5.3% (5/57) at LoE1, 21.1% (12/57) at LoE2, 29.8% (17/57) at LoE3 and 43.9% (25/57) at LoE4. In 266 of the 305 recommendations (87.2%), there was no direct link to evidence from primary studies. The strengths of the recommendations according to the SORT were as follows: 1.3% of recommendations (4/305) were rated A, 4.6% (14/305) were rated B and 24.3% (74/305) were rated C. Of the 305 recommendations, 213 (69.8%) were extracted from the text and not explicitly labelled as recommendations by the authors (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.1 Administration\u003c/h2\u003e\n \u003cp\u003eFor recreational athletes, we did not identify any recommendations related to PPE administration. Standardisation of PPE was recommended for organised sports and competitive athletes, including (digital) standardised questionnaires and forms [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e]. Furthermore, it was recommended that PPE be performed in time to allow for additional evaluations as necessary [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. Some organisations recommended a complete PPE every two to three years and/or if the level of participation changes, complemented by yearly history taking [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eIn the USA, the American Academy of Pediatrics (AAP) prefered individual examinations [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], while the National Athletic Trainers\u0026rsquo; Association (NATA) considered individual and station-based examinations to be equivalent [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. It was emphasised that previous examination results should be made available to the examiner and that further examinations and specialists need to be accessible [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.2 Indications for pre-participation evaluation\u003c/h2\u003e\n \u003cp\u003eFor recreational athletes, the American College of Sports Medicine (ACSM) recommended in 2021 that the need for PPE should be determined in advance [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] by consulting qualified sports or health professionals or by using the Physical Avidity Readiness Questionnaire Plus (PAR-Q+) [\u003cspan class=\"CitationRef\"\u003e71\u003c/span\u003e]. An international collaboration of organisations did not recommend PPE for people who intend to be physically active at light to moderate intensity [\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eIn the USA, pregnant women were recommended to undergo PPE to identify possible contraindications to sports during pregnancy [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. Some organisations also recommended PPE for specific populations of cancer survivors, e.g. those with comorbidities or metastatic disease [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.3 Scope and test selection\u003c/h2\u003e\n \u003cp\u003eFor recreational athletes, the ACSM [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] in 2021 recommended laboratory testing \u0026lsquo;depending on individual risk factors, signs, and symptoms\u0026rsquo;. According to the 2019 AAP recommendations [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], screening tests for organised sports and competitive athletes also depend on findings from the medical history and physical evaluation. In the context of elite athletes, the European Federation of Sports Medicine Associations (EFSMA) [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e] recommended thorough PPE, including diverse laboratory and imaging diagnostics, in 2021.\u003c/p\u003e\n \u003cp\u003eFor athletes with disabilities, it was recommended that problems typically related to the disability in question should be monitored [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.4 Medical and family history\u003c/h2\u003e\n \u003cp\u003eIn the USA and Europe, thorough medical and family history taking was recommended, regardless of the level of participation [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]. This could include past diagnoses or medical procedures, results of physical examinations and laboratory testing, symptoms, illnesses, medications, recreational substance consumption (e.g. alcohol or tobacco), training and work history [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eThere were additional recommendations for specific topics pertinent to athletes with disabilities, e.g. renal problems, devices or assistive equipment, catheterisation, self-care and mobility [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. For cancer survivors, comorbidities had to be considered, as well as whether the cancer treatment increased the risk of fractures, cardiovascular events, neuropathies or musculoskeletal disorders [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.5 Physical examination\u003c/h2\u003e\n \u003cp\u003eSeveral components of a physical examination can be included in PPE. These components may be related to anthropometrics, internal medicine, neurology, orthopaedics, dermatology, urology, gynaecology, ophthalmology, dentistry, psychiatry or nutrition. Some organisations suggested mandatory physical examinations for the population of interest. These could be supplemented based on the findings of their medical and family history [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eIn pregnant and postpartum women, a supplemental nutritional assessment and an assessment of contraindications were recommended [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. For athletes with disabilities, it was recommended to examine the skin for harm due to friction, shearing or pressure from a wheelchair or other assistive devices and to check bladder catheters [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.6 Anthropometrics\u003c/h2\u003e\n \u003cp\u003eAll recommendations for anthropometrics applied to organised sports and competitive athletes. In 2019, the AAP [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e] recommended measuring height, weight and BMI (considering the higher muscle mass of some athletes) to diagnose underweight and overweight. In children, growth curves were recommended to be used [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. For European elite athletes, the EFSMA [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e] complemented these measures with somatoscopy and other body measurements, as well as mobility and strength, in their 2021 recommendations.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.7 Nutrition\u003c/h2\u003e\n \u003cp\u003eWe did not identify any nutrition-related recommendations for recreational athletes. All recommendations addressed organised sports and competitive athletes. These were related to energy-balanced eating, as well as disordered eating and eating disorders (DE/ED). It was recommended to include DE/ED in routine assessments [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e]. The International Olympic Committee (IOC) provided a risk assessment model for this context [\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e]. If DE/ED is suspected, an \u0026lsquo;Anthropometric, Biochemical, Clinical, Dietary and Environmental (ABCDE) Assessment\u0026rsquo; was recommended for further investigation [\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e]. Other screening tools mentioned by the American Academy for Family Physicians (AAFP) in 2017 [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e] were SCOFF questions [\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e], Eating Disorder Inventory (EDI) [\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e] and Low Energy Availability in Females Questionnaire (LEAF-Q) [\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eFor elite athletes, the EFSMA [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e] specifically recommended a comprehensive nutritional assessment in 2021.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003e\u003cem\u003e3.3.8 Male and female athlete triads\u003c/em\u003e\u003c/h2\u003e\n \u003cp\u003eFor female participants in organised sports and competitive athletes, screening for a triad is recommended as part of PPE in the USA [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]. For male athletes, targeted screening questions were also recommended [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e62\u003c/span\u003e]. Screening for triads should begin at school age and should include a medication history (particularly hormones) [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]. Any identified element of the female athlete triad (underweight, amenorrhea or decreased bone density) should prompt further investigation for the presence of the other elements [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]. Further investigation was recommended for abnormal menstruation [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e] or underweight [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. European guidelines and consensus documents did not address the male or female athlete triad, however.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.9 Heat and hydration\u003c/h2\u003e\n \u003cp\u003eHistory questions about heat illness and risk factors, including fluid intake, training intensity, acclimatisation and screening for the sickle cell trait, were recommended for competitive athletes and in organised sports in the USA [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.10 Internal medicine\u003c/h2\u003e\n \u003cp\u003eIn general, cardiologic recommendations included a cardiac medical and family history and a physical examination for all athletes. Recommendations for further cardiologic investigations (e.g. electrocardiography [ECG]) varied according to participation level, age and other risk factors, as well as region (e.g. USA vs Europe). For example, in 2021, the European Society of Cardiology (ESC) [\u003cspan class=\"CitationRef\"\u003e66\u003c/span\u003e] recommended stratifying cardiologic assessments for people\u0026thinsp;\u0026gt;\u0026thinsp;35 years of age according to their individual cardiovascular risk, which should be evaluated using the SCORE2 instrument [\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e]. According to the ACSM recommendations of 2019 [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e], all cancer survivors should be screened for cardiovascular disease and receive a cardiopulmonary exercise test, if deemed necessary. The ESC [\u003cspan class=\"CitationRef\"\u003e66\u003c/span\u003e] recommended in 2021 that cancer survivors who received cardiotoxic therapeutics should undergo echocardiography before exercising at high intensity.\u003c/p\u003e\n \u003cp\u003eIn the context of organised sports and competitive athletes, recommendations for ECG as a baseline cardiologic examination were inconsistent. In Europe, a 12-lead ECG was generally recommended [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e64\u003c/span\u003e]. In North America, a positive (family) history and/or physical examination was sometimes required [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e] and, in some cases, a decision was made depending on resources [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e], or a shared decision-making approach was chosen [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eFurther cardiologic recommendations addressed the interpretation of cardiac imaging in athletes, which can be found in the Supplementary Information (Supplement IV).\u003c/p\u003e\n \u003cp\u003eIn the context of pneumological screening, no specific recommendations could be identified for recreational athletes. For organised sports in the USA, a thorough history taking and physical examination were recommended when asthma is suspected [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eExcept in the 2021 EFSMA recommendations for elite athletes [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e], specific blood and urine tests were not routinely recommended but could be considered depending on risk factors and findings from medical history and physical examinations [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.11 Orthopaedics\u003c/h2\u003e\n \u003cp\u003eWe did not identify any orthopaedic recommendations for recreational athletes. For organised sports and athletes of all levels, it was recommended to start with a history of injuries and surgeries, as well as a physical examination [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]. The results of these examinations could then be used to determine whether further diagnostic assessments were necessary [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eFor female athletes, particular attention should be paid to risks for anterior cruciate ligament injuries, patellofemoral pain and musculoskeletal deficits [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Recommendations for athletes with disabilities included an examination of the stability, flexibility and strength of stressed and frequently injured sites [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.12 Neurology\u003c/h2\u003e\n \u003cp\u003eThere were no neurological recommendations for recreational athletes. For organised sports and elite athletes, a thorough neurological examination was recommended for athletes with a history of concussion, seizures, cervical stenosis or spinal cord injury [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]. The AAFP [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e] recommended in 2016 that all athletes undergo a neurological and cervical spine examination to prevent cervical spine injuries.\u003c/p\u003e\n \u003cp\u003eAccording to the AAP recommendations of 2019 [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], athletes with physical impairments should receive a complete neurological assessment. In the same year, the ACSM [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e] recommended an assessment of balance and mobility for older cancer survivors and those who received neurotoxic chemotherapy.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec28\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.13 Psychiatry\u003c/h2\u003e\n \u003cp\u003eSpecific screening recommendations for psychiatric issues were not available for recreational athletes. For participants in organised sports and athletes, it was recommended to supplement medical history taking with questions about mental health [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec29\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.14 Advice to participants\u003c/h2\u003e\n \u003cp\u003eAs part of PPE, some organisations recommended counselling sports participants about health risks and preventive measures [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e]. For recreational athletes, the ACSM [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] recommended in 2021 that \u0026ldquo;pregnant women should be educated on the warning signs for when to stop exercise\u0026rdquo;.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec30\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.15 Clearance\u003c/h2\u003e\n \u003cp\u003eIn its 2019 recommendations, the AAP [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e] provided a list of key questions practitioners should consider (Box 1).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBox 1. American Academy of Pediatrics\u0026rsquo; recommendations for sports participation clearance\u003c/strong\u003e [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eDoes participation put the athlete at risk for illness or injury above the inherent hazards of the activity?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eDoes participation increase the risk of injury or illness for other participants?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eWill treatment of the underlying condition allow safe participation (medication, rehabilitation, bracing and padding)?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eCan limited participation be allowed while treatment or evaluation is completed?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eIf medical eligibility is denied for certain sports because of medical or safety concerns, can the athlete safely participate in other activities or sports?\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eMoreover, cardiovascular abnormalities should be further evaluated before starting or continuing high-intensity exercise [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Further details were provided in specialist guidelines for cardiovascular disease in athletes, but these were beyond the scope of this review. In the case of athlete triads or relative energy deficiency in sport (RED-S), the use of risk assessment tools was recommended to guide clearance decisions [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e62\u003c/span\u003e]. For athletes with disabilities, inclusion should be the primary consideration, along with safety issues [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003e[1] These are henceforth referred to as \u0026lsquo;documents\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis review identified numerous recommendations for performing PPE in sports medicine. Most of them were directed at participants in organised sports or competitive athletes, while fewer recommendations addressed PPE of recreational athletes. These were also often limited to specific subgroups, such as pregnant women or cancer survivors, and did not cover important topics that affect injury prevention, such as orthopaedics or nutrition [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost organisations agreed that essential components of PPE include thorough medical and family history taking and a physical examination in all populations. Several organisations recommended a stepwise approach to PPE in which follow-up questions and examinations are chosen based on the results of the mandatory history taking and physical evaluations [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarying and sometimes even contradictory recommendations existed for blood and urine testing, exercise stress testing and imaging, especially in the context of cardiovascular PPE. An example is the controversial use of ECG in North American versus European organisations. In North America, the use of ECG screening is more restricted than in Europe and is usually dependent on specific conditions (e.g. risk factors identified by medical or family history) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOnly a few recommendations were based on evidence; most recommendations seemed to be derived largely from expert experience and consensus. This is not surprising, as robust evidence for the positive effects of PPE on patient-relevant health outcomes is scarce [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. The lack of evidence and reliance on consensus probably contributed to the heterogeneity among recommendations from different organisations and regions. Methodological and organisational challenges in the design and conduct of screening trials also suggest that prospective high-quality studies will continue to be limited [\u003cspan additionalcitationids=\"CR80\" citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe lack of evidence on which to base recommendations was the main driver for the poor ratings of the included documents in the \u0026lsquo;Rigour of Development\u0026rsquo; domain of the AGREE II tool. This is consistent with the findings of Riding et al., who systematically reviewed guidelines for cardiovascular PPE [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. Riding et al. found that \u0026lsquo;Rigour of Development\u0026rsquo; scored lower than any of the other AGREE II domains. According to the authors, the poor-quality appraisal scores of guidelines in preventive sports medicine are attributable more to the limitations in this area of research than to the rigour applied by the guideline groups [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. In addition to limited underlying evidence, we perceived poor reporting to be another concern. Both AGREE II domains were given lower ratings due to the lack of available information on guideline methodology, funding and conflict of interest management. Therefore, the use of standardised methods and guidance for the development and reporting of guidelines (e.g. the Reporting Items for practice Guidelines in HealThcare) [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e] is desirable.\u003c/p\u003e \u003cp\u003eThe lack of solid evidence equally applies to the potential harms of PPE [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e], which need to be discussed to provide a balanced overview. One such harm was proposed to be psychological distress in athletes caused by true-positive or false-positive results [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. Hill et al. conducted an SR of the psychological distress of athletes caused by cardiovascular PPE [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. While their study showed that PPE generally caused only minimal or no psychological distress to athletes and made them feel safer, a few athletes with true-positive findings did experience distress. According to the authors, this may have been related to follow-up evaluations, sports restrictions or disqualifications [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. However, psychological distress affecting a minority of people screened can be justified if positive health outcomes are likely achieved through PPE and appropriate follow-up measures.\u003c/p\u003e \u003cp\u003eThe decisions surrounding which components to include in PPE may be seen as health decisions, for which evidence for the superiority of one intervention (to screen) over another (not to screen) is either not available or does not allow for differentiation [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]. In this context, the best choice depends on how individuals value the risks and benefits of the interventions, and shared decision-making about the scope of PPE should be the norm.\u003c/p\u003e \u003cp\u003eDespite the uncertainties associated with its benefits and harms, PPE may be a tool for ensuring that current health problems are managed appropriately and for determining whether a person is medically able to engage in a particular sport [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Implications of the research\u003c/h2\u003e \u003cp\u003eMore robust evidence for the effects of PPE on health outcomes is needed. Studies on preventive health examinations that aim to collect patient-relevant outcomes face particular methodological challenges associated with randomisation, large sample sizes and long-term follow-up [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e]. Large cluster-randomised trials [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e], registry-based studies or national cohorts may be the best approach to obtain robust evidence in this context. This might include population-based registries for fatal events or sports-related injuries, analysis of data from health insurance providers or the prospective collection and evaluation of data on preventive health examinations, including follow-up examinations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Limitations\u003c/h2\u003e \u003cp\u003eThis SR had several limitations. First, we included only documents published in English and German, so potentially relevant documents published in other languages were not included. Second, many recommendations were extracted directly from the text, as not all documents included recommendations labelled as such. We felt it was important to include these documents and extract recommendations from the text due to their coverage of highly relevant topics and their language suggesting that recommendations were being provided. To mitigate the subjectivity of this process, we performed thorough quality assurance of extractions. Third, due to resource restrictions, we applied only domains 3 and 6 of the AGREE II tool to quality appraisal and were unable to provide information about the other domains. However, these domains contain the most informative items for assessing the underlying methods and evidence used to develop recommendations, as well as the potential effects of funding or conflicts of interest. In a survey of guideline and AGREE II users, these domains had the strongest influence on the overall assessment of guideline quality and recommendations for use [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003e Our review identified recommendations for most components of PPE, ranging from indications and scope to individual diagnostic tests. They helped to define the scope of and clinical questions for the PPE guideline currently being developed in Germany. Most recommendations identified in this review addressed competitive athletes, so there is a need for a comprehensive set of recommendations for individuals who exercise in a recreational setting.\u003c/p\u003e \u003cp\u003eRecommendations for the components of PPE were heterogeneous across organisations and geographic regions and were rarely based on evidence from comparative studies. Therefore, more robust evidence for the effects of PPE on health outcomes, e.g. from large cluster-randomised trials or cohort and registry studies, is needed.\u003c/p\u003e \u003cp\u003e Reporting should be improved for future guidelines and consensus statements, both the potential benefits and harms of PPE should be considered and the preferences of the target population should be taken into account.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eABCDE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Anthropometric, Biochemical, Clinical, Dietary and Environmental (Assessment)\u003c/p\u003e\n\u003cp\u003eAAFP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Academy of Family Physicians\u003c/p\u003e\n\u003cp\u003eAAP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Academy of Pediatrics\u003c/p\u003e\n\u003cp\u003eAAOS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Academy of Orthopaedic Surgeons\u003c/p\u003e\n\u003cp\u003eAAPMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Academy of Physical Medicine and Rehabilitation\u003c/p\u003e\n\u003cp\u003eAASP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Association of Applied Sport Psychiatry\u003c/p\u003e\n\u003cp\u003eACC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American College of Cardiology\u003c/p\u003e\n\u003cp\u003eACC SECLC\u0026nbsp; \u0026nbsp; \u0026nbsp;American College of Cardiology Sports and Exercise Cardiology Leadership Council\u003c/p\u003e\n\u003cp\u003eACEP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American College of Emergency Physicians\u003c/p\u003e\n\u003cp\u003eACOG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American College of Obstreticians and Gynecologists\u003c/p\u003e\n\u003cp\u003eACS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Cancer Society\u003c/p\u003e\n\u003cp\u003eACLM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American College of Lifestyle Medicine\u003c/p\u003e\n\u003cp\u003eACRM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Congress of Rehabilitation Medicine\u003c/p\u003e\n\u003cp\u003eACSM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American College of Sports Medicine\u003c/p\u003e\n\u003cp\u003eACSEP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Australasian College of Sports and Exercise Physicians\u003c/p\u003e\n\u003cp\u003eAEPC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;AEPC\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAGREE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Appraisal of Guidelines for Research and Evaluation\u003c/p\u003e\n\u003cp\u003eAHA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Heart Association\u003c/p\u003e\n\u003cp\u003eAIS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Australian Institute of Sport\u003c/p\u003e\n\u003cp\u003eAMSSM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Medical Society for Sports Medicine\u003c/p\u003e\n\u003cp\u003eAOASM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Osteopathic Academy of Sports Medicine\u003c/p\u003e\n\u003cp\u003eAOSSM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Orthopaedic Society for Sports Medicine\u003c/p\u003e\n\u003cp\u003eAPA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Psychological Association (Division 47: Exercise and Sport Psychology)\u003c/p\u003e\n\u003cp\u003eAPHRS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Asia Pacific Heart Rhythm Society\u003c/p\u003e\n\u003cp\u003eAPTA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Physical Therapy Association\u003c/p\u003e\n\u003cp\u003eASCA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American School Counselor Association\u003c/p\u003e\n\u003cp\u003eASD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Academy for Sports Dentistry\u003c/p\u003e\n\u003cp\u003eASE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Society of Echocardiography\u003c/p\u003e\n\u003cp\u003eASSMP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Austrian Society of Sports Medicine and Prevention\u003c/p\u003e\n\u003cp\u003eBASEM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;British Association for Sports and Exercise Medicine\u003c/p\u003e\n\u003cp\u003eBSE CRY\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;British Society of Echocardiography and Cardiac Risk in the Young\u003c/p\u003e\n\u003cp\u003eCACHN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Community and Athletic Cardiovascular Health Network\u003c/p\u003e\n\u003cp\u003eCARF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Commission on Accreditation of Rehabilitation Facilities\u003c/p\u003e\n\u003cp\u003eCASEM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Canadian Academy of Sport and Exercise Medicine\u003c/p\u003e\n\u003cp\u003eCATA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Canadian Athletic Therapists Association\u003c/p\u003e\n\u003cp\u003eCATS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;College Athletic Trainers\u0026rsquo; Society\u003c/p\u003e\n\u003cp\u003eCCS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Canadian Cardiovascular Society\u003c/p\u003e\n\u003cp\u003eCDC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Centers for Disease Control\u003c/p\u003e\n\u003cp\u003eCHRS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Canadian Heart Rhythm Society\u003c/p\u003e\n\u003cp\u003eCIHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Canadian Institute of Health Research\u003c/p\u003e\n\u003cp\u003eCOC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Canadian Olympic Committee\u003c/p\u003e\n\u003cp\u003eCOPSI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Canadian Olympic and Paralympic Sport Institute Network\u003c/p\u003e\n\u003cp\u003eCPC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Canadian Paralympic Committee\u003c/p\u003e\n\u003cp\u003eCSCCA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Collegiate Strength and Conditioning Coaches Association\u003c/p\u003e\n\u003cp\u003eCSEP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Canadian Society for Exercise Physiology\u003c/p\u003e\n\u003cp\u003eCSI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Canadian Sport Institute\u003c/p\u003e\n\u003cp\u003eDVGS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Deutscher Verband f\u0026uuml;r Gesundheitssport und Sporttherapie\u003c/p\u003e\n\u003cp\u003eEA4SD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;European Association for Sports Dentistry\u003c/p\u003e\n\u003cp\u003eEACPR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;European Association for Cardiovascular Prevention and Rehabilitation\u003c/p\u003e\n\u003cp\u003eEACVI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;European Association of Cardiovascular Imaging\u003c/p\u003e\n\u003cp\u003eECG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;electrocardiography\u003c/p\u003e\n\u003cp\u003eECSEP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;European College of Sports and Exercise Physicians\u003c/p\u003e\n\u003cp\u003eEDI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Eating Disorder Inventory\u003c/p\u003e\n\u003cp\u003eEFSMA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;European Federation of Sports Medicine Associations\u003c/p\u003e\n\u003cp\u003eEHRA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;European Heart Rhythm Association\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEAPC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;European Association of Preventive Cardiology\u003c/p\u003e\n\u003cp\u003eESC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;European Society of Cardiology\u003c/p\u003e\n\u003cp\u003eESSA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Exercise and Sports Science Australia\u003c/p\u003e\n\u003cp\u003eFATC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Female Athlete Triad Coalition\u003c/p\u003e\n\u003cp\u003eFMATC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Female and Male Athlete Triad Coalition\u003c/p\u003e\n\u003cp\u003eFIFA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;F\u0026eacute;d\u0026eacute;ration Internationale de Football Association\u003c/p\u003e\n\u003cp\u003eGIN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Guidelines International Network\u003c/p\u003e\n\u003cp\u003eHRS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Heart Rhythm Society\u003c/p\u003e\n\u003cp\u003eHSF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Heart and Stroke Foundation\u003c/p\u003e\n\u003cp\u003eIAEHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Italian Association of Extra-hospital Cardiologists\u003c/p\u003e\n\u003cp\u003eIAIHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Italian Association of In-hospital Cardiologists\u003c/p\u003e\n\u003cp\u003eICISF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;International Critical Incident Stress Foundation\u003c/p\u003e\n\u003cp\u003eIOC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;International Olympic Committee\u003c/p\u003e\n\u003cp\u003eISC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Italian Society of Cardiology\u003c/p\u003e\n\u003cp\u003eISSP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Society of Sports Psychiatry\u003c/p\u003e\n\u003cp\u003eLASECS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;LASECS\u003c/p\u003e\n\u003cp\u003eLEAF-Q\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low Energy Availability in Females Questionnaire\u003c/p\u003e\n\u003cp\u003eLoE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Level of Evidence\u003c/p\u003e\n\u003cp\u003eNAIAAA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Interscholastic Athletic Administrators Association\u003c/p\u003e\n\u003cp\u003eNASMPA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Norwegian Association of Sports Medicine and Physical Activity\u003c/p\u003e\n\u003cp\u003eNATA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Athletic Trainers\u0026rsquo; Association\u003c/p\u003e\n\u003cp\u003eNCAA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Collegiate Athletics Association\u003c/p\u003e\n\u003cp\u003eNCCN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Comprehensive Cancer Network\u003c/p\u003e\n\u003cp\u003eNCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Cancer Institute\u003c/p\u003e\n\u003cp\u003eNCSF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Council on Strength and Fitness\u003c/p\u003e\n\u003cp\u003eNFHS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Federation of State High School Associations\u003c/p\u003e\n\u003cp\u003eNIH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Institutes of Health\u003c/p\u003e\n\u003cp\u003eNSCA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Strength and Conditioning Association\u003c/p\u003e\n\u003cp\u003ePAR-Q+\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Physical Activity Readiness Questionnaire Plus\u003c/p\u003e\n\u003cp\u003ePERSiST \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science\u003c/p\u003e\n\u003cp\u003ePICO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Population, Intervention, Comparison, Outcome\u003c/p\u003e\n\u003cp\u003ePRISMA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e\n\u003cp\u003ePPE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;pre-participation evaluation\u003c/p\u003e\n\u003cp\u003eRDSPT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Royal Dutch Society for Physical Therapy\u003c/p\u003e\n\u003cp\u003eRED-S\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Relative Energy Deficiency in Sports\u003c/p\u003e\n\u003cp\u003eSASMA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;South African Sports Medicine Association\u003c/p\u003e\n\u003cp\u003eSBC-DERC\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Brazilian Society of Cardiology \u0026ndash; Department of Exercise and Rehabilitation\u003c/p\u003e\n\u003cp\u003eSBM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Society for Behavioral Medicine\u003c/p\u003e\n\u003cp\u003eSCCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Society of Cardiovascular Computed Tomography\u003c/p\u003e\n\u003cp\u003eSCG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sports Cardiology Group\u003c/p\u003e\n\u003cp\u003eSCMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Society for Cardiovascular Magnetic Resonance\u003c/p\u003e\n\u003cp\u003eSCOFF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;SCOFF\u003c/p\u003e\n\u003cp\u003eSDA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sports Doctors Australia\u003c/p\u003e\n\u003cp\u003eSGS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Schweizerische Gesellschaft f\u0026uuml;r Sportmedizin\u003c/p\u003e\n\u003cp\u003eSORT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Strength of Recommendations Taxonomy\u003c/p\u003e\n\u003cp\u003eSR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Systematic Review\u003c/p\u003e\n\u003cp\u003eSSC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Spanish Society of Cardiology\u003c/p\u003e\n\u003cp\u003eSSESM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Swedish Society of Exercise and Sports Medicine\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Ms Irma Hellbrecht for retrieving full texts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupervision: KG, JB; study design and protocol development: KG, JB, AW, CJ, AH; literature search: AW, KG; document selection: AW, KG, NK, CJ, AH; quality appraisal: AW, NK, KG; data extraction: AW, NK, KG, FS; level-of-evidence assessment: NK, KG; statistical analysis and narrative synthesis: KG, AW; writing the first draft of the manuscript: AW; revisions of the manuscript for important intellectual content: KG, JB, NK, AW, FS, CJ, AH; final approval of the manuscript: KG, JB, NK, AW, FS, CJ, AH.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis SR was funded by the \u0026ldquo;Deutsche Gesellschaft f\u0026uuml;r Sportmedizin und Pr\u0026auml;vention e. V.\u0026ldquo;, a non-profit organisation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAW, NK, JB, FS, CJ, KG and AH have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data are available within the paper or its supplements\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLear SA, Hu W, Rangarajan S, Gasevic D, Leong D, Iqbal R, et al. 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BMC Health Serv Res. 2018;18(1):143. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-018-2954-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-018-2954-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 20180227.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Consensus, guideline, physical activity, pre-participation examination, pre-participation screening, recommendations, sports medical screening","lastPublishedDoi":"10.21203/rs.3.rs-4099744/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4099744/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: Pre-participation evaluation (PPE) aims to support safe participation in sports. The goal of this systematic review was to\u003cem\u003e \u003c/em\u003eaggregate evidence- and consensus-based recommendations for the PPE of recreational or competitive athletes as preparation for developing a German guideline on this subject.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Five databases, including MEDLINE, were searched in August 2022. Searches on the websites of relevant guideline organisations and specialty medical associations were also performed, complemented by citation screening. We included guidelines/consensus statements with recommendations for PPE of adult recreational athletes or competitive athletes of any age, both without chronic illness. We extracted and synthesised data in a structured manner and appraised quality using selected domains of the AGREE-II tool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: From the 6611 records found, we included 35 documents. Overall, the quality of the included documents was low. Seven documents (20%) made recommendations on the entire PPE process, while the remainder focussed on cardiovascular screening (16/35, 45.7%) or other topics. We extracted 305 recommendations. Of these, 11.8% (36/305) applied to recreational athletes, while the remaining 88.2% (269/305) applied to athletes in organised or competitive sports. A total of 12.8% (39/305) of recommendations were directly linked to evidence from primary studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Many recommendations exist for PPE, but only a few are evidence based. The lack of primary studies evaluating the effects of screening on health outcomes may have led to this lack of evidence-based guidelines and contributed to poor rigour in guideline development. Future guidelines/consensus statements require a more robust evidence base, and reporting should improve.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration:\u003c/strong\u003e PROSPERO \u003ca href=\"https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=355112\"\u003eCRD42022355112\u003c/a\u003e\u003c/p\u003e","manuscriptTitle":"Pre-participation evaluation of recreational and competitive athletes – A systematic review of guidelines and consensus statements","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-25 04:39:11","doi":"10.21203/rs.3.rs-4099744/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2024-05-09T17:49:29+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-21T10:06:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-15T00:59:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Sports Medicine-Open","date":"2024-03-14T17:51:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be793eee-c015-46c9-a24a-5cefa3f61aed","owner":[],"postedDate":"March 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-07T16:07:12+00:00","versionOfRecord":{"articleIdentity":"rs-4099744","link":"https://doi.org/10.1186/s40798-025-00837-6","journal":{"identity":"sports-medicine-open","isVorOnly":false,"title":"Sports Medicine-Open"},"publishedOn":"2025-04-05 15:57:22","publishedOnDateReadable":"April 5th, 2025"},"versionCreatedAt":"2024-03-25 04:39:11","video":"","vorDoi":"10.1186/s40798-025-00837-6","vorDoiUrl":"https://doi.org/10.1186/s40798-025-00837-6","workflowStages":[]},"version":"v1","identity":"rs-4099744","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4099744","identity":"rs-4099744","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}