Includes bibliographical references. / Background: One of the most common clinical decisions a Sports and Exercise Medicine (SEM) physician is required to make is whether an athlete presenting with symptoms or signs of an acute illness can participate in exercise training or competition. Currently, a clinical tool, known as the ‘neck check’ is used to determine eligibility to participate in exercise training or competition athletes with acute illness. This original clinical tool, first described about 20 years ago, was based mainly on an abbreviated medical history and findings of a clinical examination were excluded. Symptoms of illness ‘above-the-neck’ e.g.sneezing, rhinorrhoea or sinus congestion constitute a ‘passed’ “neck check”, whereas ‘below-the-neck’ symptoms e.g.cough and/or systemic symptoms such as fever and myalgia, constitute a ‘failed’ “neck check”. However, in the current literature, there remain very few data regarding 1) the adherence of athletes to advice given following a ‘neck check’, and 2) whether the exercise performance (e.g.the ability to finish a race) or the development of medical complications during exercise is different in athletes who “passed” or “failed” the ‘neck check’. Objective The main objectives of this dissertation are: 1) to review the available evidence with respect to medical assessment and participation risk in endurance runners presenting with symptoms of acute illness before a road race; 2) to document the range of acute illnesses in runners presenting in the 3 days before a race; 3) to determine adherence to advice given by medical staff to these runners, and 4) to determine the effects of the outcomes of the medical assessment on running performance particularly, the ability to finish the race and the medical complications experienced during the race. These data are important to improve the medical care of runners (and other athletes) presenting with acute illness before training and competition. Methods: Phase 1: Review of the literature All literature relating to the epidemiology of acute illness in athletes, risk factors for illness, and participation risk, potential medical complications and effects on performance of exercising whilst ill were sourced using established electronic databases (PubMed, Medline, Google Scholar). In addition, literature related to the background of the ‘neck check’, as well as the evolution of the current RTP guidelines in athletes with acute illness were sourced. Phase 2: Research study In a prospective cohort study, 242 runners who presented to a pre-race registration medical facility with medical concerns were assessed by SEM physicians by means of medical history and physical examination (if indicated) using a specific Pre-Race acute Illness Medical Assessment (PRIMA group). 172 of these runners had evidence suggesting acute infective illness (PRIMA-I group) and 70 runners had non-infective complaints (PRIMA-N/I group). The epidemiology (prevalence rate = % runners) of runners with symptoms, signs and specific clinical diagnoses of acute illnesses were documented in the PRIMA-I group. Following clinical evaluation, all the runners in the PRIMA-I group were then advised regarding clearance to run the race, monitoring symptoms, or not running the race, using the ‘neck check’ as a guideline. Runners in the PRIMA cohort were then tracked during and immediately after the race, and the following parameters were compared to those in a control group of runners not presenting to the medical facility at registration (CON=53 734): 1) incidence of not starting of the race (per 1000 runners) (DNS rate), 2) incidence of not finishing the race in those who started (per 1000 runners) (DNF rate), and 3) incidence of medical complications during the race in those who started (per 1000 runners) (MC rate). Results Phase 1: Review The main finding of the review is the relative paucity in clinical data with respect to participation in athletes with acute illness. Upper respiratory tract symptoms are very common in athletes, and the risk factors are discussed. Furthermore, there are different aetiologies underlying athletes’ URT symptoms (other than infection). The documented risks of exercising when systemically ill include sudden cardiac death and reduced pulmonary function, splenic rupture in patients with infectious mononucleosis, and dehydration and electrolyte disturbances when exercising with acute gastro-intestinal illness. There is little evidence in the literature regarding the effects of illness on performance; these include reduced performance, non-participation and the potential effects of WARI (wheezing after respiratory tract infection). Evidence supporting the two aspects of the neck check is reviewed: the presumed safety of exercising with localised URT symptoms, and the perceived risk of exercising with lower respiratory tract or systemic symptoms. Clinical data are severely lacking, and the available data are based on self-reported symptomatology. There are no published data regarding the use of the ‘neck check’ as a participation guideline. Phase 2: In the PRIMA-I cohort of 172 runners, the most common symptoms were sinus congestion (40.1%), cough (38.2%), sore throat (37.8%) and runny nose (25.6%). More than half the cohort (57.5%) had a diagnosis of localised URTI. However, URTI with generalised symptoms was the single most common diagnosis (22.7%). In the PRIMA-I group, 41.3% of the runners failed the ‘neck check’. Compared with the CON group, there was no significant difference in the DNS rate in the PRIMA-I group. However, in those runners who were advised not to run, the DNS rate was 565 per 1000 runners, and this was significantly higher than that of the CON group (192 per 1000 runners) (p<0.0001). PRIMA-I race starters had a higher DNF rate (31 per 1000 runners), and runners with any medical concerns (PRIMA group) had a significantly higher DNF rate (37 per 1000 runners) compared to the CON group of runners who started the race (15 per 1000 runners) (p= 0.0329). There were no documented medical complications in the PRIMA-I group who started the race, while the MC rate of the CON group was 6.7 per 1000 runners. In runners in the PRIMA-I group who had been advised not to run, 43.5% were non-adherent, and started the race despite this advice. Conclusion: Our study indicates that localised upper respiratory tract infection is responsible for the majority of acute illness in a pre-race cohort of runners. Furthermore, the data provide some evidence that it is safe for runners with acute illness to exercise if they pass the ‘neck check’. However, presenting to a pre-race registration medical facility, failing the ‘neck check’ and receiving advice against participation appear to increase the risk of not finishing a race. There is also concern about the high rate of non-adherence to advice given by the SEM physician. Finally, a pre-race registration medical assessment for runners with acute illness may reduce the risk of developing short-term medical complications during the race.

Background: Tower Hamlets is a socioeconomically disadvantaged borough, home to the UK’s largest South Asian population, a group at increased risk of obesity-related diseases. Previous studies in this population have reported high levels of adiposity and inactivity. No borough-wide study has been conducted objectively measuring physical activity patterns. This study aimed to investigate pedometer-determined activity levels of Tower Hamlets' schoolchildren, their association with adiposity and differences according to ethnicity and socioeconomic status (SES). The study was preceded by reviews investigating the association between step counts and adiposity in children and investigating the validity of pedometers as a measure of physical activity in young people. Methods: Participants were recruited from Tower Hamlets' secondary schools (n=884; 584 boys, 300 girls). A pedometer was worn for 7 days. Internationally recognised mean daily step count cut-offs (boys = 15000, girls = 12000) were used to define activity level. Body mass index (BMI), bioelectrical impedance analysis (BIA)-determined percentage body fat (%bf) and waist circumference (WC) were all measured. Children were classified as being of normal weight, overweight or obese according to international cut-off points. A questionnaire was administered to establish socioeconomic status and ethnicity. Results: A total of 884 schoolchildren were recruited (66% boys, 34% girls). Of this, 657 (74%) provided a full set of pedometer, anthropometric and socio-demographic data. Sixty-five percent of all participants were South Asian and 55% received free school meals. Significant differences in anthropometric variables were observed according to gender, ethnicity and school. The prevalence of overweight/obesity ranged widely for boys (35%, 53% and 65%) and girls (33%, 55% and 55%) according to BMI, %bf and WC, respectively. The majority of participants provided 4 or 5 days of activity data, with 15% providing data for 7 days. Inactivity was high, 83% of boys and 72% of girls failed to meet the minimum recommended daily step counts. Activity was greater during the week compared to the weekend and those that were most active during the week were also more active at the weekend. Boys (11580±3560) took significantly more steps than girls (10062±3239) and differences were also observed between schools. No significant differences in activity levels were observed according to ethnicity, SES or adiposity levels. Conclusion: The vast majority of schoolchildren in Tower Hamlets fail to reach current physical activity recommendations, irrespective of ethnicity or socioeconomic class. Inactivity is greater at the weekend. The prevalence of overweight/obesity is also higher than national averages. Intervention strategies to increase physical activity and tackle overweight/obesity in this cohort are required.

Background: Participation in sport by athletes with impairment has grown and evolved rapidly since the inception of the Paralympic Games. Athletes with visual impairment were first included in the Paralympic Games in 1976. Surveillance of illnesses and injuries forms the first important step in determination of the epidemiology and an understanding of the risk factors for both illness and injuries in these populations. Thus, surveillance can therefore assist medical teams in implementing prevention strategies. Few studies have evaluated the incidence of illness and injuries amongst athletes with impairment. For this reason, a novel web based injury and illness surveillance system (WEBIISS) was developed for use by the team physicians at the London 2012 Paralympic Games. To our knowledge, no study has specifically researched the epidemiology of illness and injuries in athletes with visual impairment during a major sport event such as the Paralympic Games. Objective: To determine the incidence associated with illness and injuries in athletes with visual impairment during the London 2012 Paralympic Games. We further aim to describe any differences between sports, age groups, gender and body systems affected in this cohort of athletes. Methods: This study was a retrospective analysis of a component of the large prospective cohort study on the epidemiology of injury and illness conducted over a 14-day period at the London 2012 Paralympic Games. The data from 711 of the 791 athletes with visual impairment who participated in the London 2012 Paralympic Games were analyzed. The following data sources were used: Firstly, de-identified information regarding age, gender, impairment, country code and sports code of athletes obtained from the International Paralympic Committee database. Secondly, information collected from the electronic medical data capture system (EMDCS) used at all the London Organizing Committee for the Olympic and Paralympic Games (LOCOG) medical stations; and thirdly a novel web-based injury and illness surveillance system (WEB-IISS) used by the team physicians. This is the most comprehensive reporting system used in elite athletes with impairment to date. Data were collected on a daily basis from 3 days prior to the start of the Paralympic Games (pre-competition period) until the last day of the 11-day Paralympic Games (competition period). Definitions: In order to determine the nature and extent of illnesses and injuries as well to enable uniformity in research studies evaluating the data collected during the London 2012 Paralympic Games, the following definitions were implemented: Illness was defined as 'any newly acquired illness as well as exacerbation of pre-existing illness that occurred during training or competition, and during or immediately before the London 2012 Paralympic Games'. Injury was defined as 'any newly acquired injury as well as exacerbation of pre-existing injury that occurred during training and/or competition period of the London 2012 Paralympic Games'. Incidence rate (IR) of illness or injury is the number of illnesses or injuries per 1000 athlete days. Incidence proportion (IP) of illness or injury is the proportion of athletes affected by illness or injury (n/100). Results: Incidence rate of illness (IR 11.9; 95% CI 9.0 - 15.7) was similar to incidence rate of injuries (IR 14.5; 95% CI 11.3 - 18.5) in VI athletes. The IR of illness for VI athletes (IR 11.9; 95% CI 9.0 - 15.7) compared well to that of illness for all impairment groups (IR 12.7; 95% CI 10.2 - 16.0). Furthermore, the IR of injuries for VI athletes (IR 14.5; 95% CI 11.3 -18.5) compared well to that of injuries for al impairment groups (IR 12.6; 95% CI 10.3 - 15.4). Gender and age did not affect the risk of illness or injuries in VI athletes. Furthermore, there was a higher IR of illness for swimmers with visual impairment compared to other sports, but this was not statistically significant. The IR of illness for VI athletes participating in swimming was 12.5 (95% CI 8.8 - 17.8) compared to that of VI non-swimmers, IR 11.8 (95% CI 8.9 - 15.6). Participation in athletics (track and field) was associated with a slightly higher risk for injury for athletes with VI compared to other sports, but this was not statistically significant. The IR of injury was 15.8 (95% CI 11.6 - 21.5) and the IP 22.1 (95% CI 16.3 - 30.1) for VI track and field athletes. The IR of injury was 13.0 (95% CI 9.6 - 17.4) and IP 18.1 (95% CI 13.5 - 24.3) amongst VI athletes not participating in track and field athletics. VI swimmers had a lower IR of injury (IR 4.1; 95% CI 1.8 - 9.5) than VI non-swimmers (IR 16.1; 95% CI 12.6 - 20.7) (p=0.002). There was a higher IR and IP of lower limb injuries compared to upper limb injuries in athletes with visual impairment. The IR for lower limb injuries in athletes with visual impairment was 7.7 (95% CI 5.8 - 10.3) and the IP was 10.8 (95% CI 8.1 - 14.4). The average IR of lower limb injuries for all para-athletes was 4.5 (95% CI 3.5 - 5.7). The IR for upper limb injuries in athletes with visual impairment was 3.0 (95% CI 1.9 - 4.5) and the IP was 4.1 (95% CI 2.7 - 6.3). The average IR for upper limb injuries for all para-athletes was 4.5 (95% CI 3.5 - 5.9). Conclusion: The findings of this study suggest that Paralympic athletes with VI had a similar incidence rate of illness and injury compared to other impairment groups; and IR of illness was similar to that of injuries. Risk of illness or injury was not affected by age group or gender, but rather sport specific differences were observed. Of particular interest was the fact that athletes with VI had a higher incidence rate of lower limb injuries than upper limb injuries.

Yes / Risk factors associated with depression in athletes include biological sex, physical pain, and history of sport-related concussion (SRC). Due to the well-documented benefits of sport and physical activity on mental health, athletes and non-athletes were recruited to assess any differences. Beyond this, athletes were also grouped by sport-type (contact/non-contact sports) due to the increased prevalence of pain and SRC in contact sports. To our knowledge, there has been no research on how these factors influence the likelihood of depression. In the current study, 144 participants completed a short survey on the above factors and the Center for Epidemiological Studies Depression Scale. Sixty-two of these reported a history of concussion. Logistic regression revealed all the above predictors to be significantly associated with the depression scale. Individuals that had previously sustained SRC, were experiencing greater physical pain and females were more likely to display poor mental health. However, we provide further evidence for the benefits of engaging in sport and physical activity as those that took part in sport were less likely to report depression. Therefore, this study provides a simple risk metric whereby sportspeople can make a better informed choice of their sporting participation, making their own cost/reward judgement.