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Para athletes present a broad range of sports-related injuries and illnesses, frequently encountering barriers when accessing healthcare services. The periodic health evaluation (PHE) is a valuable tool for continuously monitoring athletes' health, screening for health conditions, assisting in the surveillance of health problems by establishing baseline information and identifying barriers to athlete's performance. This position statement aims to guide sports healthcare providers in the PHE for Para athletes across key impairment categories: intellectual, musculoskeletal, neurological and vision. A panel of 15 international experts, including epidemiologists, physiotherapists, optometrists and physicians with expertise in Para athlete health, convened via videoconferences to discuss the position statement's purpose, methods and themes. They formed working groups to address clinical, cardiorespiratory, neuromusculoskeletal, nutritional status, mental and sleep health, concussion and female Para athlete health assessment considerations. The PHE's effectiveness lies in its comprehensive approach. Health history review can provide insights into factors impacting Para athlete health, inform physical assessments and help healthcare providers understand each athlete's needs. During the PHE, considerations should encompass the specific requirements of the sport modality and the impairment itself. These evaluations can help mitigate the common tendency of Para athletes to under-report health issues. They also enable early interventions tailored to the athlete's health history. Moreover, the PHE serves as an opportunity to educate Para athletes on preventive strategies that can be integrated into their training routines, enhancing their performance and overall health. This position statement can potentially enhance clinical translation into practice and improve the healthcare quality for Para athletes., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Injury and illness surveillance helps establish the infrastructure to provide adequate medical support at regattas and is the foundation for developing prevention strategies., Objectives: To assess the prevalence and characteristics of injuries in the 4 weeks before the start of the 2022 World Rowing Beach Sprints Finals (WRBSF) (the ' Prevalence Survey' ) and describe the incidence and nature of new-onset injuries and illnesses incurred during the WRBSF (the ' Incidence Survey' )., Methods: Athletes completed: (1) a prevalence survey recording injuries the 4 weeks before the WRBSF and (2) a recording of injuries and illnesses that occurred during the 3-day regatta., Results: Fifty-nine of 152 eligible WRBSF athletes completed the prevalence injury survey. Twenty-three (38.9%) reported experiencing at least one injury within the 4 weeks before the WRBSF. The most prevalent anatomical injury sites were the forearm (11.86%), lumbar spine (10.17%), knee (8.47%), ankle (6.78%) and hand/fingers (6.78%). During the competition, only two illness occurrences were reported; both were respiratory infections. Two athletes reported injuries: a hamstring strain and a concussion., Conclusion: Rowers presenting to the WRBSF described injuries leading up to the event that were similar to those common in classic rowing. Rowers at the event suffered injuries of the lower limb that were different from classic rowing and may be related to the addition of running to this event. An event concussion should be considered as a more likely injury in this type of rowing and future events should be prepared to manage such an injury., Competing Interests: JMD owns and operates Science of Rowing, LLC a digital publication that publishes reviews of rowing research., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aim: The participation of individuals with physical impairment in sports has numerous benefits, yet there is also the risk of sustaining sport-related injuries or illnesses. Therefore, prevention programmes of these problems are needed to ensure that individuals can maintain a healthy, active lifestyle. Currently, very few prevention interventions are accessible for these athletes. Therefore, the article aims to describe the development process of the Tailored Injury Prevention in Adapted Sports intervention, an online tailored injury and illness prevention intervention for athletes with a physical impairment., Methods: The development was guided by the Knowledge Transfer Scheme (KTS)., Results: In the first step, a cohort study and a qualitative study were conducted to define the problem statement. In the second step, a systematic review was performed in order to learn from theory. Steps 3 and 4 involved an iterative process involving collaboration with diverse expert groups. This included defining athletes' needs and creating a health problem blueprint, after which the intervention content was created. To ensure accuracy and completeness, a feedback loop was incorporated. In the final phase of this step, we refined the language used within the intervention together with athletes. Finally, an effect and process evaluation will take place in the last step of the KTS., Conclusions: Through a five-step approach of the KTS, we developed an online injury and illness prevention intervention for athletes with a physical impairment. This intervention provides direct, timely feedback based on their current health status. Furthermore, it takes the sport and the physical impairment of the athletes into account with regard to the given prevention advices., Competing Interests: EV is the editor in chief of BMJ Open Sports and Exercise Medicine, and SCML is an associate editor of para sports and epidemiology of BMJ Open Sports and Exercise Medicine., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This study explored stakeholders' perspectives on current practices, challenges and opportunities related to the return-to-sport (RTS) process in high-performance Snowsports. We conducted fourteen semi-structured interviews with athletes, coaches and health professionals from multiple countries using online video platforms. The data were transcribed verbatim and analysed based on constant comparative analysis employing the principles of Grounded Theory. Codes were grouped into categories and main concepts and a conceptual model were derived. According to the participants, RTS should be considered a continuous process to bring the athlete back to competition as fast and safely as possible, whereas speed is often prioritised over safety. Participants described the need for a structured and criteria-based process. Despite the multiple phases and the diversity of involved professionals, the process is individualised and unique, highlighting the value of having the athlete at the centre of the RTS process. It was considered essential to provide a safe environment and build trustworthy relationships. Additionally, access to resources, communication and cooperation among all experts was perceived as critical to successful RTS. Our participants described the value of continuity and an athlete-centred approach to the RTS process. The challenges, such as interprofessional communication, the lack of objective sport-specific criteria, and the diversity of resources and network structures, were perceived as practical issues that influenced the process, which should be tailored for each athlete accordingly to reach a successful RTS., Competing Interests: Competing interests: EV and CB are members of the BMJ Open Sports & Exercise Medicine (BOSEM) Editorial Board., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This paper presents an exploratory case study focusing on the applicability and value of process mining in a professional sports healthcare setting. We explore whether process mining can be retrospectively applied to readily available data at a professional sports club (Football Club Barcelona) and whether it can be used to obtain insights related to care flows., Design: Our study used discovery process mining to detect patterns and trends in athletes' Post-Pre-Participation Medical Evaluation injury route, encompassing five phases for analysis and interpretation., Results: We examined preprocessed data in event log format to determine the injury status of athletes in respective baseline groups (healthy or pathological). Our analysis found a link between thigh muscle injuries and later ankle joint problems. The process model found three loops with recurring injuries, the most common of which were thigh muscle injuries. There were no differences in injury rates or the median number of days to return to play between the healthy and pathological groups., Conclusions: This study explored the applicability and value of process mining in a professional sports healthcare setting. We established that process mining can be retrospectively applied to readily available data at a professional sports club and that this approach can be used to obtain insights related to sports healthcare flows., Competing Interests: Competing interests: Ramon Pi-Rusiñol and Gil Rodas work at the FC Barcelona Medical Department. Evert Verhagen is the Editor-in-Chief of BMJ Open Sport & Exercise Medicine., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Shared decision-making (SDM) is a trending topic in athlete health care; however, little is known about its use in a sports context. This study aimed to measure knowledge and self-perceived practice of SDM among healthcare professionals working with athletes. This study evaluates SDM attitudes and preferences and explores how healthcare professionals perceive the factors influencing SDM., Methods: A web-based cross-sectional survey with open-ended and closed-ended questions., Results: Our survey was completed by 131 healthcare professionals. The majority (63.6%) reported to prefer SDM and to be confident in their SDM skills (81.1%). Despite this inclination and confidence, only one in four clinicians reported consistent practice of SDM when feasible. Additionally, most clinicians lacked SDM knowledge. The barriers perceived by healthcare professionals included time constraints (17.6%), limited patient knowledge (17.6%), limited patient motivation (13.5%) and language barriers (16.2%). Importantly, two-thirds of the participants believed that SDM in athlete health care differs from SDM in non-athletes due to the high-pressure environment, the tension between performance and health, and the involvement of multiple stakeholders with potentially conflicting interests., Conclusions: Although healthcare professionals preferred SDM, they did not fully understand nor routinely practice it. Most healthcare professionals perceive SDM in athlete health care to differ from SDM in the general population. Therefore, to inform the implementation of SDM in athlete health care, future research is crucial to understand better what makes practising SDM unique in this setting., Competing Interests: Competing interests: SN, HPD, OD and AF declare they have no competing interests. EV is Editor-in-Chief of BMJ Open SEM., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The International Olympic Committee (IOC) Medical and Scientific Commission has supported collating and sharing evidence globally by developing sports medicine consensus statements ('Statements''). Publishing the Statements requires substantial resources that must be balanced by use and impact on policy and practice. This study aimed to gain a better understanding of awareness and uptake of the Statements globally through a survey of the National Olympic Committees (NOC), National Paralympic Committees (NPC) and International Federations (IF)., Method: A cross-sectional survey of medical commission representatives from NOCs/NPCs/IFs. A structured questionnaire was distributed through the IOC head office, informed by prior research. Questions comprised a mix of closed and open-text responses with results presented descriptively by organisation type and total., Results: 55 responses were included: 29 (52%) from NOC/NPC representatives (response rate 14%) and 26 (47%) from IF representatives (response rate 63%). All Statements had been used by at least one respondent, with the Statement addressing concussion ranked highest (used by 33/55). The main barriers to use were financial limitations (n=21), club/sport culture and behaviours (n=19) and lack of understanding from coaches/team sport personnel (n=19). Participants believed the Statements were a successful strategy for improving athlete health (n=39/51 agree or strongly agree)., Conclusion: There was clear support for the continued development of sports medicine guidance, including in the format of these Statements. To ensure Statements lead to demonstrable health benefits for athletes, input from athletes, coaches and supporting staff is needed, as well as clearer identification of the purpose and audience of each topic developed., Competing Interests: Competing interests: All authors are members of a centre affiliated with the IOC Medical Research Network, recognised for their research into the protection of athlete health research. Early results were presented and discussed in two meetings linked to the network, with attendance from representatives of 11 research centres and the IOC Medical and Scientific Commission. Neither the IOC nor its Medical Commission contributed to details and decisions about the study design, its conduct or the interpretation and discussion of results., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objective: To compare the perception towards injury risk reduction approach between athletes who have already experienced an injury and those who have not., Methods: We conducted a cross-sectional study using a one-time online survey asking athletics athletes licensed at the French Federation of Athletics (http://www.athle.fr) about their perceptions regarding injuries and injury risk reduction behaviours. We statistically compared athletes who already experienced an injury and those who did not., Results: A total of 7870 athletes were included. 90% of athletes declared having experienced at least one injury. They (1) were proportionally more men than women, (2) had significantly more years of experience in athletics, (3) had a significant difference in disciplines (more hurdles, jumps and combined events and fewer sprint athletes), (4) had a significant difference in competition levels (more national and less departmental levels) and (5) reported significantly higher values or agreements in favour of injury risk reduction approach, compared with uninjured athletes. There were significantly more athletes declaring following injury risk reduction programmes among athletes who experienced at least one injury than those who did not., Conclusions: Athletes who experienced at least one injury during their lifetime were more prone to adhere to injury risk reduction strategies than athletes who have never experienced an injury. Their entourage (coaches and health professionals) should use this fertile ground to implement injury risk reduction strategies. In addition, their experience should be disseminated to uninjured athletes to help them adhere to injury risk reduction without injury experience., Competing Interests: Competing interests: EV and PE are associate editors of the BJSM. EV is the editor-in-chief of BMJ Open Sports and Exercise Medicine. PE is the associate editor of the BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is increasing interest in the potential long-term outcomes of participation in contact and collision sports, driven by evidence of higher rates of neurodegenerative diseases among former athletes. Recent research has capitalised on large-scale administrative health data to examine health outcomes in contact sport athletes. However, there is limited research on outcomes associated with participation in rugby union, a contact sport with a relatively high incidence of head trauma and musculoskeletal injuries. Additionally, there is scope to investigate a greater range of health outcomes using large, population-based administrative data. The Kumanu Tāngata project is a retrospective cohort study that will use linked information from the New Zealand Rugby Register and health records within a comprehensive deidentified whole-population administrative research database known as the Integrated Data Infrastructure. First-class male rugby union players (N=13 227) will be compared with a general population comparison group (N=2 438 484; weighting will be applied due to demographic differences) on a range of mortality and morbidity outcomes (neurodegenerative diseases, musculoskeletal conditions, chronic physical conditions, mental health outcomes). A range of player-specific variables will also be investigated as risk factors. Analyses will consist primarily of Cox proportional hazards models. Ethics approval for the study has been granted by the Auckland Health Research Ethics Committee (Ref. AH23203). Primary research dissemination will be via peer-reviewed journal articles., Competing Interests: Competing interests: KQ has been employed by New Zealand Rugby since 2000 and currently occupies the role of Chief Scientist, New Zealand Rugby. He also sits on World Rugby’s Scientific Committee and has contributed to various World Rugby working groups focussed on player welfare issues from 2011 to the time of publication. He has received funding for flights and accommodation from World Rugby and New Zealand Rugby to attend World Rugby Medical Commission Conference meetings. KQ’s input into the project was conducted in collaboration with his coauthors, who are independent of New Zealand Rugby and World Rugby, and he declares that at no time did NZ Rugby, nor the funding agencies World Rugby and the New Zealand Rugby Foundation provide advice or input into the data analysis, interpretation of the findings, or the manuscript preparation. A copy of the submitted draft of the project was provided to the funding bodies and New Zealand Rugby at the time of submission. AJG has been a contracted concussion consultant to Rugby Australia since July 2016. He is a member of the World Rugby Concussion Working Group. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He is a member of the Australian Football League Concussion Scientific Advisory Committee. He is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant. He acknowledges unrestricted philanthropic support from the National Rugby League for research in former elite-level rugby league players. IM was employed by New Zealand Rugby from 2012 to 2019 as the Chief Medical Officer. During this time, he also held various committee appointments with World Rugby focused on player welfare matters., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Golf is an individual sport that is usually done without the supervision of a trainer or coach. Therefore, an injury prevention programme in golf will primarily be performed without supervision and feedback. However, the effectiveness of any preventive exercise programme is determined by exercise fidelity., Objective: To investigate the different instruction options of an injury prevention programme on exercise fidelity in individual golfers., Methods: We randomly assigned golfers to one of three groups receiving different exercise instructions. One group received only instructional cards (A), one received only instructional videos (B) and a third group (C) received both instructional cards and videos. The golfers were allowed to familiarise themselves with the exercises based on the provided instruction option, after which we recorded their exercise execution on video. Two authors independently scored each exercise's fidelity from these recordings., Results: In total, 18 golfers (12 women and 6 men, average age of 61.94 years) were equally divided across the 3 study groups completed 108 exercises. In group A 73.7% of exercises were executed as intended, in group B 88.6% and in group C 86.3%. Significantly more exercises were conducted correctly in groups B and C compared with group A (p<0.05)., Conclusion: Golfers who received instructions that included a video explanation had a higher exercise fidelity when compared to only written instructions., Competing Interests: Competing interests: EV is the editor in chief of BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

To explore warm-up and activation (W&A) practices in high-performance snowsports to describe their importance, application and potential improvements based on the perspectives of elite-level athletes and staff members. Qualitative study consisting of semistructured interviews with 13 international elite-level athletes, on-snow coaches, strength and conditioning coaches, sports physiotherapists and sports psychologists from different snowsports and subdisciplines: alpine skiing, freestyle skiing (park and pipe, aerials, moguls) and snowboarding (park and pipe, snowboard cross). The interviews were transcribed verbatim and analysed based on the principles of grounded theory. The main themes raised by the participants were (1) the importance of readiness for sports participation as the motive for W&A, (2) how readiness is reached with a structured W&A routine and (3) the different athlete-specific, task-specific and environmental-specific factors for optimal W&A. Athletes and staff members considered W&A an essential measure to get physically and mentally ready for sports participation. Being ready was described as a key factor for performance and injury prevention. For these athletes, adherence to W&A was the result of a process of experiencing the beneficial effects of W&A and learning from sustaining one or more injuries. Broad implementation of basic physical and mental W&A at the youth level was considered an important measure to increase the overall adoption of W&A as an inherent part of training and competition. At the elite level, W&A is performed to reach athletes' mental and physical readiness for performance enhancement and injury prevention. W&A is acknowledged as a complex and dynamic programme and is typically adapted to sport-specific demands, injury risks, environmental circumstances and individual needs and preferences. Overall, this study provides valuable contextual insights into the complexity of W&A and the factors that need to be considered to make sport-specific recommendations., Competing Interests: Competing interests: SB and EV are members of the BMJ Open Sports & Exercise Medicine (BOSEM) Editorial Board., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Snow sports such as alpine skiing or snowboarding are associated with a high risk of injury and reinjury and are subject to a very special environment with specific rehabilitation challenges that must be addressed. Due to geographic decentralisation, seasonal climatic limitations, alternation of training in off-snow and on-snow settings and unique loading patterns of practising these sports, special rehabilitation structures and processes are required compared with other sports. In addition, returning to preinjury performance requires a high level of confidence and a resumption of risk-taking in demanding situations such as high-speed skiing and high-amplitude jumps. A biopsychosocial and interdisciplinary approach can be viewed as a holistic, athlete-centred approach that promotes interprofessional communication and collaboration. This is particularly central for managing the physical/biological, psychological and social demands of injury management for snow sports. It can help ensure that rehabilitation content is well coordinated and tailored to individual needs. This is because transitions between different rehabilitation phases and caring professionals are well aligned, and rehabilitation is understood not only as purely 'physical recovery' but also as 'psychological recovery' considering the snow sports-specific setting with specific social norms. Ultimately, this may improve the rehabilitation success of snow sports athletes., Competing Interests: Competing interests: EV is the editor-in-chief of BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Non-communicable diseases (NCDs), including coronary heart disease, stroke, hypertension, type 2 diabetes, dementia, depression and cancers, are on the rise worldwide and are often associated with a lack of physical activity (PA). Globally, the levels of PA among individuals are below WHO recommendations. A lack of PA can increase morbidity and mortality, worsen the quality of life and increase the economic burden on individuals and society. In response to this trend, numerous organisations came together under one umbrella in Hamburg, Germany, in April 2021 and signed the 'Hamburg Declaration'. This represented an international commitment to take all necessary actions to increase PA and improve the health of individuals to entire communities. Individuals and organisations are working together as the 'Global Alliance for the Promotion of Physical Activity' to drive long-term individual and population-wide behaviour change by collaborating with all stakeholders in the community: active hospitals, physical activity specialists, community services and healthcare providers, all achieving sustainable health goals for their patients/clients. The 'Hamburg Declaration' calls on national and international policymakers to take concrete action to promote daily PA and exercise at a population level and in healthcare settings., Competing Interests: Competing interests: EV is Editor in Chief of BMJ Open Sports & Exercise Medicine., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Research focusing on reducing the risk of injuries has increased over the last two decades showing that prevention implementation in real life is challenging., Objective: To explore the experience and opinions of professional football stakeholders regarding injuries, their prevention and the implementation of preventive measures., Design: Qualitative study., Setting: Technical and medical staff from Qatar's premier football league., Participants: 22 professionals from 6 teams., Main Outcome: Semistructured interviews were transcribed verbatim and analysed using the thematic analysis method., Results: All the participants acknowledged the importance of injury prevention. They mentioned teamwork, trust and communication as critical factors for a successful injury prevention implementation. Teams' doctors see themselves mainly involved in the treatment and recovery process, and to a lesser degree, in the prevention process. Physiotherapists defined their primary responsibilities as screening for injury risk and providing individual exercises to players. The participants declared that the fitness coach is responsible for injury prevention implementation. All stakeholders reported that the fitness coach plays a vital role in communication by bridging the head coach and the medical staff. Stakeholders reported that the Qatari football league has a very particular context around the player, such as socioecological factors influencing injury prevention implementation., Conclusions: The fitness coach plays a vital role in the injury prevention implementation system, as one of the key actors for the process, as well as the bridge between the medical team and the head coach, resulting from their better communication with the head coaches. The findings support considering and understanding the contextual factors during the development of preventive strategies in football., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Research evidence is commonly compiled into expert-agreed consensus statements or guidelines, with an increasing trend towards their publication in peer-reviewed journals. Prominent among these has been the publication of several International Olympic Committee (IOC) tatements to help inform sport and exercise medicine (SEM) practice. This study aimed to assess the citation impact and reach of the IOC statements published between 2003 and 2020., Method: Bibliometric analysis focused on identifying core publications (original statement and linked publications) and quantifying their academic citations (number and Field-Weighted Citation Impact (FWCI)) in journal articles up to February 2022. The analysis includes descriptive data on the country of IOC statement authorship affiliations, where they were published and by whom. The extent to which the IOC statements have been cited in the peer-reviewed literature is presented, together with information about the country of authorship of the citing papers as a measure of international academic reach., Results: 29 IOC statements were composed of 61 core publications. The IOC statements have had 9535 citations from 7863 citing publications. Individual FWCI ranged from 1.2 to 24.3 for core publications. The IOC statements were coauthored by multiple authors, mostly affiliated to countries with well-resourced SEM Authors of citing publications reflected the same geographical regions (ie, the USA, Canada, Australia, UK and western Europe.)., Conclusion: Disseminating the IOC statements as open access papers in peer-reviewed journals has resulted in strong citation impact. However, this impact is centred on well-resourced academic circles that may not represent the diversity of SEM. Further research is required to identify if, and to what extent, the IOC statements have impacted SEM practice worldwide., Competing Interests: Competing interests: Several authors have been contributors to the published IOC statements reviewed in this paper. CE, CFF, EV, MS and WD all coauthored the injury and illness surveillance statement. CE coauthored the following statements: concussion and the developing youth athlete. WD coauthored the following statements: pain management in the elite athlete. WD and MS both coauthored the following statements: molecular basis of connective tissue, muscle injuries in sport, prevention, and management of chronic disease. MS coauthored the following statements: periodic health evaluation of elite athletes, use of platelet-rich plasma in sports medicine, and health consequences of a saturated sports calendar (part 1 and part 2). Author EV is editor in chief of BMJSEM., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Previous studies showed that the Nordic hamstring exercise (NHE) effectively prevents primary hamstring injury. However, no study investigated the secondary preventing effect of the NHE on hamstring reinjury. The primary purpose of this study is to investigate the effectiveness of the NHE for preventing hamstring reinjury after return to play (RTP) following a hamstring injury in football players. The secondary purpose is to determine the effect of the NHE on sprint and jump performance., Methods and Analysis: This is an international multicentre, prospective, parallel-group randomised controlled trial study. Subjects include male or female football players aged 18-40 years and within 1 week of RTP following a hamstring injury will be randomised into Nordics or a control group. Subjects in both groups continue their regular football training, but the Nordics group will perform an additional NHE programme. An online questionnaire will be sent to the subjects in both groups once per week within the first 10 weeks, then continued at months 6, 9 and 12. In a (performance) substudy, we will evaluate the effect of the NHE on sprint and vertical jump performance at three time points (at the beginning of the study, after 10 weeks and 12 months of follow-up).The primary outcomes are the incidence of hamstring reinjury within 2 and 12 months. The secondary outcomes are sprint and jump performance, adherence to the programme, duration of reinjury and reinjury burden., Ethics and Dissemination: This study is approved by the medical ethics committee of Amsterdam University Medical Center (UMC) in the Netherlands (METC 2021&#95;117), Faculty of Medicine Universitas Gadjah Mada in Indonesia (KE/FK/1248/EC/2021), Norwegian School of Sport Sciences in Norway (number 216-2 70 122) and Denmark (ethical submission in process). The study's findings will be disseminated in scientific peer-reviewed journals and presented at international conferences., Trial Registration Number: NL9711., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To investigate the influence of sports/activity types and their distribution over the curriculum years on intracurricular injury risk differences between curriculum years and sexes in Physical Education Teacher Education (PETE) studies., Methods: In a cohort study over 14 years (2000-2014), injuries reported at the medical facility of a Dutch vocational institute by PETE students who completed their full curriculum were registered. Intracurricular injury rates (IR) per 1000 hours and 95% CIs were calculated per sport, sex and curriculum year and compared with injury rate ratios (RR) and 95% CI. Exposure times per sports category per curriculum year were compared with the χ 2 test., Results: Intracurricular IR was highest for gymnastics, team ball sports and track and field (0.76-1.23, 95% CI 0.65 to 1.45). IRs were higher for female compared with male students (RR 2.38, 95% CI 1.97 to 2.87). Comparisons for all individual sports and for all three curriculum years showed the same pattern. IR for the first year was higher than for the second (RR 1.79, 95% CI 1.45 to 2.21) and third year (RR 2.74, 95% CI 2.13 to 3.54) with similar patterns for all sports categories. Over the curriculum years, exposure time distributions per sport showed small differences (p<0.001, Cramer's V=0.07)., Conclusion: Curriculum year, sex and sports types are risk factors to be independently targeted for preventive and rehabilitative measures in PETE studies. The nature and aetiology of injuries in mixed sports, and the adaption to increased loads in first-year and female PETE students, need further investigation., Competing Interests: Competing interests: EV is the editor in chief of BMJ Open Sports and Exercise Medicine, (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Elite Para athletes report a high incidence of sports injuries, illnesses and other health issues. Despite this, there are few prevention programmes in Para sport, and many of the existing prevention programmes are not adapted to Para athletes. To improve the success of preventive measures, it has been suggested that sports safety work should facilitate health promotion, including athlete health education. Therefore, the overarching aim of this project is to evaluate an accessible health promotion web platform as part of a complex intervention that aims to improve knowledge of athlete health in Para sport. In this protocol, the development, future implementation and evaluation of the intervention are described. To inform the implementation and use of such interventions, it is recommended to involve end users in the development and implementation process. Therefore, a participatory design process, including athletes and the sports organisation, was used to develop an accessible health promotion web platform. To evaluate this complex intervention, a process evaluation combining quantitative evaluation assessing causal pathways with qualitative methods assessing multifaceted pathways will be used. The primary outcomes are injury/illness incidence, athlete health parameters, health literacy and user behaviour. A cohort of elite Para athletes (n=150) from Sweden and South Africa will be invited to participate. This project will be the first that aims to improve athlete health in Para sport through pragmatic and accessible health promotion. It is a boundary-crossing project that will be conducted in a real-world sport setting, including athletes with different socioeconomic backgrounds., Competing Interests: Competing interests: EV is the editor in chief of BMJ Open Sports and Exercise Medicine, and KF, OHA, MB and MJ are associate editors., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Despite the many proven advantages of a physically active lifestyle in patient populations, prescription of exercise is currently not widely implemented in routine clinical practice. The aims of this study were twofold: (1) to assess perceptions of clinicians on the current practice of exercise is medicine (E=M) prescription in two Dutch university medical centres and (2) to determine their perceived barriers and facilitators for the implementation of E=M in routine clinical care in Dutch university medical centres., Design: A mixed methodologies study, using both online questionnaires and semi-structured interviews., Setting: Dutch university medical centres., Participants: Clinicians working within the departments of medical oncology, orthopaedics and rehabilitation medicine of two university medical centres., Results: Forty-five clinicians (response rate of 51%) completed the questionnaire, and 19 clinicians were interviewed. The results showed that even though clinicians had a positive attitude towards prescribing E=M, only a few reported to regularly prescribe E=M to their patients. The 52 identified facilitators and barriers for implementation of E=M were categorised into four main themes: (1) beliefs toward the implementation of E=M (eg, clinicians knowledge and skills, and social support), (2) factors related to the patient perspective (eg, patient priorities or motivation), (3) factors related to the referral options (eg, knowledge of and trust in local referral options) and (4) practical considerations when implementing E=M (eg, time constraints)., Conclusions: Our study showed that even though many clinicians have a positive attitude toward an active lifestyle, many are not prescribing E=M on a regular basis. In order for clinicians to effectively implement E=M, strategies should focus on increasing clinicians E=M referral skills, improving clinicians knowledge of E=M referral options and develop a support system to ensure that E=M is high on the priority list of clinicians., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To evaluate whether in fitness-related activities and recreational running over time, there is an increase in the number of novice sports athletes and whether these novice athletes have an increased injury rate compared with their experienced counterparts., Methods: Data were collected from a large population-based retrospective cross-sectional study, 'Injuries and Physical Activity in the Netherlands' (IPAN). Athletes aged ≥18 years were included. We used descriptive statistics to describe the characteristics of athletes and their injuries. The number of athletes and injuries were calculated for each year and, where applicable, for each sport separately. The injury incidence rate was expressed as the number of injuries per 1000 hours of exposure. Logistic regression analyses were performed with non-extrapolated data to analyse the differences in injury risk for novice and experienced athletes included in this study, separate for fitness-related activities and running., Results: Over the 5 years, 9209 fitness athletes reported 370 fitness-related injuries, 5426 runners reported 537 running-related injuries. Weighted data showed that, in 2010-2014, the inflow of novice fitness athletes slightly decreased, whereas the inflow of novice runners slightly increased. In each year, injury risk was higher in novice athletes compared with experienced athletes for both fitness-related activities and running. The injury incidence rates in running are much higher than in fitness-related activities., Conclusions: Over the years 2010-2014, the absolute number of novice athletes in fitness-related activities and running together increased. Although most injuries occurred in experienced athletes, injury risk was higher in novice athletes in both sports., Competing Interests: Competing interests: EV is an Editorial Board Member of BMJ Open Sport & Exercise Medicine., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In this study, we explored the perspectives about sports injury prevention of Belgium Olympic level athletes, coaches, managers and healthcare providers from various Olympic sports. We conducted a qualitative study, including 17 semistructured interviews. All interviews were transcribed verbatim and analysed by two independent coders through constant comparative data analysis based on Grounded Theory principles. Our findings overview the athlete's journey to becoming an elite athlete, and how an elite sports context influences and modulates injury prevention practice at this level. Participants described an elite athletic career as a continuous and adaptive evolving process. According to athletes and all stakeholders, sports injury prevention is a learning process shaped by individual experiences. This embodiment provides athletes with insight into the importance of ownership of their bodies and self-awareness. Thus, experience, communication, empowerment, knowledge, education, the elite athlete context and sports culture, all play a fundamental role in sports injury prevention. Our findings support the importance of contextual factors in sports injury prevention in an elite sports context. These results also bring practical implications on how we should approach injury prevention differently along an athlete's journey to becoming an elite athlete. Considering specific contextual factors and influencing the process through awareness, communication and a shared responsibility is essential to develop a healthy and successful athlete., Competing Interests: Competing interests: EV is Editor in Chief of BMJ Open Sports & Exercise Medicine., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The escalated competitive pressure and professionalisation of esports players could predispose them to mental health symptoms. We aimed to develop a model to explore the association between distress and anxiety/depression symptoms and potential associations between adaptive or maladaptive coping strategies, sleeping disturbance, alcohol consumption and eating habits in electronic football players., Methods: The present exploratory cross-sectional study includes the Distress Screener, General Health Questionnaire, Brief Cope, Sleep Disturbance Domain of the Patient-Reported Outcomes Measurement Information System, Alcohol Use Disorders Identification Test Consumption and a set of questions regarding eating habits. A two-step robust maximum likelihood method of the Structural Equation Modelling approach was used., Results: Both measurement model (χ 2 /df=1065.04 (637), p<0.001; Tucker-Lewis Index (TLI)=0.91, Comparative Fit Index (CFI)=0.92, standardised root mean residual (SRMR)=0.07 and root mean square error of approximation (RMSEA)=0.05; 95% CI 0.043 to 0.053) and hypothesised structural model (χ 2 /df=1131.98 (648); p<0.001; TLI=0.90, CFI=0.91, SRMR=0.07 and RMSEA=0.05; 95% CI 0.054 to 0.06) showed an adequate fit to the data. Stress was positively related with depression and anxiety symptoms. Only anxiety symptoms were linked with coping strategies. Maladaptive coping strategies were related to sleep disturbance, alcohol consumption and poor eating habits, whereas adaptive coping strategies were associated with less sleep disturbance, reduced alcohol consumption and better eating habits., Conclusion: An integrative approach to help electronic football players when early signs of distress are present might help avoid other mental health symptoms that interfere with players' well-being and overall health. Additionally, adequate coping strategies to manage anxiety symptoms due to distress may help counteract potential negative consequences for lifestyle habits in electronic football players., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Running injuries impact the health gains achieved through running and are linked to drop-out from this otherwise healthy activity. The need for effective prevention is apparent, however, implementation of preventive measures implies a change in runners' behaviour. This exploratory qualitative study aimed to explore Dutch recreational runners' perception on injuries, injury occurrence and prevention. An interpretative paradigm underpins this study. We conducted 12 individual semistructured interviews with male (n=6) and female runners (n=6). Through a constant comparative data analysis, we developed a conceptual model to illustrate the final product of the analysis and represent the main themes' connection. We present a framework that describes the pathway from load to injury and the self-regulatory process controlling this pathway. Runners mentioned that pain is not necessarily an injury, and they usually continue running. Once complaints become unmanageable and limit the runner's ability to participate, an injury was perceived. Based on our outcomes, we recommend that preventive strategies focus on the self-regulation by which runners manage their complaints and injuries-providing information, advice and programmes that support the runner to make well-informed, effective decisions., Competing Interests: Competing interests: EV is the editor in chief of BMJ Open Sports & Exercise Medicine., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Athletes in team sports have to quickly visually perceive actions of opponents and teammates while executing their own movements. These continuous actions are performed under time pressure and may contribute to a non-contact ACL injury. However, ACL injury screening and prevention programmes are primarily based on standardised movements in a predictable environment. The sports environment provides much greater cognitive demand because athletes must attend their attention to numerous external stimuli and inhibit impulsive actions. Any deficit or delay in attentional processing may contribute to an inability to correct potential errors in complex coordination, resulting in knee positions that increase the ACL injury risk. In this viewpoint, we advocate that ACL injury screening should include the sports specific neurocognitive demands., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Adverse long-term effects of playing football due to repetitive head impact exposure on neurocognition and mental health are controversial. To date, no studies have evaluated such effects in women., Aims: To (1) compare neurocognitive performance, cognitive symptoms and mental health in retired elite female football players (FB) with retired elite female non-contact sport athletes (CON), and to (2) assess whether findings are related to history of concussion and/or heading exposure in FB., Methods: Neurocognitive performance, mental health and cognitive symptoms were assessed using computerised tests (CNS-vital signs), paper pen tests (Category fluency, Trail-Making Test, Digit Span, Paced Auditory Serial Addition Test), questionnaires (Hospital Anxiety and Depression Scale, SF-36v2 Health Survey) and a symptom checklist. Heading exposure and concussion history were self-reported in an online survey and in a clinical interview, respectively. Linear regression was used to analyse the effect of football, concussion and heading exposure on outcomes adjusted for confounders., Results: FB (n=66) performed similar to CON (n=45) on neurocognitive tests, except for significantly lower scores on verbal memory (mean difference (MD)=-7.038, 95% CI -12.98 to -0.08, p=0.038) and verbal fluency tests (MD=-7.534, 95% CI -13.75 to -0.46, p=0.016). Among FB weaker verbal fluency performance was significantly associated with ≥2 concussions (MD=-10.36, 95% CI -18.48 to -2.83, p=0.017), and weaker verbal memory performance with frequent heading (MD=-9.166, 95% CI -17.59 to -0.123, p=0.041). The depression score differed significantly between study populations, and was significantly associated with frequent heading but not with history of concussion in FB., Conclusion: Further studies should investigate the clinical relevance of our findings and whether the observed associations point to a causal link between repetitive head impacts and verbal memory/fluency or mental health., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We aim to describe time trends of severe sports-related emergency department (ED) visits in the Netherlands, from 2009 to 2018., Methods: Data were extracted from the Dutch Injury Surveillance System by age, gender, sports activity and injury diagnosis, from 2009 to 2018. Absolute numbers and time trends of severe sports-related ED visits were calculated., Results: Between 2009 and 2018, the overall numbers of severe sports-related ED visits in the Netherlands have significantly decreased by 14% (95% CI -19% to -9%). This trend was seen among men (-12%; 95% CI -18% to -6%), women (-19%; 95% CI -26% to -11%) and individuals aged 18-34 years (-19%; 95% CI -28% to -10%). The number of ED visits has significantly decreased over time in soccer (-15%; 95% CI -24% to -6%), ice-skating (-80%; 95% CI -85% to -73%) and in inline/roller skating (-38%; 95% CI -55% to -15%). This was not the case in road cycle racing (+135%; 95% CI +85% to +198%) and mountain bike racing (+80%; 95% CI +32% to+146%). In terms of sports injury diagnoses, the number of fractured wrists (-15%; 95% CI -24% to -5%), fractured hands (-37%; 95% CI -49% to -21%), knee distortions (-66%; 95% CI -74% to -55%), and fractured lower legs (-38%; 95% CI -55% to -14%) significantly decreased over time., Conclusion: Our study shows a promising reduction in the number of severe sports-related ED visits across most age groups and sports activities. As the number of ED visits increased in road cycle and mountain bike racing, it is important to find out what caused these increases. Furthermore, it is essential to determine trends in exposure hours and to evaluate and implement injury prevention programmes specific for these sports activities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Where not too long ago we serviced athletes; nowadays, we have the responsibility to lead a multidisciplinary team that is mandated to protect the athletes' health, ensure competition availability and ability to compete at peak performance. In essence, our roles have shifted from being a service provider to a health and performance manager who steers a multidisciplinary team of specialists. In this viewpoint, we question whether we really have the skills to lead a 'team' like this effectively. We provide a potential definition of leadership and discuss the importance of leadership for health and performance teams with recent literature. Finally, we share our baseline 'leadership' pearls that allow you to elevate collaboration through leadership., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To systematically develop an injury prevention programme in judo and test its feasibility: Injury Prevention and Performance Optimization Netherlands (IPPON) intervention., Methods: We used the five-step Knowledge Transfer Scheme (KTS) guidelines. In the first two steps, we described the injury problem in judo and showed possibilities to reduce the injury rates. In the third step, the Knowledge Transfer Group (KTG) translated this information into actions in judo practice. Expert meetings and practical sessions were held. In the fourth step, we developed the injury prevention programme and evaluated its feasibility in judo practice in a pilot study. As a final step, we will evaluate the injury prevention programme on its effectiveness to reduce injuries., Results: In the first two steps, information collected indicated the need for reducing judo injuries due to high incidence rates. Injury prevention programmes have shown to be effective in reducing injuries in other sports. For judo, no injury prevention programme has yet been systematically developed. In the third step, the KTG reached consensus about the content: a trainer-based warm-up programme with dynamic exercises focusing on the shoulder, knee and ankle. In the fourth step, the intervention was developed. All exercises were approved in the pilot study. Based on the pilot study's results, the IPPON intervention was extended and has become suitable for the final step., Conclusion: We developed the IPPON intervention using the systematic guidance of the KTS. This trainer-based programme focuses on the prevention of shoulder, knee and ankle injuries in judo and consists of 36 exercises classified in three categories: (1) flexibility and agility, (2) balance and coordination and (3) strength and stability. The effectiveness and feasibility of the intervention on injury reduction among judo athletes will be conducted in a randomised controlled trial., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To identify barriers, as perceived by parents, to good care for children with life-threatening conditions., Design: In a nationwide qualitative study, we held in-depth interviews regarding end-of-life care with parents of children (aged 1 to 12 years) who were living with a life-threatening illness or who had died after a medical trajectory (a maximum of 5 years after the death of the child). Sampling was aimed at obtaining maximum variety for a number of factors. The interviews were transcribed and analysed., Setting: The Netherlands., Participants: 64 parents of 44 children., Results: Parents identified six categories of difficulties that create barriers in the care for children with a life-threatening condition. First, parents wished for more empathetic and open communication about the illness and prognosis. Second, organisational barriers create bureaucratic obstacles and a lack of continuity of care. Third, parents wished for more involvement in decision-making. Fourth, parents wished they had more support from the healthcare team on end-of-life decision-making. Fifth, parents experienced a lack of attention for the family during the illness and after the death of their child. Sixth, parents experienced an overemphasis on symptom-treatment and lack of attention for their child as a person., Conclusions: The barriers as perceived by parents focussed almost without exception on non-medical aspects: patient-doctor relationships; communication; decision-making, including end-of-life decision-making; and organisation. The perceived barriers indicate that care for children with a life-threatening condition focusses too much on symptoms and not enough on the human beings behind these symptoms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objective: The aim of this study was to investigate whether dynamic balance, measured with the anterior component of the Star Excursion Balance Test (SEBT-ANT), is a risk factor for ankle injuries in physical education teacher education (PETE) students., Design and Setting: A prospective monocentre study in first-year PETE students., Participants: A total of 196 subjects, of which 137 men (70%) and 59 women (30%)., Outcome Measures: This study consisted of measures of the SEBT-ANT at baseline (September 2015) and an injury registration procedure during a follow-up period (September 2015-June 2016). The association between the SEBT-ANT score and subsequent ankle injury was analysed with generalised estimating equations analysis at the leg level., Results: Men and women had an average SEBT-ANT score of, respectively, 65.1% and 67.7% of leg length. In 20 (15%) subjects, the first injured body site involved the ankle. Across all participants, a below average SEBT-ANT score was not associated with increased ankle injury odds (OR OR=2.43, 95% CI: 0.94 to 6.29, p=0.07). In men, a below average SEBT-ANT score indicated sevenfold increased odds for ankle injury (OR=7.06, 95% CI: 1.43 to 34.92, p=0.02). In women, this relationship was not significant (OR=0.72, 95% CI: 0.19 to 2.71, p=0.62)., Conclusions: Below average normalised SEBT-ANT scores were associated with sevenfold likelihood for ankle injuries in men. In contrast, no relationship was found for the SEBT-ANT score and ankle injuries in woman. These results may provide directions for the implementation of screening tools, as part of an injury prevention programme, to identify male PETE students with an increased likelihood for ankle injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study explored the association between concussion or musculoskeletal injuries, and the onset of mental health symptoms (MHS) in male professional rugby players over a 12-month period., Methods: Observational prospective cohort study with three measurements over a follow-up period of 12 months. At baseline, 573 participants provided informed consent. A total of 327 male professional rugby players (62% forwards, 38% backs) completed all follow-up assessments at baseline, 6 months and 12 months. The mean (±SD) age, height and weight of the participants at baseline was 25.9 (±4.4) years, 184.9 (±8.7) cm and 101.5 (±14.6) kg, respectively. Number of musculoskeletal injuries and number of confirmed concussions were assessed through single questions. Symptoms of distress, anxiety/depression, sleep disturbance, adverse alcohol use and eating disorders were assessed using validated questionnaires., Results: Professional rugby players who sustained a concussion within 12 months of baseline were more likely to develop MHS with ORs ranging from 1.5 (95% CI 1.0 to 2.1) for distress to 2.0 (1.2 to 3.6) for adverse alcohol use. Players who sustained a severe injury within 12 months of baseline were more likely to develop symptoms anxiety/depression with an OR of 1.5 (1.1 to 2.0). There was no significant association in both groups for other MHS., Conclusions: Rugby players who sustained concussion or severe injuries are up to two times more likely to develop symptoms of distress, adverse alcohol use or anxiety/depression., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Transitioning out of professional football is a challenging time in most players' lives. During these preretirement and postretirement years, professional footballers may struggle with their mental, musculoskeletal, neurocognitive and cardiovascular health. Currently, longitudinal data about these health conditions are lacking. This article presents the design of a prospective cohort study with the primary aim of gathering epidemiological evidence about the onset and course of mental, musculoskeletal, neurocognitive and cardiovascular health conditions in professional footballers during their preretirement and postretirement years and evaluating the associations between risk indicators and the health conditions under study in these players., Methods and Analysis: An observational prospective cohort study with repeated measurements over a follow-up period of 10 years will be conducted among at least 200 professional footballers (male; 27 (±1) years old). Mental health will be explored by assessing symptoms of distress, anxiety, depression, sleep disturbance, alcohol misuse, drug misuse and disordered eating. Musculoskeletal health will be explored by assessing severe joint injury and related surgery, clinical and radiological osteoarthritis, and joint function (hips, knees and ankles). Neurocognitive health will be explored by assessing the concussion, brain structure and functioning, and neurocognitive functioning. Cardiovascular health will be explored by assessing blood pressure, lipid profile and ECG abnormalities., Ethics and Dissemination: Ethical approval for the study was provided by the Medical Ethics Review Committee of the Amsterdam University Medical Centers. The results of the study will be submitted to peer-reviewed journals, will be presented at scientific conferences and will be released in the media (postpublication)., Trial Registration Number: The Dutch Trial Registry (Drake Football Study NL7999)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

In recent years, virtual sports or 'eSports' have grown exponentially both recreationally and at the professional level. eSports comprise several regulated video games played competitively, using electronic platforms. Some eSports competitions present a structure comparable to traditional sports, and eSports players, even with major skills and mental focus, need preparation and training to thrive. However, little is known about the demands of eSports competitions and continuous training. As the popularity and stakes rise, concerns about the health and emerging risks of eSports participation might arise. Indeed, in the absence of proper descriptive data about the specific characteristics of the eSports population (including factors such as screen time, physical activity, overuse injuries or training environment), effective prevention and care cannot be developed nor provided. Therefore, quality healthcare and prevention strategies are needed. In the current viewpoint, we argue that those involved with Sports Science and Medicine should lead the discussion and reflect on the health effects of eSports participation, providing scientifically-based arguments to better answer to the current eSports professionalism., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We undertook this qualitative study within an international circus company-Cirque du Soleil-to explore the narrative of artists and the artistic team in regards to injuries and their prevention and to describe the prevention of injuries from a systems thinking lens., Methods: Focus groups (FG) with artists and semistructured individual interviews with the artistic team were conducted in six selected shows. The structure of the interviews and FGs concerned the themes: 'injury', 'injury-related factors' and 'injury prevention'. Data were analysed through comparative data analysis based on Grounded Theory. Concept mapping and systems thinking approaches were used to design a map of participants' views on how to prevent injuries., Results: Injury was mainly described based on performance limitation. The factors mostly mentioned to be related to injury occurrence were physical load factors. Many of these factors were said to be connected and to influence each other. Injury prevention was mapped as a multilevel system, composed by artist-related factors (eg, technique and life style) and extrinsic factors (eg, touring conditions and equipment) that integrate different strategies and stakeholders., Conclusion: Our study reinforces the importance of multilevel injury prevention approaches with shared responsibility and open communication among stakeholders., Competing Interests: Competing interests: CB and JM are former employees of Cirque du Soleil. EV is a consultant of Cirque du Soleil.