Ann Ig 2018; 30: 367-377 doi:10.7416/ai.2018.2236 Health protection and safety in physical activity and sport promotion: the continuous evolution of roles and regulations in

R. Ricchiuti1, N. Postiglione1, F. Gallé1, G. Liguori1

Key Words: Physical Activity, Sport, Health Promotion, Safety, Sport Facilities Parole Chiave: Attività Fisica, Sport, Sicurezza, Impianti Sportivi, Promozione della Salute

Abstract

The promotion of physical activity is one of the main prevention strategies because of its fundamental role in reducing the risk of developing the major chronic diseases causing disability and death. Consistently with the approach of “health in all policies” for different age classes and health conditions, the Italian Ministry of Health identifies physical activity as a valid and economically sustainable instrument of prevention and health promotion for all the community. By highlighting the preventive role of physical activity, the Italian Government has recently inserted specific services regarding physical activity promotion among the Essential Levels of Care. The existing criticalities regarding the certification of physical fitness for sport practice, the use of defibril- lator, and the transparency and safety criteria which should be guaranteed to the users of sport facilities are discussed in this article. The current debate among Italian Institutions may contribute to resolve these criticalities and to simplify the procedures, in order to make the practice of sport and physical activity even more accessible and safe for all citizens.

Introduction - in addition to that of public health, and is influenced also by non-healthcare policies – The promotion of Physical Activity (PA) such as those regarding public transportation, represents an important component of health urban planning and finances (4-5). promotion, which allows people to exert a In Italy, at the moment, health and social higher control on their health and to improve services are continuously under revision in it; it is a global social process which includes order to reduce costs; therefore, due to its actions aimed to strengthen abilities of the positive effects, the PA promotion may re- individuals and to create at a physical, social present a successful preventive strategy for and cultural level opportunities “to make public health, and probably the most modern healthy choices simple”(1-3). The implemen- and effective measure to protect the commu- tation of PA promotion is therefore difficult, nity against those chronic diseases that are because it requires further competencies - now the main causes of morbidity, disability such as educational, sport and cultural ones and mortality in our Country (6-10).

1 Department of Movement and Wellbeing Sciences, University of Naples “Parthenope”, Naples, Italy 368 R. Ricchiuti et al.

In the last few years, on the basis of scien- take advantage of each occasion to promote tific evidences, the Italian Ministry of Health PA - both in healthy persons and in those became aware of the health and economic with risk factors or with stabilized chronic benefits deriving from PA practiced at every diseases as well – considering their specific level, age and condition. psycho-physical conditions (16). One of the strategic goals of the National In particular, the general practitioners Prevention Plan 2014-2018 is to provide (GPs), who establish with their patients an address and policies for actions aimed at effective, communicative and interactive re- subsidizing PA through an intersectorial lationship, is in a privileged position to apply approach “life-course”, “per setting”, and and adapt the best practices to the different contrasting gender and social inequalities. contexts, and may therefore facilitate the The content of this document focuses on behavioural change motivating the person the importance of movement for the general towards the continuous practice of PA. To population and states that people should this aim, he can support the patient in the practice PA safely, on the basis of their needs identification of the type of activity more and preferences, and including PA in their appreciated, sustainable and easily adaptable daily activities and/or in prevention, care or to his daily routine and work. To make this, rehabilitation paths (11). the practitioner should know the territorial On January 2017, health promotion, opportunities, such as sport, cultural and including PA promotion, has been included environmental associations, or organizations among the receivable services by a Decree for youths, adults, and the elderly, or volun- of the President of the Italian Council of tary activities (17, 18). the Ministers which updated the Essential Furthermore, in order to make PA effective Levels of Care (12). It is hoped that this and healthy, it is fundamental that before will contribute to increase the knowledge approaching to PA individuals undergo an regarding the effects of movement on health accurate preliminary evaluation aimed to and also to increase the homogeneity among draw up an activity protocol adapted to their the local actions. anatomical and physiological conditions, as Nowadays, the promotion of PA, intended for frequency as for intensity, time and type as “physical activity for health”, is a priority of activity (19-22). of health policies. Therefore, it is necessary For this reason, the Adapted Physical to guarantee its accessibility, as in facilities Activity (APA), a type of continuous phy- for PA and sport as in other places and en- sical activity planned and structured in vironments which should be comfortable order to maintain and/or improve one or and usable: this requires a multidisciplina- more fitness domains, is effective for tho- ry, intersectorial and participated method. se with “painful hypomobility syndromes Another important aspect is the definition and stabilized outcomes of clinical con- of roles and competences of all the figures ditions for whom scientific evidences do involved in this process, so as effective in- not show the appropriateness of a physical terventions can be planned and performed, or rehabilitative healthcare intervention”, considering that there is a wide variety of while in individuals at risk it produces be- types, modes and levels by which PA can nefits equal to that obtainable with drugs be practiced (13-14). (23). The prescription of APA should be Healthcare workers play a significant systematically integrated throughout the role in sensitising people to adopt an active Preventive-Diagnostic-Therapeutic-Care lifestyle. In line with the Guidelines of the paths for people with conditions, risk factors World Health Organization (15), they should or diseases (diabetes, obesity, cardiovascular Safety in physical activity and sport in Italy 369 diseases, etc.) sensitive to exercise, with a hygienists, general practitioners, sports medical certification which indicates the medicine doctors, psychologists, movement stabilization of the disease and the lack of sciences experts and figures of sport and absolute contraindications (24, 25). fitness) defined the keypoints regarding the Since the last decade, the Ministry of strategic meaning that PA assumed for public Health supports, through adequate projects, health, claiming the central role of Prevention initiatives aimed at introducing exercise Departments of the National Health System in healthcare as a therapeutic instrument in managing and coordinating preventive (Therapeutic Exercise - TE), and promotes interventions based on PA and underlining the demedicalization of problems insu- the fundamental role of the hygienists in this sceptible to clinical treatment through APA setting. The document highlighted also the programs (26, 27). APA for prevention may contribute of other specialists and healthcare be performed by individuals autonomously, operators, highlighting the priority importan- with periodical motivational reinforcements, ce of GPs and sports medicine doctors. The functional evaluation and enhancement of movement sciences experts were identified their self-monitoring ability, or under the su- as essential figures for the correct execution pervision of professionals adequately trained of PA programs and a promising opportunity and belonging to multidisciplinary teams. to build collaborations and synergies in the In Italy, the Master Degree in Movement Prevention Departments(30). Sciences for Prevention and Wellbeing (LM67) trains the figures who work in close Unfortunately, the current regulations contact with medical and paramedic person- regarding the different activities for PA nel in order to promote and spread PA and to and APA promotion, the corresponding educate people towards the right practice of certification paths, the requirements of fa- PA for health. The professional aims of the cilities, equipment, and personnel in order Movement Sciences graduates are in fact the to guarantee health protection and safety are promotion and protection of psycho-physical not yet satisfying. The main Italian current wellbeing (primary prevention), the impro- regulations are summarized below. vement or the maintenance of health status in individuals at risk (secondary prevention), the enhancement of residual motor skills in Regulations clinically stabilized persons, by preserving their autonomy through programs perfor- 1. Activities: physical fitness and certifica- med at the end of possible rehabilitative- tion for the practice physiotherapeutic paths (tertiary prevention) On the basis of the Ministerial Decree of (28, 29). April 24, 2013, “Discipline of certification In the Erice Charter, consensus document of non-agonistic and recreational sport ac- which was unanimously approved at the end tivity and guidelines on disposal and use of of the XLVII Residential Course “Adapted semiautomatic defibrillators and eventual Physical Activity in Sport, Wellness and other life-saving devices” and subsequent Fitness: new challenges for prevention and modifications and integrations, the term health promotion”, organized in 2015 by the “recreational physical activity” indicates an International School of Epidemiology and activity practiced continuously and aimed Preventive Medicine “G. D’Alessandro” and to protect and maintain the health status by the study Group “Movement Sciences for of people; this is therefore an individual or Health” of the Italian Society of Hygiene, group activity which is not finalized to the the participants (academic and territorial achievement of high sport performance and 370 R. Ricchiuti et al. which is non-competitive (jogging, football Promotion Institutions approved by CONI, or matches played with friends, etc.), and by the Ministry of the Education (school but follows specific rules from sport organi- sport games at the national level). The cer- zations, even if the practising subject does tification for agonistic PA must be drafted not belong to National Sports Federations, by a sports medicine doctor in accredited Associate Disciplines and Sport Institutions public or private centers, on the basis of approved by the Italian National Olympic Immediate Recovery Index test and heart Committee (CONI). In these cases the me- rate monitoring; this must be registered on dical certification for physical fitness is not the sport health book that the athletes should needed and the recreational activity may be have and exhibit during the sports medicine performed without any suitability commit- physical examinations (31, 35). ment (31, 32). Table 1 summarizes the classification The “non-agonistic physical activity” reported above. indicates instead that PA performed by students in extra-curricular lessons, the The Ministerial Decree of April 24, 2013 non-agonistic activities organized by CONI ratified also the guidelines regarding the or institutions and federations approved by availability and the use of semiautomatic CONI, and that practiced for school sport external defibrillators (AEDs) and other games until the national competitions. In life-saving devices, obligating recreational this case, the general practitioner or pedia- and professional sport societies to obtain trician must accomplish the anamnesis and and maintain them. The enter into force of the objective examination, the evaluation the Decree – expected for January 20, 2016, of blood pressure and the acquisition of then delayed to July 20, 2016, November the results of an electrocardiogram (ECG) 30 of the same year and finally to June 30, performed at rest at least once during the 2017 – happened on July 13, on the basis of life. For people aged >60 years and/or with the Decree of June 26, 2017, which tried to cardiovascular risk factors, or in persons clarify the previous regulations (36). affected by chronic diseases which increase In particular, regarding the recrea- the cardiovascular risk, the ECG should be tional PA, the law in force lays down prescribed and registered each year. If neces- for Recreational Sport Associations and sary, on the basis of patient’s conditions, the Recreational Sport Societies included into physician may require further examinations the telematic Register of CONI the obliga- or consultations from sports medicine or tion to have in the facility one AED and at other specialist doctors. If a person who does least a person trained on its use when races not belong to a sport society participates in from calendars of National Sport Federations manifestations with particular and high car- and associated disciplines are planned, or diovascular engagement patronised by sport in the case of sport competitive activities, organizations (running competitions with agonistic performance activities organised itineraries >20 km, cross-country , by Sport Promotion Institutions, and com- swim, cross-country , etc.), the medi- petitions organized by other recreational cal check must include an ECG, a step-test societies. Races of sports which require a and other needed examinations beyond the reduced heart effort (Attachment A) and measurement of blood pressure (31-34). those performed outside of sport facilities Finally, the “agonistic physical activity” are exonerated by this obligation (36). is the PA practiced continuously and syste- However, the obligation of AEDs is limi- matically only through the forms organi- ted only to the competition setting and it is zed by National Sport Federations, Sport not valid during training, which is in contrast Safety in physical activity and sport in Italy 371 Instrumental examinations none - ECG at rest least once in the life - ECG prescribed each year for those aged > 60 years and/or with chronic diseases - ECG at rest least once in the life test with heart - step-test or ergometric monitoring activity needed - possible further examination - ECG at rest least once in the life - activ heart with test ergometric or step-test - ity monitoring needed - possible further examination es, by: es, by: es, by: not needed Y - general practitioners - pediatricians Y - general practitioners - other specialist doctor (consultations) Y - general practitioners doctors specialist other - (consultations) Certification - - - not needed with: Yes, - anamnesis - objective examina tion - blood pressure measurement with: Yes, - anamnesis - objective examina tion - blood pressure measurement with: Yes, - anamnesis - objective examina tion mea - pressure blood - surement Evaluation (suitability) Physical Physical activity practiced continuously individually or in a group and finalized to the protection and maintenancehealth. It follows specific rulesbut does of not includes high-level associations to competitions;belong not do participants by CONI or societies approved practiced by: activity Physical curricu - in lessons sport during students - hours; lar and extra-curricular ac - practice who athletes non-agonistic - Institutions or CONI by organized tivities by CONI; and Federations approved - those who participate to school sport until the national phase games Participation - without belonging to a Sport Society - to manifestations engagement with heart elevated and particular patronized by Sport Societies (running competitions with itineraries >20 km, cross-country cycling, swim, cross- country skiing, etc.) Continuous and sistematicactivity practiced exclusivelyphysical in forms Federations, Sport National by organized by approved Institutions Promotion Sport (school Education of Ministry and CONI in the national phase) sport games Definition Recreational activity Non-agonistic activity High heart activity engagement Agonistic activity Physical activity Physical Table 1 - Differences among the different types of physical activity as defined by laws in force (31-40). as defined by laws activity types of physical among the different 1 - Differences Table 372 R. Ricchiuti et al. with the fundamental concept of health of individual health status after the end of protection (37-40). On July 3, 2017, after rehabilitation, when the clinical conditions the publication of the last Decree, CONI of one person are considered stable and they has issued an explicative circular, which cannot further improve through additional however did not provide further clarifying healthcare activities (41). information. Table 2 summarizes the professional goals, the features of corresponding motor 2. Activities: definition of roles protocols and the different clients of the two The definition and the separation of roles figures. and competences between physiotherapists and kinesiologists in the context of tertiary 3. Structures and facilities prevention is often a criticality. In 2011, the Sport structures and facilities, where Ministry of Health – with the participation the different physical activities are perfor- of the Ministry of Education, the Regions med, undergo the regulations for general and the corresponding professional delega- constructions (urban standards, building tions – established a worktable on this issue techniques, safety rules), while for field, with physiotherapy and movement science equipment and services specific regulations graduates, in order to define the competence established by sport institutions (CONI and settings of the two figures and to highlight Sport Federations) are also effective. The their possible integration, collaboration and reference rules specific for the construction juxtaposition for the protection of people’s and the management of sport facilities are health. Furthermore, the document drafted in the “Rules of CONI for sport plant de- that occasion supported the introduction of sign”, the “Safety rules for the construction APA in the national and regional organiza- and the management of sport facilities”, tion as an instrument for the reconditioning the “Regulation for the release of CONI

Table 2 - Comparison between the competences of physiotherapist and movement sciences professionals.

Physiotherapist Master Graduate on Movement Sciences for Preven- tion and Wellbeing Goals Employs the movement: Employs the movement: - as a therapy, to resolve/improve the health - to prevent health problems by promoting healthy problem (including autonomy and partici- lifestyles pation) - to fight the hypomobility and favour the socialization - for healthcare and rehabilitation purposes - for the reconditioning the subject at the end of the (specific and specialized study paths are rehabilitation needed) Features - the movement is used with other physical Physical activity is: instruments and evaluation/treatment inter- - adapted to psycho-physical characteristics of the ventions individual (even with disabilities) - supervisioned and structured through paths which - guarantee the achievement and the long-term main- tenance of physical activity levels needed Clients Individuals with: Individuals: - clinical instability - healthy - chronic diseases, following medical evalu- - inactive and elderly ation - who completed their rehabilitation path - with chronic diseases, following medical evaluation Safety in physical activity and sport in Italy 373 competence advices about the interventions all the Italian Regions and autonomous of sport plant design”, the “Regulations Provinces, works on the new Essential Levels of Sport Federations” and the Legislative of Care and in particular on the promotion Decree n. 81 of 2008 regarding work safety of PA and health protection in PA (Essential (42-49). Level F5), in line with the goals of the The CONI Services office and the Italian National Prevention Plan (11). The Group is Sports Medicine Federation (FMSI) provide currently elaborating a series of amendments a classification of planning and accreditation to the Ministerial Decree of 24 April, 2013, requirements for sport facilities. In 2008, a regarding the definition and the interpretative Consortium for the Certification of Quality criteria of non-agonistic and recreational in Sport Facilities was established, aimed activities; the exclusion of some activities to increase the quality level of facilities, from the non-agonistic certification and the equipments and management of services, exoneration from certification for all the ac- in order to guarantee to the users (agonistic tivities practiced by children aged less than 6 or not) transparency, safety, assistance du- years; the insertion of activities at high heart ring the practice, structural, environmental engagement among the agonistic activities; and hygienic adequateness of the locations, the separation of non-agonistic certification through a specific certification based on from the membership of Sport Federations technical, sports medicine and management and Sport Promotion Institutions. criteria. The declared mission of CONI and When completed, these proposals will FMSI is to assure that, while sports, places be presented to the national worktable on and organizations for sport and PA practice “Sports Medicine”, which was originally multiply, the users have the possibility to planned to be held in October 2017 at the evaluate and choose whom to entrust through Ministry of Health with the participation the Consortium (www.coni.it). of both the Ministries of Health and Sport. At now, this working group is examining several questions (most of which regarding Criticalities and perspectives issues that are discussion subjects of the inter-regional worktable), which testify the The limited clarity or the lack of applica- criticalities that sport and public health are tion of many of the regulations cited above facing while searching for an agreement. may compromise the widespread of PA for Since May 2017, another worktable ope- health, even if the initiatives and activities of rates at the Office 8 of the General Direction PA promotion are effective and sustainable of Health Prevention under the mandate of the when implemented. Ministry of Health to draft the “Theoretical In order to resolve this, some worktables and methodological addresses regarding have been established among the Italian physical activity for different age classes Ministries in the past year, in order to clari- and with reference to specific physiological fy some specific controversial and debated and/or clinical situations and to specific issues which are focused on public health population subgroups”. The Italian Society and cannot be limited only to sports medi- of Hygiene participates in this worktable cine (definitions, physical fitness suitability, through a referent proposed by the working certifications, possible additional examina- group “Movement Sciences for Health”. The tions, etc.). goal of the mandate is the elaboration of a na- Since May, 2017 the Inter-regional tional document on the promotion of PA not Technical Group “Sport activities”, compo- only in healthcare but also in life and work sed by different health competences from settings, in order to guarantee the health and 374 R. Ricchiuti et al. movement rights to all the citizens. This will The promotion of PA requires methodo- represent an address act, but also an opera- logical accuracy and an updated education, tive instrument regarding the importance adequate to the international and local con- of PA for the general population and the text. The managerial ability of the hygienists, need for a safe PA practice for all, through traditionally based on the epidemiological personalized approaches considering needs surveillance, the evaluation of cost-effec- and preferences. Some specific pathologic tiveness, the planning, organization and conditions of children and adults, pregnancy, verification of actions taken, finds therefore the early phases of life and disabilities will a physiological placement in the realization be considered specifically. of these interventions (15). The ministerial address lines will repre- sent an useful instrument for healthcare and other professionals who are involved in PA Riassunto promotion, and will contribute to define their La tutela della salute e della sicurezza nella promo- competences and roles, in order to plan and zione dell’attività motoria e sportiva in Italia: ruoli implement effective interventions. Another e normative in costante evoluzione aim of this document will be the acquisition of knowledge regarding PA for health by the La promozione dell’attività fisica è una delle prin- different stakeholders involved. cipali strategie di prevenzione in quanto fondamentale per ridurre il rischio di sviluppare molte tra le principali patologie cronico-degenerative con elevato tasso di The different items object of these mortalità e disabilità. Il Ministero della Salute italiano, worktables recognize as common factor coerentemente con l’approccio health in all policies per the promotion of sport and PA as strategies differenti fasce d’età e livello di salute della popolazione, for public health interventions. The way to identifica l’attività fisica quale strumento di prevenzione achieve these important goals is difficult and e promozione della salute valido per l’intera comunità ed it will be realized only through the collabo- economicamente sostenibile. Nel ribadire l’importanza ration, comparison and engagement of the dell’attività motoria ai fini della prevenzione, il Governo Italiano ha di recente inserito specifiche prestazioni in different figures involved. tema di promozione dell’attività fisica tra i nuovi Livelli It has to be noted that the correct employ Essenziali di Assistenza. of the movement in public health program- Nel presente contributo vengono approfondite le mes is an ambitious and complex goal which criticità ad oggi esistenti in merito alle norme vigenti can be reached, in line with the health pro- in materia di certificazione dell’idoneità alla pratica motion, not only through the sensitization sportiva, nonché all’utilizzo del defibrillatore, e ai criteri di trasparenza e sicurezza da garantire per i fruitori di and the education of citizens about the be- impianti sportivi. nefits of PA, but also through unavoidable L’acceso dibattito istituzionale in corso in Italia potrà social, economic and political interventions concorrere a risolvere tali criticità, oltre che a sempli- which make possible the implementation, ficare le attuali procedure, in modo rendere sempre più the management and the use of these pro- accessibile e sicura ai cittadini la pratica delle attività grams. 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Corresponding Author: Prof. Giorgio Liguori, Department of Movement and Wellbeing Sciences, University of Naples Parthenope, Via Medina 40, 80133 Napoli, Italy e-mail: [email protected]