REF-1319 · Riebe et al., 2015 · Medicine & Science in Sports & Exercise · Paper · PubMed

Do I need a doctor's OK before I start training?

Not if you are healthy, symptom-free and start light to moderate (ACSM, 2015). With heart, metabolic or kidney disease, or symptoms such as chest pain or fainting: clearance first.

Main caveat: Consensus, not a systematic review. No search strategy, evidence grading or voting process is described.
strong evidenceMeasured on non-athletes and recreational people

Riebe and colleagues report the outcome of a scientific roundtable that the American College of Sports Medicine (ACSM) convened in June 2014 to revise its preparticipation health screening.

The earlier process counted cardiovascular risk factors, sorted people into low, moderate and high risk and required a medical examination or exercise test before moderate or vigorous exercise for the higher classes; the panel cites evidence that this sent too many people to physicians (95% of adults over 40 would have been advised to consult one) and so became a barrier to exercise, while exercise-related cardiovascular events are rare, are often preceded by warning signs, and become less likely as people become more active.

The new model rests on three factors: the person's current level of physical activity; signs or symptoms and/or known cardiovascular, metabolic or renal disease; and the intensity of exercise they intend.

Risk-factor profiling and risk classes are removed from the screening decision, people with pulmonary disease are no longer referred automatically, and "medical clearance" (approval from a health care professional, who decides what evaluation is needed) replaces specific instructions for an examination or test.

Inactive, healthy, asymptomatic people may start light to moderate exercise without clearance and progress gradually; active, asymptomatic people without known disease may continue and progress; active people with known disease cleared within the last 12 months need not revisit their provider to continue moderate exercise; anyone who develops symptoms stops and seeks clearance; inactive people with known disease or symptoms seek clearance before starting at any intensity.

The panel adds that risk is better reduced by a sensible prescription: a 2-3-month transitional phase, warm-up and cool-down, teaching warning symptoms, and steering inactive people away from unaccustomed vigorous to near-maximal effort.

Our reading: this fills the base's explicit gap ("medical clearance before starting is outside this base", SYNTH-75) with a simple screen built on how rare events are and on who has them; it is consensus, not a trial of screening.

Protocol

Process: ACSM scientific roundtable (expert panel), June 2014; experts in risk assessment, preventive and general cardiology, public health, exercise physiology and geriatrics, and practitioners from medicine, clinical exercise physiology and health fitness.After a review of the literature and discussion, the panel proposed an evidence-informed model; no search strategy, grading system or voting method is described. Panel: n = 15 named experts (an expert panel, not a study sample), seven of them authors.
Screening factors (new model): (1) current physical activity; (2) signs or symptoms and/or known cardiovascular, metabolic or renal disease; (3) desired exercise intensity.
Definitions (Figure 2 footnotes): exercise participation = planned, structured physical activity of at least 30 min at moderate intensity on at least 3 days a week for at least the last 3 months; light intensity = 30% to <40% heart-rate or VO2 reserve, 2 to <3 METs, RPE 9-11 (Borg 6-20); moderate = 40% to <60%, 3 to <6 METs, RPE 12-13; vigorous = ≥60%, ≥6 METs, RPE ≥14; cardiovascular disease = cardiac, peripheral vascular or cerebrovascular disease; metabolic disease = type 1 and 2 diabetes mellitus.
Signs and symptoms (Figure 2 footnote): at rest or during activity — pain or discomfort in the chest, neck, jaw, arms or other areas that may result from ischaemia; shortness of breath at rest or with mild exertion; dizziness or syncope; orthopnoea or paroxysmal nocturnal dyspnoea; ankle oedema; palpitations or tachycardia; intermittent claudication; known heart murmur; unusual fatigue or shortness of breath with usual activities.
Scope: the logic model (Figure 2) is for aerobic exercise participation; the full decision boxes are in the figure, of which only the footnotes and the text describing it were available as text here.
Funding and interests: "The Exercise Preparticipation Health Screening Roundtable was generously supported by the ACSM"; no conflict-of-interest statement appears in the article text read. Three authors (Pescatello, Riebe, Thompson) are editors of the ACSM's Guidelines for Exercise Testing and Prescription, 9th edition, which this statement revises (its reference list).

Key Results

The new screening decisions as stated in the text:

Currently active? (≥30 min moderate, ≥3 days/week, ≥3 months)Known CV, metabolic or renal disease, or symptomsRecommendation
YesNone, asymptomaticContinue usual exercise; progress gradually as tolerated
YesKnown disease, asymptomatic, cleared within the last 12 monthsNo need to revisit the provider to continue a moderate-intensity programme, unless symptoms or health status change
YesDevelops signs or symptomsDiscontinue exercise; seek medical clearance before resuming at any intensity
NoNone, asymptomaticMay begin light- to moderate-intensity exercise without medical clearance; progress gradually in intensity in the absence of symptoms
NoKnown disease and/or signs or symptomsSeek medical clearance before starting, regardless of intensity

Risk evidence cited by the panel:

FindingSource cited in the statement
Vigorous activity transiently raises the risk of nonfatal heart attack and sudden cardiac death about sixfold to 17-fold vs restOnset Study; Physicians' Health Study
Absolute risk: one sudden death per 1.5 million episodes of vigorous exertion in men; per 36.5 million hours of moderate-to-vigorous exertion in womenPhysicians' and Nurses' Health Studies
One death per 396,000 h of jogging; one per 2,897,057 person-hours at YMCA centresThompson et al.; Malinow et al.
More than 10 million marathon and half-marathon runners: cardiac arrest one per 184,000 runners, sudden death one per 256,000; 0.20 cardiac arrests and 0.14 sudden deaths per 100,000 runner-hoursKim et al. (RACER)
Meta-analysis: vigorous activity (≥6 METs) went with a fivefold risk of sudden death and 3.5-fold risk of heart attack; relative risk of exertion-related heart attack 4.5 to 107 in the least active cohorts vs 0.86-3.3 in the most active; each extra weekly exercise bout lowered the risk during activity by 30% (sudden death) and 45% (heart attack)Dahabreh and Paulus
Under the previous risk-factor process, 95% of men and women over 40 would have been advised to consult a physicianWhitfield et al. (Whitfield is also an author of this statement)

Mechanisms

Measured (cited observational data): the transient risk of sudden cardiac death and heart attack rises during vigorous exertion, is far higher in habitually inactive people, and falls with each additional weekly bout of exercise; exercise-related events are often preceded by warning symptoms.
Authors' interpretation: underlying coronary disease explains most exertion-related sudden deaths over age 35 and structural heart disease (notably hypertrophic cardiomyopathy) often in younger people; because risk factors are very common and events very rare, counting risk factors predicts poorly and over-refers, so activity status, disease and symptoms, and intended intensity are the useful modulators. Age per se is not a strong predictor of exercise-related events.
Inference: the model screens for the people in whom an event is most likely (inactive, diseased or symptomatic, about to go hard); it does not detect occult disease in an asymptomatic person, which no questionnaire can.

Practical Application

Do I need a doctor's OK before I start training? Not if you are healthy, symptom-free and start light to moderate (ACSM, 2015). With heart, metabolic or kidney disease, or symptoms such as chest pain or fainting: clearance first.
Three onboarding questions (A, expert consensus; asking them at onboarding is a proposal from this entry; the base's practice now decides on the same three factors, "Who sees a clinician before starting" in [SYNTH-75], and routes, never clears): have you exercised at least 30 min at moderate intensity on 3 or more days a week for the past 3 months; do you have known heart, vascular, diabetes or kidney disease; do you have any of the listed symptoms.Inactive with known disease, or symptomatic at any activity level, routes to "see a clinician before starting"; the assistant never clears anyone itself.
Symptoms stop training, at any fitness level: chest, neck, jaw or arm discomfort, breathlessness at rest or with mild effort, dizziness or fainting, palpitations, unusual fatigue with usual activity → stop and seek medical clearance before resuming. This supports the base's red-flag line in SYNTH-75 and the house rule in SYNTH-70 (chest pain, palpitations, dizziness = a doctor).
An inactive beginner starts light to moderate and builds over 2-3 months, avoiding unaccustomed vigorous to near-maximal efforts (the panel's prescription advice): this fits SYNTH-75's frequency-then-duration order; that guide's optional short hard interval set from week 3-4 for a true-beginner cyclist (its own practice, e.g. 1 min hard) falls inside the panel's 2-3-month transitional phase, during which intensity rises gradually and inactive people are counselled against unaccustomed vigorous to near-maximal efforts; the panel names no week for a first vigorous session, so this is a tension to note, not a contradiction.
Age alone is not a reason to send someone to a doctor (the statement); a masters athlete who is active and symptom-free continues, one returning from months of inactivity counts as inactive (inference from the activity definition).
Not for competitive athletes' cardiac screening: ECG-based screening and its interpretation are a separate question (REF-1071).

Limitations

Consensus, not a systematic review. No search strategy, evidence grading or voting process is described; the model is expert judgment on observational risk data, and the statement says evidence that medical clearance or exercise testing prevents events is lacking.
Event data. Mostly from vigorous to near-maximal exercise; much less is known about light to moderate exercise (assumed lower risk) and resistance training (risk unknown, probably low, per the statement).
Aerobic exercise only. The logic model is for aerobic exercise participation.
Date and setting. 2015, a US body; the statement anticipates a fuller treatment in the 10th edition of ACSM's Guidelines, not read here.
Interests. Funded by ACSM; no conflict-of-interest statement in the article; three authors edit the ACSM guidelines being revised.
Reporting. The PDF's own citation line prints "Vol. 47, No. 8" (and an article code 4708-2473), while PubMed, Europe PMC and Crossref give issue 11 (November 2015); the pages agree. The decision boxes of Figure 2 were read from the text and footnotes only.
How this entry was checked and changed
Why this level

read from the full text (published PDF, Columbia University Academic Commons repository copy listed by OpenAlex). The rubric places a major consensus or position statement at A; it is not A+ because no systematic review underlies it, and its algorithm is expert judgment built on observational risk data — the statement itself says evidence that medical clearance and exercise testing reduce exercise-related cardiovascular events is lacking

Full text (checked 2026-10-27)
In June 2014 the ACSM convened a scientific roundtable; the new model rests on current physical activity, signs or symptoms and/or known cardiovascular, metabolic or renal disease, and desired exercise intensity (full text)
Physically inactive but otherwise healthy asymptomatic persons may begin light- to moderate-intensity exercise without medical clearance and progress gradually (full text)
Physically active asymptomatic individuals with known disease cleared within the last 12 months need not revisit their provider to continue a moderate-intensity program (full text)
Exercise participation: at least 30 min at moderate intensity on at least 3 days a week for at least the last 3 months; vigorous: 60% HRR or VO2R, 6 METs, 14 RPE (full text)
Thompson et al. reported one death per 396,000 h of jogging; Kim et al.: 0.20 cardiac arrests and 0.14 SCD per 100,000 estimated runner-hours (full text)
Relative risk for exertion-related AMI ranged from 4.5 to 107 in the least active cohorts vs 0.86–3.3 in the most active; each additional weekly bout: 30% lower risk of SCD and 45% of AMI during activity (full text)
95% of men and women over 40 yr would have been advised to consult a physician under the previous process (full text)
A progressive transitional phase (i.e., 2–3 months) during which duration and intensity are gradually increased (full text)
The roundtable was generously supported by the ACSM (full text)