Although it is well established that regular participation in physical activity has many benefits, including a lower risk of cardiovascular disease (CVD) and CVD mortality, the likelihood of experiencing an acute cardiac event (e.g., myocardial infarction or sudden cardiac death) is increased during a bout of physical activity, especially for those who are unaccustomed to vigorous-intensity exercise. Screening for CVD risk factors and the presence of signs and symptoms and/or known cardiovascular (CV), metabolic and/or pulmonary disease is a common practice to mitigate cardiac-related problems during physical-activity participation. There is, however, considerable evidence for the following: Show
In November 2015, the American College of Sports Medicine (ACSM) formally updated their preparticipation health-screening process. ACSM made this change after recent studies revealed that previous CVD risk-factor profiles and risk-classification processes resulted in excessive physician referrals, possibly creating a barrier to exercise participation. For example, Whitfield and colleagues (2014) (http://circ.ahajournals.org/content/129/10/1113) concluded that most people (nearly 95 percent) over the age of 40 years would be required to visit a physician before engaging in any form of exercise, based on previous standards. This referral recommendation held true even for an activity as simple as walking. The new screening process adopts several changes intended to reduce barriers to physical-activity participation, yet still allows for the identification of individuals who should receive medical clearance prior to initiating an exercise program or increasing the volume, frequency or intensity of an existing program. Research comparing the new prescreening algorithm to the previous version revealed a 41% decrease in the number of individuals who would be referred to a physician before beginning exercise (Whitfield et al., 2017) (https://journals.lww.com/acsm-msse/Abstract/2017/10000/Applying_the_ACSM_Preparticipation_Screening.12.aspx). This suggests that the new prescreening procedures decreased the medical-clearance barrier to physical-activity participation by decreasing the number of individuals who require physician approval prior to engagement. Some key takeaways for using the new ASCM prescreening algorithm include:
For more information about the new exercise preparticipation health screening process, see New Preparticipation Guidelines Remove Barriers to Exercise. This blog was written by Sabrena Jo and Chris Gagliardi. Sabrena Jo, M.S., has been actively involved in the fitness industry since 1987. As a certified group fitness instructor, personal trainer, and health coach, she has taught group exercise and owned her own personal-training and health-coaching businesses. Jo is a former full-time faculty member in the Kinesiology and Physical Education Department at California State University, Long Beach. She has a bachelor's degree in exercise science as well as a master's degree in physical education/biomechanics from the University of Kansas. Jo is the Director of Science and Research Content for the American Council on Exercise (ACE) and a relentless pursuer of finding ways to help people start and stick with physical activity. Jo has a passion for the aerial arts and in her spare time enjoys hanging upside down from fabric and flinging her partner around in their acrobatic routines. Chris Gagliardi is the Study Assistance Administrator at ACE. Chris holds a BS in Kinesiology from San Diego State University, as well as a Certificate in Orthotics from Northwestern University Fienberg School of Medicine. As an ACE-certified Personal Trainer and Health Coach, as well as a NSCA Certified Strength and Conditioning Specialist and NASM certified personal trainer, Chris takes great pride in sharing his enthusiasm for fitness with others and is committed to life time of learning. The idea of leading a healthy lifestyle was first introduced to Chris at the age of 12 when his father brought him to the gym for the first time. This first gym experience ignited a passion for life long fitness that would only grow stronger as the years went on. Chris has worked in the field of Health and Fitness in many capacities over the past 10 years, working with both youth and adult populations.
Approximately 46.5 million children and 7.7 million high-school students in the United States participate in organized sports each year [1]. As the number of individuals participating in sports continues to increase, so does the number of sport-related injuries. In 2012, over 1.35 million children received emergency care for sports-related injuries [2], and 39 young athletes suffered from sports-related death [1]. The purpose of pre-participation screening in sports is to decrease the number of sport-related injuries and death by identifying individual abnormalities that may predispose an athlete to injury [3]. Timing, Setting, and the Medical Team[edit | edit source]Currently, no legal guidelines govern the administration of pre-participation screenings.[7] However, many sports organizations have adapted their own regulations in regards to administration of a pre-participation exam. In all fifty states, the National Federation of State High School Associations requires students to complete some form of examination prior to participation in high school sports.[8] In addition, the National Collegiate Athletic Association (NCAA) requires a medical evaluation upon entrance into the athletic program.[8] For the non-athletic population, the ACSM recommends that a pre-exercise evaluation be performed before an individual begins a new exercise program in order to ensure exercise training can be initiated safely.[9] For the athletic population, literature suggests a pre-participation examination take place at least six weeks prior to the start of practice in order to allow adequate time for rehabilitation prior to participation.[8] Subjective History[edit | edit source]Typically, pre-participation screenings begin with a subjective examination. The American College of Sports Medicine recommends for the medical examination to include content regarding the following topics: past and present medical history, present symptoms, recent illnesses or surgeries, medication, exercise history, work history, and family history.[9] Medical history such as hypertension, obesity, diabetes, metabolic syndrome, dyslipidemia, or cardiovascular disease places the individual at risk for cardiac arrest during exercise.[4] Identifying present symptoms, recent illnesses or surgeries may aid clinicians in identifying pre-existing musculoskeletal, cardiac, etc. symptoms that predispose an individual to injury or more serious condition. Medications, such as beta-blockers, may alter an individual’s heart rate when exercising. Other habits, such as tobacco, alcohol, caffeine, or recreational drug use, can alter the body’s response to exercise.[9] Exercise and work history provides an overview of the quality, intensity, and duration of activity the individual is accustomed to performing and their tolerance for exercise. Finally, family history identifies conditions the individual may be pre-disposed to and allows for further precautions to be taken.[9] Physical Examination[edit | edit source]It is important to screen athletes before they participate in sports in order to establish a baseline of ability, evaluate the athlete's risk for injury, and direct the interventions that might be required. There is not a great deal of research that backs specific processes and components but some professional organizations have some general recommendations [8]. There are many possible elements to a PPE which can include, a medical history, medical examination, musculoskeletal examination, performance testing, and laboratory studies[8]. The sports physical therapists can conduct musculoskeletal physical examinations as a part of the PPE. There are many ways that a musculoskeletal examination can be carried out. Traditionally we have seen impairment based PE's administered that look at strength, range of motion, endurance, and so on [3]. Recently a growing trend has involved looking at functional movements to assess an athlete's risk for participating in sports. The functional movement system (FMS) was developed as a systematic way to examine movement and classify injury risk[3]. The FMS has 7 fundamental movement patterns that challenge mobility and stability of an individual[3]. A score is calculated from these 7 fundamental movement patterns that can determine whether someone is at risk for injury[3]. The FMS can also be used with Y balance test scores, and demographic risk factors to calculate an injury risk with an algorithm. This algorithm can categorize athletes at risk before participation and can be used for return to sport decisions as well [10]. This article is referenced below and the website to use the algorithm is move2perform.com. In summary there are endless combinations of items that can make up a physical examination for a PPE. The growing trend is to move away from an impairment-based examination into a functional standardized assessments that determines a quantifiable risk number. Cardiac Screening[edit | edit source]A cardiac screen is a very important aspect of pre-participation screening. This will typically occur during the medical portion of the PPE [8]. Some items that should be included are blood pressure, pulse, respiration, auscultation for heart murmurs, palpation of femoral pulses, examination for the physical stigmata of Marfan Syndrome, and a brachial artery blood pressure taken from the sitting position [7] . Sudden Cardiac Death or SCD is a rare but potential hazard that can occur with sports participation. It can often be the first and definitive manifestation of an underlying cardiac pathology[11]. A figure in the referenced article below shows a clinical decision tree for cardiovascular pre-participation screening [11]. It is evident that an ECG is vital to determine the risk according to this study and a few others. This ECG screening allows for the identification of still asymptomatic athletes with at risk cardiovascular diseases [11]. The American College of Sports Medicine or ACSM also has a risk classification that is well researched and useful for the cardiac component of a pre-participation. It uses risk factors to classify individuals into risk groups and advises whether or not there should be a medical test or exercise test recommended before participation in exercise or activity. A link to this article and its risk classification schema can be found below[12] . As with the physical examination portion of the PPE there are no concrete guidelines to the cardiac screening but there are recommendations that can be trusted and relied upon for screening purposes. If any irregularities are found or observed the patient should be referred on to the appropriate individual. Economic Considerations[edit | edit source]Economic considerations for pre-participation screenings largely deal with whether or not to implement ECG testing in America. The American Heart Association (AHA) estimates that if an ECG costs about $50 per student, the added total expense would be $50 million nationwide for the initial encounter. When one considers the number of kids who require follow-up visits and secondary evaluations based on ECG data, the AHA estimates an annual cost of $2 billion[13]. However these estimates have been debated. Chaitman states that ECGs in Florida cost as little as $29.24 through Medicare. He estimates that health programs could negotiate the cost for an ECG to around $10, which would significantly decrease the total cost[14]. Research suggests that ECG testing in addition to the traditional history and physical examination might be cost effective at saving lives[15]. Fuller states that ECG testing is more cost effective than simply using a history and physical exam to detect cardiac abnormalities[16]. This approach of combining ECG testing with a history and physical exam is already being used in Italy, and early evidence suggests that there are significant reductions (almost 90%) in sudden cardiac death risk[17]. Clearance for Sports[edit | edit source]After conducting a pre-participation screen that identifies an athlete at possible risk, the medical professional must decide whether the athlete is fit to compete. When determining if an athlete should be cleared the following questions should be considered [18]: 1. Does the condition pose an unacceptable risk or place the athlete at increased risk for further injury? 2. Does the condition place other participants at risk for injury?3. Can the athlete safely participate with treatment (eg, medication, rehabilitation, bracing, padding)? 4. Can limited participation be allowed while treatment is being completed? 5. If clearance is denied for certain sports or sport categories only, in which activities can the athlete safely participate? After considering these questions along with findings of the screen, the medical professional must make a decision whether the athlete should be cleared to participate. Sanders, Blackburn, and Boucher [8] state that clearance should be one of four conditions: 1. Unconditional clearance, cleared for all sports and all levels of participation.2. Cleared with recommendation for follow‐up – including either evaluation or treatment3. Not cleared with clearance status to be determined after further evaluation, treatment, or rehabilitation4. Not cleared in any sport or level of competition.Medicolegal Considerations[edit | edit source]Currently in the United States, a governing body that regulates the content of pre-participation screenings does not exist in professional sports, college sports, or high school sports. Additionally there is nothing that regulates cardiovascular screening. Consequently, professional teams and college teams rely on their team physicians to handle the process while high schools rely on primary care providers and volunteers[19]. The law allows for physicians to determine the components of a pre-participation screening as long as it meets the minimum standard of care determined by the members of the profession. It is important to note that physicians are not automatically liable if an athlete has an underlying serious condition that causes that athlete to die during his or her sport. For a physician to be liable in America, it has to be proven in a court of law that the physician did not meet the minimum standard of care for performing a screening and that performing a screening according to the accepted standard of care would have detected an underlying serious condition. For physicians to stay within the law and avoid legal action, they should follow the guidelines put forth by medical organizations like the American Heart Association, the American College of Sports Medicine, or the European Socirty of Cardiology. Regarding cardiac pathologies, Amercan law allows for physicians to determine the scope of screening on an athlete-by-athlete basis as long as they act according to standard, accepted practice.[20] References[edit | edit source]
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