Participation in regular physical activity confers numerous health benefits, but certain risks are involved. These hazards include risk of acute musculoskeletal injury, myocardial infarction (heart attack), and sudden cardiac death. Given the public health goal of increasing the number of individuals participating in regular physical activity, processes must be in place to identify those individuals at an increased risk of an exercise-related event. These processes should simultaneously be robust, yet not provide a barrier to participation in physical activity.
Preparticipation health screening, also called preparticipation screening (PPS), involves various measures aimed at evaluating an individual's risk for adverse exercise-related events and formulating suitable recommendations in terms of starting, continuing, or progressing in individual physical activity programs in a manner that prevents untoward events. It is also sometimes referred to as the preparticipation examination (PPE).
There are several purposes for preparticipation screening, including to identify:
Student athletes are often involved with preparticipation health screening. The American Heart Association (AHA) recommends that “a detailed physical exam along with a complete and targeted personal and family history for student-athletes is compelling—for ethical, legal, and medical reasons.” When athletes are involved, PPE is referred to as preparticipation sports examination.
The extensiveness of preparticipation screening will depend on both the demographics of program participants and characteristics of the exercise/physical activity program. As the age range of program participants increases, it is expected that the degree of preparticipation screening will concomitantly increase. For example, the level of screening for college students looking to initiate an exercise program at the campus fitness center would likely be fairly brief and might only consist of a single step.
Conversely, the preparticipation screening measures required for a weight loss program for type 2 diabetics would be expectedly more comprehensive. Along these same lines, if the physical activity program itself will only consist of moderate-intensity exercise, the extent of preparticipation screening once again will likely require a basic approach. Conversely, if the physical demands of the program are higher (e.g., vigorous-intensity exercise or participation in a scholastic/collegiate sport), a more comprehensive process of preparticipation screening is warranted.
Current trends show that Americans are living longer while the number of US citizens with chronic diseases continues to increase. In the past 100 years, life expectancy at birth in the United States increased from less than 50 years to more than 76 years. In 2014, the US Census Bureau released an article that projected that by 2050, the number of adults 65 years of age and older will be approximately 83.7 million. This number is nearly double the population of this age group (43.1 million) in 2012. In 2030, this age group is predicted to comprise about 20% of the US population, and by 2050, it should be approximately 21%. Roughly 80% of individuals aged 65 years or older are living with at least one chronic health problem, and another 50% are living with two.
Moreover, the presence of specific chronic conditions can lead to an even greater propensity of comorbidities. For instance, almost all individuals with type 2 diabetes have at least one other chronic condition and nearly half have three or more comorbidities. These factors make it increasingly likely that individuals entering a physical activity/exercise program will be at an increased risk of injury. Fitness and exercise professionals should be mindful of these facts when planning the preparticipation screening processes.
Preparticipation screening procedures must provide valid and timely data to be considered appropriate; information on health and medical history, medications, cardiovascular disease risk factors, signs/symptoms of cardiovascular disease, and exercise/physical activity habits is commonly collected. Preparticipation screening processes can be generally split into either self-guided or professionally-guided categories.
As its name implies, self-guided preparticipation screening is steered by the individual seeking to start a physical activity/exercise program, who, prior to beginning, wants to know whether it is safe to do so or not. Screening tools used for these situations must be straightforward, simple to self-administer, and easy to interpret. Two such tools commonly used include the Physical Activity Readiness Questionnaire (PAR-Q) and the American Heart Association (AHA)/American College of Sports Medicine (ACSM) Health/Fitness Facility Preparticipation Screening Questionnaire. The PAR-Q, for instance, comes in two primary forms, along with supplementary forms.
The PAR-Q is a one-page (basic) form that tells the individual whether a doctor's visit is warranted before becoming more physically active. The PAR-Qþ is a four-page, advanced form that includes additional information for prescreening by an exercise professional prior to participating in physical activities
The purpose of using self-guided preparticipation instruments, such as the PAR-Q, is to make individuals aware of any potential elevated risk they possess. In those instances where increased risk is indicated based on the screening tool, the individual is then encouraged to consult with their physician prior to initiating physical activity or exercise.
Professionally-guided preparticipation screening is performed by appropriately qualified (i.e., academically and certificated by a professional organization) fitness and exercise professionals. The processes in this screening are more advanced and encompass identifying conditions, risk factors, signs, and symptoms that are linked with an increased risk of an adverse exerciserelated event. In particular, risk stratification schema is beneficial for identifying those individuals who require further medical screening and exercise testing prior to engaging in vigorous-intensity exercise.
Prior to the preparticipation screening process, fitness and exercise professionals should first familiarize themselves with those characteristics that are most likely to increase an individual's chances of an adverse exercise-related event; identification of these particular attributes during the screening process can help prevent future injuries. The characteristics associated with increased cardiovascular and other complications related to exercise can be placed into one of four different categories:
Overall, exercise is safe for most individuals, and exercise per se does not incite adverse cardiovascular events. The risk of an acute myocardial infarction or sudden death during exercise is higher in adults compared to their younger counterparts. The higher prevalence of cardiovascular disease in older adults is responsible for this elevated risk. The absolute risk of sudden death during vigorous-intensity physical activity has been estimated to be one per year for every 15,000–18,000 people. Similarly, the risk of cardiac events associated with maximal exercise testing is related to the incidence of cardiovascular disease.
In 2013, American researchers published the paper “Preparticipation Screening—The Sports Physical Therapy Perspective” in the International Journal of Sports Physical Therapy. They stated “The PPE is recommended prior to athletic participation and required by many jurisdictions.” The authors added, “There is little research to support the process and components; however, a number of professional organizations have recommendations that direct the PPE process.”
The process of risk stratification assigns individuals into one of three risk categories (low, moderate, or high) based on these factors:
Individuals categorized as low risk are those who have no signs or symptoms, nor have they been diagnosed with cardiovascular, pulmonary, and/or metabolic disease. These individuals also possess no more than one cardiovascular disease risk factor. Low-riskstratified individuals have minimal risk for an acute cardiovascular event during exercise; this population can safely participate in either moderate- or vigorousintensity exercise.
Individuals categorized as moderate risk are those who have no signs or symptoms of, nor have they been diagnosed with, cardiovascular, pulmonary, and/or metabolic disease, but these individuals possess two or more cardiovascular disease risk factors. As such, moderate-risk-stratified individuals have an elevated risk for an acute cardiovascular event during exercise. Although it is appropriate for these individuals to begin a moderate-intensity exercise program, prior to engaging in vigorous-intensity exercise it is recommended that they first undergo a medical examination and complete a physician-supervised exercise test.
Individuals categorized as high risk are those who have one or more signs or symptoms of, or have been diagnosed with, cardiovascular, pulmonary, and/or metabolic disease. High-risk-stratified individuals have a substantial risk for an acute cardiovascular event during exercise. Accordingly, it is strongly recommended prior to engaging in either a moderateintensity or vigorous-intensity exercise program that high-risk-stratified individuals first undergo a medical examination and complete a physician-supervised exercise test.
A 25-year longitudinal study by Italian researchers determined an 89% decrease in the number of sudden cardiac death (SCD) in young athletes after a cardiovascular screening program was begun. Several other research trials have shown similar results, according to a Canadian paper published in April 2016 in the BC Medical Journal.
This same paper mentioned that in the United States, a study conducted in Minnesota over a 26-year period (from 1986 to 2011) found that the incidence of SCD was 0.7 per 100,000 person-years. Further, only 31% of SCD cases were determined to have been identifiable by a screening program that included a physical examination, a comprehensive history, and an electrocardiogram (ECG). Based partially on the questionable validity of some data, these researchers state that “to date no official recommendations have been developed for screening in this population” in Canada.
The conclusion of this paper stated in part, “Evidence for cardiovascular screening in the young competitive athlete and the effectiveness of screening tools has relied on varying data. What seems to be consistent, however, is the evidence supporting an increase in the sensitivity of a screening program that includes an ECG.”
The American Heart Association recognizes the varying data and the progressively improved quality of screening programs, but it continues to recommend against systematic screening with ECG because of “concerns about feasibility and cost-effectiveness.” Further research is proceeding to address these problems.
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American College of Sports Medicine, 401 W. Michigan St., Indianapolis, IN, 46202-3233, (317) 637-9200, Fax: (317) 634-7817, http://www.acsm.org .
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Lance C. Dalleck, BA, MS, PhD
Revised by William A. Atkins, BB, BS, MBA