Editorials

Factors at Play in the Athletic Preparticipation Examination

DOUGLAS B. MCKEAG, M.D., M.S.
Indiana University School of Medicine
Indianapolis, Indiana

ROBERT E. SALLIS, M.D.
UCR/UCLA Biomedical Sciences Program
Los Angeles, California

See related editorial. See article in this issue.

The medical community continues to benefit when physicians reexamine topics that have been widely written about, as authors Kurowski and Chandran have done in this issue of American Family Physician.¹ However, their debate over the preparticipation physical examination deals less with content (well defined and agreed to in the 1997 monograph "Preparticipation Physical Exam"²) than with theory.

What they debate is the worthiness of the examination. In an effort to give adequate consideration, one must look at the function and goals of the preparticipation examination. The purpose of the preparticipation physical examination is not so much to disqualify athletes with life-threatening conditions. It is to establish primary care in adolescents who frequently do not have a physician, to provide an opportunity for adolescents to talk to a physician about sports-related or development issues and to identify any health risks inherent in a particular sport. Adolescents are notoriously difficult to reach. A sports physical is a way to build rapport with a teenager, which frequently leads to discussion about other issues. It is an opportunity to update immunizations, identify eating disorders and obesity, discuss sexual health, counsel about drug, tobacco and alcohol use and to warn athletes of the dangers of anabolic steroids. It is an opportunity to discuss asthma, allergy and infection control. Physicians can review a sports program to make sure that parents and coaches are using adequate safety equipment and training procedures and are knowledgeable about athletes' needs for hydration and first aid. It is also a way to alert coaches about ongoing health problems that might require accommodation.

Indeed, there is a sound philosophy behind preparticipation physical examinations. Sports medicine, and specifically primary care sports medicine, has advanced to the point where there are practically no conditions that disqualify an athlete from all forms of physical activity. We know that physical activity becomes a powerful adjunct to the ongoing treatment of many chronic illnesses. It is essential that physicians involved in the preparticipation examination have the knowledge and skill to help patients find appropriate activities in which to participate. To do otherwise would be to do the athlete a disservice. Disqualification is a choice of last resort. The introduction of exercise in youth has proved to be one of the most powerful and beneficial tools that prevention-minded physicians have available. Active persons are healthier, happier and live much longer than inactive persons. Various risk factors that prey on large segments of our population are minimized with good exercise habits throughout life.

The argument against the preparticipation physical examination is moot. Consideration of the preparticipation examination confirms it as a valid and important point in rendering quality health care. Consider the goals accomplished by a good preparticipation physical examination:

• Legal conditions are met for the institution involved.
• Conditions that might adversely affect an athlete during sports participation can be identified. These conditions primarily involve the cardiac and orthopedic systems but are not limited to them.
• Conditions that have the potential to predispose an athlete to subsequent injury, such as incomplete healing of a previous injury, can be detected.
• The overall general health of the athlete can be determined.
• A relationship, on the part of the athlete, has begun with the team physician that will continue during athletic participation.
• A venue has been opened that will enable the athlete to discuss various nonathletic concerns.
• Appropriate advice and feedback can be given concerning such areas as nutrition, warm-up, cool-down and proper conditioning.
• A network to support the health care of that person has been established or enlarged.
• Preventive concerns, such as seat belts, drinking and other high-risk behaviors common to the adolescent age group, can be addressed.

The preparticipation physical examination should and, we are confident, will remain a significant part of a well-run sports medicine program. When done appropriately, and for the right reasons, it serves an extremely useful function. As with all successful medical endeavors, the right people with the right philosophy must be involved to make it work.

Douglas B. McKeag, M.D., M.S., is professor and chair of the Department of Family Medicine at Indiana University School of Medicine, Indianapolis, Ind.

Robert E. Sallis, M.D., is assistant clinical professor at UCR/University of California-Los Angeles Biomedical Sciences Program. He is codirector of sports medicine fellowship at Kaiser Permanente Medical Center in Fontana, Calif.

Address correspondence to Douglas B. McKeag, M.D., M.S., Department of Family Medicine, Indiana University School of Medicine, Indianapolis, IN 46202.

REFERENCES

1. Kurowski K, Chandran S. The preparticipation athletic evaluation. Am Fam Physician 2000;61:2683-90.
2. Smith DM, Preparticipation Evaluation Task Force. Preparticipation physical evaluation. 2d ed. American Academy of Family Physicians. Minneapolis: The Physician and Sportsmedicine, 1997.

---

It Won't Be Me Next Time: An Opinion on Preparticipation Sports Physicals

JONATHAN D. REICH, M.D.
The Watson Clinic
Lakeland, Florida

See article in this issue.

I sat in the pediatrics section meeting at a local community hospital when they asked for volunteers for preparticipation sports physical examinations. As a pediatric cardiologist, I figured I might offer valuable help. When I arrived at the enormous gymnasium of the local community college, there was no electrocardiogram machine and I learned that I was going to examine cheerleaders from the ages of six to 16 years. So, with a chaperone present I examined and cleared about 100 middle-class "cheerleaders" for an activity that has never been associated with a case of sudden cardiac death. Somewhat amused, I watched other physicians clear boys for sports such as golf, swimming and tennis. I was only surprised that no one from the debate team was present.

Kurowski and Chandran address the steps of the preparticipation physical in their article in this issue¹ of American Family Physician; however, I have reservations about clearing children who should be seeing their primary care physicians anyway, especially children who are participating in sports that the American Heart Association allows children with a single ventricle to do without restrictions. The other physicians, mostly family physicians, felt that they were providing good primary care. They diagnosed diseases such as warts and hernias. I told them that while good primary care is important, I wasn't sure that this was the reason I gave up an evening to volunteer. Most of these children had primary care physicians. I wasn't looking for warts; I was trying to keep children from dying.

There is something unsettling about volunteering your time to examine patients who can afford to receive primary care. While my colleagues may have provided a valuable service, I am not sure I see a justification for providing primary care under the guise of "sports physicals." While there is a scientific foundation and a medical need for primary care, it is questionable whether the scientific basis for the preparticipation sports physical examination has been demonstrated. The preparticipation sports physical didn't evolve from a public health need. It didn't arise out of a lack of primary care. It evolved because of media attention on athletes who had an adverse event while competing. The preparticipation sports physical is a medical event that is not inspired by medical need. If there is no scientific way of preventing athletes from getting injured or dying, I contend that an athlete can never be "cleared" to compete.

If we focus on sudden cardiac death during exercise, certainly the most catastrophic impetus for sports physicals, we do not find an epidemiologic justification for performing physicals to prevent sudden cardiac death. First, the fundamental basis of screening is to identify the specific purpose of screening. In the case of the preparticipation sports physical, the intention is not evident. There are no standardized forms, the forms that exist are inadequate, and many states have no forms. Some states do not require a medical license to perform the examination.² Studies frequently cite the history as being the most important part of the examination, yet there is no standardized history and athletes report that the history-taking is poor.³

Even if you standardized the history and physical examination so that you are trying to detect athletes who are at risk of sudden cardiac death, the incidence of sudden cardiac death is so low it could never be made a public health priority worthy of the effort. The effort is beyond trying to find a needle in a haystack. It is like trying to find a needle in Kansas. From 1985 to 1995, 158 cases of sudden deaths during competitive exercise have been documented in the United States.⁴

Depending on how you define the denominator, the incidence of sudden cardiac death in athletes is somewhere around one in 150,000 participants to one in several million participants.⁵ Only four sports (football, basketball, track and soccer) have been associated with more than five sudden deaths,⁴ yet more athletes and younger children are being included in screening. This makes the examination more inclusive, thereby making the effort less effective.

What can the preparticipation sports physical examination detect? The Mayo Clinic reported that significant cardiac abnormalities were found in 0.39 percent of 2,739 athletes who were screened.⁶ If we assume that the Mayo clinic screening procedure is reproducible nationwide, a major leap of faith considering the state of preparticipation sports physicals nationwide, then we are accepting that one in 500 children will be disqualified from competing in order to find an illness with an incidence of one in 100,000. In other words, we will be disqualifying thousands of children who will never have a problem.

Even if we accept that we could find an anomaly in one of 500 children, we have no way of knowing that these children will have a problem. It is possible the athlete who will experience sudden cardiac death will have slipped through the screening process. The one study that I am aware of to prospectively identify athletes at risk of sudden death was done at the University of Maryland in 1987 and was completely unsuccessful.⁷

The most common cause of sudden cardiac death is hypertrophic cardiomyopathy, which may have no physical examination findings and may even be associated with a normal electrocardiogram (that is, if an electrocardiographic study is performed).^5,8 Yet, compared with the other common causes of sudden cardiac death (e.g., anomalies of the coronary arteries, arrhythmogenic right ventricular dysplasia, long QT syndrome), it is easy to diagnose.^5,9 The first two entities invariably have no physical findings and a normal electrocardiogram, while long QT syndrome cannot be diagnosed without an electrocardiographic study.⁸

Yes, some hint of possible problems may be revealed by the history for some patients, but preparticipation sports physicals are usually done without the parents present. Since when do we rely on the history of adolescents who are trying to get clearance to pursue their dreams?

Of course, the point has never actually been to prevent injuries or death. If it were, the examination would have been standardized and upgraded to include electrocardiographic studies many years ago. It would appear that the preparticipation sports physical was designed to reassure parents and school administrators or to "trick" children into getting primary care. Yes, clearing athletes to compete is extremely important; however, the system currently in use is inefficient and cannot "clear" an athlete. The preparticipation sports physical is in fact detrimental because it provides a sense of assurance when there is no evidence that a disease process was prevented or even properly screened.

I know very little about orthopedic surgery. Yet, I have reviewed the literature on orthopedic preparticipation sports physicals and found it is not much different than the literature on sudden cardiac death. While there are criteria for disqualifying athletes, and a small percentage of athletes fail the criteria and are thus disqualified,¹⁰ I can find no evidence that these athletes are the ones who would be injured or that anyone can predict or prevent injuries. In addition, the orthopedic examination in preparticipation sports physicals fails the basic premise of screening tests--that abnormalities need to be detected.

If you're not convinced that we should question the usefulness of the preparticipation sports physical, ask yourself the following questions: Why are we doing thorough examinations on children who are already getting primary care? Why are we assessing children for sudden cardiac death who are going to engage in activities that have no risk of sudden cardiac death, such as cheerleading? Why do we assess children who are at minimal risk of any injury, such as those who play golf? What is the likelihood that a noncardiologist can detect arrhythmogenic right ventricular dysplasia on the basis of an adolescent's history and a five-minute physical examination? Is it possible for a preparticipation sports physical, done by a nonorthopedic surgeon nonetheless, to establish the risk of a football player tearing his anterior cruciate ligament? The reason that your answers are most likely "no," "I don't know," or "dismal," is that the terms "risk," "prevalence," "indication" and "likelihood" only have meaning in the context of science, and this effort is not being done for a scientific reason, nor is it being done scientifically.

A medical screening procedure can be effective and efficient only on an individual basis with the proper equipment. It cannot be done in a warehouse. First, only athletes who are truly at risk for sudden cardiac death need to be screened for sudden cardiac death. This would restrict the examination to football, basketball, track, soccer and perhaps ice hockey players. All other athletes could get a statement from their primary care physician that they are in good health, not that they are "cleared." This would make the preparticipation sports physical redundant. If athletes don't have primary care, then this enormous effort should be transformed into an effort to provide more primary care. Second, we refer at-risk athletes who have a reason to be cleared; for example, we should refer athletes with complaints of syncope to their family physician. The cardiologists will have at their disposal the means necessary to properly assess and perhaps even "clear" the patient from a cardiovascular standpoint. Yes, someone will have to pay for it, but that's the trade-off for responsibility. Other medical subspecialists can make their own screening process using the medical literature to try to make the process scientific and thus productive.

Meanwhile, I propose that until someone demonstrates that it is prospectively possible to prevent sudden cardiac death, we put more effort into treating sudden cardiac death. Currently, the improvements in defibrillator technology are spurring on an effort to put defibrillators in gymnasiums and airplanes. For that matter, we certainly can have defibrillators in place not only at competitive sporting events but conceivably at little league baseball games. I propose that competitive sporting events be staffed by someone who is trained in advanced cardiac life support. A defibrillator and someone who knows how to use it should be present at every competitive sporting event.

If the parents don't want to pay for screening, or if the insurance companies or the schools demand it, they can stick with the gymnasium routine. But, it won't be me they'll be seeing.

Dr. Reich practices pediatric cardiology in a private practice in Lakeland, Fla.

Address correspondence to Jonathan D. Reich, M.D., Watson Clinic, 1600 Lakeland Hills Blvd., Lakeland, FL 33805. E-mail: jdreich@hotmail.com.

REFERENCE

1. Kurowski K, Chandran S. The preparticipation athletic evaluation. Am Fam Physician 2000;61:2683-90.
2. Glover DW, Maron BJ. Profile of preparticipation in cardiovascular screening for high school athletes. JAMA 1998;279:1817-9.
3. Laure P. High-level athletes' impressions of their preparticipation sports examination. J Sports Med Phys Fitness 1996;36:291-2.
4. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. JAMA 1996;276:199-204.
5. Berger S, Dhala A, Friedberg DZ. Sudden cardiac death in infants, children, and adolescents. Pediatr Clin North Am 1999;46:221-34.
6. Smith J, Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. Mayo Clin Proc 1998;73:419-29.
7. Maron BJ, Bodison SA, Wesley YE, Tucker E, Green KJ. Results of screening a large group of intercollegiate athletes for cardiovascular disease. J Am Coll Cardiol 1987;10:1214-21.
8. Moss AJ, Adams FH, Emmanouilides GC. Moss and Adams' Heart disease in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.
9. Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339:364-9.
10. Rifat SF, Ruffin MT 4th, Gorenflo DW. Disqualifying criteria in a preparticipation sports evaluation. J Fam Pract 1995;41(1):42-50.

---

Family Practice and the Elimination of Tuberculosis

RICHARD J. O'BRIEN, M.D.
Centers for Disease Control and Prevention
Atlanta, Georgia

DAVID L. COHN, M.D.
Denver Public Health,
Denver, Colorado

See article in this issue.

After an unprecedented increase in reported cases of tuberculosis in the United States that began in 1986, the disease has been brought under control. In 1999, the number of reported cases of tuberculosis declined to an all-time low of 17,528, and the country recommitted itself to the goal of tuberculosis elimination that was first announced in 1989.¹ Although new tools, such as an improved, effective vaccine, will be needed to eliminate tuberculosis, much can be accomplished with the improved use of current technologies.

Among the available control measures, treatment of persons with active tuberculosis is of paramount importance, especially to decrease morbidity and mortality and prevent secondary transmission to others. However, in the United States, the majority of active cases of tuberculosis occur among those with latent tuberculosis infection acquired in the past. Thus, the treatment of persons with latent tuberculosis infection who are at high risk for developing active disease is also a critical component of the elimination strategy.

In recognition of the importance of latent disease, the American Thoracic Society (ATS) and the Centers for Disease Control and Prevention (CDC) have recently issued a new statement titled, "Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection."² The salient points of these new recommendations are summarized in the review of tuberculosis diagnosis, treatment and prevention by Jerant and colleagues,³ published in this issue.

Hence, the diagnosis and treatment of latent tuberculosis infection should be of major concern to family physicians, and primary care physicians will play a significant role in the elimination of tuberculosis in the United States. New cases of tuberculosis largely occur among persons in two risk groups: those who have recently been infected and those with medical conditions that facilitate the progression of latent tuberculosis infection to active disease. It is persons in these groups who are the focus of the new guidelines for management of latent tuberculosis infection. The ATS and the CDC are calling for increased testing for latent tuberculosis infection, but they are focusing on persons in these risk groups and discouraging testing in those who are at lower risk.

Although treatment of persons with active tuberculosis will often remain the domain of public health departments and medical subspecialists (pulmonologists and infectious disease subspecialists), targeted testing for latent infection and treatment of high-risk infected persons will increasingly become a function of private practice, community health centers and managed care plans. Several categories of patients are of particular relevance: persons who have recently immigrated to the United States from tuberculosis-endemic countries and those with high-risk medical conditions.

Forty percent of new cases of tuberculosis in the United States are in persons born in other countries who have reactivation of latent infections.⁴ These persons and those with the medical conditions listed in Table 1 of the review article by Jerant³ should be tested for latent infection. In addition, family physicians may see a large number of persons whose occupation places them at risk of tuberculosis and who are found to have latent tuberculosis infection.

A complete understanding of which persons should be treated and with what drug or drug regimen is essential, and the new ATS/CDC recommendations also highlight new guidelines for the treatment of latent tuberculosis infection. After repeated analysis of data from clinical trials of isoniazid for the treatment of latent infection, the statement concludes that nine months of treatment with isoniazid (INH) provides optimal benefit and is preferred for all categories of patients.⁵ Although considerable benefit is also provided by six months of isoniazid treatment, the nine-month regimen should be given to children, patients with human immunodeficiency virus (HIV) infection and those with radiographic evidence of previously untreated tuberculosis.

Based on recent data from clinical trials in HIV-infected persons, a new two-month regimen of rifampin (Rifadin) and pyrazinamide, both commonly used drugs for treating patients with active tuberculosis, appears to provide protection equivalent to that of isoniazid.⁶ This regimen is recommended for use in adults with or without HIV infection. The advantages of this much shorter treatment regimen must be balanced against the costs and higher incidence of minor side effects, but it may be especially useful in cases in which the longer course of isoniazid treatment has not proved feasible. Finally, treatment with rifampin alone for four months is also an acceptable regimen.

The guidelines on baseline testing and treatment monitoring have also been revised to emphasize clinical rather than laboratory monitoring.⁷ Clinical monitoring involves education of the patient about signs and symptoms of tuberculosis and drug toxicity, as well as careful questioning and repeated education at monthly intervals. Laboratory monitoring is indicated for HIV-infected persons, pregnant and postpartum women and those with a history of or risk factors for hepatic disease.

Changes in the epidemiology of tuberculosis and the new guidelines have set the stage for new opportunities in tuberculosis control. Risk assessment, targeted testing and implementation of new treatment regimens by primary care physicians will contribute significantly to the elimination of tuberculosis in the United States.

Dr. O'Brien is Chief of the Research and Evaluation Branch in the Division of Tuberculosis Elimination, National Center for HIV, TB, and STD Prevention, Centers for Disease Control and Prevention, Atlanta, Ga. Dr. Cohn is Associate Director of Denver Public Health and Professor of Medicine in the Division of Infectious Diseases, University of Colorado Health Sciences Center, Denver.

Address correspondence to Richard J. O'Brien, M.D., Division of Tuberculosis Elimination (E-10), National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333.

REFERENCES

1. Centers for Disease Control and Prevention. Tuberculosis elimination revisited: obstacles, opportunities, and a renewed commitment. Advisory Council for the Elimination of Tuberculosis (ACET). MMWR 1999;48(No. RR-9):1-13.
2. American Thoracic Society/Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med 2000;161(Part 2):S221-47.
3. Jerant AF, Bannon M, Rittenhouse M. Identification and management of tuberculosis. Am Fam Physician 2000;61:2667-78.
4. McKenna MT, McCray E, Onorato I. The epidemiology of tuberculosis among foreign-born persons in the United States, 1986 to 1993. N Engl J Med 1995;332:1071-6.
5. Comstock GW. How much isoniazid is needed for prevention of tuberculosis among immunocompetent adults? Int J Tuberc Lung Dis 1999;3:847-50.
6. Gordin F, Chaisson RE, Matts JP, Miller C, de Lourdes Garcia M, Hafner R, et al. Rifampin and pyrazinamide vs. isoniazid for prevention of tuberculosis in HIV-infected persons: an international randomized trial. JAMA 2000;283:1445-50.
7. Nolan CM, Goldberg SV, Buskin SE. Hepatotoxicity associated with isoniazid preventive therapy: a 7-year survey from a public health tuberculosis clinic. JAMA 1999;281:1014-8.

---

Copyright © 2000 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

---

May 1, 2000 Contents | AFP Home Page | AAFP Home | Search

---