CJSM Podcast 5

jsm-podcast-bg-1I’m pleased to present the journal’s fifth podcast, highlighting the new ACSM and FIMS consensus statement on the Preparticipation evaluation (PPE) published just last week in the November 2014 CJSM.

I was able to interview William Roberts, M.D., M.S., FACSM, the lead author of the study.  I learned a lot from the conversation with Dr. Roberts.  I hope you do too.

Listen to the podcast here, or use the iTunes link found on the main page to check out all of our podcasts.

And while you are at it, please also visit the previous blog post and take the poll:  we’re interested to know if you use electronic documentation and data storage when you conduct PPE’s (a so-called ‘e-PPE’).  Enjoy!



The November CJSM and the PPE

Halloween, El Dia de los Muertos….Guy Fawkes Day!  We end October and roll into November in an exciting way in North America and across the Atlantic…..all the more so here at CJSM, where November 1 marks the publication of our sixth and last issue of the calendar year.  Our crew–ranging from the Editor in Chief in London to our Managing Editor in Canada–can, perhaps, take a few days break and indulge in the candies, dulces, or bonfires, as the case may be.  And the rest of us can enjoy the treat of the new journal.   We have a great issue in store, and I plan on profiling over the next month several of the published studies here in the blog.  The headliner has to be the in-depth view on the athletic preparticipation physical evaluation (PPE):

Advancing the Preparticipation Physical Evaluation:  An ACSM and FIMS Joint Consensus Statement.

Check it out:  it’s free even without a subscription to the journal, for the time being.

I am working on the podcast production phase of an interview I had with the lead author, William Roberts, M.D.;  the final product promises to be a lot of fun and will be broadcast soon. One of the subjects Dr. Roberts and I touched on in that talk was the potential value of the electronic evaluation, or ‘e-PPE.’  To whet your appetite for what is to come, why don’t you take the poll at the top of this post, and let us know if you use an e-PPE in your practice (in Ohio, where I practice, we just started using them with high school athletes this spring).  Then, click on the link above to the study itself.

Stay tuned for the podcast, and be sure to check out the entire new issue.  November is here, and with it the promise of good things in the journal and on the blog.

Preparticipation screening and new player medicals – a few points to ponder

It’s currently pre-season in the UK for our Football Leagues, and many Football Club doctors like myself are being kept busy with new player signing medicals and pre-participation evaluations (PPE).

Despite the widespread use of pre-participation evaluation testing, there is still little consensus on the exact nature, composition, and effectiveness of the PPE as a screening procedure for the primary and secondary prevention of medical conditions, and as part of an overall injury prevention strategy. Similarly, there is much variation in the way that new player medicals are conducted, depending amongst other things on the Country, the Sport, and the availability of local resources.

During the PPEs in which I have been involved, in a number of different settings and in the context of a number of different sports and with a number of different teams, I have always wondered if I have been performing the most appropriate examinations and ordering the correct investigations at the right time to make a difference to the health of the sports participant.

Here are just three of many different points to ponder with regard to PPEs and player screening medicals :

1) Special tests in physical examination – which, when, who and why?

Many PPE and medical screening proformas include a battery of physical examination tests which must be completed and ticked off as either ‘normal’ or showing some abnormality which may or may not have particular relevance. One has to consider which tests are appropriate for different individuals in different sports, and the reliability and validity of these tests. It is easy to forget the difference in pre-test probabilities when comparing asymptomatic athletes with those with specific symptoms, and sometimes a puzzle to know what to do if some of the tests do turn out to be positive. Who conducts the examination obviously has an effect on reliability, validity and reproducibility. Importantly, we need to ask ourselves why we are doing the tests – is it to detect problems and potential issues, to document ‘baseline’ observations against future observations, or both?

2) Cost-effectiveness

There is a wide variation of resources available to different teams and individual athletes, and it is sometimes hard to know if a screening programme or new player medical is a cost-effective intervention. What’s even harder is to work out is which tests and investigations are the ones that are likely to give the most ‘bang for your buck.’ One example is the routine MRI scanning employed by some Football Clubs as a screening tool to detect joint problems. These are done at considerable cost, and may detect lesions whose natural history may be difficult to interpret when put into context of the whole clinical picture.

For those Clubs that are less well off, can the cost of video-analysis and functional movement testing be justified as cost-effective? What about ‘routine’ blood tests for haemoglobin and iron etc?

3) Risk-benefit ratio

Using the MRI screening issue as an example, if an asymptomatic lesion is discovered which may have a poorly understood natural course, in sharing that information with the individual how much physical and possibly psychological harm can be caused? Will scans lead to unnecessary and possibly harmful interventions? Will the results affect the player’s career in terms of ongoing transfers? Will player concern about lesions detected on scans lead to poor performance?

There are still perhaps many more questions to be answered in relation to PPE and new player medicals than we currently have the evidence-based answers for.

Check out this 2004 thematic issue of CJSM for a wider look at some of the issues involved in PPE. The other resource well worth a read is the 4th Edition of ‘Preparticipation Physical Evaluation’ published by the American Academy of Pediatrics and co-authored by the AAFP, AAP, ACSM, AMSSM, AOSSM and AOASM.

CJSM would like to know about your experience with PPEs and new player medicals – what dilemmas you have come across with these, and what goes on in your PPEs and new player medicals?

(photograph by Charlie Goldberg, UCSD School of Medicine)

Cardiac screening of athletes with ECG – is it time to focus on the older athletic population?

Roy Shephard’s article in the May edition of CJSM , ‘Is Electrocardiogram Screening of North American Athletes Now Warranted?’ discusses the ongoing controversy of the appropriateness of the use of ECGs in screening College athletes for causes of sudden cardiac death. I’m wondering if it is now the time for us to focus our thoughts on ECG screening of the older athletic population.

My own awareness of the issues around ECG screening of athletes started some 20 years ago when I presented a session on ‘The Athlete’s Heart’ as part of my Physiology degree studies at University College, London. I remember being quizzed at the end of my presentation by the Course Tutor on the effects of detraining, and wishing that I had done a little more reading to back up my claims when I gave my answer stating that, as the adaptations to the normal heart were the result of normal physiological mechanisms, detraining should always result in changes to pre-training baseline on the ECG reflecting the anatomical and physiological detraining effects. His face at the time told me the story that he wasn’t entirely convinced, but I think I got away with it!

I have continued to revisit the issues and re-evaluate the evidence as my career in Sport and Exercise Medicine (SEM) has progressed. My first clinical experience of preparticipation screening came almost a decade ago whilst working in New Zealand when I was involved in providing care for New Zealand Academy of Sport athletes. Since then, another essay on the subject during my MSc SEM studies, teaching MSc and BSc students on an annual basis on ‘The Athlete’s Heart and Sudden Cardiac Death,’ and most recently conducting screening as part of the Football Association’s mandatory screening programme of young footballers, has kept me in touch with emerging research and clinical practice.

One thought has remained with me over the years – that of the importance of fundamental epidemiological principles such as Wilson’s criteria in screening, and linked to those, the need to consider what we are trying to achieve by screening . Essentially, the cardiac screening process seeks to identify individuals at an increased risk of sudden cardiac death. What we do not wish to do is to prevent healthy individuals from enjoying all of the benefits of sport and exercise. Sudden Cardiac Death in the young is still a rare event, mainly due to the underlying age-related population prevalence of associated conditions such as hypertrophic cardiomyopathy, but what about the older population?

The emerging importance of physical activity as an important, under-recognised independent risk factor for morbidity and mortality, often associated with lifestyle diseases such as type II diabetes mellitus, has led to an increasing global effort to engage the population in regular exercise as part of both primary and secondary disease prevention strategies. Whilst it is indisputable that the population benefits of exercise far outweigh the associated risks, it is nevertheless true that the risk of sudden cardiac death during exercise in the over 35’s is considerably higher than in the younger population due to the higher prevalence of associated conditions, mainly coronary heart disease.

ACSM guidelines and AHA risk stratification criteria for exercise testing and prescription offer clinicians guidance in the risk stratification of individuals who engage with healthcare professionals prior to becoming physically active, and point towards the appropriate use of ECG and Exercise Stress Testing as part of the preparticipation evaluation process. However, many individuals, including the older population who regularly exercise or those who may be about to commence regular exercise having been sedentary, will not come under the care of a healthcare professional. These individuals are therefore unlikely to participate in cardiac screening programmes.

Many questions about population cardiac screening prior to participation in sport and exercise come to mind, including :

1) What is the risk / benefit ratio and cost effectiveness of the adoption of ECG screening and exercise stress testing as per ACSM and AHA guidelines on a population basis for those wishing to engage in exercise?

2) How regularly should ECG screening and cardiac stress testing as part of preparticipation evaluation on an ongoing basis be conducted in the older athletic population?

3) What is the best and most appropriate way to engage older individuals involved in exercising, or about to become physically active, in order to conduct screening?

4) Should we be adopting targeted screening including ECG and cardiac stress testing in the older population who are involved in regular exercise?

My greatest concern is for the safety of the older, sedentary individual who decides to take up the sport they previously played perhaps 20 years ago at College, or perhaps who wishes to participate in a 10K run for a local charity, and who does not seek appropriate healthcare advice prior to increasing their physical activity levels.

Should we be focussing our efforts more at population level on screening these older individuals when attempting to prevent sudden cardiac death related to exercise?

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