Sports Physicals, Sudden Death, and Chiropractors

A correspondent sent me a link to an article about the decision of the Wichita Falls (Texas) Independent School District to recommend that chiropractors be allowed to give sports physicals to junior high and high school students. Current policy limits examiners to physicians, physician assistants, and nurse practitioners. Adding chiropractors to this list would bring the district in line with policies in the rest of Texas, as well as in some other states. And it would “give parents more options.”

I’ve written about the attempts of some chiropractors to assume the role of family doctorsand why I think it is a terrible idea. The idea of allowing them to do sports physicals impresses me as somewhat less terrible, but not by very much.

The reasons for requiring sports physicals

The goals of the Pre-participation Athletic Exam (PAE) include:

  • To identify athletes who should not participate because of high risk of injury or death
  • To identify those who require further evaluation or treatment so they can participate safely
  • To identify conditions that do not affect athletic participation but that should be treated
  • To possibly identify those at risk for substance abuse, depression, violence, etc.
  • To provide preventive health advice
  • To satisfy legal requirements.

According to a review article in American Family Physician

Specific conditions that would exclude or limit athletic participation include hypertrophic cardiomyopathy, long QT interval syndrome, concussion, significant knee injury, sickle cell disease and uncontrolled seizures. Overall, about 1 percent of athletes who are screened are completely disqualified from sports participation.

The greatest concern is the risk of sudden death.

Sudden cardiac death

In the fifth century BC, Phidippides ran 25 miles to bring the news of victory in the battle of Marathon to Athens. After delivering his message to the archons, he collapsed and died. Sudden death during or immediately after athletic exertion continues to be a problem. Estimates of incidence range from one young athlete in 200,000 every year to 1 in 43,770 NCAA athletes and 1 in 3100 NCAA Division I male basketball players per year. A Minneapolis Heart Institute Foundation study of sudden deaths in trained athletes identified 158 deaths, 85% due to cardiovascular causes. Hypertrophic cardiomyopathy was the most common cause. Physical exams are not very good at preventing these deaths.  115 of these athletes who died suddenly had had a standard preparticipation medical evaluation, and only 4 of them had been suspected of having cardiovascular disease. Of those 4, the abnormality responsible for sudden death was correctly identified in only one.

An article in the Journal of Athletic Training characterized current screening methods as “ineffective and inefficient.” The standard history and physical exam result in an extremely small number of significant cardiac findings. Screening ECGs have been proposed but are generally considered to be ineffective because of the high false positive rate. In a study of 501 college athletes, 75 had abnormal ECGs requiring further examination, but none of them led to restrictions from participation.

Italy has an aggressive screening program that disqualifies 1.8% of athletes for

  • physical features of Marfan syndrome;
  • delayed femoral arterial pulses;
  • single, wide or fixed splits in the second heart sound;
  • systolic or diastolic murmurs of grade 2/6 or greater;
  • irregular rhythms; or
  • blood pressures greater than 145/90 mm Hg

This screening reduced the mortality of young competitive athletes by approximately 90%.  But other sources show that the overall SCD incidence in Italy remains similar to that in the US.

Screening all athletes with echocardiography would identify many athletes at risk for sudden death, but it would cost an average of $857 per patient.  False positive findings may lead to expensive further evaluations, and there are emotional costs (worry, stress, persistent fear of death even after reassurance of normality). There are also false negatives.

The American Heart Association has a list of recommended screening items including family history of sudden death and cardiovascular disease, personal history of 6 specific symptoms, 4 physical exam items, and parental verification. In one review, only 17 of 43 state forms met AHA recommendations.

Non-cardiac problems

Blood pressure, weight and vision are tested. The PAE can identify patients with post-concussive sequelae to help prevent second-impact syndrome. Patients with a single eye,  sports injuries. Patients with seizure disorders can be dissuaded from high risk sports like high diving. Exercise induced asthma can be treated. Patients with sickle cell trait can be counseled about hydration and acclimatization. Old injuries can be assessed for complete healing. Tests like duck-walking (walking in a deep squat) can detect a torn meniscus. Eating disorders may be identified. Contagious skin infections may be spotted.

There are other benefits.  The exam offers an opportunity to address prevention issues (smoking, seatbelt use, etc.). It can identify health concerns that don’t directly affect participation but that need further evaluation and treatment.

How are sports physicals done?

There is a standard form for these exams that is recommended by several medical organizations. Not all schools use this form, but all have some kind of history form to be completed by student and parents, and a checklist for things to be looked at in the physical exam.

The history is the most important part of the process, identifying up to 78% of pertinent conditions.  Unfortunately, as Dr. House says on the TV series, “patients lie.” Children and parents are motivated to get clearance to play a sport and may intentionally omit or minimize symptoms or past illnesses/injuries that they think might disqualify them. The ideal examiner is the child’s personal physician who already knows the health history and family history in depth. A family physician or pediatrician has the broad training to pick up potential problems in all areas.

Other than the cardiovascular exam recommendations from the AHA, there is little guidance about which physical exam components are worthwhile. Should we have every patient duck-walk to test for meniscal tears in the knee? Is measuring every child’s height really important? How often does a cursory exam for enlarged lymph nodes lead to a significant diagnosis? When the form calls for musculoskeletal exam of the wrist/hand/fingers, should we just look to see if all the fingers are there, or should we test strength, flexibility, and range of motion? What criteria define a significant finding in this context, and what actions are indicated for positive findings? We simply have no evidence to guide us.

There are two ways to get these exams. Students can be seen by their personal physician; but this involves cost and inconvenience, and timely appointments may not be available. Some schools offer mass screening exams with an assembly line of stations where individual tasks are accomplished, like vision testing and BP measurement, ending with a station where a physician reviews the results and examines the patient. This method is cost-effective and time-effective, but it may decrease quality.

I have participated in those mass screenings, and I hated them. They were a chore to be endured, with limited time for interactions with the patient and with little sense of purpose.  Back when I was doing them we had no guidance and little understanding of what we should be looking for; and it easily degenerated into a perfunctory task of checking items off on a list with the feeling that it wasn’t going to make any difference to anybody anyway. Only around one percent of patients have a disqualifying condition, and it can be very tedious to wade through the other 99.  I’ve always disliked doing routine physicals of any kind, because they are largely unproductive, as I explained in another post.  Doing a physical in pursuit of a diagnostic problem is fun, stimulating, and rewarding. Listening to the normal hearts of 99 often shy and embarrassed teen and pre-teen strangers is not. I’d much rather see a regular patient in my office and fill out the form based on a long-term relationship and a limited, directed physical exam.

Who can do these exams?

  • 5 states have no specific recommendations
  • 21 states allow PAs and NPs to perform these exams
  • 10 states allow chiropractors
  • 1 state allows naturopaths
  • Colorado allows chiropractors to do school physicals but requires special training and certification.

Some PAs and NPs have enough training and experience to detect cardiovascular disease, but few chiropractors do. Specific training might bring selected chiropractors up to an acceptable level, but there are other considerations. They might miss things because they still would not have the broad experience of all kinds and severities of illness that physicians get with in-hospital training, and they might be influenced by belief systems that are outside the scientific paradigm.  Less than half of chiropractors support immunization, many of them use bogus muscle testing (applied kinesiology), and many of them still imagine they are correcting mythical subluxations: those at least would have to be excluded. And they would have to be prevented from soliciting customers for chiropractic adjustments and from spreading misinformation. The whole thing is just too problematic.

Questions and answers

Q: How effective is the sports physical for identifying health problems?

A: Not nearly as effective as it could be.

Q: Which health problems should preclude athletic participation or defer it pending further testing?

A: Controversies exist; there are few absolutes, and the degree of risk varies with the magnitude of the problem.

Q: Does the requirement for sports physicals reduce the rates of injury or death?

A: There’s some evidence that it does, but it’s not entirely conclusive, and the reduction is likely small in magnitude.  And even if barred from athletic programs a young person may choose to ignore advice and risk injury or sudden death by strenuous recreational exertions.

Conclusion (AKA my humble opinion)

Sports physicals have the potential to significantly reduce the risk of injury and death, but in actual practice they are often inadequate. They could be improved by standardization and more rigor, including uniform application of AHA recommendations. Ideally, they would be done by the child’s family physician. Ideally, examiners would have specific training in what to look for and which exam procedures to use, training that will be problematic until we can support specific recommendations with better evidence.  Physicians and properly trained, experienced PAs and NPs are qualified to do these exams. Chiropractors and other alternative providers are not, even with special certification and training.

This article was originally published in the Science-Based Medicine blog.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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