Research Review By Dr. Shawn Thistle©

Date Posted:

February 2010

Study Title:

The International Olympic Committee (IOC) Consensus Statement on periodic health evaluation of elite athletes March 2009

Authors:

Ljungqvist A, Jenoure P, Engebretsen L et al.

Author's Affiliations:Publication Information:

British Journal of Sports Medicine 2009; 43(9): 631-643.

Background Information:

There is little doubt now that regular physical activity reduces the risk of many chronic diseases and other ailments. When it comes to elite and high level athletes, there is some evidence that they live longer (1), and experience lower hospitalization rates later in life compared to reference samples for heart disease and respiratory disorders (2).

However, athletes are hospitalized MORE for musculoskeletal conditions. Taken together, this research indicates that regular exercise offers a general health benefit, but that injuries can take their toll at a later time.

As fitness professionals, we are often directly involved in the health of our clients and athletes. As such, it behooves us to know about all aspects of athletic performance, including how general health conditions can affect training. One main priority of the IOC that we should all share is to protect the health of athletes. In recent Olympic Games, the IOC has increased its monitoring and reporting of injuries and health problems among the athletes.

This type of surveillance is necessary to properly develop and recommend procedures for both Preparticipation Examinations (PPE) and Periodic Health Evaluations (PHE) for elite athletes.

Here, we will review and discuss the PHE, which is meant to assess the athlete’s current health status and risk for future injury or disease. It is a form of medical screening, with the intent of identifying pathology early to facilitate prompt intervention. The PHE can also be used to monitor the health of an athlete on a continuous basis.

Although many of us would not be responsible for all components of the PHE, we should be conversant in this topic in order to better serve our clients and athletes.

Pertinent Details of a PHE:

Purpose of the Periodic Health Evaluation (PHE) and General Considerations:
  • the main purpose is to screen for injuries or medical conditions that pose a risk to the athlete’s overall health
  • a secondary purpose is to protect the rights and responsibilities of athletes, physicians, sporting organizations and professionals
  • the PHE should be performed in the primary interest of the athlete, and be based on sound scientific and medical criteria
  • the PHE should ideally be performed by a sports medicine professional, preferably the physician responsible for the regular care of the athlete
  • the PHE may represent the only contact point for a medical professional with an athlete, and should therefore be viewed as an opportunity for athlete education where appropriate
  • individual consideration should be given to type of sport, geographic location, level of competition, athlete age etc. while determining the content of the PHE
  • the timing of the PHE should allow for sufficient management of any conditions revealed before major competitions
  • some conditions (for example cardiac abnormalities) may not present symptomatically, and may only be detected in a PHE
The following section deals with individual components of the PHE. Recent emphasis has been placed on cardiovascular abnormalities that may contribute to Sudden Cardiac Death or Arrest (SCD/SCA), head injuries, and musculoskeletal injuries.

Cardiology/SCD/SCA:
  • high level athletes have an increased risk of Sudden Cardiac Arrest (SCA) – 2.8 times greater than non-athletes – this is due to the combination of intense physical activity with underlying cardiovascular disease
  • the majority of athletes who suffer SCA have no premonitory symptoms
  • Recommendations for PHE: recent evidence suggests that adding a 12-lead ECG can catch a high percentage of common cardiac abnormalities associated with SCA such as hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, ion channel disease and long and short QT syndromes
  • Historical Information Required: ask athlete about personal history of syncope, exertional chest pain, shortness of breath, palpitations, or abnormal fatigue; family history of heart conditions (especially before age 50)
  • there is currently no agreement on the utility of routine echocardiography in the PHE
Concussion and Head Injury: Concussion is defined as a pathophysiological process that affects the brain, induced by a traumatic biomechanical force.

Recommendations for Concussion Component of PHE:
  • question athlete on previous history of concussion (recognizing that accurate recall is not always possible!), progression or worsening of concussion events
  • review all previous oral and cervical spine injuries
  • review use of protective equipment including head, facial and mouth protective devices, including their state of repair
  • review the athlete’s ability to recognize and avoid/minimize high risk situations
Musculoskeletal Injuries:
  • acute injuries are most common in faster moving and contact sports, particularly those with a high risk of falling
  • overuse injuries are more common in sports involving repetitive endurance-type tasks – running, cycling, cross-country skiing for example
  • injury profile varies from sports to sport
  • Recommendations for PHE: discuss any previous and past injuries; use of taping/bracing; training approaches for rehabilitation and injury prevention (as well as performance enhancement of course); use pen and paper self-report forms if necessary
Additional Sections of the PHE:

As mentioned, the main elements of the PHE are meant to screen athletes for risk of sudden cardiac death/arrest, musculoskeletal injuries and head injury. Fitness and sports medicine professionals often encounter a variety of other health conditions in their athletes – most non-traumatic and non-cardiac in nature…they will be summarized below. It should be noted that there is a general lack of data to guide us in the assessment of these conditions in a PHE, but for now, the following represent current recommendations.

Dental:
  • use a DMF – “decayed-missing-filled” – a dental screening tool
  • erosion of teeth may result from excessive use of sports beverages (which are acidic)
  • the presence or absence of wisdom teeth may change the risk profile for mandibular fractures in combative sports
  • custom mouth guards can be discussed here if relevant
Pulmonary System:
  • the most common concern here is asthma (3-23% of summer sport athletes and 12-50% of winter sport athletes)
  • Recommendations for PHE: chest percussion and auscultation
Haematological/Immunological:
  • a blood screen should be included due to the higher-than-expected prevalence of decreased iron stores, particularly in female athletes
  • general infection can also be detected
  • blood testing has been suggested as a routine screen for blood doping
  • during intense training and immediately after competition, athletes are susceptible to immune suppression that could predispose them to infection
  • the PHE also provides a chance to review immunization/vaccination records with the athlete
  • Recommendations for PHE:comprehensive examination for pallor, evidence of infection, lymphadenopathy, splenomegaly
Allergies:
  • allergic rhinoconjunctivitis is the most common affliction – particularly in traveling athletes
  • chronic allergies can significantly affect performance, and in some arenas, simple medications to combat them are not permitted
Dermatological:
  • skin disorders are common in athletes
  • the concern in this area is for the athlete, but also other athletes who may be exposed to a contagious condition (such as athlete’s foot fungus)
  • Recommendations for PHE: comprehensive examination of sun-exposed areas and areas prone to fungal infections
Urological:
  • renal and bladder disease can be asymptomatic
  • conditions that may be common in athletes include hematuria, proteinuria and pyuria – they may not be clinically significant (and in fact may be due to training and competing) but warrant further investigation
  • Recommendations for PHE: examination for suprapubic tenderness, renal masses (via abdominal exam), urinalysis and blood work if necessary
Gastro-Intestinal:
  • those who suffer regular GI symptoms during competition should be screened carefully for underlying disease
  • intestinal infections are common in traveling athletes
  • Recommendations for PHE: comprehensive abdominal examination looking for tenderness, organomegaly, hernias
Nervous System:
  • headaches, epilepsy and peripheral nerve entrapment syndromes may be present – each warranting further investigation
  • although uncommon, stroke can occur in young adults and athletes – risk factors including family history should be investigated
  • Recommendations for PHE: cranial nerve function, motor and sensory function
Endocrine/Metabolic:
  • diabetes mellitus is common in elite athletes (to the point where many athletes gain an exemption and are allowed to use therapeutic insulin during Olympic competition)
  • athletes with existing conditions may need counseling regarding medications because some of them may be prohibited during competition
  • Recommendations for PHE: assess for signs and symptoms of diabetes and thyroid conditions primarily
Opthalmology:
  • reduced visual acuity has been detected in up to 25% of athletes undergoing a PHE – making it an important opportunity to discover a potential performance inhibiting limitation
  • Recommendations for PHE: assess visual acuity, visual fields, infective eye conditions, fundoscopic evaluation
PHE Issues Specific to Women:
  • two medical conditions that are unique to women need to be considered: the female athlete triad and iron deficiency anemia (although not unique to women, it is far more prevalent in women)
  • Female Athlete Triad: consists of under-eating or disordered eating, menstrual abnormalities (with potential anemia), and low bone density
  • the sports with the highest prevalence are those with aesthetic components that emphasize thinness, and those with weight classifications
  • the prevalence of secondary amenorrhea is reported to be as high as 65% in distance runners (compared to 2-5% in the general population) – increasing with weekly mileage!
  • the frequency of low bone density is also higher in athletes – 2-4 times higher than the general population
  • stress fractures occur more frequently in athletes with low bone mineral density and menstrual abnormalities
  • Recommendations for PHE: questionnaires to screen for disordered eating habits (EDE-Q, SCOFF questionnaire and ESP are examples), assessment of menstrual pattern, history of stress fractures, blood panel, hormonal panel

Clinical Application & Conclusions:

The information above may not be pertinent to fitness professionals on a daily basis, but in order to be part of a multidisciplinary team involved with high level athletes, strength and conditioning professionals should be aware of the medical care their athletes undergo.

Study Methods:

This paper was a collection of expert opinion from the IOC Medical Commission that reviewed the available evidence on the PHE.

Additional References:

  1. Sarna S et al. Increased life expectancy of world class athletes. Med Sci Sports Exerc 2000; 25: 237-244.
  2. Kujala UM et al. Hospital care in later life among former world class Finnish athletes. JAMA 1996; 276: 216-220.