Identifying leisure athletes at high risk for medical complications using five international pre-exercise screening tools

Abstract

Background: The purpose of pre-exercise medical screening is to identify individuals who may be at risk of medical encounters (MEs) during exercise. Currently the use of five international pre-exercise medical screening tools is recommended to identify individuals who require pre-exercise medical clearance. Aim: To determine the percentage of race entrants who are advised to obtain pre-exercise medical clearance by using five international pre-exercise medical screening tools, and to determine the level of agreement between those tools. Methods: Data from running race entrants (Two Oceans Marathon) was collected over a period of four years (2012–2015). Five pre-exercise medical screening tools (the American Heart Association (AHA), the pre-2015 American College of Sport Medicine (ACSM), the post-2015 ACSM Physical Activity Readiness Questionnaire (PAR-Q), and the European Association of Cardiovascular Prevention and Rehabilitation (EACPR)) were applied by using information from pre-race medical screening questionnaires. The percentage (95%CI) of race entrants requiring medical clearance identified by each tool and the level of agreement between tools (kappa statistic) is reported. Results: The percentage entrants requiring medical clearance for each tool was: 2011 EACPR (33.9%; 33.5-34.3); pre-2015 ACSM (33.9%; 33.5-34.3); PAR-Q (23.2%; 22.9-23.6); AHA (10.0%; 9.7-10.2); post-2015 ACSM (6.7%; 6.5-6.9). The level of agreement was high between the pre-2015 ACSM and the EACPR (K=1.00; p=0.05), moderate between the pre-2015 ACSM and the PAR-Q (K=0.75; p<0.0001) and the PAR-Q and EACPR (K=0.75; p<0.0001), but poor between the post-2015 ACSM and the PAR-Q (K=0.17; p<0.0001). Conclusion: The percentage of race entrants identified as requiring medical clearance varied considerably (6.7–33.9%) between international pre-exercise medical screening tools. The level of agreement between the tools also varied and was good (> 0.75) for three of the five pre-exercise medical screening tools. Further research should determine which specific variables are responsible for identifying participants at higher risk for medical encounters during exercise.

Key words: Pre-exercise medical screening tools, pre-exercise medical clearance, recreational endurance athletes, medical encountersBackground: Pre-exercise medical screening is needed in order to identify individuals with a high risk of developing medical complications during or after exercise. Although the level of agreement between five international pre-exercise medical screening tools has been determined, the specific domains responsible for the differences between these tools have not yet been researched. Aim: The aim of this study is to determine which domains of risk (history of cardiovascular disease [CVD], symptoms of CVD, risk factors of CVD, history of any chronic disease and chronic diseases by organ systems, history of prescription medication use and history of musculoskeletal injury) are responsible for the considerable variation between the five pre-exercise medical screening tools in identifying participants at higher risk for medical encounters during exercise. Methods: Data was collected over a period of four years (2012–2015) from entrants in the Two Oceans Marathon. This is a pre-entry only event and since 2012 it has been compulsory for all entrants to complete a pre-exercise medical questionnaire. This questionnaire was developed for the SAFER studies and was based on domains that are included in several international pre-exercise medical screening tools, among others in the EACPR, the pre-2015 ACSM and the PAR-Q guidelines. Using the information collected by means of this questionnaire, the five pre-exercise medical screening tools were applied to determine whether they identified the same race entrants as requiring pre-exercise medical clearance. This information was further used to determine the specific differences within each of the domains of risk. Results: Considerable variation was found to exist between pre-exercise medical screening tools with regard to the identification of entrants at risk in each of the six main domains. With regard to a history of CVD, the AHA identified a significantly smaller number of participants than any of the other pre-exercise medical screening tools. For symptoms of CVD, the AHA and the PAR-Q pre-exercise medical screening tools identified a significantly smaller number of participants than the other tools, and for risk factors for CVD, the post-2015 ACSM tool identified significantly fewer participants than any of the other tools. The results obtained by using the five screening tools for the identification of a history of any other chronic disease varied greatly, and with regard to prescription medication use and a history of musculoskeletal injury the AHA and the post-2015 ACSM identified a significantly lower percentage of entrants than the other three screening tools. Conclusion: No single domain could be identified as the cause of variability between the pre-exercise screening tools. The selection of a pre-exercise medical screening tool should be based on the purpose for, and the context in which the screening tool will be used. The pre-2015 ACSM and the EACPR pre-exercise medical screening tools identified a high percentage of participants for all domains of risk, except for any kidney/bladder disease.

Key words: Pre-exercise medical screening tools, pre-exercise medical clearance, recreational endurance athletes, medical encounters