Active Voice: Part 2 of Preparticipation Health Screening before Exercise – Is It Time for a Change?

By Barry A. Franklin, Ph.D., FACSM, MAACVPR, FAHA

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM.

Barry A. Franklin, Ph.D., FACSM, is director of preventive cardiology and cardiac rehabilitation at William Beaumont Hospital in Royal Oak, Mich. He is a past president of ACSM and editor-in-chief of the Journal of Cardiopulmonary Rehabilitation, and is currently serving on editorial boards of 15 prominent scientific/clinical journals. For further biographical information, see Part 1 of this commentary at the SMB online archives.

Here, Dr. Franklin presents his views on the above-titled topic in relation to the recent study by Whitfield GP, et al. published in Circulation, March 2014. Given the scope of the topic, the text is presented in two installments. Part 1 presents his analysis of past evidence on the benefits and risks of increasing physical activity and the rationale for health screening of sedentary adults who begin structured exercise. In this final installment, he re-examines these preparticipation guidelines in the context of these new data from Whitfield et al.


The Whitfield et al, article in Circulation, March 2014, evaluated two commonly recommended self-screening exercise preparticipation questionnaires, the AHA/ACSM Preparticipation Questionnaire (AAPQ) and the Physical Activity Readiness Questionnaire. The aim was to clarify the utility of these screening tools in a systematic manner. Using relevant responses from the combined 2001 to 2004 National Health and Nutrition Examination Survey database for individuals > 40 years of age, as many as 96 percent and 94 percent of men and women, respectively, would be advised to consult a physician before embarking on an exercise regimen. The investigators concluded that widespread use of the AAPQ would result in excessive medical referrals and present unfounded barriers to exercise adoption.

What do we know about developing a research-based, cost-effective, realistic approach to preparticipation screening to potentially identify the individual “at risk” for exercise-related cardiovascular events? Neither high cardiorespiratory fitness, nor regular exercise training, nor the absence of coronary risk factors guarantees protection against an exercise death. Three key modulators of exercise risk have emerged:
  • Known or suspected underlying CVD;
  • Prodromal symptoms in the days or weeks before the cardiac event;
  • The potential hazards of unaccustomed vigorous-to-high intensity physical activity.
As a general guideline, persons with known or suspected CVD, metabolic disease (e.g., diabetes mellitus), or symptoms at rest or during exercise should seek medical clearance before embarking on an exercise program or progressing to a higher exercise intensity (if already exercising). In addition, physicians and allied health professionals should promote education about exertion-related symptoms and the need, when these appear, to discontinue exercise and seek immediate medical evaluation. These symptoms often serve as harbingers of acute cardiac events. Finally, when previously sedentary individuals begin an exercise program, it is best to begin with a light-to-moderate intensity and gradually increase the intensity of exertion over time. This has been referred to as the “progressive transitional phase.” In essence, this encourages the previously inactive person to start exercise by walking, rather than jogging or running. This strategy helps to minimize musculoskeletal injury. Even more importantly, it also allows sedentary individuals to improve their cardiorespiratory fitness without going through a period during which each bout of vigorous exercise is associated with large spikes in relative cardiovascular risk.

To place the need for preparticipation medical screening prior to exercise into perspective, it is important to consider that the absolute risk associated with each bout of exercise is extremely low. The relative risk is directly related to the presence of CVD and/or symptoms and inversely related to the habitual level of activity. Furthermore, the long-term cardioprotective effect of regular physical activity is substantial. Numerous epidemiologic studies have now shown that low-fit individuals are approximately two to five times more likely to die during follow-up as compared with their more fit counterparts. This is true regardless of the presence or absence of diagnosed coronary disease or associated risk factors, including body habitus. Perhaps Per-Olof Åstrand, MD, summed it up best when he stated, “As a general rule, moderate activity is less harmful to health than inactivity.” You also could put it this way: “A medical evaluation is more urgent for those who plan to remain inactive than for those who intend to get into good physical shape.”

It’s time to revamp antedated exercise-preparticipation screening recommendations that may appear prudent, but are unfounded, impractical and cost-prohibitive. The challenge is ours.

Click here to review Part 1 of Dr. Franklin’s commentary.