Should You See A Doctor Before Starting An Exercise Program?

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The short answer is “yes, you should always consult your health care provider before starting an exercise program.”  There are good reasons for this statement.

Health care providers routinely recommend regular exercise.  This is well supported by national guidelines.  For example, the American College of Sports Medicine and the American Heart Association recommend that all adults participate in 30 minutes a day of moderate-intensity physical activity at least 5 days per week.  This is a reasonable general goal, but for many people, 30 minutes of moderate-intensity 5 days a week can be dangerous, especially for people with limited experience in regular exercise.  This article will discuss some of the health risks associated with exercise, a questionnaire that can be used to identify people at extra risk for harm from exercise, and the importance, to you, of involving your personal health care provider in planning and following an exercise program.

Most guidelines about readiness for exercise focus on heart health.  This focus derives from the facts that most fatalities associated with exercise are related to “cardiac death” (heart attacks).  Here are some statistics:

  • The estimated annual incidence of sudden cardiac death in athletes ranges from one in 50,000 to one in 300,000.
  • Among athletes who suffer sudden cardiac death in the United States,
    • one in 15,000 occurs in recreational runners.
    • one in 50,000 occurs in marathon runners.
    • one in 50,000 occur in high school athletes.
  • Among the general US population, one in 500 people die annually from sudden cardiac death, with approximately 300,000 of such deaths occurring each year.
  • African-American individuals have a slightly higher risk of sudden cardiac death than Caucasian American individuals.
  • Males are disproportionately affected relative to females, by a ratio of approximately 9:1.

With this focus upon heart-related risk factors, the American College of Sports Medicine  has published specific guidelines that health care providers can use to stratify the level of risk to an individual in starting an exercise program.  These guidelines involve counting how many risk factors for heart disease are present in an individual.  The risk factors are as follows:

  • High blood pressure
  • Abnormal cholesterol levels
  • Family history of heart disease
  • Smoking habit
  • Obesity
  • Abnormal glucose tolerance (as in diabetes)

Outside of the office of the health care provider, individuals can take a simple, self-administered questionnaire: the Physical Activity Readiness Questionnaire (PAR-Q).  The PAR-Q is easy to find on the internet.  The copy, below, is from the American College of Sports Medicine:


Physical Activity Readiness Questionnaire (PAR-Q)

  1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
  2. Do you feel pain in your chest when you do physical activity?
  3. In the past month, have you had chest pain when you were not doing physical activity?
  4. Do you lose your balance because of dizziness or do you ever lose consciousness?
  5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
  6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
  7. Do you know of any other reason why you should not do physical activity?

The American College of Sports Medicine then states:

If you answered yes to one or more of these questions, see your doctor before you start becoming much more physically active or before you have a fitness appraisal.

The American College of Sports Medicine (ACSM) has some further recommendations about beginning an exercise program.  For example, ACSM states that:

  • People beginning an exercise program should start with light-to-moderate intensity and gradually increase to personal preference. However, the minimal goal should be 30 minutes of moderate intensity activity five days per week.
  • Untreated high blood pressure (hypertension) may be aggravated by exercise and, therefore, is an exception to the risk stratification approach described, above.  Therefore, people with a personal history of high blood pressure should see their physicians for a complete medical evaluation before beginning an exercise program.
  • Women who are 55 years of age and older and men who are 45 years of age and older are generally thought to be at higher risk and may need to seek the advice of a physician before beginning an exercise program.

Since the focus of these guidelines is on heart health and safety, it may be important to undergo heart screening before starting a new exercise program.  However, to date, no standard cardiac screening protocol has been established for the athletic patient. However, some form of screening by a health care provider is customary.  The American Heart Association (AHA) stated, in 2007:

“The AHA continues to support preparticipation cardiovascular screening for student-athletes and other participants in organized competitive sports as justifiable, necessary, and compelling on the basis of ethical, legal, and medical grounds. Indeed, preparticipation screening for athletes is viewed as an important public health issue.”

The AHA recommends a screening EKG (electrocardiogram) in any athlete aged 40 years or older who is starting a new exercise program.  The European Society of Cardiology recommends a screening EKG in athletes of any age.  Clearly, it is important that anyone who is planning to start an exercise program should discuss the evaluation he or she should receive with a qualified health care provider.

National guidelines are a helpful starting-point to identify people who are at particular risk for harm from starting an exercise program.  However, it is my view that ANYONE who is STARTING or CONTINUING in an exercise program should seek input from his or her health care provider.  Aside from concerns about heart health, each of us has a unique situation that can influence our safety with exercise.  For example, asthma, COPD, arthritis, thyroid disease, diabetes, and many other chronic conditions can affect an individual’s ability to fully and safely participate in exercise.  Likewise, medications, both prescription and over-the-counter, supplements, and, even, dietary choices can affect an individual’s ability to safely participate in exercise.  Furthermore, health care providers can help people to set reasonable goals (weight loss targets, level of intensity of exercise, etc) and can help monitor and encourage the progress of an exercise program.  Therefore, even if you do not appear to have risk factors for heart disease, please involve your health care provider in your decision to start or to continue an exercise program.

Publication date: January 30, 2015

References:

Corrado D, Pellicci A, Bjornstad HH, et al, Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005 Mar; 26(5):516-524.

Corrado D, Pelliccia A, Heidbuchel H, et al, for the Section of Sports Cardiology, European Association of Cardiovascular Prevention and Rehabilitation. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J. 2010 Jan; 31(2):243-259.

Drezner JA, Chun JS, Harmon KG, et al.  Survival trends in the United States following exercise-related sudden cardiac arrest in the youth: 2000-2006. Heart Rhythm. 2008 Jun; 5(6):794-799.

Grazioli G, Merino B, Montserrat S, et al. Usefulness of echocardiography in preparticipation screening of competitive athletes.  Rev Esp Cardiol (Eng Ed). 2014 Sep; 67(9):701-705.

Maron BJ. Hypertrophic cardiomyopathy and other causes of sudden cardiac death in young competitive athletes, with considerations for preparticipation screening and criteria for disqualification. Cardiol Clin. 2007 Aug; 25(3):399-414, vi.

Maron BJ, Carney KP, Lever HM, et al. Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. J Am Coll Cardiol. 2003 Mar 19; 41(6):974-80.

Maron BJ, Thompson PD, Ackerman MJ, et al, for the American Heart Association Council on Nutrition, Physical Activity, and Metabolism.  Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.  Circulation. 2007 Mar 27; 115(12):1643-1655.

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Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations revisited: a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2008 Dec 9; 52(24):1990-1996.

Zaidi A, Sharma S. Exercise and heart disease: from athletes and arrhythmias to hypertrophic cardiomyopathy and congenital heart disease. Future Cardiol. 2013 Jan; 9(1):119-36.

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