Q: My ninth-grade daughter wants to play high school basketball this winter. Albuquerque Public Schools requires a sports physical. What’s the chance the doctor will find something wrong?
A: School has started, and many middle and high school kids are finding their way into doctors’ offices to get their sports physical form filled out. Schools in New Mexico require a sports physical every year and, though we would rather do them during our quiet period earlier in the summer, we always expect a last-minute rush.
Each year, each of us in my office performs dozens of sports physicals. Fill out the history part of the sports exam form before you go to the doctor’s office. If it’s lost or hasn’t made it home yet, you can get it online (for Albuquerque at least) at http://www.aps.edu/athletics/athletic-forms. I insist on seeing the answers to the questionnaire: “Any history of asthma?” “Anybody in the family with early heart disease? … ” and about 30 more, before signing the form.
We’re very much in the business of finding an infected needle in a haystack; I suppose it’s a little like being a TSA agent at the airport – thousands of carry-ons have to be checked and innocent shampoo bottles discarded to detect one possible terrorist. We have to do hundreds of physical exams to detect one child likely to have trouble with sports participation, but it’s important that we find him or her.
Highly publicized deaths of college and professional athletes worry everyone, including us. Preventing sudden death requires thinking about the heart, the lungs and the head. Does the kid I’m seeing have any dangerous conditions, especially of the heart? On the other side of the coin, millions of children and adolescents get great benefit from sports – exercise and obesity prevention and camaraderie with a generally drug-free, violence-free crowd, even if extremely few participants will make it to elite, highly-paid professional sports. We can’t throw out the baby with the bath water.
The most common heart problem causing sudden death during sport is hypertrophic cardiomyopathy (HCM), which means enlargement of the heart muscle for no apparent reason, leading to problems with flow of blood into and/or out of the heart. Athletes need high heart output and may die during exercise if they don’t get it. Like all causes of life-threatening heart disease in children, HCM is difficult to diagnose. When we do find it, it is by examining the heart carefully and by finding out if anyone in the family has had HCM or sudden death. Other heart conditions that can cause death in athletes are also rare, and are also sometimes diagnosed by careful history-taking and examination.
Sports physicals in Italy have, for the past 33 years, included an electrocardiogram (ECG) – that test where you’re wired up in 12 places and a machine records the electrical activity in your heart. In a study done in the northeastern Italian province of Veneto, there was an 89% reduction in the incidence of sudden cardiac death in athletes. So why don’t we do ECGs? There’s a lot of controversy about it – estimated costs for doing the test in the US would be at least $10 million for every life saved and the annual incidence of SCD in the US is close to that in the screened population in Italy. The approach most American practitioners take is to ask a lot of questions about personal history (fainting episodes, palpitations, etc.) and family history (early heart disease, sudden death), and then to target identified at-risk athletes for ECGs and other heart evaluation.
There’s also controversy about how far we should go in doing a complete evaluation of athletes, not just for the likelihood of their being injured or dying in sports, but also for adolescent risk factors of other sorts: premature sexual activity, drug use, exposure to loud nose, the traditional “sex, drugs, and rock’n’roll” that we worry about in teens. I say yes; in our office, adolescents are scheduled for 40-minute appointments, which include talking with the parent and then shooing him or her out of the room (virtually none of the parents of our patients object to this) for a confidential interview and a chaperoned physical exam with the kid.
I hope you’ll agree to this confidential interview for your daughter. We often discover important risk factors and, more often than not, we can convince adolescents to share the information with their parents. But even if they won’t, there’s a good chance we may be able to head off unwanted teen pregnancies or abortions, unsafe experimentation with drugs, or ear damage, to name just a few. I wish we saw all adolescents for yearly complete checkups – not just the athletes – so we could have this sort of evaluation for all. School-based health centers, clinics right in our schools, are a good place to “catch’em where they are,” but these clinics are available in many fewer schools than I would like.
I would encourage your daughter to get a complete history-taking and physical examination whether she will participate in sports or not. I believe that involvement in athletics, once cleared by that good history and physical, has many benefits. Play ball!
Lance Chilton, M.D., is a pediatrician at the Young Children’s Health Center in Albuquerque, associated with the University of New Mexico. Send questions to firstname.lastname@example.org.