Contraindications to Athletic Participation: Cardiac, Respiratory, and Central Nervous System Conditions

James L. Moeller, MD

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This is the first of two articles on contraindications to athletic participation. The second, on eye, spine, gastrointestinal, infectious disease, and dermatologic issues, will appear in the September issue.

In Brief: Sports activities promote health and fitness for most participants, but for some, activity can complicate an illness or even be fatal. This article, the first of a two- part series on contraindications to activity, examines the cardiac, respiratory, and central nervous system conditions that warrant activity disqualification and provides guidelines about when it's safe for patients to participate.

Physicians across the country perform thousands of preparticipation physical exams annually. The goal of these exams is to identify patients at risk for increased morbidity and mortality through athletic participation (1-4). The physician's duty is not only to disqualify patients from activities that increase the risk of morbidity and mortality (2,4,5), but to allow them to participate whenever possible (4). To do this, the physician may need to suggest alternative activities that do not pose a threat to the patient (1,3,4), or treat the patient for problems that may pose a risk (3). The physician must also disqualify patients from activities when their participation would pose an unusual risk of injury or illness to other participants (2). Though there are many situations that require physicians to make activity recommendations, only about 1% of athletes are disqualified from athletics (6-8).

This article begins a two-part series that will provide specific recommendations for disqualification from athletic participation. This first installment deals with classification of sports and the cardiovascular, respiratory, and central nervous systems. The second article will address reasons for disqualification pertaining to the visual system, axial skeleton, gastrointestinal system, blood, and skin, and will discuss controversial areas. Specific injuries and recommendations for disqualification pertaining to the appendicular skeleton are beyond the scope of this series. This series is not meant to be all-inclusive, but to cover the most common reasons for disqualification from athletics. Each patient's case should be viewed on an individual basis (5).

Scaling Sports Activities

Most people classify sports as either contact or noncontact. The American Academy of Pediatrics Committee on Sports Medicine (9) has further divided sports into the following five categories:

1. contact/collision,
2. limited contact/impact,
3. noncontact strenuous,
4. noncontact moderately strenuous, and
5. noncontact nonstrenuous (table 1: not shown).

The 26th Bethesda Conference report (10) classifies sports according to peak dynamic and static components during competition (table 2: not shown). Both of these classification systems are referred to throughout this article. Of course, some sports by their nature pose some risk of serious injury or even death, even if the classification systems indicate they are safe for persons with a particular medical condition (eg, archery and riflery have obvious inherent risks).

Cardiovascular Issues

Guidelines for participation in competitive athletics for patients with cardiovascular disease are described in the 26th Bethesda Conference report (10). This section will review some of the situations in which disqualification should be considered as outlined by the Bethesda Conference and supported by other sources. A more complete listing of recommendations regarding the cardiovascular system is provided in the Bethesda guidelines.

Hypertrophic cardiomyopathy (HCM). The leading cause of sudden cardiac death in athletes younger than 30 (10-15), HCM is characterized by a thickened ventricular septum (greater than 15 mm) as compared with the ventricular free wall (10,14). Left ventricular cavity size is generally unchanged but left ventricular filling and compliance are impaired (14).

Patients may have a history of exertional syncope (11,13,14), dizziness (8,14), or chest pain with activity. The physical exam may reveal a systolic murmur that increases with the Valsalva maneuver (11,13,14). If the patient's history and physical exam findings raise the suspicion of HCM, further diagnostic work-up including echocardiography, electrocardiography (ECG) (10,11,13,14), and possibly Holter monitoring (10,13) or genetic testing should be considered (10).

Symptomatic patients with HCM should not participate in competitive sports (10,11,14). Athletes who are asymptomatic should only be allowed to participate in low-intensity sports (10). Screening echocardiography is not recommended (10,11).

Aortic stenosis. Recommendations for athletic participation in patients with congenital aortic stenosis are based on the severity of the disease. Disease severity is graded by the severity of patients' symptoms and the systolic pressure gradient as determined by echocardiography. In some instances, cardiac catheterization may be required to assess the pressure gradient and the severity of disease.

In mild aortic stenosis (up to 20 mm Hg peak systolic pressure gradient at rest) the recommendation is that patients may participate in all competitive sports as long as they have a normal ECG, normal stress tolerance, and no exercise-induced chest pain, syncope, or arrhythmia (10). For patients with moderate disease (21 to 49 mm Hg peak systolic gradient), only low static/low-to-moderate dynamic and moderate static/low dynamic competitive sports should be allowed, and then only under certain conditions (4,10). No competitive sports are recommended for patients who have severe aortic stenosis (50 mm Hg peak systolic gradient or higher) (10).

Coarctation of the aorta. Almost all patients who have moderate or severe disease will undergo either surgical repair or the balloon procedure in their youth. Severity grading is based on the arm-leg pressure gradient, physical exam, exercise testing, and echocardiography (10).

Patients who have mild disease may participate in all competitive sports as long as there are no large collateral vessels or severe aortic root dilatation. Also, a normal exercise test, small pressure gradient, and peak systolic blood pressure no greater than 230 mm Hg should be documented. Patients may participate only in low-intensity sports if their pressure gradient is greater than 20 mm Hg or the peak systolic blood pressure is greater than 230 mm Hg (4,10).

For patients who are treated for this condition, participation in sports may resume 6 months after treatment if the pressure gradient is no greater than 20 mm Hg and the peak systolic blood pressure is no greater than 230 mm Hg. High-intensity static exercise and collision sports should be avoided for at least 1 year after treatment (10).

Infective carditis. This condition is usually caused by coxsackievirus B. Diagnosis is based on the patient history, which usually includes a respiratory illness that is complicated by other symptoms such as fatigue, dyspnea (10,13), syncope, palpitations, arrhythmias, or acute congestive heart failure (10). Chest x-ray and echocardiograpy (10,13) may help make the diagnosis, as may endomyocardial biopsy (10).

Because infective carditis may cause dangerous arrhythmias, it is recommended that patients be withdrawn from sports for 6 months after the onset of symptoms. Patients may return to competition when ventricular function is normal, cardiac dimensions are normal, and no clinically relevant arrhythmias are present on Holter monitoring (10).

Uncontrolled hypertension. Blood pressure readings that indicate hypertension differ by age group (table 3: not shown). Hypertension is diagnosed by three separate elevated blood pressure readings (10).

Patients who have mild-to-moderate hypertension without end-organ damage and concomitant heart disease should not be restricted from competitive sports (4,10). In fact, moderate dynamic and static exercise should be encouraged to help decrease blood pressure (10). Those who have severe hypertension should be restricted from high static sports until hypertension is controlled with medications and lifestyle modification (4,10).

Mitral valve prolapse. This condition is relatively common, with a prevalence of approximately 5% (10,13,16). Many athletes who have mitral valve prolapse participate in high-level competitive sports. Patients who have mitral valve prolapse may participate in all competitive sports unless:

• a history of arrhythmogenic syncope is documented,
• a family history of sudden death associated with mitral valve prolapse is noted (10,16),
• repetitive forms of supraventricular tachycardia or ventricular arrhythmia are present with exercise,
• there is moderate or marked mitral regurgitation (4,10,16), or
• a prior embolic event has occurred (10).

Patients who fit any of the above criteria may participate only in low-intensity competitive sports (10,16).

Arrhythmia Concerns

Many arrhythmias that are discovered on the preparticipation physical exam are benign and do not require activity modification. However, it is useful to review the more serious rhythm disturbances that pose a risk to active young people.

Wolff-Parkinson-White (WPW) syndrome. Evaluation of these patients should include ECG (8,17), Holter monitoring (10,18) during athletic activity, exercise testing (10,17,18), and echocardiograpy. Patients older than 20 who have no structural heart disease, palpitations, or tachycardia may participate in all competitive sports (10). Those who have syncope, near syncope, or episodes of atrial fibrillation or flutter and have a maximum heart rate at rest of greater than 240 beats per minute are restricted to low-intensity competitive sports and should be considered for radiofrequency catheter ablation of the accessory pathway (10,17).

Premature ventricular contractions (PVCs). If PVCs increase during exercise testing such that they produce symptoms, patients can participate only in low-intensity competitive sports. Patients whose PVCs are suppressed by drug therapy and those who have structural heart disease and PVCs are also limited to low-intensity competitive sports (10).

Ventricular tachycardia. Noninvasive tests for ventricular tachycardia include ECG, 24-hour Holter monitoring, exercise testing, and echocardiography. If testing documents ventricular tachycardia, patients should not compete in any sport for 6 months after the last episode (10). Patients may return to athletics if there have been no clinical recurrences, ventricular tachycardia is not reproducible by exercise or exercise testing, and no structural heart disease is present (10,19). Only low-intensity competitive sports are allowed if structural heart disease and ventricular tachycardia are present (10).

Ventricular flutter, ventricular fibrillation. Patients who have ventricular flutter or ventricular fibrillation may participate only in low-intensity competitive sports and only if there have been no episodes of ventricular flutter or fibrillation during 6 months of treatment (10).

Atrioventricular block. Patients who have first-degree block may participate at all levels of competition if they are asymptomatic and the block does not worsen with exercise. Those who have second-degree type I (Wenckebach) block may participate in all sports if the block does not worsen with exercise. A block that worsens with exercise indicates a need for further evaluation (10).

Patients who have second degree type II (Mobitz) block or congenital complete heart block may participate in all sports if they are asymptomatic (10,19), and if heart rate increases with exertion with no or only occasional PVCs and no ventricular tachycardia. For participation clearance, a narrow QRS complex must be present on ECG (10).

Long QT syndrome. Patients who have this condition are at risk for sudden death with activity and should be restricted from all competitive sports (10,19).

Respiratory Recommendations

Though asthma is by far the most common respiratory condition that can limit activity in young people, physicians should be prepared to make participation recommendations about some of the less common conditions: tuberculosis, pulmonary insufficiency, and pneumothorax.

Tuberculosis. One condition that should bar an athlete from all competitive sports is active tuberculosis (4). The reason is the risk of transmission of tuberculosis to competitors or teammates.

Asthma. There is no need to restrict patients' activity as long as the asthma is well controlled. Patients whose asthma is poorly controlled should be restricted from contact sports and strenuous noncontact sports (4); this holds true for chronic and exercise-induced asthma. These patients may return to full activities once medication controls the asthmatic condition.

Pulmonary insufficiency. As the population ages, many people will remain active into their 60s and beyond. Because of this, there will be many patients with chronic illnesses who wish to remain active. For patients who have pulmonary insufficiency, there is no need to restrict activity as long as exercise testing does not cause unsatisfactory deoxygenation. If significant deoxygenation occurs with exercise, these patients should be restricted to nonstrenuous noncontact sports (9).

Pneumothorax. Primary spontaneous pneumothorax is a condition that occurs usually in lean males (20), and is believed to be caused by the rupture of unsuspected alveolar blebs from apical bullous disease (19,20). Because of the increased risk of recurrence, only nonstrenuous activities are allowed for patients who have undergone conservative treatment for primary spontaneous pneumothorax (4). Those who wish to return to more strenuous or even contact activities after their pneumothorax resolves with conservative measures should be counseled on the risks of recurrence; however, those who are treated with thoracotomy or other invasive procedures may usually resume all sports (4) after 2 to 4 weeks (19). It is important that patients realize there is an increased risk of recurrence, especially on the contralateral side. Patients should be advised to discontinue contact sports when pneumothorax recurs (4).

CNS Caveats

Questioning patients about their seizure and concussion history helps reveal red flags that might point to a need for activity restriction because of central nervous system problems.

Seizure disorder. Seizures during physical exertion are infrequent, and only one rare type of seizure disorder, tonic seizure, has been shown to be induced by activity (19). Patients whose seizures are well controlled with medication may participate in all sports (4,9). Head trauma may precipitate seizure activity in patients who have epilepsy, but this should not prevent medically well-controlled patients from participating in contact sports if they follow normal safeguards and use adequate head protection (21). Sports such as swimming, weight lifting, archery, and riflery require special consideration because seizure during activity could result in death (9). Patients whose seizures are poorly controlled should be barred from contact/collision sports and limited contact/impact sports (4,9). These patients also should avoid swimming, weight lifting, archery, and riflery (9).

Concussion. There are many different classification systems for concussion, and none is perfect. Several classification systems are compared in table 4. Many gray areas exist in each classification system regarding return-to-play criteria. Most physicians agree that a patient should be disqualified from the current activity if sensorium does not clear quickly or if other symptoms and signs are present, such as loss of consciousness, post-traumatic amnesia, confusion, dizziness, or headache (22-27). Evaluation may require a CT scan or referral to a neurosurgeon, depending on severity (25).

Table 4. Comparison of Classifications of Concussion
Cantu (22) Grade 1 (mild) No LOC; PTA less than 30 min	Colorado (23) Grade 1 Confusion without amnesia, no LOC	Nelson (26) Grade O Head struck or moved rapidly; not stunned or dazed initially; subsequently complains of headache and difficulty concentrating	Kulund (24) Mild Stunned, dazed; no confusion, dizziness, nausea, or visual disturbance; feels well after 1 or 2 min; coordinated	Torg (27) Grade 1 'Bell rung,' short-term confusion, unsteady gait, dazed appearance, no LOC or posttraumatic amnesia
Grade 2 (moderate) LOC less than 5 min or PTA less than 30 min	Grade 2 Confusion with amnesia, no LOC	Grade 1 Stunned or dazed initially; no LOC or amnesia; 'bell rung,' sensorium clears less than 1 min	Moderate LOC, mental confusion, retrograde amnesia, tinnitus, dizziness; skill recovery may be rapid	Grade 2 PTA, vertigo
Grade 3 (severe) LOC greater than or equal to 5 min or PTA greater than or equal to 24 hr	Grade 3 LOC	Grade 2 Headache, cloudy sensorium greater than 1 min, no LOC, may have tinnitus or amnesia, may be irritable, hyperexcitable, confused, dizzy	Severe Longer LOC, headache, confusion, PTA, retrograde amnesia	Grade 3 PTA, retrograde amnesia, vertigo
		Grade 3 LOC less than 1 min, not comatose (arousable with noxious stimuli), demonstrates grade 2 symptoms during recovery		Grade 4 Immediate, transient LOC
		Grade 4 LOC greater than 1 min, not comatose, demonstrates grade 2 symptoms during recovery		Grade 5 Paralytic coma, cardiorespiratory arrest
				Grade 6 Death
Key: LOC = loss of consciousness, PTA = posttraumatic amnesia

Determinations about return to play should be made case-by-case depending on the severity of the injury. A patient continuing to have symptoms from a prior concussion should not be allowed to participate in contact sports until those symptoms clear (22,23,28.29). How long the patient must be asymptomatic before return to play is also controversial. Guidelines for return to play after a concussion as outlined by Cantu (22) are presented in table 5.

Table 5. Guidelines for Return to Play After Concussion
Grade	1st concussion	2nd concussion	3rd concussion
1 (mild)	May return to play if asymptomatic* for 1 wk	Return to play in 2 wk if asymptomatic for 1 wk	Terminate season; return next season if asymptomatic
2 (moderate)	Return to play after asymptomatic for 1 wk	Minimum of 1 mo; may return to play then if asymptomatic for 1 wk; consider terminating season	Terminate season; return next season if asymptomatic
3 (severe)	Minimum of 1 mo; may return to play if asymptomatic for 1 wk	Terminate season; may return to play next season if asymptomatic
*No headache, dizziness, or impaired orientation, concentration, or memory during rest or exertion Reprinted from Cantu RC: Guidelines for return to contact sports after a cerebral concussion. Phys Sportmed 1986;14(10):75-83

Returning to play too soon puts patients at risk for second impact syndrome, a condition that may occur when a second head injury is sustained before the symptoms of a first head injury have completely cleared (28,30-32). Rapid cerebral swelling leads to rapid neurologic deterioration and death (28,31). The second impact can be minor and not even directly to the head (ie, a Valsalva maneuver or a strong blow to the chest) (28,30).

On a Safe Track

Despite published recommendations that say certain patients should be disqualified from athletic participation, each patient's case should be considered individually. All efforts should be made to allow athletes to participate so long as they do not increase the risk of injury or death to themselves or others.

References

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Dr Moeller is associate director of Primary Care Sports Medicine at the University of Pittsburgh Medical Center in Pittsburgh. He is an assistant professor in the departments of family medicine and orthopaedic surgery. He is a member of the American College of Sports Medicine and the American Medical Society for Sports Medicine. Address correspondence to James L. Moeller, MD, University Orthopaedics, Inc, Kaufman Bldg, Suite 1010, 3471 Fifth Ave, Pittsburgh, PA 15213; e-mail to jmoeller@uoi.upmc.edu.

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