The International Olympic Committee (IOC) Consensus Statement on Periodic Health Evaluation of Elite Athletes, March 2009

INTRODUCTION The Olympic Games is the largest sport event in the world. In Beijing, 10,500 athletes competed, selected from a large group of elite athletes in 204 countries. Sports participation on the elite level, aside from winning medals, fame and other rewards, is also important from a health perspective. There is no longer any doubt that regular physical activity reduces the risk of premature mortality in general, and of coronary heart disease, hypertension, colon cancer, obesity, and diabetes mellitus in particular. The question is whether the health benefits of sports participation outweigh the risk of injury and long-term disability, especially in high-level athletes.1 have studied the incidence of chronic disease and life expectancy of former male world-class athletes from Finland in endurance sports, power sports and team sports. The overall life expectancy was longer in the high-level athlete compared to a reference group (75.6 vs 69.9 years). The same group also showed that the rate of hospitalization later in life was lower for endurance sports and power sports compared to the reference group.2 This resulted from a lower rate of hospital care for heart disease, respiratory disease and cancer. However, the athletes were more likely to have been hospitalized for musculoskeletal disorders. Thus, the evidence suggests that although there is a general health benefit from sports participation, injuries represent a significant side effect. One priority of the International Olympic Committee (IOC) is to protect the health of the athlete. During recent years, prevention of injuries and illnesses has been high on the IOC agenda. During the Athens Games an injury surveillance system was applied for all team sports.3 During the Beijing Games, the IOC ran, for the first time, an injury surveillance system covering all the athletes, showing a 10% incidence of injuries.4 In Vancouver and London the surveillance system will include disease conditions as well. The surveillance studies are prerequisites for providing evidence for health development in sports as well as for developing prevention programs. Another method to decrease injuries and diseases in the elite athlete is to perform a pre-participation examination (PPE) or periodic health evaluation (PHE) of all elite athletes.5 PHE in various forms have been available for many years, but a recent analyses5 has questioned the efficacy of PHEs in detecting serious problems in the elite athlete. In March 2009, the IOC assembled an expert group to discuss the current state of health evaluations for athletes, aiming to provide recommendations for a practical PHE for the elite athlete, as well as to outline the need for further research. The task of the group was to review the benefits as well as potential negative effects of PHE at the elite sport level. The group did not take any position as to whether PHE should be recommended as compulsory for participation in sport. That is for the relevant sports authorities to decide. The PHE can serve many purposes. It includes a comprehensive assessment of the athlete's current health status and risk of future injury or disease and, typically, is the entry point for medical care of the athlete. The PHE also serves as a tool for continuous health monitoring in athletes. Recent advances in this field relate to: (1) data on sudden cardiac death and other noncardiac medical problems, and the detection of risk factors and groups; (2) a consensus conference on concussion; (3) data on eating disorders; and (4) data on risk factors for musculoskeletal injuries. This paper addresses each of these advances in more detail after a discussion on the purpose of a PHE and the evidence we have supporting the different components of the PHE. PURPOSES OF THE MEDICAL EVALUATION In a narrow sense, the main purpose of the PHE is to screen for injuries or medical conditions that may place an athlete at risk for safe participation. Athletes may be affected by conditions that do not have overt symptoms and that can only be detected by periodic health evaluations. One example is cardiovascular abnormalities, such as hypertrophic cardiomyopathy, arrythmogenic right ventricular cardiomyopathy or congenital coronary arteries anomalies. These are typically silent until a potentially fatal arrhythmia occurs, but may in some cases be detected through a careful cardiovascular examination. Screening is a strategy used in a population to detect a disease in individuals without signs or symptoms of that disease. The intention is to identify pathologic conditions early, thus enabling earlier intervention and management in the hope of reducing future morbidity and mortality. Although screening may lead to an earlier diagnosis, not all screening programs have been shown to benefit the person being screened. To ensure that screening programs confer the intended benefit, the World Health Organisation published what have become known as the Wilson-Jungner criteria for appraising a screening programme.6 The main criteria are that the condition being screened for is an important health problem (depends not just on how serious the condition is, but also how common it is), that there is a detectable early stage, that treatment at an early stage is of more benefit than at a later stage and that a suitable test is available to detect disease in the early stage. From a public health perspective, there is insufficient evidence to date to mandate any specific screening tests for elite athletes apart from those recommended for the general population. This is mainly the consequence of the low risk of serious conditions in this population. An important limitation is also the lack of suitable screening tests; such tests must be reliable (repeatable, good inter-observer agreement), sensitive (detects all those with increased risk), specific (detects only those with increased risk), affordable to to the screening population and to However, the PHE may serve other than just screening athletes for future health One is to ensure that current health problems are and, to whether an athlete is suitable to in a sport or elite athletes with to medical care do not medical for injuries or disease, significant silent conditions are common and, although not from a health perspective, may sports An example of this is is common in athletes. health evaluations and monitoring represent an to and such also provide an to identify conditions that are to An example is can be detected on a test of Another important of PHEs is that the athlete an to a with the health will be in providing the PHE also an to for may the elite athlete at risk for future injury or disease. 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