Residency · Residency · Family Medicine

Exercise Prescription and the Preparticipation Physical Examination

Overview

Physical activity is one of the most potent preventive interventions in medicine, reducing the risk of cardiovascular disease, diabetes, cancer, depression, and all-cause mortality. Family physicians must be skilled in writing effective exercise prescriptions for diverse populations and performing preparticipation physical examinations (PPEs) to identify conditions that may place athletes at risk.

Exercise as Medicine

Health Benefits of Physical Activity

Regular moderate physical activity reduces all-cause mortality by 30 to 40%. It lowers the risk of cardiovascular disease, type 2 diabetes, colon cancer, breast cancer, depression, anxiety, dementia, osteoporosis, and falls. Physical activity improves glycemic control, blood pressure, lipid profile, weight management, sleep, cognitive function, and functional independence in older adults. These benefits occur across all age groups, body types, and chronic disease states.

Current Guidelines (AHA/ACSM/HHS)

Adults should engage in at least 150 minutes per week of moderate-intensity aerobic activity or at least 75 minutes per week of vigorous-intensity activity (or an equivalent combination), plus muscle-strengthening activities involving all major muscle groups on at least 2 days per week. Additional benefit accrues up to 300 minutes per week of moderate or 150 minutes per week of vigorous activity. Children and adolescents should engage in at least 60 minutes per day of moderate-to-vigorous activity, including muscle- and bone-strengthening activities at least 3 days per week. Older adults follow the same recommendations as adults with the addition of balance training and multicomponent exercise incorporating aerobic, strength, balance, and flexibility activities. Pregnant women should engage in at least 150 minutes per week of moderate-intensity aerobic activity while avoiding supine exercise after the first trimester, contact sports, high altitude, and scuba diving.

Sedentary Behavior

Prolonged sitting independently increases mortality risk even in those meeting exercise guidelines. Breaking up sitting every 30 to 60 minutes with brief activity is recommended. For patients who are far from meeting guidelines, "move more, sit less" messaging is an appropriate starting point.

Writing an Exercise Prescription (FITT-VP)

Components

The FITT-VP framework structures exercise prescriptions. Frequency refers to how many days per week (3 to 5 days for aerobic, 2 to 3 days for resistance). Intensity is classified as light, moderate, or vigorous. Moderate intensity is defined by a positive "talk test" (can talk but not sing), a rating of perceived exertion of 11 to 13 out of 20, 64 to 76% of maximum heart rate, or 3 to 5.9 METs. Vigorous intensity means the person can only speak a few words, with an RPE of 14 to 17, 77 to 95% of maximum heart rate, or 6 or more METs. Time refers to duration per session, typically 20 to 60 minutes for aerobic exercise. Type refers to the mode of exercise such as walking, cycling, swimming, resistance bands, or bodyweight exercises. Volume captures the total amount of activity, with the goal being 500 to 1,000 MET-minutes per week. Progression should be gradual, following the 10% per week rule for volume increases.

Practical Prescribing

Prescriptions should start where the patient is, recognizing that any increase from baseline is beneficial. The message "some is better than none; more is generally better" is key. Walking is the most accessible and safest exercise, with pedometer goals aiming for 7,000 to 10,000 steps per day. Barriers such as time, cost, transportation, childcare, safety, and motivation should be addressed. Motivational interviewing and SMART goals enhance success. Group exercise, community resources, and exercise referral schemes can be leveraged. Writing the prescription on a prescription pad emphasizes its importance.

Disease-Specific Prescriptions

For type 2 diabetes, the prescription is 150 minutes per week of aerobic exercise plus 2 to 3 days of resistance training, avoiding prolonged gaps of more than 2 consecutive days, with blood glucose monitoring and insulin dose reduction on exercise days if hypoglycemia risk is present. For hypertension, aerobic exercise is preferred, isometric handgrip exercise has emerging evidence, and Valsalva during resistance training should be avoided. Heart failure patients benefit from cardiac rehabilitation with a slow start and supervised exercise programs. COPD patients benefit from pulmonary rehabilitation combining aerobic and resistance exercise, which improves dyspnea and quality of life. For osteoporosis, weight-bearing impact exercise, resistance training, and balance exercises for fall prevention are recommended, avoiding high-impact and flexion exercises in severe cases. For depression, 150 minutes per week of moderate aerobic exercise has comparable efficacy to SSRIs for mild to moderate depression. Obesity management requires 225 to 420 minutes per week for weight loss combined with dietary modification, with resistance training to preserve lean mass. Pregnant patients should engage in moderate aerobic activity, pelvic floor exercises, and avoid contact sports, hot yoga, and scuba diving.

Pre-Exercise Risk Assessment

Most adults can safely begin moderate-intensity exercise without medical clearance. The ACSM Pre-Exercise Screening Algorithm is based on current exercise status, presence of cardiovascular, metabolic, or renal disease, and signs or symptoms. Currently active individuals without disease or symptoms can continue moderate exercise or progress to vigorous without clearance. Currently inactive individuals without disease or symptoms can begin moderate exercise without clearance but should obtain medical clearance before vigorous exercise. Those with known cardiovascular, metabolic, or renal disease need medical clearance before moderate or vigorous exercise. Exercise stress testing is not routinely required and should be reserved for high-risk patients or specific clinical questions.

Preparticipation Physical Examination (PPE)

Purpose

The PPE aims to detect conditions that may predispose to injury, illness, or sudden cardiac death, establish a baseline health status, determine fitness for sport participation, and counsel on injury prevention and health optimization. It is required by most schools and sport governing bodies.

PPE Components

History (Most Important Component)

The AHA recommends a 14-element cardiac screening approach. Personal history questions address chest pain or discomfort with exertion, syncope or near-syncope (especially with exercise), excessive dyspnea or fatigue with exercise, heart murmur or hypertension, and prior restrictions or cardiac testing. Family history questions cover premature cardiac death (before age 50), cardiomyopathy, Marfan syndrome, long QT syndrome, arrhythmias, and unexplained drowning or seizure. Additional history elements include prior concussions and recovery patterns, musculoskeletal injury history, heat-related illness history, sickle cell trait status, medication and supplement use (including performance-enhancing substances), menstrual history (for female athlete triad/RED-S screening), and mental health screening.

Physical Examination

Vital signs include blood pressure and heart rate with hypertension staged per AAP guidelines, along with height, weight, and BMI. Cardiovascular auscultation is performed in both supine and standing positions using dynamic maneuvers to detect hypertrophic cardiomyopathy (HCM). An increase in murmur intensity with standing or Valsalva suggests HCM because decreased preload increases left ventricular outflow tract obstruction, while a decrease in murmur with squatting also suggests HCM. Marfan screening evaluates for arm span exceeding height, arachnodactyly, pectus excavatum or carinatum, scoliosis, high-arched palate, joint hypermobility, and lens subluxation. The musculoskeletal exam includes a 2-minute screening exam assessing general alignment, range of motion, and strength, with a sport-specific focused exam. Skin inspection for herpes, impetigo, and tinea is relevant for contact sport clearance. Genitourinary examination assesses for a single testicle (requiring contact sport counseling) and inguinal hernia. Neurological examination is indicated if there is a history of concussion or neurological symptoms.

Cardiac Conditions Causing Sudden Cardiac Death in Athletes

Hypertrophic Cardiomyopathy (HCM)

HCM is the most common cause of sudden cardiac death in young athletes in the United States. It involves asymmetric septal hypertrophy with dynamic left ventricular outflow tract obstruction. It may be undetectable on exam, though a systolic murmur that increases with Valsalva or standing is characteristic. ECG may show left ventricular hypertrophy, deep Q waves, and T-wave inversions but is not part of routine U.S. screening. Echocardiography is diagnostic, with septal wall thickness of 15 mm or greater.

Coronary Artery Anomalies

Coronary artery anomalies are the second most common cause of sudden cardiac death in young athletes. They involve anomalous origin of a coronary artery from the wrong sinus, with compression occurring during exercise. There are often no warning symptoms, making detection on routine exam difficult. CT angiography or MRA is diagnostic.

Commotio Cordis

Commotio cordis is sudden cardiac arrest from blunt chest wall impact, typically from a baseball, during the vulnerable phase of the cardiac cycle. It causes ventricular fibrillation and requires immediate CPR and AED use. Chest protectors may reduce but do not eliminate risk.

Long QT Syndrome

Long QT syndrome is an inherited channelopathy predisposing to torsades de pointes, defined by QTc greater than 470 ms in males or greater than 480 ms in females. It can be triggered by exercise (especially swimming for LQT1), emotional stress, and auditory stimuli. Management includes beta-blockers, with an ICD for high-risk patients.

Other Conditions

Other conditions causing sudden cardiac death in athletes include arrhythmogenic right ventricular cardiomyopathy (ARVC), Wolff-Parkinson-White (WPW) syndrome, myocarditis, and aortic root dilation (Marfan syndrome).

ECG Screening Debate

In the United States, the AHA and AAP do not recommend routine ECG for mass screening, citing high false-positive rates, cost, limited resources, and psychological impact. European (ESC) and international (IOC, FIFA) guidelines recommend ECG as part of the PPE due to higher sensitivity for detecting HCM, WPW, long QT syndrome, and ARVC. The Seattle Criteria and International ECG Interpretation Standards help distinguish normal athletic adaptations from pathological findings to reduce false positives. Family physicians should know when to obtain an ECG: for positive cardiac history, concerning exam findings, or family history of sudden cardiac death or channelopathy.

Clearance Categories

Clearance may be unrestricted (cleared for all participation), conditional (cleared with specific restrictions, treatment, or monitoring such as protective equipment or activity modification), or withheld (not cleared, either temporarily pending further evaluation or permanently for conditions incompatible with safe participation). Very few conditions absolutely preclude all sport participation, and individualized assessment is essential.

Relative Energy Deficiency in Sport (RED-S) / Female Athlete Triad

RED-S exists on a spectrum where low energy availability (with or without an eating disorder) leads to menstrual dysfunction and impaired bone health. It has been renamed from "female athlete triad" to RED-S because it affects males as well. Screening includes menstrual history, dietary assessment, stress fracture history, and bone density when indicated. Management involves increasing caloric intake, reducing training load, calcium and vitamin D supplementation, consideration of oral contraceptives for bone protection (though evidence is limited), and psychology referral for eating disorder.

<image>A sample exercise prescription template showing the FITT-VP components (Frequency, Intensity, Time, Type, Volume, Progression) filled out for a sedentary patient with type 2 diabetes, including specific aerobic and resistance training recommendations, safety precautions, blood glucose monitoring guidance, and progression milestones over 12 weeks.</image>

<image>The AHA 14-element cardiac screening questionnaire for preparticipation physical examinations displayed as a checklist, divided into personal history questions (8 elements: chest pain, syncope, dyspnea, murmur, hypertension, fatigue, prior restrictions, prior cardiac testing) and family history questions (4 elements: premature death, cardiomyopathy, channelopathy, Marfan), with red flag responses highlighted that warrant further evaluation.</image>

<image>An ECG comparison showing normal athletic adaptations (sinus bradycardia, early repolarization, isolated voltage criteria for LVH) versus pathological findings requiring further evaluation (deep T-wave inversions, pathological Q waves, prolonged QTc, pre-excitation pattern, ST depression), based on the International ECG Interpretation Standards for athletes.</image>

Clinical Pearls

Physical activity has a dose-response relationship with health benefits: some activity is better than none, and benefits increase up to 3 to 5 times the recommended minimum before plateauing. The "talk test" is the simplest and most practical way to gauge exercise intensity in primary care: if a patient can talk comfortably but not sing, they are at moderate intensity. Walking is the most accessible exercise and is appropriate as a first-line prescription for almost any patient, including those with chronic disease. The most important component of the PPE is the history, not the physical exam; cardiac screening questions about syncope with exertion, family history of sudden death, and exertional chest pain are critical. A murmur that gets louder with standing or Valsalva maneuver should raise concern for hypertrophic cardiomyopathy and warrants echocardiography before clearance. Pre-exercise medical clearance is not needed for asymptomatic, healthy individuals beginning moderate-intensity exercise; unnecessary barriers reduce physical activity adoption. RED-S (Relative Energy Deficiency in Sport) affects both male and female athletes; screen for menstrual dysfunction, stress fractures, and dietary restriction in any athlete with unexplained fatigue or declining performance. Exercise is as effective as SSRIs for mild-to-moderate depression and should be prescribed as part of a comprehensive treatment plan.

References

• Piercy KL et al. Physical Activity Guidelines for Americans, 2nd Edition. HHS. 2018
• Riebe D et al. Updating ACSM's Recommendations for Exercise Preparticipation Health Screening. ACSM. 2015
• Maron BJ et al. AHA/ACC Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities. Circulation. 2015
• Drezner JA et al. International Criteria for ECG Interpretation in Athletes. Br J Sports Med. 2017
• Mountjoy M et al. IOC Consensus Statement on RED-S. Br J Sports Med. 2018

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