DUTIES, ROLE, AND RESPONSIBILITIES OF THE TEAM PHYSICIAN

The duties of the team physician to a team may be
outlined in a letter of agreement or contract between
the organization and physician.


The duties to the individual athlete should be considered
as with any other patient–physician relationship.


Balancing this duty to team and athlete must be considered
in every situation.


A consensus statement on the duties of the team
physician has been created by several organizations
and available in its entirety from these groups:
a. American Academy of Family Physicians (AAFP)
b. American Academy of Orthopedic Surgeons
(AAOS)
c. American College of Sports Medicine (ACSM)
d. American Medical Society for Sports Medicine
(AMSSM)
e. American Orthopedic Society for Sports Medicine
(AOSSM)
f. American Osteopathic Academy of Sports
Medicine (AOASM)
• Qualifications from this consensus statement include
the following:
a. Medical or osteopathic degree with unrestricted
license to practice medicine
b. Fundamental knowledge of emergency care
regarding sporting events
c. Trained in CPR
d. Working knowledge of trauma, musculoskeletal
injuries and medical conditions affecting the athlete


Medical duties from this statement stated that the
team physician has ultimate responsibility to include
coordination of the preparticipation screening; management
of on-field injuries; medical management of
injury and illness; coordination of rehabilitation and
return to participation; coordination of medical care,
education, and documentation; and record keeping.


Administrative duties include establishing relationships,
education, development of a chain of command,
plan and train for emergencies, address
equipment and supply issues (as needed to provide
adequate medical coverage), provide for event coverage,
and assess environments concerns and playing
conditions.


Standard definitions of negligence generally apply.
The physician is held to what the reasonable, prudent
man would do. As guidelines become more
established, these may become the basis for duties
and responsibilities of the team physician.

DEFINITIONS of terms in LEGAL ISSUES

Law: A body of rules or standards of action or conduct
ordained or established by some authority. The
law of a state is found in statutory and constitutional
enactments as interpreted by its courts and contemplates
both statutory and case law.


Lawful: Legal, permitted by the law. Not forbidden
by law, not illegal.


Contract: An agreement between two or more parties
which creates legally binding obligations to do or
not to do a particular thing. A valid contract must
involve competent parties, proper subject matter, consideration,
and mutuality of agreement and of obligation.


Expressed: An express contract is openly expressed
in writing or orally stated in distinct and explicit language.


Implied: An implied contract is one inferred by the
conduct of the parties to exist.


Bilateral: A bilateral contract is one involving mutual
promises between parties.


Unilateral: A unilateral contract is a one-sided promise
where one party undertakes an obligation without
receiving in return any express engagement or promise
of performance from the other.


Civil law: Body of law that a nation or state has
established for itself. Law determining private
rights and liabilities as distinguished from criminal
or natural law. Laws concerned with civil or private
rights and remedies as contrasted with criminal
laws.


Criminal law: The branch of law which defines what
public wrongs are considered crimes and assigns punishment
for those wrongs. It declares what conduct is
criminal, and prescribes the punishment to be
imposed for such conduct.


Natural law: The moral or ethical law, formulated in
accordance with reason, natural justice, and the original
state of nature.


Case law: Law based on judicial precedent rather
than legislative enactment. The body of law founded
in adjudicated cases as distinguished from statute,
common law. It includes the aggregate of reported
cases that interpret statutes, regulations, and constitutional
provisions.


Tort: A wrongful injury, a private or civil wrong. A
tort is some action or conduct by someone (defendant)
which causes injury or damage to another (plaintiff).
Torts may be intentional (when the defendant intends
to violate a legal duty) or negligent (when the defendant
fails to exercise the proper degree of care established
by law). A legal wrong committed on the
person or property independent of contract. It may be
either (1) a direct invasion of some legal right of the
individual; (2) the infraction of some public duty by
which special damage accrues to the individual; or (3)
the violation of some private obligation by which like
damage occurs to the individual.


Negligence: The inadvertent or unintentional failure
to exercise that care which a reasonable, prudent, and
careful person would exercise; conduct which violates
certain legal standards of due care. Negligence constitutes
grounds for recovery in a tort action, if it causes
injury to the plaintiff.


Liability: Any type of obligation or debt owed to
another party. An obligation or mandate to do or
refrain from doing something. An obligation one is
bound in law or justice to perform.


Plaintiff: Person who brings a lawsuit; the complainant;
the prosecution in a criminal case. The party
who complains or sues in a civil action and is so
named on the record.


Defendant: The person accused in a criminal case or
sued in a civil action. The person defending or denying
wrongdoing.


Captain of the ship doctrine: This doctrine imposes
liability on the surgeon in charge of an operation for
negligence of his or her assistants when those assistants
are under the surgeon’s control, even though the assistants are also employees of the hospital (Nolan
and Nolan-Haley, 1990).

RELATIONSHIP WITH COLLEAGUES

Among the problems that can arise for a team physician
are those involving other physicians participating
in the care of the athlete–patient. There must be sensitivity
demonstrated to the relationship of all medical
professionals involved.


The sports physician must never criticize the actions
of another physician to the athlete–patient. Private
discussions with the primary care physician regarding
recommended therapy should be undertaken.


The sports physician is in a position to positively
influence his or her colleague’s care of athletes in the
future by such positive input.


If playing restrictions have been imposed on an athlete
by a primary care physician, while not countermanding
them, the sports physician must always insist
on an individual assessment of the athlete’s return to
play status.


Consultation between the sports physician and the
athlete’s primary care physician usually solves the
problem and provides an opportunity for education.


Sports medicine is a team effort involving physicians
and many paramedical disciplines. The sport’s physician
recognizes that these can be helpful while coordinating
the athlete’s care. The sports physician must
insist that such assistants adhere to the same high ethical
standards he or she practices.


The sports medicine physician has an obligation to
expose quackery and unproved practices employed in
the guise of improving performance, thus protecting
athletes and their careers.

DRUG USE

It is common knowledge that there is illicit drug use
by athletes at all levels: recreational drugs, anabolic
steroids, pain controlling agents, ergogenics, and
alcohol.


Therapeutic medications are an integral part of sports
medicine. Used appropriately, they control pain and
inflammation, speed recovery, and hasten return to
function.


It is the obligation of the sports physician to know
each drug thoroughly, especially its potential effect(s)
on the safety or effectiveness of the athlete’s performance.
Appropriately prescribed drugs must not expose
the athlete to potential disqualification, e.g., as in the
prevention of exercise-induced asthma, when an
effective legal medication can be found.


Nowadays, available testing makes it impossible to
catch all participants who use banned substances.
That is rapidly changing.


There are those who would remove all bans on
enhancing agents, hormones for instance, allowing for
a “free-for-all” with unrestricted use.


There are two major arguments against such an attitude:
one should not condone cheating; and the essence
of sport itself.

POTENTIAL FOR DIVIDED LOYALTIES

While rare in high school and uncommon in college
sports, there is major distrust between professional
athletes and team physicians (George, 2002).


Athletes may feel that there are too many instances
when the quality of their treatment is often secondary
to the doctor’s obligation to team owners and coaches.


A salaried position can interfere with the traditional
doctor–patient relationship.


To many the role of the salaried physician leads to a
conflict of interest. Such a conflict exists when the
employed sports physician’s objective professional
duties are compromised by personal interests, e.g., the
financial reward of his or her association with a professional
team as well as the publicity and high visibility
one gets from such a position.


It is an ethical breach for anything but the athlete’s
health interest to be considered, again, recognizing
judgment errors in too conservative or too liberal therapy
can occur.


The ultimate welfare of the athlete may seem in conflict
with the wishes of parents or spouse, coaches or
team management. The fact that an organization or
someone other than the athlete pays the physician is
immaterial. The loyalty of the sports physician is to
the continued healthy physician–patient relationship.


Decisions must be made solely based on sound medical
judgment. A reasonable third party, e.g. a university
or professional team, will understand this. If it
does not, the physician should remove his or her services
from that party.
• Occasionally, wishes of the athlete-patient conflict
with what the physician believes are in the athlete’s
best interest. If after negotiation and additional consultation
the sports physician feels uncomfortable
with another’s recommendation, continued care of
the athlete-patient could be difficult or impossible.
The athlete should be reassigned to another physician.


For the professional athlete, the unfavorable mix of
high salaries and short careers can make for risky
decision making by both the athlete and the physician.
Coaches often encourage physicians to rush players
back on to the field to win games. Players themselves
often desire to rush back too quickly.


Teammates should not be allowed to pressure injured
athletes by suggesting they are malingering while collecting
a substantial income. Under these circumstances
many physicians play by the rules of the
coaching staff.


An untimely death or worsening injury sets the stage
for lack of trust in the team physician.


By actions alone, the team physician demonstrates
that his or her utmost responsibility is to protect the
players. If a player should not be on the playing field,
that players will not be there.

THE SPORTS PHYSICIAN’S RESPONSIBILITIES

An athlete’s autonomy, his or her interests and desires,
and the third principle of medical ethics must always
be taken into consideration in any decision made by a
sports physician. Such decisions should always be
made in the athlete’s best interest.


Whether the decision involves a diagnostic test or the
athlete’s eligibility, its end result is the maintenance of
good health with the least risk to the athlete.


Conflict between physician and athlete should always
be minimal or absent.


While autonomy is respected, most athletes can and
should rely on their sports physician to lead them in
the decision making process.


It is quickly recognized by the sports physician that
one solution rarely fits all with the same problem. The
same set of circumstances can lead to a different suggested
solution by the same sports physician.


Exactness and infallibility, while desirable, are not traits
of even the finest sports physicians (Maron, 1994).


The sports physician’s primary duty is to make the
best effort to maintain or restore health and functional
ability (Howe, 1988).


The athlete’s welfare must guide all efforts.


To be a good sports physician, he or she must have a
genuine appreciation for the importance of athletics in
his or her client’s life. The precepts of Dr. O’Donoghue
for sports physicians are timeless: accept athletics, avoid
expediency, adopt the best methods, act promptly, and
try to achieve perfection (O’ Donoghue, 1984).


The injured athlete must know the diagnosis, understand
its implications, and participate in all therapeutic
decisions.


Despite the athlete’s wishes, the sports physician
cannot do less than seek the best possible outcome.


All sports medicine physicians gain knowledge and
better judgment with experience, soon recognizing
many recommendations or forms of therapy have
risks as well as benefits.


Harm can come to the athlete-patient from unnecessary
or excessive restriction as well as from failure to
restrict activity when appropriate.


The sports physician does not operate in a vacuum. To
make sports oriented medical decisions, one must be
well versed in current recommendations for eligibility
and continued participation and not depend on his or
her own limited personal experience or unscientific
reasoning (Mitten, 1999).


Recognizing the wide range of opinions and individual
fallibility, athlete-patients can assert their right to
another opinion.


Continuing education of the sports physician aids in the
development of a suitable level of skill and knowledge
and their maintenance (26th Bethesda Conference,
1994).


While sports physicians will be able to treat most
referrals, they must be aware of their own level of
competence. They must know when and where to
refer for specialized consultation or therapy. It is
essential to know their colleague’s ability, personality,
and empathy for athletes in order to make competent
referrals (Rizve and Thompson, 2002).


The referred patient should not be abandoned. The
consultant may gain insight from the referring physician.
This affords the athlete continuing support from
his or her primary sports physician.


There is no obligation to accept without question the
recommendations of consultants, especially if incongruent
with the referring physician’s knowledge of the
patient.


All the above lead to trust established between athlete
and physician, allowing for more comfortable resolution
of the decision making process.

OTHER CONSIDERATIONS FOR THE TEAM PHYSICIAN

Sports medicine abounds with opportunities for
research. Simply keeping accurate epidemiologic and
injury data has the potential to impact training regimens,
competition rules, or mandates for protective
equipment (Rice, 2000).


Every would-be team physician must research the
medical liability risk and insurance coverage associated
with the position. A written contract or memorandum
of understanding with the institution or team that
defines responsibilities and level of coverage expected
is essential—even if no compensation is to be
received (Rice, 2002). Good Samaritan laws exist in
many states but the exact law varies widely between
different jurisdictions. Most Good Samaritan laws
apply only if the physician is receiving no compensation
for his or her services. Compensation may be
defined by a specific dollar amount, or as little as
receiving a team shirt to wear at games!


Compensation as a team physician is variable. Almost
all work with teams competing at less than collegiate
level is voluntary. Deferring offers for nominal remuneration
in favor of paying a trainer’s salary can be a
beneficial and time saving option (Rice, 2002). Most
team physicians work with athletic teams solely for
professional and personal satisfaction owing to their
interest in sports and athletes.

COMMUNICATION RESPONSIBILITIES OF THE TEAM PHYSICIAN

For a team to receive optimal medical care, the team
physician and trainer must communicate openly and
clearly. Even before the season, they need to discuss
medical treatment protocols, which preferably are
documented in writing (Rice, 2002). When an injury
occurs there can be no confusion over who will go on
the field for initial evaluation and who will communicate
to the coach the extent of an athlete’s injury and
playing status.


A team physician needs to develop good rapport with
the coach. Offering injury prevention suggestions and
player health education may demonstrate to the coach
a shared desire to assist the team attaining their goals.
Most importantly, a team physician must keep the
coach informed of an injured player’s ability to continue
to compete safely. Without breaching player
confidentially, the team physician should provide the
coach a timeframe for further evaluation or the
player’s return. In general, this should be communicated
in terms of a sport-specific timeline, such as: the
player is out for a play, out for a series, reassessment
will be done at half-time or game’s end, or the player
is likely lost for the remaining part of the season.


A team physician may also be required to discuss a
player’s medical condition with the school officials.
Administrators often need to know specifics regarding
physician recommendations: how long will the player
miss class or be in the hospital. They seldom need to
know medical or personal details of the athlete’s situation.
Remember that the athlete’s confidentiality is
the first concern. Members of the media rarely, if ever,
need information from the team physician.


Well-defined criteria for dealing with the media should
be established. If a team physician is encouraged to
participate in an interview, insist that written questions
be submitted before-hand so that appropriate remarks
can be constructed for the record. These planned
responses can be reviewed with team coaches, trainers,
and administrators to ensure their consistency, accuracy,
and regard for the athlete’s privacy.


A team physician may need to discuss an athlete’s medical
condition with his parents, especially if working
with minors. It may be beneficial to send a letter to
parents prior to the season, describing the role of the team
physician and the continued importance of their personal
primary care physician to the athlete’s overall health.


As mentioned above, the team physician coordinates
specialty care as medically indicated. In doing so, he
or she should provide the pertinent information necessary
to the respective medical consultant’s care and
receive written documentation of recommendations
from medical specialists.

ADMINISTRATIVE RESPONSIBILITIES OF THE TEAM PHYSICIAN

The team physician’s primary concern is the coordination
of medical supervision. This organization
includes: making sure qualified medical personnel are
attending practices and competitions as needed,
designing a plan for sideline evaluation, and having
necessary medical equipment readily available. The
team physician encourages defined roles and responsibilities
for all involved in the medical care of the
team, along with establishing a medical chain of command.
The team physician may not make all the daily
decisions but should have full authority concerning
medical policy-making.


The team physician needs to lead the planning for and
practicing of medical emergencies and urgencies. In
addition to having an emergency treatment and transport
plan, the team physician also must know the medical
capabilities of surrounding hospitals—particularly
around away competitions sites—so that injured athletes
are brought to medical facilities that are best
equipped to handle their specific medical problem
(Herring et al, 2000a).


The team physician should implement protocols that
facilitate timely and quality medical care for situations
when he or she is not immediately available.
Preestablished guidelines for return to play are very
helpful, especially when injuries to impact athletes
result in high pressure for returning to competition
before appropriate healing has occurred (Herring et al,
2000b). The ACSM consensus statement on return-toplay
issues more fully details the responsibilities of
the team physician when returning athletes to competition
(Herring et al, 2002).


The team physician oversees the playing environment.
He or she should evaluate both practice and game
facilities for safety. A safe playing environment also
involves appropriate and properly fitting protective
equipment, available hydration, and an activity level
appropriate for the climate.

MEDICAL RESPONSIBILITIES OF THE TEAM PHYSICIAN

The first responsibility of a team physician is to determining
whether an athlete is fit to participate. This
evaluation most commonly occurs during the preparticipation
physical. This examination may or may not
be preformed by the team physician, but the team
physician should review the documentation of this
examination so that he or she will know of any condition
that may limit competition or predispose the
athlete or other participants to injury. This preparticipation
physical must be done prior to athletic training
or participation—preferably 6–8 weeks beforehand so
that all potentially disqualifying conditions can be
fully evaluated without missing jeopardizing scheduled
participation (Herring et al, 2000a).


Sideline and event coverage is the most obvious responsibility
of the team physician. A physician should cover
all collision and high-risk sports. Other athletic events
can be covered by any allied health professional who is
trained in recognition and initial treatment of athletic
injuries (Herring et al, 2000a). A team physician must
continually remind himself or herself that he or she is
more than a spectator. The physician should be a
“dispassionate observer,” meaning that the emotions of
competition must not affect medical decision making.
Attention should be directed to the safety of the participants,
not the immediate passions of the game.
• The team physician should focus attention on aspects
of play and individuals who are more prone to injury.
In other words, the seasoned team physician will carefully
follow the game, but not always follow the ball.
For instance, in American football relatively little injury
information can be gained by watching the flight of
the ball on punts, kickoffs, and passes. Rather, injuries
occur and attention should be focused on linemen, quarterbacks
after releasing the ball, and wide-receivers after
catching the ball. In every sport, special attention should
be given to situations and players at high risk for injury.


The team physician must be prepared to handle nonparticipant
emergencies for it is not uncommon for the
team physician to be called on to treat an ill-fallen
coach, referee, or spectator.


The team physician insures accurate diagnosis through
use of additional studies and specialty consults, communicates
information clearly and confidentially regarding the player’s condition to those who need to
know, coordinates the rehabilitation process, and
determines when the athlete is able to compete again.
This essential process involves active communication
with athletes, parents, athletic trainers, physical therapists,
coaches, administrators, and other medical specialists
as necessary (Rice, 2002).


Pursuing active follow-up with medical specialists is a
critical duty. Team physicians may refer athletes to
subspecialty providers to assist in treatment or with
clearance for athletic participation; however, information
from these visits does not naturally flow back to
the team physician. Assuming that the specialty
provider will call with any important information, or
that all pertinent information will flow back through
the health care system, will result in confusion for the
team physician and danger for the athletes. Shadow
files, tickler lists, and other reminder systems can help
team doctors actively and personally follow up on
referrals, thus preventing the always embarrassing and
often dangerous situations that result from incomplete
medical communication between subspecialists and
the team physician.


Documentation of medical care is often mistakenly
neglected in the team setting. The team physician
needs to keep formal and confidential medical records
that detail communication with consultants, give
treatment and follow-up instructions, and provide
details for insurance and reimbursement purposes
(Rice, 2002).


The team physician should have final say of when an
athlete is initially cleared to begin competition and
when a previously injured athlete may return to play
(Herring et al, 2000a).

CORE KNOWLEDGE OF THE TEAM PHYSICIAN

To perform his or her duties effectively, a team physician
needs an understanding of the medical conditions
common to the athlete. This knowledge should encompass
many areas of medicine, including but not limited
to—orthopedics, cardiopulmonary medicine, neurology,
dermatology, and sound principles of rehabilitation
(Herring et al, 2000b).


The team physician also needs expertise in pharmacology.
Practical pharmacology for the team physician
includes not only knowing how to treat illnesses, but
also an understanding of performance enhancing drugs
and herbal medicines. Team physicians must be familiar
with the substances that are banned by the governing
athletic association so that an athlete does not inadvertently
lose eligibility to compete (Melion et al, 1997).


A team physician must have a general knowledge of
behavioral medicine and psychology. Mood disturbances
and mental illnesses (like depression) affect
athletes and can be very common in injured athletes.



A team physician’s knowledge of exercise science and
nutrition can help prevent injuries, as well as maximize
an athlete’s performance. Disordered eating and overtraining
can prove devastating if not recognized early
and treated effectively (Herring et al, 2000b).

TIME REQUIREMENTS OF A TEAM PHYSICIAN

A team physician must have an office schedule that
can accommodate athletes with urgent and time sensitive
medical needs.


Most team physicians have designated training room
time each week, at least one to two evenings, where
they can evaluate new and follow-up existing injuries
of team members. This is an especially important setting
in which to communicate with the trainer on the
rehabilitation progress of athletes’ injuries (Herring
et al, 2001). An athlete’s behavior and responses can
vary widely depending on the familiarity of the environment;
hence, training rooms should ideally be
held in the athlete’s “native environment,” at a location
convenient to athletes and close to practice or
training facilities.



Team physicians often neglect team practices. While
it is not necessary that all practices be attended, occasional,
brief appearances during practice will allow
the physician to gain insight into the environment and
conditions in which the athletes train, the team’s training
regimen, and interactions between coaches and
players. A better appreciation of all these factors can
prove invaluable in the physician’s medical decision
making. Additionally, brief appearances at practice
help the physician build collegial relationships with
coaches and players, establishing his or her role as a
part of the team and distinguishing the physician from
other officials, support staff, and media representatives
who only participate in game-day activities.


Amount of time spent at the actual competition
depends on the team physician’s role and availability,
as well as state laws and regulations of the governing
athletic association. Some laws mandate that a physician
be in attendance for every game. Other laws
allow nonphysician medical personnel, such as an athletic
trainer, to cover an event with on-call physician
backup (Herring et al, 2000a).


A doctor who is the team physician for an entire institution
must decide whether to attend all the games for
a few teams, or to attend a few games for every team.
We recommend that team physicians attend at least
part of one practice and at least one game for each
team they supervise. Providing good team medicine is
very difficult without observing the interactions and
conditions of play and practice.

WHAT IS A TEAM PHYSICIAN?

Very little has been published about the duties and responsibilities of a team physician and no formal
studies exist as to the qualifications and skills necessary to be effective in these duties.


The following consensus statement from the
American College of Sports Medicine (ACSM)
defines the unique role of a team physician:
The Team Physician must have unrestricted medical
license and be an MD or DO who is responsible for
treating and coordinating the medical care of the athletic
team members. The principal responsibility of the
team physician is to provide for the well-being of individual
athletes—enabling each to realize his or her full
potential. The team physician should possess special
proficiency in the care of musculoskeletal injuries and
medical conditions encountered in sports. The team
physician also must actively integrate medical expertise
with other healthcare providers, including medical
specialists, athletic trainers, and allied health professionals.
The team physician must ultimately assume
responsibility within the team structure for making
medical decisions that affect the athlete’s safe participation.
(Herring et al, 2000b)


Doctors from many specialties serve in the role of team
physician with primary care physicians comprising the
majority. The most common fields of medicine with the
percentage of the total in parentheses is family practice
(25.5%), orthopedic surgery (16.2%), osteopathic medicine
(10.9%), internal medicine (10.1%), general practice
(6.3%), pediatrics (5.4%), emergency medicine
(4.9%), general urgery (4.5%), obstetrics/gynecology
(2.8%), cardiology (2.0%), and all others (11.5%)
(Melion, Walsh, Shelton, 1997).


The team physician is part of a team of professionals
that cares for the athletes and contributes to their success
by maximizing training and competition preparation.
He or she also assists by accurately diagnosing
ailments and promptly, yet completely, rehabilitating
injuries to get athletes back to competition as quickly
and safely as possible. In addition to expertise in the
common medical conditions encountered in athletes,
other necessary qualities include: flexibility and availability,
good communication skills, a desire to educate,
and an understanding of injury prevention
principles (Herring et al, 2000b).

Artériopatie oblitérante des membres inférieurs

No studies showed reduction in the risk of occurrence of arteritis
lower limbs in physically active individuals (prevention
primary) but many articles have reported a net profit of activity
in the physical treatment of arteritis of the lower limbs.
The Transatlantic Inter-Society Consensus in its consensus conference
on peripheral vascular disease (12) between stresses the importance of other-
of regular physical exercise, if possible as medically supervised
study shows Regensteiner & Co (see Table 4). In this randomized, 10 peripheral arterial disease were subjected to a training program at home
explained by a nurse and maintained by telephone interviews
weekly. The other group was subjected to a training program on
medically supervised treadmill at 3 sessions per week. after three
months a 137% improvement in the walking distance (PM) is found in
supervised the group, without significant improvement in the other group. other
studies show an improvement in the 2 groups but increasingly
important in the supervised group.
Also according to this consensus conference, the comparison of
benefits between physical activity and shows a balloon angioplasty
superiority of angioplasty as six months on the quality of life of the
walking distance. However, there is significant difference after
2 years of follow up, while there are advantages of complications -
during interventional angioplasty.
If we now compare the physical activity cal to surgery by
bypass, we find that the best results are obtained by combining
2 techniques (PM increased by 263% against 173% for surgery alone and
151% for the year only) (Lundgren & Co 1989).

    Table 4: Changes in scope of work groups "physical activity" in relation to groups "cookies".

Risk of major coronary events

1. primary prevention
Wannamethe & Co (1) showed a significant decrease
major coronary events related to vector increased activity
physics at a moderate level, without further significant benefit to increase the
tivity level of activity. The relative risk (RR) reached 0.60 (95CI 0.50-0.72) as
shown in Table 2.

       Table 2: Relative risk of major coronary event according to physical activity.

Colditz & Co (2), in their meta-analysis, found a RR of incident
major coronary of 0.55 between the least active subjects and the subjects most
assets. The level of activity does not need to be raised as suggested by the study
American Nurses on 72,488 women aged 40 to 65 years followed on
8 years: the practice of 3 or more hours of walking per week was associated with a
significantly reduced risk of coronary events (RR = 0.65).
2. secondary prevention
a. angina:
Schuler & Co (3) conducted a study of 113 patients with angina
pectoris followed for 12 months. After randomization, 56 were included in
an intensive retraining program (2 hours of group training by
week and 20 min drive individual per day) combined with a diet
without lipid-lowering medication lipid-lowering, the other 57
represented the control group subjected to "treatment as usual." Each subject
received a coronary angiography and myocardial scintigraphy in
baseline and after 12 months. In the group "intervention", it is found a
decrease in body weight 5%, total cholesterol by 10%, triglycerides by 24% and increased HDL by 3% (all statistically
significant).
There is also an improvement in myocardial oxygen consumption
10%. On the angiograms, the lesions progressed in 23% of
case (against 48% in the group "controls"), stabilized in 45% of cases
(control: 35%) and decreased in 32% (control: 17%).

Table 3: Changes in biological parameters and angiographic groups according .

b. Heart failure:
Whether ischemic or secondary to fibrosis,
heart failure is accompanied by fatigue and dyspnea
effort. Oka & Co (4) have shown, firstly, that patients
congestive heart failure spontaneously reduce their activity level
daily physical to avoid these symptoms, and, secondly, that there is a
gap between the subject's physical ability and level of daily exercise, if
although the level of physical activity through the heart failure is low,
compared to its theoretical possibilities.
The comparison made by Silva & co (5) between a group under a
training program for 3 months and a control group shows
a significant improvement in distance covered in 6 min (355 m) in the
group "intervention."

Another study conducted by Oka and co (6) observed the benefits ofphysical activity at home continued for 3 months in patientswith heart failure stage II or III. She showed asignificant decrease in fatigue, and improved capacityphysical and quality of life without adverse event during thisperiod.Finally, Beneke & Co (7) followed 16 men with impairedheart over 3 weeks by subjecting them to a training program (15min bike 5 times a week and 10 min of treadmill walking three times aweeks). They observed a significant improvement in VO2 max of 18% andan increase in spontaneous walking speed of 70% (increase due42% for an increase in muscle strength and 58% at abetter economy of gesture).Physical activity can thus improve physical capacity andquality of life of patients with heart failure without significant change in themortality.c. Ischemic heart disease:Going back to the 1970s, we find that programsre-cardio existed, emphasizing the importance of the activityphysics, together with measures of lifestyle in preventingrecurrent myocardial infarction and unstable angina.Different criteria have been analyzed such as tele-diastolic volumes andTV-systolic, stroke volume, ejection fraction, the diametercoronary, VO2 max, the maximum level of effort, and the walking on6 min.In 1995, Pitscheider & Co (8) assigned 83 patients who presentedmyocardial infarction trans-wall, in a control group (no programparticular) and a group re-entrainment. Monitoring focused on three months and hasto demonstrate a significant decrease in end-diastolic volume of7% and the tele-systolic volume of 12% in the "intervention" withoutsignificant change in the "control" group. The decrease in volumeswas even more notable in patients with myocardial less.The fl ude Adachi & Co (9) of 1996 focused on measuring the volumeejection by comparing 39 patients with previous myocardial in 3groups of physical activity (1: control, 2: low, 3: highintensity). Monitoring focused on two months. In group 3, the stroke volumehas improved both at rest and after a violent effort of 6 min asejection fraction. Group 2 has seen an improvement in its volumeejection during exercise, without change in stroke volume at rest or theejection fraction. The "control" group showed no change significantly between these two dates. These results confirm the interest of the activity

in physical reconditioning during exercise in patients corona nothings, andsuggests that the level of training must be relatively high.Hambrechet & Co (10) also divided their patientscoronary artery in 2 groups: a control group of 33 patients and a groupintervention of 29 patients undergoing a program of re-packagingexercise (group exercise and physical activity questionnaire for leisure). Thefollowed then focused on one year. It is noted a significant improvement in thegroup "intervention" of 7% of VO2 max, 14% of the intensity of effortmaximum when there is a reduction of these data in the group"Witness". The author evaluated to 1400 kcal / week minimum level of exercisephysical recreation for a profit (in the average groupIntervention: 1876 kcal / wk, control group: 1187 kcal / wk (p <0.001)). The studyalso included to measure the caliber coronary angiography;group "intervention": 28% regression, 62% unchanged, up 10%,"control" group: 6% regression, 49% unchanged, 45% increase. The levelNo minimum physical activity clears the way for stabilizing the lesions is encrypted bythe author at 1533 kcal / wk, and 2200 kcal / wk for a regressionlesions (about 3 hours of cycling at 16km / h in the first case and 4:30 in thesecond).The following study, carried out by Verrill & Co (11), concerns the extent ofdistance walked in 6 min, and validated test reflecting the subject's possibilitiesin everyday life. This study focuses on 14 programs of re-entrainmentCardiac short by 1054 patients aged 40 to 89 years. It allowsshow a significant lengthening of 15% in the walking distance as wellin men than in women and that, regardless of age,stressing the imp ortance to also include older patients intraining programs.

Benefits of physical activity on Health

Physical activity is associated with lower mortality in both
men than in women. This is demonstrated in numerous studies
dealing specifically with different age, a gender or a
specific socio-professional class. A Danish study seems
particularly suitable for this early chapter: it has tracked 30,640
people, men and women aged 20 to 93 years, on an average
5.14 years. It sought to observe the relationship between mortality,
all causes, and physical activity in leisure, occupational,
sports, and related to transport (to cycle). Mortality quartiles 3
increasing level of recreational physical activity, compared with the mortality of quar tile
the most sedentary was: 0.68 (95% CI 0.64-0.71), 0.61 (95% IC0.57-0.66) and
0.53 (95% CI 0.41-0.68) (Table 1). Among the most active half, the
participants in a sporting activity showed a mortality halved.
Finally, those using bicycles as a means of transport enjoyed a
reduced by 40% mortality. (0)
After this introduction edifying, we will now detail the
impact of physical activity on different devices.