2012, September/October Adirondac Adirondoc
On a recent business trip for my “day job,” I stopped by the hotel’s fitness center for a workout. I was struck by the instructions: “Be sure to consult with a physician before using this equipment.” I was curious how a physician would respond to a call from a patient perhaps hundreds of miles away asking permission to use an exercise bike, but also realized the warning likely came from the hotel’s legal department rather than from a physician.
It may be a surprise to some readers to learn that the United States is one of the few developed countries that continue to cling to the practice of routine physical examinations of apparently healthy people. A Canadian task force, for example, recommended against routine annual physicals over three decades ago. Many experts believe that the practice, along with accompanying testing, may do more harm than good by triggering a cascade of additional unneeded tests and treatment.
One might argue than an individual about to embark on a strenuous wilderness trek is a “special case” for which prior consultation with a health professional and a complete physical examination would be wise. The wilderness adventure travel/education industry is all over the map on this issue. The National Outdoor Leadership School (NOLS) has a highly prescriptive process, by which many participants of a certain age are required to have a physical, including a stress electrocardiogram. In contrast, a respected international mountain guiding company, Alpine Ascents International, takes older individuals into situations much/ more rigorous than those of NOLS with nothing more than a brief personal health history.
There is no helpful statement or guideline from a recognized wilderness medicine professional organization addressing this question either. Thus, the health-conscious adult about to stretch the limits of his or her past trekking experience has less guidance than the user of an exercise bike in my hotel. What to do?
First, it is critical to recognize the limitations of our ability to predict important outcomes on the basis of a physical examination. For most adults engaging in vigorous exercise, the “important outcome” of greatest concern is sudden cardiac death (SCD). It is true that vigorous exercise can provoke SCD in some individuals. Unfortunately, cardiologists are quite clear that no validated tests permit prediction of SCD in a specific individual; indeed, for about half of individuals with SCD, death is the first sign of heart disease. The running community implicitly acknowledges this. Although marathon running carries a very real risk of SCD (about one in 250,000 participant hours), no marathons require anything from participants beyond a signature and a check.
Beyond the issue of cardiac risk, are there other things about which to consult a physician prior to a major trek? There may be, although most of these do not require an examination. Being sure that immunizations are up to date is important for anyone, and before a wilderness trip is as good a time to do this as any. Folks with chronic diseases should consider the impact of trekking on their conditions. I discussed asthma in a recent column. Hypertension, diabetes, migraine, and gastroesophageal reflux, for example, may be affected by the changes in physical effort, mealtimes, sleep patterns, and fluid intake that are part-and-parcel of an extended backpacking trip. Reviewing this with a knowledgeable professional is certainly wise.
Bone and joint issues merit particular attention. Individuals who have undergone orthopedic surgery, especially knee or hip procedures, should be sure to review their trek plans with their surgeons. Such discussions should be very specific: not “a few days of hiking” but rather “five days of carrying a fifty-pound pack about five miles a day over rocky terrain with 1000- to 3000-foot elevation changes.” Regular, vigorous aerobic exercise, such as mountain hiking, is one of the best health behaviors in which individuals can engage. Incorporating this into one’s life will do far more to insure health than any “complete physical examination”!
~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide, a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. John Epling, MD, chair of family medicine at Upstate Medical University, provided helpful comments on this manuscript.Readiness