Rider:
Important Injury Prevention Tool, But Not Foolproof
Most experts agree that you should have your child periodically undergo a thorough pre-participation physical examination (PPE) - or what used to be called a sports physical. Not only can a PPE be an effective tool in identifying athletes who should not be playing sports because they have congenital heart defects or a history of concussions , but it is also useful in identifying medical problems effecting sports participation, such as asthma or the female athlete triad .
Parents need to understand, however, that the ability of PPEs to detect the kind of cardiac abnormalities that can predispose athletes to sudden cardiac death is limited.
In fact, the American Heart Association admits that screening by history-taking and physical examination alone (without non-invasive testing) is insufficient to guarantee detection of many critical cardiovascular abnormalities in large populations of young athletes.
No national standard
There a number of problems with PPEs, primarily because national standards do not exist :
- As recently as 1998, 8 states had no standardized questionnaires for the history and physical examination components of a PPE, the screening forms of another 12 states contained four or fewer of the AHA cardiac screening questions;
- In 1999, only 17.2% of the PPE forms in one high school study asked questions about exercise-related cardiac symptoms, a previous diagnosis of a heart murmur or high blood pressure, and about family history of heart attack before age 50 or sudden cardiac death (three main components of the cardiac history portion of the PPE recommended by the AHA);
- According to a 2014 study (Madsen NL, et al. 2014), only 23 state high school athletic associations (46%) used a state-wide mandated PPE form, and, of those, only 8 states - covering only 11% of US high school athletes - use a form containing all the elements developed and recommended by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine ("PPE Monograph"); and
- The person allowed to perform a PPE also varies from state to state: 21 states allow a PPE to be conducted by a nurse or physician's assistant; and 11 states allow chiropractors to perform a PPE.
My advice is to make sure that whoever performs your child's PPE asks the right questions even if they aren't required.
PPE goals and objectives
A PPE has the following goals and objectives:
- Meet legal requirements for participation in interscholastic sports, insurance or club mandates;
- Maintain and promote health and safety of athlete in training and competition by:Identifying conditions that may limit participation or predispose an athlete to injury, disability, or (in rare cases) death;
- Evaluating overall fitness (the examiner may recommend a conditioning/strengthening program );
- Treating current injuries, and preventing future injuries;
- Help athletes to participate safely, not disqualify them from competition. Studies show that only 0.3 to 1.3% of athletes are denied clearance as a result of a PPE;
- Educate athlete on variety of health topics (time constraints often limit the opportunity for education, however); and
- Give athlete chance to discuss health goals as they relate to their own athletic performance.
Who should conduct the PPE?
A child's primary care physician is usually well-qualified to conduct a PPE, given his or her broad training and because he or she knows when to consult with specialists if problems requiring further clinical expertise are detected.
Parents should not assume, however, that their child's doctor knows how to conduct a complete PPE and should make sure their child's doctor is knowledgeable about the required elements in today's PPE, which is much more sophisticated than the general health exam previously used.
Parents should ask their child's doctor for the manual Preparticipation Physical Evaluation developed jointly by the American Academy of Family Physicians, the American Academy of Pediatrics, the American Medical Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine, which includes specific questions to ask in taking a medical history and instructions on how to conduct a sports-related musculoskeletal examination (see below). Parents can also access online the full NATA's 2014 Position Statement on PPEs , which contains helpful lists of topics which should be covered during the PPE, along with lists of questions.
Where should a PPE be performed?
There are three basic types of settings for the PPE: office-based, assembly line, and station, each with its own advantages and disadvantages:
1. Office-Based (primary care physicians in the office)
- Advantages:
- Familiarity with patient: The doctor's familiarity with the athlete makes it easier to complete the PPE form more thoroughly because a complete medical history from prior exams should be available.
- Privacy which facilitates open communication:The doctor may have more time and privacy to educate and counsel the athlete on sensitive health issues (drugs, alcohol, use of performance enhancing drugs , female athlete triad etc.)
- Continuity of care: If athlete has seen the same doctor year after year, the continuity of care offers a critical advantage in detecting, evaluating and treating conditions discovered during the PPE.
- Disadvantages
- Time constraints: The doctor's busy office schedule may allow for only a short general health screen, which may not be adequate to detect conditions predisposing an athlete to injury.
- Lack of expertise: A primary care physician may lack interest in or knowledge of sports-related medical problems, and may feel uncomfortable or unqualified to determine whether an athlete should receive medical clearance to play sports.
- No continuity of care:An athlete may not have an ongoing relationship with a particular physician or practice.
- Cost. Not all athletes can afford private, office-based PPE (high co-pay or deductible or no health insurance coverage at all)
2. Assembly-line (single physician examines one athlete after the other)
- Advantages:
- Disadvantages:
-
Possible communication problems
- Lack of individual attention
- Increased risk that insufficient medical history will be taken
- Lack of continuity from year to year (assuming different physicians conduct exams)
3. Station (multiple examiners conduct discrete portions of PPE in sequence)
- Advantages:
- Time- and cost-efficient: Hundreds of PPEs can be performed in single day with well-trained staff.
- Better communication: An athlete may talk more openly with medical personnel in a "team" setting. A station-exam is likely to impart greater knowledge to all members of medical team and coaches of individual athlete's medical condition
- Specialized expertise: The station approach allows the use of physicians with specialized expertise (cardiologist, orthopedist etc.).
- Disadvantages:
- Noise and confusion.The setting itself can become confusing and noisy.
- Lack of privacy: An athlete may be reluctant to discuss intimate personal health concerns in such an open setting
- Time constraints: An athlete may feel rushed. Time constraints may restrict the opportunity to educate and counsel athlete.
- Care can be compromised: The lack of time and privacy may make it difficult for the athlete and his parents to fully understand the need for additional testing or basis for disqualification. Coordination of care may be compromised because medical personnel may not know athlete previously.
Exam timing and frequency
Experts differ on how often an athlete should have a PPE:
- Six weeks before pre-season: The five-society monograph recommends that the PPE be performed six weeks before pre-season begins to allow adequate to correct problems identified through rehabilitation or conditioning program. The NATA's 2014 PPE position statement recommends four to six weeks.
- Annually or less?
- Some experts believe a full PPE should be performed annually
- The AHA recommends obtaining a comprehensive personal and family history from an athlete entering high school or college, with an interim history and blood pressure check each year for the next 3 to 4 years, significant changes or abnormalities triggering another physical exam and further testing. For the high school athlete, the AHA recommends a complete physical every 2 years.
- The NATA recommends that a complete PPE be performed at each new level of participation, and, when warranted during interim years, a review of the medical history and
subsequent evaluation should be conducted.
PPE: exam components
- Medical history. Providing a complete medical history is the most critical component of the PPE. Because athletes tend to forget important information and because parents have great knowledge of family medical history, the form should be completed by both athlete and parent.
- Physical Exam (key components)
- Height and weight. A sudden weight change may indicate the presence of disordered eating/female athlete triad (large gain in muscle mass that cannot be explained by weight training alone) or use of performance enhancing drugs;
- Eyes, ears, nose, throat: Visual acuity, pupil size, visual correction. Bloodshot eyes or discolored teeth may be signs of an eating disorder;
- Cardiovascular (blood pressure, pulse, listening to the heart to check for murmur, hypertrophic cardiomyopathy ). In contrast to some other countries (such as Italy), the standard of care in the United States, according to American Heart Association, is not to include an electrocardiogram (EKG) or echocardiogram (ultrasound of heart) as a routine part of the PPE in the belief that a complete and careful personal and family history and physical exam designed to identify or raise suspicion of heart problems are most cost-effective (particularly in light of the fact that the ability to detect life-threatening cardiac abnormalities is only marginally improved by additional non-invasive testing, which often leads to false positive results in athletes because of their intense training). Only athletes who have symptoms or significant family medical history should be further evaluated with specific diagnostic tests (i.e. echocardiogram etc.). Remember also that sudden cardiac death in youth athletes is extremely rare (about 100 deaths per year);
- Lungs;
- Abdomen (infectious mononucleosis should rule out contact or strenuous sports participation for at least 3 weeks after onset due to risk of spleen rupture);
- Skin (Impetigo, herpes simplex, scabies, rashes, infections , and infestations; increased acne, especially on back, face and chest, abnormally large breasts in males (gynecomastia), stretch marks (cutaneous striae)) may indicate steroid use;
- Musculoskeletal. There are three different types of screening exams:
- General (quick assessment of range of motion, gross muscle strength, and muscle asymmetry, identification of significant injuries; appropriate for athletes with no injury symptoms)
- Joint-specific testing (much more thorough than general screen but significantly more time consuming; perform only if athlete has symptoms of current injury or history of previous injury, weakness or instability)
- Sport-specific testing (focus on areas of greatest stress for particular sport; for example, runners would be assessed for knee and ankle instability, strength and flexibility; recommended only for highly competitive athletes)
- Neurologic: Only performed if musculoskeletal exam is abnormal or on athletes with a history of concussions .
Conditions limiting participation
The ultimate decision on whether to participate is for the athlete and his or her parents to make.
The following abnormalities may make it unsafe for your child to participate in sports:
- Acute illness
- Blood-borne pathogens. Because the risk of transmission is so low (less than 1 in 1,000,000 games), HIV-positive athletes may participate unless their health is compromised.
- Heart disease (hypertrophic cardiomyopathy, rhythm and conduction abnormalities, systemic hypertension, and valvular heart disease, but not benign functional murmur or mild mitral valve prolapse)
- Skin (contagious lesions or skin conditions should rule out participation in contact sports)
- Eating disorder/female athlete triad
- Eyes (functionally one-eyed athletes permitted only in sports that allow protective eyewear and do not involve projected objects (swimming, track and field, gymnastics, and not allowed to participate in wresting, boxing, or martial arts)
- Pregnancy (no contact, collision, or strenuous sports)
- Kidney(no high-contact sports for one-kidney athletes; flack jacket for moderate contact sports)
- Musculoskeletal (depending on degree and type of injury, risk to athlete, and demands of sport)
- Seizure disorder (one or more seizures within last 6 months held out of competition, especially in high-risk sports (skiing, gymnastics, high diving, collision sports, shooting, archery)
- Asthma (but only if symptoms not controlled)
Sources:
Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al. American Heart Association Council on Nutrition, Physical Activity and Metabolism. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007;115:1643-455.
Mahle WT, et. al. Key Concepts in the Evaluation of Screening Approaches for Heart Disease in Children and Adolescents. Circulation 2012;125:00-00. DOI: 10.1161/CIR.0b013e3182579f25 (accessed April 30, 2012).
Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic Trainers' Association Position Statement: Preparticipation Physical Examination and Disqualifying Conditions. J Athl Tr. 2014;49(1):102-120. doi:10.4085/1062-6050-48.6.05.
Madsen NL, Drezner JA, Salerno JC. The Preparticipation Physical Evaluation: An Analysis of Clinical Practice. Clin J Sports Med. 2014; 24(2):142-149.
Updated February 1, 2017
Teaser title:
Pre-participation Physical Evaluations: Guide for Parents
Teaser text:
Most experts agree that you should have your child undergo a thorough preparticipation evaluation or sports physical (PPE) every year. Not only can a PPE be an effective tool in identifying athletes who should not be playing sports because they have congenital heart defects or a history of concussions, but it is also useful in identifying medical problems effecting sports participation, such as asthma or the female athlete triad.