Athletic Training Management

1. Athletic Training Management Chapter 15 Preparticipation Physical Examinations

2. PPE • The Preparticipation physical examination (PPE) is a major tool in injury prevention • The ability to provide optimal care to an athlete begins here • Intro of the athlete to you often begins here

3. Principles • The design should collect medical information about the athlete • The design should assess risk factors • There is no required standard format, but there is a national consortium that has published a monograph through Physician and Sportsmedicine

4. Goals of the PPE • Landry and Bernhardt identified five reasons for performing preparticipation physical examinations: • 1. To identify athletes at risk of sudden death. • 2. To identify medical conditions that may require further evaluation and treatment before participation. • 3. To identify orthopedic conditions that may require further evaluation and treatment, including physical therapy, before participation. • 4. To identify at-risk adolescents and young adults who are at risk for substance abuse, STDs, pregnancy, violence, depression, and so on. • 5. To satisfy legal requirements of athletic governing boards.

5. Goals • Sport specificity is essential • The PPE should be used to identify qualifying characteristics for a particular sport in addition to disqualifying conditions • The American Academy of Pediatrics Committee on Sports Medicine has established recommendations for contraindications to participation

6. Goals • These goals are based on demands of particular sports • They divide sports into collision/contact, limited contact/impact sports, strenuous noncontact sports, moderately strenuous noncontact sports, and nonstrenuous noncontact sports

7. Goals • The primary goal of the PPE is to identify factors that may decrease injury potential and improve performance • Examples include hamstring tightness in football players, shoulder flexibility in baseball players or tennis players • Hamstring tightness may lead to low back injury • Shoulder tightness leads to compensation placing overload on the rotator cuff among other things

8. Goals • Once identified, any potential problems may be remedied • Accurate, reproducible records are essential • Others should be able to get the same results • Information from the PPE can also be seen as baseline data allowing comparisons with others at a position

9. Goals • This allows sports specificity or even within sport differences to be accounted for

10. Methods • Three main methods are: • office visit • Advantages include knowing the patient • assembly line approach • Set it up in the locker room, everyone seen by the same provider in turn • Advantages include minimal personnel • mass screening station approach • Space available method puts athletes at the next available station

11. Methods • Straight line approach sends the athlete to stations in a predetermined order • This is what we do at UT • Where and how the PPE is done is a function of the type of institution • In colleges mostly the station approach • In HS all three methods are used, probably equally • In the multiple examiner setup there is more time with each individual and more problems are identified

12. Methods • Success of the station exam is directly related to the medical specialties of the physicians participating in the exam

13. Frequency and Timing • Many researchers recommend the PPE be done 4-8 weeks before the first competition • This allows time for follow-up and for rehab of injuries identified that were previously unknown • Frequency recommendations are variable, however • Some recommend it be performed at the beginning of the sport season, others at the beginning of the year

14. Frequency and Timing • AMA recommends at the beginning of any change in level of competition • AMA also recommends a review of an athlete’s history at the beginning of each competitive season • This is the foundation of our “updates” • NCAA requires a PPE on entry into a collegiate athletic program and after that an update each year • Further PPEs not warranted except by history

15. Frequency and Timing • This is not supported by the consortium previously mentioned which recommends a new exam every two years if an excellent support staff (ATs) is available, otherwise a new one every year • National Federation recommends a new exam yearly • Ohio and Michigan both require a new exam every year

16. Components of the PPE • History • Most studies suggest that approximately 70 percent of problems are identified during the PPE through adequate history taking alone • athlete’s personal medical history (immunizations, removal of spleen, hepatitis, surgeries, etc.) • family medical history (asthma, diabetes, genetic disorders, alcohol abuse, cardiovascular disease prevalence, etc.) • personal orthopedic history (previous injuries, surgeries, rehabilitation, etc.)

17. Components of the PPE • General history: Hospitalizations, surgeries, chronic medical problems, or illnesses since the previous examination. • Cardiovascular risk factors: Dizziness, lightheadedness, syncope during or after exercise; chest pain and palpitations during or after exercise; shortness of breath and fatigue out of proportion; high blood pressure, high cholesterol, recent viral illnesses (mononucleosis, myocarditis); family history of hypertrophic cardiomyopathy or of sudden cardiac death prior to 50 years of age; family history of Marfan syndrome; cocaine use or anabolic steroid use; prior restrictions to athletic participation due to cardiovascular concerns.

18. Components of the PPE • Dermatologic: Current skin problems such as warts, rashes, acne, herpes, or blisters. • Drug use: Medication usage, including prescription and over-the-counter; allergy information should be obtained, including allergy to medications, as well as to the environment, food, and/or insects; drug or alcohol abuse in athlete or family members; steroid usage. • Female athletes: Menstrual history, including age of onset (menarche), most recent menstruation, regularity of cycle, and any missed cycles (amenorrhea); adequate nutrition and calcium intake; any irregular eating habits. • Heat-related illness: Prior incidences of problems with the heat, including heat cramps, exhaustion, stroke, or malignant hyperthermia.

19. Components of the PPE • Musculoskeletal: Type and severity of prior injury, such as sprains, strains, fractures; swelling or pain; past treatment and rehabilitation of any prior injuries. • Neurologic: Frequent headaches, migraines, and/or seizures. • Concussion: Incidence, type, and severity of prior head injuries; presence of concussive symptoms. • Spinal Injury: Prior burners or stingers, any numbness or tingling in arms, legs, hands, or feet. • Pulmonary: Shortness of breath, wheezing, or coughing during or after activity; seasonal allergies; any episodes of exercise-induced asthma.

20. Components of the PPE • Sickle cell trait: Athletes of African ancestry should be asked if they carry the sickle cell trait. • Solitary organs: Prevalence of one paired organ (eye, testes, kidney, etc.). • Weight: Questions regarding body image, perceived ideal weight, and recent weight changes. • Other: Depression, anxiety, general stress

21. Components of the PPE • Medical Exam • The general medical examination starts with some vital statistics of the athlete such as age, sex, height, weight, blood pressure, and heart rate. The exam then proceeds to evaluate various body regions and systems, including head, eyes, ears, nose, throat, chest, abdomen, skin condition, genitalia, and possible hernia. The general medical examination is designed to identify the presence of common medical conditions.

22. Components of the PPE • Additionally, Arnheim advocates Tanner staging as a guide to physical maturity when adolescents participate in collision or contact sports • The AMA Board of Trustees also recommends that athletes have a proper assessment of physical maturity to ensure a proper match within their level of athletic participation • Musculoskeletal (orthopedic) examination is designed to assess the integrity of the athlete’s joints and muscles. • may include an assessment of major joints; manual, isotonic, or isokinetic muscle strength assessment; and joint flexibility. • Consideration of the demands of an athlete’s particular sport is essential during this examination. • The more extensive this examination, the more powerful the PPE can be as an injury prevention tool.

23. Components of the PPE • Cardiovascular Screening • cardiac screening remains controversial • some authors recommend ECGs and echocardiograms to improve identification of those at risk • PPE consortium states that there is only indirect evidence that cardiovascular screening could help identify conditions such as hypertrophic cardiomyopathy

24. Components of the PPE • PPE consortium states a test detecting between 1:100,000 and 1:300,000 athletes at risk of sudden cardiac death would have to be very specific and sensitive to justify the cost of adding this test to a nationwide PPE system

25. Components of the PPE • Maron, et. al., stated in 1996 that cardiac screening should include a history noting the following: • History of chest pain or discomfort or syncope/near syncope. • History of excessive, unexplained, and unexpected shortness of breath or fatigue associated with exercise. • Past detection of a heart murmur or increased systolic blood pressure. • Family history of premature death (sudden or otherwise) or significant disability from cardiovascular disease in close relative(s) younger than 50 years. • Specific knowledge of the occurrence within the family of conditions such as hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan’s syndrome, or clinically important arrhythmia.

26. Components of the PPE • Sports specificity • Flexibility, strength, power, anaerobic endurance, aerobic endurance • Establish flexibility with a sit-and-reach test and goniometer measurements • Establish strength with manual exercises, dynamometers • Establish power with power activities (vertical jump, etc.) • Establish anaerobic endurance with specific activity (40-yard dash, shuttle run, sit-ups in one minute, etc.) • Establish aerobic endurance with specific activity (distance in a twelve-minute run, step-test, submaximal treadmill or bicycle tests, etc.)14

27. Components of the PPE • Neurological exam for those in collision/contact sports • IMPACT or other neurological screening exam for baseline

28. Medical Disqualification • Decisions • Passed: • Unconditional • No reservations • Cleared for all activities and all levels of exertion • No current or preexisting medical problems • No contraindications for collision or contact sports • Passed with conditions: • Has a medical problem that needs follow-up • Able to participate in sports at present • Follow-up must occur before athletic participation • Passed with reservations: • No collision sports • No contact sports • Failed with reservations: • Not cleared for requested activity (may be considered for other sports) • Collision not permitted, contact limited • Contact not permitted, noncontact sports allowed • Failed with conditions: • -Can be reconsidered after medical problem is addressed • Failed: • Unconditional • No reservations • Cannot be cleared for any sport or any level of competition

29. Personnel • Varies with setting • See table 15-2, pp 212-213 • Who can give an exam is highly variable from state to state • According to Glover and Maron • 8 states do not require any history • 40 % of state forms have nothing from the 1996 Bethesda conference on cardiovascular screening recommendations • Another study found that ANYONE can sign a PPE in 4 of the states

30. Legal Issues • Sexual propriety accusations • Battery section of malpractice law • Actions such as listening to heart and respiratory sounds through a stethoscope or palpation of abdominal, pelvic, or breast areas for legitimate medical reasons may be seen by the patient as having sexual overtones • Prevent with a health care professional observer of same sex as patient in the exam room

31. Legal Issues • If no observer is available, refer the athlete to their family physician • If the athlete persists in wanting an exam and doesn’t want an observer, get them to sign the record to that effect • PPE consortium suggests having physicians of both sexes available for the station exam and mandating same sex as the patient physicians do the exam • A consent form granting actual consent should be obtained allowing the exam to be given, including the physical exertion assessments

32. Legal Issues • In athletes eighteen years of age or older, this may be done directly. • If the athletes are minors, consent must be obtained from the parents or guardians. • Remember that the athlete in no way waives rights in this situation, only the parents do

33. Legal Issues • Should an athlete wish to participate after having been disqualified, and the parents agree, then waiver of liability forms are the only safeguard against later legal action. The athlete must be given “full disclosure of all information” that would allow the athlete to make a reasoned and competent decision to participate • This includes all foreseeable risks of participation. These waivers have been upheld in various courts.

34. Legal Issues • In some conditions, such as cardiovascular or neurological complications, the team physicians may disqualify a person who still wishes to play. Under these conditions, the conservative approach would be for the athlete to file suit against the physician for denying the right to participate, allowing the courts to issue an order allowing the participation to occur. A copy of the order should then be entered in the athlete’s medical file.

35. Legal Issues • It should also be noted that if the athlete is married, unless a spouse also signs a waiver, the spouse is not precluded from bringing action for “loss of consortium” against the school or team, athletic trainers, and physicians • This is more of a problem for colleges and universities and for professional teams than high schools

36. HIPAA and FERPA • These laws apply here • HIPAA regulations define protected health information as “any information, whether oral or recorded in any form or medium...created or received by a healthcare provider, health plan, public health authority, employer, life insurer, school or university, or healthcare clearing house...relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of healthcare to an individual.”

37. HIPAA and FERPA • Contrary to popular opinion, release of the decision to coaches as to whether an athlete is cleared to play or disqualified (but without detailed medical information) falls within the allowable exchange of information • Release of information for treatment, consulting with other providers, referring to other providers, or contacting a patient’s family are all allowed by HIPAA

38. HIPAA and FERPA • When the PPE is completed by an athlete’s family physician as is often the case in secondary schools, HIPAA rules apply to the physician’s release of information to the athletic trainer and team physician • A signed release is needed for release of information • For more information, see the Department of Health and Human Services Office of Civil Rights web site (www.hhs.gov/ocr.hippa)