Preparticipation Screening of High School Athletes

Are Recommendations Enough?

Michael C. Koester, MD, ATC; Chris L. Amundson, MS, ATC, CSCS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 8 - AUGUST 2003

ABSTRACT

BACKGROUND: The American Heart Association (AHA) recommends cardiovascular screening and injury history for all student-athletes to prevent sudden cardiac death and related problems. No standard preparticipation physical evaluation (PPE) form is currently required, and the qualifications of those who perform these evaluations vary.

OBJECTIVE: To assess the PPE process of high school student-athletes in Oregon.

METHODS: A survey was mailed to the athletic directors at 258 Oregon high schools that were members of the Oregon Schools Activities Association (OSAA) and had interscholastic athletic programs for the 1999-2000 school year. Directors were asked to complete the survey and return it with a copy of the PPE form they used if they were not already using the recommended form.

RESULTS: Responses were received from 154 (60%) of the 258 high schools surveyed. Seventy-five (53%) of the 142 forms evaluated contained fewer than 5 of the AHA recommendations for cardiac screening. Forty-two schools (27%) were implementing the PPE form recommended by the OSAA.

CONCLUSION: Most Oregon high schools were not adequately screening student-athletes for injury history or for cardiovascular conditions as recommended by the AHA. We recommend required use of an approved PPE form and specific guidelines for healthcare providers who perform the exam.

Historically, the purpose of the preparticipation physical evaluation (PPE) has been to detect physical conditions that may disqualify an athlete from competition and to fulfill any perceived insurance requirements. Currently, the requirements for the scope and focus of the PPE are being debated. The PPE may be one of the few times clinicians can ask otherwise healthy teens about high-risk behaviors, such as smoking, experimenting with drugs, riding with a drunken driver, or having unprotected sex. Many authorities contend that the PPE should be used as a forum to provide high-risk health behavior screening and education for adolescent athletes^1-3; however, a consensus has been building toward maximizing the PPE to prevent further athletic injuries and attempting to minimize sudden cardiac death.^4-7

In 1996, an expert panel appointed by the American Heart Association (AHA) defined a careful cardiac history and physical examination that they believe should be the standard for preparticipation cardiovascular screening.⁸ The AHA recommendations represent a consensus based on the clinical experiences and judgments of the panel. The cardiac history questions, however, have not been scientifically validated. Despite the AHA cardiovascular recommendations, a well-publicized monograph,⁵ and numerous other publications^3,9-11 that outlined the proper content of the PPE and highlighted the need for improvement, most high schools and colleges across the nation are not following these guidelines.^12-14

Our study aimed to assess the preparticipation screening of high school student-athletes. The state of Oregon provided an excellent model, because no statewide requirements regarding the PPE existed at the time of our study. In May 1999, the Oregon Schools Activities Association (OSAA) recommended, but did not require, a specific and comprehensive PPE form for use by member schools (verbal communication, Thad Stanford, MD, JD, November 1999). The OSAA also recommended that a licensed physician or a specially trained nurse practitioner be authorized to perform the PPE.

Methods

In January 2000, a survey was mailed to the athletic directors of all 258 OSAA member high schools participating in interscholastic athletics for the 1999-2000 school year. One of the survey questions asked whether the school implemented the OSAA recommended form or used its own. If the school used its own form, we asked respondents to return a copy to us along with the completed survey. We also asked the directors which healthcare professionals were allowed to perform the PPE, specifically listing allopathic and osteopathic physicians, physician assistants, nurse practitioners, chiropractors, and naturopathic clinicians.

We analyzed the history and physical exam questions that were pertinent to the cardiovascular system, musculoskeletal injuries, and head injuries. We evaluated each form by determining which of the 13 specific areas recommended by the AHA consensus panel⁸ were addressed (table 1). Based on criteria developed by Glover and Maron¹³ and Pfister et al,¹⁴ forms were classified as adequate, intermediate, or inadequate for cardiovascular evaluation. Forms were considered adequate if they addressed 9 or more of the 13 AHA recommended items and inadequate if they contained 4 or fewer.

Results

A total of 154 high school athletic directors (60%) responded to our survey. Twelve (8%) athletic directors reported that they were not implementing the form recommended by the OSAA but did not include the form they were using. Eight (5%) schools had no required PPE form, and 1 (<1%) school did not require a PPE. We included these 9 "forms" in the analysis as having none of the elements being reviewed.

Forty-two (27%) schools were using the PPE form recommended by the OSAA. Less than half of all schools (64; 45%) used a PPE that asked about a history of musculoskeletal injuries; 110 (77%) inquired about previous head injuries. Nearly 40% (54) of the reviewed forms did not require a parental signature, thus giving no verification of the student's medical or family history. Overall, 50 (35%) of the 142 forms evaluated met the criteria for being classified as adequate for cardiovascular screening. Only 8 of the 100 forms used by schools that did not use the OSAA-recommended form met the criteria for adequate cardiovascular screening. About half (72; 47%) of the schools accepted PPEs performed by nurse practitioners, 39 (25%) accepted PPEs by physician assistants, 22 (14%) by chiropractors, and 12 (8%) by naturopathic clinicians.

Discussion

Creating a zero-risk circumstance in competitive sports is not possible, and athletes are expected to assume some risks. However, two areas (cardiovascular and previous injuries) raise concerns, because conditions detected by the PPE could allow early therapeutic interventions to prevent serious adverse events on the playing field.

Cardiovascular concerns. Our data are consistent with prior studies^12,13 that indicate cardiovascular screening falls far short of AHA recommendations. However, the overall rate of adequate cardiovascular exams being conducted in Oregon was twice what Gomez et al¹² found in their nationwide survey of certified athletic trainers in 500 high schools. The precise components of the PPE that Gomez et al evaluated were similar to those used in our study. Our findings also exceed the 26% adequacy rate found in a study of college athletic programs.¹⁴ Despite results that exceeded those previously reported in other studies, recommendations alone, rather than requirements to comply, resulted in more than 60% of all responding high schools failing to comply with the PPE standards set by the AHA.

Regarding which healthcare providers are performing the PPE, our findings were largely in accordance with the state requirements reviewed by Glover and Maron.¹³ We did not anticipate, however, that 12 (8%) high schools would accept PPEs performed by naturopathic clinicians, nor did we anticipate the high number of chiropractors being allowed to perform the examination. The large number of nurse practitioners and physician assistants performing the PPE did not surprise us. Many schools, particularly those in rural areas, may have difficulty obtaining the services of a physician.

The large number of chiropractors and naturopathic clinicians allowed to perform the PPE raises concerns. The detection of potentially fatal cardiovascular disease requires a thorough history and physical examination. Key findings often are detected only after careful cardiac auscultation. While the training and experience of physician assistants and nurse practitioners may vary, naturopathic clinicians and chiropractors have limited training in the detection of cardiovascular pathology.¹³ The AHA recommends "that athletic screening be performed by a healthcare worker with the requisite training, medical skills, and background to reliably obtain a detailed cardiovascular history, perform a physical examination, and recognize heart disease."⁸

The AHA guidelines recommend establishing a formal certification process in states where nonphysician healthcare workers (including chiropractors) are permitted to perform preparticipation screening.⁸ The AHA further recommends that the preparticipation cardiovascular exam should emphasize precordial auscultation with the patient both supine and standing to identify heart murmurs consistent with dynamic left ventricular outflow obstruction, assessment of femoral artery pulses to exclude coarctation of the aorta, recognition of the physical stigmata of Marfan syndrome, and brachial blood pressure measurement in the sitting position.⁸

In 2001, the Oregon state legislature passed a law that requires the use of a specific PPE form and specifies that a licensed physician, certified nurse practitioner, licensed physician assistant, or a licensed chiropractor who has clinical training and experience in detecting cardiopulmonary diseases and defects is allowed to perform the examination.

Injury history. A thorough injury history is a vital component of the PPE,^15,16 because young athletes are likely to incur subsequent trauma if an injury has not been properly rehabilitated. Our finding that less than half of the PPE questionnaires asked about past musculoskeletal injuries shows that one of the most important aspects of the PPE is often absent. Given the available data on reinjury rates and studies^17,18 that show the risk of further concussions increases with each subsequent head injury, every PPE should include questions in these areas.

Conclusions and Recommendations

Our findings confirm previous reports regarding the overall inadequacy of preparticipation cardiovascular screening of high school athletes.^12,13 In addition, injury history questions are less than optimal. Because inadequate rehabilitation of an injury may have a long-term impact on a student's quality of life, more attention to injury history is desirable. We believe our findings underscore the fact that statewide recommendations alone do not produce sufficient compliance with the AHA guidelines, nor do they provide adequate screening for past injuries. We propose that each state's high school athletic association require a specific PPE form and, in conjunction with its state medical association, make specific requirements as to the minimum qualifications of all preparticipation examiners.

References

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Dr Koester is a pediatrician at Good Shepherd Medical Group and team physician at Hermiston High School in Hermiston, Oregon. Mr Amundson is a physical therapy student at Pacific University in Forest Grove, Oregon. Address correspondence to Michael C. Koester, MD, ATC, 105 SE Crestline Dr, Hermiston, OR 97838; e-mail to mkoester@eoni.com.

Disclosure information: Dr Koester and Mr Amundson disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.