Effectiveness of the Pre-Participation Physical Examinations and the Need for Standardization
Lack of standardization of the PPE in the United States has led to studies indicating poor effectiveness.3,4 Controversy over which components and procedures continues to limit the evaluation of the effectiveness of the PPE.2 Several studies have attempted to establish a level of standardization in the United States. While all 50 states require a PPE for high school students, there is a lack of consistency across all states in almost all components.1,4,7,8 In 2005, a study found that 81% of states had adequate PPEs4 but that 85% of states had PPEs that predated the 1996 AHA guidelines for CV screening.8 Findings were similar at the collegiate level, where both the NCAA and the NAIA require a PPE upon entrance to the institution, but there is a lack of standardization as to what constitutes a good PPE.7
The majority of the literature on the PPE consists of level 5 and 6 evidence, including opinion papers, literature reviews, and case reports from respected authors and sports medicine societies. Only a few studies have attempted to establish evidenced based outcomes for the PPE. In a comprehensive literature search, Wingfield et al9 identified 310 articles that met the selection criteria, with 25 articles identified as original research directly relating to the PPE. The majority of these examined cardiovascular diseases and screening procedures. The 5 studies that assessed the format or effectiveness of the PPE concluded that it was inadequate. Several studies have concluded that the PPE was not standardized and did not consistently address the AHA recommendations for cardiovascular screening history and physical exams. Additionally, there were a variety of health care professionals that administered the PPE’s (some of which did not have adequate training) which may increase the lack of consistency. Carek and Mainous10 reviewed 176 articles to determine whether the PPE in the literature satisfied the basic requirements for medical screening as required by the United States Preventive Services Task Force (USPSTF) (www.uspreventiveservicestaskforce.org). Both the Wingfield9 and the Carek and Mainous10 reviews identify lack of standardization of the PPE as a key issue in the PPE not meeting the standards for a reliable screening tool.
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Researchers in Germany, reviewed the medical histories adolescent athletes and found that over 16% needed follow up with musculoskeletal system pathologies, nearly 16% needed follow up with general medical conditions, and only 1% answered questions that indicated follow up for cardiovascular conditions.11 When compared to clinical examinations, almost 34% of the athletes had suspicious findings for musculoskeletal conditions, almost 10% had general medical conditions,11 and 3% had cardiovascular issues.7,11
Administration of the Pre-Participation Physical Examinations
The PPE should be completed 4 to 6 weeks prior to participation.1-3 This allows time for any follow up screenings. Individual or multi-station PPE screening methods are acceptable methods of administration. A licensed physician (MD or DO) is the most appropriate medical professional to direct the PPE.1,2 The qualification of the health care professional who performs the PPE is based on practitioner availability, clinical expertise, and individual state laws, but the training of MD/DO physicians makes them the best qualified to perform the exam. For adolescent athletes, it is recommended that their primary care physician perform the PPE. However, it has been reported that there are several states that allow non-physician providers (physician assistants, nurse practitioners, and chiropractors) to perform the PPE.7
Determining participation is based on information gathered during the PPE and is arguably the most important purpose of the PPE. As a result of the PPE, the physician will take the following
There is general agreement in the literature on the rates for athletes qualifying (85% to 97%), qualifying with conditions (3% to 13%), or being disqualified (less than 2 to 3%) for sports participation.3,10 If the athlete is not cleared for participation, the rationale must be communicated to the individual, parent (if athlete is a minor), medical staff (including AT), and the coaching staff.2,10 HIPPA and FERPA guidelines must be followed. A conference meeting is preferred and allows the physician to discuss all issues.
Most clearance issues revolve around the physician identifying musculoskeletal system conditions where a follow up therapy and/or treatment is recommended. These orthopedic issues temporarily restrict an athlete from full participation.2,10 In some cases, medical conditions may require an athlete to be restricted until he or she is fully recovered from an illness (fever), some may require a follow up with his or her primary care MD for medication treatment (asthma), and others may require specific monitoring pre, during, and post exercise (diabetes). Certain medical conditions may restrict an athlete from participating in types of sports.2 For example, an athlete with Down syndrome that has been diagnosed with atlantoaxial instability is likely restricted from collision sports but may have clearance for contact or non-contact sports. Many athletes qualify and are cleared for participation in sports today that previously would have presented with conditions that were considered disqualifying. For example, an athlete with Marfan syndrome, with its high association to SCD, may be required to submit to regular serial cardiac, ophthalmologic, and musculoskeletal evaluations as well as being required to sign written consent or a legal waiver in order to participate,2 but may not be restricted.