NATA Issues New Recommendations on Preparticipation Physicals and Disqualifying Conditions

 Dallas, February 5, 2014 – With the continued increase in high school and college sports participation, there has been a related rise in sudden death. Most deaths have been attributed to congenital or cardiovascular conditions, heat stroke and sickle cell trait among others. To address these issues, the National Athletic Trainers’ Association has released a position statement, “Preparticipation Physician Examinations (PPE) and Disqualifying Conditions,” and recommends the sports medicine community consider adopting a standardized process for conducting the PPE to ensure a safe playing environment for athletes and to help identify those conditions that may predispose an athlete to injury or sudden death.
 
The statement, created by the NATA Research & Education Foundation, appears in the January Journal of Athletic Training, NATA’s scientific publication.
 
During the 2010-2011 academic year, more than 7.6 million high school students participated in organized interscholastic sports, compared with 7.1 million in 2005-2006. Similarly, 444,077 NCAA student athletes participated in college sports in 2010-2011, compared with 393,509 in 2005-2006. For nearly 40 years, the PPE screening has been routinely used to identify conditions that put athletes at risk, yet debate continues as to its efficacy and the lack of standardization in the process has created confusion.
 
“The different organizations charged with developing and revising the PPE – from state high school associations to medical associations, state health and education departments to legislators – often have different missions,” says Kevin Conley, PhD, ATC, associate professor and director of Athletic Training Education at the University of Pittsburgh and lead author of the statement. “This can lead to confusion, and yet the PPE represents the sole source of medical evaluation for 30 percent to 88 percent of children and adolescents annually. We are recommending a standardized PPE process to determine risk factors and ascertain that athletes are physically and mentally prepared for sports participation.”
 
Key PPE Statement Recommendations
 
Based on current and scientific evidence and best practices, NATA has developed the following PPE guidelines designed for physicians, athletic trainers, and other health care professionals to apply regardless of the sport or an athlete’s performance goals. The association has identified conditions that may threaten the health and safety of those involved in organized sports and may require further evaluation and intervention or disqualification.
 
Medical and Family History

• A comprehensive medical and family history should be obtained from each participant and remains the cornerstone of the PPE. This history identifies 75 percent of problems that affect initial athletic participation.
• Take into account the areas of greatest concern for sports participation and particularly the American Heart Association recommendations for preparticipation cardiovascular screening of competitive athletes.
• Histories should be reviewed carefully, and both the athletes and parents should be questioned and reconfirm their responses.
• Particular attention should be given to musculoskeletal injuries, often common causes for restriction or disqualification, as well as prior surgeries or related underlying conditions that might predispose an athlete to injury.

 
Physical Examinations
A general physical examination is recommended. The screening should include a check of vital signs (e.g. height, weight and blood pressure; visual acuity, cardiovascular/pulmonary, abdominal, neurologic and general medical and musculoskeletal examinations). Although another provider may record the initial vital signs for efficiency, the data should always be reviewed by the physician. Further examination should be based on potential concerns uncovered during the history.
 
Cardiovascular screening

• Specific questions regarding risk factors and symptoms of a cardiovascular disease should be asked during the history portion of the PPE. As noted earlier, a positive response to any question should be confirmed and further evaluation conducted if necessary.
• Auscultation – or listening to – the heart should be performed initially with the patient in both standing and supine positions and during squat-to-stand motions to clarify any type of murmur.
• Although echocardiography (ECG) is not considered a routine part of a PPE screening, the results may have benefits in some cases. ECGs and stress tests remain the most commonly recommended diagnostic tests for patients with an abnormal cardiovascular history or exam.

 
Neurologic screening

• A thorough neurologic screening is necessary if the athlete has a history of concussions, seizure disorder, cervical spine stenosis or spinal cord injury.
• The athlete should be evaluated for full range of neck motion. Symptoms such as weakness, paresthesia or numbness in the arms, hands or legs should prompt further testing.
• Individuals playing sports that are associated with a high risk of concussions may be considered for baseline neuropsychological testing during the PPE.Athletes with a history of three or more concussions or delayed recovery may need to be considered for temporary or permanent disqualification from contact sports.

 
Orthopaedic screening

• The musculoskeletal history screening and physical examination can be combined for athletes who have no previous injuries.If the athlete has any signs or symptoms of pain or tenderness, or reduced range of motion during the general exam, a site-specific exam should be performed.
• The exam should be used to identify conditions that would make sports participation unsafe and to facilitate programs for injury prevention.
• Clearance for participation must be based on the degree and type of injury and the requirements of the sport. Additionally, protective padding, taping or bracing may allow the athlete to compete safely.

 
General medical screening
The use of routine laboratory or other screening tests such as urinanalysis, complete blood count or chemistry profile during the PPE is not supported by current studies. 
However, appropriate tests and screenings may be warranted for athletes who have a history of anemia, diabetes mellitus type 1 or 2, sickle cell trait, cardiovascular conditions or exercise-induced bronchospasms; or are female and have abnormal menstrual cycles.
 
 
Medication use

• All medications and supplements currently used by the athlete should be reviewed during the physical exam.
• Listed medications may alert the examiner to medical conditions that have not been disclosed on health forms.
• Athletes and parents should be questioned on the use of prescription and over-the-counter medications, energy drinks that can affect athletic performance and banned substances.

 
Nutritional assessment

• Sports medicine providers should be familiar with the current NATA position statement that outlines the prevention, detection and management of disordered eating in athletes: http://www.nata.org/sites/default/files/PreventingDetectingAndManagingDisorderedEating.pdf
• Ensuring proper nutrition is essential for optimal athletic performance and should be addressed during the PPE.
• The athlete’s height and weight should be evaluated for under-nutrition or obesity, and concerns about disordered eating should be pursued.

 
Heat and hydration-related illness risk factors

• Current consensus guidelines for heat acclimatization in secondary school athletes should be reviewed. http://www.nata.org/health-issues/Heat-Acclimatization.
• Questions related to previous problems associated with heat acclimatization should be included in the medical history form. 
• Education about preventing its onset and maintaining proper hydration should be provided.

 
Mental health considerations
·          As part of the health history portion of the PPE, questions to determine the mental health status of the athlete should be included along with a plan for referral and follow-up.
·          Added visibility that athletes receive due to sports participation may contribute to a mental health concern and require further attention.
·          The athletic trainer working with team coaches and school mental health professionals will help to ensure the athlete receives appropriate care.
 
Administration of PPE

• Privacy must be respected at all times when the findings of the PPE are communicated. Written authorization must be provided by the athlete or the legal guardian if the athlete is a minor and before any private health information is released.
• The PPE may be conducted 4-6 weeks before preseason training begins to allow time for proper follow-up of findings requiring additional evaluation. It is also practical to conduct the PPE on the day preseason training begins or the day before because athletes usually report one to two days early. Because of this short timeline, clearance for some athletes who require additional evaluation may be delayed.
• A complete PPE should be performed at each new level of participation. When warranted during interim years, a review of the medical history and subsequent evaluation should be conducted.

 
 
Determining clearance
Clearing an athlete to participate in a sport should be based on previously published guidelines and the best evidence available. Team physicians and institutions have the legal right to restrict an individual from athletic participation provided the decision is individualized, reasonably made and based on competent medical evidence.
 
“A standardized approach to PPEs is most desirable and should be conducted by a licensed physician with the participation of athletic trainers and health care professionals committed to the same standard of care,” adds Conley. “These suggested guidelines offer a comprehensive approach that we hope will be seriously reviewed and adapted by other sports and health organizations at the state and national levels.  Ensuring safe participation and reducing the risk of acute, chronic or catastrophic injury or death remains our primary goal.”
 
About NATA: National Athletic Trainers’ Association (NATA) – Health Care for Life & Sport
Athletic trainers are health care professionals who specialize in the prevention, diagnosis, treatment and rehabilitation of injuries and sport-related illnesses. They prevent and treat chronic musculoskeletal injuries from sports, physical and occupational activity, and provide immediate care for acute injuries. Athletic trainers offer a continuum of care that is unparalleled in health care. The National Athletic Trainers' Association represents and supports 39,000 members of the athletic training profession.