A Growing List

As preparticipation physical exams grow in length and scope, athletic trainers are searching for new ways to fine tune the process.

By Laura Smith

Laura Smith is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 13.6, September 2003, http://www.momentummedia.com/articles/tc/tc1306/growinglist.htm

When preparticipation physical exams started 30 years ago, they usually consisted of a few quick questions and a cursory examination. The idea was simply to find out if an athlete had any obvious health problems that would keep him or her from participating safely.

In the three decades since, however, the goals for the PPE have expanded exponentially. Many schools now view the PPE not just as a qualifying exam, but as an opportunity to promote the overall well-being of their student-athletes.

“We believe we owe it to our student-athletes to look at their total health during their PPE, and that involves a lot more than it used to,” says Dale Rudd, ATC, Head Athletic Trainer at UCLA. “We just finished one of our PPE days, and we had several student-athletes leave with referrals for psychological services—they discussed issues with the physician and decided they could benefit from some help. It’s amazing what you can learn during the PPE if you take enough time to ask the right questions.”

With these new goals for the PPE have come new questions, however. How in-depth should the health history go? How do we best screen for cardiac problems? Can PPEs also help uncover musculoskeletal deficiencies? Is there any way to streamline the process? The following provides some answers, new ideas, and opinions on how to get the most from the preparticipation physical.

Perhaps the biggest philosophical change in the PPE over time has been the increased emphasis placed on the athletes’ health history questionnaire. “If you ask me which is more important, the questionnaire or the exam, it’s the questionnaire, hands down,” says Brent Rich, MD, Team Physician at Arizona State University. “Most student-athletes are at the peak of their physical health, and that means we’re not likely to turn up anything on a physical exam. We get more and better information by focusing on their personal and family histories.”

“When you evaluate a school’s preparticipation physical exam procedure, the number one thing to look at is the history form they are using,” agrees Central Missouri State Team Physician David Glover, MD. “The questionnaire is the biggest factor determining the PPE’s effectiveness.”

How do you know if your PPE questionnaire is on target? The first resource to consult is a monograph called Preparticipation Physical Evaluation developed a decade ago through the cooperation of the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. The monograph was updated in 1996 and will be reviewed and updated on an ongoing basis to keep pace with research, according to Rich, an author on the 1996 version.

“The monograph contains a list of about 30 questions that ought to be on every PPE form,” he says. “It’s considered the gold standard—based on the research, these are the questions that are most likely to reveal underlying problems that pose risks.”

Areas addressed in the monograph include cardiac assessment, head injuries, heat illness, allergies, orthopedic issues, eating and weight issues, and the female athlete triad. “Individual schools should see the monograph as a scaffold on which to build their own PPE form,” Rich explains.

“Get a copy of the monograph and compare it to the form you’re using,” Glover recommends. “Doing that will give you a good idea of the adequacy of your form, and a good form will carry your PPE procedure a long way.”

Of all the key areas in the monograph, the one that has raised the most questions is cardiac screening. While the incidence of sudden cardiac death is low (estimates range from one in 100,000 to one in 200,000 athletes per year), the shock of an athlete in seemingly perfect health dying suddenly on the playing field keeps the issue at center stage.

Sudden death in young athletes is most often caused by congenital cardiovascular abnormalities that can sometimes be identified during exams through electrocardiograms and echocardiograms. But there are problems: The tests are expensive, and often what they reveal are normal variants. Combined with the low incidence of sudden death, deciding what cardiac tests to do during a PPE poses one of the toughest decisions a head athletic trainer can face.

“We’ve questioned over the past 10 years whether we should be doing routine echocardiograms during the PPE,” says Richard Ray, EdD, ATC, Head Athletic Trainer at Hope College. “But the bottom line is, most student-athletes are at the peak of their physical health, and mass screening tests are extremely unlikely to find anything. You add that on top of the expense, and it’s frustrating.”

“A lot of schools have gone to the extreme of testing everyone and have found two things,” says Eastern Kentucky University Head Athletic Trainer Bobby Barton, DA, ATC. “One, they weren’t identifying nearly as many problems as they had hoped they would be able to, and two, the athletes who did die of sudden cardiac death had such unique cardiovascular problems that the tests had not been able to identify the problem anyway.”

“When one in 100,000 athletes has a problem, and the chances of finding that one athlete are slim, we feel like the cost of doing echos on everyone probably outweighs the benefit,” says JoHan Wang, ATC, Director of Athletic Training at Stanford University. “But then you hear of an athlete who dies, and you wonder.”

In response, most athletic trainers and physicians use a thorough health history to identify student-athletes at risk and then conduct tests in individual cases. “A good cardiac history—personal and family—is the most important thing,” says Gerald Fletcher, MD, Mayo Clinic (Jacksonville) cardiologist and national spokesperson for the American Heart Association. The AHA has issued a list of recommended questions for a cardiac history, and those questions have been incorporated into the current PPE monograph. AHA recommendations are updated every five years to reflect new data.

“Mass testing is expensive and impractical,” Fletcher says, “and even a physical exam presents challenges. A good physician will pick up on an enlarged heart—but athletes often have larger hearts than average people do. You can pick up on a slower-than-normal pulse rate, but athletes often have that, too. An athlete may have a heart murmur, but as many as 50 percent of people have benign heart murmurs at some point in their childhood.

“But, if you know that an athlete’s father died suddenly at age 40 from heart disease, or that there is a history of arrhythmia in the family, then you know that the athlete is at greater risk, and you are going to have to monitor them very carefully,” he continues. “This has been found to be the most effective way of screening out problems.”

At Eastern Kentucky, Barton takes a comprehensive cardiac history, and then brings in a cardiologist to assist with the PPE. “The general practitioner reviews the history and if, on the basis of that and his exam, he feels there is a need for further evaluation, he sends the student-athlete down to the cardiologist,” Barton says. “Then the cardiologist decides if it’s necessary to order testing.”

With the increased importance of the health history questionnaire, the student-athlete’s ability to fill it out correctly is critical. Many athletic trainers have taken steps to help athletes answer questions in a more deliberate manner.

“Getting good information is always a tough issue,” says Rudd. “Some athletes just want to speed through it and circle all the no’s.”

“You have to remember that their objective is different from yours,” says Glover. “You want to make sure they are healthy, but their objective is to play, so they’ll tell you what you want to hear.”

Therefore, Rudd makes sure to talk with student-athletes before they fill out the form, stressing the importance of answering the questions completely and honestly. “I remind them that they are signing their name to it, and our ability to provide them with good health care is going to depend on them being truthful,” he says. “I also tell them that if they aren’t honest with us and something crops up later, it’s going to be a lot more difficult to deal with. I emphasize that we’re only here to help, and it’s going to be a lot easier to identify things and help them now than to have something happen in the middle of the season when they’re going to miss playing time.”

At Eastern Kentucky, Barton takes the quest for full answers a step further. “We actually have a nurse or a nurse practitioner ask each student-athlete the questions,” he says. “It’s time-consuming, but it’s worth it, because we get much better responses.”

However, athletic trainers should be aware that student-athletes might not always be willing to answer questions about their personal history. A 1999 study published in The Archives of Family Medicine found that the majority of student-athletes were uncomfortable with physicians raising questions during a PPE about personal issues not directly related to sports, such as alcohol and nicotine use or risky sexual behaviors.

“The key is always giving them the option of saying, ‘I’d rather not discuss that,’” Glover says. “It’s also important to realize that how you phrase your questions makes a big difference, and to take care with your timing. Staying away from more sensitive topics until later in the exam after you’ve built a rapport with the student-athlete is the best way to get them to be open with you.”

Since family history is as important as the athlete’s personal history, it’s critical to encourage student-athletes to ask their parents or other family members for help on questions when they’re unsure of the answers. “A student-athlete who doesn’t know the answer to a question may just circle ‘no’ rather than admitting that they don’t know,” Barton says. “It’s important to stress to them that this is a risky, unwise thing to do.” If they cannot access information at all because parts of their family history aren’t available to them, they should feel free to simply tell the physician.

Helping parents develop positive attitudes toward the PPE can help, too. “Parents and student-athletes should complete this form together, at least for high school athletes and college freshmen,” says Jon Almquist, ATC, Specialist for the Athletic Training Program for the Fairfax (Va.) County Public School System. “It’s important to communicate to parents that this is something that could save their child’s life. Instead of telling them, ‘I know this is a major pain, but everybody’s got to do it, so just get it over with,’ we should be telling them that it’s a great opportunity to have a good physical done for their child and to have a physician discuss some issues that may affect them in the long term.”

For example, ensuring that parents understand the gravity of the cardiac history is vital. “A lot of parents will think, ‘Johnny is a healthy kid—there’s nothing we need to tell the doctor,’” Fletcher says. “The fact that Johnny’s grandfather died at age 40 doesn’t strike them as significant to Johnny’s health, so they don’t tell the physician doing the PPE.”

“Coaches can also be very helpful getting the message across,” Rudd adds. “We ask them to emphasize with their players the importance of filling out the forms accurately and taking their time.”

As more and more topics are added to the PPE questionnaire, time becomes a problem, both for the student-athlete answering the long list of questions and the athletic trainers reviewing the answers. Stanford University is attempting to solve the problem with an online form. Their student-athletes no longer put pencil to paper to answer health history questions, but instead log on to a secure Web site and fill out an interactive form that bases its questions on the athlete’s previous responses.

Stanford’s ePPE focuses on the same set of core areas that traditional forms do: past medical problems; heart and lung problems; heat-related problems; head, neck and spine injuries; orthopedic injuries; history of injury treatment; family history; current health; and nutrition. However, it’s the system’s ability to hone in on an individual’s risk areas and probe for more information that makes it unique.

“The form is ‘nested and branched,’” says Gordon Matheson, MD, PhD, Chief of Sports Medicine at Stanford, who helped to choose the ePPE’s questions. “There can be as many as 3,500 separate data elements, but they’re nested in 75 questions.

“Take the nutrition section, for example,” he continues. “The form asks a handful of general questions like, ‘Do you want to weigh more or less than you do now?’ If the student-athlete answers ‘no’ to the general nutrition questions, they will move right on to the next section. But if they answer with some yes’s, another set of questions will drop down to explore that issue further.”

The same goes for sections like cardiac history: A student-athlete who answers yes to a question about a family history of sudden death will be asked a subset of more specific questions. The branching can even vary depending on an athlete’s gender.

“To get a traditional health history this comprehensive, the student-athlete would have to sit down and go through 40 pages of material, a lot of which wouldn’t apply to them,” Matheson says. “And then someone would have to read 40 pages of answers, taking notes on what was significant.”

Instead, when the student-athlete has completed the ePPE, the program generates a list of only the pertinent findings. Athletes take this summary with them to their physical exam, and the physician focuses the exam on those issues. “A sample of the type of data included in the summary would be, ‘Jane Doe had a concussion in July 1999, was treated by a doctor, missed three practices, and has had no symptoms since,’” Matheson says.

“We get a lot more information than with the traditional form,” he continues. “It’s very, very sensitive. We pick up a lot of cardiovascular issues that we wouldn’t have before. It just doesn’t miss a thing.”

“I think we detect a lot of subtle issues that we used to miss,” Wang says. “We identified a huge number of disordered eating cases last year, and I think many of those would have slipped through in the old system.”

The time required to complete the questionnaire can vary greatly. “We had two student-athletes who took three hours to do it,” Wang says. “But for someone without a lot of pre-existing issues, it can take as short as 20 minutes.

“We had no problem getting the freshman to accept the system, but our returning student-athlete’s complained a little bit about the time it took,” he continues. “We told them it’s more than worth the time.”

Student-athletes receive a packet during the summer that explains the ePPE procedure and gives them the information they need to access and complete the form before coming back to school in the fall. They can log on and off as many times as they need to, pausing to track down answers to questions they are unsure of. However, no one else can view the forms while in progress or even once they’re completed. “The system is totally secure and HIPAA-compliant,” Wang says. “The only thing anyone will ever see is the summary.”

While more emphasis has been placed on health histories in PPEs, some sports teams have also expanded the exam to test for musculoskeletal problems. If any strength or agility deficits are found, the athletic trainer or strength coach can develop a program to help the athlete correct the problem.

Derek Steveson, PT, Physical Therapist for the Arizona Diamondbacks, has designed such tests for his major league baseball players and recommends a simpler test for athletes at lower levels.

With the Diamondbacks, Steveson has the luxury of using a variety of position-specific tests. “We have different tests for the pitchers, the catchers, and the position players,” Steveson says. “With the position players, for example, we have them do a rotational hop, because a ground ball or a fly ball is going to require them to turn and rotate off one leg.”

When time and resources for musculoskeletal evaluation are limited, Steveson recommends the balance-reach test. “It’s a great place to start if you want to have one cursory test to evaluate all athletes,” he says.

For the balance-reach test, ask athletes to stand on one leg and perform a one-legged squat, counter-balancing with their other leg. Then ask them to extend their opposite arm and reach as far across their body as possible, either knee-height or floor-height. To evaluate strength, they can perform the test repeatedly to exhaustion.

Steveson feels the balance-reach test reveals functional capability better than separate tests for different abilities. “If you do a separate strength test, a balance test, and a range of motion test, you can’t accurately extrapolate from that data the athlete’s ability to perform,” Steveson says. “With the balance-reach test, you get to assess full body motion.”

An athletic trainer, strength and conditioning coach, or physical therapist should be measuring athletes’ results on the balance-reach test. “Having someone who understands functional testing administer the test is important,” Steveson says. “I dictate my results into a tape recorder as I go. Another good option would be to have a standardized form where the tester could check off hip internal rotation, ankle dorsal flexion, generalized ability to control one-legged movements, general flexibility, and how many times the athlete could perform the test.”

From individual athlete’s results, an athletic trainer can spot any deficiency and then work with the strength and conditioning coach to strengthen the weakness. For example, if the athlete is able to extend her reach quite far but has trouble balancing on one leg, she may need more work on agility, but less flexibility work.

Steveson also suggests using the results to spot deficiencies throughout the entire team. “The athletic trainer could look through the forms and say, ‘The biggest thing most of these athletes are lacking is a rotational component to their hip, so I’m going to design a program to address that,” he says.

“Having a musculoskeletal testing protocol in your PPE may seem like a minor point compared to heart murmurs, diabetes, and previous ACL reconstructions,” he continues, “but it’s imperative. If you don’t, you’re much more likely to find yourself with a full athletic training room as the season goes on.”

The monograph Preparticipation Physical Evaluation is available by contacting the American Academy of Family Physicians at (800) 274-2237, or by logging onto https://secure.aafp.org/cgi-bin/catalog.pl?op=view_items&product_id=199&category_id=21.

Along with deciding what tests and questions to include on the PPE, simply organizing the exam can be a challenge. Here are some tips from those who have spent years setting up PPEs:

Schedule Early. “The ideal time to do PPEs is six to eight weeks before the start of the student-athlete’s most intensive training for their sport,” says Richard Ray, EdD, ATC, Head Athletic Trainer at Hope College. “It helps you accommodate the coaches’ needs, and it gives you enough time to address any problems you uncover. If you are doing PPEs the day before the season starts and find a problem, it can be tough on the student-athlete. It may be only a temporary problem that time and treatment will take care of, but they aren’t going to be able to start the season with the team.”

Delegate Areas of Expertise. “Instead of trying to line up all the people needed to do the exam myself, I appoint a team leader for the athletic trainers, another for the nurses, and another for the physicians,” says JoHan Wang, ATC, Director of Athletic Training at Stanford University. “These are people who have been involved with our PPEs before and are familiar with our process. I ask them to go out and recruit all the people they need for their team, and then to tell me who they have.”

Hold an Orientation. “I think the best thing we do to ensure there aren’t any major catastrophes is hold an orientation the day before the PPEs with all of the people who are going to help,” Wang says. “We get the nurses, physicians, physical therapists, athletic trainers, nutritionist, and administrative staff all together in a room and discuss the game plan for the day. We answer any questions they have, and we always throw in a free meal to show our appreciation.”

Follow Up. “Don’t have a station unless you have a plan in place for how that information is going to be used,” Ray advises. For short-term issues, such as x-rays that needs to be ordered, the key is immediate follow-up. For longer-term issues, like an athlete with an allergy or chronic illness, the key is making sure the information stays with the athlete throughout their season and is readily available to athletic trainers responsible for their care.

Divide and Conquer. “We’re discussing abandoning the idea of mass physicals and doing them by team instead,” Wang says. “We know that because of the time pressure and long hours, we’re missing things. In the new system, the athletic trainer responsible for each team would organize that team’s PPE and run the entire exam in our athletic training room. We think it will be a lot easier to deal with fewer athletes on several different days than with everyone at once in a few concentrated days.”

The Health Insurance Portability and Accountability Act of 1996 is raising questions for some athletic trainers regarding the way they collect and use information during the PPE.

“Over the years, we’ve had upper-level athletic training students stay in the rooms with the physicians during the exam to take notes,” says Eastern Kentucky University Head Athletic Trainer Bobby Barton, DA, ATC. “They’re the ones who record information like, ‘This student-athlete will need a follow-up x-ray at the end of the season.’ With HIPAA, we’re not sure whether we can continue this practice.”

“The biggest area of concern for us is communication with coaches,” says Jon Almquist, ATC, Specialist for the Athletic Training Program for the Fairfax (Va.) County Public School System. “Physicians should be free to communicate with the athletic trainers about the PPE, because we are both medical professionals responsible for the student-athlete’s care. But how much can we tell the coach about the reason a student-athlete might not be cleared to play?”

As with other aspects of HIPAA, the best protection is a good release form. “There needs to be a release signed up front,” says Matthew Mitton, JD, Counselor at the National Sports Law Institute in Milwaukee, Wis. “There should be a very clear understanding with the student-athlete about why the PPE is being done, to whom the findings will be disclosed, and why they will be disclosed—and that should be solely for the purpose of protecting their health and safety.”

But with more types of information being discussed during PPEs—drug testing, STDs, psychological issues—a blanket release for the entire exam may not be sufficient. “The student-athlete should have the right to say, ‘It’s okay with me if you disclose to my coach that I have asthma, but not information about psychological concerns,’” Mitton says.

In determining whether the release form and procedures you’re using for your PPE conform to HIPAA guidelines, it’s best not to make assumptions. “We’re going to consult with the director of our student health center and our legal counsel before we make any decisions,” says Barton.

For more details on HIPAA, log on to www.momentummedia.com/articles/tc/tc1302/hipaa.htm.