Optimizing the collegiate preparticipation physical evaluation.

BACKGROUND: Today's collegiate student athlete is a highly diverse individual and as such is at higher risk for many health problems both on and off the field. OBJECTIVE: To determine if a preparticipation evaluation (PPE) can be optimized to help the collegiate team physician and athletic trainer assess both current and past health issues of student athletes. DATA SOURCES: Utilizing MEDLINE and other medical literature database search engines, the authors conducted detailed literature searches on this subject. Key words used in these searches included preparticipation physical evaluation, collegiate, athlete, cardiovascular, preventive healthcare, high risk, alcohol, tobacco, sexually transmitted disease, motor vehicle accident, adolescent, and female. METHODS: Approximately 35 articles were selected for review for this report. Authors reviewed articles within their particular area of content responsibility. Personal communications with several sports medicine experts were also conducted. RESULTS: Twenty-three articles were selected for inclusion, in addition to information obtained from the American College of Sports Medicine and National Collegiate Athletic Association (NCAA) Web sites. Utilizing these sources, as well as guidance and suggestions from other sports medicine physicians, the authors determined that the NCAA-mandated PPE should deliver an overview of the athlete's entire health status. CONCLUSIONS: As detailed in this report, it is recommended that the NCAA PPE serve as a tool in tracking and assessing both current and past health issues of student athletes. These health issues would include (1) on-field health concerns such as cardiac and musculoskeletal conditions, (2) off-field health concerns (that may adversely impact on-field performance) such as sexual activity and substance abuse, and (3) health issues unique to the female student athlete, such as eating habits, nutritional record, and menstrual history. Primary care physicians should be involved in all PPEs as they have the necessary expertise to recognize potential problems in these areas.     

Preparticipation physical examination: selected issues for the female athlete.

OBJECTIVE: The purpose of this article was to examine the preparticipation examination (PPE) with regard to the female athlete. Ever-increasing participation of women in competitive sport has created a requirement for more gender-specific sport medicine knowledge. In particular, physicians and other health care professionals should be aware of the triad of disordered eating, amenorrhea (and other menstrual dysfunction), and osteoporosis (or altered bone mineral density) collectively described as the female athlete triad. Suggested additions to the standard PPE may help identify athletes at risk. DATA SOURCES/METHODS: A literature search was carried out using MEDLINE for years 1966 to 2003, with keywords female athlete triad, PPE, female athlete, eating disorders, amenorrhea, and osteoporosis. Further studies were identified through reference lists. RESULTS: Better recognition and prevention of these problems is essential. At present, there is little evidence-based information available to guide the practicing clinician in this area. It remains to be determined which methods are the most sensitive and specific for detecting the triad disorders, as well as the most economical and time-efficient. CONCLUSIONS: The PPE offers an excellent opportunity to screen for these entities, as well to initiate early treatment. It is recommended that a standardized form (or part of the form) be developed for the female athlete.     

Substance abuse.

The three types of drugs commonly used in sports--therapeutic drugs, performance-enhancing drugs, and recreational drugs--have been discussed and presented in a way that should be helpful to health care providers dealing with athletes. The goal of this article has been not only to present information concerning drugs but also to raise the awareness level so that abuse of all types of drugs will be considered by athletic trainers, physicians, and health care providers when they deal with athletes. The role of the physician in the area of drug abuse is no different than the physician's role in dealing with any health problem, diagnosis, and management. The responsibility of the physician who deals with athletes always has been, is, and always will be the health and safety of the athlete.     

Sideline preparedness for the team physician: consensus statement

The objective of the Sideline Preparedness Statement is to provide physicians who are responsible for making decisions regarding the medical care of athletes with guidelines for identifying and planning for medical care and services at the site of practice or competition. It is not intended as a standard of care and should not be interpreted as such. The Sideline Preparedness Statement is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the health care professional. Individual treatment will turn on the specific facts and circumstances presented to the physician at the event. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. The Sideline Preparedness Statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.     

Psychological issues related to injury in athletes and the team physician: a consensus statement

This document provides an overview of selected medical issues that are important to team physicians who are responsible for the care and treatment of athletes. It is not intended as a standard of care, and should not be interpreted as such. This document is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the healthcare profession. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization.     

Neck Injuries

When a neck injury is suspected, the on-site physician must first provide basic trauma care, which includes establishing an airway as necessary, assessing breathing, and checking circulation and neurologic compromise. A few targeted questions during history taking and a directed physical exam will help rule out serious cervical injuries, which are uncommon. More common are minor injuries, such as “burners.” Team physicians must also be well-versed in immobilizing and transporting the patient, administering a thorough neurologic exam, and establishing when the athlete can return to competition.     

The Volunteer Team Physician: When Are You Exempt from Civil Liability?

In brief: Qualified immunity statutes designed to protect volunteer team physicians from liability for damages are very restrictive. In most states that have such statutes, if the physician's activities fit the law's definition of emergency care, he or she is liable only in cases of gross negligence or worse. But if the treatment given a fallen athlete does not qualify as emergency care, the physician can be sued for ordinary negligence. General medical care and advice to athletes and field assessments of injured athletes' ability to return to play are not usually defined as emergency care. Some precautions for medical personnel to take before volunteering their time at school athletic events are suggested.     

Attention deficit hyperactivity disorder and the athlete: an American Medical Society for Sports Medicine position statement

Attention deficit hyperactivity disorder (ADHD) is an important issue for the physician taking care of athletes since ADHD is common in the athletic population, and comorbid issues affect athletes of all ages. The health care provider taking care of athletes should be familiar with making the diagnosis of ADHD, the management of ADHD, and how treatment medications impact exercise and performance. In this statement, the term "Team Physician" is used in reference to all healthcare providers that take care of athletes. These providers should understand the side effects of medications, regulatory issues regarding stimulant medications, and indications for additional testing. This position statement is not intended to be a comprehensive review of ADHD, but rather a directed review of the core issues related to the athlete with ADHD.     

Sports injuries at the 1985 Junior Olympics. An epidemiologic analysis

The XIX Junior Olympic Games, hosted in Iowa City, Iowa, in August of 1985, involved 3,028 athletes who participated for 7 days in 13 different sports at 8 separate sites. Medical coverage for the Games was provided by the University of Iowa Sports Medicine Service. Staffing for the events involved approximately 75 physicians, 60 athletic trainers, and other health care personnel. A triage protocol was established prior to the Games whereby the athletic trainer would make first contact with the injured athlete and would evaluate and treat the injury based on standing orders. If in the judgment of the trainer, the athlete needed to be referred to a physician, one would be available, either on site or on call. During the Games, 1,113 medical encounters were recorded, 121 of those being deemed serious enough to withhold an athlete from competition pending further evaluation and treatment. The 121 significant injuries and illnesses involved 116 athletes (66% male, 34% female). Thirty-four percent of the significant injuries only required treatment by the trainer, while 46% were referred to an on site physician and 20% needed a specialty consultant. Seventeen percent of the significant injuries resulted in the athlete being medically disqualified for the remainder of the event. The most common injuries/illnesses were contusions (26%), sprains (21%), heat (17%), strains (9%), and other illnesses (12%). According to body region, 44% of the 121 injuries were to the lower extremity, 26% to the head, neck, and trunk, and 12% to the upper extremity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of the preparticipation physical examination form to screen for the female athlete triad in Canadian interuniversity sport universities.

OBJECTIVE: The purpose of this study was to survey universities affiliated with Canadian Interuniversity Sport on existing screening protocols for the female athlete triad, and to identify any potential areas for improvement of this system. DESIGN: Surveys were faxed or e-mailed to Canadian Interuniversity Sport-affiliated universities in Canada, and preparticipation physical examination (PPE)/medical history forms from each institution were analyzed. SETTING: The Fowler Kennedy Sports Medicine Clinic at the University of Western Ontario. PARTICIPANTS: In 2000, of the 48 universities, 35 responded (73.0% response rate). In 2002, 39 of 49 universities responded (79.6%). MAIN OUTCOME MEASUREMENTS: Although the majority of institutions surveyed implement a PPE form (80.0% in 2000, 87.2% in 2002), only 70.6% to 75.0% of these institutions actually conduct a follow-up when deemed necessary. However, the number of forms including a specific female section increased from 46.4% in 2000 to 61.8% in 2002. Also encouraging is the percentage of universities attempting to increase awareness of the triad disorders (33.3% in 2002 vs. 14.3% in 2000). It is interesting to note that in over half of the institutions surveyed both years, the athletic therapist or trainer is responsible for analyzing the completed PPE forms. CONCLUSIONS: This study has shown substantial improvement from 2000 to 2002 in the development of the PPE across Canada, even in a relatively short period of 2 years. However, this study also demonstrates the lack of uniformity within Canada of the PPE forms.There remains a need to improve the PPE form to target a section of the form specifically to female athletes, or else cases may be missed. The triad is also not found solely in sports where leanness is associated with better performance. Better efforts need to made to increase awareness of the triad and its risks among female athletes, as well as provide educational opportunities for athletic therapists, who are the first line of intervention in many cases. CLINICAL RELEVANCE: The key to successful prevention and intervention is education. This study demonstrates the need for education for all people directly involved with the athlete, and the need to work together to promote a healthy and realistic body image and increase awareness of the female athlete triad among athletes.     

Team physician consensus statement

The objective of the Team Physician Consensus Statement is to provide physicians, school administrators, team owners, the general public, and individuals who are responsible for making decisions regarding the medical care of athletes and teams with guidelines for choosing a qualified team physician and an outline of the duties expected of a team physician. Ultimately, by educating decision makers about the need for a qualified team physician, the goal is to ensure that athletes and teams are provided the very best medical care. The Consensus Statement was developed by the collaboration of six major professional associations concerned about clinical sports medicine issues: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. These organizations have committed to forming an ongoing project-based alliance to "bring together sports medicine organizations to best serve active people and athletes."     

Preparticipation cardiovascular screening

Regular aerobic exercise provides many health benefits regardless of age, and should be promoted by health care providers to all patients. In older athletes, coronary artery disease is the most common cause of sudden death. There is widespread consensus, however, that the overall health benefits derived from exercise outweigh the risks of participation. Screening should focus on identifying signs and symptoms of underlying cardiovascular disease by obtaining a personal and family history and performing a focused physical examination according to the recommendations of the AHA. Exercise testing is recommended in males older than 40 and females older than 50, and individuals with cardiac risk factors. Cardiovascular PPE screening in young athletes remains a challenge, because potentially fatal abnormalities are uncommon and in some cases are undetectable without sophisticated testing. Most sudden cardiac deaths in athletes are caused by anomalies that are clinically silent, are rare, or are difficult to detect by history and physical examination. Many athletes may not experience symptoms consistent with heart disease or may not report family histories of sudden cardiac death. Important clues to a cardiac abnormality include history of syncope, chest pain, and family history of sudden death. Any underlying condition suspected on the basis of history or physical examination requires further diagnostic evaluation before the athlete can be cleared for activity. Currently there is considerable variability and inconsistency among state requirements for PPEs. A national adoption of a more uniform PPE screening process should be encouraged. The screening process should include the AHA's cardiovascular screening recommendations, as this would assist in closing the gap between screening practices recommended by sports medicine experts and the reality of current screening practices. Although the extent of screening continues to be debated, clinical guidelines for performing PPEs and determining clearance have been established. Without a uniform implementation of the current guidelines, it will not be possible to assess the value of the current cardiovascular screening recommendations in detecting and preventing cardiovascular death in young athletes. Physicians should be aware of the emerging role of genetic testing for cardiovascular diseases in athletes with a family history of heart disease or sudden death. Advances in the diagnosis and understanding of cardiovascular disease may provide better tools for preventing sudden death of young athletes in the future [11].     

The athlete's pharmacy

Athletes use a variety of substances for the treatment of pain, injury, common illnesses, or to gain an advantage in competition. A growing concern is that many young athletes may use potentially dangerous, but legal, medications without consulting health professionals. Physicians providing care for athletes should be aware of any medications that an athlete is taking and how these substances may interact with performance, exercise, environment, and other medicines. Moreover, it is vital that physicians are familiar with these medications so that athletes are properly educated on the potential benefits and/or risks, and how each substance may affect the body.     

The Role of the Family Physician in Sports Medicine

In brief: Sports medicine is often considered an orthopedic subspecialty, but family physicians represent the grass roots of athletic care. Millions of competitive and recreational athletes from all age-groups turn to family physicians with their sports-related problems. In this round-table discussion we asked four physicians to talk about the role of the family practitioner in providing comprehensive care, prescribing exercise, and functioning as team physician and educator. They also discuss ethics, the preparticipation screening exam, sources of sports medicine information, and a sports medicine curriculum.     

Chronic Exercise Preserves Lean Muscle Mass in Masters Athletes

Magic Johnson's second retirement from the Los Angeles Lakers speaks to the fear athletes have of contracting HIV while participating in sports. Many of your patients may share the anxiety publicly expressed by a few professional basketball players about playing alongside Magic Johnson. Because athletes often turn to primary care physicians to address such concerns, we gathered two medical experts and a college athlete to discuss athletes' perceptions of HIV and the medical evidence of the transmission risk in sports.     

2002 Refshauge lecture when to retire after concussion?

The management of an athlete with recurrent concussions, whether persistently symptomatic or not, remains anecdotal. There are no evidence-based guidelines upon which a team physician can advise the athlete. All doctors involved in athlete care need to be aware of the potential for medicolegal problems if athletes are inappropriately returned to sport prematurely or in the case of professional athletes held out of sport or retired on the basis of non-scientific recommendations.     

第14届世界游泳锦标赛运动员损伤与疾病调查

目的:了解高水平游泳运动员在国际赛事中的损伤与疾病发生特点。方法:对第14届世界游泳锦标赛中前往医疗站就诊的运动员的损伤和疾病情况进行登记。医疗站医生收集运动员的医疗报告,每天上报给组委会医疗保障部,比赛结束后统一分析处理。按照国际奥委会损伤疾病监控系统(IOC injury and illness surveillance system)对运动员的损伤和疾病情况进行归类、统计分析,与以往数据比较。结果:整个赛期2165名注册运动员中,172名运动员就诊,运动损伤53例(24‰),女性运动员损伤发生率(n=21,18‰)低于男性(n=32,32‰)。游泳项目的损伤病例数最多(n=20),公开水域项目的损伤发生率最高(50‰)。运动损伤好发部位为头部躯干(35.8%)、下肢(35.8%)。最常见的损伤类型为皮肤擦伤,占全部就诊运动损伤病例的34%。整个赛期共发生疾病99例(46‰),呼吸道感染高发(n=40,40.4%),因牙齿问题到定点医院就诊的运动员人数最多(n=10,8例牙齿疾病,2例外伤导致牙齿断裂)。结果显示:与历届游泳锦标赛相比,本次比赛中运动员损伤发生率大为下降,呼吸系统感染是运动员的最常见疾病。预防牙病和牙齿健康应该得到重视。     

Health and sports law collide: do professional athletes have an unfettered choice to accept risk of harm?

Is there a positive duty at law to prevent an athlete with a serious medical disability from performance, despite the player accepting the risk? Is high risk of serious injury or death in the athletic context equivalent to euthanasia? Euthanized death is a predictable consequence of deliberate action. Accepting high risk in the athletic context is distinguishable. Athletes are often more likely able to make voluntary decisions without the burdens of incurable pain and clouding medications. Should policy reasons, nonetheless, preclude athletes from accepting high or uncertain risks of serious injury or death? What standard of medical certainty or legal certainty is appropriate regarding the "right to risk"? The higher the risk of serious injury or death and the less the medical uncertainty the more tort law might trump contract principles. In contrast, medically certain outcomes are easier to knowingly and voluntarily assume by way of contract. Waivers are contracts and present a conflict between a person's rights to have freedom to contract and negligence. Contracts shift the risk. An athlete can be disqualified to avoid a significant risk of injury that cannot be eliminated through reasonable medical accommodations. The problem is that physicians tend to be conservative and without any input from informed athletes, many otherwise disabled players would be refused participation, albeit with a high risk. If an athlete is able to seek medical treatment that reduces the risk and does so, an athlete's will to return should not be ignored. The team must substantiate the restriction by justifying a relatively certain and substantial risk. An athlete may agree to accept high risk of serious injury or death through a contractual waiver to insulate others from liability in negligence. Independent legal advice and advice from medical experts ensure that such waivers are legally enforceable. As medical law has broad application, dealing with improving the rights, rules and policies of health care as it relates to the use of advanced medical technologies in potentially vulnerable persons and consequently the right to accept risk, is as important both evaluative and meritorious exercise for all health and legal systems throughout the world.     

Treatment of recurrent concussion

The management of an athlete with recurrent concussions, whether persistently symptomatic or not, remains anecdotal. Currently, there are no evidence-based guidelines upon which a team physician can advise the athlete. All doctors involved in athlete care need to be aware of the potential for medicolegal problems if athletes are inappropriately returned to sport prematurely or, in the case of professional athletes, held out of sport or retired on the basis of nonscientific recommendations. This paper discusses such issues.