Preparticipation Exams Research Articles

Classification of Premature Ventricular Contractions in Athletes During Routine Preparticipation Exams.

Large-scale data on incidental premature ventricular contraction (PVC) prevalence and morphologies have been lacking, leaving many providers without guidance on further cardiac testing for patients with incidental PVCs on ECG. Athletes offer an intriguing cohort to understand the clinical significance, prevalence, and common morphologies of incidental PVCs because they often undergo ECG screening during preparticipation exams. Digital ECGs were obtained from 10 728 screened athletes aged 14 to 35 years during mass screenings in schools and professional sports teams between 2014 and 2021. A retrospective analysis of ECGs with PVCs was performed using the simultaneous display of frontal (limb) and horizontal (precordial) plane leads. PVCs were coded for morphology and categorized as benign or nonbenign using recommended criteria. Twenty-six athletes (0.24%) were found to have at least 1 PVC. Among these, 50% were female, 65% were White, 8% were Asian, 4% were Hispanic, and 23% were Black. Nineteen of the 26 (73%) ECGs had PVCs with a left bundle branch block pattern compared with 7 (27%) with a right bundle branch block pattern. Twenty-four ECGs (96%) had PVCs with benign patterns, including 18 with right ventricular outflow tract, 5 with left anterior fascicle, and 2 with left posterior fascicle morphology. There is a low prevalence of PVCs on routine ECG screening of young athletes, and most PVCs are of benign morphology in this population. This study highlights the value of using digital ECG recorders with simultaneous lead display to guide decision-making about further cardiac testing and referrals in young athletes with PVCs. Using our results and review of the literature, we propose methods and algorithms of PVC evaluation on screening ECGs to help guide many providers with risk stratification and decision-making about further cardiac testing and electrophysiology referrals in young athletes with PVCs.

Abstract 10579: Prevalence and Morphology of Premature Ventricular Contractions on Routine Athletic Electrocardiogram Screening

Introduction: The clinical implications of incidental premature ventricular contractions (PVCs) are poorly understood. Though controversial, athletes often receive electrocardiograms (ECGs) during pre-participation exams. The prevalence and morphologies of PVCs in this cohort have not been widely reported. Recent studies have defined benign PVC morphologic patterns in athlete populations that may guide clinical evaluations. Methods: Digital ECGs were obtained from 10,728 screened athletes aged 14 to 35 at school and professional team screenings in California. Captured PVCs were analyzed using simultaneous frontal and horizontal plane leads, displaying each standard ECG lead in full-length, allowing for morphologic categorization. PVCs were coded for morphology and benign status using recommended criteria outlined in Figure 1. Results: Twenty-six of 10,728 athletes (0.24%) had at least one PVC (Figure 1); 7 of those (27%) had bigeminy and 3 of those (12%) had trigeminy. Overall, participants were 43% female, 62% White, 12% Black, 9% Asian, and 8% Hispanic. Of those with PVCs, 50% were female, 65% were White, 23% were Black, 8% were Asian, and 4% were Hispanic. Twenty-four ECGs (92%) had PVCs with benign patterns, including 17 with right ventricular outflow tract, 5 with left anterior fascicle, and 2 with left posterior fascicle morphology. Two ECGs had non-benign PVCs with left bundle branch patterns and superior axes. Both of these athletes had normal echocardiograms and exercise testing and are being followed closely. Conclusions: We found a low prevalence of PVCs on routine ECG screening of young athletes, although evaluation of PVC prevalence and frequency are limited by the short duration of an ECG. Most incidental PVCs among young athletes had benign patterns. This study also demonstrates the value of digital ECG recorders to display simultaneous frontal and horizontal plane leads for the morphologic categorization of PVCs which may guide further workup.

Rater Reliability of the Functional Movement Screen: An Evidence-to-Practice Review

The purpose of this evidence-to-practice review is to summarize a systematic review on the inter- and intrarater reliability of the Functional Movement Screen (FMS). Reliability is crucial to the FMS, as clinicians may retest to view a patient’s changes and improvements in movement patterns. This review and analysis looked at 7 studies which showed that both inter- and intrarater reliability were good. Studies were only included if the primary focus was on inter- and intrarater reliability. Clinicians had varying levels of familiarity with the FMS process. Athletic training students with less than one year to no experience were found to have poor reliability. The findings also supported that clinicians who treated the same patient would have similar results about 80% of the time. The same clinician completing several screenings with the different patient would have reliable results about 85% of the time. Interrater reliability is an important aspect to a clinician’s ability to monitor progress or modifications that a patient may exhibit. Overall, the FMS has good inter- and intrarater reliability and can be a predictor of injury risk and mobility. For both inter- and intrarater reliability to improve, it is beneficial for clinicians to have clinical experience and practice using the test to aid in accurate scoring. Certification in FMS is a way to develop repetition training from a reliable source, but it is unclear from these studies if certification changes reliability. The FMS screening serves as a useful tool because it allows for unlimited testing, video recordings for patient education or additional clinician evaluation, and is reliable among clinicians. We suggest that components of the FMS be used clinically for injury prevention, such as pre-participation exams and return-to-play criteria for injuries if scored by a formally trained clinician with experience assessing patient functional movement.

The Prevalence Of NCAA Division III Athletes With Positive Depression Screening

PURPOSE: Mental health is a growing area of concern for college athletes. A 2015 report from the NIMH estimated that 6.7% of all American adults experienced an episode of MDD within the past 12 months. Episodes were highest in college-age individuals and females. While there is currently no standardized protocol for screening student- athletes for depressive symptoms during pre-participation physical exams, it has been adopted by some. Our retrospective cohort study evaluates the prevalence of depressive symptoms in student-athletes at a division III college. METHODS: The entire entire student-athlete population (N =729) of a single division III college was screened for depressive symptoms over the course of one year using the clinically validated questionnaires, PHQ-2 followed by PHQ-9 if positive. Screening was performed during routine pre-participation physicals for sport over a one-year period. Depression screening results were evaluated by gender, sport, class year, and time of year data was collected, and then compared to published national rates. RESULTS: The prevalence of clinically significant depressive symptoms using the PHQ screening tools in our study was 4.1%, significantly lower than the prevalence of 23.7% cited by Wolanin et al in 2016 using CES-D screening (z= 12.45, p = <.001). Inconsistent with previously published data, there was no overall significant gender difference, χ2 = 1.58, p =.21. However there was a statistically significant difference in women reporting moderate to severe depressive symptoms compared to men, χ2 = 16.36, p =.001. There was no statistical difference with season of screening, χ2 = 4.52, p = .61. CONCLUSIONS: In this sample, PHQ screening revealed depressive symptoms in less than 5% of division III student-athletes from a single school. Female college athletes reported significantly more moderate-severe depressive symptoms than males. There was no statistical difference in the time of year screening was performed. Hypothesized explanations for the differences in results obtained through our study and previously published data include, environment of screening, screening tool used, and level of collegiate play. More cross-sectional studies are needed to better elucidate rates of depression in our student-athlete population across all divisions.

Abstract 148: American Heart Association Athlete Prescreening Recommendations: An Evaluation of Knowledge and Compliance

Objective: The purpose of this study was to determine the level of knowledge and compliance with American Heart Association (AHA) recommended guidelines for sudden cardiac death (SCD) risk screening of providers completing prescreening exams and school officials requiring prescreening exams. Methods: Retrospective review was completed on 704 patient pre-participation exams (PPEs) between 1/1/2014 and 12/31/2015. Patient demographics and evidence of AHA screening recommendation documentation were collected. Surveys were sent to providers within Gundersen Health System who perform PPEs and to school officials within the service area to assess knowledge and compliance with AHA recommendations. Results: There were relatively equal numbers of females and males in the sample population (46% and 54%) with a mean age of 14.3. More than half of the PPEs were the first for the patient. Evidence of documentation was found on average 67% of the time for personal history criteria with the exception of prior high blood pressure at 58%. Provider survey responses indicated assessment of personal history items at always or most of the time between 81% and 100%. Evidence of documentation for family history criteria was found on average 66% of the time with the exception of a relative with unexplained fainting or seizures at 54%; whereas survey data indicated assessment rates at 71% and 97% (always or most of the time). Physical exam criteria were found documented on average 93% of the time in the electronic medical record (EMR), with the exception of Marfan syndrome screen at only 52%. Providers reported on the survey that assessment was always or most of the time done between 30% and 100% of the time. Awareness of the AHA 14-point prescreening recommendations was reported by only 50% of providers completing exams and 0% of the school officials. Conclusions: Knowledge and awareness of the AHA 14-point recommendations for PPEs is low in our area. Providers recall performing recommended assessments at a higher rate than what was found documented in the EMR. This study has highlighted an area for improvement and opportunities for educational efforts both within our system and in collaboration with our community.

Borderline and Long QT Syndrome in Adolescent Athletes Taking Medications

PurposeAdolescent athletes undergo preparticipation screening for long QT syndrome. Medications that are associated with QT interval prolongation are increasingly being prescribed to precollege students. The side effect profile of these medications during exercise is unknown. The aims of this study were to (1) measure the prevalence of medications known to be associated with QT interval prolongation taken by adolescents participating in athletics and (2) to determine the association between the use of these medications and QT interval prolongation in adolescents participating in athletics. MethodsSports preparticipation exams were performed on 484 students at an urban high school. This consisted of a physical examination, 12-Lead electrocardiogram, and health history including current prescription and over-the-counter medications. Electrocardiograms were interpreted by a pediatric cardiologist using Bazett's correction formula. Descriptive statistics were used to characterize the cohort. The participants' parents consented to the preparticipation examination before history and physicals. ResultsNo athletes exhibited a corrected QT interval >500 ms. Borderline long QT was identified in 6.65% of the subjects. In this study, 7.64% of the subjects reported that they were taking medications associated with QT prolongation. After controlling for age and gender, medication usage was not significantly related to the presence a borderline long QT interval. ConclusionsAlthough adolescent athletes are taking medications associated with QT interval prolongation, their side effect profile during exercise is unknown. Although there was no significant association between medications and borderline long QT, these data were taken from adolescent athletes at rest. The prevalence of adolescents participating in athletics and taking medications associated with QT interval prolongation was significant. There appears to be a very low risk of QT prolongation >500 ms at rest in this cohort.

Prevention of eating disorders in female athletes.

Eating disorders are serious mental diseases that frequently appear in female athletes. They are abnormal eating behaviors that can be diagnosed only by strict criteria. Disordered eating, although also characterized as abnormal eating behavior, does not include all the criteria for diagnosing eating disorders and is therefore a way to recognize the problem in its early stages. It is important to identify factors to avoid clinical progression in this high-risk population. Therefore, the purpose of this review is to discuss critical information for the prevention of eating disorders in female athletes. This review discusses the major correlates for the development of an eating disorder. We also discuss which athletes are possibly at highest risk for eating disorders, including those from lean sports and female adolescent athletes. There is an urgent need for the demystification of myths surrounding body weight and performance in sports. This review includes studies that tested different prevention programs’ effectiveness, and the majority showed positive results. Educational programs are the best method for primary prevention of eating disorders. For secondary prevention, early identification is essential and should be performed by preparticipation exams, the recognition of dietary markers, and the use of validated self-report questionnaires or clinical interviews. In addition, more randomized clinical trials are needed with athletes from multiple sports in order for the most reliable recommendations to be made and for some sporting regulations to be changed.

Nonprescription Pain Medication Use in Collegiate Athletes: A Comparison of Samples

Background: Despite recent research, nonprescription pain medication use among collegiate athletes across all divisions of the National Collegiate Athletic Association (NCAA) is still not well understood. Hypothesis: Non–Division I-A NCAA athletes have a different usage pattern of nonprescription pain medication than NCAA Division I-A football athletes. Methods: A modified version of a nonprescription medication usage survey that had been used with Division I-A football athletes was distributed to Division II and Division III athletes during pre-participation exams. The statistics were analyzed by calculating the z-ratio for the significance of the difference between 2 independent proportions. Results: A total of 198 athletes from 16 different sports were surveyed. It was found that 62% of athletes used nonprescription medications for sports-related pain, which was significantly lower than previous findings for Division I-A football athletes: 12% reported taking more than the recommended dose; 1.5% reported taking nonprescription pain medication for > 10 consecutive days; and 38% reported that they read the label the first time they took a new nonprescription pain medication. These results, when compared with findings on Division I-A football athletes, demonstrated that Division II and III athletes are less likely to take more than the recommended dose of nonprescription pain medications and are less likely to use the medications for > 10 consecutive days—characteristics that are used to define misuse. Similar results were found when comparing Division I-A football athletes with non–Division I-A football athletes. Conclusions: Athletes from NCAA Division II and Division III sports appear to use nonprescription pain medication for sports-related pain less often and have lower rates of misuse than do Division I-A football athletes. Division I-A football athletes may be more likely to misuse nonprescription pain medication than non–Division I-A athletes. Special attention should be paid to this population to help reduce adverse event risks.

Overuse Injuries and Burnout in Youth Sports

Overuse Injuries and Burnout in Youth Sports

Preparticipation screening and prevention of sudden cardiac death in athletes: Implications for primary care

The purposes of this article are to explore the mechanism of sudden cardiac death (SCD) in young athletes and examine how preparticipation screenings help identify precipitating cardiac abnormalities. Electrocardiogram (ECG) testing has been implicated to play an important role in detecting subtle abnormalities that may cause SCD, but the routine implementation of this diagnostic tool remains a debate among experts. This report was compiled by reviewing the scientific literature on SCD in athletes, preparticipation exams, and current screening guidelines using CINAHL, MEDLINE, and PubMed search engines. Although the American Heart Association guidelines do not include ECG testing for preparticipation screenings, the implementation of routine ECG testing for preparticipation sports physicals is effective in preventing SCD in athletes. Primary care providers should be aware of current guidelines for screening patients for heart diseases that predispose them to SCD and their legal obligations to be sure these athletes are safe. The implementation of ECG testing will assist in the decision whether to disqualify an athlete from participation as a result of preexisting cardiac conditions, and ultimately preventing the untimely death of a young athlete.

The effect of sport on computerized electrocardiogram measurements in college athletes

Broad criteria for abnormal electrocardiogram (ECG) findings, requiring additional testing, have been recommended for preparticipation exams (PPE) of athletes. As these criteria have not considered the sport in which athletes participate, we examined the effect of sports on the computerized ECG measurements obtained in college athletes. During the Stanford 2007 PPE, computerized 12-lead ECGs (Schiller AG) were obtained in 641 athletes (350 male/291 female, age 19.5 ± 2 years). Athletes were engaged in 22 different sports and were grouped into 16 categories: baseball/softball, basketball, crew, crosscountry, fencing, field events, football linemen, football other positions, golf, gymnastics, racquet sports, sailing, track/field, volleyball, water sports, and wrestling. The analysis focused on ECG leads V2, aVF and V5 which provide a three-dimensional representation of the heart's electrical activity. As marked ECG differences exist between males and females, the data are presented by gender. In males, ANOVA analysis yielded significant ECG differences between sports for heart rate, QRS duration, QTc, J-amplitude in V2 and V5, spatial vector length (SVL) of the P wave, SVL R wave, and SVL T wave, and RS(sum) (p < 0.05). In females ECG differences between sports were found for heart rate, QRS duration, QRS axis and SVL T wave (p < 0.05). Poor correlations were found between body dimensions and ECG measurements (r < 0.50). Significant ECG changes exist between college athletes participating in different sports, and these differences were more apparent in males than females. Therefore, sport-specific ECG criteria for abnormal ECG findings should be developed to obtain a more useful approach to ECG screening in athletes.

Team Management of the Female Athlete Triad: Part 1: What to Look for, What to Ask

The female athlete triad of disordered eating, amenorrhea, and osteoporosis affects many active women and girls, especially those in sports that emphasize appearance or leanness. Because of the athlete's psychological defense mechanisms and the stigma surrounding disordered eating, physicians may need to ask targeted questions about nutrition habits when assessing a patient who has a stress fracture or amenorrhea, or during preparticipation exams. Carefully worded questions can help. Physical signs and symptoms include unexplained recurrent or stress fracture, dry hair, low body temperature, lanugo, and fatigue. Targeted lab tests to assess nutritional and hormonal status are essential in making a diagnosis that will steer treatment, as are optimal radiologic tests like dual-energy x-ray absorptiometry for assessing bone density.

Echocardiographic diagnosis of clinically silent congenital coronary artery anomalies

Background The incidence of congenital coronary anomalies is mainly derived from autopsy series and pre-participation exams in athletes. Limited data exist regarding the spectrum of coronary anomalies that can be detected in asymptomatic patients. We sought to describe echocardiographically detected congenital coronary artery anomalies in asymptomatic children after implementing a screening protocol mandating identification of coronary artery origin and proximal course in all initial studies. Methods Our database was searched from 1/1/1993 to 3/31/2006 and all echocardiograms coded for coronary anomalies were identified. Clinically “silent” congenital coronary anomalies were culled from that group. Results Of the 168 “silent” coronary anomalies detected, 111 were anomalies of aortic origin, including 59 patients with “high coronary takeoff” and 30 patients with “wrong sinus” origin of either the left or right coronary artery. Small coronary fistulas were seen in 57. Associated congenital heart defects were found in 53% of individuals with coronary anomalies. Conclusions This study comprises the largest group of echocardiographically detected, “silent” but potentially clinically significant, congenital coronary anomalies in children. Prospective echocardiographic diagnosis of “high coronary takeoff”, a risk factor for injury during cardio-pulmonary bypass, and asymptomatic intraseptal coronary stenosis are described for the first time.

Preparticipation Evaluation of Collegiate Athletes

0730 A preparticipation physical evaluation (PPE) is required by most school districts, state athletic associations, the NCAA, and sport governing bodies. Although guidelines for the content of the PPE exist, there is a paucity of data regarding findings using the guidelines since they have been available. In addition, there are no published studies using the current guidelines that describe the comprehensive findings of the PPE in collegiate athletes. PURPOSE: To determine the frequencies and types of findings during PPE screening of collegiate athletes using curently recommended guidelines. METHODS: Preparticipation exams were conducted on NCAA Division I student-athletes incorporating the recommendations set forth by the Amercian Heart Association and the Preparticipation Physical Evaluation monograph (2nd edition). The initial PPE for each subject was analyzed with respect to the initial and final clearance status. RESULTS: The PPE for 596 student-athletes (272 women, 324 men) from 22 different sports was reviewed. 550 (92.3%) were cleared for full participation. 44 (7.4%) required additional evaluation before final clearance status could be determined. Of those requiring additional evaluation, preliminary analysis indicates 67% were for musculoskeletal problems and 33% were for medical problems. One studentathlete was ultimately disqualified. Elevated blood pressure (38 subjects, 6.4%) and abnormal visual acuity (43 subjects, 7.2%) were the most common abnormal findings. CONCLUSIONS: Preparticipation screening using the most current recommendations yields findings that are within the range of studies previously published in which the content of the PPE varied. The overall disqualification rate among collegiate athletes is low. Elevated blood pressure and abnormal visual acuity are the most frequent abnormal findings.

Preparticipation Evaluation of Collegiate Athletes

0730 A preparticipation physical evaluation (PPE) is required by most school districts, state athletic associations, the NCAA, and sport governing bodies. Although guidelines for the content of the PPE exist, there is a paucity of data regarding findings using the guidelines since they have been available. In addition, there are no published studies using the current guidelines that describe the comprehensive findings of the PPE in collegiate athletes. PURPOSE: To determine the frequencies and types of findings during PPE screening of collegiate athletes using curently recommended guidelines. METHODS: Preparticipation exams were conducted on NCAA Division I student-athletes incorporating the recommendations set forth by the Amercian Heart Association and the Preparticipation Physical Evaluation monograph (2nd edition). The initial PPE for each subject was analyzed with respect to the initial and final clearance status. RESULTS: The PPE for 596 student-athletes (272 women, 324 men) from 22 different sports was reviewed. 550 (92.3%) were cleared for full participation. 44 (7.4%) required additional evaluation before final clearance status could be determined. Of those requiring additional evaluation, preliminary analysis indicates 67% were for musculoskeletal problems and 33% were for medical problems. One studentathlete was ultimately disqualified. Elevated blood pressure (38 subjects, 6.4%) and abnormal visual acuity (43 subjects, 7.2%) were the most common abnormal findings. CONCLUSIONS: Preparticipation screening using the most current recommendations yields findings that are within the range of studies previously published in which the content of the PPE varied. The overall disqualification rate among collegiate athletes is low. Elevated blood pressure and abnormal visual acuity are the most frequent abnormal findings.

Team Management of the Female Athlete Triad

The female athlete triad of disordered eating, amenorrhea, and osteoporosis affects many active women and girls, especially those in sports that emphasize appearance or leanness. Because of the athlete's psychological defense mechanisms and the stigma surrounding disordered eating, physicians may need to ask targeted questions about nutrition habits when assessing a patient who has a stress fracture or amenorrhea, or during preparticipation exams. Carefully worded questions can help. Physical signs and symptoms include unexplained recurrent or stress fracture, dry hair, low body temperature, lanugo, and fatigue. Targeted lab tests to assess nutritional and hormonal status are essential in making a diagnosis that will steer treatment, as are optimal radiologic tests like dual-energy x-ray absorptiometry for assessing bone density.

901-68 Prospective Screening of 5615 High School Athletes for Sudden Cardiac Death

Screening for common causes (hypertrophic cardiomyopathy and anomalous coronary artery) of sudden cardiac death (SCD) in high school athletes (HSA) during pre-participation exams is varied and relatively unstudied. Efforts to improve diagnoses of potentially serious or lethal congenital heart conditions are needed. We prospectively evaluated HSA at 34 different high schools over three years. Cardiovascular screening included obtaining a history of angina or anginal equivalents, or a family history of SCD before age 35 years. A 12-lead EKG and a cardiovascular physical exam were performed. Abnormalities resulted in a cardiac ultrasound (CU). Abnormal EKG for LVH was defined in boys as SVl and RV5 &gt; 50 mm and in girls as SVl plus RV5 &gt; 40 mm. Follow-up of cardiovascular abnormalities followed 16th Bethesda Conference Guidelines. 5.615 HSA (3378 boys, 2237 girls) were evaluated. 115 (2%) had abnormal cardiovascular history, 196 (3.5%) had abnormal cardiovascular exam, 193 (3.5%) had abnormal EKG and 126 (2%) had combined abnormalities. All 630 (11%) with abnormal cardiovascular screening underwent CU at the time of their exam. 43 HSA (7% of CU performed) were found to have minor abnormalities. No serious previously undetected abnormality was noted with CU. No LVH was seen in 28 HSA with LVH by ECG. 5140 (91.5%) HSA were approved for competitive sports; 435 (7.8%) HSA were approved for competitive sports after follow-up by local M.D. (recommended primarily for evaluation of mild hypertension); 40 (0.7%) HSA were not approved due to anginal symptoms (n = 16) requiring subsequent treadmill testing (all of which were normal); systolic BP &gt; 170 or diastolic BP &gt; 110 (n = 5), carotid bruit (n = 2), severe Al by exam (n = 1), WPW (n = 6). PVC's (n = 5), RBBB (n = 4), SVT (n = 1). EKG alone led to disqualification in 16 or 1/350 HSA undergoing screening. No cases of hypertrophic cardiomyopathy or anomalous coronary artery were detected prospectively. One SCD occurred in an approved HSA due to anomalous coronary artery. Common causes of SCD in HSA are rare and/or methods to detect them are insensitive; serious CU abnormalities in this population are rare; EKG added to the cardiovascular history and physical exam increases the ability to detect potentially serious abnormalities necessitating further cardiovascular testing before approval for competitive sports.

A model system for pre-participation physical exams

A model system for pre-participation physical exams

Keys to Successful Preparticipation Exams.

Timing, frequency, and types of screening tests can be hot topics of debate among physicians trying to determine how best to evaluate patients for athletic participation. Because of the wide range of opinions concerning many elements of preparticipation physical exams, we brought together three medical experts to discuss a few important aspects of these screenings.

Burners.

In brief The authors surveyed 201 NCAA brief Division III football players about their experiences with transient brachial plexopathy. Of the 201 players, 65% had suffered this injury during their college careers, 52% during the 1991; football season and 57% recurrently. Of the injured players, 70% said they had had burners that they did not report to anyone. To reduce the incidence and frequency of this common, often unreported injury, the authors suggest physicians watch more closely for signs and symptoms on the field, ask patients about the injury during preparticipation exams, and prescribe conditioning exercises and equipment modifications.