Preparticipation Evaluation Research Articles

Risk Stratification for Athletes and Adventurers in High-Altitude Environments: Recommendations for Preparticipation Evaluation.

High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.

Preparticipation Evaluation for Climbing Sports

Climbing is a popular wilderness sport among a wide variety of professional athletes and amateur enthusiasts, and many styles are performed across many environments. Potential risks confront climbers, including personal health or exacerbation of a chronic condition, in addition to climbing-specific risks or injuries. Although it is not common to perform a preparticipation evaluation (PPE) for climbing, a climber or a guide agency may request such an evaluation before participation. Formats from traditional sports PPEs can be drawn upon, but often do not directly apply. The purpose of this article was to incorporate findings from expert opinion from professional societies in wilderness medicine and in sports medicine, with findings from the literature of both climbing epidemiology and traditional sports PPEs, into a general PPE that would be sufficient for the broad sport of climbing. The emphasis is on low altitude climbing, and an overview of different climbing styles is included. Knowledge of climbing morbidity and mortality, and a standardized approach to the PPE that involves adequate history taking and counseling have the potential for achieving risk reduction and will facilitate further study on the evaluation of the efficacy of PPEs.

Ethical, Legal, and Administrative Considerations for Preparticipation Evaluation for Wilderness Sports and Adventures.

Preparticipation evaluations (PPEs) are common in team, organized, or traditional sports but not common in wilderness sports or adventures. Regarding ethical, legal, and administrative considerations, the same principles can be used as in traditional sports. Clinicians should be trained to perform such a PPE to avoid missing essential components and to maximize the quality of the PPE. In general, participants' privacy should be observed; office-based settings may be best for professional and billing purposes, and adequate documentation of a complete evaluation, including clearance issues, should be essential components. Additional environmental and personal health issues relative to the wilderness activity should be documented, and referral for further screening should be made as deemed necessary, if unable to be performed by the primary clinician. Travel medicine principles should be incorporated, and recommendations for travel or adventure insurance should be made.

The Impact of Prior Upper Extremity Surgery on Orthopaedic Injury and Surgery in Collegiate Athletes

Objectives:Upper extremity injuries are common in youth, collegiate, and professional athletics, and may require operative management. The influence of a prior upper extremity surgery on subsequent athletic participation, injury, and surgery in college is not well understood. The purpose of this study was to investigate the impact of prior upper extremity surgery in Division I collegiate athletes on participation, injury rates, and surgery rates in college.Methods:Division I athletes who began participation in collegiate athletics from 2003 - 2009 were retrospectively identified. These athletes represented 21 sports teams at a single institution. Athletes with prior upper extremity orthopaedic surgery, including shoulder, elbow, and wrist/hand surgery, were identified through preparticipation evaluation forms. Sport, seasons played, injuries sustained during college, days missed, and college orthopaedic surgeries and diagnostic imaging were collected through sports archives, medical records, and the Sports Injury Monitoring System (SIMS) and compared to athletes with no prior history of upper extremity surgery. Subgroup analysis was performed for athletes with a history of shoulder, elbow, and wrist/hand surgeries.Results:Between 2003 and 2009, 1,145 athletes completed pre-participation evaluation forms. In total, 77 athletes (6.7%) had a history of one or more upper extremity surgeries prior to collegiate athletics. History of upper extremity surgery was most common in incoming men's water polo (15.0%), baseball (14.9%), and football (12.6%) athletes. Athletes with a prior upper extremity surgery had a higher rate of upper extremity injury in college compared to controls (Hazard Ratio = 4.127, p <0.01), and missed more days for upper extremity injuries per season (16.5 days vs. 6.7 days, p = 0.03). Athletes with a prior shoulder surgery (n=20) also had a higher rate of upper extremity injury in college compared to controls (Hazard Ratio= 15,083, p=0.02). They missed more total athletic days per season (77.5 days vs. 29.8 days, p <0.01), had more MRIs (0.96 vs. 0.40, p <0.01), and underwent more total orthopaedic surgeries per season in college compared to controls (0.23 vs. 0.08, p <0.01). Career length was not significantly different between athletes with a history of upper extremity surgery and control athletes.Conclusion:Collegiate athletes who had an upper extremity surgery prior to college had increased rates of upper extremity injury and missed more days due to upper extremity injury in college. Those with prior shoulder surgery additionally had more diagnostic imaging and orthopaedic surgery in college. Careful consideration of these athletes, particularly those who have had prior shoulder surgery, may be beneficial in the recruitment process. Moreover, athletes and athletic trainers should be made aware of the increased injury rates in this population, so that appropriate counseling and rehabilitation may be provided.

Recommending exercise to healthy older adults: the preparticipation evaluation and exercise prescription.

The office-based preparticipation evaluation for older adults addresses cardiovascular status, muscle strength, flexibility, balance, and agility. The Kasch pulse-recovery test and the sit-and-reach test are practical methods for evaluating aerobic capacity and flexibility, respectively. Other measures, such as assessment of body composition or bone density, help establish goals and provide baselines for measuring exercise progress. The prescription for older people is aimed at maintaining current function and moving patients to the next activity level. The prescription specifies type, frequency, duration, and intensity of exercise. Case reports describe how key pieces of information from the preparticipation exam can lead to specific exercise recommendations.

Early Screening for Cardiovascular Abnormalities With Preparticipation Echocardiography

The traditional history and physical (H&P) is a poor screening modality to identify athletes at risk for sudden cardiac death (SCD). Although better than H&P alone, electrocardiograms (ECG) have also been found to have high false positive rates. Portable echocardiogram by a non-cardiologist (PENC) physician done during preparticipation evaluation (PPE) allows for direct measurements of the heart to more accurately identify patients with structural abnormalities that can result in SCD. Therefore, it is worthwhile to assess the feasibility of PENC as part of PPEs. PURPOSE: To investigate the feasibility of incorporating PENC into routine PPEs. METHODS: Thirty-five Division I male college athletes were prospectively enrolled in the study after informed consent was obtained. Each athlete underwent a screening H&P, ECG, and PENC. The H&P was based on the 12-element preparticipation cardiovascular screening guidelines from the American Heart Association. The ECGs were interpreted using the 2010 European Society of Cardiology criteria. The PENC measurements were obtained in the parasternal long-axis view. End-diastolic measurements were recorded of the left ventricular (LV) diameter, LV posterior wall thickness, interventricular septal wall thickness, aortic root diameter, and ascending aorta. The length of time for screening at each station was recorded and reported in seconds (sec). A paired t-test with alpha level of <0.5 was used to compare length of time (mean ± standard deviation) of each screening method. RESULTS: Six athletes had a positive finding in H&P screening and four athletes had positive ECG findings. One athlete had both a positive H&P and screening ECG. All athletes had negative PENC screens. All four athletes with positive ECG findings have been referred for formal evaluation with cardiology_outcome of cardiology referrals pending. The length of time for screening was significantly shorter with PENC (137.7 ± 40.4 sec) compared with H&P (244.2 ± 80.0 sec) and ECG (244.9 ± 85.6 sec, P<0.01). The screening time did not differ between H&P and ECG (P=.97). CONCLUSION: Incorporating PENC into PPEs has the potential to limit the number of false positive cardiac screens. PENC was the fastest screening modality compared with traditional H&P and ECG methods and can feasibly be incorporated into PPE screening.

General Medical - Soccer

HISTORY: During freshman pre-participation evaluation, blood panel revealed high ferritin levels (517.6 ng/mL) in an 18-year old Division-I female soccer player. Retest values confirmed levels at 570.7 ng/mL; she was referred to team physician. Following clearance for activity, she was participating in strenuous exercise and experienced vision change, severe headache, and lightheadedness. Symptoms lasted roughly 90 min. To relieve symptoms, she was removed from practice and placed in a dark, quiet room. She began bi-weekly 500mL bloodletting treatments in efforts to decrease ferritin levels. Four more vision change episodes have occurred since initial treatment. Symptoms lasted 30-90 min with the aid of Nodolor 65/100/325mg. PHYSICAL EXAMINATION: After first vision change episode, she underwent an EKG, CT, chest radiograph, and CBC blood panel. All results were within normal limits. She had a negative eye exam. No abnormalities with brain MRI but MRA showed a small benign left maxillary sinus mucosal retention cyst. Several CBC blood panel and ferritin blood tests were taken; demonstrating consistent elevated ferritin (range: 397.6-753.0 ng/mL). A hematologist ordered regular bi-weekly phlebotomy treatments consisting of 500mL blood draws. Following the second vision change episode, a full cardiac evaluation was ordered including an echocardiogram, EKG, 30-day heart monitor, exercise stress test, and table tilt test. Monthly ferritin blood tests are performed to determine if phlebotomy treatments are needed to maintain ferritin levels. DIFFERENTIAL DIAGNOSIS: 1. Dehydration 2. Head Injury 3. Migraines 4. Cardiac Condition 5. Hereditary Hemochromotosis TEST AND RESULTS: EKG, echocardiogram, Heart Monitoring, Exercise Stress Test, Table Tilt Test •Normal sinus rhythm, no evidence of ischemia CT brain, MRI, MRA •Small left maxillary sinus mucosal retention cyst, no evidence of aneurysm or vascular stenosis Chest X-ray •Normal Ferritin Blood Test •Elevated Ferritin level, 397.6-753.0 ng/mL FINAL WORKING DIAGNOSIS: Hereditary Hemochromotosis TREATMENT AND OUTCOMES: 1. Phlebotomy Treatments A. Initial phlebotomy treatments performed bi-weekly, 500mL drawn B. Activity monitored C. Nodolor 65/100/325mg taken at immediate onset of symptoms, then 1 every hour until symptoms resolve

Injuries and Illnesses in the Preparticipation Evaluation Data of 1693 College Student-Athletes

Background: While the preparticipation evaluation (PPE) is widely used by medical practitioners, its overall effectiveness is unknown, in part because there are no standardized or centralized mechanisms to collect and analyze medical history information. Purpose: To report on the injuries and illnesses identified with the use of an electronic PPE (ePPE) completed by first-time National Collegiate Athletic Association Division 1 varsity sport participants (N = 1693; 797 women, 896 men) upon entry to a single institution between 2010 and 2013. Study Design: Cross-sectional study; Level of evidence, 3. Results: In total, 3126 discrete past injuries were reported (women, 1473 injuries; men, 1653 injuries). Time loss from sport participation averaged 31.4 days for each injury (women, 32.2 days; men, 30.7 days), and aggregate time loss from sport for all student-athletes before the ePPE was 256 years. Eleven percent of student-athletes had injuries that were unresolved and still symptomatic at the time of the ePPE. Thirty percent of injured student-athletes had a history of ≥1 surgeries for an injury (women, 176; men, 213), and these accounted for 57% of the time lost from sport before college participation. Head injuries accounted for 9% (110 women, 173 men), and loss of consciousness was reported in 19% of these. One in 3 student-athletes answered “yes” to ≥1 of the American Heart Association questions on cardiovascular health. While 15% of women reported a history of stress fracture, only 3% reported a diagnosed eating disorder. Conclusion: While some data in this population are self-evident, we were not aware of the high frequency of past injuries, the magnitude of time lost from sport, the high frequency of past surgery, and the number of participants still symptomatic from injuries. The ePPE is a valuable tool for collecting and analyzing aggregate injury and illness data in athletes, such as the finding that 11% of injuries that were reported were unresolved and still symptomatic.

AN ASSESSMENT OF THE PERFORMANCE OF PRE-PARTICIPATION GUIDELINES APPLIED TO NOVICE OLDER ENDURANCE ATHLETES

Despite robust growth in participation in marathons and endurance sports among older individuals, there is a lack of uniform recommendations for pre-participation cardiovascular evaluation (PPE) of these athletes. we evaluated the performance of 2 current PPE guidelines on a sample of novice runners

The cardiovascular Preparticipation Evaluation (PPE) for the primary care and sports medicine physician, Part I.

The cardiovascular Preparticipation Evaluation (PPE) for the primary care and sports medicine physician, Part I.

The Cardiovascular Preparticipation Evaluation (PPE) for the Primary Care and Sports Medicine Physician, Part II

The Cardiovascular Preparticipation Evaluation (PPE) for the Primary Care and Sports Medicine Physician, Part II

The Cardiovascular Preparticipation Evaluation (PPE) for the Primary Care and Sports Medicine Physician, Part I

The Cardiovascular Preparticipation Evaluation (PPE) for the Primary Care and Sports Medicine Physician, Part I

Physical activity and kidney diseases

Regular physical activity (PA) in the early school years is recommended by several scientific associations for primary prevention of cardiovascular disease. Long-term observational studies have shown that subjects who exercise regularly have significantly less coronary heart disease (CHD) and a reduced risk of cardiovascular disease (CVD). Exercise reduces serum triglycerides, increases serum high density lipoprotein-cholesterol, lowers the blood pressure in patients with primary hypertension [1]. Regular exercise reduces the production of atherogenic cytokines and increases production of atheroprotective cytokines. It should be mentioned, however, that other factors may be associated with physical activity (e.g. a healthy diet, avoiding cigarette smoking, regular medical care) and may contribute to the improved health. No long term studies have been produced on the effects of PA during childhood on CHD and CVD in adult life but indirect evidence suggests that it may produce benefit. Regular exercise, on the other end, is associated with potential adverse effects (eg, musculoskeletal injuries, arrhythmias, myocardial infarction, and rhabdomyolysis); however, the absolute risk of kidney disease during exercise is low [2]. Consensus guidelines for the pre-participation physical evaluation (PPE) suggest a PPE for all children, even those who do not participate in organized sports, as an opportunity to promote health and fitness. PPE includes a medical and family history and a physical examination, with particular emphasis on the musculoskeletal and cardiovascular systems [3]. Exercise induces profound changes in the renal haemodynamics and in electrolyte and protein excretion. Proteinuria, hematuria and changes in serum electrolyte balance have been reported during intense PA; the increase in glomerular filtration may explain these transient alterations but the “nutcracker” compression on the renal vein may have a role. Haemoglobinuria and myoglobinuria may be observed under special exercise conditions [4]. PA does not worse nor reverse kidney disease but may reduce cardiovascular risk in chronic renal disease [5]. Children on dialysis and after a renal transplantation performing aerobic physical exercise show improvements in exercise tolerance, in quality of health and uraemic symptom scores; they gain weight loss, cardiovascular reactivity, avoiding an increase in blood pressure medication [6].

89 The Electrocardiographic Phenotype in Athletes with Hypertrophic Cardiomyopathy: Implications for Pre-Participation Cardiovascular Evaluation Using Electrocardiography

BackgroundPre-participation cardiovascular evaluation is being recommended by a growing number of sporting bodies and scientific organisations in an attempt to identify athletes harbouring quiescent cardiac conditions which put them at...

TEST-RETEST RELIABILITY OF AN ELITE ATHLETE–QUESTIONNAIRE FOR THE EVALUATION OF TRAINING-RELATED INJURY RISK FACTORS

BackgroundSince the 2009 International Olympic Committee consensus statement, health promotion and injury prevention has been of prime importance in the health care of elite athletes. However, to date, most studies...

Reliability and Validity of Clinician ECG Interpretation for Athletes

Electrocardiogram (ECG) with preparticipation evaluation (PPE) for athletes remains controversial in the United States and diagnostic accuracy of clinician ECG interpretation is unclear. This study aimed to assess reliability and validity of clinician ECG interpretation using expert-validated ECGs according to the 2010 European Society of Cardiology (ESC) interpretation criteria. This is a blinded, prospective study of diagnostic accuracy of clinician ECG interpretation. Anonymized ECGs were validated for normal and abnormal patterns by blinded expert interpreters according to the ESC interpretation criteria from October 2011 through March 2012. Six pairs of clinician interpreters were recruited from relevant clinical specialties in an academic medical center in March 2012. Each clinician interpreted 85 ECGs according to the ESC interpretation guidelines. Cohen and Fleiss' kappa, sensitivity, and specificity were calculated within specialties and across primary care and cardiology specialty groups. Experts interpreted 189 ECGs yielding a kappa of 0.63, demonstrating "substantial" inter-rater agreement. A total of 85 validated ECGs, including 26 abnormals, were selected for clinician interpretation. The kappa across cardiology specialists was "substantial" and "moderate" across primary care (0.69 vs 0.52, respectively, P < 0.001). Sensitivity and specificity to detect abnormal patterns were similar between cardiology and primary care groups (sensitivity 93.3% vs 81.3%, respectively, P = 0.31; specificity 88.8% vs 89.8%, respectively, P = 0.91). Clinician ECG interpretation according to the ESC interpretation criteria appears to demonstrate limited reliability and validity. Before widespread adoption of ECG for PPE of U.S. athletes, further research of training focused on improved reliability and validity of clinician ECG interpretation is warranted.

Effects of Prior Knee Surgery on Subsequent Injury, Imaging, and Surgery in NCAA Collegiate Athletes

Background: High school and professional athletes with a history of orthopaedic surgery have decreased career lengths and are at a greater risk for reinjury compared with their peers. It is unknown whether the same risk applies to intercollegiate athletes. Purpose: To determine the effect of prior knee surgery in National Collegiate Athletic Association (NCAA) Division I athletes in the United States. Study Design: Cohort study; Level of evidence, 3. Methods: Division I athletes who began participation in collegiate athletics at a single institution from fall 2003 to spring 2008 were identified. Athletes with a history of orthopaedic surgery were identified through preparticipation evaluation forms. Data on the number of seasons and games played, number of days missed, diagnostic imaging, athletic injuries sustained, and surgical operations during college were collected through medical records and the Sports Injury Monitoring System (SIMS). Results: During the 5-year study period, 456 athletes completed preparticipation evaluation forms. Of these, 104 athletes (22.8%) had a history of orthopaedic surgery (Ortho group). Forty-eight (10.5% of all athletes) had a history of knee surgery (Knee group), 16 (3.5%) had a history of anterior cruciate ligament reconstruction (ACL group), and 28 (6.1%) had a history of multiple surgeries (Multiple group). Days missed per season due to any injury and due to knee injury were increased for all surgical groups compared with controls (P < .016). The rate of knee injury and knee surgery while in college was significantly increased for all surgery groups. Athletes in the Knee and ACL groups were 6.8- and 19.6-fold more likely to sustain a knee injury and 14.4- and 892.9-fold more likely to undergo a knee surgery during their collegiate careers compared with controls (P < .001). The number of MRIs per season were 0.83 for the Knee group (P < .001), 1.29 for the ACL (P = .009), and 0.97 for the Multiple group (P < .001), compared with 0.37 for controls. Average career length and percentage of games played were not significantly different between any of the surgery groups compared with controls. Conclusion: Athletes who had a history of knee surgery before participation in collegiate athletics miss more days due to injury, have increased rates of knee injury and knee surgery, and require more MRIs during their collegiate careers than their peers.

Cardiovascular Screening Practices in Collegiate Student-Athletes

To evaluate screening practices and preparticipation evaluation (PPE) forms used to identify, or raise suspicion of, cardiovascular abnormalities in collegiate student-athletes. Phone and e-mail survey. National Collegiate Athletic Association (NCAA) Division I universities. All 347 NCAA Division I universities were invited to participate in 2010-2011; 257 universities (74%) elected to participate. Information about the preparticipation screening process was obtained from team physicians and/or certified athletic trainers. PPE forms were evaluated for the inclusion of the 12 specific American Heart Association (AHA) recommendations for cardiovascular screening of competitive athletes from the 2007 AHA Council on Nutrition, Physical Activity, and Metabolism consensus panel endorsed by the American College of Cardiology Foundation. All 257 participating universities (100%) required preparticipation screening for freshman and transfer athletes, and 83 universities (32%) required an annual PPE for returning athletes. The PPE was performed on campus at 85% of the universities, whereas 15% of universities allowed the PPE to be completed by the athlete's choice of physician before he or she arrived on campus. Eleven universities (4%) used the recently updated American College of Sports Medicine 4th edition PPE. Sixteen universities (6%) used the American College of Sports Medicine 3rd edition PPE. The remaining 260 universities (90%) did not use either of these forms. Of the 257 Division I universities, only 21 universities (8%) met the AHA recommendations by including all 12 cardiovascular screening items on their PPE forms. The majority (92%) of NCAA Division I universities do not use PPE forms that meet the AHA recommendations for cardiovascular screening; therefore, they may not be effectively screening collegiate student-athletes for cardiovascular abnormalities that could lead to sudden cardiac death.

Incidence of Sudden Cardiac Death in Minnesota High School Athletes 1993–2012 Screened With a Standardized Pre-Participation Evaluation

This study sought to determine the incidence of sudden cardiac death (SCD) during Minnesota State High School League (MSHSL) games and practices for high school (HS) athletes (12 to 19 years of age, with most age 15 to 18 years of age) using a uniform statewide pre-participation health screening examination (PPE) form every 3 years on a defined population across 19 academic years. Adding electrocardiographic screening is being considered by some to reduce cardiac death rates in athletes, but the death rates in defined groups screened by the current U.S. PPE recommendations are unknown. MSHSL participation records were surveyed to determine the number of unduplicated athletes for 1993/1994 through 2011/2012 academic years, and catastrophic insurance records were used to find cardiac deaths. There were 4 SCDs (2 cross country, 1 basketball, 1 wrestling), all male, during practice or games in 1,666,509 unduplicated athletes participating in ≥ 1 sports. The incidence of SCD in athletes screened every 3 years with a history and physical during MSHSL activities is 0.24 per 100,000 athlete-years over 19 years and 0.11 per 100,000 athlete-years over the past decade. The incidence of SCD in athletes screened every 3 years with standard PPE during MSHSL activities is 0.24 per 100,000 athlete-years in 19 academic years. This incidence is much lower than that observed in studies of Division 1 National Collegiate Athletic Association and Italian athletes (ages 18 to 25 and mean age 24 years, respectively). Our data do not warrant screening HS athletes with electrocardiography to prevent SCD episodes. The decision to screen athletes with electrocardiography should consider age, training intensity, and genetic predisposition.

Preparticipation Evaluation of Novice, Middle-Age, Long-Distance Runners

The purpose of this study was to assess the cardiovascular health and risk profile in middle-age men making an entry to participate for their first time in a long-distance race. Male first-time participants, 45 yr and older, in the world's largest cross-country running race, the Lidingöloppet, were evaluated with a medical history and physical examination, European systematic coronary risk evaluation (SCORE), 12-lead ECG, echocardiography, and blood tests. Further diagnostic workup was performed when clinically indicated. Of 265 eligible runners, 153 (58%, age 51 ± 5 yr) completed the study. Although the 10-yr fatal cardiovascular event risk was low (SCORE, 1%; interquartile range, 0%-1%), mild abnormalities were common, for example, elevated blood pressure (19%), left ventricular hypertrophy (6%), and elevated LDL cholesterol (5%). ECG changes compatible with the "athlete's heart" were present in 82%, for example, sinus bradycardia (61%) and/or early repolarization (32%). ECG changes considered training unrelated were found in 24%, for example, prolonged QTc-interval (13%), left axis deviation (5.3%), and left atrial enlargement (4%). In 14 runners (9%), additional diagnostic workup was clinically motivated, and 4 runners (2%) were ultimately discouraged from vigorous exercise because of QTc intervals >500 ms (n = 2), symptomatic atrioventricular block (n = 1), and cardiac tumor (n = 1). The physician examination and the ECG identified 12 of the 14 participants requiring further evaluation. Cardiovascular evaluation of middle-age men, including a physician examination and a 12-lead ECG, appears useful to identify individuals requiring further testing before vigorous exercise. The additional yield of routine echocardiography was small.