The Preparticipation Physical Examination: Steps Toward Consensus Uniformity
Abstract & commentary
Synopsis: The preparticipation physical exam is an effective way to identify athletes at risk and help others to perform better. It should be augmented by the acquisition of more historical information from the athletes.
Source: Glover DW, et al. The preparticipation physical examination: Steps toward consensus uniformity. Phys Sports Med 1999;27:29-34.
Glover and colleagues provide a nice historical review of the role of the preparticipation physical examination in organized athletics in this country. They identify several problems, including a lack of standardization of the examination, the difficulty in detecting certain conditions, the rarity of serious medical conditions in young athletes, and the large population of athletes who must be screened annually in this process.
The last 30 years has seen a maturation of the preparticipation physical examination process, going from a simple history and physical that initially focused on a quick listen of the heart and a check for hernias to the development of a fairly sophisticated preparticipation physical evaluation form that was published jointly in 1992 by several medical academies. This form was subsequently updated in 1996 and now serves as an excellent foundation for the preparticipation examination.
Glover et al list several important objectives for the preparticipation examination, including liability protection (the original purpose designed to shift liability from institutions to the physicians conducting the examinations), detection of injuries and illnesses that preclude participation in sports, opportunities to detect other illnesses or injuries that require attention and treatment, primary prevention of illness in this population above and beyond sports injury, and certain administrative functions as well. Not all of these goals have been attained. One of the major risks is a catastrophic cardiovascular event. Screening tests are not sophisticated enough to clearly identify all those individuals at risk for sudden cardiac death. There is, however, some evidence that a 12-lead electrocardiogram can identify many athletes with hypertrophic cardiomyopathy, the most common cause of sudden death in young athletes. Performing an electrocardiogram on all athletes, however, would be expensive and would probably create many false positives that would require more testing and even more expense. Thus, it is not clear at this point that such aggressive screening is practical.
Glover et al conclude that while there are some limitations, the preparticipation examination can be an effective way to identify some athletes at risk, help others to perform better, and even, on occasion, create a forum for the physicians to promote a healthy lifestyle among these athletes. They recommend that the preparticipation examination be augmented with the acquisition of more historical information from each of the athletes, and then a more focused physical examination should be performed. They also feel that four main areas should be pursued to further enhance the quality of the preparticipation examination: a standardized form should be used for all the evaluations, and this form should be used nationwide. The standardized exam should have a minimum number of basic steps that can be adaptable and easily expandable, and it should serve as the foundation for a national data bank to allow the measurement of large-scale outcomes in this population in the future.
Comment by James D. Heckman, MD
This commentary provides a nice overview of the current state of the art of the preparticipation physical examination. It shows how the preparticipation physical has changed over the last 30 years, moving from simply a way to protect the institutions from lawsuit to an effective intervention tool to prevent injury and illness in this population. The second edition of the preparticipation physical evaluation form is available from the American Academy of Family Physicians and the American Academy of Pediatrics. Its use should be encouraged at all levels of organized athletic participation, particularly as it facilitates the identification of athletes at risk and of current injuries or illnesses that need to be treated. I cannot agree that during this examination is the ideal opportunity to engage the student athlete in discussions of illnesses, injuries, and behaviors above and beyond the scope of their athletic participation. While it may be the only opportunity to have these students officially engaged with health care providers, discussing such risky behaviors as steroid or drug use, smoking, or unprotected sex goes far beyond the purpose of the examination, further complicating the already complex exercise and risking a lack of cooperation by the students in the more fundamental aspects of this encounter. Certainly, the collation of data on this population of patients across the nation would be a superb source of clinical research material, and a national registry of codified information should be supported.
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