Team Physician Issues: Preparticipation Evaluation

Bernie Lalonde MD

Key Points

The sports medicine team drives the preparticipation evaluation, deciding the content, frequency, personnel, and format to be used.
Areas of emphasis change according to sport, such as concussion assessment for football.
Adequate cardiovascular history includes questions on exertional chest pain, syncope, excessive shortness of breath, and/or fatigue with exercise; past or present detection of a murmur or increased blood pressure; and family history.
The increase in number of female participants adds to the need to understand the unique needs of female athletes. Disordered eating, amenorrhea, and osteopenia/osteoporosis have been called the female athlete triad.
Subtle, nonthreatening questions are recommended to try to identify eating disorders.

The preparticipation evaluation (PPE) has been the foundation of medical evaluation of athletes in some form or another for most Western countries. It varies from government-mandated obligations, such as in Italy, to selective evaluations of specific teams dependent largely on the idiosyncrasies of respective sports organizations. Such as it is, the PPE lacks uniformity and evidence-based validity. Nonetheless, it is a tool widely used in the sport medicine community. The sport medicine team largely drives this process. It decides the content, the frequency, the personnel, and the format to be used.

Purpose

Because the evidence is lacking, there are some who would argue that, based on the low yield of significant participation barring findings, the justification of such endeavors is weak at best. The majority would argue differently. One has to examine the overall purpose of the PPE to justify the energies expended. The following items represent some, but not all, of the suggested purposes of the PPE.

Uncover pre-existing life-threatening pathologies (i.e., cardiac abnormalities)
Establish a baseline for the general health of the athlete
Obtain knowledge of known medical problems
Obtain baseline neuropsychological testing
Obtain a relevant family history
Assess the pertinent musculoskeletal issues, past or present, to ensure that proper rehabilitation protocols have been adhered to
Record significant dietary concerns
Review allergies and strategies to prevent or intervene
Review drug and supplement history and fill in the appropriate Therapeutic Use Exemption forms for the respective governing bodies; the opportunity to counsel at this point is a very real one
Review immunization schedules and address inadequacies
Opportunity for sport medicine team to establish and develop a relationship with the athlete; this cannot be overstated

Frequency

The timing and frequency of the PPE will be dictated by the sport involved, the level of competition, the sheer number of athletes, and the resources of that sport organization. When dealing with an elite international team, the sport medicine team of the Canadian Alpine Ski Team has twice-yearly assessments performed by a consortium of physicians, physiotherapists, trainers, sports vision experts, psychologists, nutritionists, and physiologists who congregate to discuss each individual athlete in great detail. This clearly represents one end of the spectrum. At the other end, one could foresee an entry-level assessment performed by a physician/therapist or other with reassessment on an ad hoc basis only. Entry-level evaluations could be more extensive, with scaled-down versions in subsequent years.

Personnel

The choice of professional personnel to perform these tasks is largely decided by the concerned parties. It has varied from physicians, osteopaths, athletic therapists, physiotherapists, chiropractors, and nurses. The choice should be made with the notion in mind of the purpose and goals of the PPE. It is logical to assume that the head of that team be a sport medicine practitioner, primary care physician, orthopedic specialist, or osteopathic physician.

Format

The individual physician in consort with his team will have to decide the content of the PPE. Certain areas of the assessment need to be emphasized depending on the sport involved (e.g., concussion assessments would not be a priority in a sport like curling, whereas it has obvious importance in football). It is up to the team to insert into its PPE the necessary requirements to achieve the goals of the overall PPE.

How the team decides to obtain this information varies. Paper-based documents are on the way out. More sophisticated web-based approaches may be the wave of the future. The Stanford University group is just one example of a web-based approach (1). Visit www.stanford.edu/dept/sportsmed to see the Stanford University approach.

What behooves the physician charged with this task is to ascertain what and how the information is to be used. Carrying large busy folders with a traveling team is a thing of the past. Complete medical profiles can be transported on a computer, a disc, or a personal digital assistant (PDA), or they can even be web based. Central locations for storage can be a doctor’s office in the case of a local or school-based team, a national team office in the case of a traveling team, or a trainer’s/therapist’s computer.

History

It still holds true, as Sir William Osler stated in his book, The Principles and Practice of Medicine, which was published initially in 1892 and subsequently often revised, that the patient will give you the diagnosis if you only listen.

Although the emphasis on its varying components may shift depending on the cohort on hand, the basic elements of history taking are the same for medicine in general: present history, past history, family history, systems review, allergy and medication history, dietary history, and psychological and social history.

There are elements of the history taking that do need particular emphasis in the athletic screening process, and these are discussed in the following sections.

Cardiovascular

The current state of cardiovascular screening has been expertly reviewed by various authors (2). Evidence-based medicine has not as yet answered the question of the most appropriate methodology to pursue in our quest of cardiovascular screening and the prevention of catastrophic events related to the heart. There are conflicting perspectives worldwide. The Italian experience, which is extensive in light of their federally mandated requirements for PPE for all athletes, would seem to favor a more aggressive investigative approach. The American model relies more heavily on the questionnaire approach and ponders the cost effectiveness of relying on the technology approach. The reader is referred to the thematic issue concerning PPE of the Clinical Journal of Sport Medicine, published in May 2004, for a more in-depth discussion of this contentious subject.

The European Society of Cardiology recently published a consensus statement outlining their position (3). It needs to be read in light of the consensus statement of the American Heart Association (AHA) (4). What the two positions do agree upon is the requirements of an adequate cardiovascular history, which should include the following:

Questions on exertional chest pain, syncope, excessive shortness of breath, and/or fatigue associated with exercise
Past or present detection of a murmur or increased blood pressure
Family history of premature death or significant disability from cardiovascular disease in close relatives less than 50 years old or specific knowledge of occurrences or certain conditions (i.e., hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT, Marfan syndrome, or important arrhythmias)

The contentious issue is whether a 12-lead electrocardiogram (ECG) is warranted as a screening tool to help identify those individuals at risk for sudden death. The reader is encouraged to review the available evidence to institute his or her team’s policy (3,4).

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