1. NATA Position Statement
Preparticipation Physical Examination and Disqualifying Conditions
2014

2. Warm up Questions Do you require PPE’s or “perform the PPE”?
Who is the Medical Professional signature?
General Practice Physician (DO or MD)
Orthopedic Surgeon
PA, Nurse, Chiropractor
What is the purpose of the PPE?

3. Objective of the Position Statement
To present athletic trainers with recommendations for the content and administration of the Preparticipation Physical Examination (PPE) as well as considerations for determine safe participation in sports and identifying disqualifying conditions.

4. Interesting Facts
= 7.6 million High School Students used a standardized PPE, p102
A complete Medical History identifies approximately 75% of problems that affect initial athletic participation. p106
SCD occurs in about 0.5 per 100,000 high school athletes per academic year. p107
EIB in elite athletes, 6-21%, so screen. p113
30% of young adults (18-25) had the highest level of Mental Health Illness, p115

5. Background How long have we been doing PPEs? Are they standardized?
40 years according to the NATA.
Are they standardized?
Example: High School State Association
Why do PPE’s?
NCAA did not mandate PPE’s for all athletes until recently.
Recommendations – 29 specific statements
Each “graded”, SORT – Strength of Recommendation Taxonomy. A, B, C

6. SORT
“A” – Recommendation based on consistent and good quality experimental evidence (morbidity, mortality, exercise and cognitive performance, physiologic responses)
“B” – Recommendation based on inconsistent or limited quality Experimental Evidence.
“C” – Recommendation based on consensus; usual practice, opinion, disease-oriented evidence, case studies of dx, tx, prevention , or screening.

7. American Medical Association Group on Science and Technology
To identify those athletes who have medical conditions that place them at substantial risk for injury or sudden death and to disqualify them from participation or ensure they receive adequate medical treatment.
Do not disqualify athletes unless there is a compelling medical reason.

8. Only “A” Recommendation
Orthopedic Screening
9. The musculoskeletal hx screening and examination can be combined for asymptomatic Athletes with no previous injuries. If player has either a previous injury or signs . . The relevant elements of a site specific examination should be performed.

9. Sections of Recommendations
Medical and Family History
Physical Examination
General Health Screening
Cardiovascular Screening
Neurologic Screening
Orthopaedic Screening
General Medical Screening
Medical Use
Nutritional Assessment
Heat and Hydration Related Illness Risk Factors
Mental Health Considerations

10. Table 2 –The 12-Element American Heart Association Recommendations for PPE Heart
Medical Hx
PersonalX
1. Exertional chest pain/discomfort
2. Unexplained syncope/near syncope
3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated system Blood Pressure

11. Table 2 Cont.
Family Hx
6. Premature death before 50 y due to heart disease in >1
7. Disability from heart disease in a close relative age < 50y
8. Specific knowledge of certain cardiac conditions in family members, examples listed page 104

12. Table 2 Cont. Physician Examination 9. Heart Murmur
10. Femoral pulses to exclude aortic coarctation
11. Physical stigmata of Marfan Syndrome
12. Brachial Artery Blood pressure (sitting position) taken in both arms.

13. Other Tables of Note
Table 3 - Questions Regarding Presence of Cardiovascular Risk Factors
Table 4 - The 90-Second Musculoskeletal Screening Examination
Table 5 – Conditions Associated with Abnormal Arterial Pulse Waves
Table 6 – Classification of Sports According to Cardiovascular Demands
Table 7 – Spine Condition Participation Recommendations
Table 8 – Classification of Sports by Contact
Table 9 – Mental Health-Related Survey

14. Table 9 Mental Health Survey (Yes or No)
I often have trouble sleeping.
I wish I had more energy most days of the week.
I think about things over and over.
I feel anxious and nervous much of time.
I often fell sad or depressed.
I struggle with being confident.
I don’t feel hopeful about the future.
I have a hard time managing my emotions. (Frustration, anger, impatience)
I have feelings of hurting myself or others.

15. Recommendations continued
Administration of PPE #
Determining Clearance # 28-29
29. Team Physicians and Institutions have the legal right to restrict an individual from participating in athletics, provided the decision is individualized, reasonably make, and based on competent medical evidence.

16. Let’s Stop and Discuss How to you do it? What do you do that is GREAT?
Stations vs Individuals?
In house vs Community Medical Professionals?
What do you do that is GREAT?
Anything you want to improve?
Red Flags< how does your referral process work?
Do you address all “areas” including mental health?

17. The Evidence: Background and Literature Review
“Evidence to support the above-referenced recommendations and the best practices in developing and delivering a comprehensive PPE follows.
Good read! Pages 106 – 115.

18. Laboratory and Diagnostic Screening
Anemia
Sickle Cell Trait
Diabetes Mellitus
Lipid Disorders
Exercised-Induced Bronchospasm (EIB)
Medication use
Nutritional Assessment
Heat-Related Illness and Hydration Risk Factors
Mental Health Consideration

19. Nutritional Assessment
Medication use
Document everything (supplements/medications) and justify including energy drinks.
Nutritional Assessment
See previous NATA Position Statement for screening.
Heat-Related Illness and Hydration Risk Factors
See precious NATA Position Statement
Mental Health Consideration
1 in 5 teens in the US suffer from a mental disorder sever enough to affect daily life. (2010)
REFER to a Psychologist!

20. PPE Administration FERPA and HIPPA Timing Instrument Method
4-6 weeks prior to pre-season practice
Instrument
The American Academy of Pediatrics template
Method
Athlete’s Personnel Physician or Larger Scale Screening

21. Determination of Clearance
Personnel
Physician (Doctor of Medicine or Osteopathy) with clinical training.
Determination of Clearance
Occasionally, an abnormality or condition is found that may limit an athlete’s participation or predispose them to further injury.
A specific risk analysis to provide guidance has not been developed.

22. Determination of Clearance
Does the condition pose an unacceptable risk or place the athlete at increased risk?
Does the condition place other participants at risk for injury?
Can the athlete safely participate with treatment (eg, medication, bracing)?

23. Determination of Clearance cont.
Can limited participation be allowed while Tx is being completed?
If clearance is denied for certain sports categories, which activities can the athlete safely participate?

24. Discussion and Questions

25. Take Away Points