Post on 29-Oct-2019
A SURVEY OF PREPARTICIPATION PHYSICAL EXAMINATION COMPONENTS AT NCAA DIVISION III INSTITUTIONS
A THESIS
Submitted to the Faculty of the School of Graduate Studies and Research
of California University of Pennsylvania in partial fulfillment of the requirements for the degree of
Master of Science
BY
Beth Anne Conroy
Research Adviser, Dr. William Biddington
California, Pennsylvania2006
ii
iii
ACKNOWLEDGEMENTS
I would like to take this opportunity to thank the
many people who played an important role in the completion
of this thesis. First, I would like to thank my advisor
Dr. William Biddington and the members of my committee: Dr.
Carol Biddington and Mrs. Ellen West. Their knowledge,
input, and experience was invaluable to the success of this
product.
I would also like to thank my classmates, faculty,
coaches, and students at California University of
Pennsylvania for their support and a fun year. To the
softball team, thanks for a fun season and the devil went
down to Georgia!
Finally, I would like to thank my family for always
supporting me and understanding my desire to complete my
Masters Degree. I appreciate all the help, especially
taking care of my puppy, Molly. I love you all: Mom, Dad,
Erin, Joe, Missy, and Molly.
iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE . . . . . . . . . . . . . . . . ii
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS . . . . . . . . . . . . . . . iv
LIST OF TABLES . . . . . . . . . . . . . . . . vii
LIST OF FIGURES . . . . . . . . . . . . . . . ix
INTRODUCTION . . . . . . . . . . . . . . . . . 1
METHODS . . . . . . . . . . . . . . . . . . 5
Research Design. . . . . . . . . . . . . . . 5
Subjects. . . . . . . . . . . . . . . . . . 6
Panel of Experts . . . . . . . . . . . . . . 6
Instruments . . . . . . . . . . . . . . . . 7
Procedures . . . . . . . . . . . . . . . . 8
Hypotheses . . . . . . . . . . . . . . . . 9
Data Analysis . . . . . . . . . . . . . . . 9
RESULTS . . . . . . . . . . . . . . . . . . . 11
Demographic Data . . . . . . . . . . . . . . 11
Hypotheses Testing . . . . . . . . . . . . . 14
Additional Findings . . . . . . . . . . . . . 34
DISCUSSION . . . . . . . . . . . . . . . . . 38
Discussion of Results . . . . . . . . . . . . 38
Conclusions . . . . . . . . . . . . . . . . 45
v
Recommendations . . . . . . . . . . . . . . 45
REFERENCES . . . . . . . . . . . . . . . . . 47
APPENDICES . . . . . . . . . . . . . . . . . 50
A. Review of the Literature . . . . . . . . . . . . 51
Purpose of the PPE. . . . . . . . . . . . . 52
Components of the PPE . . . . . . . . . . . 55
Medical History. . . . . . . . . . . . . 56
Physical Examination. . . . . . . . . . . 59
Issues Concerning the PPE . . . . . . . . . 60
Summary . . . . . . . . . . . . . . . . . 65
B. The Problem . . . . . . . . . . . . . . . 68
Statement of the Problem . . . . . . . . . . 69
Definition of Terms . . . . . . . . . . . . 69
Basic Assumptions . . . . . . . . . . . . . 70
Limitations of the Study . . . . . . . . . . 71
Significance of the Study . . . . . . . . . 71
C. Additional Methods . . . . . . . . . . . . . 72
Panel of Experts Cover Letter (C1) . . . . . . 73
Preliminary Preparticipation Physical Examination
Survey (C2) . . . . . . . . . . . . . . . 75
Preparticipation Physical Examination
Survey (C3) . . . . . . . . . . . . . . . 80
Institutional Review Board (C4) . . . . . . . 89
Subject Cover Letter (C5) . . . . . . . . . 95
vi
Follow-up Subject Cover Letter (C6). . . . . . 97
Frequency Tables for Results (C7) . . . . . . 99
REFERENCES . . . . . . . . . . . . . . . . . 116
ABSTRACT . . . . . . . . . . . . . . . . . . 119
vii
LIST OF TABLES
Table Page
1 Frequency of Number of Examiners . . . . . . 11
2 Frequency of Examiner Credentials . . . . . . 12
3 Years in Sports Medicine by Percentage . . . . 13
4 Level of Education by Frequency. . . . . . . 13
5 Musculoskeletal Exam Components for Orthopedist And ATC . . . . . . . . . . . . . . . . 27
6 Medical History Components by Number of Examiners . . . . . . . . . . . . . . . 28
7 Physical Exam Components for the Five Groups . 32
8 Average of PPE Monograph Components by Percentage . . . . . . . . . . . . . . . 34
9 Frequency of PPE Designer . . . . . . . . . 35
10 Frequency of AHA Components . . . . . . . . 41
11 All Medical History Components by Credentials . 100
12 All Cardiovascular History Components by Credentials . . . . . . . . . . . . . . 102
13 All Musculoskeletal History Components by Credentials . . . . . . . . . . . . . . 103
14 All Neurological History Components by Credentials . . . . . . . . . . . . . . 104
15 All Immunizations by Credentials . . . . . . 105
16 All Physical Exam Components by Credentials . . 106
17 All Musculoskeletal Exam Components byCredentials . . . . . . . . . . . . . . 107
18 All Medical History Components by Examiner Groups. . . . . . . . . . . . . . . . . 108
viii
19 All Cardiovascular History Components byExaminer Groups . . . . . . . . . . . . . 110
20 All Musculoskeletal History Components by Examiner Groups . . . . . . . . . . . . . 111
21 All Neurological History Components by Examiner Groups . . . . . . . . . . . . . 112
22 All Immunizations by Examiner Groups. . . . . 113
23 All Physical Exam Components by Examiner Groups. . . . . . . . . . . . . . . . . 114
24 All Musculoskeletal Exam Components by Examiner Groups . . . . . . . . . . . . . 115
ix
LIST OF FIGURES
Figure Page
1 Frequency of Number of Examiners . . . . . . 12
2 Level of Education by Frequency. . . . . . . 14
3 Medical History Components for Physicians. . . 16
4 Medical History Components for CNP and RN. . . 17
5 Medical History Components for PA and ATC. . . 19
6 Cardiovascular Components for Physicians . . . 20
7 Cardiovascular Components for Allied Health Professionals . . . . . . . . . . . . . . 21
8 Musculoskeletal Components for Physicians. . . 22
9 Musculoskeletal Components for Allied Health Professionals . . . . . . . . . . . . . . 22
10 Neurological Components for Physicians . . . . 23
11 Neurological Components for Allied Health Professionals . . . . . . . . . . . . . . 24
12 Physical Exam Components by Physicians . . . . 25
13 Physical Exam Components by Allied Health Professionals . . . . . . . . . . . . . . 26
14 Cardiovascular Components by Number ofExaminers . . . . . . . . . . . . . . . 29
15 Musculoskeletal Components by Number ofExaminers . . . . . . . . . . . . . . . 30
16 Neurological Components by Number of Examiners. 31
17 Musculoskeletal Exam Components by Number ofExaminers . . . . . . . . . . . . . . . 33
18 Frequency of Component Categories . . . . . . 34
x
19 Frequency of Where PPE Administered . . . . . 36
20 Sport Specific PPEs by Frequency . . . . . . 36
INTRODUCTION
Since 1977, the National Collegiate Athletic
Association (NCAA) has recommended that all student-
athletes, upon entrance to the athletics program, be
required to have a Preparticipation Physical Examination
(PPE).1 The PPE is used to collect a student athlete’s
history and determine clearance for sports. The NCAA
offers recommendations for components to be included in the
PPE, but does not have a standardized format.1 Without
standardization, the exact objectives of the PPE vary. The
main objective of the PPE is to detect underlying or
preexisting conditions that may predispose the athlete to
life-threatening or disabling events.2-7 With one in 596
(0.2%) college athletes disqualified from competition, the
PPE should be viewed as a positive tool that assists him or
her in achieving the goals of competition.2,3 The PPE is not
intended to discourage or exclude any athlete from
participation.2,8 Reed6 notes that the objectives do not
require injury surveillance, do not establish fitness
requirements for participation, and do not pretend to take
the place of the yearly evaluation by a personal physician.
As guidelines, the NCAA recommends that the components
of the PPE should be from the American Heart Association
2
(AHA) Cardiovascular Screening9 and the 3rd edition of the
Preparticipation Physical Evaluation10 with emphasis on
cardiovascular, musculoskeletal, and neurological
assessment.1 While between 70-75% of all problems are
identified with a comprehensive history, it has been
reported that only 39% of student-athletes’ answers on a
history questionnaire agree with the answers given by
parents using the same questionnaire.2,10,11 Because of the
disagreement, it is recommended that both the student-
athlete, and parents or guardians complete the
questionnaire.10,12 Koester13 notes that a history of an
injury requires further evaluation to test strength and
function to ensure a complete rehabilitation occurred.
Only 3.1 – 13.9% of all athletes require further evaluation
before being cleared for activity.8 Therefore, it is
necessary to provide institutions with a standardized form
that emphasizes the recommended components.
According to the NCAA Sports Medicine Handbook,1
student-athletes should undergo an initial medical
evaluation and interim history for each following season.
The initial PPE should contain a complete health history,
immunization history, and a physical examination. The
interim history should contain all changes in medical
status and blood pressure measurement.1 Upon entry into the
3
athletic program, student-athletes are asked to fill out a
comprehensive medical history with emphasis on
cardiovascular, neurological, and musculoskeletal history.1
Following a review of the medical history, a physical
examination should be performed by a physician.10 There are
two stages to the physical: general screening and follow-
up evaluation to any problems identified in the medical
history. Even though the PPE is not intended to be the
annual screening, Peltz14 found 78% of adolescents view the
PPE as their annual health assessment.
Currently, a variety of allied health professionals
who have various training and limited interest in sports
medicine administer the PPE.4,7,9,15,16 One concern is the
physician administering the exam may not have the
background in sports medicine to understand the
requirements to participate.3 On the same concern,
orthopedics, who may not be as familiar as Primary Care
Physician (PCP), administer the general physical exam.3 In
a study involving 712 athletes, new injuries had no
relationship to previous injury, flexibility, range of
motion, or strength.17 But then it is near impossible to
create an environment with zero-risk of injury.9,12
Unfortunately, with the proof of inadequate cardiovascular
screening and the lack of screening for menstrual
4
dysfunction and eating disorders, the current NCAA PPE is
not efficient in providing the opportunity for healthy
participation by the athlete.3,5,7,15 Maron et al9 state “the
extent to which the PPE efforts can be supported at any
level of competitive athletics is mitigated by cost-
efficiency considerations, practical limitations and the
awareness that it is not possible to achieve zero-risk
circumstances.” The quality of the PPE is the
responsibility of the medical providers administering it.7
In the past, the format was made by the athletic
administration and the physician would perform the PPE as
it was given to him or her.7
The purpose of this study was to compare NCAA member
institutions procedures and components concerning PPE for
student-athletes. This study attempted to answer the
following research questions:
1) Are there reoccurring components of the PPE in
institutions where examiners have the same
credentials?
2) Will those institutions with the same number of
examiners have similar sets of components of the PPE?
3) Do institutions use the components recommended by the
PPE monograph 3rd edition?
5
METHODS
The methods section of this study describes the
procedures used to conduct this research study. This
chapter includes sections explaining: (1) Research Design,
(2) Subjects, (3) Panel of Experts, (4) Instrumentation,
(5) Procedures, (6) Hypotheses, and (7) Data Analysis.
Research Design
A descriptive research design utilizing a survey was
used for this study. The survey, designed by the
researcher, was completed by the Head Certified Athletic
Trainer (ATC) at NCAA Division III institutions over the
internet. The dependent variable was the components of the
PPE. The independent variables were the credentials of the
examiners, number of examiners, and recognized components
of the PPE 3rd edition monograph. The design of the study
possessed the potential to present information that could
be used to bring more awareness of PPE components. The
limitation in conducting this research was the variation in
pre-participation examining procedures, providing a
challenge to organizing data for analysis.
6
Subjects
The subjects (N = 139) in this study consisted of all
NCAA Division III Head ATCs. An email list was created
through the NCAA school and conference athletic webpage by
the researcher. The entire population of NCAA Division III
Head ATCs (439) was included in the list but only 373 had
valid email addresses. The subjects completed a survey
over the internet, and implied informed consent upon
completion of the survey. Demographics collected about the
subjects included the number of examiners, years of sports
medicine experience, credentials, and level of education.
In terms of data collection and analysis, the subjects
remained anonymous. The limitations of the subjects were
invalid email addresses, no ATC at the institutions, or the
institution’s webpage had no contact information.
Panel of Experts
Before the survey was used, the researcher organized a
panel of experts. The panel consisted of three NCAA
Division III Head ATCs with knowledge of the components of
a PPE, development of PPE, and experience with the PPE at
the collegiate level. The three panel members were
7
excluded from the survey. The panel members added to the
content validity of the survey and made any necessary
changes. The panel members were sent a cover letter
(Appendix C1) explaining the design and their
responsibilities in this study as well as a copy of the
preliminary Preparticipation Physical Examination Survey
(PPES) (Appendix C2). After reviewing the survey, the
panel members provided critiques and the following
revisions were made per the suggestions: questions about
fees and previous medical records were added and the
components of urine analysis and blood work were added.
Instrumentation
The PPES (Appendix C3) was created by the researcher
for the purpose of gathering data about the PPE. The
subject was asked to identify the components of their PPE
as well as education level of administrators, credentials
of administrators, years of experience of administrators,
and number of administrators. Additional inquiries were
who designs the institution’s PPE, when and where the PPE
is conducted, and how often the PPE is conducted. The
entire survey should have taken no more than 15 minutes to
complete. Responses were categorically organized into
8
frequency tables, and percentage of occurrence was
calculated for each component.
Procedures
The study was reviewed by the California University of
Pennsylvania Institutional Review Board (IRB) (Appendix
C4). Following approval, a cover letter and the
preliminary PPES was sent to the panel of experts. After a
revision of the survey, a web page was developed using
Survey Monkey to house the PPES. An email list was created
through the NCAA school and conference athletic webpage.
An e-mail was sent to the subjects with a cover letter
(Appendix C5) explaining the purpose and significance of
the study. The e-mail contained a link to the survey
website for completion. Subsequent e-mails (Appendix C6)
were sent to the population until the desired ≥40% response
rate was met. There was no obligation to participate and
no way to trace the survey back to the contributing
subject. Gathered data was then analyzed in terms of the
research hypotheses.
9
Hypotheses
The following are the hypotheses that were
investigated by this study:
1) There will be reoccurring components of the PPE in
institutions where examiners have the same credentials.
2) Those institutions with the same number of examiners
will have similar sets of components of the PPE.
3) There will not be a large number of institution’s using
the components recommended by the PPE monograph 3rd
edition.
Data Analysis
A descriptive analysis of the data was used to assess
the research hypotheses. The data gathered has been
described by the use of frequency tables, percentage of
occurrence, and other applicable anecdotal notes and
observations. The components of the PPE were grouped into
seven categories: medical history, cardiovascular history,
musculoskeletal history, neurological history,
immunizations, physical exam, and musculoskeletal exam.
For the analysis of hypothesis 1, the data was grouped by
the credentials of administrators: Physicians (Primary
10
Care Physicians (PCP), Orthopedist, and Physician) and
Allied Health Professionals (Certified Nurse Practitioner
(CNP), Registered Nurse (RN), Physician’s Assistant (PA),
and ATC). For the analysis of hypothesis 2, the data was
grouped by the number of examiners: 0-2, 3-5, 6-8, 8-11,
and 12-14. For hypothesis 3, an average of the PPE 3rd
edition monograph was used. Components were considered
reoccurring if the frequency was 75% or higher because this
is similar to a 0.6 to 0.8 moderately high ratio in
inferential statistical analysis.18
11
RESULTS
The following section encompasses the information
obtained through the collection and analysis of the
Preparticipation Physical Examination Survey distributed to
NCAA Division III institutions. The results have been
divided into the subsequent sections: (1) Demographic
Data, (2) Hypotheses Testing, and (3) Additional Findings.
Demographic Data
Of the 373 NCAA Division III institutions that
received the study, 139 responded. As illustrated in Table
1, the range for examiners was 0-14 (4.35 ± 4.123).
Table 1. Frequency of Number of ExaminersNumber of Examiners Frequency Percentage
0-2 60 43.23-5 34 24.56-8 22 15.8
9-11 10 7.212-14 13 9.4
12
0
5
10
15
20
25
30
35
40
45
0-2Examiners
3-5Examiners
6-8Examiners
9-11Examiners
12-14Examiners
Examiner Ranges
Frequency by Percentage
Figure 1. Frequency of Number of Examiners
Table 2 illustrates the frequency of credentials of
examiners.
Table 2. Frequency of Examiner CredentialsCredential Frequency
Primary Care Physician 110Orthopedist 51Any type of physician 130Certified Nurse Practioner 37Registered Nurse 25Physician’s Assistant 28Certified Athletic Trainer 80Athletic Training Student 34Other Medical Professionals 3
Of the 139 institutions, there were 604 examiners
administering the PPE. The average number of years in
sports medicine (Table 3) for the examiners was 2.27 ±
1.26.
13
Table 3. Years in Sports Medicine by PercentageYears in Sports
MedicinePercent
1-3 41.84-6 16.67-10 14.410+ 27.2
Table 4 reports the level of education for the
examiners.
Table 4. Level of Education by FrequencyLevel of Education Frequency PercentageStudent 145 24.0Bachelor 42 7.0Master 125 20.7Doctorate 8 1.3MD 188 31.1DO 29 4.8PA 27 4.5CNP 40 6.6
14
StudentBachelor
MasterDoctorate
MDDO
PACNP
Level of Education
0
50
100
150
200
Freq
uenc
y
Level of Education
Figure 2. Level of Education by Frequency
Hypotheses Testing
The PPE was divided up into seven sections: (1)
Medical History, (2) Cardiovascular History, (3)
Musculoskeletal History, (4) Neurological History, (5)
Immunizations, (6) Physical Exam, and (7) Musculoskeletal
exam. The results for the hypotheses were also divided
into the sections. Frequency tables for all results can be
found in Appendix C7. The following hypotheses were
investigated by this study:
15
Hypothesis 1: There will be reoccurring components of
the PPE in institutions where examiners have the same
credentials.
Conclusion: As illustrated in Figure 3, 15 of a
possible 37 medical history (hx) components were reported
to be used by more than 75% of the institutions where some
type of physician was an examiner. These components are:
prior restrictions to participation, chronic medical
conditions, medications, allergies, asthma, coughing,
wheezing, or difficulty breathing during or after exercise,
family hx of asthma, use of an inhaler, heat illnesses,
fainting, vomiting, cramping from the heat, mononucleosis,
vision problems, glasses or contacts, gaining or losing
weight, and menstrual hx.
16
60
70
80
90
100
Prio
r Re
stri
ctio
ns
Chro
nic
Cond
itio
nsMe
dica
tion
sAl
lerg
ies
Asth
ma
Coug
hing
, wh
eezi
ng,
or .
..
Fami
ly h
x of
ast
hma
Use
of a
n in
hale
r
Heat
ill
ness
es
Fain
ting
, vo
miti
ng,
cra.
..
Mono
nucl
eosi
s
Visi
on p
robl
ems
Glas
ses
or c
onta
cts
Gain
ing
or l
osin
g we
ight
Mens
trua
l hx
Medical History Components for Physicians
Frequency by Percentage
PCP
Orthopedist
Physician
Figure 3. The 15 medical history components for Physicians with a frequency higher than 75%.
17
In Figure 4, two of the allied health professionals
(CNP and RN) reported 12 of the 37 medical hx components to
be used by more than 75% of the institutions. These
components are: prior restrictions to participation,
chronic medical conditions, medications, allergies, asthma,
coughing, wheezing, or difficulty breathing during or after
exercise, family hx of asthma, use of an inhaler, heat
illnesses, vision problems, glasses or contacts, and
menstrual hx.
60
70
80
90
100
Prior Restrictions
Chronic Conditions
Medications
Allergies
Asthma
Coughing, wheezing,...
Family hx of asthma
Use of an inhaler
Heat illnesses
Vision problems
Glasses or contacts
Menstrual hx
Medical History Components for CNP and RN
Frequency by Percentage
CNP
RN
Figure 4. The 12 medical hx components for CNP and RN with a frequency higher than 75%.
In Figure 5, the other two allied health professionals
(PA and ATC) were reported to have a group of 17 medical hx
components. These components are: prior restrictions to
participation, chronic medical conditions, medications,
allergies, asthma, coughing, wheezing, or difficulty
18
breathing during or after exercise, family hx of asthma,
use of an inhaler, paired organs, heat illnesses, fainting,
vomiting, cramping from the heat, mononucleosis, vision
problems, glasses or contacts, gaining or losing weight,
menstrual hx, and periods within the last 12 months.
19
60
70
80
90
100
Prio
r Re
stri
ctio
ns
Chro
nic
Cond
itio
ns
Medi
cati
ons
Alle
rgie
sAs
thma
Coug
hing
, wh
eezi
ng,
or..
.
Fami
ly h
x of
ast
hma
Use
of a
n in
hale
r
Pair
ed o
rgan
s
Heat
ill
ness
es
Fain
ting
, vo
miti
ng,
cr..
.
Mono
nucl
eosi
s
Visi
on p
robl
ems
Glas
ses
or c
onta
cts
Gain
ing
or l
osin
g we
ight
Mens
trua
l hx
Peri
ods
in 1
2 mo
nths
Medical History Components for PA and ATC
Frequency by Percentage
PA
ATC
Figure 5. The 17 medical hx components for PA and ATC with a frequency higher than 75%.
20
As illustrated in Figure 6, six of the possible 11
cardiovascular components for physicians were reported to
be used by more than 75% of the institutions. These
components are: passing out during exercise, chest pain,
discomfort, or pressure during exercise, high blood
pressure, high cholesterol, heart murmur, or heart
infection, family hx of sudden death, family hx of heart
problems, and any family member dying before the age of 50.
60
70
80
90
100
Passing out during ...
Chest pain, discomfo...
High BP, High choles...
Family Hx of sudden ...
Family HX of heart ...
Any family member dyi..
Cardiovascular Components for Physicians
Frequency by Percentage
PCP
Orthopedist
Physician
Figure 6. The six cardiovascular components for physicians with a frequency higher than 75%.
As illustrated in Figure 7, institutions with allied
health professionals reported seven components to be used
by more than 75%. These components are: passing out during
exercise, chest pain, discomfort, or pressure during
exercise, heart racing or skipping beats, high blood
21
pressure, high cholesterol, heart murmur, or heart
infection, family hx of sudden death, family hx of heart
problems, and any family member dying before the age of 50.
60
70
80
90
100
Passing out durin...
Chest pain, disco...
Heart racing or s...
High BP, High cho...
Family hx of sudd..
Family hx of hear...
Any family member...
Cardiovascular Components for Allied Health Professionals
Frequency by Percentage
CNP
RN
PA
ATC
Figure 7. The seven cardiovascular components for allied health professionals with a frequency higher than 75%.
In Figures 8 and 9, five of the possible nine
musculoskeletal components were reported to be used by more
than 75% of institutions with physicians and allied health
professionals. These components are: surgery,
hospitalization, previous injuries, fractures (fx) or
dislocations, and stress fx.
22
60
70
80
90
100
Surgery
Hospitalization
Previous injuries
Fx or dislocation
Stress Fx
Musculoskeletal Components for Physicians
Frequency by Percentage
PCP
Orthopedist
Physician
Figure 8. The five musculoskeletal components by physicians with a frequency higher than 75%.
60
70
80
90
100
Surgery
Hospitalization
Previous injuries
Fx or dislocation
Stress Fx
Musculoskeletal Components for Allied Health Professionals
Frequency by Percentage
CNP
RN
PA
ATC
Figure 9. The five musculoskeletal components by allied health professionals with a frequency higher than 75%.
23
As illustrated in Figure 10, of the possible eight
neurological components, only two components (previous head
injury or concussion and seizures) were reported to be used
by more than 75% of the institutions with physicians.
60
70
80
90
100
Previous headinjury orconcussion
Seizures
Neurological Components for Physicians
Frequency by Percentage
PCP
Orthopedist
Physician
Figure 10. The two neurological components for physicians with a frequency higher than 75%.
For the allied health professionals, four of the eight
neurological components were reported to have a frequency
higher than 75%. These components are: previous head
injury or concussion, seizures, headaches with exercise,
and numbness, tingling, or weakness in arms or legs.
(Figure 11).
24
60
70
80
90
100
Previous
head injury
or
concussion
Seizures
Headaches
with
exercise
Numbness,
tingling or
weakness in
arms or
legs
Neurological Components for Allied Health Professionals
Frequency by Percentage
CNP
RN
PA
ATC
Figure 11. The four neurological components for allied health professionals with a frequency higher than 75%.
For immunization records, only orthopedist, CNP, and
RN reported tetanus immunization at a frequency higher than
75%. MMR was also reported at 75% frequency for CNP. None
of the other 11 immunizations had a frequency higher than
75%.
In the physical exam portion of the PPE, physicians
were reported to use 10 of the possible 24 components at a
frequency higher than 75% (Figure 12). These components
are: height, weight, ears, nose, lungs, blood pressure
seated, heart rate, heart murmurs, abdomen, and
musculoskeletal exam.
25
60
70
80
90
100
Height
Weight
Ears
Nose
Lungs
Blood Pressure Seated
Heart Rate
Heart Murmurs
Abdomen
Musculoskeletal exam
Physical Exam Components for Physicians
Frequency by Percentage
PCP
Orthopedist
Physician
Figure 12. The 10 physical exam components by physicians with a frequency higher than 75%.
As illustrated in Figure 13, institutions with allied
health professionals reported 12 of the 24 physical exam
components at a frequency higher than 75%. These
components are: height, weight, visual acuity, ears, nose,
lungs, blood pressure seated, heart rate, heart murmurs,
abdomen, skin, and musculoskeletal exam.
26
60
70
80
90
100
Height
Weight
Visual acuity
Ears
Nose
Lungs
Blood Pressure Seated
Heart Rate
Heart Murmurs
Abdomen
Skin
Musculoskeletal exam
Physical Exam Components for Allied Health Professionals
Frequency by Percentage
CNP
RN
PA
ATC
Figure 13. The 12 physical exam components for allied health professionals with a frequency higher than 75%.
For the musculoskeletal exam components, only the
orthopedist and ATC had components reported at a frequency
higher than 75%. As illustrated in Table 5, the 10
components are posture, cervical flexion, extension,
rotation, and lateral flexion, shoulder shrug and
abduction, internal and external rotation of the shoulder,
back extension, and back flexion.
27
Table 5. Musculoskeletal Exam Components for Orthopedist and ATC
Component Orthopedist ATCPosture 76.5 67.5Cervical Flexion 88.2 77.5Cervical Extension 88.2 77.5Cervical Rotation 86.3 75.0Cervical Lateral Flexion
86.3 76.3
Shoulder Shrug 80.4 70.0Shoulder Abduction 86.3 71.3Internal and External Rotation of the shoulder
76.5 70.0
Back Extension 82.4 72.5Back Flexion 86.3 76.3
Hypothesis 2: Those institutions with the same number
of examiners will have similar sets of components of the
PPE.
Conclusion: For medical hx components (Table 6),
institutions with 0-2 and 3-5 examiners reported 12 of the
37 components at a frequency higher than 75%. At
institutions with 6-8 examiners, 15 medical hx components
were reported at a frequency higher than 75%. As for
institutions with 9-11 examiners, 16 medical hx components
were reported at a frequency higher than 75%. For
institutions with the most examiners, 12-14, 19 of the 37
medical hx components were reported at a frequency higher
than 75%.
28
Table 6. Medical History Components by Number of ExaminersComponent Total 0-2 3-5 6-8 9-11 12-14
Prior Restrictions 83.5 78.3 91.2 86.4 80.0 84.6Chronic Medical Conditions 95.7 91.7 97.1 100.0 100.0 100.0Medications 96.4 91.7 100.0 100.0 100.0 100.0Supplements 64.7 58.3 70.6 68.2 60.0 76.9Allergies 96.4 93.3 100.0 95.5 100.0 100.0Asthma 96.4 93.3 100.0 100.0 100.0 76.9Coughing, wheezing, or difficulty breathing during or after exercise
86.3 78.3 91.2 95.5 90.0 92.3
Family Hx of Asthma 74.8 65.0 76.5 90.9 90.0 92.3Use of an inhaler 77.0 73.3 76.5 86.4 80.0 76.9Paired organs 68.3 65.0 64.7 77.3 90.0 76.9Mononucleosis 71.2 66.7 67.7 77.3 90.0 76.9Heat illnesses 82.7 78.3 79.4 90.9 90.0 92.3Fainting, vomiting, cramping from the heat
76.3 76.7 70.6 63.6 100.0 92.3
Hospitalization for the heat 55.4 55.0 41.2 50.0 80.0 84.6Vision problems 82.0 78.3 79.4 90.9 70.0 100.0Glasses or contacts 87.1 78.3 88.2 95.5 100.0 100.0Gaining or losing weight 70.5 65.0 67.7 81.8 90.0 69.2Menstrual history 84.9 83.3 82.4 90.9 90.0 84.6Periods within last 12 months 70.5 75.0 67.7 63.6 50.0 84.6
29
As illustrated in Figure 14, of the possible 11
cardiovascular components, a group of seven components were
reported at a frequency higher than 75%. These components
are: passing out during exercise, chest pain, discomfort,
or pressure during exercise, heart racing or skipping
beats, high blood pressure, high cholesterol, heart murmur,
or heart infection, family hx of heart problems, family
history of heart problems, and any family member dying
before the age of 50.
60
70
80
90
100
Passing out during...
Chest pain, discom...
Heart racing or sk...
High BP, High chol...
Family Hx of sudde...
Family HX of heart...
Any family member ...
Cardiovascular Components by Number of Examiners
Frequency by Percentage
Total
0-2 Examiners
3-5 Examiners
6-8 Examiners
9-11 Examiners
12-14 Examiners
Figure 14. The seven cardiovascular components for all groups with a frequency higher than 75%.
Of the 10 musculoskeletal components, seven components
were reported to be used at a frequency higher than 75% by
the five groups of examiners. As illustrated in Figure 15,
these components are: surgery, hospitalization, previous
30
injuries, fx or dislocations, stress fx, treatments, and
braces, casts, or crutches.
60
70
80
90
100
Surgery
Hospitalization
Previous injuries
Fx or dislocation
Stress Fx
Treatments
Braces, casts, or c...
Musculoskeletal Components by Number of Examiners
Frequency by Percentage
Total
0-2 Examiners
3-5 Examiners
6-8 Examiners
9-11 Examiners
12-14 Examiners
Figure 15. The seven musculoskeletal components by the five groups with a frequency higher than 75%.
As illustrated in Figure 16, the five groups of
examiners reported four of the eight neurological
components to be used at a frequency higher than 75%.
These components are: previous head injury or concussion,
seizures, headaches with exercise, and numbness, tingling,
or weakness in arms or legs.
31
60
70
80
90
100
Previous head in...
Seizures
Headaches with e...
Numbness, tinglin..
Neurological Components by Number of Examiners
Frequency by Percentage
Total 0-2 Examiners 3-5 Examiners
6-8 Examiners 9-11 Examiners 12-14 Examiners
Figure 16. The four neurological components for the five groups with a frequency higher than 75%.
For immunization records, only the tetanus
immunization was reported at a frequency higher than 75%
for institutions with either 3-5, 6-8, or 9-11 examiners.
As illustrated in Table 7, five of the 25 physical
exam components were reported at a frequency higher than
75% by the institutions with 0-2 examiners. At
institutions with 3-5 examiners, six components were
reported at a frequency higher than 75%. For institutions
with 6-8 and 9-11 examiners, 10 components were reported at
a frequency higher than 75% but the schools with the most
examiners, 12-14, only eight components were reported at a
frequency higher than 75%.
32
Table 7. Physical Exam Components for the Five GroupsComponent Total 0-2 3-5 6-8 9-11 12-14
Height 92.1 85.0 94.1 100.0 100.0 100.0Weight 92.8 86.7 94.1 100.0 100.0 100.0Visual Acuity 67.6 61.7 61.8 77.3 60.0 100.0Ears 71.9 73.3 70.6 72.7 90.0 53.9Nose 70.5 70.0 70.6 72.7 90.0 53.9Lungs 77.7 75.0 79.4 86.4 80.0 69.2Blood Pressure Seated
91.4 85.0 91.2 100.0 100.0 100.0
Radial Pulse 65.5 60.0 67.7 77.3 60.0 69.2Heart Rate 6.5 76.7 70.6 81.8 80.0 84.6Heart Murmurs 77.0 71.7 73.5 90.9 90.0 84.6Abdomen 74.8 68.3 76.5 81.8 90.0 76.9Musculoskeletal exam
83.5 71.7 88.2 95.5 100.0 92.3
In Figure 17, only the groups with 3-5, 6-8, and 9-11
examiners reported musculoskeletal exam components at a
frequency higher than 75%. The 11 of 19 components are:
posture, cervical flexion, extension, rotation, and lateral
flexion, shoulder shrug and abduction, internal and
external rotation of the shoulder, back extension, back
flexion, and squat.
33
60
70
80
90
100
Posture
Cervical Flexion
Cervical Extension
Cervical Rotation
Cervical lateral fl...
Shoulder shrug
Shoulder abduction
IR & ER of GH
Back Extension
Back Flexion
Squat
Musculoskeletal Exam Components by Number of Examiners
Frequency by Percentage
Total
3-5 Examiners
6-8 Examiners9-11 Examiners
Figure 17. The 11 musculoskeletal exam components with a frequency higher than 75%.
Hypothesis 3: There will not be a large number of
institution’s using the components recommended by the PPE
monograph 3rd edition.
Conclusion: In this survey, the respondents had a
possible 110 components of the PPE monograph 3rd edition to
report as being used at their institution. Table 8 and
Figure 18 illustrate the averages and number of components
for the seven sections of the PPE. From 139 institutions,
only an average of 65 (59.1%) components are used from the
PPE monograph 3rd edition. Therefore, the hypothesis is
supported because the frequency is not higher than 75%.
34
Table 8. Average of PPE Monograph Components by Percentage Components Average Number of
ComponentsPercentage of Components
Medical hx 22.7 37 61.4Cardiovascular hx 7.4 11 67.6Musculoskeletal hx 6.1 9 68.2Neurological hx 5.0 8 62.9Immunizations 3.3 10 32.8Physical Exam 12.3 20 61.9Musculoskeletal Exam
8.1 15 53.8
Total PPE 65.0 110 59.1
05
10152025303540
Medical Hx
Cardiovascular hx
Musculoskeletal hx
Neurological hx
Immunizations
Physical Exam
Orthopedic Exam
Frequency of Component Categories
Frequency
Average
Number ofComponents
Figure 18. Average frequency of components compared to the number of possible components per section.
Additional Findings
Several tests were run using all the data from the
PPES in an attempt to discover additional findings.
35
Frequencies were run to discover the credentials of PPE
designers, where PPE is administered, sport specific PPEs,
fees for PPE, previous medical records, institutions using
immunizations, and institutions that perform
musculoskeletal exams.
As illustrated in Table 9, 50.40% of the institutions
use some type of physician.
Table 9. Frequency of PPE DesignerDesigner Frequency Percentage
PCP 55 39.6Orthopedist 45 18.0Physician 70 50.4CNP 17 12.2RN 14 10.1PA 1 0.7ATC 114 82.0AD 3 2.2
In Figure 19, the site with the highest frequency of
percentage is Athletic Training Site (Station-based).
36
Frequency of Where PPE Administered
0
5
10
15
20
25
30
35
40
45
50
Where administered?
Frequency by Percentage
Athlete's PCP(physician)
Athlete's PCP(station)
UniversityHealth Center(physician)UniversityHealth Center(station)AthleticTraining Site(physician)AthleticTraining Site(station)
Figure 19. Frequency of Where PPE Administered.
Of the 139 institutions, 20 reported to have sport
specific PPEs for some or all of their Division III sports.
Of the 33 sports, 27 were reported to have sport specific
PPEs (Figure 20).
0
4
8
12
16
20
Baseball
Basketball (W)
Basketball (M)
Bowling
Cheerleading
Cross Country
Equestrian
Fencing
Field Hockey
Football
Golf
Ice Hockey (M)
Track & Field
Lacrosse (W)
Lacrosse (M)
Rowing
Rugby
Soccer (W)
Soccer (M)
Softball
Squash
Swimming & Diving
Tennis
Volleyball (W)
Volleyball (M)
Waterpolo
Wrestling
Sport Specific PPEs
Figure 20. Sport Specific PPEs by Frequency.
37
For the 139 institutions who participated, 28 (20.1%)
reported to have a fee to the student for the PPE and 98
(70.5) reported to get previous medical records for
athletes. Even though the PPE monograph 3rd edition
includes a musculoskeletal exam, only 102 (73.4%) perform
musculoskeletal exams with an average of 10.95 components
used for the musculoskeletal exam. Even though the PPE
monograph only recommends immunizations, 111 (79.9%) have
records of immunizations, 18 (12.9%) institutions reported
to use the school’s requirements for admittance, and 10
(7.2%) reported to not record any immunizations.
38
DISCUSSION
In discussion of the findings of this study, the
following sections are presented: (1) Discussion of
Results, (2) Conclusions, and (3) Recommendations for
Further Study.
Discussion of Results
In this study, the purpose was to compare NCAA
Division III institutions procedures and components for
PPEs. Because the NCAA recommends institutions perform a
PPE for every student-athlete prior to participation, the
need to study the current institutions’ PPE, which is not
standardized, is apparent. Without standardization,
institutions have developed various PPEs which may or may
not have validated components and are administered by
various allied health professionals. Of the 373
institutions who were contacted, 139 (37.3%) responded to
the PPES online.
Currently, a variety of allied health professionals
administer the PPE.4,7,9,15,16 According to the PPE monograph,
physicians are responsible for the coordination and
supervision of PPEs.10 In looking at the demographics of
39
NCAA Division III, some type of physician administers the
PPE at 130 of the 139 (93.5%). Previous studies have shown
that 75% of the physicians have been orthopedists, which
differs from the 79.1% (110) that currently use a PCP.3,16
Luckily, the physician does not administer the exam alone.
An average of 4.35 examiners with backgrounds in allied
health administer the PPE. Of the 604 examiners, only
35.9% were physicians and 24% were students. The other
examiners have varying degrees from bachelor’s to
doctorate.
Based on the credentials of the examiners,
orthopedists and PAs have the most reoccurring components
with 47 and 44 respectively. Although, PAs and
orthopedists are only responsible for designing 0.7% and
18% of the PPEs. The credentials with the highest
percentage for designing the PPE are ATC (82%) and PCP
(39.6%). Based on these findings, examiner credentials do
not ensure that the set of reoccurring components will be
included in the PPE because the examiner may not have
influence in the design of the PPE.
One factor that may influence the design of the PPE is
the number of examiners administering the PPE.
Institutions with the most reoccurring components had
between 9 and 11 examiners with 52 components, but these
40
institutions only accounted for 7.2% of the sample.
Institutions with zero to two examiners accounted for 43.2%
but only had 28 reoccurring components which is similar to
the sample’s 30 reoccurring components. The overall
variation of examiner credentials and number of examiners
illustrates the variance in PPE procedures utilized by
Division III institutions. The literature supports this
finding because PPEs have been limited by time, money, and
resources.2,9,11,14
According to the NCAA, institutions are advised to use
the PPE 3rd edition monograph and AHA cardiovascular
screening guidelines for the development of the PPE.1 Of
the 110 PPE 3rd edition monograph components included in
this study, only an average of 65 (59.1%) components were
found to be reoccurring among the Division III
institutions. Of the seven sections to the PPES, none
were found to have an average of 75% of the components
included. Thus, a monograph authored by six medical
societies is not frequently used by Division III
institutions.
From the PPE 3rd edition, 37 general medical history
questions were asked and only 12 were found higher than
75%. There were similar sets of components asked by all
credentials and groups of examiners. The components with
41
the highest frequencies, all over 90%, were chronic medical
conditions, medications, allergies, and asthma. The
components with the lowest frequencies (40% or lower) were
questions concerning disordered eating and behavioral
patterns. Considering athletes are two to three times more
likely to develop disordered eating habits, these
components are necessary in providing the student-athlete
with a healthy playing environment.19
In a study from 1995 to 1997, Division III
institutions were found to have inadequate cardiovascular
screening forms.16 From this study, an average of 7.43
(67.6%) of the 11 cardiovascular hx components were used.
Six of these components are recommended by the AHA. When
comparing the results from 1997 to current usages, all six
components showed signs of higher use with the component on
chest pain having an increased use by 40% (Table 10).
Table 10. Frequency of AHA Components
AHA Component 199716 2006Chest pain 47.0 87.8Premature/sudden death 56.0 87.8Family hx of heart disease 59.0 87.8Heart Murmur 71.0 92.1Passing Out (syncope) 73.0 73.0High Blood Pressure 73.0 92.1
Unfortunately, the frequencies of these components are
not 100% and not all components meet the 75% requirement to
42
be considered reoccurring for all groups. Passing out
(syncope) is not reoccurring for PCP, CNP, RN, and
institutions with zero to two examiners. Plus, the
frequency is still below 75% for all institutions. The
overall increase in component usage is proof of improvement
and awareness of cardiovascular screening.
Considering athletics requires optimal musculoskeletal
function, some might believe the PPE would have thorough
screening. On average, six of the nine components are
screened for by Division III institutions but only four of
the nine are found to be reoccurring higher than 75%. This
similar set of components are surgery, hospitalization,
previous injuries, and fractures or dislocations. But the
components concerning the detailed history (diagnostics,
treatments, and bracing) are lacking in usage. Higher
frequencies of all components are seen with more examiners
but there are fewer institutions with many examiners.
Previously, research has shown student-athletes do not
understand the medical terminology especially when
questioned about neurological history.10,20 Thus, a
complete, detailed questionnaire is necessary in
neurological screening, but only two components (previous
head injury and seizures) are found to be reoccurring
amongst all groups. The components concerning the details
43
of head injury are only reoccurring for PAs and
institutions with more examiners. As previously stated,
using a PA examiner does not mean the set of reoccurring
components will be included in the design of the PPE.
The PPE 3rd edition monograph recommends 10
immunizations be performed and recorded for student-
athletes. Even though 111 institutions reported having
immunization records, not all 10 immunizations are included
by all the institutions. None of the groups by credentials
or number of examiners have a similar set of reoccurring
immunizations. Twenty-eight of the institutions reported
using the institution’s immunizations requirements for the
general public or having no records of immunizations.
Considering the immunizations can assist in the prevention
of diseases or infections, the lack of immunizations and
records of immunizations is alarming.
After a history of the athlete is taken, a physical
exam should be performed for further investigation and
prevention of possible injuries or problems.10 Out of the
20 components, an average of 12.3 components are used with
the components of height, weight, and blood pressure having
the highest reoccurrences about 90%. Once again, PAs have
the most components (12) reoccur and institutions with zero
to two examiners only have five components reoccur. The
44
components with the lowest frequencies were Body Mass Index
(BMI), oral cavity, and femoral pulse. According to the
AHA, femoral pulse is a recommended component to the
cardiovascular screening and the 6.5% usage is far below
the 75% usage for reoccurrence. All groups have similar
sets of components but there is a lack of consistency
amongst the groups with some components having frequencies
closer to 100% and others barely being 75%. The majority
of the components fall below 75% reoccurrence and this
pattern applies to all sections of the PPE.
The final part to the PPE should be the 15 component
musculoskeletal exam. Only 102 (73.4%) institutions
perform a musculoskeletal exam with an average of 10.95
components. There is no set of reoccurring components for
the sample, but there are for institutions with more than
three examiners. Of the credentials, only orthopedists and
ATCs have a set of reoccurring components. The
orthopedists, which have 10 set of components, specialize
in musculoskeletal injuries and should be the most
thorough. This specialist is only used by 51 of the
institutions, even though full, pain free range of motion
is necessary in ensuring the student-athletes are prepared
for the season. Fortunately for student-athletes at 24 of
45
the institutions, examiners use all 15 components of the
musculoskeletal exam.
Conclusions
Since the purpose of the PPE is the discovery of
conditions related to the athlete’s whole health and well-
being, it is the responsibility of the sports medicine team
to perform a complete medical history and physical
examination.2-7 Unfortunately, the PPE does require a lot
of time and money.2,9,11,14 Professionals do not come cheap
and are busy with their professions. Luckily, only 3.1-
13.9% of student-athletes require further evaluation but
maybe with a more complete PPE, this number will rise as
conditions are discovered.8 With only an average of 65
(59.1%) components and 30 reoccurring above 75%, there is a
lack of screening. Considering six medical societies
author the PPE 3rd edition monograph, which is endorsed by
the NATA, awareness of this tool needs to be encouraged.
Recommendations
Based on the results of this study, the following
recommendations for application were made. First, there is
46
a need to bring about awareness of the PPE 3rd edition
monograph because there is a lack of components used.
Secondly, a variety of allied health professionals should
be used because the set of reoccurring components is
different for each profession. Since the more examiners
administering the PPE, also, had more reoccurring
components, institutions should use more than three
examiners.
47
REFERENCES
1. 2005-2006 NCAA Sports Medicine Handbook. Medical evaluation, immunizations and records. 2005:8-9. Available on www.ncaa.org/library/sports_sciences/sports_med_handbook /2005-06/. Accessed on September 10, 2005.
2. Myers A, Sickles T. Preparticipation sports examination. Adolescent Med. 1998;25:225-236.
3. Joy EA, Paisley TS, Price R Jr, Rassner L, Thiese SM. Optimizing the collegiate preparticipation physical evaluation. Clin J Sport Med. 2004;14:183-187.
4. Glover DW, Maron BL, Matheson GO. The preparticipation physical examination: steps toward consensus and uniformity. Phys Sportsmed. 1999;27:29.
5. Best TM. The preparticipaton evaluation: an opportunity for change and consensus. Clin J Sport Med. 2004;14:107-108.
6. Reed FE. Improving the preparticipation exam process. J S Carolina Med Assoc. 2001;97:342-346.
7. Wingfield K, Matheson GO, Meeuwsisse W. Preparticipation evaluation: an evidence-based review. Clin J Sport Med. 2004;14:109-122.
8. Boyanjian-O’Neill L, Cardone D, Dexter W, et al.Determining clearance during the preparticipation evaluation. Phys Sportsmed[serial online]. 2004;32(11). Available on www.physsportsmed.com. Accessed on June 27, 2005.
9. Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, Clark LT, Mitten MJ, Crawford MD, Atkins DL, Driscoll DJ, Epstein AE. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee and Congenital Cardiac Defect Committee, American Heart Association. Circulation.1996;94:850-856 [addendum in 97:2294] Available on www.ahajournals.org. Accessed on June 28, 2005.
48
10. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopatheic Academy of Sports Medicine: Preparticipation Physical Evaluation, ed 3. Minneapolis, MN:McGraw-Hill:2004.
11. Colletti TP. Sports preparticipation evaluation. Phys Assistant. 2001;25(7):31-41.
12. O’Connor DL, Kibler WB, Krowchuk DP, Rice L, O’Connor DL. The preparticipation sports physical. JAAPA. 2001;14:47-56.
13. Koester MC. Making the preparticipation athletic evaluation more than just a “sports physical” part 2: performing a focused physical exam. Contemporary Pediatrics. 2003;20:107-118.
14. Peltz JE, Haskell WL, Matheson GO. A comprehensive and cost-effective preparticipation exam implemented on the world wide web. Med Sci Sports Exerc. 1999;31:1727-1735.
15. Hulkower S, Fagan B, Watts J, Ketterman E. Do preparticipation clinical exams reduce morbidity and mortality for athletes? J Fam Practice 2005;54:628-632.
16. Pfister GC, Uffer JC, Maron J. Preparticipation cardiovascular screening for US collegiate student-athletes. JAMA. 2000;283:1597-1599.
17. Garrick JG. Preparticipation orthopedic screening evaluation. Clin J Sport Med 2004;14:123-126.
18. Arnold BL, Gansneder BM, Perrin DH. Research methods in athletic training. Philadelphia, PA:F.A.Davis Company:2005.
19. Black DR, Larkin LJS, Coster DC, Leverenz LJ, Abood DA. Physiologic screening test for eating disorders/disordered eating among female collegiate athletes. J Athl Train. 2003;38:286-297.
49
20. LaBotz M, Martin MR, Kimura IF, Hetzler RK, Nichols AW. A comparison of a preparticipation evaluation history form and a symptom-based concussion survey in the identification of previous head injury in collegiate athletes. Clin J Sport Med. 2005;15:73-78.
50
APPENDICES
51
APPENDIX A
Review of the Literature
52
Every year across the country, student-athletes at
NCAA institutions are required to have a PPE. The PPE is
used to collect a student athlete’s history and determine
clearance for sports. The NCAA offers recommendations for
components to be included in the PPE, but does not have a
standardized format. Without standardization, institutions
have developed various PPEs which may or may not have
validated items and are administered by various
professionals. This literature review discusses previous
literature regarding the PPE in NCAA institutions, and is
divided into three sections: (1) Purpose of the PPE, (2)
Components of the PPE, and (3) Issues concerning the PPE.
A summary of the literature review will be provided at the
end.
Purpose of the Preparticipation Physical Examination
Since 1977, the NCAA has recommended that all student-
athletes upon entrance to the athletics program be required
to have a PPE.1 The PPE is not intended to discourage or
exclude any athlete from participation.2,3 Only 3.1 – 13.9%
of all athletes require further evaluation before being
cleared for activity.3 With one in 596 (0.2%) college
athletes disqualified from competition, the PPE should be
53
viewed as a positive tool that assists him or her in
achieving the goals of competition.2,4 For ATCs, the PPE is
the first step in injury prevention.5
In order to understand the current purpose of the PPE,
it is necessary to review the history of the PPE.
Beginning more than 35 years ago, the first-generation PPE
came into use by athletic teams and focused on the heart,
hernias, and current health of the athlete which were
considered the biggest threats to the athlete.6 During
1977, the NCAA was battling litigation concerning athletic
injuries during competition. As a result, the NCAA
Committee on Competitive Safeguards and Medical Aspects of
Sports (CSAMS) published a position statement recommending
PPEs for all student-athletes.7 The original NCAA PPE
focused on health history, general, and musculoskeletal
examination.7 For the musculoskeletal examination, Garrick8
developed five purposes: (1) meet legal and insurance
requirements, (2) assure coaches that team members would
start the season with some common level of health and
fitness, (3) discovery of treatable conditions that might
interfere with participation, (4) aid in predicting and
preventing future injuries, and (5) appropriate for all
sports.
54
In 1992, five organizations: the American Academy of
Family Physicians (AAFP), American Academy of Pediatrics
(AAP), American Medical Society for Sports Medicine
(AMSSM), American Orthopedic Society for Sports Medicine
(AOSSM), and American Osteopathic Academy of Sports
Medicine (AOASM) produced the monograph of the PPE.9 Since
then, a second edition (1996) has been published with the
support of the American College of Sports Medicine (ACSM).9
The third and most recent edition (2004) is authored by the
six medical societies and endorsed by the NATA, Sports
Physical Therapy Section of the American Physical Therapy
Association, and the Special Olympics Medical Committee.
The updates include the American College of Cardiology
position from the 26th Bethesda Conference10 in 1994 and the
AHA11 position statement on Cardiovascular Screening in from
1996.
Recently, the ACSM teamed with the American Academy of
Orthopaedic Surgeons (AAOS), AAFP, AMSSM, AOSSM, and AOASM
to form a Team Physician Consensus which released a
position statement (2003) titled Female Athlete Issues.12
There continues to be progress made toward a consensus on
the issue of the PPE. Even after all the progress and
attention by medical societies though, the PPE is not
standardized and the purpose is still debated.
55
Without standardization, the exact objectives of the
PPE vary. One objective that remains constant is the
fulfillment of legal and insurance requirements of the
institution.2,4,6,8,13-17 In practice, the PPE has become a
legal way of providing clearance for participation rather
than an opportunity for general health maintenance.16
Peltz16 found 78% of adolescents view the PPE as their
annual health assessment. Many agree the PPE provides an
opportunity to educate and counsel athletes on athletic and
non-athletic health-related issues.2,4,6,15 However, the main
objective of the PPE is to detect underlying or preexisting
conditions that may predispose the athlete to life-
threatening or disabling events.2,4,6,13,15,17 Reed15 notes that
the objectives of the PPE do not require injury
surveillance, do not establish fitness requirements for
participation, and do not pretend to take the place of the
yearly evaluation by a personal physician.
Components of the Preparticipation Physical Examination
Every year, NCAA institutions prepare to administer
PPEs. According to the NCAA Sports Medicine Handbook,1
student-athletes should undergo an initial medical
evaluation and interim history for each following seasons.
56
The initial PPE should contain a complete health history,
immunization history, and a physical examination. The
interim history should contain all changes in medical
status and blood pressure measurement.1 The NCAA recommends
the components of the PPE should be from the AHA
Cardiovascular Screening11 and the third edition of the
Preparticipation Physical Evaluation.9 Institutions can
choose to have a PCP office based PPE or station
examinations on campus. The PCP examination may be
conducted through the athlete’s PCP or the institution’s
PCP. The station examination is conducted by the sports
medicine team which may include nurse practitioner,
physician assistants, and/or ATCs. No matter how the PPE
is administered, it is the responsibility of a physician
who is a Doctor of Medicine (MD) or Doctor of Osteopathy
(DO) with training and unrestricted medical license to
coordinate and supervise the PPE.9
Medical History
Upon entry into the athletic program, student-athletes
are asked to fill out a comprehensive medical history. The
NCAA suggests the questionnaire places emphasis on
cardiovascular, neurological, and musculoskeletal history.1
An immunization record is recommended to include Measles,
57
Mumps, Rubella (MMR), Hepatitis B, Meningitis, Diphtheria,
and tetanus.1 Between 70-75% of all problems are identified
with a comprehensive history.2,9,18 However, only 39% of
student-athletes’ answers on a history questionnaire agree
with the answers given by parents using the same
questionnaire.2,9,18 Because of the disagreement, it is
recommended that both the student-athlete and parents or
guardians complete the questionnaire.9,14 After completion,
the history should be reviewed for any abnormalities that
would require further investigation.9
The components of the medical history should have
primary questions which address issues of greatest concern
for sports participation. Following the primary questions,
there should be secondary questions to gather further
information on the primary question. Primary questions
should include: (1) prior denial or restriction to
participation, (2) chronic medical condition, (3)
medications and supplements, (4) allergies, (5)
cardiovascular problems, (6) surgical history, (7)
musculoskeletal injuries, (8) asthma, (9) paired organs,
(10) viral illness, (11) dermatologic conditions, (12)
neurological conditions, (13) heat illness, sickle cell
trait or disease, (14) vision, (15) nutritional concerns,
(16) general concerns, and (17) menstrual history (females
58
only).9 According to the AHA guidelines on cardiovascular
screening, nine of the 12 items should be screened in the
medical history and all are supported by the 3rd monograph
PPE. In the medical history, the nine of the items the
items should include: (1) chest pains, (2) heart race or
skip, (3) passed out during or after exercise, (4) heart
murmur, (5) high blood pressure and cholesterol, (6) tests
on heart, (7) sudden cardiac death in family under the age
of 50, (8) family history of heart problems, and (9) Marfan
syndrome.9-11 In a 2004 report of 625 institutions, 74% of
the colleges used less than nine of the 12 AHA screening
guidelines, which is the minimum number of items to be
considered adequate.4 This report demonstrates that the AHA
guidelines are not consistently followed by all
institutions.4,19
For proper follow-up procedures, a detailed injury
report is necessary to ensure healthy participation. In
musculoskeletal injuries, questions should include: (1)
missed practice or games for injury, (2) fractures and
dislocations, (3) stress fractures, (4) injuries that
required surgery, physical therapy, brace, or crutches, (5)
neck injury, and (6) regularly use a brace.9 Most
athletes do not understand the medical terminology to
describe the types of injuries especially when involving
59
the head. Therefore, neurological conditions require
detailed questions which include: (1) previous head
injury, (2) amnesia, (3) seizures, (4) numbness, tingling,
or weakness from a hit or fall, and (5) unable to move arms
or legs after hit or fall.9 In order to cover all the
bases, a comprehensive history, as described above, is
necessary to ensure health participation.2,9,15
Physical Examination
Following a review of the medical history, a physical
examination should be performed by a physician.9 There are
two stages to the physical: general screening and follow-up
evaluation to any problems identified in the medical
history. The standard components of the physical exam
include: (1) height, (2) weight, (3) Head, eyes, ears,
nose, and throat (HEENT), (4) cardiovascular system, (5)
lungs, (6) abdomen, (7) genitalia (men only), (8) skin, (9)
musculoskeletal system, and (10) neurological system.9 The
cardiovascular screening includes the final three items
from the AHA: blood pressure, radial and femoral pulses,
and heart rate and rhythm.11 The musculoskeletal system
screening should include a 14-point general screening and
joint-specific testing where necessary. Approximately, 14%
of athletes require a follow-up and 43.2% of those are for
60
knee injuries.4 Koester20 notes that a history of an injury
requires further evaluation to test strength and function
to ensure a complete rehabilitation occurred. Function is
tested through drills such as running, cutting, agility,
jumping. When an athlete has a history of neurological
injuries, gathering a neurological assessment provides a
baseline for future return to play.21 As far as sport-
specific examinations, some physicians believe it should be
conducted because sports have varying injuries that are
considered higher risk for that sport.9 However, fitness
testing is not required nor recommended by the authoring
societies of the Preparticipation Physical Evaluation
monograph.9
Issues Concerning the Preparticipation Physical Examination
Among physicians, the PPE is debated as to the best
method of administering the exam and the components to
include. One of the debated issues is how to administer
the exam. The PCP office examination allows for the
building of a relationship, detailed history, and is
conducive to counseling the athlete. On the other hand,
the station-based examination can provide specialized
personnel and is cost-effective.2 With the ever growing
61
technology, web-based PPEs have become another type of
information collection. In a study performed by Stanford
University,16 athletes were asked which method they
preferred in collecting the medical history. Of the 3327
student-athletes questioned, 89% preferred the online
questionnaire, and 84% of the students admitted to being
more honest on the computer than on paper or in an
interview.16 This leads professionals to believe that
internet surveys might be the most efficient method of
collecting data.
Besides the debate on how to collect the information,
there is the issue of who collects the information.
Currently, a variety of allied health professionals who
have various training and limited interest in sports
medicine administer the PPE.6,11,17,19,22 Not only is there a
lack of knowledge on sports medicine among physicians, but
orthopedists who may not be as familiar as PCP administer
the general physical exam. One study reported who
administers the PPE and found that 451 of 713 (75%) used
orthopedists and not PCPs.4,22 The quality of the PPE is the
responsibility of the medical providers administering it.17
In the past, the format was made by the athletic
administration and the physician would perform the PPE as
it was given to him or her.17
62
Another issue with the PPE is the lack of evidence
proving a decrease in injuries. It appears that there
would be an abundant evidence that joint or structure once
injured would have a higher risk of future incidences.7
Yet, there has not been a study that provides evidence that
the PPE actually prevents or identifies problems
efficiently.17,19 Reportedly, 372 of 563 (66%) student-
athletes believed the PPE to be unnecessary for safe
participation. Ironically, 499 of 563 (88.6%) student-
athletes believe the PPE prevents severe injuries or death,
and 429 of 563 (76.2%) student-athletes believe the PPE
prevents minor injuries.23 In a study involving 712
athletes, new injuries had no relationship to previous
injury, flexibility, range of motion, or strength.8 While
it may be nearly impossible to create an environment with
zero-risk of injury, Reed believes that the problem lies in
the current injury recording.11,14,15 Even with the current
changes in the PPE, there is no standard form, no required
injury surveillance, and no standard fitness requirements
for participation.15
When the PPE was first developed, the process was
hampered by lack of a clear purpose since various state
boards and medical societies developed their own screening
tool.6 Maron et al11 state “the extent to which the PPE
63
efforts can be supported at any level of competitive
athletics is mitigated by cost-efficiency considerations,
practical limitations and the awareness that it is not
possible to achieve zero-risk circumstances.” Quite
possibly the biggest limitations to the PPE are time and
money.2,11,18 Physician office exams are hindered because of
the cost and time required, as well as poor communication
between the sports medicine department. The station based
exam is hindered by adequate personnel for the stations and
facilities that provide privacy.2 The time and cost to have
a physician interview or review a questionnaire results
also limits the implementation of a comprehensive medical
history.16
According to the authoring societies of the PPE
monograph, screening should include female menstrual
history and nutrition as well.9 In a 2003 study, 138
schools were surveyed on their screening of eating
disorders and menstrual dysfunction. Of the 79% of schools
that screened for menstrual dysfunction, only 24% used a
comprehensive menstrual history. Of the schools that
screened for eating disorders (68%), only 5% used a
validated screening tool and the others would be considered
insufficient by experts.24 This is poor screening
considering athletes are two to three times more likely
64
than the general population of college students to develop
an eating disorder or disordered eating.25 With the lack of
screening for menstrual dysfunction and eating disorders,
athletes are at risk for unhealthy participation.
Furthermore, neurological screening, according to the
3rd monograph, for previous head injuries is only covered by
two questions.9 LaBotz et al26 reported 29 of 172 (17%)
student-athletes answered positively for one of the two
questions. Unfortunately, athletes do not understand all
the symptoms related to head injuries which can lead to
underreporting.26 Mild traumatic brain injury (MTBI) can
impact long-term cognitive function, and put the athlete at
risk for additional concussive events.26 Because of this
risk, LaBotz et al26 compared responses to the Concussion
Symptom Survey (CSS), which is a 14 item questionnaire,
with the two questions from the 3rd monograph. Of the 172
athletes who responded, 82 (48%) answered positively for
one or more of the 14 symptoms.26 Thus, a 31% difference
in head injuries leaves the question of whether the
sensitivity of the PPE can be enhanced through
standardization.
65
Summary
Every year across the country, student-athletes at
NCAA institutions are required to have a PPE. The NCAA
offers recommendations for components to be included in the
PPE, but does not have a standardized format.1 Without
standardization, the exact objectives of the PPE vary. The
main objective of the PPE is to detect underlying or
preexisting conditions that may predispose the athlete to
life-threatening or disabling events.2,4,6,13,15,17 Reed15 notes
that none of the objectives require injury surveillance, do
not establish fitness requirements for participation, and
do not pretend to take the place of the yearly evaluation
by a personal physician.
Furthermore, the NCAA recommends the components of the
PPE should be from the AHA Cardiovascular Screening11 and
the third edition of the Preparticipation Physical
Evaluation9 with emphasis on cardiovascular,
musculoskeletal, and neurological assessment.1 Between 70-
75% of all problems are identified with a comprehensive
history but it has been proven that only 39% of student-
athletes answers on a history questionnaire agree with the
answers given by parents using the same questionnaire.2,9,18
Because of the disagreement, it is recommended that both
66
the student-athlete and parents or guardians complete the
questionnaire.9,14 Only 3.1 – 13.9% of all athletes require
further evaluation before being cleared for activity.3
Koester20 notes that a history of an injury requires further
evaluation to test strength and function to ensure a
complete rehabilitation occurred.
Currently, a variety of allied health professionals
who have various training and limited interest in sports
medicine administer the PPE.6,11,17,19,22 Not only is there a
lack of knowledge on sports medicine among physicians, but
orthopedics who may not be as familiar as PCP administer
the general physical exam.4 Reportedly, 372 of 563 (66%)
student-athletes believed the PPE to be unnecessary for
safe participation. Ironically, 499 of 563 (88.6%)
student-athletes believe the PPE prevents severe injuries
or death, and 429 of 563 (76.2%) student-athletes believe
the PPE prevents minor injuries.23 Even though, a study
involving 712 athletes reported new injuries had no
relationship to previous injury, flexibility, range of
motion, or strength.7 But then it is near impossible to
create an environment with zero-risk of injury.11,14
Unfortunately, with inadequate cardiovascular
screening and lack of screening for menstrual dysfunction
and eating disorders, the current NCAA PPE is not
67
sufficient for providing healthy participation by the
athlete.4,13,17,19 Even the recommended components may not be
sufficient because athletes do not understand all the
symptoms associated with injuries.26 Therefore, the
question of whether the sensitivity of the PPE can be
enhanced through standardization is still unanswered.
68
APPENDIX B
The Problem
69
Statement of the Problem
The purpose of this study is to compare NCAA member
institutions policies and procedures concerning PPE for
student-athletes. PPEs are used to gather patient history
and determine clearance for sport. The NCAA has
recommendations for areas to be covered in a PPE but does
not require all institutions to perform one nor specify how
to collect the information. Also, while PPEs provide the
sports medicine team with information about how to prevent
injuries, not all use the information as a preventative
tool.
Definition of Terms
For clarification, the following definitions are
provided:
1) Cardiovascular history - athlete’s medical and family
history concerning the cardiovascular system. The
AHA11 recommends 12 items be included in the screening.
2) Medical history - athlete’s medical background
concerning all aspects of health. The NCAA suggests
the questionnaire places emphasis on cardiovascular,
neurological, and musculoskeletal history.1
70
3) Musculoskeletal history - athletes medical background
concerning all injuries to bones, muscles, ligaments,
tendons, and other joint structures
4) Neurological history - athletes medical background
concerning head injuries and nerve injuries
5) Physical Examination - portion of the PPE where
athletes are screened by a health professional,
preferably a physician, for abnormalities and further
evaluation of findings from the medical history are
investigated
6) Preparticipation Physical Examination (PPE)- medical
screening prior to athletic season
7) Primary Care Physician (PCP) - a physician who is in
some sense a generalist, such as a family
practitioner, pediatrician, or general internist.
Basic Assumptions
The following assumptions will be made in regard to
this study:
1) The institutions that will be sampled perform a PPE
every year for all student-athletes.
2) All survey questions will be answered correctly and to
the best of the ability of the Head ATC.
71
3) The sample obtained from the list is representative of
the population.
Limitation of the Study
The following statement reflects the potential
limitation for the study:
Only Division III institutions with a valid e-mail
address that is listed online for the Head ATC will be
surveyed.
Significance of the Study
The NCAA recommends all member institutions conduct
PPE. Institutions use the PPEs to gather a history and
status of all student-athletes. There is a monograph,
which provides guidelines for components, written by seven
medical societies and endorsed by the NATA, but a
standardized format does not exist. Because PPEs are not
regulated by a standard, the contents and procedures for
PPEs can vary between institutions. Comparing
institutions’ PPEs will provide the sports medicine teams
with various procedures to collect the history and find
areas of weakness in the procedure. Also, the sports
medicine team can use the information to predict future
problems and risks to the student-athlete.
72
APPENDIX C
Additional Methods
73
APPENDIX C1
Panel of Experts Cover Letter
74
Date February 2, 2006
Dear________________:
I am a graduate athletic training student at California University of Pennsylvania pursuing a Master of Science degree in Athletic Training. To fulfill the thesis requirement for this program, I am conducting a descriptive study. The objective of this study is to compare the components of National Collegiate Athletic Association (NCAA) Division III institutions Preparticipation Physical Examinations.
In order to increase the content validity of the instrument, a panel of experts has been chosen to review the survey. You have been selected as one of the three professionals at a NCAA Division III to be on this panel. Due to your position and experience, your feedback is very important to the success of this study. The information obtained by this panel of experts review will be used to make revisions and create the final survey to be distributed to the population sample. Your responses are voluntary and will be confidential.
Please answer the following questions based on the attached survey and make any other additional comments you deem appropriate. Please return your comments and revisions via email no later than February 9, 2006. If you have any questions or concerns, please do not hesitate to contact me.
1. Are the questions appropriate, valid, and understandable?
2. Comment on the overall presentation of the survey.
3. Which questions, if any, should be excluded from the survey?
4. Which questions, if any, should be added to the survey?
Thank you in advance for your time and efforts.
Sincerely,
Beth A. Conroy, ATC, CSCSCalifornia University of Pennsylvania
75
APPENDIX C2
Preliminary Preparticipation Physical Examination Survey
76
Preparticipation Physical Examination Survey
1) Who administers the PPE?PCP, Orthopedist, RN, PA, ATC, ATS, other_____________
2) Who designs the PPE?PCP, Orthopedist, RN, PA, ATC, ATS, AD, other______________
3) Is the PPE a PCP office exam or station exam on campus? ___________
4) How many examiners administer the PPE?5) What is the level of education for all examiners?
Student, BA, BS, MS, EdD, PhD, MD, DO, RN, PA, other_________
6) How many years of experience in sports medicine do examiners have? ________ Provide the number of years for each examiner.
7) When is the PPE performed? _Day before preseason_During Fall semester_During Spring Semester_6-8 weeks before preseason_other_______________
8) How often is the PPE administered?9) Do returning athletes receive a full physical?10) Do you use a paper PPE or web-based PPE?11) Are there sport specific PPEs or a standard
institutional PPE for all sports?
Medical HistoryCheck all that apply to your institution’s current PPE. Does the PPE ask about:
_prior restrictions to participation_chronic medical conditions_medications_over-the-counter drugs_supplements_allergies_anaphylaxis_EpiPens_hospitalization from allergies_asthma_coughing, wheezing, or difficulty breathing during or
after exercise_family history of asthma_use of an inhaler_paired organs
77
_mononucleosis_dermatologic conditions_heat illnesses_fainting, vomiting, cramping from the heat_hospitalization from heat_having an IV_sickle cell disease_vision problems_glasses or contacts_protective eyewear in competition_eye surgery_nutrition_gaining or losing weight_controlling the diet_diet pills, diuretics, laxatives, or other weight
loss techniques_additional exercise outside of training for sport_menstrual history_periods within the last 12 months_stress level_depression_cigarette smoking_chewing tobacco, snuff, or dip_alcohol use
Cardiovascular HistoryCheck all that apply concerning cardiovascular screening. Does the PPE ask about:
_passing out during exercise_nearly passing out after exercise_chest pain, discomfort, or pressure during exercise_heart racing or skipping beats_high blood pressure, high cholesterol, heart murmur,
or heart infection_previous heart tests (ECG, echocardiogram)_family history of sudden death_family history of heart problems_any family member dieing before the age of 50_family history of Marfan syndrome_missed practices or games for chest pains
Musculoskeletal HistoryCheck all that apply concerning the musculoskeletal history. Does the PPE ask about:
_surgery_hospitalization
78
_previous injuries_missed practices or games from injury_fractures or dislocations_stress fractures_x-rays, MRI, CT, surgery, injections, rehabilitation,
PT, braces, casts, or crutchesNeurological HistoryCheck all that apply concerning the neurological History. Does the PPE ask about:
_previous head injury or concussion_seizures_headaches with exercise_numbness, tingling, or weakness in arms or legs_missing a practice or games for a head injury_seeing a doctor for a head injury_x-ray or CT scan for a head injury_hospitalization for a head injury
Immunization RecordsWhat immunizations are required for participation?
_Tetanus_MMR_Hepatitis B_Influenza_Poliomyelitis_Hepatitis A_pneumococcal_Meningococcal_varicella
Physical Examination
1) Check all that are included in the physical examination._Height_weight_visual acuity_pupil size_BMI_oral cavity_ears_nose_lungs_blood pressure seated_blood pressure standing_blood pressure supine_radial pulse
79
_femoral pulse_heart rate_heart rhythm_heart murmurs_abdomen_genitalia (males)_skin_musculoskeletal exam_neurological exam
2) Does the PPE use a general musculoskeletal screening for all athletes?
3) If yes, check all areas included in the screening?_Posture_cervical flexion_cervical extension_cervical rotation_cervical lateral flexion_shoulder shrug_resisted shoulder shrug_shoulder abduction_resisted shoulder abduction_internal and external rotation of the shoulder_elbow ROM_pronation and supination of the forearm_finger ROM_back extension_back flexion_duck walk_squat_calf raises_single leg balanceother _______
4) Does the PPE use joint specific testing when athlete has history of previous injury?
5) Does the PPE use functional testing of an athlete with a previous history?
6) If yes, list the functional tests used?7) Does the PPE use sport specific tests?
80
APPENDIX C3
Preparticipation Physical Examination Survey
81
Preparticipation Physical Examination Survey
1) Who administers the PPE? Check all that apply.• Primary Care Physician (PCP)• Orthopedist, Certified • Nurse Practioner• Registered Nurse (RN)• Physician’s Assistant (PA)• Certified Athletic Trainer (ATC)• Student Athletic Trainer (ATS)• Other
2) If you answered other, state who administers the PPE.
3) Who designs the PPE? Check all that apply.• PCP• Orthopedist• Certified Nurse Practioner• RN• PA• ATC • ATS • Athletic Director• other
4) If other, state who.
5) Where is the PPE administered? (Station-based exam= more than 1 examiner)
• Athlete’s PCP office (physician only)• Athlete’s PCP office (station-based exam)• Student/University Health Center (physician only)• Student/University Health Center (station-based
exam)• Athletic Training Site (physician only)• Athletic Training Site (station-based exam)
6) How many examiners administer the PPE and what is the education level for each? How many years of experience in sports medicine do they have? (14 slots for examiners)
Education level Years Sports Medicine• Student 1-3
82
• Bachelor 4-6• Master 7-10• Doctorate 10+• MD• DO• PA• Certified Nurse Practioner
7) When is the PPE performed? • Day before preseason• During Fall semester• During spring semester• 6-8 weeks before preseason• Other
8) If other, state when.
9) How often is the PPE administered?• Annually• Biannually• 1st year as an athlete• No PPE
10) Do returning athletes have a full PPE or an updated medical history screening?
• Full PPE• Updated medical history screening• Other (please specify)_______________
11) Do you use a paper PPE or web-based PPE?• Paper PPE• Web-based PPE
12) Are there sport specific PPEs or a standard institutional PPE for all sports?
• Sport specific• Standard institutional
13) What sports have sport specific PPEs? Check all that apply.
• Archery• Baseball• Basketball (W)
83
• Basketball (M)• Bowling• Cross Country• Equestrian• Fencing• Field Hockey• Football• Golf• Gymnastics (W)• Gymnastics (M)• Ice Hockey (W)• Ice Hockey (M)• Track & Field • Lacrosse (W)• Lacrosse (M)• Rifle• Rugby• Skiing• Soccer (W)• Soccer (M)• Softball• Squash• Swimming & Diving• Tennis• Volleyball (W)• Volleyball (M)• Waterpolo• Wrestling• Other (please specify)_______________
14) Is there a fee charged to the student for the physical?
• Yes• No
15) Do you obtain records of previous injuries from athlete’s doctors, physical therapists, and ATCs?
• Yes • No
84
Medical History16) What items does your institution’s PPE currently ask
about? Check all that apply.• Prior restrictions to participation• Chronic medical conditions• Medications• Over-the-counter drugs• Supplements• Allergies• Anaphylaxis• EpiPens• Hospitalization from allergies• Asthma• Coughing, wheezing, or difficulty breathing
during or after exercise• Family history of asthma• Use of an inhaler• Paired organs• Mononucleosis• Dermatologic conditions• Heat illnesses• Fainting, vomiting, cramping from the heat• Hospitalization from heat• Having an IV• Sickle cell disease• Vision problems• Glasses or contacts• Protective eyewear in competition• Eye surgery• Nutrition• Gaining or losing weight• Controlling the diet• Diet pills, diuretics, laxatives, or other weight
loss techniques• Additional exercise outside of training for sport• Menstrual history• Periods within the last 12 months• Stress level• Depression• Cigarette smoking• Chewing tobacco, snuff, or dip• Alcohol use
85
• Other (please specify)
Cardiovascular History17) What items does your institution’s PPE currently ask
about? Check all that apply.• Passing out during exercise• Nearly passing out after exercise• Chest pain, discomfort, or pressure during
exercise• Heart racing or skipping beats• High blood pressure, high cholesterol, heart
murmur, or heart infection• Previous heart tests (ECG, echocardiogram)• Family history of sudden death• Family history of heart problems• Any family member dieing before the age of 50• Family history of Marfan syndrome• Missed practices or games for chest pains• Other (please specify)
Musculoskeletal History18) What items does your institution’s PPE currently ask
about? Check all that apply.• Surgery• Hospitalization• Previous injuries• Missed practices or games from injury• Fractures or dislocations• Stress fractures• Diagnostic Test (x-rays, MRI, CT)• Treatments (injections, rehabilitation, PT,
braces, casts, or crutches)• Other(please specify)
Neurological History19) What items does your institution’s PPE currently ask
about? Check all that apply.• Previous head injury or concussion• Seizures• Headaches with exercise• Numbness, tingling, or weakness in arms or legs• Missing a practice or games for a head injury• Seeing a doctor for a head injury
86
• X-ray or CT scan for a head injury• Hospitalization for a head injury• Other (please specify)
Immunization Records20) What immunizations are required for participation?
• Tetanus• MMR• Hepatitis B• Influenza• Poliomyelitis• Hepatitis A• Pneumococcal• Meningococcal• Varicella• Diphtheria• TB test• Other (please specify)
Physical Examination21) Check all that are included in the physical
examination.• Height• Weight• Visual acuity• Pupil size• BMI• Oral cavity• Ears• Nose• Lungs• Blood pressure seated• Blood pressure standing• Blood pressure supine• Radial pulse• Femoral pulse• Heart rate• Heart rhythm• Heart murmurs• Abdomen• Genitalia (males)• Skin
87
• Musculoskeletal exam• Neurological exam• Urine analysis• Blood work• Other (please specify)
22) Does the PPE use a general musculoskeletal screening for all athletes?
• Yes• No
23) If yes, check all areas included in the screening?• Posture• Cervical flexion• Cervical extension• Cervical rotation• Cervical lateral flexion• Shoulder shrug• Resisted shoulder shrug• Shoulder abduction• Resisted shoulder abduction• Internal and external rotation of the shoulder• Elbow ROM• Pronation and supination of the forearm• Finger ROM• Back extension• Back flexion• Duck walk• Squat• Calf raises• Single leg balance• Other (please specify)
24) Does the PPE use joint specific testing when an athlete has a history of previous injury?
• Yes• No
25) Does the PPE use functional testing of an athlete with a previous history?
• Yes• No
88
26) If yes, list the functional tests used?
27) Does the PPE use sport specific tests?• Yes• No
89
APPENDIX C4
Institutional Review Board
90
91
92
93
94
95
APPENDIX C5
Subject Cover Letter
96
Date February 20, 2006
Dear Head ATC:
My name is Beth Conroy, and I am currently a graduate athletic training student attending California University of Pennsylvania. As part of my thesis project for the Master of Science in Athletic Training, I am conducting a survey to identify the current Preparticipation Physical Examination (PPE) components utilized by National Collegiate Athletic Association (NCAA) Division III institutions. Information gathered carries with it the potential to be a tool in preventing injuries.
Please click here: (Ctrl + Click) http://www.surveymonkey.com/s.asp?u=310601782656 to visit the website containing the Preparticipation Physical Examination Survey which has been approved by the California University of Pennsylvania IRB. It consists of questions pertaining to the components of your PPE. Please visit the website and complete the survey no later thanFriday March 3, 2006. Your participation in this study is strictly voluntary. The information provided by you is completely confidential. Informed consent will be implied upon completion of the survey. All results will be stored on a hard drive and only available to the researcher and research advisor. If you have any questions, please feel free to contact me at con0957@cup.edu or 724-938-4562.
I hope that you will take the time to participate in this study. Thank you in advance for your time and efforts.
Sincerely,
Beth A. Conroy, ATC, CSCSCalifornia University of Pennsylvania
97
APPENDIX C6
Follow-up Subject Cover Letter
98
Date March 1, 2006
Dear Head ATC:
This is a follow-up email concerning the Preparticipation Physical Examination Survey. Thank you to those who have already completed the survey. Your help is greatly appreciated and valued. This second email is slightly early than expected due to a technically error. Currently, the website is work properly.
For those who would like to participate but have not yet, please click here: (Ctrl + Click) http://www.surveymonkey.com/s.asp?u=310601782656 to visit the website containing the Preparticipation Physical Examination Survey which has been approved by the California University of Pennsylvania IRB. It consists of questions pertaining to the components of your PPE. Please visit the website and complete the survey no later than Wednesday March 8, 2006. Your participation in this study is strictly voluntary. The information provided by you is completely confidential. Informed consent will be implied upon completion of the survey. All results will be stored on a hard drive and only available to the researcher and research advisor. If you have any questions, please feel free to contact me at con0957@cup.edu or 724-938-4562.
I hope that you will take the time to participate in this study. Thank you in advance for your time and efforts.
Sincerely,
Beth A. Conroy, ATC, CSCSCalifornia University of Pennsylvania
99
APPENDIX C7
Frequency Tables for Results
100
Table 11. All Medical History Components by CredentialsComponent PCP Orthopedist Physician CNP RN PA ATC Prior restrictions to participation 83.6 92.2 84.6 91.9 92.0 85.7 85.0
Chronic medical conditions 95.5 98.0 95.4 97.3 96.0 96.4 98.8Medications 95.5 100.0 96.2 97.3 96.0 96.4 98.8Over-the-Counter drugs 62.7 66.7 62.3 70.3 68.0 67.9 65.0Supplements 66.4 66.7 64.6 62.2 56.0 71.4 71.3Allergies 95.5 100.0 96.2 97.3 92.0 92.9 97.5Anaphylaxis 55.5 54.9 53.8 48.6 60.0 64.3 62.5EpiPens 53.6 56.9 55.4 51.4 48.0 60.7 60.0Hospitalization from allergies 42.7 60.8 46.2 40.5 56.0 57.1 50.0Asthma 95.5 98.0 96.2 97.3 96.0 96.4 97.5Coughing, wheezing, or difficulty breathing during or after exercise
86.4 92.2 85.4 83.8 92.0 96.4 90.0
Family history of asthma 78.2 84.3 76.9 70.3 80.0 89.3 75.0Use of an inhaler 74.5 78.4 75.4 78.4 76.0 82.1 78.8Paired organs 74.5 70.6 70.8 59.5 68.0 82.1 70.0Dermatologic conditions 54.5 54.9 53.1 45.9 52.0 67.9 58.8Heat illnesses 83.6 88.2 83.1 73.0 80.0 85.7 88.8Fainting, vomiting, cramping from the heat 76.4 84.3 75.4 64.9 68.0 78.6 81.3
Hospitalization from heat 55.5 60.8 56.2 45.9 52.0 64.3 58.8Mononucleosis 68.2 76.5 69.2 70.3 72.0 71.4 75.0Having an IV 10.0 9.8 9.2 16.2 8.0 17.9 10.0Sickle cell disease 48.2 60.8 50.0 48.6 36.0 57.1 51.3
101
Table 11. All Medical History Components by Credentials (cont.)Component PCP Orthopedist Physician CNP RN PA ATC Vision problems 80.9 86.3 81.5 78.4 84.0 96.4 86.3Glasses or contacts 85.5 94.1 86.2 81.1 92.0 89.3 93.8Protective eyewear in competition 50.9 56.9 53.8 56.8 52.0 60.7 65.0
Eye Surgery 40.9 49.0 40.0 43.2 36.0 46.4 42.5Nutrition 39.1 41.2 39.2 27.0 32.0 39.3 43.8Gaining or losing weight 70.9 76.5 70.8 62.2 64.0 75.0 76.3Controlling the diet 31.8 35.3 31.5 27.0 24.0 35.7 37.5
Diet pills, diuretics, laxatives, or other weight loss techniques
40.0 47.1 40.8 32.4 32.0 46.4 46.3
Additional exercise outside of training for sport 17.3 21.6 20.0 16.2 16.0 28.6 22.5
Menstrual history 84.5 82.4 84.6 86.5 84.0 92.9 85.0Periods within the last 12 months 71.8 68.6 70.8 64.9 60.0 75.0 68.8
Stress level 26.4 31.4 26.9 29.7 20.0 39.3 28.8Depression 40.0 35.3 38.5 40.5 36.0 50.0 37.5Cigarette smoking 44.5 39.2 45.4 40.5 48.0 32.1 47.5
Chewing tobacco, snuff, or dip 40.9 35.3 39.2 27.0 36.0 28.6 41.3
Alcohol use 41.8 37.3 40.8 37.8 40.0 32.1 37.5
102
Table 12. All Cardiovascular History Components by CredentialsComponent PCP Orthopedist Physician CNP RN PA ATC
Passing out during exercise 71.8 76.5 72.3 67.6 72.0 78.6 81.3Nearly passing out after exercise 41.8 43.1 41.5 29.7 36.0 46.4 42.5
Chest pain, discomfort, or pressure during exercise
86.4 90.2 86.9 91.9 88.0 92.9 91.3
Heart racing or skipping beats 67.3 72.5 69.2 70.3 72.0 82.1 71.3High blood pressure, high cholesterol, heart murmur, or heart infection
90.9 96.1 91.5 94.6 92.0 96.4 96.3
Previous heart test (ECG, echocardiogram) 58.2 62.7 56.2 43.2 60.0 67.9 57.5
Family history of sudden death 88.2 86.3 87.7 86.5 96.0 96.4 88.8Family history of heart problems
88.2 92.2 88.5 83.8 96.0 96.4 91.3
Any family member dying before the age of 50 83.6 76.5 82.3 83.8 88.0 96.4 85.0
Family history of Marfan Syndrome 48.2 43.1 47.7 51.4 48.0 50.0 43.8
Missed practices or games for chest pains 24.5 19.6 23.1 18.9 20.0 28.6 23.8
103
Table 13. All Musculoskeletal History Components by Credentials
Component PCP Orthopedist Physician CNP RN PA ATCSurgery 94.5 100.0 95.4 97.3 92.0 92.9 97.5Hospitalization 85.5 86.3 85.4 91.9 76.0 85.7 83.8Previous injuries 96.4 96.1 95.4 94.6 96.0 92.9 96.3Missed practices or games from injury 35.5 43.1 36.9 37.8 32.0 53.6 50.0Fractures or dislocations 90.9 98.0 92.3 91.9 88.0 89.3 96.3Stress fractures 67.3 76.5 68.5 75.7 68.0 75.0 72.5Diagnostic tests (x-rays, MRI, CT) 45.5 41.2 43.1 32.4 44.0 39.3 41.3Treatments (injections, rehabilitation, PT) 44.5 45.1 43.8 40.5 36.0 57.1 48.8Braces, casts, or crutches 50.0 64.7 52.3 43.2 44.0 64.3 65.0
104
Table 14. All Neurological History Components by CredentialsComponent PCP Orthopedist Physician CNP RN PA ATC
Previous head injury or concussion 94.5 98.0 94.6 91.9 92.0 92.9 97.5Seizures 89.1 84.3 86.9 94.6 84.0 92.9 88.8Headaches with exercise 65.5 74.5 65.4 59.5 64.0 75.0 73.8Numbness, tingling, or weakness in arms or legs 64.5 70.6 66.2 59.5 64.0 78.6 73.8Missing a practice or games for a head injury 39.1 37.3 38.5 32.4 28.0 46.4 40.0Seeing a doctor for a head injury 53.6 52.9 53.1 43.2 36.0 53.6 52.5X-ray or CT scan for a head injury 42.7 35.3 40.8 29.7 32.0 46.4 38.8Hospitalization for a head injury 54.5 66.7 56.9 51.4 52.0 64.3 58.8
105
Table 15. All Immunizations by Credentials
Component PCP Orthopedist Physician CNP RN PA ATCTetanus 72.7 76.5 73.1 75.7 80.0 67.9 73.8MMR 64.5 64.7 64.6 75.7 56.0 60.7 63.8Hepatitis B 49.1 45.1 48.5 64.9 52.0 42.9 50.0Influenza 13.6 5.9 12.3 24.3 8.0 7.1 11.3Poliomyelitis 19.1 21.6 20.0 13.5 20.0 17.9 17.5Hepatitis A 18.2 9.8 16.9 16.2 12.0 10.7 16.3Pneumococcal 10.9 3.9 9.2 8.1 0.0 3.6 7.5Meningococcal 28.2 27.5 27.7 35.1 24.0 17.9 27.5Varicella 17.3 13.7 16.2 13.5 4.0 7.1 15.0Diphtheria 39.1 37.3 38.5 40.5 44.0 42.9 36.3TB test 50.9 47.1 50.0 48.6 48.0 39.3 48.8
106
Table 16. All Physical Exam Components by Credentials
Component PCP Orthopedist Physician CNP RN PA ATCHeight 91.8 96.1 91.5 91.9 96.0 96.4 97.5Weight 91.8 98.0 92.3 91.9 96.0 96.4 98.8Visual acuity 72.7 66.7 68.5 54.1 72.0 75.0 70.0Pupil size 22.7 23.5 23.1 16.2 16.0 28.6 23.8BMI 9.1 7.8 9.2 13.5 4.0 10.7 8.8Oral cavity 31.8 39.2 30.8 35.1 32.0 39.3 33.8Ears 78.2 68.6 73.8 73.0 76.0 85.7 72.5Nose 76.4 66.7 72.3 70.3 76.0 85.7 71.3Lungs 83.6 76.5 80.0 78.4 80.0 89.3 77.5Blood pressure seated 90.9 94.1 90.8 91.9 96.0 92.9 96.3Blood pressure standing 5.5 3.9 5.4 10.8 0.0 7.1 5.0Blood pressure supine 3.6 5.9 3.8 5.4 0.0 7.1 2.5Radial pulse 61.8 66.7 64.6 59.5 56.0 50.0 70.0Femoral pulse 7.3 3.9 6.9 0.0 8.0 7.1 5.0Heart rate 76.4 82.4 77.7 75.7 88.0 89.3 81.3Heart rhythm 54.5 66.7 56.2 45.9 72.0 60.7 66.3Heart murmurs 80.0 80.4 78.5 78.4 84.0 85.7 81.3Abdomen 80.9 78.4 76.9 67.6 80.0 78.6 77.5Genitalia (males) 60.0 47.1 53.1 51.4 64.0 67.9 46.3Skin 60.9 58.8 57.7 56.8 56.0 78.6 56.3Musculoskeletal exam 83.6 98.0 85.4 81.1 80.0 89.3 91.3Neurological exam 60.0 66.7 57.7 59.5 52.0 71.4 57.5Urine analysis 27.3 15.7 23.8 29.7 16.0 32.1 17.5Blood work 10.9 5.9 9.2 13.5 8.0 7.1 2.5
107
Table 17. All Musculoskeletal Exam Components by CredentialsComponent PCP Orthopedist Physician CNP RN PA ATC
Posture 58.2 76.5 60.8 54.1 56.0 64.3 67.5Cervical flexion 57.3 88.2 63.1 56.8 64.0 71.4 77.5Cervical extension 57.3 88.2 63.1 56.8 64.0 71.4 77.5Cervical rotation 56.4 86.3 61.5 56.8 64.0 71.4 75.0Cervical lateral flexion 57.3 86.3 62.3 56.8 64.0 71.4 76.3Shoulder shrug 52.7 80.4 58.5 54.1 56.0 60.7 70.0Resisted shoulder shrug 44.5 66.7 50.8 40.5 44.0 57.1 62.5Shoulder abduction 54.5 86.3 60.8 59.5 52.0 71.4 71.3Resisted shoulder abduction 48.2 70.6 54.6 45.9 44.0 64.3 67.5Internal and external rotation of the shoulder 50.9 76.5 56.9 51.4 44.0 60.7 70.0
Elbow ROM 47.3 68.6 52.3 51.4 40.0 53.6 63.8Pronation and supination of the forearm 44.5 62.7 48.5 43.2 36.0 50.0 58.8
Finger ROM 36.4 49.0 40.0 32.4 28.0 39.3 47.5Back extension 57.3 82.4 60.8 56.8 56.0 60.7 72.5Back flexion 57.3 86.3 62.3 56.8 60.0 67.9 76.3Duck walk 39.1 49.0 41.5 35.1 32.0 46.4 48.8Squat 51.8 72.5 53.1 37.8 56.0 53.6 66.3Calf raises 43.6 58.8 45.4 35.1 40.0 42.9 57.5Single leg balance 31.8 39.2 33.8 27.0 36.0 35.7 41.3
108
Table 18. All Medical History Components by Examiner Groups
Component Total 0-2 3-5 6-8 9-11 12-14Prior restrictions to participation*
83.5 78.3 91.2 86.4 80.0 84.6
Chronic medical conditions* 95.7 91.7 97.1 100.0 100.0 100.0
Medications* 96.4 91.7 100.0 100.0 100.0 100.0
Over-the-Counter drugs* 63.3 58.3 73.5 68.2 40.0 69.2
Supplements* 64.7 58.3 70.6 68.2 60.0 76.9
Allergies* 96.4 93.3 100.0 95.5 100.0 100.0
Anaphylaxis* 54.7 51.7 52.9 54.5 60.0 69.2
EpiPens* 56.1 60.0 47.1 68.2 40.0 53.8
Hospitalization from allergies* 45.3 31.7 55.9 54.5 30.0 76.9
Asthma* 96.4 93.3 100.0 100.0 100.0 92.3Coughing, wheezing, or difficulty breathing during or after exercise†
86.3 78.3 91.2 95.5 90.0 92.3
Family history of asthma* 74.8 65.0 76.5 90.9 90.0 76.9
Use of an inhaler* 77.0 73.3 76.5 86.4 80.0 76.9
Paired organs* 68.3 65.0 64.7 77.3 90.0 61.5
Mononucleosis* 71.2 66.7 67.6 77.3 90.0 76.9
Dermatologic conditions* 54.0 55.0 52.9 54.5 50.0 53.8
Heat illnesses* 82.7 78.3 79.4 90.9 90.0 92.3Fainting, vomiting, cramping from the heat*
76.3 76.7 70.6 63.6 100.0 92.3
Hospitalization from heat* 55.4 55.0 41.2 50.0 80.0 84.6
Having an IV* 10.1 6.7 17.6 13.6 10.0 0.0
Sickle cell disease* 48.9 46.7 38.2 59.1 70.0 53.8
*PPE 3rd edition component †AHA Cardiovascular Screening & PPE 3rd Edition Component
109
Table 18. All Medical History Components by Examiner Groups (cont.)
Component Total 0-2 3-5 6-8 9-11 12-14Vision problems* 82.0 78.3 79.4 90.9 70.0 100.0
Glasses or contacts* 87.1 78.3 88.2 95.5 100.0 100.0Protective eyewear in competition* 56.8 46.7 73.5 50.0 40.0 84.6
Eye Surgery* 41.0 36.7 38.2 45.5 40.0 61.5
Nutrition* 38.8 33.3 35.3 40.9 50.0 61.5
Gaining or losing weight* 70.5 65.0 67.6 81.8 90.0 69.2
Controlling the diet* 31.7 25.0 32.4 31.8 30.0 61.5Diet pills, diuretics, laxatives, or other weight loss techniques* 40.3 41.7 32.4 45.5 30.0 53.8
Additional exercise outside of training for sport*
19.4 13.3 20.6 31.8 10.0 30.8
Menstrual history* 84.9 83.3 82.4 90.9 90.0 84.6Periods within the last 12 months* 70.5 75.0 67.6 63.6 50.0 84.6
Stress level* 25.9 21.7 23.5 31.8 10.0 53.8
Depression* 40.3 41.7 38.2 40.9 40.0 38.5
Cigarette smoking* 56.3 43.3 50.0 45.5 30.0 53.8
Chewing tobacco, snuff, or dip* 38.8 35.0 41.2 40.9 30.0 53.8
Alcohol use* 39.6 36.7 41.2 45.5 30.0 46.2
* PPE 3rd edition component† AHA Cardiovascular Screening & PPE 3rd Edition Component
110
Table 19. All Cardiovascular History Components by Examiner Groups
Component Total 0-2 3-5 6-8 9-11 12-14Passing out during exercise† 73.4 65.0 79.4 81.8 80.0 76.9Nearly passing out after exercise* 40.3 38.3 35.3 45.5 20.0 69.2
Chest pain, discomfort, or pressure during exercise†
87.8 80.0 94.1 95.5 90.0 92.3
Heart racing or skipping beats* 68.3 65.0 67.6 68.2 70.0 84.6High blood pressure, high cholesterol, heart murmur, or heart infection†
92.1 88.3 91.2 95.5 100.0 100.0
Previous heart test (ECG, echocardiogram)* 56.1 56.7 50.0 54.5 60.0 69.2
Family history of sudden death† 87.8 81.7 91.2 95.5 90.0 92.3
Family history of heart problems† 87.8 85.0 85.3 90.9 90.0 100.0Any family member dying before the age of 50†
81.3 76.7 79.4 86.4 90.0 92.3
Family history of Marfan Syndrome* 45.3 35.0 47.1 54.5 70.0 53.8
Missed practices or games for chest pains* 23.0 23.3 23.5 27.3 10.0 23.1
* PPE 3rd edition component† AHA Cardiovascular Screening & PPE 3rd Edition Component
111
Table 20. All Musculoskeletal History Components by Examiner Groups
Component Total 0-2 3-5 6-8 9-11 12-14Surgery* 95.7 91.7 100.0 95.5 100.0 100.0
Hospitalization* 84.2 83.3 85.3 81.8 90.0 84.6
Previous injuries* 95.7 93.3 97.1 95.5 100.0 100.0Missed practices or games from injury* 38.1 26.7 44.1 45.5 50.0 53.8
Fractures or dislocations* 92.8 88.3 97.1 90.9 100.0 100.0
Stress fractures* 69.1 60.0 61.8 77.3 100.0 92.3Diagnostic tests (x-rays, MRI, CT)*
41.7 38.3 44.1 36.4 50.0 53.8
Treatments (injections, rehabilitation, PT)* 43.2 38.3 38.2 40.9 50.0 76.9
Braces, casts, or crutches* 53.2 43.3 52.9 63.6 80.0 61.5* PPE 3rd edition component
112
Table 21. All Neurological History Components by Examiner Groups
Component Total 0-2 3-5 6-8 9-11 12-14Previous head injury orconcussion*
95.0 91.7 100.0 95.5 100.0 92.3
Seizures* 87.8 85.0 88.2 86.4 100.0 92.3
Headaches with exercise* 66.9 58.3 52.9 86.4 80.0 100.0Numbness, tingling, or weakness in arms or legs*
64.7 58.3 55.9 81.8 60.0 92.3
Missing a practice or games for a head injury* 38.1 36.7 35.3 45.5 10.0 61.5
Seeing a doctor for a head injury*
53.2 55.0 44.1 54.5 50.0 69.2
X-ray or CT scan for a head injury* 40.3 45.0 29.4 40.9 30.0 53.8
Hospitalization for a head injury* 56.8 53.3 50.0 63.6 70.0 69.2
* PPE 3rd edition component
113
Table 22. All Immunizations by Examiner Groups
Component Total 0-2 3-5 6-8 9-11 12-14Tetanus* 74.1 71.7 79.4 81.8 90.0 46.2MMR* 65.5 68.3 67.6 72.7 60.0 38.5Hepatitis B* 49.6 45.0 55.9 68.2 50.0 23.1Influenza* 12.2 10.0 20.6 18.2 0.0 0.0Poliomyelitis* 19.4 20.0 20.6 22.7 10.0 15.4Hepatitis A† 15.8 16.7 23.5 13.6 0.0 7.7Pneumococcal† 8.6 11.7 5.9 9.1 0.0 7.7Meningococcal† 28.1 25.0 44.1 31.8 10.0 7.7Varicella† 16.5 16.7 26.5 13.6 0.0 7.7Diphtheria* 38.1 33.3 52.9 45.5 20.0 23.1TB test 49.6 45.0 64.7 50.0 50.0 30.8* PPE 3rd edition “strongly recommended” immunizations† PPE 3rd edition “to be considered” immunizations
114
Table 23. All Physical Exam Components by Examiner Groups
Component Total 0-2 3-5 6-8 9-11 12-14Height* 92.1 85.0 94.1 100.0 100.0 100.0
Weight* 92.8 86.7 94.1 100.0 100.0 100.0
Visual acuity* 67.6 61.7 61.8 77.3 60.0 100.0
Pupil size* 23.0 18.3 26.5 31.8 10.0 30.8
BMI* 9.4 6.7 17.6 9.1 0.0 7.7
Oral cavity* 30.2 28.3 35.3 36.4 40.0 7.7
Ears* 71.9 73.3 70.6 72.7 90.0 53.8
Nose* 70.5 70.0 70.6 72.7 90.0 53.8
Lungs* 77.7 75.0 79.4 86.4 80.0 69.2
Blood pressure seated† 91.4 85.0 91.2 100.0 100.0 100.0
Blood pressure standing 5.8 8.3 2.9 9.1 0.0 0.0
Blood pressure supine 4.3 6.7 2.9 0.0 10.0 0.0
Radial pulse* 65.5 60.0 67.6 77.3 60.0 69.2
Femoral pulse† 6.5 8.3 2.9 13.6 0.0 0.0
Heart rate* 77.0 76.7 70.6 81.8 80.0 84.6
Heart rhythm* 56.8 40.0 70.6 68.2 70.0 69.2
Heart murmurs† 77.7 71.7 73.5 90.9 90.0 84.6
Abdomen* 74.8 68.3 76.5 81.8 90.0 76.9
Genitalia (males)* 50.4 53.3 44.1 68.2 50.0 23.1
Skin* 56.1 53.3 58.8 63.6 70.0 38.5
Musculoskeletal exam* 83.5 71.7 88.2 95.5 100.0 92.3
Neurological exam* 56.8 55.0 50.0 68.2 70.0 53.8
Urine analysis 23.0 28.3 14.7 31.8 10.0 15.4
Blood work 8.6 15.0 5.9 4.5 0.0 0.0
* PPE 3rd edition component † AHA Cardiovascular Screening & PPE 3rd Edition Component
115
Table 24. All Musculoskeletal Exam Components by Examiner Groups
Component Total 0-2 3-5 6-8 9-11 12-14Posture* 59.0 50.0 58.8 72.7 80.0 61.5
Cervical flexion* 62.6 43.3 76.5 81.8 80.0 69.2
Cervical extension* 62.6 43.3 76.5 81.8 80.0 69.2
Cervical rotation* 61.2 41.7 76.5 81.8 80.0 61.5
Cervical lateral flexion* 61.9 41.7 76.5 86.4 80.0 61.5
Shoulder shrug 57.6 43.3 70.6 72.7 80.0 46.2
Resisted shoulder shrug* 48.9 36.7 55.9 63.6 70.0 46.2
Shoulder abduction 59.7 45.0 64.7 81.8 80.0 61.5
Resisted shoulder abduction* 52.5 38.3 55.9 72.7 70.0 61.5Internal and external rotation of the shoulder* 56.1 43.3 61.8 77.3 60.0 61.5
Elbow ROM* 51.8 38.3 61.8 68.2 70.0 46.2Pronation and supination of the forearm* 46.8 36.7 55.9 54.5 70.0 38.5
Finger ROM Back extension* 38.1 31.7 47.1 50.0 40.0 23.1
Back extension* 59.0 43.3 70.6 72.7 80.0 61.5
Back flexion* 61.2 43.3 73.5 81.8 80.0 61.5
Duck walk* 40.3 28.3 44.1 50.0 60.0 53.8
Squat 52.5 35.0 64.7 63.6 80.0 61.5
Calf raises* 45.3 33.3 55.9 59.1 70.0 30.8
Single leg balance 32.4 21.7 44.1 50.0 40.0 15.4
* PPE 3rd edition component
116
REFERENCES
1. 2005-2006 NCAA Sports Medicine Handbook. Medical evaluation, immunizations and records. 2005:8-9. Available on www.ncaa.org/library/sports_sciences/sports_med_handbook /2005-06/. Accessed on September 10, 2005.
2. Myers A, Sickles T. Preparticipation sports examination.Adolescent Med. 1998;25:225-236.
3. Boyanjian-O’Neill L, Cardone D, Dexter W, et al.Determining clearance during the preparticipation evaluation. Phys Sportsmed[serial online]. 2004;32(11). Available on www.physsportsmed.com. Accessed on June 27, 2005.
4. Joy EA, Paisley TS, Price R Jr, Rassner L, Thiese SM. Optimizing the collegiate preparticipation physical evaluation. Clin J Sport Med. 2004;14:183-187.
5. Ray R. Management Strategies in Athletic Training 2nded. Human Kinetics: Champaign,FL;2000:254-268.
6. Glover DW, Maron BL, Matheson GO. The preparticipation physical examination: steps toward consensus and uniformity. Phys Sportsmed. 1999;27:29.
7. Committee on Competitive Safeguards and Medical Aspects of Sports. NCAA News July 1977. Available on www.ncaa.org. Accessed on September 15, 2005.
8. Garrick JG. Preparticipation orthopedic screening Evaluation. Clin J Sport Med 2004;14:123-126.
9. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopatheic Academy of Sports Medicine: Preparticipation Physical Evaluation, ed 3. Minneapolis, MN:McGraw-Hill:2004.
10. Maron BJ, Isner JM, McKenna WJ. 26th Bethesda Conference: Recommendations for determining the eligibility for competition in athletes with cardiovascular abnormalities. JACC. 1994:24(4)845-899.
117
11. Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, Clark LT, Mitten MJ, Crawford MD, Atkins DL, Driscoll DJ, Epstein AE. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee and Congenital Cardiac Def Committee, American Heart Association. Circulation. 1996;94:850-856 [addendum in 97:2294] Available on www.ahajournals.org. Accessed on June 28, 2005.
12. Lombardo JA. Preparticipation Examination. In Cantu RC, LJ Micheli,eds. ACSM’s guidelines for the team physician. Philadelphia: Lea & Febiger;1991:71-94.
13. Best TM. The preparticipaton evaluation: an opportunity for change and consensus. Clin J Sport Med. 2004;14:107-108.
14. O’Connor DL, Kibler WB, Krowchuk DP, Rice L, O’Connor DL. The preparticipation sports physical. JAAPA. 2001;14:47-56.
15. Reed FE. Improving the preparticipation exam process. J S Carolina Med Assoc. 2001;97:342-346.
16. Peltz JE, Haskell WL, Matheson GO. A comprehensive and cost-effective preparticipation exam implemented on the world wide web. Med Sci Sports Exerc. 1999;31:1727-1735.
17. Wingfield K, Matheson GO, Meeuwsisse W. Preparticipation evaluation: an evidence-based review. Clin J Sport Med.2004;14:109-122.
18. Colletti TP. Sports preparticipation evaluation. Phys Assistant. 2001;25(7):31-41.
19. Hulkower S, Fagan B, Watts J, Ketterman E. Do preparticipation clinical exams reduce morbidity and mortality for athletes? J Fam Practice 2005;54:628-632.
20. Koester MC. Making the preparticipation athletic evaluation more than just a “sports physical” part 2: performing a focused physical exam. Contemporary Pediatrics. 2003;20:107-118.
21. McCrory P. Preparticipation assessment for head injury. Clin J Sport Med. 2004;14:139-144.
118
22. Pfister GC, Uffer JC, Maron J. Preparticipation cardiovascular screening for US collegiate student-athletes. JAMA. 2000;283:1597-1599.
23. Carek PJ, Futrell M. Athletes’ view of the preparticipation physical examination. Arch Fam Med. 1999;8:307-312.
24. Beals KA. Eating disorder and menstrual dysfunction screening, education, and treatment programs: survey results from NCAA division 1 schools. Phys Sportsmed[serial online]. 2003;31(7). Available on www.physsportmed.com. Accessed on June 27, 2005.
25. Black DR, Larkin LJS, Coster DC, Leverenz LJ, Abood DA. Physiologic screening test for eating disorders/disordered eating among female collegiate athletes. J Athl Train. 2003;38:286-297.
26. LaBotz M, Martin MR, Kimura IF, Hetzler RK, Nichols AW. A comparison of a preparticipation evaluation history form and a symptom-based concussion survey in the identification of previous head injury in collegiate athletes. Clin J Sport Med. 2005;15:73-78.
119
ABSTRACT
TITLE: A SURVEY OF PREPARTICIPATION PHYSICALEXAMINATION COMPONENTS AT NCAA DIVISION III INSTITUTIONS
RESEARCHER: Beth A. Conroy, ATC, CSCS
ADVISOR: William Biddington EdD, ATC
DATE: May 2006
RESEARCH TYPE: Master’s Thesis
PURPOSE: The purpose of this study was to compare NCAA member institutions procedures and components concerning PPE for student-athletes.
PROBLEM: The NCAA has recommendations for areas to be covered in a PPE but does not require nor standardize the PPE.
METHOD: A descriptive research design, using 139 NCAA Division III Head ATCs, was conducted. The instrument used was the Preparticipation Physical Examination Survey, which was developed by the researcher.
FINDINGS: An average of 65 (59.1%) components from the PPE 3rd edition monograph were found to be used by the institutions. Thirty components were found to be reoccurring for the institutions. The use of an allied health professional does not mean they are responsible for the design of the PPE.
CONCLUSION: The lack of PPE components used by the sample of Division III institutions supports the need to bring awareness to the PPE 3rd
edition monograph.