NATA Position Statement

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

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

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

4. Interesting Facts • 2010-2011 = 7.6 million High School Students used a standardized PPE, p102 • A complete Medical History identifies approximately 75% of problems that affect initial athletic participation. p106 • SCD occurs in about 0.5 per 100,000 high school athletes per academic year. p107 • EIB in elite athletes, 6-21%, so screen. p113 • 30% of young adults (18-25) had the highest level of Mental Health Illness, p115

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

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

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

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

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

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

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

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

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

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

15. Recommendations continued • Administration of PPE #22 - 27 • Determining Clearance # 28-29 29. Team Physicians and Institutions have the legal right to restrict an individual from participating in athletics, provided the decision is individualized, reasonably make, and based on competent medical evidence.

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

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

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

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

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

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

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

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

24. Discussion and Questions

25. Take Away Points