Authors: Rose Uzoma Elekanachi
Rose Uzoma Elekanachi. BPT, MSc, mMRTB
29 Shaw Road,
Bridgewater, MA, 02324
Rose Uzoma Elekanachi is a Nigerian Physical therapist and a recent Graduate of Bridgewater State University with a Masters in Physical Education with a concentration in Exercise Science. She is also a member of the Medical Rehabilitation Therapist Board in Nigeria.
Physical Exam Risk Factors for Cardiovascular Abnormalities in College Sport Athletes: A Systematic Review
The preparticipation physical examination (PPE) is an important area of the care and safety of any active athletic individuals. The evaluation involves a process that brings about the discovery of life threatening or disabling conditions that could prevent athletes’ participation from sporting activities or predispose them to injuries or death.
The preparticipation evaluation was not made to prevent or exclude athletes from participation, rather to help athletes practice safe sport participation. There has been a long ongoing debate on the inclusion and importance of cardiovascular analysis as a part of the PPE as cardiovascular abnormalities is a risk factor that predisposes collegiate athlete to sport injuries or even death. The objective of the proposed project was to identify the clinical methods that most effectively assess cardiovascular abnormalities in intercollegiate athletes through a systematic review of existing published research studies in which cardiovascular abnormalities in intercollegiate athletes were included as measurement variables.
Keywords: Preparticipation Evaluation (PPE), Cardiovascular Abnormalities, Collegiate Athlete, Injury risk assessment
In the United States and internationally, leagues that do not have a players’ unions may require the pre-participation evaluation (PPE); however, they do not necessarily have contracts that have been collectively bargained by a trade union throughout many professional sports and a requirement before participation in National Collegiate Athletic Association (NCCA) governed intercollegiate athletics (13). Sport-related injuries can have substantial impact on the long-term health of student-athletes. Injuries can be sustained at any point in time, but during sport participation injuries are mostly sustained at the pre-season period or the in-season period (15). In order to curb the incidence of sport injuries, the PPE was introduced to clear sport athletes before the season begins and confirms that the sport athlete was free from underlying factors that could predispose the athlete to sport injuries. If underlying factors were identified, the PPE gives medical professionals an opportunity to give the player the best medical advice so that he/she can go back into the field of play as soon as possible (15).
Maron et al, 2005 stated that the inconsistency of the different components of the PPE affected its effectiveness. There has been a lot of effort to bring about PPE consistency but that has not been effective because individuals (coaches and athletic trainers) don’t see a reason to use a PPE. The PPE is used to collect an athlete’s medical history, musculoskeletal, neurological and cardiovascular examination to determine clearance for sports participation which has being used in both the professional level and can be used in the lower divisions such as collegiate athletes. The main objective when PPE is used, is to detect underlying or pre-existing conditions (medical problems) with life threatening complications that may predispose the athlete to life-threatening or disabling events due to inherited or acquired conditions.
Some countries make it a mandate that all competitive athletes undergo preparticipation screening, while in some countries it is recommended in order to prevent sudden cardiac issues in predisposed athletes (11). In 2011, La Grache et al. discovered that there is evidence to show screening reduces sudden death in athletes, but the potential evasive impact of exclusion from the sport has not been quantified. While the prevalence of some conditions, which are screened for such as coronary artery anomalies and long QT syndromes, are stable across different populations, the prevalence of underlying conditions such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysphasia shows considerable geographic variability (11). Therefore, justifying the need for a mandate on PPE in countries known for prevalent underlying conditions.
While the potential benefits of the PPE are substantial, there are numerous challenges with the process of administering the PPE that currently limit its effectiveness. Foremost of these challenges is the continued use of non-uniform paper questionnaires that limit the ability to collect and analyze standardized data on millions of participants completing the PPE each year.
This makes it difficult to keep track of the athlete’s data base on their past evaluations for reference and for research purposes. Irrespective of the idea that the value of PPE is unknown, there are no indicators of a quick change on the PPE that makes a careful evaluation of athletes possible. The interest to measure the effectiveness of PPE is to determine its value and measure what the outcome would be if the data is collected electronically. In 2015, Matheson et al noted that an electronic questionnaire ideally would solve other problems for stakeholders, improving administrative efficiency, reduce cost, and streamline the PPE process.
Researchers (13, 5, 6) have carried out studies on data, injury and illnesses among collegiate athletes and have reported the immense size of injuries and illness being reported during sport activities over the years. There has been little or no record on prevention of these injuries or how participation of the collegiate athletes in Preparticipation evaluation have alleviated the occurrence of injuries and illnesses among collegiate athletes.
In 2001, McManus stated that Preparticipation screening is a means of facilitating better detection of cardiac disease in the young athlete, and even with future application of genetic testing; it’s unlikely to provide any guarantee of preventing sudden cardiac death. The history and physical examination by medical practitioner are unlikely to detect the prodromal signs and symptoms of cardiovascular abnormalities in many young athletes. “In terms of the detection capability of the screening process, addition of a diagnostic ECG and the assistance of specialist in the pediatric cardiology would be a great help” (14).
Therefore, the objective of the proposed study is to identify the clinical method that most effectively assess cardiovascular abnormalities in collegiate athletes through a systematic review of existing published research studies in which cardiovascular abnormalities in intercollegiate athletes were included as measurement variables.
Initial Search and Screening
In this study, the 2009 PRISMA checklist and guidelines (16) was used to ensure the review of each research study was systematic and efficient, and the recording and reporting was accurate. Additionally, use of the PRISMA checklist and guidelines helped to ensure the transparency and validity of study findings (16).
For this review, the following databases was analyzed: SportDiscus, Cochrane Database, and PubMed. Primary research studies in which the following keywords was used were included in the initial sample: Preparticipation evaluation (PPE); cardiovascular abnormalities; upper Extremity injury; collegiate athlete; injury risk assessment. Studies in which risk of cardiovascular anomalies were measured using the PPE meet the inclusion criteria.
Further screening and eligibility criteria was determined as studies were identified and in accordance with the PRISMA checklist and guidelines.
Data Collection and Reporting
After systematic review of studies that met the inclusion criteria, specific assessment data was extracted and a table containing the following data was created: purpose of the study, length of study (time), sample size, average age of participants, and sex of participants, NCAA level, sport, cardiovascular abnormalities and risk factors. The variability and estimated effect size of measures was also in this study. Finally, the strengths and weakness of the individual studies was documented in this study as well as its potential relevance of the results that were noted by the researchers.
After the screening process was complete, 7 prospective studies which involved collegiate athletes were identified. Three studies were specific to young athletes under the age of 35 years, who were into different sports or sporting activities, 2 were specific to collegiate athletes who participated in different divisions under the governance of the National Collegiate Athletic Association (NCAA), while 2 studies were specific to collegiate NCAA participating universities who have collegiate athletes participating in several sports. 1 was limited to male athletes and while, 6 was not limited to any sexes. Sample sizes ranges from 20-5,258 collegiate athletes and 20-300 NCAA participating universities. The overall reports of Cardiac abnormalities from physical examinations ranged from 3.7% in male collegiate athletes to 37% in young competitive athletes. The most common screening for cardiovascular abnormalities included Preparticipation evaluation and 12 Lead Electrocardiogram but there is a constant debate on if there should be combination of both methods of just one based on resulting response to PPE. The presence of cardiovascular abnormalities was reported based on athletes’ information on the PPE and needed clearance by an athletic trainer, or physician in 3 studies while 4 others and 2 required 12 lead ECG screening after PPE was completed.
Identified Clinical Assessments for Examination of Risk Factors.
None of the prospective studies that met the inclusion criteria that were identified that involved evaluation of all parts or part of the clinical assessment recommended in the PPE fourth ed. This review was able to identify several clinical examination modalities that have quite an initial evidence to indicate risk factors.
In 2014, Megan et al in a study on the cardiovascular screening on practices in collegiate athletes which evaluated screening practices and preparticipation evaluation (PPE) forms used to identify or raise suspicion of cardiovascular abnormalities in collegiate students’ athletes. 347 NCAA Division 1 universities were invited to participate in this study, 257 (74 %) agreed to participate in this study, all 257 universities required preparticipation evaluation screening for all freshman and transfer athletes and 83 universities (32%) requires an annual PPE for returning athletes. 85% of the universities required the PPE to be completed on campus, while 15% of the universities allowed the PPE to be completed by the athletes’ physician of choice before they arrive at the campus. 11 universities (4%) used the AHA recently updated PPE 4th, 16 universities (6%) used the AHA PPE 3rd edition while 260 universities didn’t use either of these forms. Only 21 universities of all the 257 division 1 universities in this study met the AHA recommendation by including all 12 cardiovascular screening on their PPE forms (18).
According to a research by Morse et al, 2010 it was reported that ‘Although the American Heart Association guidelines do not include ECG testing for preparticipation screening, the implementation of routine ECG testing for preparticipation sports physicals is effective in preventing Sudden Cardiac Death in athletes’. This conclusion was reported after examination of the preparticipation screening and prevention of sudden cardiac death in athletes: Implication for primary care. Data for this study was compiled by a review on the scientific literature on SCD in athletes, preparticipation exams, and current screening guidelines using CINAHL, MEDLINE and PubMed search engines (17). The implementation of ECG testing will assist the decision whether to disqualify an athlete from participation because of pre-existing cardiac conditions, and ultimately preventing the untimely death of a young athlete (17).
Three different studies (12, 8-9) in this review examined Preparticipation Evaluation (PPE) and prevention of sudden cardiac death in young collegiate athlete. The results proposed that most sudden cardiac death are due to silent cardiovascular diseases, and preparticipation screening of athletes at risk is thus of major Importance (8). In 2007, Maron et al reported that each condition known to be responsible for sudden cardiac death in young athletes occurs infrequently in the general population, ranging from the relatively common Hypertrophic Cardiomyopathy to much rarer conditions, such as congenital coronary artery anomalies, arrhythmogenic right ventricular dysplasia, ion channelopathies, and Marfan syndrome. Scientific committees such as American College of Cardiology, the American Heart Association (AHA) and the European Society of Cardiology (ESC) and others as reported by Chartard et al, 2015 recommended a Preparticipation Screening PPS program also known as PPE to provide medical clearance for participation in competitive sports, all recommendations included questionnaires relating to family history, personal history as well as a physical examination.
The necessity of a systemic resting 12 Lead ECG Screening is still under several debates between the North-American and European recommendations (8). However, the American Heart Association still does not recommend an ECG based on its numerous concerns including feasibility, cost-efficiency, prospect of high false positive results and the lack of physicians qualified to interpret ECGs (12). These tend to be different with professional sports as stricter rules and regulations are upheld. Figure 1 elaborately shows the different aspect of the PPE used for screening as reported by in 2013 by Borrione, P et al.
Figure 1 shows the AHA recommendations for preparticipationcardiovascular screening of competitive athletes.
In 2016, Drezner et al in another study on the electrocardiographic screening in National Collegiate Athletic Association Athletes which involved 35 National Collegiate Athletic Association institutions and the screening involved both standard history, physical examination (PPE) as recommended by the American Heart Association and a 12-lead electrocardiogram (ECG) at rest. From the 5,258 athletes accessed from the 17 intercollegiate screened at least one positive cardiac symptom of family history response was reported by 1,750 athletes (33.3%), it was also reported that the physical examination was abnormal in 108 athletes (2.1%) and electrocardiographic abnormalities were present in 192 athletes (3.7%). 13 athletes (0.25%) were identified with serious cardiac conditions including hypertrophic cardiomyopathy, large atrial septal defects with right ventricular dilations and ventricular pre-excitation. The false positive rate for history was 33.3%, PE 2.0% and ECG 3.4%. It was then concluded that electrographic screening in National Collegiate Athletic Association athletes has a low false-positive rate and provides superior accuracy compared with standardized history and PE to detect athletes with dangerous cardiovascular conditions.
In this review, a 2017 feasibility study by Gleason et al on the early screening for cardiovascular abnormalities with preparticipation echocardiography using a cross-sectional design to compare 3 screening methods to identify cardiovascular abnormalities. This study involved 35 division 1 male collegiate athletes who were enrolled with each athlete undergoing a screening with the traditional Physical and history (H&P) using the AHA 12 element preparticipation cardiovascular screening guidelines, ECG interpreted using the 2013 Seattle criteria and limited portable echocardiogram by a frontline physician (PEFP) obtained in the parasternal long axis view. The result of this study showed that the length of the time for screening was significantly shorter with limited PEFP (137.7 + 40.4seconds) in comparison with H&P (244.2 + 80.0 seconds) and ECG (244.9 + 85.6 seconds, 0.01). 6 athletes were reported to have positive findings in H&P screening and 3 athletes had positive ECG findings. One athlete was reported to have both a positive H&P and ECG screening. The three athletes with positive ECGs had negative PEFP screens. All the 3 athletes with positive ECG findings and the 2 athletes with a borderline finding on limited PEFP were referred for formal evaluation with a cardiologist. None of the 5 athletes were disqualified from competing after cardiac rehabilitation but one of the athletes with a positive screening-limited ECHO was determined to need annual monitoring. Gleason et al, concluded that incorporating limited PEFP into PPEs has the potential to limit the number of false-positive and false-negative cardiac sections which some researchers fear would occur if ECG or further testing modality apart from PPE was used to clear athletes. Limited PEFP was the fastest screening modality compared to traditional H&P and ECG methods. Considering time-driven activity-based levels of cost analysis, limited as part of the PPE gives the highest value; the most accurate and reliable information and the lowest money and time expenditure.
Cardiovascular abnormalities and sudden cardiac death assessment in college athletes and ways to identify and reduce its incidence has been a long-standing goal of sports medicine practitioners, coaches and athletic trainers. Some of the challenges that have been reported in developing a proper clinical assessment method for cardiovascular abnormalities have been the cost of effectiveness, feasibility when these assessments involve large populations of collegiate athletes, and diagnostic accuracy such as fear of false positive or false-positive results. Several clinical assessment strategies have been proposed with variations of specificity to the given populations resulting in several results. After an extensive review of the different literatures, that covered different sample sizes I found evidence that supported the use of PPE according to the AHA recommendation for cardiovascular screening for collegiate athletes. There seems to be a major level of evidence supporting the recommendation as seen in Figure 1 on the use of medical history, personal history, family history, and physical examination including exertional chest pain, unexplained syncope, excessive exertional and unexplained dyspnea, prior recognition of heart murmur, elevated systemic blood pressure, history of premature death, disability from heart disease in a close relative < 50 years of age, specific knowledge of certain cardiac conditions in family members, femoral pulses to exclude aortic coartation, physical stagmata of Marfan syndrome, brachial artery blood pressure in collegiate athletes as the risk factors for future injury, although this risk factors are limited to the athletes who are mainly exposed to sports that predisposes them to cardiovascular injuries, accidents or sudden cardiac death.
One of the numerous goals of the preparticipation evaluation/screening is to identify the potential risk of cardiovascular abnormalities or presence of functional deficits which could result in future injuries or deaths. The results of this review supported the use of the PPE as well as recommended that the process in which the PPE is completed, and the clearance methods which for some universities involved the athletes taken the PPE to be completed at home and cleared by a physician be reviewed. As several researches used in this review identified that many universities do not use the 12-component PPE as recommended by AHA. In addition to the personal and family history, a physical examination should be completed by a physician, nurse practitioner and athletic trainer that understands the 12 components of the PPE. The combination of the PPE with an ECG screening has been seen to correctly identify collegiate athletes with risk of cardiovascular abnormalities and sudden cardiac death. According to Gleason et al, AHA have withdrawn their support of ECG as part of PPE because of the sensitivity, specificity, results in many false- positive screens while failing to identify athletes who are truly at risk of SCD and the cost effect of an ECG screen (10). In 2017, the limited PEFP was used with the PPE in a study by Gleason et al, and noted to be cost effective and with the allocation of time as a valuable resource it helped to reduce athletes referred for formal cardiac evaluations based on false-positive results for screening history, physical examinations and ECG screening.
The limitations of this review include; the diversity of the selected studies, also because this review was centered on cardiovascular abnormalities risk factors, the inclusion criteria had a respectively broad athlete or participating NCAA university population, including the direct comparison between clinical assessment modalities.
In conclusion, none of the prospective studies that were identified in this review refuted the use of the currently recommended sports PPE to access cardiovascular abnormalities in collegiate athletes as well as young competitive athletes. There are several evidences to support the generalized use of the PPE and assessment of personal history, family history, physical examination which are the 12- point screening questionnaire for cardiovascular screening as recommended by the American Heart Association. Administration of this questionnaire by qualified Physicians, Nurse practitioner or athletic trainers would give better and accurate results with a 12 lead ECG follow up to properly screen collegiate athletes of cardiovascular symptoms. PPE Administration with 12 Lead ECG annually and an updated PPE with rest and stress ECG testing biannually may yield more benefits for prospectively evaluating cardiovascular abnormalities risk factors for collegiate athletes entering or participating in specific sports or positions of increased cardiovascular abnormalities risk exposure.
APPLICATIONS IN SPORT
There has been a constant debate over the past few years on the most accurate and cost-effective way to administer the preparticipation evaluation to properly eliminate risk factors that could predispose sports athletes to sudden cardiac death. The use of an updated PPE administered annually by well-trained athletic trainers, inclusion of a 12 lead ECG for athletes with more than one cardiac symptom in all college sports and teams with high cardiovascular risk will not only improve/monitor their health and fitness levels but would also help to closely detect impending cardiovascular abnormalities and early detection would further prevent the occurrence of sudden cardiac deaths that are recorded in specific sports or position of increased cardiovascular abnormalities risk exposure.
All thanks to Dr Jennifer Mead (Advisor and Reader) and Dr Daniel Chase (Second Reader) of Bridgewater State University for their assistance/guidance throughout the process of this study.
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