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.

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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,

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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.

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APPENDIX B

The Problem

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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

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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.

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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.

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APPENDIX C

Additional Methods

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APPENDIX C1

Panel of Experts Cover Letter

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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

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APPENDIX C2

Preliminary Preparticipation Physical Examination Survey

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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

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_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

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_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

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_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?

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APPENDIX C3

Preparticipation Physical Examination Survey

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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

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• 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)

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• 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

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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

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• 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

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• 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

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• 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

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26) If yes, list the functional tests used?

27) Does the PPE use sport specific tests?• Yes• No

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APPENDIX C4

Institutional Review Board

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APPENDIX C5

Subject Cover Letter

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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

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APPENDIX C6

Follow-up Subject Cover Letter

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.