Physiotherapist Delivered Preparticipation Examination: Rationale and Evidence

Abstract

Preparticipation examinations are often performed based on the assumption that the exam contributes to the identification of risk factors for injury and, therefore, lead to the implementation of appropriate injury prevention strategies for athletes. Research evidence supporting the components, benefits, and limitations of the preparticipation examination performed by a physiotherapist is the focus of this paper. Evidence exists that some specific preparticipation examination components will identify known risk factors which may be addressed in the context of injury prevention strategies for that athlete. Examinations should use existing evidence-based practice to identify valid and appropriate tests examining known risk factors. Physiotherapists are encouraged to continue development, implementation, and evaluation of appropriate training techniques for the athletes to minimize their risk of injury. Physiotherapists need to be aware of athlete confidentiality issues as well as the importance of cost effectiveness of preparticipation examinations. The future of physiotherapist delivered preparticipation examinations may lie in the utilization of an evidence-based approach to risk factor identification, development and evaluation of prevention strategies, and development and evaluation of performance enhancement strategies for the athlete.

INTRODUCTION

A preparticipation examination, also called a pre-season examination or a screening examination was original described in 1978.¹ The intent of this examination was that it would (i) fulfill the athlete's institution legal and insurance requirements, (ii) assure the coaches that team members would start the season with some common level of health and fitness, (iii) provide the medical team with the opportunity to discover treatable conditions that might interfere with or be worsened by athletic participation, (iv) potentially aid in predicting/preventing future injuries, and (v) be appropriate for all sports. A musculoskeletal version of the original preparticipation examination is often performed annually by physiotherapists working with athletic teams to anticipate and preclude physiological and biomechanical problems for athletes prior to the commencement of a sport season. As such, the ultimate goal of such a preparticipation examination is injury prevention. Additional and parallel objectives to injury prevention include assurance of optimal musculoskeletal health, to optimize performance (physiological and biomechanical), to develop a professional relationship with the athlete and to educate the athlete.^2–9 Ideally, a preparticipation examination should also make it possible to identify the factors common to athletes with great performances which would facilitate the identification of such factors in other athletes.^2,3,10,11

Research evidence supporting the preparticipation examination performed by a physiotherapist is the focus of this paper. This paper will not discuss the medical screening or preparticipation evaluation of athletes that is often performed by physicians to ensure optimal medical health for sport participation despite underlying medical conditions (i.e. asthma, diabetes, menstrual dysfunction, depression), to review medications and vaccinations, and to prevent sudden death of the athlete.¹²

Definition and Role of the Preparticipation Examination

Preparticipation examinations are performed based on the assumption that they can enhance performance of the athlete and identify potentially modifiable risk factors for injury. Modifiable risk factors are those that can potentially reduce injury rates through the implementation of injury prevention strategies.^11,13 Evidence exists that modifiable risks, such as, decreased levels of sport specific training in the off season, endurance, strength, and balance do increase the risk of injury in sport.^14–22 Non-modifiable risk factors are those factors that can not be altered to reduce injury rates through the implementation of injury prevention strategies.^11,13 Examples of a non-modifiable risk factor would be age, gender, and previous injury. An ideal preparticipation examination system applicable to all sports does not exist, although there are examples of sport-specific preparticipation examinations. A comprehensive examination should identify the sport-specific biomechanical and physiological requirements for training and competition, as well as when these requirements exceed the athlete's ability to perform.^2–4,10,11 Additionally, the examination should be capable of detecting possible biomechanical and physiological deficits that might be a precursor to injury.^{2–4, 10,11} Upon recognition of potentially modifiable risk factors by the physiotherapist, sport-specific injury prevention strategies can be implemented to reduce such risks.^{2–4, 10,11}

Identifying Risk Factors for Injury

The injury prevention model developed by vanMechelen et al^23,24 suggests that the incidence and severity of sport injury need to be established prior to identifying risk factors for injury. Sport injury prevention strategies may be developed and evaluated if a good understanding exists of injury rates, the participant population at risk, and the risk factors associated with injury for this population.^11,18,25 Sport injury risk factors are defined as those entities which contribute to the occurrence of athletic injury.^11,13 Both intrinsic (i.e. decreased strength, previous injury) and extrinsic factors (i.e. shoes, equipment) that may increase susceptibility to injury should be identified prior to the occurrence of an injury-inciting event.¹³ Further, Bahr and Krosshaug²⁶ identified the importance of recognizing that one or more factors (i.e. biomechanics, playing situation, player/opponent behaviour) may generate an injury-inciting event. An understanding of sport-specific mechanisms of injury will facilitate the identification of potential risk factors during the preparticipation examination and subsequent delivery of appropriate and sport-specific injury prevention strategies.

The use of validated sport-specific injury surveillance will assist the therapist in identifying risk factors and their component biomechanical and physiological aspects contributing to injury in that sport.²⁷ Given the limited evidence that exists identifying sport-specific risk factors for injury using adequate sport-specific injury surveil-lance, the support for injury prevention strategies is often based on anecdotal evidence.²⁸ In a systematic review of the literature regarding prevention strategies for injury in sport at any age, MacKay et al²⁹ concluded that very few well designed prospective studies exist. In order for the physiotherapist to provide the most appropriate, evidence-based preparticipation examination, they must stay current with the research identifying sport-specific risk factors and injury prevention strategies pertinent to their athletes. Desirable features of the preparticipation examination include valid and reliable measurement of these risk factors in order to assess the athlete's risk of injury as well as to compare the athlete's test results within a sport in a given year, across years, and with other sports.

Who is Using Preparticipation Examinations?

Judging from informal discussions with coaches, athletes, and support personnel (in various sports communities around the world) as well as reports in the literature, it would appear that most elite teams and many university and high school based teams are using some form of preparticipation examination.^12,30,31 Examples of the use of physiotherapist delivered preparticipation examinations include football and triathlon teams in the United Kingdom.³ In these examples, teams had a complete physiotherapy assessment of every player that included flexibility, range of motion, balance, and core stability tests. These tests provided a baseline measurement of the musculoskeletal status of the athletes and enabled the physiotherapist to plan specific training and injury prevention programs tailored for individual players. In addition, a preparticipation evaluation by a physician is critical but beyond the scope of this paper.¹²

Components of the Preparticipation Examination

Although no standard examination has been identified across sports, certain consistencies exist among these examinations. Based on the literature and informal discussions with health care professionals monitoring other sport teams, preparticipation examinations consistently include athlete questionnaires, standard neuro-musculoskeletal examinations, and some form of functional testing. A good preparticipation examination should be accurate, practical in order to apply to a large number of subjects, and testing procedures must be safe and acceptable to most individuals.³² A preparticipation examination should be performed in a 45 minute time frame, similar to the time allotted for a physiotherapy assessment in the sport medicine setting. An example of a format used for preparticipation assessment for elite athletes can be found in Appendix A.

Despite the limited consistency among preparticipation examinations, the importance of musculoskeletal screening is evident in the fact that athletes frequently resume full athletic participation following a significant injury with considerable deficits in strength, range of movement and proprioception.^33–35 Consistent evidence exists that one of the most likely predictors of injury is a previous injury.^16,36–39 Therefore, any post injury deficits should be fully assessed with a goal of designing a rehabilitation program to restore full function. Such an assessment should include an athlete questionnaire that identifies the nature and date of any previous injury; lists any residual problems; describes the nature, date, and symptoms of any current injury; as well as any past or current treatment received for these injuries. ^{5,40, 41} For example, identification of previous injury (i.e. ankle sprain) and providing appropriate prevention strategies (i.e. wobble board training) will reduce the risk of recurrent injury.⁴²

There is evidence that muscle strength ratios ^{33,38,43–48} are an individual risk factor for a particular injury in athletes. The standard neuro-musculoskeletal examination which tests for strength in the form of isometric, concentric, or eccentric testing contribute to the identification of such strength ratios. The standard neuro-musculoskeletal examination should also include a neurological examination, active and passive range of motion testing, articular testing in the form of joint glides, muscle recruitment testing (especially around the torso and pelvis), static and dynamic postural and balance investigations, and appropriate functional tests. For example, Gabbe et al⁴⁹ provide evidence that Australian Football players with increased quadriceps flexibility (as measured by the modified Thomas test) were less likely to sustain a hamstring injury. Evidence also exists to support investigation of torso and core strength with regard to lower quadrant injury prevention as well as injury reoccurrence.^50–55 Improving balance has been shown to be important in injury prevention in sports such as soccer.^56,57 Additionally, Trojian et al⁵⁸ demonstrated the ability to predict ankle sprain injury with a positive single leg balance test in high school and varsity athletes. Validated testing methods for the preparticipation examination should always be used. For torso strength, for example, two validated testing methods exist: a) modified double straight leg lowering test ^59–62 and b) flexor endurance test.⁶³ It is strongly suggested that neuro-musculoskeletal screening assessments be particular to the sport the athletes are involved in. For example, sports with high risk of specific joint or muscle injuries (i.e. swimmers' shoulder, pitchers' elbows) should have specific assessments performed on these areas.⁵ Many validated orthopaedic tests for various regions of the body can be found in medical and physiotherapy textbooks and should be used for the preparticipation examination (i.e. Patrick's test for examining hip range of motion).^64–66

Many functional performance tests exist and are commonly recommended for inclusion in a preparticipation examination (i.e. sit-ups, push-ups, endurance runs, sprints, and agility activities).^67,68 For example, Hewitt et al⁶⁹ demonstrate the identification of high-risk landing force profiles in youth athletes using a functional box drop vertical jump test. It is suggested that not only the clinical test outcome be scored (i.e. sit-up repetitions) but also the form and efficiency of the underlying functional movement involved in the test.⁷⁰ For example, taking note of the weight that an athlete can hold during a lunge test and how the athlete's body was aligned during the test. Scoring such function can be challenging as few validated systems exist. The examiner is advised to develop scoring methodologies and submit this scoring method to future research scrutiny.

Additional Benefits of the Preparticipation Examination

In addition to potential injury prevention and performance enhancement, the preparticipation examination allows the physiotherapist additional opportunities. This examination provides an opportunity for the physiotherapist to commence their professional relationship with the athlete. This relationship allows the physiotherapist to educate the athlete on issues such as injury prevention (i.e. importance of core strength, stretching, warm-up), immediate injury management (i.e. RICE management for acute inflammation), and appropriate equipment use (i.e. helmets, mouth guards, shin pads). The examination enables the physiotherapist to become fully aware of the athlete's past history and gives them insight into the athlete's physical, mental, and emotional state. Additionally, the athletes are typically given the opportunity to discuss any pertinent issues with the physiotherapist.

Limitations with the Preparticipation Examination

Many limitations exist with the current state of the physiotherapist delivered preparticipation examination.³ As with any preparticipation examination performed by health care professionals, often no uniformity of protocols is used.¹² As a result, concrete recommendations concerning the findings from a preparticipation examination are lacking and are often attributed to “(i) the lack of consensus regarding the threshold for abnormality, (ii) the unavailability of data indicating the predictive value of specific physical ___abnormalities' for injury, and (iii) the lack of definitive proof that corrective interventions alter outcome.”⁷¹ Extensive examinations are often performed with various resultant recommendations, but frequently no follow-up occurs. Literature and clinical experience suggest follow up at 6 weeks to ensure that the recommended actions have been taken.³

The extent of the examination is limited by financial and time constraints. The examinations are time consuming for both the athlete and the examiner leading to potential compliance issues from the athlete. The time consuming nature of the preparticipation examination can potentially interfere with the time available to treat athletes. As such, the physiotherapist may have to prioritize the most essential components of the examination based on the sport-specific requirements for each athlete. Overall, if the process is to be cost-effective then it has been suggested that it needs to be regularly audited and evaluated.³

Reliability issues are of primary concern with multiple examinations performed by health care professionals from different disciplines (i.e. athletic therapist, physiotherapist, chiropractor, medical doctor) or other support team members (i.e. strength trainer, physiologist) on the same athlete or by different examiners on different athletes within a team. Smith and Laskowski⁷¹ recognize that in order to integrate the history and physical examination components of a preparticipation examination, one requires a substantially higher level of knowledge and skill on the part of the examiner. Therefore, the task may be impractical, especially at the high school and youth sports levels that are utilizing non-medical trained personal.

Confidentiality is a very important issue to consider. Individuals within the specific sport organization (i.e. athlete, coach, physician) and outside the sport organization (i.e. National Olympic Committee) who have access to the data from the preparticipation examination must be clearly identified. Some health care professionals suggest that the traveling athlete should have a medical passport (i.e. hard copy or electronic record) containing all relevant information to ensure complete communication of the athlete's medical information to all involved in their care.^3,72,73

CONCLUSION

Preparticipation examinations are often performed based on the assumption that they contribute to the identification of risk factors for injury, and therefore, lead to the implementation of appropriate injury prevention strategies for athletes. However, despite evidence identifying some specific risk factors for injury that may be identified in a preparticipation examination, little global evidence exists supporting the use of preparticipation examinations to reduce injury rates among athletes. Identification of previous injury (such as ankle sprains) and providing appropriate prevention strategies (such as balance training) has been shown to reduce the risk of recurrent injury. There is also evidence that some specific preparticipation examination components will identify known risk factors (i.e. specific strength, flexibility, balance tests) which may be addressed in the context of injury prevention strategies for that athlete. However, much needed research to further validate specific components of the preparticipation exam and provide further evidence for identification of sport-specific risk factors is needed. Currently, physiotherapists rely on the examples supported in the literature for injury prevention in conjunction with their clinical expertise and judgment within their own team practices. The future of physiotherapist delivered preparticipation examinations may lie in the utilization of an evidence-based approach to risk factor identification, development and evaluation of prevention strategies, and development and evaluation of performance enhancement strategies for the athlete.

APPENDIX A: PRE-PARTICIPATION PHYSIOTHERAPY ASSESSMENT