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Study Finds Inconsistencies in States' Sports-Physical Requirements

State-by-state variance in pre-participation physical evaluations for youth athletes suggests a need for nationwide standardization, concludes a study published online in JAMA Pediatrics this week.

The study evaluated pre-participation physical evaluation (PPE) policies and cardiovascular screening content of all 50 states and the District of Columbia. Those policies were compared with the pre-participation physical evaluation-fourth edition (PPE-4) consensus recommendations, created by the American Academy of Family PhysiciansAmerican Academy of PediatricsAmerican College of Sports Medicine, and American Medical Society for Sports Medicine, to see which states lived up to the latest guidelines and which fell short.

Fifty of the 51 jurisdictions evaluated required a PPE before participation, with only Vermont leaving that decision in the hands of individual school systems. Twenty-seven states required the use of a specific PPE form, with 19 requiring or recommending the use of the PPE-4 form and four others using a modified version of it. Fifteen states, however, required or recommended the use of a form not associated with any PPE monograph.

A majority of the states—41, to be exact—had revised their PPE forms since 2010. However, the remaining 10 had either not revised their PPE forms for more than five years or failed to provide a revision date.

States were found to vary in terms of PPE frequency as well. Forty-one required annual PPEs before youths were allowed to participate in sports, while seven required biennial PPEs. South Dakota required a PPE "less frequently," according to the study, while two other states had an unspecified frequency. States also varied in terms of when PPEs began, with fewer than half requiring PPEs for middle school or junior high student-athletes.

Well and Good

In terms of cardiovascular screening, the PPE-4 recommends addressing 12 personal and family history items, including questions about shortness of breath, lightheadedness, discomfort or pain in the chest, and whether anyone in the student-athlete's family has heart problems or died of heart problems. Only 22 states addressed all 12 of the recommended questions in their own forms, with all states addressing a total of seven of the 12 on average. Fifteen addressed three or fewer items.

The authors of the PPE-4 strongly recommended the nationwide adoption of a standardized PPE approach, but the National Federation of State High School Associations lacks the authority to enforce that requirement. Therefore, each state's association has its own rules and regulations regarding preparticipation physical examinations.

Based on the findings of this study, the authors recommend that all states "adopt and mandate use of a nationally recognized and standardized PPE form as outlined in the PPE-4." Additionally, they suggest "that states move toward an electronic PPE process to facilitate data collection," as it would "improve the PPE questions and communication between medical providers, schools, and family stakeholders regarding student health and safety."

With sudden cardiac death ranking as the leading cause of death in youth-athletes during sports, the PPE—specifically the cardiovascular screening component—could be a valuable asset in preventing such tragedies, the authors suggest.

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