Before joining a high school sports team, most students in the U.S. have to complete a preparticipation physical evaluation (PPE). This preseason physical is intended to check that a student is healthy enough to participate in competitive sports, but a new study from the American Academy of Pediatrics found that the requirements of the physicals vary widely across states -- so students are not always screened for conditions that could lead to big problems.
The study found that the District of Columbia and every state, except for Vermont, requires a PPE for student athletes, but there are no national standards for them. The National Federation of State High School Associations endorses PPEs, but does not have the jurisdiction to require them nationally. State high school athletic associations typically determine the requirements in each state.
PPE-4 is the evaluation recommended by leading medical organizations, including the AAP. The PPE-4 asks about 12 items regarding personal and family history that can help "identify subjects with rare electrical cardiac abnormalities," the study says.
However, only 23 states require or recommend using the PPE-4 or a version similar to it, the study found.
On average, states' PPEs completely addressed seven of the 12 personal and family history items that the PPE-4 recommended. Twenty-two states addressed all 12 of the items, while 15 states addressed three or fewer of the items.
To investigate how frequently states reviewed their PPEs, researchers collected data on the most recent PPE revision from each state. According to the study, "the NFHS states that the participation evaluation process should be reviewed no less than every 3 years." Most states had not revised their PPE forms in the past two years, and 10 states either did not revise forms in the past five years or did not provide the researchers with a revision date. The study didn't explain what types of revisions were made.
The content and usefulness of PPEs is highly debated, as physicians attempt to ascertain the best -- and most practical -- way to identify abnormalities.
"The preseason physical is so important, because some of these pre-existing cardiac conditions may be very subtle and difficult to screen for," Barry Boden, a sports researcher and doctor, told The Huffington Post in a conversation last month. However, he explained, "there are a lot of cardiac anomalies which you’re not going to be able to detect, even with [an electrocardiogram]."
This season alone, at least nine high school football players died after collapsing on the field or sidelines. Many student athlete deaths on fields and courts are caused by pre-existing conditions, such as cardiac problems, that players are unaware they have.
There were twice as many indirect fatalities -- caused by conditions such as cardiac arrests, asthma or heat stroke -- than direct fatalities -- caused by head injuries, for example -- between 1990 and 2010 in high school and college football, a 2013 study led by Boden found.
"We do need to do a better job of screening these athletes," Boden said.