Physical Therapist's Role in High School Sports Cardiovascular and Musculoskeletal Screening by Connor Tripp

On July 24, 2023, USC Trojan basketball phenom and NBA prospect Lebron James Jr. suffered a sudden cardiac arrest during practice.¹ The 18-year-old athlete was immediately treated in the team’s practice facility by medical staff then rushed to the hospital for continued care. After determining that “Bronny” has a congenital birth defect known as hypertrophic cardiomyopathy, a condition in which the left ventricle of the heart becomes thickened and stiff leading to reduced cardiac output, he was soon discharged home with uncertainty as to his return to sport. This entire unfortunate situation got me thinking. Bronny James is an elite athlete ranking in the top 20 best prospective basketball players coming into college this season. Certainly, this level of athlete comes with no chance of cardiovascular risk, right? Was this just a freak accident that is not likely to happen? It is no shock that this story made the front page as it concerns the son of NBA legend Lebron James, but how often do events like this happen to everyday “normal” high school athletes?

According to Brett Toresdahl et al., an observational study was conducted from 2009 to 2011 looking at the incidence of sudden cardiac arrest (SCA) in high school athletes. They reported 26 SCA cases with 18 of them occurring during exercise, concluding that the likelihood of a high school athlete suffering from SCA was 1.14 per 100,000 student-athletes with a relative risk of 3.65 compared to student nonathletes (.31 per 100,000). The authors then conclude that this collected data poses the fact that more advanced screening should occur prior to sports in high school athletes.² I not only thoroughly agree with this statement, but asked myself “Since there is clearly a need for cardiovascular screening for high school athletes, would it not also be beneficial to screen for other causes of common high school injuries?” While these numbers are not absurdly high, the fact that these events could potentially be prevented through proper screening leads me to believe that the numbers could, and more importantly, SHOULD be lower.

Let’s take a slight break from cardiovascular concerns and talk about common high school injuries with respect to the musculoskeletal system. Dilip Patel et al., state that most high school athletic injuries are related to acute trauma or repetitive overuse with injuries commonly related to the following factors: sudden increase in intensity, volume, and duration of activity; poor conditioning and training techniques; inadequate training; and inappropriate equipment. Some other less commonly associated factors were as follows: predisposed genetic anatomic variation, hard surfaces, decreased flexibility, neuromuscular conditions, and others. The authors also report that in the U.S., there are roughly 2 million injuries, half a million doctor visits, and approximately 30,000 hospitalizations each year due to high school sports injuries indicating a risk of 2.44 per 1,000 athletes. Muscle strains and ligamentous sprains were the most common of the injuries with roughly 80% of all injuries being new injuries.³ These numbers are absolutely astounding. While there is not really any true way to completely prevent an injury, especially with contact sports such as football, basketball, or soccer, certainly there is a way to reduce the incidence of these injuries, much like the cardiovascular events mentioned prior.

The purpose of this blog is to discuss the ways in which I believe physical therapists could play a huge role and provide an effective solution to reducing the incidence of these cardiovascular and musculoskeletal events. One of the first things I remember being told when I began physical therapy school in January of last year was that physical therapists are “movement experts.” Our skillset grants us the perfect opportunity to provide high school athletes with the proper screening prior to their athletic seasons. In the next few paragraphs, I would like to shed light on the ways in which physical therapists could not only reduce the incidence of injuries but potentially save the lives of high school athletes.

First, let’s discuss the current role of physical therapists in high school athletics and what our scope of practice allows. Barbara Sanders et al. discuss our scope of practice when it comes to preparticipation physical examinations (PPEs).⁴ They explain that each state has different laws regarding the physical therapist’s scope of practice regarding whether they are permitted to conduct a PPE or sign off without provider referral or fellow sign-off. For the states that do not allow PTs to participate in sports physicals, it is then our role to advocate for our profession and explain how important it is for us to be a part of this examination to screen high school athletes. Having explained that, let’s assume for the remainder of this blog that we are discussing states that allow PTs to conduct PPEs. Before determining what examination components physical therapists can perform during a sports physical, I wanted to find out what things are commonly done by providers who are often performing these exams. Donald Davis et al. explain just that in this article about sports physicals. In this article, they explain that the PPE is an evaluation conducted as a collaborative effort among the following organizations: the American Academy of Orthopedic Surgeons (AAOS), American Orthopedic Society for Sports Medicine ((AOSSM), American Family Physician (AFP), and American Academy of Pediatrics (AAP).⁵ Did you notice how no physical therapists’ organizations such as the APTA were mentioned? Interesting. Anyways, here is a list of the components of a physical exam:

·       Medical and family history including medication history of chest pain, fatigue, heart conditions, etc.

·       Physical exam including heart rate, blood pressure, height, weight, vision, pulmonary, neurological, and abdominal exams; skin and genital exam; heart and lung sounds, orthopedic screens of strength and range of motion; EKG (if warranted)

·       Nutrition assessment

·       Mental health assessment

·       Heat and hydration risk factors

All the examination methods mentioned cover a wide variety of potential conditions that commonly appear in the young athlete population, but one thing stood out to me in this article. The authors state, “Occasionally an EKG provider will approach the preparticipation physical provider and offer his or her services to complete screening EKGs for all participants. While this is not considered bad practice, it does not appear to be warranted as a screening method.  Rather, cardiac abnormalities that become apparent upon a careful auscultation examination or by way of a review of either the athlete's or family's history should be sent for a complete examination which may entail an EKG or echocardiogram.”⁵ I personally believe that this is poor practice and laziness when it comes to proper medical management. This should ALWAYS be warranted as a screening method, in my personal and professional opinion. Just because the apparently “healthy” athlete in front of the provider appears to not have any sort of medical abnormalities does not mean a simple screen should not be performed. After all, I would assume that Bronny James’ physical didn’t warrant further screening, and we saw what happened to him. Clearly, not all cardiovascular conditions can be ruled out simply by listening to heart sounds and asking a few simple questions. Now that we’ve covered what is typically performed at a sports physical, let’s discuss what sets physical therapists apart in regard to both cardiovascular and musculoskeletal screening and examinations.

              We’ll start with cardiovascular. In the three years spent in physical therapy school, several classes are dedicated to the cardiovascular system with special attention to screenings and exams that can be performed to rule out any sinister medical pathology warranting referral to another provider for treatment. Any proper physical therapy session typically begins with a detailed subjective history very similar to the one explained in the previous paragraph. Several questions are asked about significant past medical history, medication, pain, etc. Also similarly, basic objective measures should be taken such as height, weight, BMI, heart rate, respiratory rate, SpO2, heart sounds, and lung sounds. At this point, this is where our expertise kicks in. But I would suspect that one of the reasons that physical therapists do not conduct exercise testing aside from the lack of equipment would be the fear of adverse responses and lack of confidence with cardiovascular concerns. A study conducted by R Scott Van Zant in 2013 sent out a 25-item survey to 2,673 physical therapists asking them to state from 1 (strongly disagree) to 5 (strongly agree) their opinion regarding specific elements of cardiovascular clinical practice.⁶ The only items where <80% of the therapists were in overall agreement were in the following categories: identifying underlying cardiovascular disease, education on cardiovascular medications, blood chemistry, cardiovascular family history, BMI, and body composition. The article concludes that “Physical therapists support most CVD prevention behaviors, but not given elements of patient education and identifying underlying CVD/risk factors.”⁶ So perhaps the issue is that physical therapists are not as confident in assessing cardiovascular risk in the first place, and if they are not confident in assessing the risk, how confident are they when things go south?

              Physical therapists have an excellent tool at their disposal prior to exercise testing that should often be used called the Physical Activity Readiness Questionnaire (PAR-Q). This tool was created to standardize screening prior to exercise for people between the ages of 15-69.⁷ Once completed, this questionnaire will tell us whether the patient is ready for exercise or needs a referral to seek further medical consultation. Along with the implementation of the PAR-Q, physical therapists have the responsibility of recognizing both absolute and relative contraindications to exercise testing. Here are lists of both:⁸

o   Absolute contraindications

§  Recent change in resting EKG suggesting ischemia

§  Recent MI within 2 days

§  Unstable angina

§  Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise

§  Severe symptomatic aortic stenosis

§  Uncontrolled heart failure

§  Acute PE or pulmonary infarction

§  Acute myocarditis or pericarditis

§  Suspected dissecting aneurysm

§  Acute infections

o   Relative contraindications

§  Left coronary stenosis

§  Moderate stenotic valvular heart disease

§  Electrolyte abnormalities

§  Severe arterial hypertension

·       Systolic >200, diastolic >110 at rest

§  Tachyarrhythmias or bradyarrhythmia

§  Hypertrophic cardiomyopathy or other outflow tract obstructions

§  Neuromuscular, MSK, or rheumatoid disorders exacerbated by exercise

§  2^nd or 3^rd degree heart block

§  Ventricular aneurism

§  Uncontrolled metabolic disease (diabetes, thyrotoxicosis, or myxedema)

§  Chronic infections disease (mono, hepatitis, AIDS)

 

Is it a lot to remember? Yes. However, it is critically important to recognize these conditions before determining if a patient is prepared to participate in exercise testing. Once the patient has been through these processes and cleared, they should begin exercise tests to assess for abnormal responses to exercise.

              As mentioned before, one of the limitations physical therapists admit to is their knowledge of response to exercise. Several components should be taken into consideration when monitoring the patient during the selected exercise test which are as follows:⁸

• Subjective response – rate of perceived exertion (RPE), dyspnea on exertion (DOE), angina, muscle fatigue
• EKG – minimal changes in waveform or deviation from normal sinus rhythm
• SpO2 >95 at rest and throughout, should not decrease by 5 or more
• Systolic BP – 5-10mmHg increase per MET
• Diastolic BP - +/- 10 per MET
• HR – 10 beat increase per met, post-exercise recovery >12 per minute
• o   Percentage of HR max: 208-70% of age
• o   60-80% of max for testing

Once the therapist is confident in recognizing these components during the selected test, the test can be performed. When selecting the test to be performed for the athlete, several things should be considered such as the specific sport the athlete competes in, the equipment available for use, and the patient’s physical, mental, or psychological limitations. A graded exercise test is considered the gold standard to measure exercise capacity as it drives the patient closest to physiological failure before the test ends with the most accurate representation of their response to exercise. Examples of these tests would be the Wingate, Bruce, or Ramp protocols. If the patient is not able to perform a graded test, submaximal tests can be performed such as the 6-minute walk test, modified Bruce, or YMCA bike protocols. These are some common tests used widely in the physical therapy field; however, any test can be created by the therapist that mimics the patient’s particular sport as long as it is repeatable, measurable, and dosed properly.

              Cardiovascular testing seems like a terrifying thing to do, but I would ask you to consider this: the risk of adverse patient response to exercise does not exist with the test performed, it exists with the patient. It is easy to decide not to conduct exercise tests because you assume the patient has no health concerns or perhaps you are not confident in doing the tests, but the risk of serious cardiac events does not decrease just because the test isn’t done. Actually, I would argue the exact opposite. Not performing these tests would be a disservice to the patient as physical therapists can be the ones to expose cardiovascular health concerns and get the patient the help they need before it is too late. It makes so much more sense for a patient to have a cardiovascular event in the presence of a medical professional rather than on the court or field where no one may be available for immediate medical attention. In a 2009 article explaining the role of physical therapists in assessing cardiovascular risk, Susa Scherer et al. put it perfectly when they said “…in both education and scope of practice, physical therapists have the knowledge to make well-educated decisions about exercise appropriateness particularly if the exercise is supervised in the physical therapy clinical setting.”⁹ Now that we’ve discussed the cardiovascular side of screening and how PTs can be an influence, let’s transition into musculoskeletal concerns.

              As mentioned previously, there is an incredibly high rate of high school sports-related injuries across the U.S. due to several components that can be broken into modifiable and non-modifiable risk factors (modifiable meaning factors in which we can change, non-modifiable meaning those which we cannot). Physiopedia lists some of these factors:¹⁰

Modifiable:

• Conditioning (strength, endurance, power, etc.)
• Physical inactivity
• Sport-specific skill
• Diet
• Obesity
• High cholesterol/blood pressure
• Balance
• Joint mobility
• Biomechanics

Non-Modifiable:

• Age
• Biological sex
• Anatomy/body type
• Genetics
• Prior injuries

These modifiable risk factors are the things that physical therapists have extensive knowledge of investigating and discussing to assess the risk of injury and theoretically reduce injury rates across the country. It is my own personal opinion that many physical therapists likely have more knowledge and are more comfortable with musculoskeletal screening as there is likely a perceived lesser risk association. But even having said this, how often are physical therapists performing gross performance screens?

              A quick and effective way physical therapists learn to screen for some of these risk factors is upper and lower quarter screens in which we assess gross active and passive motion, strength, light touch sensation, both deep tendon and pathological reflexes, and neural tension. If any abnormalities are found within these subsystems, deeper examinations can be performed to identify the cause of the problem to target interventions. To perform these actions on the upper and lower extremities should take no longer than 5 minutes and can give tons of valuable information. I worked as a physical therapy technician for nearly 3 years before beginning physical therapy school and did a 6-week clinical rotation at the beginning of my second year of PT school with both experiences being in an outpatient orthopedic clinic. How many times did I see a quarter screen performed? Zero. Not even one. And I have no clue why honestly. Perhaps because therapists assume everything has been cleared up to that point? Maybe they haven’t done one in a while and don’t remember how? Or perhaps when athletes come into the clinic, they think that since they’re athletes, everything must be fine! Yet we hear of stories like Bronny James and others who suffer from serious events that potentially could have been prevented. The quarter screen is an excellent tool that should be used to assess musculoskeletal and other concerns, and in my opinion, it is vastly underused.

              Another excellent way to screen young athletes is by use of a functional movement screen (FMS) which is a movement analysis looking for functional asymmetries based on the following functional tasks: squatting, stepping, lunging, reaching, leg raising, pushups, and rotary stability.¹¹ Each task is graded from 0-3 with 0 being if there is pain with movement, 1 being unable to perform as described, 2 being completed with compensations, and 3 being performed perfectly. Any deviation from a perfect score could give insight into impaired patient mobility or stability needed to complete the task. On the sheet used to guide this test is a list of components that the therapist looks for when giving grades based on performance. A score of at least 14/21 indicates a reduced risk of injury while a score of 13 or less indicates an increased risk of injury.¹² This is another great example of a quick and easy test to conduct to assess the risk of injury for the young athlete.

              Balance was another component mentioned in the modifiable risk factors that physical therapists can address. I think that balance is a system that most people don’t understand how physical therapists can play a role, but they certainly can. Balance is composed of three primary systems: vision, vestibular (inner ear function), and somatosensory (body awareness). One very simple and effective test that we learn is called a modified clinical test of sensory interaction on balance (mCTSIB) in which the tester has the subject perform 30-second standing balance tests in 4 different situations. These are eyes open on solid ground, eyes closed on solid ground, eyes open on a foam pad, and eyes closed on a foam pad. Based on how the patient performs in each category, we then know which subsystems of balance are strong and which are weak. We then can offer interventions and treatment strategies to work on the weaker subsystems to improve balance. Much like the quarter screens, the mCTSIB is a quick and valuable tool that PTs can use to assess for balance.

              As far as sports performance/skill, biomechanics, and conditioning are concerned, I feel like this is where PTs shine. As movement experts, we are trained in how to analyze sport-specific movement patterns for any abnormalities or compensations that could pose the risk of injury, and conditioning tests would look very similar to cardiovascular exercise tests with a sport-specific approach. The purpose of specialized performance testing, like the FMS, is to look for limb asymmetry, measure the athlete’s capability to generate and tolerate force, and identify impairments that would reduce performance, limit function, or increase risk of injury.¹³ Here is a list of some common performance tests and what they measure:¹³

These types of testing allow physical therapists to assess various components related to musculoskeletal performance while being able to select each test based on the athlete’s needs.

              The only other components that we haven’t discussed are physical inactivity, diet, and obesity with their respective comorbidities such as hypertension or hypercholesterolemia. According to a 2014 study by Annette Adams et al., there is an association between childhood obesity and upper and lower extremity injuries such as fractures, sprains, and strains.¹⁴ This steady increase in national childhood obesity rates has also been linked to increased back, knee, and hip pain which could all predispose children to not only cardiovascular diseases such as hypertension or diabetes but musculoskeletal injuries as well. This pain could then limit the child’s participation in sports and other physical activities leading to further potential complications from a sedentary lifestyle. Per ACSM guidelines for physical activity in children and adolescents, this population should be participating in 60 minutes of moderate-to-vigorous planned exercise daily.¹⁵ While it is not within physical therapist’s scope of practice to give specific diet recommendations, we are able to educate the patient and the family members on the importance of eating healthy and living an active lifestyle. We also can hand out brochures or pamphlets about these topics or refer out to a registered dietician or the family’s primary care physician for further intervention if necessary. Education is such a powerful tool that every physical therapist can and SHOULD use with their patients regarding health and wellness.

              Our goal when we created this website was to find a need in the physical therapy field and attempt to fill it. As I was thinking about what I would like to do for this project, the story of Bronny James was the first thing that came to mind as it shocked the world to see someone who is considered an elite athlete suffer from a heart attack with no known cardiovascular history. As someone who was active in high school athletics, I remember how superficial the screening process was (at least for me, not to generalize) to say whether an athlete was cleared for sports, and I believe that the reason that the numbers for cardiovascular and musculoskeletal injuries are due to this lack of in-depth screening and examinations for underlying causes. Am I biased as a future physical therapist that we could be the solution to this issue? Of course, I am; however, the extensive training we receive concerning screening for these adverse events leads me to think that we should be the answer. I hope that through reading this blog, you have gained an understanding of how physical therapists can be of great use in ensuring that high school athletes are screened properly for cardiovascular and musculoskeletal concerns during yearly sports physicals.

 

Citations

1.   Boone, Kyle. Bronny James Cardiac arrest updates: What we know as son of Lebron James recovers from heart issue. CBSSports.com. August 8, 2023. Accessed October 30, 2023. https://www.cbssports.com/college-basketball/news/bronny-james-cardiac-arrest-updates-what-we-know-as-son-of-lebron-james-recovers-from-heart-issue/.

2. Toresdahl BG, Rao AL, Harmon KG, Drezner JA. Incidence of sudden cardiac arrest in high school student athletes on school campus. Heart Rhythm. 2014;11(7):1190-1194. doi:10.1016/j.hrthm.2014.04.017

3. Patel DR, Yamasaki A, Brown K. Epidemiology of sports-related musculoskeletal injuries in young athletes in United States. Transl Pediatr. 2017 Jul;6(3):160-166. doi: 10.21037/tp.2017.04.08. PMID: 28795006; PMCID: PMC5532190.

4. Sanders B, Blackburn TA, Boucher B. Preparticipation screening - the sports physical therapy perspective. Int J Sports Phys Ther. 2013 Apr;8(2):180-93. PMID: 23593556; PMCID: PMC3625797. Accessed October 15, 2023

5. Davis DD, Gerena LA, Kane SM. Sports Physicals. [Updated 2022 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Accessed October 15, 2023. https://www.ncbi.nlm.nih.gov/books/NBK556111/

6. Van Zant RS, Cape KJ, Roach K, Sweeney J. Physical therapists' perceptions of knowledge and clinical behavior regarding cardiovascular disease prevention. Cardiopulm Phys Ther J. 2013 Jun;24(2):18-26. PMID: 23801901; PMCID: PMC3691705. Accessed October 15, 2023

7. Physical activity readiness questionnaire (PAR-Q, par-Q+). APTA. Accessed November 5, 2023. https://www.apta.org/patient-care/evidence-based-practice-resources/test-measures/physical-activity-readiness-questionnaire-par-q-par-q#:~:text=It%20screens%20for%20evidence%20of,physician%20about%20beginning%20physical%20activity.

8. Karlyn Green PT, DPT, OCS, CCS. Exercise Testing. PowerPoint presented at: Campbell University, Lillington, NC. Accessed October 15, 2023.

9. Scherer S. Addressing Cardiovascular Risk as Part of Physical Therapist Practice-What about Practice Recommendations for Physical Therapists? Cardiopulm Phys Ther J. 2009 Sep;20(3):27-9. PMID: 20467521; PMCID: PMC2845247. Accessed October 15, 2023.

10. Risk factors and injury mechanisms in sports injuries. Physiopedia. Accessed October 15, 2023. https://www.physio-pedia.com/Risk_Factors_and_Injury_Mechanisms_in_Sports_Injuries.

11. Functional Movement Screen (FMS). Physiopedia. Accessed November 8, 2023. https://www.physio-pedia.com/Functional_Movement_Screen_%28FMS%29.

12. Functional movement screen. American college of sports medicine. Accessed November 8, 2023. https://www.acsm.org/docs/default-source/regional-chapter-individual-folders/northland/nacsm--wes-e--fms9a9b0c1f5032400f990d8b57689b0158.pdf?sfvrsn=3668bbe0_0.   

13. Hollis Bixby PT, DPT, OCS. Performance Measures. PowerPoint presented at: Campbell University, Lillington, NC, Accessed November 8, 2023.

14. Adams AL, Kessler JI, Deramerian K, Smith N, Black MH, Porter AH, Jacobsen SJ, Koebnick C. Associations between childhood obesity and upper and lower extremity injuries. Inj Prev. 2013 Jun;19(3):191-7. doi: 10.1136/injuryprev-2012-040341. Epub 2012 Jul 11. PMID: 22789612; PMCID: PMC3747966.

15. Physical activity in children and adolescents. ACSM. Accessed November 8, 2023. https://www.acsm.org/docs/default-source/files-for-resource-library/physical-activity-in-children-and-adolescents.pdf?sfvrsn=be7978a7_2.