A pre-participation evaluation should include markers of health. They are typically looking "for signs or symptoms of underlying disease, or who may be at higher risk of an adverse event during exercise" (Essa, 2018)
The presence of increased risk in a screen should lead to further assessment.
Physical Activity Readiness Questionnaire (PAR-Q)
The PAR-Q has been designed to identify the small number of adults for whom physical activity may be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.
Answer yes or no to the following questions:
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you answered yes:
If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before taking a fitness test or substantially increasing your physical activity. You should ask for a medical clearance along with information about specific exercise limitations you may have.
In most cases, you will still be able to do any type of activity you want as long as you adhere to some guidelines.
If you answered no:
If you answered no to all the PAR-Q questions, you can be reasonably sure that you can exercise safely and have a low risk of having any medical complications from exercise.
It is still important to start slowing and increase gradually. It may also be helpful to have a fitness assessment with a personal trainer or coach in order to determine where to begin.
When to delay the start of an exercise program:
If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising.
If you are or may be pregnant, talk with your doctor before you start becoming more active.
Keep in mind, that if your health changes, so that you then answer "YES" to any of the above questions, tell your fitness or health professional, and ask whether you should change your physical activity plan.
ESSA designed PPE Stage 1 Questionnaire
Exercise and Sports Science Australia (ESSA), in association with Sports Medicine Australia (SMA) devised a PPE, with some elements that pass criteria mentioned above.
Where this specific evaluation fails is in the following recommendation:
"IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise." This recommendation fails to evaluate movement-based risk factors, thus presents probable false negatives for exercising.
ESSA, 2018. https://www.essa.org.au/for-gps/adult-pre-exercise-screening-system/
F-MARC designed PPE
This PPE fails to account for a major risk factor in injury - motor control.
It is recommended that the FMS, SFMA and FCS are used as appropriate (in the absence of pain, presence of pain/injury and passing of the FMS) in addition to specific tests within the F-MARC PPE, for soccer players.
SCREEN first for competency and risk to tell you whether you need to do more ASSESSMENT for causes/contributing factors/complicating factors, ie regress, or to proceed to TEST capacity, ie progress.
Any of these could be used in Pre-Participation Evaluations (PPE's).
Choose a screen, assessment battery or test battery that reveals the ability to respond, then adapt to external and internal stimuli. Recognise that the heirarchy of evaluation is:
1) below bodyweight
2) at bodyweight
3) above bodyweight
Assessments should reveal either the cause/contributing factor or complicating factor to why the person is rated as below competence or at below minimum capacity. A test that follows from a competent assessment and screen should also reveal cause/contributing factor or complicating factor to why the person is rated as below competence or at below minimum capacity.
Recommendations made in this learning module honour the above. Those evaluations that do not clearly honour the above are not recommended.
There are three areas to evaluate pre-participation.
Health systems of the human.
Function as it relates to movement competency as a human, not as a human within a sport.
Performance as it relates to fundamental human movement capacity.
Performance as it relates to sports-specific movement capacity.
Evaluations should reveal competency and capacity separately to avoid confusion as to what is the limiting factor in a persons capacity. For example, an individual who has movement competency issues and is then tested for capacity will most likely demonstrate reduced capacity - to the less focussed assessor, the deficits may be blamed on reduced capacity, directing interventions there, failing to recognise that reduced competency affects expression of capacity. Some evaluations combine competency and capacity in one test, a flaw in testing. For example, consider an individual who is tested for single hop for distance but who has an underlying ankle dorsiflexion limitation, below competent. This individual is less likely to express sufficient force production to hop a minimum acceptable distance, and/or is less likely to express sufficient dynamic motor control and/or force absorption to land with competence. A reduced hop distance, below minimum acceptable, might be seen as a capacity problem if the underlying mobility or motor control problems in the lower quarter and trunk were NOT first revealed with a competency screen.
Recommendations made in this mindmap are held against four criteria:
1. Is the evaluation reliable?
2. Is there some evidence of validity of the findings from the evaluation?
3. Is the evaluation sensitive to change?
4. Is it portable and easy to administer once trained?
Evaluations that go some way towards addressing the above criteria are given preference in recommendation.
A pre-participation evaluation should be reliable between sessions and between individual evaluators. This provides objectivity and improves communication between testers.
Any exisiting pre-participation evaluation should be scrutinised for the presence or absence of reliability studies.
The degree to which a test measures what it claims, or purports, to be measuring.
For example, a pre-participation evaluation is typically looking "for signs or symptoms of underlying disease, or who may be at higher risk of an adverse event during exercise" (Essa, 2018)
The presence of increased risk in a screen should lead to further assessment. See individual injury discussions within this module for risks and predisposing factors for ACL, patellofemoral pain, shoulder tendinopathy and lateral ankle injury.
ESSA, 2018. https://www.essa.org.au/for-gps/adult-pre-exercise-screening-system/
Criterion or concrete validity is the extent to which a measure is related to an outcome. Criterion validity is often divided into concurrent and predictive validity.
Concurrent validity refers to a comparison between the measure in question and an outcome assessed at the same time.
Predictive validity, on the other hand, compares the measure in question with an outcome assessed at a later time.
Concerns have been raised whether the variable ACL return-to-sport criteria utilized in current clinical practice are stringent enough to achieve safe and successful return-to-sport. For example, strength and hop tests have been shown to overestimate knee function after ACL injury. This is an example of the measure in question (limb symmetry index cut points in strength and hop tests) NOT being comparable in importance to estimated pre-injury capacity. Applying limb-symmetry index's of 90%, which is common in clinical practice, is an example of poor criterion validity.
Wellsandt, E., Failla, M. J., & Snyder-Mackler, L. (2017). Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther, 1-18. doi:10.2519/jospt.2017.7285 http://www.ncbi.nlm.nih.gov/pubmed/28355978
Content validity (also known as logical validity) refers to the extent to which a measure represents all facets of a given construct.
For example, a pre-participation evaluation may lack content validity if it only assesses the range of motion and strength of an individual, ie the part specific competence and capacity, but fails to take into account the behavioral dimension, or pattern-specific competence and capacity.
Further, a pre-participation evaluation may lack content validity if it does not evaluate seemingly unrelated elements. For example, the essence of regional interdependence is that pain or movement-below-competence anywhere can affect a movement pattern in the whole kinetic chain.
Regional interdependence: Wainner, R. S., Whitman, J. M., Cleland, J. A., & Flynn, T. W. (2007). Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther, 37(11), 658-660. doi:10.2519/jospt.2007.0110 https://www.ncbi.nlm.nih.gov/pubmed/18057674
Modifiable and sensitive to change
A measure used in a pre-participation evaluation should be modifiable. For example, a pre-participation evaluation which only includes the presence or not of previous injury is one that is revealing that which is not modifiable. A PPE should include indicators, with criteria, of modifiable risk factors. The PPE itself should be able to detect when changes to those risk factors have occurred, ie the scale of measurement should reflect significant change, for better or worse.
Easily administered once trained, and portable
All PPE's require technical instruction for testers, with reflective practice. The purpose is to bring all testers up to not miss important information. This reduces false negatives. It also ensures individuals are directed onwards for higher level testing when they pass minimum levels of competency, ie normal risk. It also ensures individuals are directed appropriately for further assessment when they do not pass minimum levels of competency. For example, an individual who's resting blood pressure is 150/110 has undergone a reliable test, with construct validity of a measure that is modifiable, sensitive to change, using an easily administered test that is portable, and which directs the person to be further assessed as to what might be causing, contributing or complicating normal blood pressure.
In PPE's that relate to risk factors for ACL injury, there exist baseline screens and assessments that can be taught, easily administered in small time periods, require minimal equipment that is portable and that can be reliable, valid for risk factors, capture modifiable risks and are sensitive to change.
Q: "How do you define screen, test, assess, and evaluate?"
A: Screen, test and assess are all versions of evaluate.
Evaluate is the "parent" word that is a verb, to form an idea of the value of the subject.
A screen is a evaluation that filters a subject into two main categories - pass or fail. Another way to describe the category is - competent or not. The screen is there to look for RISK and COMPETENCE of movement. A screen is NOT for predicting injury. A movement screen does not tell us what is wrong. It only tells us that some movement is below acceptable.
An assessment is a evaluation that reveals DISABILITY. An assessment is used to tell us what is contributing to the individual having risk, or incompetence.
A test is an evaluation to tell us about the ABILITY of the individual. When an individual passes a screen, we know they are competent, but we don't know about their capacity, so we test them for ABILITY.
Like any injury, a pre-participation evaluation can be interpreted in two ways:
1. Evaluate someone who has not been injured - the aim of the evaluation is to look for readiness for the event, generally and specifically; and
2. Evaluate someone who HAS been injured - the aim of the evaluation is to look for readiness for the event in addition to structural integrity of the injured part.
For example, a person who has suffered a lateral ligament sprain should have their ligament evaluated for structural integrity, in addition to potential causes, contributing factors and complicating factors.
The following guidelines for obtaining a diagnosis are up-to-date and based on information from the Cochrane Collaboration, an organisation whose mission is “to ensure that patients receive effective interventions for the best health outcomes based on up-to-date evidence, and that healthcare providers have up-to-date and easy access to the latest evidence.”
• Clinical tests include those for disruption of ligaments, and include the anterior drawer test of ATFL function and inversion tilt test of both ATFL and CFL function. The reliability of these tests has been questioned in recent systematic reviews (Hubbard & Hicks-Little, 2008), and it has been suggested that these tests alone are not sufficient to accurately determine the extent of ligament damage because of the large variation in individual variation .
Containing an evaluation to these two tests would do a disservice to the individual, as they do not evaluate the contribution of the part to the patterns and power required for the activity. See below for PPE's that further evaluate these elements.
Hubbard, T. J., & Hicks-Little, C. A. (2008). Ankle Ligament Healing After an Acute Ankle Sprain: An Evidence-Based Approach. J Athl Train, 43(5), 523-529.
At least two studies suggested that shorter cleat length was associated with a reduced risk of knee and ankle injuries (Lambson et al, 1996; Robey et al, 1971).
The shoe to surface interface has been strongly correlated with ACL injury (Pope, 2002) such that rubber matting, in combination with rubber-soled shoes was a direct cause of ACL injuries in Australia military recruits. It has also been suggested that such interfaces may indirectly increase risk via changing human movement factors (Letha et al, 2006)
Pope, R. P. (2002). Rubber matting on an obstacle course causes anterior cruciate ligament ruptures and its removal eliminates them. Mil Med, 167(4), 355-358. https://www.ncbi.nlm.nih.gov/pubmed/11977890
Lambson, R. B., Barnhill, B. S., & Higgins, R. W. (1996). Football cleat design and its effect on anterior cruciate ligament injuries. A three-year prospective study. Am J Sports Med, 24(2), 155-159. doi:10.1177/036354659602400206
Robey, J. M., Blyth, C. S., & Mueller, F. O. (1971). Athletic injuries. Application of epidemiologic methods. Jama, 217(2), 184-189. https://www.ncbi.nlm.nih.gov/pubmed/5108781
Letha, Y. G., Marjorie, J. A., Elizabeth, A. A., Roald, B., Bruce, D. B., Marlene, D., . . . Bing, Y. (2006). Understanding and Preventing Noncontact Anterior Cruciate Ligament Injuries: A Review of the Hunt Valley II Meeting, January 2005. Am J Sports Med, 34(9), 1512-1532. https://doi.org/10.1177/0363546506286866
Velocity Sports Performance are bringing a sports medicine specialist on to the team to work with the Chinese Womens Weightlifting Team through the Tokyo Olympics. See the job description below.
It's always going to be a really interesting project working in China at that level, with a successful team that’s looking to continue to innovate to improve. They are also deploying one of their performance specialists, who will be part of that project team as well.
It would be really interesting for someone who is demonstrated as competent at a high level, loves a challenge and loves weightlifting.
Please share with anyone you know who may be a good fit.
Contact VSP directly via the attached pdf.
Watch the video, then click the link below it to get actionable support on taking steps to being a PT in professional sports.
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