Female Athlete Triad Screening in National Collegiate Athletic Association Division I Athletes: Is the Preparticipation Evaluation Form Effective?
Mencias T., Noon M., Hoch AZ. Clincial Journal of Sports Medicine. 2012: ahead of publisher
The number of female athletes continues to increase in collegiate athletics; however, there are medical issues specific to females (e.g., female athlete triad [triad]) that may not be getting enough attention in the preparticipation evaluation (PPE). The purpose of this study was to assess the screening practices and PPE forms used to identify college athletes at risk for triad. All 347 NCAA Division I universities were invited to participate in a phone or email survey study. From that sample, 257 universities participated, and the authors collected 287 PPE forms. Authors of the survey wanted to collect information regarding the PPE screening process and practices; such as, frequency, timing, location of screening, and credentials of the examiners. In addition, the PPE forms were collected and analyzed by the authors using 12 items constructed by the Female Athlete Triad Coalition for the primary screening of the triad (these items have not yet been validated for screening athletes). Researchers found that all of the universities require a PPE for incoming athletes, but only 83 universities (32%) require a PPE for returning athletes. Twelve universities (5%) completed a full PPE every 2 years. Only 11 (4%) universities were using the most recent edition of the PPE form (4th edition). Sixteen universities (6%) were using the 3rd edition released in 2005. The remaining 260 universities (90%) did not use either of these forms. Two-hundred and forty (94%) universities used a standardized PPE form, and the remaining 15 universities (6%) accepted any form brought in by the athlete’s primary care physician. The orthopedic portion of the screening was typically conducted by an orthopedic surgeon (42%). Only 25 (9%) universities had 9 or more of the 12 recommended items for screening the triad in their forms, 127 universities (44%) had 4 items or less, and 63 if the universities (22%) had only 1 of 2 of the items. Only twenty (7%) of the PPE forms included a 72-hour nutritional assessment form. The most commonly omitted items on PPE come from the disordered eating category (e.g.,“does your weight affect the way you feel about yourself?”) . The 4th edition PPE form addresses 7 of the 12 items and the 3rd edition addresses 6 of the 12.
The triad consists of dysfunctional eating that can lead to dysfunctional menstruation and diminished bone health. Each of these concerns are addressed by the 12-items that are recommended for screening the triad on the PPE forms (8 disordered eating questions, 3 dysfunctional menstruation questions, and 1 bone health question); however, it is important to note that these items have not been well tested yet. Many of the universities do not follow up on return athlete, and those who do typically only require medical history updates reviewed by their athletic trainer. In these situations, only updates from athletes that the athletic trainer deems as “red flags” end up completing a full PPE. This may allow athletes who are at risk for developing the triad after their freshman year to be overlooked. In addition, to potentially missing high-risk return athletes, many forms were missing criteria that may be important for evaluating risk of the triad. Over half of the PPE forms did not ask about a history on disordered eating. Though the 12-item questionnaire may not be validated it may be a quick and easy to complete and help raise a flag for more thorough evaluations. Researchers suggest that the PPE forms currently being utilized by NCAA Division I universities may not be effectively screening for the Female Athlete Triad. Improved preparticiaption screening for the triad may lead to more frequent identification of athletes who are at risk and in need of further evaluation. Should there be a gender specific PPE form to correspond specifically to gender specific medical conditions?
Written by: Jane McDevitt MS, ATC, CSCS
Reviewed by: Jeffrey Driban
Mencias T, Noon M, & Hoch AZ (2012). Female athlete triad screening in national collegiate athletic association division I athletes: is the preparticipation evaluation form effective? Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 22 (2), 122-5 PMID: 22266742
Thanks for an interesting blog post on the issue of the PPE and screening for Female Athlete Triad as part of the Pre-participation Evaluation. The issue of gender-specific PPE forms is an interesting one, since some conditions such as the triad are gender specific. This raises the further question – should PPE forms be sports-specific?
Of course, the gold standard would perhaps be an individualised PPE form based not only on gender specificity, but also on sport and perhaps other factors such as family history.
Whilst PPE forms are a good framework for recording information during a PPE, there is no substitute for a targeted PPE conducted by an experienced physician.
Dr Christopher Hughes.
Web Editor, Clinical Journal of Sport Medicine
Dr. Hughes: Thanks for the comment. I agree that individualized PPE would be very helpful. The introduction of more computer adaptive surveys/questionnaires like some PROMIS measures (https://www.nihpromis.org/) indicate that this may be more feasible in the next few years. These forms could be a good standardized reporting form and adjunct to evaluations conducted by medical personnel.
I agree with the both of you. I think a more individualized PPE form is necessary. Also I think this article brings to attention the fact that many schools are not even using the NCAA 4th edition form. I would love to know what the schools are using if they are not using the 4th edition form. A validated, individualized form would be beneficial for schools to use to help determine any at-risk athletes for further evaluation.
I was just reading about the 4th edition. Sounds like a good tool but it also sounds rather long and its not cheap either. I really wish my pay doubled as fast as the amount of work I have to do.
Jake, I do not know a whole lot about the 4th edition PPE form. The form itself is free (https://www.ppesportsevaluation.org/evalform.pdf). It is 4 pages long, however, it should be filled out prior to screening visit by the patient or with the assistance of their guardian. What makes the 4th edition form expensive?
The whole guide is $160. The form itself is free yes and while much of it is to be filled out by the athlete or parents or both some of it still has to be done by a clinician.
I havent filled out a form but I was reading some info about it and it said it could be up to 1500 questions. That would take some time I would imagine.
Thanks so much for that information. I can imagine the the clinician would still need to go over most of those questions. 1500 questions does seem like a lot. I wonder if it is upwards of 1500 questions due to specific follow up questions that are not on the form. I did not count the questions on the form but it doesn't seem like there are 1500 questions. Maybe that is a good reason to have an individualized form to get rid of questions that are not relevant to that athlete.
I agree that gender specific PPE forms are a good idea because different genders have specific issues that need to be addressed. That being said, I don't know that adding additional questions about disordered eating would necessarily help catch high-risk athletes with that issue, since individuals with disordered eating patterns tend to be secretive about their problem and are quite good at hiding it from others. If you add questions about disordered eating, who is to say that those individuals would not just lie on the form to avoid being confronted about their problem?
I was thinking about that when I was reading this article. Typically athletes with disordered eating know they have a problem and would lie on the form. However, I feel asking isn't hurting the athlete and could be beneficial if the athlete does want help with the problem. But you are right probably more education on the risks they are taking with this disease may lead to more truthful answers or less athletes falling into disordered eating.
As I was reading this article and the previous comments I found it somewhat surprising that there isn't a standardized form that all universities have to use. The NCAA has all sorts of rules and regulations about sport participation so to me it would make sense that they would include use of a standardized form. I think a computerized PPE form is an interesting idea and it would give more individualized follow up questions based on an athlete's responses. Although Female Athlete Triad is gender specific issue and there are sports both male and female that are at a higher risk for athletes with eating disorders; anyone in any sport could potentially have an eating disorder. I have to wonder if a sport specific PPE form would still miss athletes who may be at moderate or high risk.
Good point Kirsten, everyone tends to focus on eating disorders in females, but they do happen in males too. I agree that a computerized form would be the next step in the evolution of PPEs; that way everyone could use a standardized PPE (perhaps provided straight from the NCAA) and it would be logistically a lot easier to have sport or gender specific PPEs available. It makes sense, since I think most programs now keep athlete injury records in some kind of computerized data base anyway.
This article is very interesting to me. I am GA currently (part time) working with the university's cheer and dance team. With this responsibility, besides the injury prevention, recognition, and treatment, comes a host of other challenges that, as a new GA in the Athletic Training world, I am not so comfortable addressing just yet. There is a huge element of style, and pressure to look "just right" for this sport, and this increases the vulnerability for eating disorders, etc to increase. With my short time working with this team, I have had numerous encounters already. As part of their preseason paperwork, we have first years completed a detailed PPE and go through our physical process with our sports med/gen med doctors on staff. As for returners, as an athletic training staff, we have them fill out a returning athlete form of a PPE, and like the article said, review it for an "red flags" we deem neccessary for further discussion, or evaluations. Inevitably, the questions of "do you skip meals, and if yes how many" or "do you control you eating", "would you like to maintain, lose or gain weight" are constant red flags if checked yes. This poses a challenge for many health care providers as to how in depth do we want to go. Hopefully, each of us says…very, to ensure optimal health for our athletes, but the problem is that females are very defensive when talking about weight and eating habits, and it sometimes doesn't allow for a proper eval when necessary. Its a fine line to walk, and constant suggestion on improvements and idea to help these athletes is always welcomed.
I support the idea of a gender specific PPE forms, and also a challenge to make sure each element of the Female Athlete Triad screening is included on the PPE for females. I also support the idea of a regulated universal PPE form for all schools to use. This will ensure that each element of the PPE is being discuss and viewed for potential problems and lapses. It only makes sense to do it that way. Also, resorting to always following the line of over cautious when i comes to eating disorders (both for men and women) is a safe idea to follow.
Great article, thanks for the post.
As a female as well as coming from playing in a division 1 and 2 setting in college, I know that screening for Female Athlete Triad as part of the PPE must be conducted better. I feel like it is very likely for females who want to fall in between the cracks have the ability to. I think it very relevant to follow up with females and not necessarily for males. In the male population there are bigger issues to worry about. In a perfect world, given enough time you could follow up with the male population but I think time would be better spent on banned substances with males.