Course:KIN366/ConceptLibrary/Athlete Prescreening

Movement Experiences for Children
KIN 366
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Instructor:	Dr. Shannon S.D. Bredin
Email:	shannon.bredin@ubc.ca
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Athlete prescreening, also referred to as pre-participation screening or evaluation, generally consists of a set of systematic and routine evaluations given to an athlete before participation in competitive sport (Maron, et al., 1996). It has the intended purpose of revealing clinically relevant conditions, such as a pre-existing cardiovascular abnormality, in order to decrease the risks associated with athletic participation (Maron, et al., 1996). An athletic prescreen should be a brief, yet comprehensive evaluation of the athlete, with the most important aspect being a ‘patient history’ component (Bratton, 1997). Although a general physical examination focusing on the areas involved in sport should be done, according to guidelines laid out by Bratton in 1997, laboratory tests are not normally required. This type of individualized testing allows an examining physician to make an informed decision as to whether the athlete should be allowed to participate or not (Bratton, 1997). Once the athletic prescreen is complete, disqualification from competitive sport may occur and would be based on the athlete’s physical abnormality, the amount of energy required to participate in their given sport, and how much contact they may encounter while playing (Bratton, 1997). An athlete should undergo their pre-participation screening a recommended 4-6 weeks before competitive athletic practice commences, as this allows time for potential conditions to be fully investigated and for prevention or rehabilitation practices to be implemented before the season begins (Peterson & Bernhardt, 2011; Bratton, 1997). The age at which pre-screening typically begins is approximately 12-14, which coincides with the age at which competitive athletic competition tends to begin (Corrado et al., 2011).

Available Athlete Prescreening Tools

Pre-participation Physical Evaluation (PPE)

Very generally, the Pre-participation Physical Examination attempts to do what all athletic pre-screening measures do; it hopes to “identify medical conditions that may affect safe and effective participation in organized sports” (Carek & Mainous, 2003, p. 661). Use of the PPE is most prevalent within the U.S., where it has become the standard for high school and collegiate athletes who are preparing for athletic involvement (Carek & Mainous, 2003). Nearly all middle and high school students in the U.S. require proof of a completed PPE every 1-2 years. Due to liability concerns, most institutions that demand this requirement strictly prohibit participation until documentation has been verified (Peterson & Bernhardt, 2011). This practice is continued at some clubs and levels, but is less consistent and varies depending on both sport and region (Peterson & Bernhardt, 2011).

Components

Lombardo and Badolato identify the primary components of the PPE as medical history, a physical examination, a diagnostic examination, and finally, the determination of clearance (2001). Clearance is one of the most important aspects of the PPE and is divided into 4 levels: unrestricted clearance, clearance after further evaluation or therapy, limited clearance for certain sports, or not cleared (Lombardo & Badolato, 2001). Certain guidelines have been put in place to help categorize different sports into levels of contact and strenuousness, aiding in the determination of clearance. To assure that these guidelines are being followed, the PPE is best performed by a physician who is familiar with these recommendations (Lombardo & Badolato, 2001).

Objectives

Specific objectives as outlined by the American Medical Association Group on Science and Technology, indicate that physicians using this evaluation should attempt: "1) to identify those athletes who have medical conditions that place them at substantial risk for injury or sudden death and disqualify them from participation or ensure they receive adequate medical treatment before participation and 2) to not disqualify athletes unless there is a compelling medical reason" (Carek & Mainous, 2003, p. 661).

Similarly, the Pre-participation Physical Examination Task Force highlighted the three primary objectives of the PPE as: “1) to detect conditions that may predispose to injury, 2) to detect conditions that may be life threatening or disabling, and 3) to meet legal and insurance requirements” (Carek & Mainous, 2003, p. 661).

Female Considerations

Over the past 30 years, girl’s sport participation has seen dramatic increases (Rumball, et al., 2004). With this influx in mind, it is important to tailor the standard evaluation of a female athlete in a way that addresses her needs, as they may differ slightly from those of male athletes. Specific areas of concern have been identified as the ‘female athlete triad’, which includes disordered eating, menstrual cycle disturbances and osteopenia/osteoporosis (Rumball, et al., 2004). Though these should be considered, it is important to be mindful that each sport and individual will have different predispositions. Even though the PPE only contains a few questions relating to the female triad, it is recommended as a good way to detect early signs and symptoms, and to help develop a trusting relationship between patient and physician, creating an atmosphere where the athlete feels comfortable to disclose such personal information (Rumball, et al., 2004).

The Functional Movement Screen (FMS)

The FMS is a pre-participation evaluation tool that offers an alternative approach to prescreening, as it assesses an individual’s fundamental movement patterns in a dynamic and functional manner (Cook, et al., 2006). The FMS is used as a screening tool to prevent musculoskeletal injuries, as opposed to most other pre-screening tools that predominantly look to rule out cardiac abnormalities. The test uses seven different fundamental movement patterns that require both mobility and stability. These movements demonstrate an athlete’s basic locomotor, manipulative, and stabilizing movement capabilities (Cook, et al., 2006). The human body is a ‘kinetic chain,’ meaning that the body is a “linked system of interdependent segments” (Cook, et al., 2006, p. 64); therefore injury or imbalance in one segment can affect the entire body. The FMS tests (see below) will make such weaknesses plain to the observer by placing the athlete in extreme positions that demand very specific stability and mobility patterns (Cook, et al., 2006).

Components

Proprioception is defined as “a specialized variation of the sensory modality of touch that encompasses the sensation of joint movement and joint position sense” (Cook, et al., 2006, p. 64). Proprioception forms the basis on which the FMS was created. As growth and development occur, proprioception is developed through reflexive movements that occur in order to perform basic tasks (Cook, et al., 2006). This development universally happens in a proximal to distal manner, meaning that an infant first learns to stabilize joints that are closer to the center of the body before learning to stabilize joints that are further away from the center of the body (Cook, et al., 2006).

There are seven movements within the FMS and they all attempt to challenge the body to move in a proximal-to-distal manner, isolating inefficient movement patterns (Cook, et al., 2006). The seven tests included are:

Deep Squat
Hurdle Step
In-line Lunge
Shoulder Mobility
Active Straight Leg Raise
Trunk Stability Push Up
Rotary Stability

Benefits

It has been seen that even some high level athletes have trouble when they undergo the simple FMS testing (Cook, et al., 2006). In these cases, the athlete has usually developed compensatory movement patterns that tend to be inefficient and, if continued, will cause poor biomechanics to develop and lead to possible injury (Cook, et al., 2006). If FMS is done regularly and movement inefficiencies are identified, preventative strategies can be employed to avoid and fix muscular imbalances and therefore prevent injury (Cook, et al., 2006). It is important that these tests are routine so that the quality of an athlete’s movement patterns is continually being checked and maintained.

Downfalls

Unfortunately, research related to movement-based assessments is limited, as there are only a few that are currently being utilized (Cook, et al., 2006).

PAR-Q+ and ePARmed-X+

The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is a simple 4-page document that asks an individual health related questions, with the intention of providing physical activity clearance (Bredin, et al., 2013). The first page is intended to clear healthy individuals, with the subsequent pages only used by those who require follow up inquiries. If the participant answers yes to the more in-depth questions on pages 2 and 3, they are referred to a qualified medical professional or to the electronic Physical Activity Readiness Medical Examination (ePARmed-X+) in order to receive additional advice (Bredin, et al., 2013).

The original versions of both these tests were Canada’s leading prescreening tools until their weaknesses were exposed, and their lack of empirical basis began to draw criticism (Bredin, et al., 2013). To address the concerns raised, the PAR-Q+, and the ePARmed-X+ were developed. These newer tools are part of a risk stratification strategy that aims to help fitness and health care professionals who are attempting to encourage individuals to be active. The questionnaires are designed to place an individual upon an evidence-based ‘risk continuum,’ according to their current disease severity and the number of co-morbid (simultaneous) conditions they may be dealing with (Bredin, et al., 2013). From the information gained through application of these measures, a health professional is able to prescribe individualized and appropriate physical activity guidelines or prescriptions.

Benefits

Unlike many of the prescreening tools available, the PAR-Q+ and the ePARmed-X+ are evidence based, and therefore meet the standards required by medical fields (Bredin, et al. 2013). Unlike the PPE and FMS, these measures are accessible online and are easy to complete (Bredin, et al., 2013). Whereas the original versions had an attached age restriction, their updates have been altered to include all ages (Bredin, et al., 2013). These accessible measures easily allow individuals who would normally be disqualified from participation to safely self-screen themselves back into physical activity, while efficiently providing them with the appropriate guidelines needed to minimize the risk associated with participation.

Athlete Prescreening and Sudden Cardiac Death (SCD)

Prescreening in athletics has received most of its current attention due to its potential to decrease the occurrence of Sudden Cardiac Death (SCD) in young, unsuspecting athletes. Sudden Cardiac Death is broadly defined as death within one hour of the onset of heart related symptoms. Sudden, non-traumatic deaths are rare in sport, but the cases that do occur are tragic and commonly due to cardiac arrest. For many years it was debated as to why this type of death was occurring in competitive athletes, as they are among the healthiest populations and regularly manage high amounts of intense exercise without any obvious symptoms (Corrado, et al., 2011). It has now been discovered that SCD among athletes is most commonly caused by “an abrupt ventricular tachyarrhythmia as a consequence of a wide spectrum of cardiovascular diseases” (Corrado, et al., 2011, p. 934). These diseases are often silent and asymptomatic in daily living and therefore an athlete may unknowingly put themselves in danger, as athletic engagement acts as a trigger for SCD in the predisposed individual (Corrado, et al., 2011; Corrado, et al., 2003). This key factor makes it so that prescreening is the only strategy for preventing these athletic fatalities (Corrado, et al., 2011). As adolescents and young adults who participate in competitive sport have approximately three times the risk of SCD when compared with their non-athletic counterparts, identifying young athletes affected by these otherwise asymptomatic conditions has become the primary purpose for many pre-participation screening protocols (Corrado, et al., 2011).

Common Conditions Causing SCD

According to Corrado et al., atherosclerotic coronary artery disease is the most common silent killer of those who suffer SCD after the age of 35 years (2011). In young athletes however, the most prevalent cause of SCD appears to be genetic or congenital (from birth) cardiac abnormalities. Among such conditions are hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, as well as congenital coronary anomaly (Corrado, et al., 2011).

Prevalence

The overall prevalence rate of SCD in young athletes has been estimated to fall between 0.2 – 0.7% (Corrado, et al., 2011). Sudden Cardiac Death has shown a clear predominance in men with a male to female ratio of 10:1(Corrado, et al., 2011). It was estimated in a study by Van Camp, et al. (1995) that the incidence of exercise-related death in females is approximately 1 in 769, 000. The higher occurrence of SCD in males has traditionally been explained because they more commonly participate in competitive sport (Corrado, et al., 2011). It may also be the case that males simply have a higher over all prevalence of cardiac diseases (Corrado, et al., 2011). According to Maron, et al., hypertrophic cardiomyopathy (HCM) is a common cause of SCD, especially in African American athletes (2003). Since HCM is more prevalent in this ethnic group, African Americans may be more at risk for SCD than other groups (Curtis & Bourji, 2014).

Italy: A Case Study on SCD Prevention

In 1982, the Region of Veneto, Italy became the first nation to introduce mandatory and systematic pre-participation athletic screening (Corrado, et al., 2006). This gave researchers the opportunity to see what impact a uniform initiative could have on the rates of SCD in young, athletic populations (Corrado, et al., 2006). This program was based on the use of a 12-lead ECG and allowed researchers to study the different SCD rates in athletes and non-athletes. With this opportunity, researchers have been able to deduce that the incidence of athletic SCD has declined in young athletes since the introduction of mandatory screening (Corrado, et al., 2006). The major finding of this study was that young competitive athletes saw an 89% decrease in the incident rate of SCD over the 26 year study period (Corrado, et al., 2006). In contrast, the non-athletic, unscreened population did not see any significant change (Corrado, et al., 2006). In addition to reducing SCD rates in athletic populations, follow up examinations for the athletes who were disqualified for hypertrophic cardiomyopathy revealed that none of the afflicted individuals had died (Corrado, et al., 2006).

Associated Debates and Issues

ECG Vs. No ECG

As mentioned above, Bratton’s guidelines (1997) have suggested that laboratory testing is not necessary. However, there is considerable debate between the suggestions outlined by European and American physicians (Corrado, et al., 2011). American cardiologists and sport medicine physicians have agreed that a pre-participation screening using only patient history and a physical examination is sufficient, even though this type of testing has limited power in detecting hidden cardiovascular abnormalities (Corrado, et al., 2011). Results have been seen however, that by including the use of a twelve lead electro-cardiogram (ECG), these detection rates can be greatly increased, as its use allows conditions with ECG abnormalities to be caught (Corrado, et al., 2011). European countries are more likely than the U.S. to insist on the use of this technology, based primarily on the evidence from the 2006 study by Corrado et al. that described a significant drop in SCD cases since the implementation of a mandatory ECG pre-screening protocol in 1982. Utilizing the data from this large population-based Italian study, a finding to note is that out of 33,735 athletes who participated in this ECG screening, there were 22 found to have hypertrophic cardiomyopathy (HCM), a condition responsible for approximately one third of the SCD cases in younger athletes in the US (Corrado, et al., 1998). Comparatively, when looking at the cases of these 22 athletes, only 5 would have been detected through the use of U.S. (no ECG) standards alone (Corrado, et al., 2011). With these findings, it has been estimated that including the use of ECG in prescreening improves its sensitivity by 77% (Corrado, et al., 1998). This creates a compelling argument for the inclusion of ECG into North American guidelines. However, in a study done by Maron et al. (2009), SCD rates in Minnesota, U.S. were compared with SCD rates in the Veneto region of Italy and were found to be very similar, despite the fact that each of the countries use a different pre-screening protocol. This indicates that pre-screening athletes with ECG may not actually lower the rates of SCD (Maron et al., 2009). There has also been criticism of the Italian study done by Corrado, et al. in 2006 due to the fact that is was not a controlled trial. Since it was not controlled, there may have been other factors involved in lowering the rates of SCD in Italy after 1982 when ECG screening was deemed mandatory (Corrado, et al., 2011). However, Corrado et al. maintain that their argument remains compelling due to the convenient timing of the dramatic drop in SCD rates after implementation of the ECG program (2011).

False-Positive Results

‘Athlete’s Heart’ refers to the adaptations of a heart as it undergoes repeatedly sustained exercise (Corrado, et al., 2011). With this adaptation, the ECG of the heart changes, potentially making it more prone to showing ‘false-positives’ (Corrado, et al. 2011). Because of this, it was traditionally thought that the ECG was an unreliable tool for detecting cardiac abnormalities in athletes (Corrado, et al., 2011). Many studies have disproved this misconception however, and it has since been found that the false-positives rate is as low as 3% when using this technology (Corrado, et al., 2011).

Monetary Costs of ECG Prescreening

A recent study in the United States of America released a statement stating that if an ECG is added to the pre-participation protocol of athletes between the ages of 14-22 years old, it would cost approximately $42,000 per ‘life-year’ saved (Corrado, et al., 2011). This amount is below the usual benchmark used to determine if a medical treatment is economically viable, which is $50,000 per ‘life-year’ (Corrado, et al., 2011). The costs and feasibility depend on the where the program is implemented, and cost considerations should include training of specialized physicians and physicians’ time (Corrado, et al., 2011). It has been argued that the use of ECG is not necessary for recreational athletes (Curtis & Bourji, 2014). Since the recreational athletic population is at a lesser risk for SCD and that the majority of the athletic population is at the recreational level, it would not be cost-effective to use an ECG pre-screening protocol for the entire athletic population (Curtis & Bourji, 2014). Implementing the ECG pre-screening protocol for only high performance level athletes would potentially help reduce costs.

Individual Costs for Young Athletes

Disqualification from competitive sport may have severe consequences for a young athlete (Corrado, et al., 2011). Prescreening for the presence of conditions such as abnormalities of the heart may potentially affect their future physical activity opportunities, it may diminish their happiness, and likely inhibit a future professional sporting career if abnormalities are found (Corrado, et al., 2011). According to Corrado et al. (2011), the risk of SCD if sport is continued with an abnormality present is, “relatively unknown, difficult to assess and relatively low” (p. 941). With this being the case, there is concern as to whether or not prescreening is really beneficial. Addressing this, Corrado et al. (2011) continue on to say, “the screening perspective…is that the risk of SCD associated with competitive sports in the setting of potentially life-threatening cardiovascular disease is a controllable factor, and the devastating impact of even infrequent fatal events in the young athletic population justifies appropriate restriction from competition” (p. 941). The hope of prescreening is simply to promote the safety of athletes, and therefore permanently restricting athletes from competition for non-lethal issues is considered arbitrary and unproductive (Corrado, et al., 2011). Presently, and proceeding forward, a main goal of prescreening athletes should be to reduce the number of disqualifications from sport, while finding ways to adapt activities for the disqualified individual instead of prohibiting physical activity altogether (Corrado, et al., 2011).

Additional Benefits of Medical Pre-screening for Athletes

In addition to the benefit of preventing the loss of young, unsuspecting lives, research on athletic prescreening has noted additional benefits associated with encouraging the practice of medical pre-screening.

Family

The benefit of prescreening extends beyond the athlete, as the detection of asymptomatic heart disease can spur further testing on the individual’s relatives who may also be living with a life threatening condition, thus potentially saving additional lives (Corrado, et al., 2011).

Doctor-Patient Relationship

Required sports examinations are additionally beneficial as they are an opportunity for a child, adolescent or young adult to visit their physician on a regular basis. This provides physicians a chance to develop a healthy doctor-patient relationship, look for disqualifying conditions, check for general health, be available for counseling of sexual issues, to discuss the importance of academics and to discourage delinquent behaviour such as smoking, or alcohol and drug use (Bratton, 1997).

Effectiveness

Pre-Participation Physical Evaluation

Upon review of the Pre-Participation Evaluation that is popular in the U.S., Carek and Mainous discovered that many evaluating studies did not use randomized control groups, nor did they adequately describe athletes that were identified as false-positives or false-negatives (2003). This means that the accuracy of the screening test has not presented and therefore fails to meet basic criteria of an effective athletic prescreen measure (Carek & Mainous, 2003). Though its effectiveness cannot be proven, it should be noted that administering the PPE has not led to reports of any harmful effects (Carek & Mainous, 2003).

“Based on the results of this review, scientific evidence is lacking to support the ability of the PPE to satisfy the basic requirements for medical screening. We could not determine the effectiveness of these examinations in detecting physical abnormalities serious enough to limit or restrict athletic participation. The absence of a comparison group, the unknown rate of actual participation of athletes in these examinations, and inconsistent definitions of a physical abnormality serious enough to limit athletic participation contributed to the inability to determine the sensitivity and false-negative rate of the PPE. These values are essential in determining the value of a medical screening tool.” (Carek & Mainous, 2003, p. 662)

Functional Movement Screen (FMS)

The FMS has proven to have both good inter-rater and intra-rater reliability, according to a study done by Smith et al. (2013). This is important for any screen to have, as it would lose its efficacy if the results are inconsistent. The FMS is also relatively quick to do and requires minimal equipment, making it a convenient screen to incorporate into an athlete’s training regimen.

Practical Application

Evidence based on the Italian system suggests that ECG should be introduced into the North American protocols for athlete pre-screening in order to improve their effectiveness at detecting potentially fatal cardiac conditions (Corrado, et al., 2011). However, it has been argued by Curtis and Bouji that the use of ECG is not warranted for pre-screening of athletes at the recreational level (2014). Although the revised guidelines of the PPE issued by the American Health Association in 2007 still solely recommends a medical history and physical approach, they acknowledge the effectiveness of the ECG. However, the consensus is that logistics hinder its inclusion in the U.S. system (Corrado, et al., 2011). This may not be the best stance for policy makers to take, as previously mentioned reviews reveal that the PPE is not empirically sound and seems to be unreliable (Carek & Mainous, 2003). Because of this, more appropriate and proven measures (such as ECG) need to be seriously considered. Since pre-screening does not prevent all cases of SCD that occur, Piper and Stainsby argue that having trained personnel and proper equipment at sporting venues is just as important as the pre-screening process (2013).

For coaches, teachers and medical professionals who are attempting to encourage physical activity at a grassroots level, the PAR-Q+ and the ePARmed-X+ might be an easy, accessible and proven alternative to ensure participant safety (Bredin, et al., 2013). Both of these forms can be found online at http://eparmedx.com/. This risk stratification technique can be adopted for any setting, making physical activity participation safer for everyone.

When dealing with young athletes in particular, it is essential that the pre-screening methods do not dissuade children from being active. As mentioned above, it is of utmost importance that those young athletes who have interfering health conditions receive treatment, and altered or alternative activity options in order to keep them engaged in sport and/or physical activity. Research regarding the resources given to an athlete after disqualification from sport is most adequately addressed by the PAR-Q+ and the ePARmed-X+, as they provide advice for an athlete on how to modify activity in a manner that encourages continued participation.

The FMS is a useful tool that may be employed by athletic trainers, athletic therapists, physiotherapists, kinesiologists, personal trainers, strength and conditioning coaches, or any other individual with an FMS certification. Its use is not yet widespread but is becoming more popular among various sports teams. The use of the FMS is not well documented, especially at the young athlete level, however it is simple to use and may prove to be an effective tool for preventing injuries due to muscular imbalances.

References

Bratton, R.L. (1997). Preparticipation screening of children for sports. Sports Medicine (Auckland), 24(5),300-307. doi: 10.2165/00007256-199724050-00002

Bredin, S.D., Gledhill, N., Jamnik, V.K., & Warburton, D.E.R. (2013). PAR-Q+ and ePARmed-X+: New risk stratification and physical activity clearance strategy for physicians and patients alike. Candian Family Physician, 59(3),273-277. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3596208/

Carek, P.J., & Mainous III, A. (2003). The preparticipation physical examination for athletics: a systematic review of current recommendations. British Medical Journal (International Ed.), 327(7418), 661-664. doi:10.1136/bmjusa.02120003

Cook, G., Burton, L. & Hoogenboom, B. (2006). Pre-participation screening: The use of fundamental movements as an assessment of function – part 1. North American Journal of Sports Physical Therapy, 1(2), 62-72. Retrieved from http://www-ncbi- nlm-nih-gov.ezproxy.library.ubc.ca/pmc/articles/PMC2953313/

Corrado, D., Schmied, C., Basso, C., Borjesson, M., Schiavon, M., Pelliccia, A., … Thiene, G. (2011). Risk of sports: Do we need a pre-participation screening for competitive and leisure athletes? European Heart Journal,32(8), 934 – 944. doi:10.1093/eurheartj/ehq482

Corrado, D., Basso, C., Rizzoli, G., Schiavon, M., & Gaetano, T. (2003). Does sports activity enhance the risk of sudden death in adolescents and young adults?. Journal of the American College of Cardiology, 42(11), 1959-1963.doi:10.1016/j.jacc.2003.03.002

Corrado, C., Basso, C., Pavei, A., Michieli, P., Schaivon, M., & Thiene, G. (2006). Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. The Journal of the American Medical Association, 296(13), 1593-1601. doi:10.1001/jama.296.13.1593.

Corrado D, Basso C, Schiavon M, Thiene G. (1998). Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med, 339, 364–369.

Curtis, A.B., Bourji, M. (2014). ECG Screening Is Not Warrented for the Recreational Athlete. Journal of the American College of Cardiology, 63(19), 2035-2036. doi:10.1016/j.jacc.2014.01.045

Lombardo, J.A., & Badolato, S.K. (2001). The preparticipation examination. Clinical Cornerstone, 3(5),10-22. doi:10.1016/S1098-3597(01)90066-3

Maron, B.J., Thompson, P.D., Puffer, J.C., McGrew, C.A., Strong, W.B., Douglas, P.S., … Epstein, A.E. (1996). Cardiovascular preparticipation screening of competitive athletes: A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenial Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation, 94(4), 850-856. Retrieved from http://circ. ahajournals.org/content/94/4/850.full

Maron B.J., Carney K., Lever H., et al. (2003). Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. J Am Coll Cardiol, 41(6), 974-980. doi:10.1016/S0735-1097(02)02976-5.

Maron B.J., Haas T.S., Doerer J.J., Thompson P.D., James H.S. (2009). Comparison of U.S. and Italian experiences with sudden cardiac deaths in young competitive athletes and implications for preparticipation screening strategies. Am J Cardiol, 104, 276–280. Retrieved from http://www.sciencedirect.com/science/article/pii/S0002914909007711

Peterson, A.R., & Bernhardt, D.T. (2011). The preparticipation sports evaluation. Pediatrics in Review, 32(5),53-65. doi:10.1542/pir.32-5-e53

Piper, S., & Stainsby, B. (2013). Addressing the risk factors and prevention of Sudden Cardiac Death in young athletes: a case report. Journal Of The Canadian Chiropractic Association, 57(4), 350-355.

Rumball, J.S., & Lebrun, C.M. (2004). Preparticipation physical examination: Selected issues for the female athlete. Clinical Journal of Sport Medicine, 14(3),153-160. Retrieved from http:// graphics. tx.ovid.com.ezproxy.library.ubc.ca/ovftpdfs/ FPDDNCFBCBAJMO00/ fs035/ovft/live/gv010/ 00042752/ 00042752-200405000-00008.pdf

Smith, C.A., Chimera, N., Wright, N.J., Warren, M. (2013). Interrater and Intrarater Reliability of the Functional Movement Screen. Journal of Strength and Conditioning Research, 27(4), 982-987. doi: 10.1519/JSC.0b013e3182606df2

Van Camp, S.P., Bloor, C.M., Mueller, F.O., et al. (1995). Nontraumatic sports death in high school and college athletes. Med Sci Sports Exercise, 27, 641–647.