Safety Concerns

TMA Opposes Chiropractors Performing Sports Exams 

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Legislative Affairs Feature – July 2012 

Tex Med. 2012;108(7):43-45.

By Ken Ortolon
Senior Editor 

In 2011, Texas lawmakers focused much attention on school sports injuries, passing legislation to set protocols for athletes to play following concussions and a bill requiring schools to replace or recondition aging football helmets.

But Texas Medical Association officials believe the Texas Legislature likely is not done with school sports injuries. They say it is possible legislators will revisit sports concussions in 2013, as well as whether pre-participation physicals should look more closely for heart conditions that could exclude students from sports activities.

And, TMA officials say lawmakers may also examine who is conducting those physicals. Current University Interscholastic League (UIL) rules allow physicians, physician assistants, nurse practitioners, and chiropractors to perform physicals. But a special TMA subcommittee that vetted sports injury-related bills last session questions whether chiropractors have the necessary training to adequately conduct sports physicals.

"Chiropractors should not be involved in pre-participation sports physicals," said Keller pediatrician Jason Terk, MD, who served on the TMA subcommittee as chair of the TMA Council on Science and Public Health. "They simply do not have that skill."

During its meeting in May, the TMA House of Delegates adopted a resolution that says only licensed physicians, or their appropriately supervised physician assistants, or advanced practice nurses should perform sports physicals.

Chiropractor a Physician? 

 Current UIL guidelines require pre-participation physical examinations at least before junior high school and in the first and third years of high school.

In 2002, the UIL Medical Advisory Committee recommended removing chiropractors from the list of health care professionals who could perform the exams. Mark Cousins, PhD, director of athletics for UIL, says that followed a legal opinion from the Attorney General's office.

"The rule at that time said it [the physical exam form] was to be signed by a physician," Dr. Cousins said. "There continued to be questions about whether a chiropractor qualified as a physician. So we got an unofficial opinion from our lawyer, who was an assistant attorney general, and he concluded that a chiropractor did not meet the definition of a physician."

The Texas Chiropractic Association (TCA), however, successfully sued to block the change in UIL rules. At the time, TCA argued that chiropractors are qualified to perform the physicals and that UIL lacks the authority to decide which health care professionals could perform them.

The Texas Board of Chiropractic Examiners also contended that UIL was attempting to usurp its authority, saying that it is up to that board to determine what chiropractors can and cannot do.

In 2011, State Rep. Eddie Lucio III (D-Brownsville) filed legislation that would have given UIL the authority to decide who can administer school sports physicals. That bill, House Bill 52, did not pass, but Troy Alexander, associate director of TMA's Legislative Affairs Department, says similar legislation probably will be filed again in 2013.

Where's the Training?  

Dr. Cousins says UIL has no data on how many chiropractors are doing school sports physicals, but the organization, which oversees all school sports activities in the state, knows that some chiropractors are doing them.

And, Mr. Alexander says at least one Austin chiropractor puts out a sign each year advertising sports physicals.

Dr. Terk and Austin pediatric neurosurgeon T.J. Spinks, MD, say chiropractic training simply does not cover many organ systems included in the sports physicals.

"Their training is focused solely on manipulation of the musculoskeletal system," Dr. Spinks said.

The required physical does cover the musculoskeletal system, including the neck, back, shoulders, arms, joints, and more. But it also examines organs such as the heart, eyes, ears, lungs, abdomen, and others.

"I'm not familiar with any kind of chiropractic program where the use of a stethoscope is extensively taught, much less the interpretation of what you're hearing," said Dr. Terk, who himself does a significant number of physical exams each year for student athletes.

He describes the sports physical exam he performs as a "complete head-to-toe examination."

"It's a pretty extensive assessment," he said. "The bottom line is my name is going on that form, and I need to make sure that if this person participates in sports that I've done whatever I can to make sure that any condition that could potentially affect the athlete's safety or health is identified and dealt with."

Taking Another Look 

Dr. Spinks says school sports injuries, particularly concussions, became a hot topic in the legislature because of recent media interest in the issue. "We've had so many high-profile concussions; there has been so much talk about concussions in the media that it's increased awareness everywhere."

Mr. Alexander says the National Football League (NFL) also pushes policies to address concussions in young athletes before they reach the NFL.

"I wouldn't be surprised if there is more attention on concussion issues next session," said Dr. Spinks. "And I think heart issues are becoming more prominent in the public perception, as well."

In fact, TMA recommended an interim legislative study of heart conditions in student athletes to determine if current UIL guidelines for sports physicals provide adequate screening of student athletes with serious conditions such as heart irregularities, asthma, and related concerns. That study, however, was not included among interim charges issued by either House Speaker Joe Strauss or Lt. Gov. David Dewhurst.

Mr. Alexander says data show an increasing number of students being identified with some type of heart condition that could affect their ability to participate in sports.

Dr. Terk, however, says the issue of whether echocardiography should be a required part of the sports physical is "an open question." He says he's not aware of any authoritative body that recommends more extensive cardiac screening.

And, Dr. Cousins says the UIL-required physical already meets the 12 recommendations of the American Heart Association for pre-participation cardiovascular screening.

Those recommendations include taking a medical history for exertional chest pain or discomfort, prior recognition of a heart murmur, elevated systemic blood pressure, family history of premature death from a heart attack, and more.

Dr. Cousins says the UIL Medical Advisory Committee is "trying to stay on top of" cardiac issues, but is not prepared to recommend changes in the pre-participation physicals.

"The evidence at this point would not necessitate them making a recommendation that cardiac screening be a mandatory part of the physical at this time," he said.

 Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email. 

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