The Pre-Participation Sports Examination General

1
The Pre-Participation Sports ExaminationGeneral
Special Needs Populations

• Jeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFP
• Family Sports Medicine
• St. Lukes University Health Network
• Jim Thorpe, Bethlehem, PA
• Assistant Clinical Professor Family and Primary
  Care Sports Medicine
• UMDNJ Robert Wood Johnson Medical School
• UMDNJ New Jersey Medical School
• Philadelphia College of Osteopathic Medicine
• Medical Consultant Healthy Athletes
  Initiative
• Special Olympics NJ
• NJ Academy of Family Physicians

2
The Pre-Participation Exam (PPE)

• Primary goal is to evaluate the health and safety
  of the athlete
• Objective is to be INCLUSIVE, not to try to
  exclude participation
• NOT a substitute for the regular health
  examinations by the Primary Care Physician

3
Primary Objectives

• Detect conditions that may limit participation
• Atlanto-axial instability in Down Syndrome
• Heart murmurs Innocent vs. Hypertrophic
  Cardiomyopathy (HCM)
• Detect conditions that may lead to injury
• Lack of physical conditioning, weak muscles
• Poor exercise tolerance, heat intolerance
• High number of major joint problems Miserable
  Misalignment Syndrome
• Meet legal and insurance requirements

4
Secondary Objectives

• Assess athletes general health
• May be the ONLY opportunity you have to see this
  patient and discuss issues such as immunizations,
  substance abuse, and birth control
• Counsel athlete on health-related issues
• Assess growth development
• Tanner staging can be helpful where less mature
  athlete is playing against a more mature athlete
  HIGH risk for injury in contact sports (Exam can
  be embarrassing)
• Assess fitness level performance
• Help identify weaknesses that may increase
  chances of injury (e.g., swimmers with weak
  pectoral muscles)

5
Timing

• Best if performed at a MINIMUM of SIX weeks
  before practice starts
• Gives time to identify correct problems noted
  on exam

6
Frequency

• Vary from before each season to every few years
  (few is variable)
• Optional short interval history and go after
  specific changes or problems
• Once yearly is most popular

7
Methods

• Private office by Primary Care Physician
• Multi-station exam with different providers of
  various types (physicians, nurses, PAs)
• Each type of station has advantages and
  disadvantages
• In-school physical
• Currently not required in NJ to get athletes to
  have a Medical Home. However, there are
  exceptions.

8
Private Office Advantages

• PCP knows the PMHx, the FHx, Immunizations
• Less likely to overlook problems
• Young athletes will be more willing to discuss
  sensitive issues with a known person
• Easier and less embarrassing to do GU exam (if
  indicated)
• Less chance for abnormalities to be overlooked
  and not addressed

9
Private Office Disadvantages

• Many athletes do not have a PCP
• Limited time for appointments time consuming
• Varying levels of knowledge and interest in sport
  specific problems
• Must be well versed in sports-specific demands
• Greater cost many cannot afford
• Higher income athletes will tend to go to
  different specialists for each problem found
• Tendency for poor communication between PCP and
  school athletic staff
• Many un-indicated disallowed athletes

10
Multi-Station Advantages

• Cost effective and easy to screen large numbers
  of athletes
• Specialized personnel at each station
• Usually 5 to 6 stations
• Good communication with school athletic staff
  since the coach athletic trainers are usually
  part of the team

11
Multi-Station Disadvantages

• Requires a large amount of space
• Hurried, noisy, with minimal privacy
• Difficult for GU exam, heart murmurs
• Continuity of care easily lost, problems noted
  are NOT followed up upon
• Lack of communication with parents
• Particular consultant may put unreasonable
  demands on an athlete
• Varying levels of training of school physicians

12
Multi-Station Requirements

• Station
• Sign-in, Ht/Wt, vital signs, vision
• History review, physical (medical, orthopedic,
  neurological) assessment/clearance

• Personnel
• Coach, trainer, nurse, volunteer
• Physician

13
Multi-Station Options

• Station
• Specific orthopedic exam
• Flexibility
• Body composition
• Strength
• Speed, agility, power, endurance, balance

• Personnel
• Physician
• Trainer or therapist
• Physiologist
• Trainer, coach, therapist, physiologist
• Trainer, coach, physiologist

14
MEDICAL HISTORY IS KEY!

• Statistics show that a good history will identify
  63 to 74 of medical problems
• Anecdotal information from the athlete agrees
  with the parents less than half of the time
• Reference Medicine Science in Sports
  Exercise. 199931(12) 1727.

15
Key Questions

• The following questions need to be asked or put
  on a questionnaire that is reviewed

16
Ever been treated in a hospital or had surgery?

• Important to know number and severity of
  Traumatic Brain Injuries (concussions)
• Determine if certain medical conditions are under
  control enough to allow or limit participation
• Diabetes, asthma
• Has enough time passed to allow for healing and
  rehabilitation after surgery?

17
Taking any Rx or OTC Drugs?

• History of Rxs important to assess control
• Diabetes, asthma
• Does the athlete require any emergency drugs that
  the coach/AT will need to know about AND how to
  use them?
• Get information on birth control measures
  menstrual history
• Amenorrhea in women athletes can lead to a high
  risk of stress fractures (Female Athletic Triad)
• Good way to introduce talk on STDs

18
Taking any Rx or OTC Drugs?

• Get information on use of OTC drugs because
  athletes tend to abuse these
• OTC asthma, decongestants, diet pills can cause
  increased heart rate and arrhythmias
• NSAIDs can cause increased bleeding
• Laxatives (wrestlers) can cause electrolyte
  abnormalities
• Try to get history of illicit drug use
• Alcohol, tobacco, marijuana, steroids

19
Allergies?

• Drugs
• Know which drugs can and CANT be given in case
  of an emergency
• Bees insects important in outdoor sports
• Need to carry an EpiPen?

20
Skin Problems or Rashes?

• Mainly looking for herpes, scabies, lice,
  molluscum contagiosum
• Impetigo, herpes, and other conditions can be
  spread by mats, helmets, towels
• Acne and other atopic conditions can be
  exacerbated by clothing or equipment

21
History of Head Injury, LOC, Seizure, Burners or
Stingers?

• History of seizure (epilepsy?)
• Loss of consciousness (LOC) headache Hx
  important to determine ability to resist
  Traumatic Brain Injury (TBI) risk for Second
  Impact Syndrome
• Burners/stingers are brachial plexus injuries
• Usually resolve but are occasionally permanent
• Cervical cord neuropraxia with transient
  quadriplegia is rare
• Associated with cervical stenosis, congenital
  fusions, cervical instability, disc problems

22
ANY History of Recurrent Burners/Stingers or
Transient Quadriplegia?

• NEED cervical spine films BEFORE being allowed to
  participate!

23
Concussion?

• Concussion accounts for 6 to10 of all sport
  related injuries
• Higher risk among high school athletes in contact
  sports (Langlois 2006)
• 1.6 to 3.8 million sports-related TBIs occur each
  year
• TBIs can be cumulative
• Cognitive function (Punch Drunk)
• Memory
• Ability to learn
• Reaction time
• Increased risk of Second Impact Syndrome
• Primarily in younger (pre-adolescent) athletes

24
Heat or Muscle Cramps?

• History of dizziness or passing out during
  activities in the heat
• Determines ability to tolerate heat or prolonged
  events
• Marathons

25
Difficulty Breathing?

• During or after activity?
• Seasonal allergies vs. asthma
• Also could be cardiac
• HCM
• Valvular disease
• Arrhythmias

26
Special Equipment/Braces?

• Inspect for fit function
• Risk to other players?

27
Problems with Eyes/Glasses?

• Is athlete single-eyed
• Less than 20/50 as best in one eye
• Hx of orbital fractures

28
Sprains, Strains, Fractures, or Dislocations?

• Need to determine need for rehabilitation PRIOR
  to being allowed to participate

29
Other Questions

• Medical problem or injury since last evaluation
  (periodic exam)?
• Immunizations up to date?
• Td, Hep B, MMR, Meningitis
• Women Date of first and last menses longest
  time between menses?
• Family use of tobacco, alcohol, street drugs?
• How about yourself?

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Most Important Questions

• Ever passed out or became significantly dizzy
  during/after exercise?
• Ever have chest pain during/after exercise?
• Do you tire more quickly than your peers?
• Hx of increased BP or heart murmur?
• Hx of heart racing/skipping beats?
• FHx of sudden death before age 50?
• Hx of concussion (Traumatic Brain Injury)

31
Keep in Mind

• 90 of sudden death in athletes lt30 y/o is
  cardiovascular Reference Spotlight on sudden
  cardiac death. Cardiovascular Research.
  200150(2)173-176.
• Syncope or near-syncope may be a sign of
  underlying hypertrophic cardiomyopathy
• Chest pain may be atherosclerotic
• Dyspnea on exertion may be caused by asthma,
  valvular disease, or coronary artery disease
• Palpitations may be arrhythmia, WPW

32
Key Components of the Physical Exam
33
Height Weight

• Compare to growth charts for age/sex
• Body fat male 5 to 10 female 12 to 15
• Very thin Ask about diet, weight loss, body
  image (r/o anorexia, bulimia)
• Optional Body composition
• Skin fold calipers easiest
• Electronic scales
• Total immersion more accurate
• Good time to discuss weight in athletes where
  weight is important
• Wrestling, ice skating, gymnastics

34
Eyes

• Absence of 1 eye or vision gt20/50 in the best
  eye AVOID COLLISION SPORTS!
• Anisicoria slight/baseline is normal and should
  be noted (1-2mm)
• Large difference needs neurological work-up first

35
Cardiovascular System

• BP Use correct size cuff!
• gt110/70 mmHg for lt10 y/o or gt120/80 mmHg for gt10
  y/o must be evaluated (Latest JNC guidelines)
• Check pulses symmetrical femoral and radial
  pulse is a good screen for coarctation of the
  aorta
• Murmurs deep inspiration, valsalva, squatting
• Innocent, mitral valve prolapse, hypertrophic
  cardiomyopathy, aortic sclerosis
• Arrhythmia EKG to evaluate
• 24 hour monitor

36
Neurological

• Baseline testing Neuropsych testing
• Memory, Cognitive function
• Ability to learn
• Orientation
• VERY useful if athlete receives TBI
• Presence of post-concussive symptoms
• More accurate for determining return to play
• Can demonstrate loss of baseline function

37
Practice Recommendation

• Anyone with traumatic brain injury and a recorded
  Glasgow Coma Scale of 13 or less at any stage
  after the first 30 minutes OR who received a CT
  scan of the head as part of their initial
  assessment should be routinely followed up with,
  as a minimum, a written booklet about managing
  the effects of traumatic brain injury and a phone
  call in the first week after the injury
• Approved Source National Guideline
  Clearinghouse
• Website http//www.guideline.gov/summary/summary.
  aspx?doc_id10281nbr 005397stringconcussion
• Level of Evidence B - A well-designed,
  nonrandomized clinical trial. A non-quantitative
  systematic review with appropriate search
  strategies and well-substantiated conclusions.

38
Other

• Lungs look for symmetry of movement, listen for
  wheezes/rubs
• Abdomen check for organomegaly, tenderness,
  rigidity
• Skin check for rashes and growths

39
Practice Recommendation

• In a population of stable asthmatics short acting
  beta-agonists, mast cell stabilizers, or
  anti-cholinergics will provide a significant
  protective effect against exercise-induced
  broncho-constriction with few adverse effects
• Approved source Cochrane Database
• Website http//www.cochrane.org/reviews/en/ab0023
  07.html
• Strength of Evidence Twenty-four trials (518
  participants) conducted in 13 countries between
  1976 and 1998 were included. All drugs were
  effective at attenuating the exercise-induced
  bronchoconstriction response but to varying
  degrees even within the same individual. Compared
  to anti-cholinergic agents, mast cell stabilizers
  were somewhat more effective at attenuating
  bronchoconstriction.

40
Genitourinary

• Male
• Hernia?
• Testes both descended?
• Single should counsel about collision sports
• Female
• Pelvic exam not necessary part of basic exam
• Do w/ Hx of severe menstrual irregularities,
  primary or secondary amenorrhea
• Both Maturity development (self rating?)

41
Musculoskeletal

• Need to assess major muscle groups and joints via
  a screening exam
• Follow up closely on any abnormalities noted
• Decreased ROM, function
• Hyper-flexibility

42
Laboratory Testing

• Traditionally UA dip for protein/glucose
• Non-pathologic proteinuria VERY common
• U-glucose NOT reliable unproven in large
  studies for DM screening
• Same for CBC, Hct, Fe, Ferritin, Sickle trait
• Cardiovascular screening (EKG, Echo) under
  investigation for cost-effectiveness
• Screen only those at risk or positive findings
• Reference Exercise-induced Proteinuria? The
  Journal of Family Practice. 201261(1)23-26.

43
Determining ClearanceMOST IMPORTANT PART!

• Does the problem put the athlete at greater risk
  for injury?
• Is the athlete a risk to other players?
• Can the athlete safely participate with
  treatment, rehabilitation, medicine, bracing or
  padding?
• Can limited participation be allowed?
• If clearance is denied, are there other
  activities that the athlete can safely
  participate in?

44
Clearance is based on AAP Committee on Sports
Medicine Recommendations for Participation in
Competitive Sports

• Based upon the amount of contact/collision and
  intensity of exercise

45
Contact Non-Contact
46
Some Specifics
47
Acute Illness

• Individual assessment
• Generally accepted to limit activity during fever
• URIs and strenuous activity (e.g., cycling) can
  cause significant impact on the immune system

48
Cardiovascular Abnormalities

• May Dispose to Sudden Death!
• Mild hypertension No restrictions
• Moderate to severe hypertension need assessment
  and possible treatment
• Benign functional murmurs No restriction
• Mild mitral valve prolapse No restriction

49
MVP with

• PMHx of syncope
• Chest pain/tightness increased w/ activity
• FHx of sudden death
• Moderate to severe regurgitation
• REASSESS!
• HIGH RISK!
• Reference Recommendations for competitive
  sports participation in athletes with
  cardiovascular disease. European Heart Journal.
  200526(14)1422-1445.

50
Hypertrophic Cardiomyopathy(HCM, IHSS)

• Most common cause of sudden death in athletes
• Usually find
• Marked LVH (Need to differentiate from normal
  LVH in conditioned athletes)
• Significant L outflow obstruction Arrhythmias,
  both increased by activity
• PMHx of syncope or FHx of sudden death in a young
  relative
• May participate in LOW intensity activities

51
Symptoms HCM

• Most are ASYMPTOMATIC until Sudden Cardiac Death
  (can be the 1st symptom)
• Symptoms with activity
• Chest pain
• Shortness of breath
• Lightheadedness
• Dizziness
• Loss of consciousness
• Children often do not show signs of HCM
• After puberty

52
Basketball Star's Sudden Death Brings Awareness
of Deadly Heart Disease By Dan O'Donnell Story
Created Mar 7, 2011 Story Updated Mar 8, 2011
MILWAUKEE - The shockwaves from high school
basketball star Wes Leonard's sudden death last
week have reverberated from Fennville, Mich.
across the nation. An autopsy revealed that
Leonard suffered cardiac arrest brought on by
dilated caridomyopathy (DCM), a condition more
commonly referred to as an "enlarged heart." 
53
Incidence HCM

• 0.2 to 0.5 of the general population
• All types of HCM (obstructive vs non-obstructive)
• Appears in all racial groups
• Sarcomeres (contractile elements) in the heart
  replicate causing heart muscle cells to increase
  in size
• Results in the thickening of the heart muscle
• Typically an autosomal dominant trait
• 50 chance of passing trait

54
Cardiovascular RisksALL Causes

• SCD per year in healthy patients
• 1/133,000 Men
• 1/769,000 Women
• AMI w/in 1 hour of exercise 2 to 10
• 2.1 10x higher than in sedentary patients
• SCD 6-164x greater than sedentary patients
• Recommend higher level of screening in high risk
  patients
• Reference Exercise acute CV events placing
  the risks into perspective a scientific
  statement from the AHA Council on Nutrition,
  Physical Activity, Metabolism and the Council
  on Clinical Cardiology. Circulation.
  2007115(17)2358-68.

55
Who Should Be Screened?

• Low risk
• Men lt45 Women lt55
• Asymptomatic
• Meet no more than 1 risk factor
• Moderate risk
• Older than preceding
• 2 or more risk factors
• High risk
• Signs/symptoms of CVS, pulmonary, metabolic
  disease or family history of SCD

56
Visual Impairment

• Considered if singled-eyed or best vision in
  one eye gt20/50
• NO effective eye protection for
• Martial arts, boxing, wrestling gtgtgtgtDisallow!
• High risk
• Football, baseball, racquetball
• Eye guards exist but protection is limited

57
Practice Recommendation

• Functionally 1-eyed athletes and those who have
  had an eye injury or surgery must not participate
  in boxing or full-contact martial arts. (Eye
  protection is not practical in boxing or
  wrestling and is not allowed in full-contact
  martial arts.)
• Approved Source National Guideline
  Clearinghouse
• Website http//www.guideline.gov/summary/summary.
  aspx?doc_id4861nbr 3502ss6xl999
• Strength of Evidence Although the evidence for
  each recommendation is not specifically stated
  the evidence is drawn from reports from American
  National Standards Institute. Occupational and
  educational personal eye and face protection
  devices. Washington (DC) American National
  Standards Institute 2003 and American Society
  for Testing and Materials. Annual book of ASTM
  standards Vol 15.07. Sports equipment safety
  and traction for footwear amusement rides
  consumer products. West Conshohocken (PA)
  American Society for Testing and Materials 2003.
  

58
Kidney/Renal

• Incidence of renal trauma is 5 to 25, but is
  mostly mild
• Other injuries more common that renal
• Solitary kidney
• Pelvic, iliac, multicystic, hydronephrotic,
  uteropelvic jct abns gtgtgt No Collision Sports!
• Normal position
• Counsel and sign consent
• Reference Single kidney and sports
  participation perception versus reality.
  Pediatrics. 2006118(3) 1019-1027.

59
Hepato/Splenomegaly

• Liver determine primary cause (e.g., mono)
• OK to return once organ reduces size
• Spleen Acute splenomegaly associated with HIGH
  risk of rupture with minimal provocation!
• Chronic splenomegaly need to assess and treat
  individually

60

• Hernia Only remove if symptomatic
• Gyn No restriction w/ single ovary
• Do look for menstrual irregularities
• Female athletic triad
• (Amenorrhea, anorexia, osteoporosis)
• Testicular Single may play all sports CUP!
• Undescended testes more serious
• Increased risk of Ca
• Sickle Cell
• Trait No restrictions altitudes lt4000 ft
• Disease Very limited
• Even mild hypoxia can lead to sickling

61
Neurological Problems

• Burners/Stingers Can play once asymptomatic
• Recurrent need atlanto-axial evaluation
• Transient Quadriplegia NOT associated w/
  increased risk of permanent quadriplegia
• However, MUST be evaluated
• Orthopedist or Neurosurgeon

62
Traumatic Brain Injury(Concussions)

• TBI classified by
• 1 Amnesia
• 2 Symptoms w/ activity and at rest
• Both physical and mental function
• 3 Loss of consciousness
• NUMBER of events (damage is cumulative!)
• Neuropsych testing (pre-participation,
  post-injury)

63
Traumatic Brain Injury(Concussions)

• Need to be aware of Post TBI Syndrome Second
  Impact Syndrome
• Pay close attention to subtle neuro signs and
  complaints of headache, poor concentration, dizzy
• Athlete must be symptom free w/ activity and at
  rest and back to baseline Neuropsych testing
  before being allowed to play
• Minor trauma can lead to rapid cerebral edema
• More common in younger/pre-adolescent athletes

64
October 29, 2010 Friday "It was just a routine
play. I don't think there was anything special,"
Orrick told the Miami County Republic after the
game. "I think he just hit the ground pretty hard
with his head. He came on the sideline and told
one of my assistants, 'my head is really
hurting.' He sat down on the bench. He then stood
up, but his legs went underneath him and
collapsed there."
Nathan Stiles 17 y/o Spring Hill HS, Kansas City
NBC Action News also reports that Stiles was
taking part in his first game since returning
from a concussion suffered in early October.
Stiles' father confirmed this to the Kansas City
Star, noting that his son suffered a concussion
during the homecoming game earlier in the month,
but was cleared to play Thursday.
Reference Al Spivak AOL News
10/30/2010 http//www.fanhouse.com/2010/10/30/nath
an-stiles-kansas-high-school-football-player-dies-
after-in/
65
Return to Play NP testing based

• Administer BEFORE starting any sports
• Mainly contact sports
• Studies demonstrate good correlation between
  reported symptoms and changes in neuropsych
  testing at 2 hours
• However, correlation is lost at 48 hours to 2
  weeks
• Most athletes returned to baseline in 2-4 weeks
• More accurate at aiding in determining return to
  play than patients reports of symptoms
• Other more advanced computer-based systems for
  determining return to play

66
Neuropsych Testing

• Standardized Assessment of Concussion
• Brain Injury Association of America
• 8201 Greensboro Drive
• Suite 611
• McLean, VA 22102
• 703-761-0750 / 800-444-6443
• Cost?

67
SCAT Sideline Concussion Assessment Tool

• Developed by Prague Group 2004
• Symptom score sheet post-injury
• Mental function assessment in several areas
• Not a full neuro-psych test
• Does have some baseline to compare with
  post-injury

68
(No Transcript)
69
SCAT2
70
ImPACT Univ of Pittsburgh

• Computerized system to evaluate concussion
  management and safe return to play
• Battery of scientifically validated
  neuro-cognitive testing on large populations
• Does not require baseline testing for individual
  athlete
• Does not allow for individual variation
• Expensive!
• Already in use at the professional level, some
  colleges high schools
• Becoming more available for on field management

71
CogState Sport

• Also computer based system
• Requires a baseline
• Data submitted to secure online server
• After injury, athlete can be re-tested from any
  web-connected computer able to compare scores
• CogState also does analysis on pre- and post-
  tests
• Reports by Email

72
Return to Play

• Based on Zurich protocols published in Consensus
  Statement on Concussion in Sport 3rd
  International Conference on Concussion in Sport
  Held in Zurich, November 2008
• Clinical Journal of Sport Medicine. 200919(3)
  185-200.

73
Chronic Traumatic Encephalopathy (CTE)

• Found most commonly in athletes with multiple
  head injuries
• Can be an accumulation of multiple small hits
  not all causing symptoms
• 73 of pro football players with CTE died in
  middle age (mean 45 y/o)
• 64 of deaths have been from
• Suicide
• Abnormal erratic behavior
• Substance abuse

74
Symptoms CTE

• Cognitive changes (69)
• Memory loss/dementia
• Personality/Behavioral changes (65)
• Aggressive/violent behavior
• Confusion
• Paranoia
• Movement abnormalities (41)
• Parkinsons (Dementia pugilistica)
• Gait/Speech problems

75
Treatment CTE

• NONE!
• Treat symptoms
• Prevention is currently the only available
  treatment option

76
The Special Needs Population

• Special Olympics NJ
• NJ Academy of Family Physicians

77
Special Olympics (SO)

• Established early 1960s by Eunice Kennedy
  Shriver developed by the Joseph P Kennedy
  Foundation
• Mission To provide sports training
• competition for persons with mental
• retardation
• Winter summer events every 4 years
• Local, state, regional, national, international
• Local 300-600 athletes
• International 1500-6000 athletes
• 1st international games were 1968 in Soldier
  Field, Chicago

78
Eligibility

• At least 8 y/o identified as having
• Mental retardation by an agency or professional
• Cognitive delays
• Learning or vocational problems requiring special
  designed instruction
• No maximum age limits
• Training programs can begin at 6 y/o

79
Summer Sports

• Swimming diving
• Track field
• Basketball
• Bowling
• Cycling
• Equestrian
• Soccer

• Golf
• Gymnastics
• Powerlifting
• Roller skating
• Softball
• Tennis
• Volleyball

80
Winter Sports

• Alpine skiing
• Cross-country skiing
• Figure skating
• Floor hockey
• Speed skating

81
Prohibited Sports

• Any sport w/ direct 1-on-1 competition
• Considered dangerous for mentally retarded
  athletes
• Wrestling
• Shooting
• Fencing
• Ski jumping

• Javelin
• Vault
• Triple jump
• Platform diving
• Trampoline
• Biathlon
• Boxing
• Rugby
• Football (US)

82
Organization of Games

• Levels of participation
• Age, Sex, Ability
• Developmental sports for those w/ severe
  limitations
• Coaches
• Special education teachers, athletic instructors,
  parents
• Extensive knowledge of the physical mental
  characteristics of each athlete
• Low ratio athlete/coaches 41
• Volunteers
• Support services
• Administration
• Physicians, nurses, PTs OTs, trainers
• Work directly with SO executive director

83
Pre-Participation Exam

• Questionnaire 1 tool
• Done initially yearly
• Coaches must have an updated reviewed
  questionnaire at ALL competitions
• 44 to 71 of problems that can affect ability to
  compete are identified by questionnaire
• Physical
• Initially every 3 years
• Athletes develop new problems
• Htn, visual problems, concussions, surgery
• Identifies approximately 29 problems

84
Common Problems

• Visual 25
• Refractive, cataracts, myopia, blindness
• Hearing 8
• Seizures 19
• Medical 6 (similar to general population)
• 30 use medications
• Emotional behavioral
• Much higher than general population

85
Complex Problems

• Atlanto-axial instability
• Most common most controversial
• Spinal cord problems
• Injuries
• Meningomyelocele
• Spinal bifida
• Hydrocephalus
• Cerebral palsy
• Wheelchair athletes
• Amputees (congenital acquired)
• Visual hearing impairment
• Seizures
• Type 1 Diabetes

86
Atlanto-Axial Instability

• Up to 15 of athletes have Down syndrome
• All have abnormal collagen that leads to
  increased ligamentous laxity and decreased muscle
  tone
• Annular /- Transverse ligament of C1 (Axis)
  stabilizes articulation of the odontoid process
  of C2 (Atlas) w/ C1
• Laxity may allow forward translation of C1 on C2
  causing compression of the cervical spinal cord
• Reference Participation by Individuals with Down
  Syndrome Who Have Atlantoaxial Instability.
  Special Olympics. www.specialolympics.org.
  Accessed 12/10/12. http//sports.specialolympics.o
  rg/specialo.org/Special_/English/Coach/Coaching/Ba
  sics_o/Down_Syn.htm

87
Atlanto-Axial Instability

• Reports of athletes with Down syndrome
  experiencing spontaneous subluxation
  catastrophic spinal cord injury during surgery
  requiring intubation (anecdotal)
• Also with blows to the head and major falls
• 2 experience symptoms related to AAI
• Abnormal gait, neck pain, limited C-spine ROM,
  spasticity, hyper-reflexia, clonus, sensory
  deficits, upper motor neuron signs
• Asymptomatic AAI is of major concern
• Highest risk between 5 to 10 years of age

88
Atlanto-Axial Instability

• SO requires C-spine x-rays in neutral,
  hyper-extension and hyper-flexion
• Evaluation of the Atlantodens interval spinal
  canal at C1-C2
• Intervals gt 4.5 (5) mm are positive
• 17 of athletes w/ AAI
• Neurosurgical evaluation required before allowing
  any participation
• Reassessment every 3 to 5 years
• Unsure if indicated if initial evaluation normal

89
Atlanto-Axial Instability

• Participation allowed in most events except
• Butterfly stroke
• Diving starts in swimming
• Pentathlon
• High jump
• Equestrian sports
• Artistic gymnastics
• Soccer
• Squat lifts
• Alpine skiing

90
Atlanto-Axial Instability

• American Academy of Pediatrics Comm. on Sports
  Medicine Fitness concluded potential but
  unproven value
• Current literature does NOT provide evidence for
  or against screening
• Long term longitudinal studies are lacking
• Natural history of AAI is unknown
• 85 of patients w/ AAI 5mm or gt have no symptoms
• At this time screening is SO requirement

91
Spinal Cord Injured Athletes

• Predisposed to injuries 20 to wheelchair use
• Loss of motor sensory function below the level
  of the injury
• Lack of autonomic function
• Thermoregulation
• Autonomic dysreflexia

92
Thermal Regulation

• Seen 10ly in lesions above T-8
• Loss of vasomotor responses
• Hypothalamus response limited by loss of impulse
  from below the injury
• Reduced venous return from the paralyzed muscles
  below the injury
• Impaired sweating below lesion reduces effective
  body area for evaporative cooling

93
Thermal Regulation

• Body core temps that go to either extreme
  in hot cold environments
• Hypo but 10ly extreme Hyperthermia
• Need to be aware of
• Clumsiness/Erratic wheelchair control
• Headache
• Confusion or other mental status change
• Dizziness
• Nausea/vomiting

94
Prevention

• Acclimatization of athletes 2 weeks prior
• Daily posting of temp heat stress index
• Combination of solar ambient heat and relative
  humidity
• Systematic schedule of fluid intake
• Before, during after events
• Daily weights
• Availability of resuscitative and transportation
  services

95
Autonomic Dysreflexia

• Occurs in injuries above T-6
• Loss of inhibition of the Sympathetic NS
• Sweating above lesion
• Hyperthermia
• Acute hypertension
• Cardiac dysrhythmias
• Multiple triggers
• Bowel bladder distention
• Pressure sores
• Tight clothing
• Acute fractures
• Environmental (temperature)

96
Treatment

• Remove athlete from activity
• Remove sensory stimulus
• Clothing
• Bladder catheterization/bowel evacuation
• Cooler/warmer environment
• Transport to hospital may be necessary
• Uncontrolled hypertension or dysrhythmia
• Usually self-limited
• Watch for self-induced (Boosting)

97
Wheelchair Athletes

• Usually other significant medical problems
• 10ly Overuse injuries to wrist shoulders
• Rotator cuff impingement/tendonitis
• Biceps tendonitis
• Fractures to the hands wrists
• Epiphyseal plate weakest point
• Lower extremity fractures infrequent
• Pressure sores
• Due to increase pressure lower blood flow
• Insidious onset due to lack of sensation
• Tx Custom seats, moisture absorption, padding

98
Cerebral Palsy

• Spasticity, athetosis, ataxia
• Progressively decreasing muscle/tendon
  flexibility strength gtgt Contractures
• Impaired hand-eye coordination
• Mental retardation
• Seizures
• Extreme risk for overuse injuries!
• 50 in wheelchairs
• Modification of events to accommodate
• Get inventive (Adaptive Sports Program)

99
Athletes w/ Amputations

• Indications for amputation
• Circulatory problems Necrosis or infarction
• Life threatening cancer, infection
• Congenital deformity rendering limb insensate
• Upper limb more common in younger
• Length of limb preserved to protect epiphysis
• Appliances are smaller require frequent
  adjustments to accommodate growth
• Prostheses are abused need repair/adjustment
• Skin breakdown/ Phantom limb pain is less
  frequent in younger athletes

100
Problems

• Overgrowth of stump is common
• Skin breakdown common in sports due to friction
  pressure
• Alteration center of gravity gtgt Problems with
  balance (10ly lower limb amputees)
• Hyperextension of knee lumbar spine
• Early detection is key 20 decreased sensation in
  limb
• Athletes may compete using prostheses but no
  other assistive device

101
Visual Impairment

• Partial sight to total blindness
• Legal blindness acuity lt 20/200, visual field lt
  200
• No related physical disabilities except due to
  lack of experience with certain activities
• Modifications to equipment, rules strategy may
  be required
• Tactile audio clues
• Tethers or guide wires
• Step stroke counting
• Guides

102
Hearing Impairment

• Tend not to consider themselves disabled
• Subculture of society
• Variations
• Mild threshold 27-40 dB
• Profound threshold gt 90 dB
• Behavioral disorders 20 communication challenges
• No related physical disabilities except due to
  lack of experience with certain activities

103
Seizures

• Common in athletes with developmental
  disabilities
• Familiarity with meds side effects
• Attention span cognitive impairment
• Decreased potential for seizures w/ exercise
• Metabolic acidosis due to lactate buildup
  incomplete respiratory compensation
• Decreased pH gtgt Stabilizes neuromembranes
• Good control must be obtained prior to
  participation in activities
• Be prepared as with ALL athletesReference
  Howard GM, Radloff, M, Sevier TL. Epilepsy and
  sports participation. Current Sports Medical
  Reports. 2004 Feb3(1)15-9.

104
Insulin Dependent Diabetes

• Need to monitor glucose
• 30 min before activity
• Immediately before activity
• Every 30-45 min during activity
• Ideal pre-exercise range is 120-180 mg/dL
• gt 200 mg/dL Postpone take extra insulin to get
  glucose levels down 1st
• Exercise with elevated glucose will cause levels
  to RISE further which can lead to increased
  diuresis, dehydration, and keto-acidosis

105
Insulin Adjustments

• Moderate exercise
• AM activity reduce Reg by 25
• PM activity reduce Reg by 25 as well as NPH or
  Long Acting
• Strenuous or Long Term
• AM activity reduce Reg by 50
• PM activity reduce Reg by 50 as well as NPH or
  Long Acting
• Insulin pumps or Glargine as above
• Liberal hydration
• lt 1hr water alone OK
• gt 1hr think Na replacement
• (Sport drinks remember they contain CHO!!)

106
Complications

• Autonomic dysfunction
• Avoid power lifting 20 bradycardia syncope
• Increased hot cold intolerance
• Hyperglycemia treat watch for KA
• Hypoglycemia
• Tremors, sweating, palpitations, pallor, hunger
• Long acting CHOs, glucagons
• Late onset hypoglycemia 6-28 hrs later
• Replace glycogen w/in 1 hr of activity
• Avoid activity near intermediate insulin peaks
• Use long-acting to avoid peaks
• Watch for Neuro-glypenic Syndrome

107
Special Concerns

• Some problems out of scope of practice for Family
  Physicians
• Dental disease
• Complex Cardiac problems
• Advanced Orthopedic problems
• Ophthalmic problems
• Need to establish referral network of physicians
• Part of Healthy Athletes Initiative SOI

108
Special Concerns

• Podiatric problems difficulty finding good
  athletic shoes that fit
• Pes planus
• Toenail fungus
• Tinea groin abscesses
• Orthostatic hypotension

109
Special Concerns Communication Disorders

• Elective mutism
• Children usually 3-5
• Have the ability to speak /- use language, but
  refuse to except under certain circumstances, or
  only to certain individuals
• Hearing impairment
• Seen at young age with delayed or abnormal speech
  language development
• Can be mild, moderate, severe uni- or bilateral

110
Autism

• Pervasive developmental disorder with significant
  impairment in
• Socialization
• Communication
• Sensory/motor development
• 710,000 births
• Associated with
• Mental retardation
• Seizure disorders
• Psychiatric disorders

111
Approach to the patient

• Approach slowly
• Speak in a slow clear voice
• Try to maintain eye contact
• Be aware too much may cause the patient to
  withdraw
• Use hand gestures along with language
• Let the patient touch
• E.g., stethoscope, otoscope, splints, your hands
• Watch the patient caretaker for clues

112
Healthy Athletes InitiativeMedFest

• NJ Academy of Family Physicians
• Special Olympics NJ

113
MedFest ProgramSONJ and NJAFP

• March 9, 2003 the first MedFest occurred in
  Lawrenceville, NJ. This model has been copied by
  a number of other organizations
• August 2005 an agreement was signed between SOI
  and AAFP
• March 2012 Almost 1000 athletes have been
  certified to participate that otherwise would
  have never had the opportunity

114
Some Pictures From MedFest 1Before We Start
115
Registration
116
Vitals
117
History Review
118
Heart Lung
119
Orthopedic
120
Ear, Nose Throat
121
Check out!
122
Thank you!!
123
Contact Information
Jeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFP New
Jersey Academy of Family Physicians 224 West
State Street Trenton, NJ 08608 Phone
609-394-1711 Fax [phone] MedFest
Coordinator and NJAFP Office Manager Dr.
Zlotnick Maddoc007_at_aol.com Candida Taylor
candida_at_njafp.org NJAFP Executive Vice
PresidentRay Saputelli, MBA, CAE
ray_at_njafp.orgDeputy Executive Vice
President Theresa J. Barrett, MS, CAE
theresa_at_njafp.org