Pre-Participation Physical Examination

1
(No Transcript)
2
Pre-Participation Physical Examination

• A Principle Tool for Injury Prevention

3
What is a PPE?

• A tool for injury prevention, used to gather
  medical information about athletes to ensure that
  they are ready to participate in sports
• The athletes initial exposure to the sports
  medicine team

4
Principles Governing PPE

• Collects medical info about athlete to ensure
  readiness to participate in a sport
• Design of PPE should allow assessment of risk
  factors detect any disease /or injury that
  might create problems
• Each question should be understandable
• Ensure instruments used are properly calibrated
• Each instrument used in PPE should be valid
  reliable

5
Goals of PPE (Kibler, 1990)

• Provide an objective, sport-specific
  musculoskeletal exam
• Obtain (-) information that alters participation
• Obtain () information to decrease injury
  potential increase performance
• Provide a reproducible record for comparison in
  the future
• Provide baseline data for sport-specific
  conditioning

6
Timing Frequency of PPE

• Timing
• Researchers say to perform PPE 4-8 weeks prior to
  start of season
• Allows time to f/u on evals, rehab, etc.
• Some say at beginning of season
• Some say in the season prior to start (i.e.
  May/June for fall sports)
• Frequency
• Beginning of each sport season
• Beginning of each year
• At new level of competition (high school)
• Health history update each year

7
Personnel

• General practice physician
• Orthopedist
• Cardiologist
• Athletic trainer
• Exercise physiologist
• Psychologist
• School nurse
• Strength coach

8
formats of the examination

• Mass screening
• locker room
• Individual exams

9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
Components of PPE
13
HISTORY

• chronic medical illnesses,
• surgical history
• allergies
• current medications
• groups disagreed on questions related to
  cardiovascular,
• neurologic, musculoskeletal, and weight issues.
• Preparticipation Physical Examination Task Force

14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
HEENT

• eye exam
• Any differences in pupil size (anisocoria)at
  baseline
• visual acuity.
• An athlete should have corrected vision of 20/40
  or better if engaging in collision and contact
  sports
• Protective eyewear
• single eye
• contraindication to participation boxing and
  wrestling
• mouth
• evidence of bulimic activity and/or
• tobacco
• A high, arched palate Marfans syndrome
• ear
• ruptured tympanic membrane
• risk factor for participation in swimming and
  diving

19
Cardiovascular PPE?

• Risk of sudden death in young athlete
• 1/100,000
• Mengtwomen USAHCM
• Age risk ItalyARVD
• geographical diff. GermanyMyocarditis
• 
  ChinaMarfan
• Silent cardiovascular abnormalities
• Such deaths among athletes are unexpected,
  dramatic, and often elicit community calls for
  preventive measures
• Beta blockers in sport is limitted
• Defibrilator is nessesary

20
goal

• early identification of structural cardiac
  disease associated with sudden death
• reduction of the risk of disease progression
  associated with athletic training and
  competition.

21
(No Transcript)
22
Etiologies of sudden unexplained cardiac death in
children and adolescents.
Structural and Functional Abnormalities Primary Electrical Abnormalities Acquired Lesions Congenital Heart Disease
HCM LQTS Commotio cordis Aortic valve stenosis
ARVD Brugada syndrome Drug abuse Postoperative congenital heart disease
Coronary artery abnormalities Wolff-Parkinson-White syndrome Atherosclerotic coronary artery disease Coarctation of the aorta
Primary pulmonary hypertension Ventricular tachycardia/fibrillation
Myocarditis Heart block
Dilated cardiomyopathy
Marfan syndrome with aortic dissection
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
Recommendations and guidelines

• The American Heart Association(AHA)
• the Bethesda Conference
• the Italian Guidelines (COCIS)
• European Society of Cardiology(ESC)
• International Olympic Committee(IOC)

27
the Bethesda Conference
28
AHA Cardiovascular PPE Recommendations

• 1st yr at institution/high school
• - Comprehensive personal and family history
• - physical examination by qualified examiner
• - CV PPE every 2 years after initial screening
• - During intervening years history )
• Rewritten in 1998 for collegiate athletes
• Each year after initial CV PPE
• - history
• - blood pressure measurement

29
PPE Cardiovascular tests

• The AHA states it is not necessary to recommend
  the use of highly expensive cardiovascular
  disease tests such as electrocardiography,
  echocardiography or graded exercise testing
• HOWEVER, they do not discourage the use of these
  tests

30
Personnel of CV PPE

• Recommended by AHA
• healthcare worker with medical background to
  reliably obtain a CV history, perform a physical
  exam and recognize cardiovascular disease.
• preferably a licensed physician
• Non-physician healthcare workers must establish a
  formal certification in cardiovascular
  examinations

31
The American Heart Association(AHA) and
European Society of Cardiology recommendations
Family and Personal History
 1. Premature sudden cardiac death
 2. Heart disease in surviving relatives less than 50 years old
 3. Heart murmur
 4. Systemic hypertension
 5. Fatigue
 6. Syncope/near-syncope
 7. Excessive/unexplained exertional dyspnea
 8. Exertional chest pain
Physical Examination
 9. Heart murmur (supine/standing )
10. Femoral arterial pulses (to exclude coarctation of aorta)
11. Stigmata of Marfan syndrome
12. Brachial blood pressure measurement (sitting)
32
Stigmata of Marfan syndrome

• Kyphosis
• High arched palate
• Pectus excavatum
• Arachnodactyly
• Arm span gt height 1.051 or greater
• Mitral Valve Prolapse
• Aortic Insufficiency
• Myopia
• Lenticular dislocation

33
the Italian Guidelines (COCIS)

• 12-lead electrocardiogram (ECG)
• history
• physical examination

34
investigations

• ECG
• echocardiography
• cardiac magnetic resonance imaging (CMR)
• exercise testing
• ambulatory Holter ECG recording
• implanted loop recorder tilt table examination
• electrophysiologic testing with programmed
  stimulation
• Diagnostic myocardial biopsy
• genetic testing

35
CV PPE

• ECG
• ECG alterations in elite athletes are mostly T
  wave changes, ST segment elevation, and increases
  in R and/or S wave voltage
• showing ECG abnormalities strongly suggestive of
  HCM, with diffuse symmetric and pronounced T wave
  inversion, associated with increased R or S wave
  voltages or deep Q wave
• A few others showed ECG patterns suggestive of
  ARVC with T wave inversion in V1 to V3 (or V4
• sensitivity 50, positive predictive value 7

36
(No Transcript)
37

• Echocardiography
• HCM
• asymmetric left ventricular (LV) wall thickenin
• a maximal LV end-diastolic wall thickness of 15
  mm or more (or on occasion, 13 or 14 mm)
• valvular heart disease (e.g., mitral valve
  prolapse and aortic valve stenosis)
• aortic root dilatation
• mitral valve prolapse in Marfan or related
  syndromes
• LV dysfunction and/or enlargement (evident in
  myocarditis and dilated cardiomyopathy)

38

• some important diseases may escape detection
  despite expert screening methodology. For
  example, the HCM phenotype may not be evident
  when echocardiography is performed in the
  pre-hypertrophic phase (i.e., a patient less than
  14 years of age)
• Annual serial echocardiography is recommended
  in HCM family members throughout adolescence

39
Athletes with Cardiovascular conditions

• referred to a cardiovascular specialist for
  further evaluation and/or confirmation
• refer to 36th Bethesda Conference guidelines
• Written in 2005 by American College of Cardiology
• Recommendations for determining eligibility for
  competition in athletes with cardiovascular
  abnormalities
• (Maron, 2005)

40
Judgment of Participation

• The American Academy of Pediatrics states
• Along with specialist and Bethesda
  guidelines, should consider
• risks of participation
• the advice of knowledgeable experts
• current health status
• the level of competition, position and sport
• availability of effective protective equipment
• sport can be modified?
• ability of the athlete and parents to understand
  and accept risks involved in participation

41
Judgment of Participation

• How strenuous the sport is, is another factor
  that should be considered for athletes with
  cardiovascular problems
• A strenuous sport places many demands on the
  cardiovascular system

42
CARDIAC
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
Exercise Stress Test

• High Risk Individual
• Generally no indication for individual planning
  mild to moderate exercise

47
BRUCE PROTOCOL

• Stage 1 0-3 min 1.7 mph 10 grade 5.0 Mets
• Stage 2 3-6 min 2.5 mph 12 grade 6.8 Mets
• Stage 3 6-9 min 3.4 mph 14 grade 9.4 Mets
• Stage 4 9-12 min 4.2 mph 16 grade 13.3 Mets
• Stage 5 12-15 min 5.0mph 18 grade 16.6 Mets
• Stage 6 15-18 min 5.5 mph 20 grade 19.5 Mets
• Stage 7 18-21 min 6.0 mph 22 grade 22.7 Mets

48
6 Minute Walk Test

• purpose This test measures aerobic fitness
• equipment required measuring tape to mark out
  the track distances, stopwatch, chairs positioned
  for resting.
• procedure The walking course is laid out in a 50
  yard (45.72m) rectangular area (dimensions 45 x 5
  yards), with cones placed at regular intervals to
  indicate distance walked. The aim of this test is
  to walk as quickly as possible for six minutes to
  cover as much ground as possible. Subjects are
  set their own pace (a preliminary trail is useful
  to practice pacing), and are able to stop for a
  rest if they desire.

49
6 Minute Walk Test

• purpose This test measures aerobic fitness

50
Athletic Heart Syndrome

• Normal Adaptations to Exercise

51
Athletic Heart Syndrome

• Endurance training
• Increased left ventricular chamber size

52
Athletic Heart Syndrome

• Strength training
• Increased left ventricular mass

53
Athletic Heart Syndrome

• Arrhythmia

• How slow is too slow?

54
Athletic Heart Syndrome

• Why is there bradycardia?
• Heart is more efficient with each beat
• Greater muscle mass, greater chamber size
• More blood pumped per beat

55
(No Transcript)
56
(No Transcript)
57
The American Heart Association(AHA) and
European Society of Cardiology recommendations
Family and Personal History
 1. Premature sudden cardiac death
 2. Heart disease in surviving relatives less than 50 years old
 3. Heart murmur
 4. Systemic hypertension
 5. Fatigue
 6. Syncope/near-syncope
 7. Excessive/unexplained exertional dyspnea
 8. Exertional chest pain
Physical Examination
 9. Heart murmur (supine/standing )
10. Femoral arterial pulses (to exclude coarctation of aorta)
11. Stigmata of Marfan syndrome
12. Brachial blood pressure measurement (sitting)
58
PULMONARY

• Exercise-induced asthma
• Participation is allowed for all sports if
  the asthma is under control. Only athletes with
  severe asthma will need restrictions on activity
• primary spontaneous pneumothorax

59
ABDOMEN

• Organomegaly
• An acutely enlarged liver or spleen is a
  contraindication to collision/contact or
  limited-contact sports
• Infectious mononucleosis can cause acute
  splenomegaly(3 weeks)
• young female athletes is the presence of a gravid
  uterus.

60
NEUROLOGIC

• past history of concussions
• second impact syndrome,
• History of a seizure disorder
• Burners/stingers or pinched nerves
• transient quadriplegia

61
???? ??????? ?????? ??????? ?? ?????? ?????(
?????)
62
MUSCULOSKELETAL

• In general, clearance is denied to an athlete
  with a musculoskeletal injury who has
• persistent effusion or edema
• loss of functional ability,strength that is
  less than 85 to 90 of the unaffected side,
• decreased range of motion

63

• Spinal conditions that are cause for
  disqualification include
• symptomatic spondylolysis
• spondylolisthesis
• functional cervical spinal stenosis
• spear tacklers spine
• herniated discs with cord compression

64
spear tacklers spine

• congenital narrowing of the canal the spinal cord
  passes through (foramen magnum)
• the second is injury to the spine due to trauma

65
(No Transcript)
66
RISK INCREASES WITH

• Congenital narrowing of the spine at the neck.
• Activities that have a high risk of trauma to the
  neck.
• Arthritis of the spine.
• High risk sports, such as football, rugby,
  wrestling, hockey, auto racing, gymnastics,
  diving, martial arts, or boxing.
• Poor neck strength and flexibility.
• Previous neck injury.
• Poor tackling technique.
• Wearing poorly fitted or padded protective
  equipment.

67
DERMATOLOGIC

• herpes simplex, impetigo,boils, scabies, and
  molluscum contagiosum.
• When an athlete is contagious, participation
  in sports that involve mats (such as wrestling,
  gymnastics,and martial arts) as well as
  contact/collision sports or limited-contact
  sports should not be allowed

68
GENITOURINARY

• single kidney
• be assessed on an individual basis
• flak jacket
• single testicle
• protective cup
• The athlete and parents must be informed of
  the risks of injuryor loss to the remaining
  testicle

69
ROUTINE SCREENING TESTS

• Routine laboratory tests such as urinalysis or
  complete blood count, are not recommended
• the history or physical examination
• raises concerns, then further tests should be
• ordered

70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
(No Transcript)
74
Thank you very much for your attention