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1 دکتر باقری مقدم 88/9/17 Pre-Participation Physical Examination A Principle Tool for Injury Prevention 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 athlete’s initial exposure to the sport’s medicine team 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 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 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 Personnel • • • • • • • • General practice physician Orthopedist Cardiologist Athletic trainer Exercise physiologist Psychologist School nurse Strength coach formats of the examination • Mass screening • locker room • Individual exams Components of PPE 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 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 :Marfan’s syndrome ear ruptured tympanic membrane risk factor for participation in swimming and diving Cardiovascular PPE? • Risk of sudden death in young athlete: 1/100,000 Men>women USA:HCM Age risk Italy:ARVD geographical diff. Germany:Myocarditis China:Marfan • 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 goal • early identification of structural cardiac disease associated with sudden death • reduction of the risk of disease progression associated with athletic training and competition. 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 Recommendations and guidelines • • • • • The American Heart Association(AHA) the Bethesda Conference the Italian Guidelines (COCIS) European Society of Cardiology(ESC) International Olympic Committee(IOC) the Bethesda Conference 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 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 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 The American Heart Association(AHA) and European Society of Cardiology recommendations Family and Personal History Physical Examination 1. Premature sudden cardiac death 9. Heart murmur (supine/standing ) 2. Heart disease in surviving relatives less than 50 years old 3. Heart murmur 10. Femoral arterial pulses (to exclude coarctation of aorta) 4. Systemic hypertension 11. Stigmata of Marfan syndrome 5. Fatigue 12. Brachial blood pressure measurement (sitting) 6. Syncope/near-syncope 7. Excessive/unexplained exertional dyspnea 8. Exertional chest pain Stigmata of Marfan syndrome • • • • • • • • • Kyphosis High arched palate Pectus excavatum Arachnodactyly Arm span > height 1.05:1 or greater Mitral Valve Prolapse Aortic Insufficiency Myopia Lenticular dislocation the Italian Guidelines (COCIS) • 12-lead electrocardiogram (ECG) • history • physical examination 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 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% • 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) • 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 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) 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 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 CARDIAC Exercise Stress Test • High Risk Individual • Generally no indication for individual planning mild to moderate exercise BRUCE PROTOCOL Stage 1 Stage 2 Stage 3 Stage 4 Mets Stage 5 Mets Stage 6 Mets Stage 7 Mets 0-3 min 3-6 min 6-9 min 9-12 min 1.7 mph 2.5 mph 3.4 mph 4.2 mph 10% grade 5.0 Mets 12% grade 6.8 Mets 14% grade 9.4 Mets 16% grade 13.3 12-15 min 5.0mph 18% grade 16.6 15-18 min 5.5 mph 20% grade 19.5 18-21 min 6.0 mph 22% grade 22.7 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. 6 Minute Walk Test purpose: This test measures aerobic fitness Athletic Heart Syndrome • Normal Adaptations to Exercise Athletic Heart Syndrome • Endurance training – Increased left ventricular chamber size Athletic Heart Syndrome • Strength training – Increased left ventricular mass Athletic Heart Syndrome • Arrhythmia •How slow is too slow? 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 The American Heart Association(AHA) and European Society of Cardiology recommendations Family and Personal History Physical Examination 1. Premature sudden cardiac death 2. Heart disease in surviving relatives less than 50 years old 9. Heart murmur (supine/standing ) 3. Heart murmur 10. Femoral arterial pulses (to exclude coarctation of aorta) 4. Systemic hypertension 5. Fatigue 11. Stigmata of Marfan syndrome 6. Syncope/near-syncope 7. Excessive/unexplained exertional dyspnea 8. Exertional chest pain 12. Brachial blood pressure measurement (sitting) 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 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. NEUROLOGIC • past history of concussions second impact syndrome, • History of a seizure disorder • Burners/stingers or pinched nerves • transient quadriplegia جدول راهنماي بازگشت بيماران به فعاليت ورزشي( كانتو) دومنب تكان مغزي درجه اولنب تكان مغزي درجه اول 1هفتهيب عالمت ابشد بس از 2هفته تروص رد 1هفتهيتم العيب درجه دوم 2هفتهيب عالمت ابشد بس از 1ماه تروص رد سومنب تكان مغزي در صورت يب عالميت فصل بعدي در صورت يب عالميت فصل ف اييتم العيب بعدي 1هفته لص بعدي درجه سوم ب از 1هفتهيب در صورت يب عالميت ا ماه دع فصل بعدي عالميت ات اخر رمع از ورزش هاي رقابيت منع مي شود 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 • Spinal conditions that are cause for disqualification include: • symptomatic spondylolysis • spondylolisthesis • functional cervical spinal stenosis • spear tackler’s spine • herniated discs with cord compression spear tackler’s spine • congenital narrowing of the canal the spinal cord passes through (foramen magnum) • the second is injury to the spine due to trauma 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. 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 limitedcontact sports should not be allowed 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 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