Download The Pre-Participation Examination - American Osteopathic Association

The Pre-Participation Examination
Daniel D. Day, D.O.
VCOM/Virginia Tech Sports Medicine
ROME 2012
Saturday May 5th, 2012
Objectives
• Review pre-participation exam (PPE) Objectives
and History behind it.
• Review the paperwork for PPE
• Review history components of the PPE
• Review physical exam components of the
PPE
• Clearance issues and RTP
Primary Objectives of PPE
• Detect conditions that
may predispose to injury
– Untreated injuries/illness
or incomplete rehab
– Lack of conditioning
– Congenital or
developmental issues
Geise, EA, et al. AFP 2007; 75: 1008-114
Page 1
Primary Objectives of PPE
• Conditions that might limit safe participation
–
–
–
–
–
–
–
Medications/supplements
Illicit drug use
Obesity
Eating habits
Menstrual history
Congenital diseases
Hearing or vision problems
• Legal/State/Insurance requirements
Secondary Objectives of PPE
• General Health
– Only exam for up to 80% of
athletes
• General Health Counseling
– Sexual activity
– Substance abuse
• Level of Fitness
–
–
–
–
Body composition
Flexibility and strength
Power and speed
Balance and agility
Carek Arch Fam Med 1999 8:307-312
http://www.ruf.rice.edu/~ricerec/fitness/images/testi
ng_composition.jpg
http://bcom.ac.uk/images/website/bodpod.jpg
What Do Athletes Think?
• In one study, 36% athletes
reported having “poor” quality
PPE
– Poor history and exam
– Not targeted to past injuries
• Carek reported 66% feel they
can safely participate without
PPE
– However, over 75% believed that
PPE could prevent injuries
• Not appropriate for certain issues
to be raised
– Gynecologic
– Substances
– Eating disorders
Laure, P J Sports Med Phys Fitness 1996; 36: 291-292.
Carek Arch Fam Med 1999 8:307-312
Page 2
PPE follow up
• Not to keep kids from
playing…
• 0.3% to 1.3% of athletes
are denied clearance
during PPE
• 3.2% to 13.5% of athletes
need further evaluation
When To Do PPEs
• Multiple approaches
– Annual
– Entry level
– Every season
• Timing of Exam
– Ideally 6 weeks prior to season
Where to do PPEs?
PCP Office Based
• Disadvantages
– Limited?
– Lack of sport med
knowledge?
– Cost?
• Advantages
–
–
–
–
Continuity
Complete H&P
Medical records
Privacy
http://www.academicprimarycare.com/
Page 3
Where to do PPEs?
Station Screening
• Disadvantages
– Large, noisy, poorly run?
– Lack of continuity, privacy,
follow-up
– Not addressing all areas equally
– PCP not involved?
• Advantages
http://www.sdcorp.net/public/comp_queue.jpg
–
–
–
–
Multi - station
Specialized personnel
Time & cost effective
Additional testing facilitated
Cost
• History is the MOST cost effective screen
– Over 75% of conditions that may prohibit or alter
participation
• No evidence that PPE change death rates!
• Not cost-effective:
– Labs
– EKGs
– ECHOs
– Spirometry
– Stress Test
Kurowski, K. AFP 2000; 61: 2683-2690
http://www1.istockphoto.com/file_thumbview_approve/8
32406/2/istockphoto_832406_ekg_heart_monitor.jpg
History
• Filled out by parents prior
to exam
– Only 39% correlation
between parents and
athlete’s history
• A good history will
identify over 75% of
problems
Carek, PJ. AFM 1999; 8: 307-312
Page 4
http://espn.go.com/media/pg2/2001/0801/photo/r_stringer_si.jpg
http://www.sekiproductions.com/photographyjpegs/gathers1large2.jpeg
http://www.mensracing.com/photos/usatfoutdoor02/usout147.jpg
http://www.toptenz.net/wp-content/uploads/2008/11/reggie-lewis.jpg
First Recorded incident??
• In 490 BC, Phidippides
– Young Greek messenger
– Ran 26.2 miles from Marathon to Athens delivering
the news of the Greek victory over the Persians
– Then he collapsed and died
• This is probably the first recorded incident of
sudden death of an athlete
http://www.hughston.com/hha/a_16_4_4.htm
http://paralympic.nortia.org/Images/Athens/Phidippides.jpg
Page 5
History Components
Cardiac History - Causes of Sudden
Death in Sports
• Adults (age > 35 years):
– Atherosclerotic coronary artery disease
• Young competitive athletes (age ≤35
years):
– Hypertrophic cardiomyopathy
– Arrhythmogenic right ventricular
cardiomyopathy
– Pre-excitation syndromes and conduction
diseases
– Ion channel diseases
Maron et al Circ 1996 94:850-56
Cardiac History - HCM/HOCM/IHSS
• Abnormal septal thickening
– Creates pressure difference across
the outflow tract of the LV or RV
– Leading to diastolic dysfunction
– May lead to SOB with exercise
and angina
• Abnormal muscle pattern
– May leads to arrhythmias
– Ventricular tachycardia and
fibrillation
http://health.yahoo.com/media/healthwise/h5550921.jpg
Page 6
Cardiac History - Sudden Death
• In US, most common in football
or basketball
– Accounts for 2/3 of sudden death of
athletes
– In the rest of the world, soccer is
most commonly associated with
sudden death
• Sudden death occurs in about 1
to 2 in 200,000 athletes annually
– Males > Females
– Hypertrophic cardiomyopathy
account for 1/3 of cases
http://www.emedicine.com/PED/topic1102.htm
• Risk of sudden death 4-6% per year
Cardiac History
Paterick, TE. JAMA 2005; 294 (23): 3011-3018
Maron et al Circ 1996 94:850-56
History – Head Injury
• 1.6 to 3.8 traumatic brain
injuries/year
– 21% in high school athletes
• Concussions represent an
estimated:
– Up to 13% of all high school
athletic injuries
– 3-6% of interscholastic football
athletes
– 4-8% of collegiate athletes
• 53% of concussed high school
athletes go unreported
http://www.vtnews.vt.edu/articles/2008/11/2008-709.html
Halsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615
Broglio, SP, et al. Journal of Athletic Training 2009;44(4):342–349.
Frommer, LJ, et al. JAT 2011; 46 (1): 76-84
Page 7
History – Head Injury
• If yes…
– Medical F/u or testing
– Helpful to find out RTP
timeline
– Number of concussions,
etc.
History - Pulmonary
•
Bronchospasm:
– 19.3% of regular exercisers
– 17% of 1996 Olympians
– 50% of cyclists
– 22% 1998 Olympians
– 50% cross country skiers
• Exercise induced asthma
(EIA)
– Airway narrowing during or after
exercise in chronic asthmatics
– Often used to describe both EIA/EIB
• Exercise induced
bronchospasm (EIB)
– Symptoms occur only after cessation
of strenuous exercise
• Cough, wheezing, SOB, Chest
tightness
• History alone, can often underdiagnose or over-diagnose EIB
Holzer, K Clin J Sport Med 2004;14:134–138
History - Musculoskeletal
• History provides 92% sensitivity in
detecting MS injury
• General Screen vs. Joint (Sport)
Specific Exam
• Usefulness of the examination has
been based on 2 criteria:
– Capacity of the screen to identify
abnormalities picked up on a more
comprehensive orthopedic
examination
– Identification of conditions predictive
of an increased likelihood of
subsequent injuries**
Garrick, J Clin J Sport Med 2004;14:123–126
Page 8
History – Female Athlete Triad
• Weight & eating
issues
– Regular weight
loss/gain
– Fad diets
– Diet pills, sauna
– Disordered eating
patterns
– Additional exercise
• Menstrual history
– Start, length, flow
– Regular?
– Sexually active
History - Other
•
•
•
•
•
•
Stress issues
Support systems
Substance use/abuse
Ergogenic aids
Blood-borne illness
Good opportunity to develop
trust with the athlete!
Physical Exam Components
Page 9
Physical Exam
• A SCREENING exam…
• Understand the loads and
motions of sports to appreciate
the demands on the body
• Vital signs
–
–
–
–
–
Height and weight
Body composition
Blood pressure
Pulse
Respiratory rate
Physical Exam - HEENT
•
•
•
•
Visual acuity (20/40)
EOMFI/PERRLA
Teeth
Leukoplakia
– Tobacco
• High arch palate/ectopic
lens/detached retina
– Marfan’s?
Physical Exam - Cardiovascular
• Blood Pressure
– HTN in children
– Associated with an increased risk (not
a cause) for sudden death and complex
arrhythmia
– Average SBP and/or DBP
>/= 95th %
• Sex, age, and height
– Pre-hypertension in children
• Average SBP or DBP levels
>/= 90th %
• Check pulses
– Radial > femoral pulse = coarctation
Page 10
Physical Exam - Cardiovascular
• Cardiac Auscultation
–
–
–
–
S1, S2
Fixed or variably split S2
Extra sounds
S3 “KentukEE”
• S1=ken; S2=tuc; S3=ky
• Ventricular gallop
• Benign in youth and athletes
– S4 “TENNessee”
• S4=tenn; S1=ess; S2=ee
• Atrial gallop
• Benign in youth and athletes
– MVP mid-systolic click, late
systolic murmur
– Murmurs
Grade
Description
Grade 1
Very faint, heard only after listener has
"tuned in“. May not be heard in all
positions
Grade 2
Quiet, but heard immediately after
placing the stethoscope on the chest
Grade 3
Moderately loud
Grade 4
Loud, with palpable thrill (i.e., a
tremor or vibration felt on palpation)
Grade 5
Very loud, with thrill. May be heard
when stethoscope is partly off the chest
Very loud, with thrill. May be heard
http://static.howstuffworks.com/gif/adam/images/en/heart
Grade
6
-beat-picture.jpg with stethoscope entirely off the chest
Physical Exam - Cardiovascular
• Murmur Maneuvers
– Squatting
•
•
•
•
 venous return
 LV blood volume
 stroke volume
 systemic resistance
– Standing
•  venous return
•  LV blood volume
•  stroke volume
A
– Valsalva
P
T
M
•  venous return
Physical Exam - Cardiovascular
• Aortic Stenosis
– Harsh systolic murmur
• Innocent (Flow) Murmur
– Systolic murmur
– Blood is flowing faster than usual
• ↑ amount of blood flowing through the heart
– Squatting
• ↑ venous return
• ↑ intensity of murmur
– Valsalva
• ↓ venous return
• ↓ intensity of murmur
http://www.nhlbi.nih.gov/health/dci/images/heart_murmur.jpg
Page 11
Physical Exam - Cardiovascular
• HCM/HOCM/IHSS
– ABNORMAL RESPONSE
– Squatting
• ↑ Preload
• ↓ LV gradient
• Decreased intensity of murmur*
– Valsalva
• ↓ Preload
• ↑ LV gradient
• Increased intensity of murmur
http://health.yahoo.com/media/healthwise/h5550921.jpg
Physical Exam-Cardiovascular
Summary
• Murmurs are common…investigate further if...
– Systolic murmur  3/6
– Diastolic murmur
– Any murmur that increases with standing/decreases
with squat
– Unsure type or cardiac symptoms by history
• Arrhythmias - investigate
– Disappearance with exercise USUALLY indicates
benign
Physical Examination - Skin
• Skin: sports specific
–
–
–
–
–
–
–
–
Acne
Eczema
Impetigo
MRSA
Herpes
Molluscum contagiosum
Fungal
Mites
http://www.emedicine.com/ped/images/1765molluscum_contagiosum_closeup.jpg
http://www.cgh.com.sg/caring/issue82/images/impetigo.jpg
Page 12
Physical Examination
• Hernia exam
• Lungs
• Abdomen
– Organomegaly?
• Neuro
– DTR’s
– Sensation
– Balance
• Tanner Staging*
Physical Exam - MSK
• 2 minute screen – Sn 51%, Sp 97%
• General Screen vs. Joint (Sport) Specific
Exam
• Capacity of the screen being able to
identify abnormalities picked up on a
more comprehensive orthopedic exam
• Identification of conditions predictive of
an increased likelihood of subsequent
injuries
• If injury or history of pain look more
closely at those joints
Garrick, J Clin J Sport Med 2004;14:123–126
Page 13
PE – MSK Posture/ROM
Garrick, J Clin J Sport Med 2004;14:123–126
PE – MSK Back
• Range of motion
•Scoliosis screen
Garrick, J Clin J Sport Med 2004;14:123–126
•Special tests?
PE – MSK Hands
•
•
•
•
•
Alignment
ROM ABduct/ADduct
MCP/PIP/DIP
Nails
Cap refill or pulse
Garrick, J Clin J Sport Med 2004;14:123–126
http://pro.corbis.com/images/CB005360.jpg
Page 14
PE – MSK Shoulder/Elbow
•
•
•
•
ROM
Strength
Shrug
Special Tests?
Garrick, J Clin J Sport Med 2004;14:123–126
PE – MSK Knee, Foot and Ankle
• Screening for knee, foot and ankle
pathology…
–
–
–
–
–
–
SHOES OFF
Feet/arches
Toe/heel walk
Balance on one foot
Duck walk
Special tests?
Garrick, J Clin J Sport Med
2004;14:123–126
Marfan’s Screen*
• 1:5000 athletes screened
• History
– Personal and family
• Physical findings
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–
–
–
–
Tall and thin
Long extremities
Arachnodactyly
Pectus excavatum
Hypermobility of joints
• About 85% of those <18 years
– High arched palate
Glorioso, J, and M Reeves. Curr Sports Med Rep 2002; 1: 67-74
Dean, J. Heart 2002;88;97-103
Page 15
Screening/Baseline Tests
Screening Test - EKG
 90% of athletes with HCM will have EKG
changes: T wave inversion, ST-segment
flattening/depression, Increased R/S voltage
in percordial leads, Deep Q wave
(Pigozzi Clin Sports Med 27 (2008) 153–181.)
Maron, et al. JACC Vol. 45, No. 8, 2005. Task Force 1
Screening Test
- EKG
• Low incidence
and cost are what
limit doing EKG
routinely for PPE
Page 16
Baseline Tests
• Pulmonary
– Peak Flow
– EIB – Bronchial Provocation
Challenge test
• Gold Standard – Eucapnic
voluntary hyperventilation
testing (EVH) (High Sn/Sp)
• Methacholine challenge test
(High Sp/Low Sn)
• Testing recommended for elite
athletes
• Recreational athletes may
benefit from trial of B-agonists
Baseline Testing Concussion
• 3rd International Conference on
Concussion, Zurich (2008)
–
–
–
–
Classification
Evaluation
Treatment
Pre-participation
• Previous head, face or cervical spine
injuries
• Disproportionate impact vs symptom
severity matching
• Neuropsychological testing
– RTP issues
– 0.5 to 2.4 per 1000 collegiate
athlete-exposures
• 5% to 18.3% of all injuries
Page 17
Baseline Testing - Concussion
• Symptom Score
• Memory
• Balance
– Balance Error Scoring
System (BESS)
Baseline Testing - Concussion
• ImPACT Testing
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–
•
–
–
–
–
–
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•
Baseline
24-72 hours after injury
6 test modules
Attention
Memory
Working memory
Visual scanning
Reaction time
Processing speed
4 composite scores
–
–
–
–
Verbal Memory
Visual Memory
Reaction Time
Processing Speed
Collins, et al. Neurosurgery 58:275-286, 2006
http://www.impacttest.com/index.php
Page 18
Screening Labs – Sickle Dex
• Now Required for all Division 1 athletes
• In top four non-traumatic sports deaths in
high school and college athletes
• 1 in 12 African-Americans have sickle
cell trait
• Acclimatization is key
– 1 in 2,000 to 1 in 10,000 white Americans
• Heat, dehydration, altitude, and asthma
can increase the risk
• Strenuous exercise evokes forces that in
concert foster sickling
–
–
–
–
Severe hypoxemia
Metabolic acidosis
Hyperthermia
RBC dehydration
Van Camp SP, et al. Med Sci Sports Exerc. 1995;27:641-647
http://www2.med.umich.edu/prmc/media/newsroom/assets/im
ages/SickleCell_1222183673073.jpg
Screening Labs - Ferritin
• Mechanisms include:
– Poor intake
– Decreased absorption
– Increasing requirement
• Ferritin directly proportional to total
body stores
– Acute phase reactant
• Controversy over ferritin cutoff values
in athletes
• Low ferritin affects VO2 max, time to
exhaustion/endurance, energy
efficiency
Page 19
Other Baseline Testing
• Strength
– Manual muscle testing
– Functional testing
• Flexibility
• Body Composition/BMI
sanduskychiropractic.com
concordmonitor.com
Clearance Issues/RTP
Cardiac Return/Eligibility to Play
36th Bethesda Conference Guidelines
Journal of the American College of Cardiology
Volume 45, 2005
1312-1375
Page 20
Clearance Issues
• Heat related illness
• Infectious disease
– Skin
– Mono (RTP after 21-28 days)
• ADHD/ADD
• Seizures
– Well controlled may participate
– Rarely associated with activity
– Caution in higher risk sports
• Scuba/swimming
• Burners & Stingers
• Single Paired Organ
Clearance Issues with Concussion
• Specific number of
concussions has not been
established
• Repetitive concussions are
associated with
neurocognitive deficits
• Red Flags:
– Less time between concussions
– Less force resulting in
concussion
– Longer recovery after
concussion
Page 21
Questions?
Page 22