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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 – – – – – 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 – – • – – – – – – • 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? 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