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Boston University School of Medicine asks all individuals involved in the development and presentation of Continuing Medical Education (CME) activities to disclose all relationships with commercial interests. This information is disclosed to CME activity participants. Boston University School of Medicine has procedures to resolve apparent conflicts of interest. In addition, presenters are asked to disclose when any discussion of unapproved use of pharmaceuticals and devices is being discussed. I, Albert C. Hergenroeder, MD have no commercial relationships to disclose. Preparticipation Sports Examination Albert C. Hergenroeder, M.D. Section of Adolescent Medicine and Sports Medicine SAHM Workshop 2015 Pediatrics Goals •The audience will understand the purposes and administration of the preparticipation sports examination (PPE) Page 2 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:09 AM Objectives. The audience will be able to discuss: 1. Purposes of the PPE/what form to use 2. Distinguishing PPE from annual visit 3. Administering the PPE 4. Key historical data 5. Most common complaints Page 3 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:10 AM Objectives (cont’d). The audience will be able to discuss: 6. Sudden death in sports 7. Key PE findings 8. Musculoskeletal exam 9. Laboratory evaluation Page 4 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:10 AM #1 Objectives of the PPE •Primary ‐Screen for life-threatening or disabling conditions ‐Screen for conditions that may predispose to injury or illness •Secondary ‐Determine general health ‐Serve as an entry point to health system ‐Opportunity to initiate discussion of health related topics PPE 4th Edition AAP Page 5 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:11 AM What form to use? •American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine. Preparticipation Physical Evaulation. 4th Edition. Elk Grove. American Academy of Pediatrics; 2010. (PPE 4) •Added personal and family history questions designed to identify rare channelopathies. Page 6 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:11 AM How often does a PPE need to be done? Who can do it •80% states require an annual PPE. Page 7 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:11 AM Caswell 2015 #2 PPE ≠ Annual evaluation •Not comprehensive •Does not address HEADDS •Assumptions ‐Most athletes are healthy ‐Most have had previous medical evaluations Page 8 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:12 AM #3 Administration •Plan 6 weeks before season starts ‐May, prior to leaving school •Station approach ‐More sensitive •One provider doing evaluation ‐Faster and more holistic •Know how you will handle work-ups and disqualifications Page 9 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:12 AM #4 History – most sensitive data •Current injuries •Menstrual history •Injuries last year •Weight changes •Cardiac questions •Recent illness •Medical problems •PMH •Meds •Concussion symptoms Page 10 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:13 AM #5 What are the most common complaints by athletes at the PPE? Page 11 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:13 AM (+) history reported at PPE •Musculoskeletal 20% •Concussion 5% •Dizziness, fainting, frequent headache, Sz 3% •Current meds 3% Durant 1992 Page 12 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:14 AM #6 Unexpected sudden death in athletes Pediatrics U.S National Registry of Sudden Death in Athletes U. of Minnesota, 1987 - 2006 Pediatrics Figure 2. Flow diagram summarizing causes of death in 1866 young competitive athletes. *Suicide (n=22); lightning (n=12); drowning (n=10 and 3 during the swimming segment of triathlon events); cerebral aneurysm (n=9); rhabdomyolysis (n=8); epilepsy (n=2); a... Maron 2009 Maron 2009 Page 15 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:14 AM 513/1866 unable to ascribe cause of death Pediatrics Figure 1. Number of cardiovascular (CV), trauma-related, and other sudden death events in 1866 young competitive athletes, tabulated by year. Page 17 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:15 AM Deaths in sports from cardiovascular or related causes •Incidence is not known Kaltman. NHLBI 2011 •75 – 100 sudden cardiac deaths in young athletes/year in the U.S. Maron 2009, 2012 •11% in females Page 18 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:15 AM Public health context •2,700 16-19 yo killed in MVA in US (2010) CDC •2,436 15-19 yo killed by guns in US (2009) ‐~ 2/3 homicide Children’s Defense Fund ‐~ 1/3 suicide Page 19 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:16 AM In U.S. In Italy, #1 cause is ARVC Maron 2007 Maron 1996 Page 20 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:16 AM Sudden unexpected death 1-40 year olds •25-40% are autopsy negative •25-35% of these could be challenopathies ‐Most common LQTS Drezner 2013 •27 (53%) of states have not updated their PPE forms to include questions designed to screen for channelopathies, from PPE4 Caswell 2015 Page 21 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:17 AM Abnormal ECG findings suggestive of primary electrical disease Ventricular pre-excitation PR interval <120 ms with a delta wave (slurred upstroke in the QRS complex) and wide QRS (>120 ms) Long QT interval* QTc ≥470 ms (male) QTc ≥480 ms (female) QTc ≥500 ms (marked QT prolongation) Short QT interval* QTc ≤320 ms Brugada-like ECG pattern High take-off and downsloping ST segment elevation followed by a negative T wave in ≥2 leads in V1–V3 Profound sinus bradycardia <30 bpm or sinus pauses ≥3 s Atrial tachyarrhythmias Supraventricular tachycardia, atrial-fibrillation, atrial-flutter Premature ventricular contractions Drezner 2013 ≥2 PVCs per 10 s tracing Ventricular arrhythmias Couplets, triplets, and non-sustained ventricular tachycardia Note: These ECG findings are unrelated to regular training or expected physiological adaptation to exercise, may suggest the presence of pathological cardiovascular disease, and require further diagnostic evaluation. *The QT interval corrected for heart rate is ideally measured with heart rates of 60–90 bpm. Consider repeating the ECG after mild aerobic activity for borderline or abnormal QTc values with a heart rate <50 bpm. Page 22 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:17 AM Sudden Cardiac Death in Sports •Previous symptoms ‐Passing out when training ‐Chest pain ‐Irregular heart rate •These symptoms preclude exercise until evaluated Page 23 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:18 AM Cardiac syncope more likely if 1 of 4 factors (100% identified) •Family history of: ‐Syncope; Heart problems (arrhythmias, congenital heart disease, and cardiomyopathies); Sudden death in family members younger than 50. •Exertional syncope •Abnormal PE or ECG Tretter 2013; similar Ritter 2000 Page 24 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:18 AM Cardiac syncope less likely to have •Previous syncope •Prodromal symptoms (dizzy, visual, auditory changes, nausea, diaphoresis) •Trigger event •Vasovagal more likely if standing for long time Page 25 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:18 AM If cardiac history is positive •Preclude from sports participation regardless of PE •EKG •ECHO •Stress test with 12 lead EKG •Event capture/holter monitor Circulation 2004 36th Bethesda Conference Page 26 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:19 AM Should screening ECG be part of the PPE? •30% won’t be identified by screening, including ECG: coronary artery anomalies, some HCM, dilated aorta, and dilated cardiomyopathy Page 27 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:19 AM Should screening ECG be part of the PPE? •Corrado et al 2006 ‐1982 law requiring PPE and 12 lead ECG ‐89% reduction in annual incidence of SCD 1979 – 2004 ‐Intervention not just ECG: more meticulous PPE screening; ‐Elite Italian athletes, 24 yo, AA not included ‐MDs put in jail for missing ARVC Page 28 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:19 AM Page 29 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:20 AM Veneto vs. Minnesota •No difference in rates of SCD over the 1993 – 2004 period Maron 2009 Page 30 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:20 AM Should screening ECG be part of the PPE? •NHLBI report – not enough data to recommend routine screening •AHA does not endorse routine ECG screening Circulation 2012 Page 31 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:20 AM Public pressure to “do something” •“Fortunately there is much more to do than wring out hands in endless debate…. •Using the most accurate detection methods – a combination of EKG and MRI - our mobile van has screened 500 athletes and other students… •We also know that sitting on the sidelines & doing nothing while tragedy continues to strike is not at Leader in the Texas Medical Center, Houston Chronicle 3/20/11 option.” Page 32 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:20 AM Continued pressure to screen •Local clinic in Texas is screening patients with ECGs and having parents of youth who have died as speakers for their testimonials. •Advocating for legislation that if a player passes out, has dizziness, they have to have a work-up before clearance ‐Legislating medical decision making Page 33 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:21 AM Can the PPE predict EIB? •NO •Allergic rhinitis, asthma or EIB was found in 11/24 subjects with EIB diagnosed by spirometry Hallstrand TS 2002 •PE not helpful in PPE •12% of athletes with EIB were using short acting ß2 •If short acting ß2 > 2x/week, use ICS Boulet 2015 Page 34 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:21 AM #7 Key PE findings •Physical examination ‐Height ‐Weight •Overweight or underweight? •What to do about >> 95% and < 5%? ‐Case by case ‐>> 95% concern about deconditioning ‐< 5% concern about malnutrition Page 35 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:21 AM Predicting stress fx in female runners •5.4% over 11 months (prospective) •Prior fracture was 6x risk of stress fx over 12 months •Menarche > 15 •BMI < 19 •Prior participation in dance or gymnastics Tenforde 2013 ‐Each increased risk 2-3x Page 36 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:22 AM # of risk factors Risk of stress fx 0 1.4 1 1.7 2 13 3 36 4 100 Tenforde 2013 Page 37 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:22 AM #7 Key PE findings (cont’d) •Pulse ‐Resting < 40 beats per minute or > 120 •Temperature ‐Don’t exercise if temp > 100.8 o C Page 38 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:22 AM #7 PE findings – ↑BP (cont’d) •“Athletes found to have stage 2 hypertension or findings of end organ damage should not be allowed to participate in any competitive sport until their bp is further evaluated, treated, and under control, at which time eligibility for participation can be reevaluated.” •Limited evidence shows no greater risk of acute events with strenuous dynamic or static exercise PPE AAP 2010 Page 39 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:23 AM Age Severe ↑BP ♂ (2010): >5 mm above 99% for height = 50% Severe ↑BP ♀ (2010): >5 mm above 99% for height = 50% 12 137/95 136/94 14 142/96 139/96 17 149/100 142/97 > 18 160/100* 4th Task Force 2004; 36th Bethesda; JNC7* Page 40 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:23 AM Classification of sports according to cardiovascular demands (based on combined static and dynamic components). Demorest 2010 Page 41 Pediatrics ©2010 by American Academy of Pediatrics xxx00.#####.ppt 5/24/2017 2:37:24 AM Relevance to football, other sports •“In certain sports and team positions, bulk and body mass are valued, expected, and promoted. This practice should not be encouraged because of the health risks associated with obesity…” Demorest, et al AAP Policy Statement 2010 Page 42 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:24 AM Hypertension during weight lifting •Experienced weight lifters •Intraarterial catheter, brachial artery •Double leg press - Mean 355/281 mm Hg MacDougal 1983 MSSE •Single arm curls - Mean 293/230 •With large muscle groups contracting at great force, SBP can exceed 300 mm Hg; DBP > 200. MacDougal 1985 JAP Page 43 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:25 AM #7 Key PE findings (cont’d) •Limited PE ‐Visual acuity •Best correct 20/40 or uncorrected < 20/200 •Corrective eyewear ‐Cardiac – lying and standing ‐Organomegaly ‐Paired organs Page 44 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:25 AM Page 45 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:26 AM Page 46 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:26 AM Page 47 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:26 AM #8 Musculoskeletal exam •Musculoskeletal exam ‐2 minute exam ‐Done by a qualified health care provider ‐History more useful in predicting injury Garrick 2004 Page 48 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:26 AM Page 49 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:27 AM Page 50 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:27 AM Page 51 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:27 AM #9 Laboratory evaluation •Routine U/A and CBC not indicated Page 52 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:28 AM Summary PPE is not the same as an annual exam Key historical data Musculoskeletal Cardiac – check to see if you have the PPE4 Sudden death Cardiac >> Asthma and heat stroke Pay attention to presyncope, palpitations Page 53 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:28 AM Summary (cont’d) •EIB cannot be predicted during PPE •Stress fractures in females are higher if menarche > 15, BMI < 19, previous stress fracture and prior participation in dance or gymnastics •Targeted PE: vs, eye, cardiac, paired organs •No lab data indicated for all – case by case Page 54 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:28 AM Page 55 Pediatrics xxx00.#####.ppt 5/24/2017 2:37:28 AM