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Title: The PreParticipation Sports Examination General


1
The Pre-Participation Sports ExaminationGeneral
Special Needs Populations
  • Jeffrey A Zlotnick MD CAQ FAAFP
  • Asst. Clinical Professor Family and Primary Care
    Sports Medicine
  • UMDNJ - Robert Wood Johnson Medical School
  • UMDNJ - New Jersey Medical School
  • Philadelphia College of Osteopathic Medicine
  • Medical Consultant Healthy Athletes
    Initiative
  • Special Olympics NJ
  • NJ Academy of Family Physicians

2
The Pre-Participation Exam
  • Primary Goal is the Health and Safety of the
    athlete
  • Objective is to be INCLUSIVE, not to try to
    exclude participation
  • NOT a substitute for the regular health
    examinations by the Primary Care Physician

3
Primary Objectives
  • Detect conditions that may limit participation
  • Atlanto-axial instability in Downs
  • Heart murmurs Innocent vs. HCM
  • Detect conditions that may lead to injury
  • Lack of physical conditioning, weak muscles
  • Poor exercise tolerance, heat intolerance
  • High amount of major joint problems ex
  • Miserable Misalignment Syndrome
  • Meet legal and insurance requirements

4
Secondary Objectives
  • Assess the general health of the athlete
  • May be the ONLY opportunity you will have to see
    this patient go into issues such as
    immunizations, substance abuse,
  • birth control
  • Counsel the athlete on health related issues
  • Assess growth development
  • Tanner staging can be helpful where less mature
    athlete is playing against a more mature
    athlete HIGH risk for injury in contact sports
    (Exam can be embarrassing)
  • Assess fitness level performance
  • Help identify weaknesses that may increase
    chances of injury ex Swimmers with weak
    pectorals muscles

5
Timing
  • Best done at a MINIMUM of SIX weeks prior to the
    start of practices
  • Gives time to identify correct problems that
    were noted on the exam

6
Frequency
  • Vary from before each season to every few years
    (few is variable)
  • Optional short interval history and go after
    specific changes or problems
  • Once yearly is the most popular

7
Methods
  • Private office by Primary Care Physician
  • Multi-station exam with different providers of
    various types (physicians, nurses, PAs)
  • Each type has its advantages and disadvantages
  • In-school physical
  • Currently not in NJ to get athletes to have a
    Medical Home. However, there are exceptions

8
Private Office Advantages
  • PCP knows the PMHx, the FHx, Immunizations
  • Less likely to overlook problems
  • Young athlete will be more willing to discuss
    sensitive issues with a known person
  • Easier/Less embarrassing to do GU exam (if
    indicated)
  • Less chance that abnormalities found will be
    overlooked and not followed up on

9
Private Office Disadvantages
  • Many athletes dont have a PCP
  • Limited time for appointments Time consuming
  • Varying levels of knowledge and interest in sport
    specific problems
  • Must be well versed in Sports-specific demands
  • Greater cost Many cant afford
  • Higher income athletes will tend to go to
    different specialists for each problem found
  • Tendency for poor communication between the PCP
    and the school athletic staff
  • Many un-indicated disallowed athletes

10
Multi-Station Advantages
  • Cost-effective and easy to screen large numbers
    of athletes
  • Specialized personnel at each station
  • Usually 5-6 stations
  • Good communication with the school athletic staff
    since the Coach ATs are usually part of the
    team

11
Multi-Station Disadvantages
  • Requires a large amount of space
  • Hurried, noisy, with minimal privacy
  • Difficult for GU exam, Heart murmurs
  • Continuity of care easily lost, problems noted
    are NOT followed up upon
  • Lack of communication with parents
  • Particular consultant may put unreasonable
    demands on an athlete
  • Varying level of training of school physicians

12
Multi-Station Required
  • Station
  • Sign-in, Ht/Wt, Vital signs, Vision
  • History review, Physical (medical, orthopedic,
    neurological) assessment/clearance
  • Personnel
  • Coach, Trainer, Nurse, volunteer
  • Physician

13
Multi-Station Optional
  • Station
  • Specific orthopedic exam
  • Flexibility
  • Body composition
  • Strength
  • Speed, agility, power, endurance, balance
  • Personnel
  • Physician
  • Trainer or therapist
  • Physiologist
  • Trainer, coach, therapist, physiologist
  • Trainer, coach, physiologist

14
MEDICAL HISTORY IS KEY!!
  • Statistics show that a good history will identify
    63-74 of medical problems!!
  • Statistics also show that information from the
    athlete agrees with the parents ONLY 39 of the
    time!!

15
Key Questions
  • Need to be asked or put on a questionnaire that
    is reviewed

16
Ever been treated in a hospital or had surgery?
  • Important to know number and severity of
    Traumatic Brain Injuries (concussions)
  • Determine if certain medical conditions are under
    control enough to allow or limit participation
  • Diabetes, Asthma
  • Has enough time been allowed to heal and
    rehabilitate from surgery?

17
Taking any Rxs, OTCs, Drugs?
  • History of Rxs important to assess control
  • Diabetes, Asthma
  • Does the athlete require any emergency drugs that
    the coach/AT will need to know about AND how to
    use them!!
  • Get information on birth control measures,
    menstrual history
  • Amenorrhea in women athletes can lead to a high
    risk of stress fractures (Female Athletic Triad)
  • Good way to introduce talk on STDs

18
Taking any Rxs, OTCs, Drugs 2
  • Get information on OTC use as athletes tend to
    abuse these
  • OTC asthma, decongestants, diet pills can cause
    increased heart rate and arrhythmia's
  • NSAIDs can cause increased bleeding
  • Laxatives (wrestlers) can cause electrolyte
    abnormalities
  • Try to get history of illicit drug use
  • Alcohol, tobacco, marijuana, steroids

19
Allergies?
  • Drugs
  • Know what can and CANT be given in case of an
    emergency
  • Bees, Insects - important in outdoor sports
  • Need to carry an EpiPen?

20
Skin Problems, Rashes?
  • Mainly looking for herpes, scabies, lice,
    molluscum contagiosum
  • Impetigo, herpes and others can be spread by
    mats, helmets, towels
  • Acne and other atopic conditions can be
    exacerbated by clothing or equipment

21
History of Head Injury, LOC, Seizure, Burners or
Stingers?
  • Seizure history (epilepsy?)
  • LOC HA Hx important to determine ability to
    resist Traumatic Brain Injury risk for Second
    Impact Syndrome
  • Burners/stingers are Brachial plexus injuries
  • Usually resolve but are occasionally permanent
  • Cervical cord neuropraxia w/ transient
    quadriplegia Rare!
  • Associated w/ cervical stenosis, congenital
    fusions, cervical instability, disc problems

22
ANY History of Recurrent burners/stingers, or
transient quadriplegia?
  • NEED Cervical spine films BEFORE being allowed to
    participate!!

23
Concussion?
  • Traumatic Brain Injury (concussion)
  • High School 5.5 of injuries
  • College 1.6-6.4
  • Major sports
  • Football, Boxing, Hockey, Soccer
  • TBI is cumulative! Can negatively affect
  • Cognitive Function (Punch Drunk)
  • Memory
  • Ability to learn
  • Reaction time
  • Increased risk of Second Impact Syndrome
  • Primarily younger (pre-adolescent) athletes

24
Heat or muscle cramps?
  • History of dizziness or passing out during
    activities in the heat
  • Determines ability to tolerate heat or prolonged
    events
  • Marathons

25
Difficulty Breathing?
  • During or after activity?
  • Seasonal allergies vs. asthma
  • Also could be cardiac
  • HCM
  • Valvular disease
  • Arrhythmia's

26
Special Equipment/Braces?
  • Inspect for fit function
  • Risk to other players?

27
Problems with Eyes/Glasses?
  • Is athlete single-eyed
  • Less than 20/50 as best in one eye
  • Hx of orbital fractures

28
Sprains/ Strains/ Fractures/ Dislocations?
  • Need to determine need for rehabilitation PRIOR
    to being allowed to participate

29
Other Questions
  • Medical problem or injury since last evaluation
    (periodic exam)
  • Immunizations up to date?
  • Td, Hep B, MMR, Meningitis
  • Women 1st menses, last menses, Longest time
    between menses
  • Family use of tobacco, alcohol, street drugs
  • How about yourself??

30
Most Important Questions
  • Ever passed out or became significantly dizzy
    during/after exercise?
  • Ever have chest pain during/after exercise?
  • Do you tire more quickly than your peers?
  • Hx of increased BP, heart murmur?
  • Hx of heart racing/skipping beats?
  • FHx of sudden death before age 50?
  • Hx of concussion (Traumatic Brain Injury)

31
Keep in mind
  • 90 of sudden death in athletes lt30 y/o is
    cardiovascular
  • Syncope or near-syncope may be a sign of
    underlying hypertrophic cardiomyopathy
  • Chest pain may be atherosclerotic
  • Dyspnea on exertion may be asthma, valvular
    disease, or coronary artery disease
  • Palpitations may be arrhythmia, WPW

32
Key Components of the Physical Exam
33
Height Weight
  • Compare to growth charts for age/sex
  • Body fat male 5-10, female 12-15
  • Very thin Ask about diet, weight loss, body
    image (r/o anorexia, bulimia)
  • Optional Body composition
  • Skin fold calipers easiest
  • Electronic scales
  • Total immersion more accurate
  • Good time to discuss weight in athletes where
    weight is important
  • Wrestling, Ice Skating, Gymnastics

34
Eyes
  • Absence of 1 eye or vision gt20/50 in the best
    eye AVOID COLLISION SPORTS!
  • Anisicoria slight/baseline is normal and should
    be noted (1-2mm)
  • Large difference needs neurological workup first!

35
Cardiovascular
  • BP Use correct size cuff!!
  • gt110/70 for lt10 y/o or gt120/80 for gt10 y/o must
    be evaluated (Latest JNC guidelines)
  • Check pulses Symmetrical femoral and radial
    pulse is a good screen for Coarctation of the
    aorta
  • Murmurs deep inspiration, valsalva, squatting
  • Innocent, Mitral valve prolapse, Hypertrophic
    cardiomyopathy, Aortic sclerosis
  • Arrhythmia EKG to evaluate
  • 24 hour monitor

36
Neurological
  • Baseline testing Neuropsych testing
  • Memory, Cognitive function
  • Ability to learn
  • Orientation
  • VERY useful if athlete receives TBI
  • Presence of post-concussive symptoms
  • More accurate for determining return to play
  • Can demonstrate loss of baseline function

37
Practice Recommendation
  • Anyone with traumatic brain injury and a recorded
    Glasgow Coma Scale of 13 or less at any stage
    after the first 30 minutes OR who received a CT
    scan of the head as part of their initial
    assessment should be routinely followed up with,
    as a minimum, a written booklet about managing
    the effects of traumatic brain injury and a phone
    call in the first week after the injury
  • Approved Source National Guideline
    Clearinghouse
  • Website http//www.guideline.gov/summary/summary.
    aspx?doc_id10281nbr 005397stringconcussion
  • Level of Evidence B - A well-designed,
    nonrandomized clinical trial. A non-quantitative
    systematic review with appropriate search
    strategies and well-substantiated conclusions

38
Other
  • Lungs look for symmetry of movement, listen for
    wheezes/rubs
  • Abdomen check for organomegaly, tenderness,
    rigidity
  • Skin check for rashes. growths

39
Practice Recommendation
  • In a population of stable asthmatics short acting
    beta-agonists, mast cell stabilizers, or
    anti-cholinergics will provide a significant
    protective effect against exercise-induced
    broncho-constriction with few adverse effects
  • Approved source Cochrane Database
  • Website http//www.cochrane.org/reviews/en/ab0023
    07.html
  • Strength of Evidence Twenty-four trials (518
    participants) conducted in 13 countries between
    1976 and 1998 were included. All drugs were
    effective at attenuating the exercise-induced
    bronchoconstriction response but to varying
    degrees even within the same individual. Compared
    to anti-cholinergic agents, mast cell stabilizers
    were somewhat more effective at attenuating
    bronchoconstriction

40
Genito-Urinary
  • Male
  • Hernia (?)
  • Testes both descended
  • Single should counsel about collision sports
  • Female
  • Pelvic not necessary part of basic exam
  • Do w/ Hx of severe menstrual irregularities,
    primary or secondary amenorrhea
  • Both Maturity development (self rating?)

41
Musculo-Skeletal
  • Need to assess major muscle groups and joints via
    a screening exam
  • Follow up closely on any abnormalities noted
  • -Decreased ROM, function -
    Hyper-flexibility
  • Refer to Figures 1-10 (pgs 22-27)
  • Pre-participation Physician Evaluation 2nd
    Edition 1997
  • The Physician and Sports Medicine,
  • A Division of McGraw Hill Co. Minneapolis, MN
  • (PDF files on NJAFP website)

42
Laboratory Testing
  • Traditionally UA dip for protein/glucose
  • Non-pathologic proteinuria VERY common
  • U-glucose NOT reliable unproven in large
    studies for DM screening
  • Same for CBC, Hct, Fe, Ferritin, Sickle trait
  • Cardiovascular screening (EKG, Echo) under
    investigation for cost-effectiveness
  • Screen only those at risk or positive findings

43
Determining ClearanceMOST IMPORTANT PART!!
  • Does the problem put the athlete at greater risk
    for injury?
  • Is the athlete a risk to other players?
  • Can the athlete safely participate with
    treatment, rehabilitation, medicine, bracing or
    padding?
  • Can limited participation be allowed?
  • If clearance is denied, are there other
    activities that the athlete can safely
    participate in?

44
Clearance is based on AAP Committee on Sports
Medicine Recommendations for Participation in
Competitive Sports
  • Based upon the amount of contact/collision and
    intensity of exercise (Table 7)
  • Pre-participation Physician Evaluation 2nd
    Edition 1997
  • The Physician and Sports Medicine
  • A Division of McGraw Hill Co.
  • Minneapolis, MN

45
Contact Non-Contact
46
Some Specifics
47
Acute Illness
  • Individual assessment
  • Generally accepted to limit activity during fever
  • URIs and strenuous activity (re cycling) can
    cause significant impact on the immune system

48
Cardiovascular Abnormalities
  • May Dispose to Sudden Death!!
  • Mild Hypertension No restrictions
  • Moderate to Severe need assessment and possible
    treatment
  • Benign functional murmurs No restriction
  • Mild Mitral valve prolapse No restriction

49
MVP with
  • PMHx of syncope
  • Chest pain/tightness increased w/ activity
  • FHx of sudden death
  • Moderate to Severe regurgitation
  • REASSESS!!
  • HIGH RISK!!

50
Hypertrophic Cardiomyopathy(HCM, IHSS)
  • Most common cause of sudden death in athletes
  • Usually find
  • Marked LVH (Need to differentiate from normal
    LVH in conditioned athletes)
  • Significant L outflow obstruction Arrhythmia's
    Both increased by activity
  • PMHx of syncope or FHx of sudden death in a young
    relative
  • May participate in LOW intensity activities

51
Cardiovascular Risks
  • SCD per year in healthy patients
  • 1 / 133,000 Men
  • 1 / 769,000 Women
  • AMI w/in 1 hour of exercise 2-10
  • 2.1 10x higher than in sedentary patients
  • SCD 6-164x greater than sedentary patients
  • Recommend higher level of screening in high risk
    patients
  • Circulation 2007 Exercise and Acute CV Events
    Placing Risks Into Perspective

52
Who Should Be Screened?
  • Low risk
  • Men lt45 Women lt55
  • Asymptomatic
  • Meet no more than 1 risk factor
  • Moderate risk
  • Older than preceding
  • 2 or more risk factors
  • High risk
  • Signs / symptoms of CVS, Pulmonary, Metabolic
    disease or family history of SCD

53
Visual Impairment
  • Considered if singled-eyed or best vision in
    one eye gt20/50
  • NO effective eye protection for
  • Martial arts, Boxing, Wrestling gtgtgtgtDisallow!
  • High risk
  • Football, Baseball, Racquetball
  • Eye guards exist but protection is limited

54
Practice Recommendation
  • Functionally 1-eyed athletes and those who have
    had an eye injury or surgery must not participate
    in boxing or full-contact martial arts. (Eye
    protection is not practical in boxing or
    wrestling and is not allowed in full-contact
    martial arts.)
  • Approved Source National Guideline
    Clearinghouse
  • Website http//www.guideline.gov/summary/summary.
    aspx?doc_id4861nbr 3502ss6xl999
  • Strength of Evidence Although the evidence for
    each recommendation is not specifically stated
    the evidence is drawn from reports from American
    National Standards Institute. Occupational and
    educational personal eye and face protection
    devices. Washington (DC) American National
    Standards Institute 2003 and American Society
    for Testing and Materials. Annual book of ASTM
    standards Vol 15.07. Sports equipment safety
    and traction for footwear amusement rides
    consumer products. West Conshohocken (PA)
    American Society for Testing and Materials 2003.

55
Kidney/Renal
  • Incidence of renal trauma is 5-25, but is mostly
    mild
  • Solitary kidney
  • Pelvic, Iliac, Multicystic, Hydronephrotic,
    Uteropelvic jct abns gtgtgt No Collision Sports!
  • Normal position
  • Counsel and sign consent
  • Extra padding

56
Hepato/Splenomegaly
  • Liver determine primary cause (ex mono)
  • OK to return once organ reduces size
  • Spleen Acute splenomegaly associated w/ HIGH
    risk rupture with Minimal provocation!!
  • Chronic splenomegaly need to assess and treat
    individually

57
  • Hernia Only remove if symptomatic
  • Gyn No restriction w/ single ovary
  • Do look for menstrual irregularities
  • Female athletic triad
  • (Amenorrhea, anorexia, osteoporosis)
  • Testicular Single may play all sports CUP!
  • Undescended testes more serious
  • Increased risk of Ca
  • Sickle Cell
  • Trait No restrictions altitudes lt4000 ft.
  • Disease Very limited
  • Even mild hypoxia can lead to sickling!!

58
Neurological Problems
  • Burners/Stingers Can play once asymptomatic
  • Recurrent need atlanto-axial evaluation
  • Transient Quadriplegia NOT associated w/
    increased risk of permanent quadriplegia
  • However, MUST be evaluated
  • Orthopedist or Neurosurgeon

59
Traumatic Brain Injury
  • TBI classified by
  • 1 Amnesia
  • 2 Symptoms w/ activity and at rest
  • Both physical and mental function
  • 3 Loss of Consciousness
  • NUMBER of events (damage is cumulative!)
  • Neuropsych testing (pre-participation,
    post-injury)

60
Traumatic Brain Injury
  • Need to be aware of Post TBI Syndrome Second
    Impact Syndrome
  • Pay close attention to subtle neuro signs and
    complaints of headache, poor concentration, dizzy
  • Athlete must be symptom free w/ activity and at
    rest and back to baseline Neuropsych testing
    before being allowed to play
  • Minor trauma can lead to rapid cerebral edema
  • More common in younger / pre-adolescent athletes

61
Traumatic Brain InjuryReturn to Play NP testing
based
  • ALL athletes must have baseline Neuropsych
    testing prior to starting sports
  • After TBI, administer NP testing at
  • 2hrs, 48hrs, 1 wk, 2 wks, 1 mos
  • Return to play is determined by return to
    baseline on NP testing
  • More accurate than time/symptom based methods
  • Other more advanced computer based systems for
    determining return to play

62
Neuropsych Testing
  • Standardized Assessment of Concussion
  • Brain Injury Association of America
  • 8201 Greensboro Drive
  • Suite 611
  • McLean, VA 22102
  • 703-761-0750 / 800-444-6443
  • Cost ??

63
SCAT Sideline Concussion Assessment Tool
  • Developed by Prague Group 2004
  • Symptom score sheet post-injury
  • Mental function assessment in several areas
  • Not a full neuro-psych test
  • Does have some baseline to compare with
    post-injury

64
(No Transcript)
65
ImPACT Univ of Pittsburgh
  • Computerized system to evaluate concussion
    management and safe return to play
  • Battery of scientifically validated
    neuro-cognitive testing on large populations
  • Does not require baseline testing for individual
    athlete
  • Does not allow for individual variation
  • Expensive!!
  • Already in use at the pro level some colleges
    high schools
  • Becoming more available for on field management

66
Special Olympics
  • Established early 1960s by Eunice Kennedy
    Shriver developed by the Joseph P Kennedy
    Foundation
  • Mission To provide sports training
  • competition for persons with mental
  • retardation
  • Winter summer events every 4 years
  • Local, state, regional, national, international
  • Local 300-600 athletes
  • International 1500-6000 athletes
  • 1st International Games were 1968 in Soldier
    Field, Chicago

67
Eligibility
  • At least 8 y/o identified as having
  • Mental retardation by an agency or professional
  • Cognitive delays
  • Learning or vocational problems requiring special
    designed instruction
  • No maximum age limits
  • Training programs can begin at 6 y/o

68
Summer Sports
  • Swimming diving
  • Track field
  • Basketball
  • Bowling
  • Cycling
  • Equestrian
  • Soccer
  • Golf
  • Gymnastics
  • Powerlifting
  • Roller skating
  • Softball
  • Tennis
  • Volleyball

69
Winter Sports
  • Alpine Skiing
  • Cross-country skiing
  • Figure skating
  • Floor hockey
  • Speed skating

70
Prohibited Sports
  • Any sport w/ direct 1-on-1 competition
  • Considered dangerous for mentally retarded
    athletes
  • Wrestling
  • Shooting
  • Fencing
  • Ski jumping
  • Javelin
  • Vault
  • Triple jump
  • Platform diving
  • Trampoline
  • Biathlon
  • Boxing
  • Rugby
  • Football (US)

71
Organization of Games
  • Levels of participation
  • Age, Sex, Ability
  • Developmental sports for those w/ severe
    limitations
  • Coaches
  • Special-ed teachers, athletic instructors,
    parents
  • Extensive knowledge of the physical mental
    characteristics of each athlete
  • Low ratio athlete/coaches 41
  • Volunteers
  • Support services
  • Administration
  • Physicians, nurses, PTs OTs, trainers
  • Work directly with SO executive director

72
Pre-Participation Exam
  • Questionnaire 1 tool
  • Done initially yearly
  • Coaches must have an updated reviewed
    questionnaire at ALL competitions
  • 44 - 71 of problems that can affect ability to
    compete are identified by questionnaire
  • Physical
  • Initially every 3 years
  • Athletes develop new problems
  • Htn, visual problems, concussions, surgery
  • Identifies approx 29 problems

73
Common Problems
  • Visual 25
  • Refractive, cataracts, myopia, blindness
  • Hearing 8
  • Seizures 19
  • Medical 6 (similar to general population)
  • 30 use medications
  • Emotional behavioral
  • Much higher than in general population

74
Complex Problems
  • Atlanto-axial instability
  • Most common most controversial
  • Spinal cord problems
  • Injuries
  • Meningomyelocele
  • Spinal bifida
  • Hydrocephalus
  • Cerebral palsy
  • Wheelchair athletes
  • Amputees (congenital acquired)
  • Visual hearing impairment
  • Seizures
  • Type 1 Diabetes

75
Atlanto-Axial Instability
  • Up to 15 of Down syndrome
  • All have abnormal collagen that leads to
    increased ligamentous laxity and decreased muscle
    tone
  • Annular /- Transverse ligament of C1 (Axis)
    stabilizes articulation of the odontoid process
    of C2 (Atlas) w/ C1
  • Laxity may allow forward translation of C1 on C2
    causing compression of the cervical spinal cord

76
Atlanto-Axial Instability
  • Reports of Down syndrome patients experiencing
    spontaneous subluxation catastrophic spinal
    cord injury during surgery requiring intubation
    (anecdotal)
  • Also with blows to the head and major falls
  • 2 experience symptoms related to AAI
  • Abnormal gait, neck pain, limited C-spine ROM,
    spasticity, hyperreflexia, clonus, sensory
    deficits, upper motor neuron signs
  • Asymptomatic AAI is of major concern
  • Highest risk between 5-10 yrs of age

77
Atlanto-Axial Instability
  • SO requires C-spine x-rays in neutral,
    hyper-extension and hyper-flexion
  • Evaluation of the Atlantodens interval spinal
    canal at C1-C2
  • Intervals gt 4.5 (5) mm are positive
  • 17 of athletes w/ AAI
  • Neurosurgical evaluation required before allowing
    any participation
  • Reassessment every 3-5 years
  • Unsure if indicated if initial evaluation normal

78
Atlanto-Axial Instability
  • Participation allowed in most events except
  • Butterfly stroke
  • Diving starts in swimming
  • Pentathlon
  • High jump
  • Equestrian sports
  • Artistic gymnastics
  • Soccer
  • Squat lifts
  • Alpine skiing

79
Atlanto-Axial Instability
  • American Academy of Pediatrics Comm. on Sports
    Medicine Fitness concluded potential but
    unproven value
  • Current literature does NOT provide evidence for
    or against screening
  • Long term longitudinal studies are lacking
  • Natural history of AAI is unknown
  • 85 of pts w/ AAI 5mm or gt have no symptoms
  • At this time screening is SO requirement

80
Spinal Cord Injured Athletes
  • Predisposed to injuries 20 to wheelchair use
  • Loss of motor sensory function below the level
    of the injury
  • Lack of autonomic function
  • Thermoregulation
  • Autonomic dysreflexia

81
Thermal Regulation
  • Seen 10ly in lesions above T-8
  • Loss of vasomotor responses
  • Hypothalamus response limited by loss of impulse
    from below the injury
  • Reduced venous return from the paralyzed muscles
    below the injury
  • Impaired sweating below lesion reduces effective
    body area for evaporative cooling

82
Thermal Regulation
  • Body core temps that go to either extreme
    in hot cold environments
  • Hypo but 10ly extreme Hyperthermia
  • Need to be aware of
  • Clumsiness / Erratic wheelchair control
  • Headache
  • Confusion or other mental status change
  • Dizziness
  • Nausea / vomiting

83
Prevention
  • Acclimatization of athletes 2 weeks prior
  • Daily posting of temp heat stress index
  • Combination of solar ambient heat and relative
    humidity
  • Systematic schedule of fluid intake
  • Before, during, after events
  • Daily weights
  • Availability of resuscitative and transportation
    services

84
Autonomic Dysreflexia
  • Occurs in injuries above T-6
  • Loss of inhibition of the Sympathetic NS
  • Sweating above lesion
  • Hyperthermia
  • Acute hypertension
  • Cardiac dysrhythmias
  • Multiple triggers
  • Bowel bladder distention
  • Pressure sores
  • Tight clothing
  • Acute fractures
  • Environmental (temperature)

85
Treatment
  • Remove athlete from activity
  • Remove sensory stimulus
  • Clothing
  • Bladder catheterization/bowel evacuation
  • Cooler/warmer environment
  • Transport to hospital may be necessary
  • Uncontrolled hypertension or dysrhythmia
  • Usually self-limited
  • Watch for self-induced (Boosting)

86
Wheelchair Athletes
  • Usually other significant medical problems
  • 10ly Overuse injuries to wrist shoulders
  • Rotator cuff impingement / tendonitis
  • Biceps tendonitis
  • Fractures to the hands wrists
  • Epiphyseal plate weakest point
  • Lower extremity fractures infrequent
  • Pressure sores
  • Due to increase pressure lower blood flow
  • Insidious onset due to lack of sensation
  • Tx Custom seats, moisture absorption, padding

87
Cerebral Palsy
  • Spasticity, athetosis, ataxia
  • Progressively decreasing muscle/tendon
    flexibility strength gtgt Contractures
  • Impaired hand-eye coordination
  • Mental retardation
  • Seizures
  • Extreme risk for overuse injuries!
  • 50 in wheelchairs
  • Modification of events to accommodate
  • Get inventive (Adaptive Sports Program)

88
Athletes w/ Amputations
  • Indications for amputation
  • Circulatory problems Necrosis or infarction
  • Life threatening cancer, infection
  • Congenital deformity rendering limb insensate
  • Upper limb more common in younger
  • Length of limb preserved to protect epiphysis
  • Appliances are smaller require frequent
    adjustments to accommodate growth
  • Prostheses are abused need repair/adjustment
  • Skin breakdown/ Phantom limb pain is less
    frequent in younger athletes

89
Problems
  • Overgrowth of stump is common
  • Skin breakdown common in sports due to friction
    pressure
  • Alteration center of gravity gtgt Problems with
    balance (10ly lower limb amputees)
  • Hyperextension of knee lumbar spine
  • Early detection is key 20 decreased sensation in
    limb
  • Athletes may compete using prostheses but no
    other assistive device

90
Visual Impairment
  • Partial sight to total blindness
  • Legal blindness acuity lt 20/200, visual field lt
    200
  • No related physical disabilities except due to
    lack of experience with certain activities
  • Modifications to equipment, rules strategy may
    be required
  • Tactile audio clues
  • Tethers or guide wires
  • Step stroke counting
  • Guides

91
Hearing Impairment
  • Tend not to consider themselves disabled
  • Subculture of society
  • Variations
  • Mild threshold 27-40 dB
  • Profound threshold gt 90 dB
  • Behavioral disorders 20 communication challenges
  • No related physical disabilities except due to
    lack of experience with certain activities

92
Seizures
  • Common in athletes with developmental
    disabilities
  • Familiarity with meds side effects
  • Attention span cognitive impairment
  • Decreased potential for seizures w/ exercise
  • Metabolic acidosis due to lactate buildup
    incomplete respiratory compensation
  • Decreased pH gtgt Stabilizes neuromembranes
  • Good control must be obtained prior to
    participation in activities
  • Be prepared as with ALL athletes

93
Insulin Dependant Diabetes
  • Need to monitor glucose
  • 30 min before activity
  • Immediately before activity
  • Every 30-45 min during activity
  • Ideal pre-exercise range is 120-180 mg/dl
  • gt 200 mg/dl Postpone take extra insulin to get
    glucose levels down 1st
  • Exercise with elevated glucose will cause levels
    to RISE further which can lead to increased
    diuresis, dehydration, and keto-acidosis

94
Insulin Adjustments
  • Moderate exercise
  • AM activity reduce Reg by 25
  • PM activity reduce Reg by 25 as well as NPH or
    Long Acting
  • Strenuous or Long Term
  • AM activity reduce Reg by 50
  • PM activity reduce Reg by 50 as well as NPH or
    Long Acting
  • Insulin pumps or Glargine as above
  • Liberal hydration
  • lt 1hr water alone OK
  • gt 1hr think Na replacement
  • (Sport drinks remember they contain CHO!!)

95
Complications
  • Autonomic dysfunction
  • Avoid power lifting 20 bradycardia syncope
  • Increased hot cold intolerance
  • Hyperglycemia treat watch for KA
  • Hypoglycemia
  • Tremors, sweating, palpitations, pallor, hunger
  • Long acting CHOs, glucagons
  • Late onset hypoglycemia 6-28 hrs later
  • Replace glycogen w/in 1 hr of activity
  • Avoid activity near intermediate insulin peaks
  • Use long-acting to avoid peaks
  • Watch for Neuro-glypenic Syndrome

96
Special Concerns
  • Some problems out of scope of practice for Family
    Physicians
  • Dental disease
  • Complex Cardiac problems
  • Advanced Orthopedic problems
  • Ophthalmic problems
  • Need to establish referral network of physicians

97
Special Concerns
  • Podiatric problems difficulty finding good
    athletic shoes that fit
  • Pes planus
  • Toenail fungus
  • Tinea groin abscesses
  • Orthostatic hypotension

98
Healthy Athletes InitiativeMedFest
  • NJ Academy of Family Physicians
  • Special Olympics NJ

99
Healthy Athletes Initiative
  • March 9, 2003 the first MedFest occurred in
    Lawrenceville, NJ. This model has been copied by
    a number of other organizations
  • August 2005 an agreement was signed between SOI
    and AAFP
  • March 2009 Over 500 athletes have been certified
    to participate that otherwise would have never
    had the opportunity

100
Some Pictures From MedFest 1Before We Start
101
Registration
102
Vitals
103
History Review
104
Heart Lung
105
Orthopedic
106
Ear, Nose Throat
107
Check out!
108
Thank you!!
109
Contact Information
Jeffrey A. Zlotnick, MD, CAQ, FAAFP New Jersey
Academy of Family Physicians 224 West State St
The Lutine House Trenton, NJ 08608 Phone
609-394-1711 Fax 609-394-7712 Email
Maddoc007_at_aol.com or Exec. Director Ray
Saputelli, CAE - ray_at_njafp.org Deputy Exec.
Director Theresa J Barrett, MS CMP -
theresa_at_njafp.org Office Manager Candida Taylor
candida_at_njafp.org
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