Title: The PreParticipation Sports Examination General
1The 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
2The 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
3Primary 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
4Secondary 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
5Timing
- 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
6Frequency
- 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
7Methods
- 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
8Private 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
9Private 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
10Multi-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
11Multi-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
12Multi-Station Required
- Station
- Sign-in, Ht/Wt, Vital signs, Vision
- History review, Physical (medical, orthopedic,
neurological) assessment/clearance
- Personnel
- Coach, Trainer, Nurse, volunteer
- Physician
13Multi-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
14MEDICAL 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!!
15Key Questions
- Need to be asked or put on a questionnaire that
is reviewed
16Ever 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?
17Taking 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
18Taking 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
19Allergies?
- Drugs
- Know what can and CANT be given in case of an
emergency - Bees, Insects - important in outdoor sports
- Need to carry an EpiPen?
20Skin 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
21History 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
22ANY History of Recurrent burners/stingers, or
transient quadriplegia?
- NEED Cervical spine films BEFORE being allowed to
participate!!
23Concussion?
- 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
24Heat or muscle cramps?
- History of dizziness or passing out during
activities in the heat - Determines ability to tolerate heat or prolonged
events - Marathons
25Difficulty Breathing?
- During or after activity?
- Seasonal allergies vs. asthma
- Also could be cardiac
- HCM
- Valvular disease
- Arrhythmia's
26Special Equipment/Braces?
- Inspect for fit function
- Risk to other players?
27Problems with Eyes/Glasses?
- Is athlete single-eyed
- Less than 20/50 as best in one eye
- Hx of orbital fractures
28Sprains/ Strains/ Fractures/ Dislocations?
- Need to determine need for rehabilitation PRIOR
to being allowed to participate
29Other 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??
30Most 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)
31Keep 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
32Key Components of the Physical Exam
33Height 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
34Eyes
- 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!
35Cardiovascular
- 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
36Neurological
- 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
37Practice 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
38Other
- Lungs look for symmetry of movement, listen for
wheezes/rubs - Abdomen check for organomegaly, tenderness,
rigidity - Skin check for rashes. growths
39Practice 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
40Genito-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?)
41Musculo-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)
42Laboratory 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
43Determining 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?
44Clearance 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
45Contact Non-Contact
46Some Specifics
47Acute Illness
- Individual assessment
- Generally accepted to limit activity during fever
- URIs and strenuous activity (re cycling) can
cause significant impact on the immune system
48Cardiovascular 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
49MVP with
- PMHx of syncope
- Chest pain/tightness increased w/ activity
- FHx of sudden death
- Moderate to Severe regurgitation
- REASSESS!!
- HIGH RISK!!
50Hypertrophic 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
51Cardiovascular 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
52Who 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
53Visual 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
54Practice 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.
55Kidney/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
56Hepato/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!!
58Neurological 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
59Traumatic 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)
60Traumatic 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
61Traumatic 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
62Neuropsych 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 ??
63SCAT 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)
65ImPACT 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
66Special 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
67Eligibility
- 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
68Summer Sports
- Swimming diving
- Track field
- Basketball
- Bowling
- Cycling
- Equestrian
- Soccer
- Golf
- Gymnastics
- Powerlifting
- Roller skating
- Softball
- Tennis
- Volleyball
69Winter Sports
- Alpine Skiing
- Cross-country skiing
- Figure skating
- Floor hockey
- Speed skating
70Prohibited 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)
71Organization 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
72Pre-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
73Common 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
74Complex 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
75Atlanto-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
76Atlanto-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
77Atlanto-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
78Atlanto-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
79Atlanto-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
80Spinal 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
81Thermal 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 -
82Thermal 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
83Prevention
- 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
84Autonomic 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)
85Treatment
- 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)
86Wheelchair 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
87Cerebral 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)
88Athletes 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
89Problems
- 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
90Visual 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
91Hearing 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
92Seizures
- 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
93Insulin 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
94Insulin 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!!)
95Complications
- 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
96Special 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
97Special Concerns
- Podiatric problems difficulty finding good
athletic shoes that fit - Pes planus
- Toenail fungus
- Tinea groin abscesses
- Orthostatic hypotension
98Healthy Athletes InitiativeMedFest
- NJ Academy of Family Physicians
-
- Special Olympics NJ
99Healthy 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
100Some Pictures From MedFest 1Before We Start
101Registration
102Vitals
103History Review
104Heart Lung
105Orthopedic
106Ear, Nose Throat
107Check out!
108Thank you!!
109Contact 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