Title: Pre-Participation Physical Examination
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2Pre-Participation Physical Examination
- A Principle Tool for Injury Prevention
3What is a PPE?
- A tool for injury prevention, used to gather
medical information about athletes to ensure that
they are ready to participate in sports - The athletes initial exposure to the sports
medicine team
4Principles Governing PPE
- Collects medical info about athlete to ensure
readiness to participate in a sport - Design of PPE should allow assessment of risk
factors detect any disease /or injury that
might create problems - Each question should be understandable
- Ensure instruments used are properly calibrated
- Each instrument used in PPE should be valid
reliable
5Goals of PPE (Kibler, 1990)
- Provide an objective, sport-specific
musculoskeletal exam - Obtain (-) information that alters participation
- Obtain () information to decrease injury
potential increase performance - Provide a reproducible record for comparison in
the future - Provide baseline data for sport-specific
conditioning
6Timing Frequency of PPE
- Timing
- Researchers say to perform PPE 4-8 weeks prior to
start of season - Allows time to f/u on evals, rehab, etc.
- Some say at beginning of season
- Some say in the season prior to start (i.e.
May/June for fall sports) - Frequency
- Beginning of each sport season
- Beginning of each year
- At new level of competition (high school)
- Health history update each year
7Personnel
- General practice physician
- Orthopedist
- Cardiologist
- Athletic trainer
- Exercise physiologist
- Psychologist
- School nurse
- Strength coach
8formats of the examination
- Mass screening
- locker room
- Individual exams
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12Components of PPE
13HISTORY
- chronic medical illnesses,
- surgical history
- allergies
- current medications
- groups disagreed on questions related to
cardiovascular, - neurologic, musculoskeletal, and weight issues.
- Preparticipation Physical Examination Task Force
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18HEENT
- eye exam
- Any differences in pupil size (anisocoria)at
baseline - visual acuity.
- An athlete should have corrected vision of 20/40
or better if engaging in collision and contact
sports - Protective eyewear
- single eye
- contraindication to participation boxing and
wrestling - mouth
- evidence of bulimic activity and/or
- tobacco
- A high, arched palate Marfans syndrome
- ear
- ruptured tympanic membrane
- risk factor for participation in swimming and
diving
19Cardiovascular PPE?
- Risk of sudden death in young athlete
- 1/100,000
- Mengtwomen USAHCM
- Age risk ItalyARVD
- geographical diff. GermanyMyocarditis
-
ChinaMarfan -
- Silent cardiovascular abnormalities
- Such deaths among athletes are unexpected,
dramatic, and often elicit community calls for
preventive measures - Beta blockers in sport is limitted
- Defibrilator is nessesary
20 goal
- early identification of structural cardiac
disease associated with sudden death - reduction of the risk of disease progression
associated with athletic training and
competition.
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22Etiologies of sudden unexplained cardiac death in
children and adolescents.
Structural and Functional Abnormalities Primary Electrical Abnormalities Acquired Lesions Congenital Heart Disease
HCM LQTS Commotio cordis Aortic valve stenosis
ARVD Brugada syndrome Drug abuse Postoperative congenital heart disease
Coronary artery abnormalities Wolff-Parkinson-White syndrome Atherosclerotic coronary artery disease Coarctation of the aorta
Primary pulmonary hypertension Ventricular tachycardia/fibrillation
Myocarditis Heart block
Dilated cardiomyopathy
Marfan syndrome with aortic dissection
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26Recommendations and guidelines
- The American Heart Association(AHA)
- the Bethesda Conference
- the Italian Guidelines (COCIS)
- European Society of Cardiology(ESC)
- International Olympic Committee(IOC)
27the Bethesda Conference
28AHA Cardiovascular PPE Recommendations
- 1st yr at institution/high school
- - Comprehensive personal and family history
- - physical examination by qualified examiner
- - CV PPE every 2 years after initial screening
- - During intervening years history )
- Rewritten in 1998 for collegiate athletes
- Each year after initial CV PPE
- - history
- - blood pressure measurement
29PPE Cardiovascular tests
- The AHA states it is not necessary to recommend
the use of highly expensive cardiovascular
disease tests such as electrocardiography,
echocardiography or graded exercise testing - HOWEVER, they do not discourage the use of these
tests
30Personnel of CV PPE
- Recommended by AHA
- healthcare worker with medical background to
reliably obtain a CV history, perform a physical
exam and recognize cardiovascular disease. - preferably a licensed physician
- Non-physician healthcare workers must establish a
formal certification in cardiovascular
examinations
31The American Heart Association(AHA) and
European Society of Cardiology recommendations
Family and Personal History
 1. Premature sudden cardiac death
 2. Heart disease in surviving relatives less than 50 years old
 3. Heart murmur
 4. Systemic hypertension
 5. Fatigue
 6. Syncope/near-syncope
 7. Excessive/unexplained exertional dyspnea
 8. Exertional chest pain
Physical Examination
 9. Heart murmur (supine/standing )
10. Femoral arterial pulses (to exclude coarctation of aorta)
11. Stigmata of Marfan syndrome
12. Brachial blood pressure measurement (sitting)
32Stigmata of Marfan syndrome
- Kyphosis
- High arched palate
- Pectus excavatum
- Arachnodactyly
- Arm span gt height 1.051 or greater
- Mitral Valve Prolapse
- Aortic Insufficiency
- Myopia
- Lenticular dislocation
33the Italian Guidelines (COCIS)
- 12-lead electrocardiogram (ECG)
- history
- physical examination
34 investigations
-
- ECG
- echocardiography
- cardiac magnetic resonance imaging (CMR)
- exercise testing
- ambulatory Holter ECG recording
- implanted loop recorder tilt table examination
- electrophysiologic testing with programmed
stimulation - Diagnostic myocardial biopsy
- genetic testing
35CV PPE
-
- ECG
- ECG alterations in elite athletes are mostly T
wave changes, ST segment elevation, and increases
in R and/or S wave voltage - showing ECG abnormalities strongly suggestive of
HCM, with diffuse symmetric and pronounced T wave
inversion, associated with increased R or S wave
voltages or deep Q wave - A few others showed ECG patterns suggestive of
ARVC with T wave inversion in V1 to V3 (or V4 - sensitivity 50, positive predictive value 7
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37- Echocardiography
- HCM
- asymmetric left ventricular (LV) wall thickenin
- a maximal LV end-diastolic wall thickness of 15
mm or more (or on occasion, 13 or 14 mm) - valvular heart disease (e.g., mitral valve
prolapse and aortic valve stenosis) - aortic root dilatation
- mitral valve prolapse in Marfan or related
syndromes - LV dysfunction and/or enlargement (evident in
myocarditis and dilated cardiomyopathy)
38- some important diseases may escape detection
despite expert screening methodology. For
example, the HCM phenotype may not be evident
when echocardiography is performed in the
pre-hypertrophic phase (i.e., a patient less than
14 years of age) - Annual serial echocardiography is recommended
in HCM family members throughout adolescence
39Athletes with Cardiovascular conditions
- referred to a cardiovascular specialist for
further evaluation and/or confirmation - refer to 36th Bethesda Conference guidelines
- Written in 2005 by American College of Cardiology
- Recommendations for determining eligibility for
competition in athletes with cardiovascular
abnormalities - (Maron, 2005)
40Judgment of Participation
- The American Academy of Pediatrics states
- Along with specialist and Bethesda
guidelines, should consider - risks of participation
- the advice of knowledgeable experts
- current health status
- the level of competition, position and sport
- availability of effective protective equipment
- sport can be modified?
- ability of the athlete and parents to understand
and accept risks involved in participation
41Judgment of Participation
- How strenuous the sport is, is another factor
that should be considered for athletes with
cardiovascular problems - A strenuous sport places many demands on the
cardiovascular system
42CARDIAC
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46Exercise Stress Test
- High Risk Individual
- Generally no indication for individual planning
mild to moderate exercise
47BRUCE PROTOCOL
- Stage 1 0-3 min 1.7 mph 10 grade 5.0 Mets
- Stage 2 3-6 min 2.5 mph 12 grade 6.8 Mets
- Stage 3 6-9 min 3.4 mph 14 grade 9.4 Mets
- Stage 4 9-12 min 4.2 mph 16 grade 13.3 Mets
- Stage 5 12-15 min 5.0mph 18 grade 16.6 Mets
- Stage 6 15-18 min 5.5 mph 20 grade 19.5 Mets
- Stage 7 18-21 min 6.0 mph 22 grade 22.7 Mets
486 Minute Walk Test
- purpose This test measures aerobic fitness
- equipment required measuring tape to mark out
the track distances, stopwatch, chairs positioned
for resting. - procedure The walking course is laid out in a 50
yard (45.72m) rectangular area (dimensions 45 x 5
yards), with cones placed at regular intervals to
indicate distance walked. The aim of this test is
to walk as quickly as possible for six minutes to
cover as much ground as possible. Subjects are
set their own pace (a preliminary trail is useful
to practice pacing), and are able to stop for a
rest if they desire.
496 Minute Walk Test
- purpose This test measures aerobic fitness
50Athletic Heart Syndrome
- Normal Adaptations to Exercise
51Athletic Heart Syndrome
- Endurance training
- Increased left ventricular chamber size
52Athletic Heart Syndrome
- Strength training
- Increased left ventricular mass
53Athletic Heart Syndrome
54Athletic Heart Syndrome
- Why is there bradycardia?
- Heart is more efficient with each beat
- Greater muscle mass, greater chamber size
- More blood pumped per beat
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57The American Heart Association(AHA) and
European Society of Cardiology recommendations
Family and Personal History
 1. Premature sudden cardiac death
 2. Heart disease in surviving relatives less than 50 years old
 3. Heart murmur
 4. Systemic hypertension
 5. Fatigue
 6. Syncope/near-syncope
 7. Excessive/unexplained exertional dyspnea
 8. Exertional chest pain
Physical Examination
 9. Heart murmur (supine/standing )
10. Femoral arterial pulses (to exclude coarctation of aorta)
11. Stigmata of Marfan syndrome
12. Brachial blood pressure measurement (sitting)
58PULMONARY
- Exercise-induced asthma
- Participation is allowed for all sports if
the asthma is under control. Only athletes with
severe asthma will need restrictions on activity - primary spontaneous pneumothorax
59ABDOMEN
- Organomegaly
- An acutely enlarged liver or spleen is a
contraindication to collision/contact or
limited-contact sports - Infectious mononucleosis can cause acute
splenomegaly(3 weeks) - young female athletes is the presence of a gravid
uterus.
60NEUROLOGIC
- past history of concussions
- second impact syndrome,
- History of a seizure disorder
- Burners/stingers or pinched nerves
- transient quadriplegia
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62MUSCULOSKELETAL
- In general, clearance is denied to an athlete
with a musculoskeletal injury who has - persistent effusion or edema
- loss of functional ability,strength that is
less than 85 to 90 of the unaffected side, - decreased range of motion
63- Spinal conditions that are cause for
disqualification include - symptomatic spondylolysis
- spondylolisthesis
- functional cervical spinal stenosis
- spear tacklers spine
- herniated discs with cord compression
64spear tacklers spine
- congenital narrowing of the canal the spinal cord
passes through (foramen magnum) - the second is injury to the spine due to trauma
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66RISK INCREASES WITH
- Congenital narrowing of the spine at the neck.
- Activities that have a high risk of trauma to the
neck. - Arthritis of the spine.
- High risk sports, such as football, rugby,
wrestling, hockey, auto racing, gymnastics,
diving, martial arts, or boxing. - Poor neck strength and flexibility.
- Previous neck injury.
- Poor tackling technique.
- Wearing poorly fitted or padded protective
equipment.
67DERMATOLOGIC
- herpes simplex, impetigo,boils, scabies, and
molluscum contagiosum. - When an athlete is contagious, participation
in sports that involve mats (such as wrestling,
gymnastics,and martial arts) as well as
contact/collision sports or limited-contact
sports should not be allowed
68GENITOURINARY
- single kidney
- be assessed on an individual basis
- flak jacket
- single testicle
- protective cup
- The athlete and parents must be informed of
the risks of injuryor loss to the remaining
testicle
69ROUTINE SCREENING TESTS
- Routine laboratory tests such as urinalysis or
complete blood count, are not recommended - the history or physical examination
- raises concerns, then further tests should be
- ordered
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74Thank you very much for your attention