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The Pre-Participation Sports Examination
General & Special Needs Populations
Jeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFPFamily & Sports Medicine
St. Luke’s University Health NetworkJim Thorpe, Bethlehem, PA
Assistant Clinical Professor Family and Primary Care Sports MedicineUMDNJ – Robert Wood Johnson Medical School
UMDNJ – New Jersey Medical SchoolPhiladelphia College of Osteopathic Medicine
Medical Consultant – “Healthy Athletes Initiative” Special Olympics NJ
NJ Academy of Family Physicians
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
The Pre-Participation Exam (PPE) Primary goal is to evaluate 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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Primary Objectives Detect conditions that may limit
participation– Atlanto-axial instability in Down Syndrome
– Heart murmurs: Innocent vs. Hypertrophic Cardiomyopathy (HCM)
Detect conditions that may lead to injury– Lack of physical conditioning, weak muscles
– Poor exercise tolerance, heat intolerance
– High number of major joint problems: “Miserable Misalignment Syndrome”
Meet legal and insurance requirements
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Secondary Objectives Assess athlete’s general health
– May be the ONLY opportunity you have to see this patient and discuss issues such as immunizations, substance abuse, and birth control
Counsel 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
(e.g., swimmers with weak pectoral muscles)
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Timing
Best if performed at a MINIMUM of SIX weeks before practice starts
Gives time to identify & correct problems noted on exam
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 most popular
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Methods
Private office by Primary Care Physician Multi-station exam with different providers
of various types (physicians, nurses, PAs) Each type of station has advantages and
disadvantages In-school physical
– Currently not required in NJ to get athletes to have a “Medical Home.” However, there are exceptions.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Private Office – Advantages
PCP knows the PMHx, the FHx, Immunizations Less likely to overlook problems Young athletes will be more willing to discuss
sensitive issues with a known person Easier and less embarrassing to do GU exam (if
indicated)
Less chance for abnormalities to be overlooked and not addressed
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Private Office – Disadvantages Many athletes do not 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 cannot afford– Higher income athletes will tend to go to different specialists for
each problem found
Tendency for poor communication between PCP and school athletic staff– Many un-indicated disallowed athletes
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Multi-Station – Advantages
Cost effective and easy to screen large numbers of athletes
Specialized personnel at each station– Usually 5 to 6 stations
Good communication with school athletic staff since the coach & athletic trainers are usually part of the team
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 levels of training of school
physicians
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Multi-Station – Requirements
Station Sign-in, Ht/Wt, vital
signs, vision History review,
physical (medical, orthopedic, & neurological) assessment/clearance
Personnel Coach, trainer, nurse,
volunteer Physician
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Multi-Station – Options
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
MEDICAL HISTORY IS KEY!
Statistics show that a good history will identify 63% to 74% of medical problems
Anecdotal information from the athlete agrees with the parents less than half of the time
Reference: Medicine & Science in Sports & Exercise. 1999;31(12): 1727.
Key Questions
The following questions need to be asked or put on a questionnaire that
is reviewed
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 passed to allow for healing and rehabilitation after surgery?
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Taking any Rx or OTC Drugs? History of Rx’s 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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Taking any Rx or OTC Drugs? Get information on use of OTC drugs
because athletes tend to abuse these:– OTC asthma, decongestants, & diet pills can
cause increased heart rate and arrhythmias– NSAIDs can cause increased bleeding– Laxatives (wrestlers) can cause electrolyte
abnormalities Try to get history of illicit drug use
– Alcohol, tobacco, marijuana, steroids
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Allergies?
Drugs– Know which drugs can and CAN’T be given in
case of an emergency Bees & insects – important in outdoor
sports– Need to carry an EpiPen®?
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Skin Problems or Rashes?
Mainly looking for herpes, scabies, lice, & molluscum contagiosum
Impetigo, herpes, and other conditions can be spread by mats, helmets, & towels
Acne and other atopic conditions can be exacerbated by clothing or equipment
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
History of Head Injury, LOC, Seizure, “Burners or Stingers?” History of seizure (epilepsy?) Loss of consciousness (LOC) & headache Hx
important to determine ability to resist Traumatic Brain Injury (TBI) & risk for Second Impact Syndrome
Burners/stingers are brachial plexus injuries– Usually resolve but are occasionally permanent
Cervical cord neuropraxia with transient quadriplegia is rare– Associated with cervical stenosis, congenital fusions,
cervical instability, disc problems
ANY History of Recurrent Burners/Stingers or Transient
Quadriplegia?
NEED cervical spine films BEFORE being allowed to
participate!
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Concussion? Concussion accounts for 6% to10% of all sport Concussion accounts for 6% to10% of all sport
related injuriesrelated injuries– Higher risk among high school athletes in contact sports (Langlois Higher risk among high school athletes in contact sports (Langlois
2006)2006)
1.6 to 3.8 million sports-related TBIs occur each 1.6 to 3.8 million sports-related TBIs occur each yearyear
TBIs can be cumulative– Cognitive function (“Punch Drunk”)– Memory– Ability to learn– Reaction time
Increased risk of Second Impact Syndrome – Primarily in younger (pre-adolescent) athletes
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Heat or Muscle Cramps?
History of dizziness or passing out during activities in the heat
Determines ability to tolerate heat or prolonged events– Marathons
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Difficulty Breathing?
During or after activity? Seasonal allergies vs. asthma Also could be cardiac
– HCM– Valvular disease– Arrhythmias
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Special Equipment/Braces?
Inspect for fit & function Risk to other players?
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Problems with Eyes/Glasses?
Is athlete “single-eyed”– Less than 20/50 as best in one eye
Hx of orbital fractures
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Sprains, Strains, Fractures, or Dislocations?
Need to determine need for rehabilitation PRIOR to being allowed to participate
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Other Questions Medical problem or injury since last
evaluation (periodic exam)? Immunizations up to date?
– Td, Hep B, MMR, Meningitis
Women: Date of first and last menses; longest time between menses?
Family use of tobacco, alcohol, street drugs?– How about yourself?
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 or heart murmur? Hx of heart racing/skipping beats? FHx of sudden death before age 50? Hx of concussion (Traumatic Brain Injury)
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Keep in Mind 90% of sudden death in athletes <30 y/o is
cardiovascular Reference: Spotlight on sudden cardiac death. Cardiovascular Research. 2001:50(2):173-176.
Syncope or near-syncope may be a sign of underlying hypertrophic cardiomyopathy
Chest pain may be atherosclerotic Dyspnea on exertion may be caused by
asthma, valvular disease, or coronary artery disease
Palpitations may be arrhythmia, WPW
Key Components of the Physical Exam
Height & Weight Compare to growth charts for age/sex
– Body fat: male 5% to 10%; female 12% to 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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Eyes
Absence of 1 eye or vision >20/50 in the best eye: AVOID COLLISION SPORTS!
Anisicoria: slight/baseline is normal and should be noted (1-2mm)
Large difference needs neurological work-up first
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Cardiovascular System BP: Use correct size cuff!
– >110/70 mmHg for <10 y/o or >120/80 mmHg* for >10 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
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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_id=10281&nbr=
005397&string=concussion Level of Evidence: B - A well-designed, nonrandomized clinical trial. A non-
quantitative systematic review with appropriate search strategies and well-substantiated conclusions.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Other
Lungs: look for symmetry of movement, listen for wheezes/rubs
Abdomen: check for organomegaly, tenderness, rigidity
Skin: check for rashes and growths
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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/ab002307.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.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
GenitourinaryMale: Hernia? Testes both descended? Single: should counsel about collision sports
Female: Pelvic exam not necessary part of basic exam Do w/ Hx of severe menstrual irregularities,
primary or secondary amenorrhea
Both: Maturity & development (self rating?)
Musculoskeletal
Need to assess major muscle groups and joints via a screening exam
Follow up closely on any abnormalities noted– Decreased ROM, function– Hyper-flexibility
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 Reference: Exercise-induced Proteinuria? The Journal of Family Practice. 2012;61(1):23-26.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Determining ClearanceMOST IMPORTANT PART!MOST IMPORTANT PART!1 Does the problem put the athlete at greater risk for
injury?2 Is the athlete a risk to other players?3 Can the athlete safely participate with treatment,
rehabilitation, medicine, bracing or padding?4 Can limited participation be allowed?5 If clearance is denied, are there other activities
that the athlete can safely participate in?
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Contact Non-Contact
Contact/ Collision
Limited Contact/ Collision
Strenuous Moderate Non- Strenuous
Boxing Field Hockey Football Ice Hockey Lacrosse Martial Arts Rodeo Soccer Wrestling
Baseball Basketball Bicycling Diving Field Sports Gymnastics Horseback Riding Skating Skiing (all) Softball Squash/Handball Volleyball
Aerobic Dance Crew Fencing Discus, Javelin, Shot put Running Track Swimming Tennis Weight lifting
Badminton Curling Table tennis
Archery Golf Riflery
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Some Specifics
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Acute Illness
Individual assessment Generally accepted to limit activity during
fever URIs and strenuous activity (e.g., cycling)
can cause significant impact on the immune system
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Cardiovascular Abnormalities
May Dispose to Sudden Death!May Dispose to Sudden Death! Mild hypertension: No restrictions Moderate to severe hypertension: need
assessment and possible treatment Benign functional murmurs: No restriction Mild mitral valve prolapse: No restriction
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
MVP with:
PMHx of syncope Chest pain/tightness increased w/ activity FHx of sudden death Moderate to severe regurgitation REASSESS! HIGH RISK!HIGH RISK!Reference: Recommendations for competitive sports participation in athletes with cardiovascular disease. European Heart
Journal. 2005;26(14):1422-1445.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 & Arrhythmias, both increased by activity
– PMHx of syncope or FHx of sudden death in a young relative
May participate in LOW intensity activities
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Symptoms HCM Most are ASYMPTOMATIC until Sudden
Cardiac Death (can be the 1st symptom) Symptoms with activity:
– Chest pain– Shortness of breath– Lightheadedness– Dizziness– Loss of consciousness
Children often do not show signs of HCM– After puberty
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Basketball Star's Sudden Death Brings Awareness of Deadly
Heart Disease
By Dan O'Donnell Story Created: Mar 7, 2011 Story Updated: Mar 8, 2011
MILWAUKEE - The shockwaves from high school basketball star Wes Leonard's sudden death last week have reverberated from Fennville, Mich. across the nation.An autopsy revealed that Leonard suffered cardiac arrest brought on by dilated caridomyopathy (DCM), a condition more commonly referred to as an "enlarged heart."
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Incidence HCM
0.2% to 0.5% of the general population– All types of HCM (obstructive vs non-
obstructive) Appears in all racial groups Sarcomeres (contractile elements) in the
heart replicate causing heart muscle cells to increase in size– Results in the thickening of the heart muscle
Typically an autosomal dominant trait– 50% chance of passing trait
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Cardiovascular RisksALL Causes SCD per year in healthy patients
– 1/133,000 Men– 1/769,000 Women
AMI w/in 1 hour of exercise 2% to 10%– 2.1 – 10x higher than in sedentary patients
SCD 6-164x greater than sedentary patients Recommend higher level of screening in
high risk patientsReference: Exercise & acute CV events placing the risks into perspective: a scientific statement from the
AHA Council on Nutrition, Physical Activity, & Metabolism and the Council on Clinical Cardiology. Circulation. 2007;115(17):2358-68.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Who Should Be Screened? Low risk:
Men <45 Women <55 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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Visual Impairment
Considered + if singled-eyed or best vision in one eye >20/50
NO effective eye protection for – Martial arts, boxing, wrestling >>>>Disallow!
High risk:– Football, baseball, racquetball
Eye guards exist but protection is limited
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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_id=4861&nbr=
3502&ss=6&xl=999 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.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Kidney/Renal Incidence of renal trauma is 5% to 25%, but
is mostly mild– Other injuries more common that renal
Solitary kidney:– Pelvic, iliac, multicystic, hydronephrotic,
uteropelvic jct abn’s >>> No Collision Sports!– Normal position:
Counsel and sign consent
Reference: Single kidney and sports participation: perception versus reality. Pediatrics. 2006;118(3): 1019-1027.
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Hepato/Splenomegaly
Liver: determine primary cause (e.g., mono)– OK to return once organ reduces size
Spleen: Acute splenomegaly associated with HIGH risk of rupture with minimal provocation!
Chronic splenomegaly: need to assess and treat individually
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 <4000 ft– Disease: Very limited
Even mild hypoxia can lead to sickling
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Traumatic Brain Injury(Concussions)
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)
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Traumatic Brain Injury(Concussions) 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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
October 29, 2010 Friday
"It was just a routine play. I don't think there was anything special," Orrick told the Miami County Republic after the game. "I think he just hit the ground pretty hard with his head. He came on the sideline and told one of my assistants, 'my head is really hurting.' He sat down on the bench. He then stood up, but his legs went underneath him and collapsed there."
NBC Action News also reports that Stiles was taking part in his first game since returning from a concussion suffered in early October. Stiles' father confirmed this to the Kansas City Star, noting that his son suffered a concussion during the homecoming game earlier in the month, but was cleared to play Thursday.
Reference: Al Spivak AOL News 10/30/2010
http://www.fanhouse.com/2010/10/30/nathan-stiles-kansas-high-school-football-player-dies-
after-in/
Nathan Stiles 17 y/o
Spring Hill HS, Kansas City
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Return to Play: NP testing based
Administer BEFORE starting any sports– Mainly contact sports
Studies demonstrate good correlation between reported symptoms and changes in neuropsych testing at 2 hours
However, correlation is lost at 48 hours to 2 weeks Most athletes returned to baseline in 2-4 weeks More accurate at aiding in determining return to
play than patients reports of symptoms Other more advanced computer-based
systems for determining return to play
Neuropsych Testing
Standardized Assessment of ConcussionBrain Injury Association of
America
8201 Greensboro Drive
Suite 611
McLean, VA 22102
703-761-0750 / 800-444-6443
Cost?
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
SCAT2
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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 professional level, some colleges
& high schools– Becoming more available for on field management
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
CogState Sport Also computer based system Requires a baseline
– Data submitted to secure online server After injury, athlete can be re-tested from
any web-connected computer & able to compare scores
CogState also does analysis on pre- and post- tests– Reports by Email
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Return to Play
Based on Zurich protocols published in Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008
Clinical Journal of Sport Medicine. 2009;19(3): 185-200.
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Chronic Traumatic Encephalopathy (CTE)
Found most commonly in athletes with multiple head “injuries”– Can be an accumulation of multiple small “hits” & not
all causing symptoms 73% of pro football players with CTE died in
middle age (mean 45 y/o) 64% of deaths have been from
– Suicide– Abnormal erratic behavior– Substance abuse
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Symptoms CTE
Cognitive changes (69%)– Memory loss/dementia
Personality/Behavioral changes (65%)– Aggressive/violent behavior– Confusion– Paranoia
Movement abnormalities (41%)– Parkinsons (Dementia pugilistica)– Gait/Speech problems
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Treatment CTE
NONE! Treat symptoms Prevention is currently the only available
treatment option
The Special Needs Population
Special Olympics NJ
NJ Academy of Family Physicians
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Special Olympics (SO) Established early 1960’s 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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Summer Sports
Swimming & diving Track & field Basketball Bowling Cycling Equestrian Soccer
Golf Gymnastics Powerlifting Roller skating Softball Tennis Volleyball
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Winter Sports
Alpine skiing Cross-country skiing Figure skating Floor hockey Speed skating
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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)
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Organization of Games Levels of participation
– Age, Sex, Ability– “Developmental” sports for those w/ severe limitations
Coaches– Special education teachers, athletic instructors, parents– Extensive knowledge of the physical & mental
characteristics of each athlete– Low ratio athlete/coaches ~ 4:1
Volunteers– Support services
Administration– Physicians, nurses, PT’s & OT’s, trainers– Work directly with SO executive director
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Pre-Participation Exam Questionnaire: #1 tool
– Done initially & yearly
– Coaches must have an updated & reviewed questionnaire at ALL competitions
– 44% to 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 approximately 29% problems
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 general population
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Atlanto-Axial Instability Up to 15% of athletes have 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
Reference: Participation by Individuals with Down Syndrome Who Have Atlantoaxial Instability. Special Olympics. www.specialolympics.org. Accessed 12/10/12. http://sports.specialolympics.org/specialo.org/Special_/English/Coach/Coaching/Basics_o/Down_Syn.htm
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Atlanto-Axial Instability Reports of athletes with Down syndrome
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, hyper-reflexia, clonus, sensory deficits, upper motor neuron signs
Asymptomatic AAI is of major concern– Highest risk between 5 to 10 years of age
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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 > 4.5 (5) mm are positive
– ~ 17% of athletes w/ AAI Neurosurgical evaluation required before
allowing any participation Reassessment every 3 to 5 years
– Unsure if indicated if initial evaluation normal
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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 patients w/ AAI 5mm or > have no
symptoms At this time screening is SO requirement
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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)
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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”)
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Cerebral Palsy Spasticity, athetosis, ataxia Progressively decreasing muscle/tendon
flexibility & strength >> 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”)
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Problems
Overgrowth of stump is common Skin breakdown common in sports due to
friction & pressure Alteration center of gravity >> 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
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Visual Impairment Partial sight to total blindness
– Legal blindness: acuity < 20/200, visual field < 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
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Hearing Impairment Tend not to consider themselves disabled
– “Subculture” of society Variations:
– Mild: threshold 27-40 dB– Profound: threshold > 90 dB
Behavioral disorders 20 communication challenges
No related physical disabilities except due to lack of experience with certain activities
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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 >> Stabilizes neuromembranes
Good control must be obtained prior to participation in activities
Be prepared as with ALL athletesReference: Howard GM, Radloff, M, Sevier TL. Epilepsy and sports participation. Current Sports Medical Reports.
2004 Feb;3(1):15-9.
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Insulin Dependent 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– > 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
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
– < 1hr: water alone OK
– > 1hr: think Na+ replacement (Sport drinks: remember they contain CHO!!)
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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 CHO’s, 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
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
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
Part of “Healthy Athlete’s Initiative” SOI
Special Concerns
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Special Concerns
Podiatric problems: difficulty finding good athletic shoes that fit
– Pes planus Toenail fungus Tinea & groin abscesses Orthostatic hypotension
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Special Concerns: Communication Disorders
Elective mutism
– Children usually 3-5
– Have the ability to speak +/- use language, but refuse to except under certain circumstances, or only to certain individuals
Hearing impairment
– Seen at young age with delayed or abnormal speech & language development
– Can be mild, moderate, severe & uni- or bilateral
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Autism Pervasive developmental disorder with significant
impairment in – Socialization
– Communication
– Sensory/motor development
7:10,000 births Associated with
– Mental retardation
– Seizure disorders
– Psychiatric disorders
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Approach to the patient
Approach slowly Speak in a slow clear voice Try to maintain eye contact
– Be aware too much may cause the patient to withdraw
Use hand gestures along with language Let the patient touch
– E.g., stethoscope, otoscope, splints, your hands Watch the patient & caretaker for clues
Healthy Athletes InitiativeMedFest
NJ Academy of Family Physicians
&
Special Olympics NJ
MedFest ProgramSONJ and NJAFP 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 2012: Almost 1000 athletes have been certified to participate that otherwise would have never had the opportunity
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Some Pictures From MedFest 1:Before We Start…
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Registration
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Vitals
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
History Review
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Heart & Lung
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Orthopedic
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Ear, Nose & Throat
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Check out!
Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians
Thank you!!
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Contact InformationJeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFPNew Jersey Academy of Family Physicians224 West State StreetTrenton, NJ 08608Phone: 609-394-1711 ~ Fax: 609-394-7712
MedFest Coordinator and NJAFP Office Manager: Dr. Zlotnick – [email protected] Candida Taylor – [email protected]
NJAFP Executive Vice President:Ray Saputelli, MBA, CAE – [email protected]
Deputy Executive Vice President:Theresa J. Barrett, MS, CAE – [email protected]