The pre participation sports examination general special needs populations
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The Pre-Participation Sports Examination General & Special Needs Populations. Jeffrey A Zlotnick MD CAQ FAAFP Family & Sports Medicine Coordinated Health Systems Allentown, Bethlehem, Lehighton PA Phillipsburg NJ Asst. Clinical Professor Family and Primary Care Sports Medicine

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The Pre-Participation Sports Examination General & Special Needs Populations

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The pre participation sports examination general special needs populations

The Pre-Participation Sports ExaminationGeneral & Special Needs Populations

Jeffrey A Zlotnick MD CAQ FAAFP

Family & Sports Medicine

Coordinated Health Systems

Allentown, Bethlehem, Lehighton PA Phillipsburg NJ

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


The pre participation exam

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

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


Primary objectives

Primary Objectives

  • Detect conditions that may limit participation

    • Atlanto-axial instability in Down’s

    • 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

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Secondary objectives

    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

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Timing

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Frequency

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Methods

    Methods

    • Private office by Primary Care Physician

    • Multi-station exam with different providers of various types (physicians, nurses, PA’s)

    • 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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Private office advantages

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Private office disadvantages

    Private Office Disadvantages

    • Many athletes don’t 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 can’t 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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Multi station advantages

    Multi-StationAdvantages

    • 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 & AT’s are usually part of the team

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Multi station disadvantages

    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

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    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, NP, PA

    Multi-Station Required

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Multi station optional

    Station

    Specific orthopedic exam

    Flexibility

    Body composition

    Strength

    Speed, agility, power, endurance, balance

    Personnel

    Physician, NP, PA, AT

    Trainer or therapist

    Physiologist

    Trainer, coach, therapist, physiologist

    Trainer, coach, physiologist

    Multi-Station Optional

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Medical history is key

    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!!

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Key questions

    Key Questions

    Need to be asked or put on a questionnaire that is reviewed


    Ever been treated in a hospital or had surgery

    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?

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Taking any rx s otc s drugs

    Taking any Rx’s, OTC’s, 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 STD’s

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Taking any rx s otc s drugs 2

    Taking any Rx’s, OTC’s, 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

      • NSAID’s 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

    Allergies?

    • Drugs

      • Know what 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 rashes

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    History of head injury loc seizure burners or stingers

    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

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Any history of recurrent burners stingers or transient quadriplegia

    ANY History of Recurrent burners/stingers, or transient quadriplegia?

    NEED Cervical spine films BEFORE being allowed to participate!!


    Concussion

    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

  • Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Heat or muscle cramps

    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

    Difficulty Breathing?

    • During or after activity?

    • Seasonal: allergies vs. asthma

    • Also could be cardiac

      • HCM

      • Valvular disease

      • Arrhythmia's

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Special equipment braces

    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

    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 dislocations

    Sprains/ Strains/ Fractures/ 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

    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??”

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Most important questions

    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)

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Keep in mind

    Keep in mind:

    • 90% of sudden death in athletes <30 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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Key components of the physical exam

    Key Components of the Physical Exam


    Height weight

    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


  • The pre participation sports examination general special needs populations

    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 workup first!

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Cardiovascular

    Cardiovascular

    • BP: Use correct size cuff!!

    • >110/70 for <10 y/o or >120/80* 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

      • Echo

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Neurological

    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


    Other

    Other

    • Lungs: look for symmetry of movement, listen for wheezes/rubs

    • Abdomen: check for organomegaly, tenderness, rigidity

    • Skin: check for rashes. growths

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Genito urinary

    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?)

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Musculo skeletal

    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


    Laboratory testing

    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 cell trait now “required”

    • Cardiovascular screening (EKG, Echo) under investigation for cost-effectiveness

    • Screen only those at risk or positive findings

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Screening mandated

    Screening Mandated

    • April 14, 2010

    • The Division I Legislative Council of the National Collegiate Athletic Association approved a new rule mandating that all athletes be tested for the sickle cell trait.

    • The rule, however, allows athletes to opt out of testing if they sign a waiver “releasing an institution from liability."

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Determining clearance most important part

    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?

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    The pre participation sports examination general special needs populations

    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


    Contact non contact

    Contact Non-Contact

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Some specifics

    Some Specifics

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Acute illness

    Acute Illness

    • Individual assessment

    • Generally accepted to limit activity during fever

    • URI’s and strenuous activity (re: cycling) can cause significant impact on the immune system

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Cardiovascular abnormalities

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Mvp with

    MVP with:

    • PMHx of syncope

    • Chest pain/tightness increased w/ activity

    • FHx of sudden death

    • Moderate to Severe regurgitation

      REASSESS!!

      HIGH RISK!!

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Hypertrophic cardiomyopathy hcm ihss

    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

    • Family Hx key!

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Incidence hcm

    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


    Non obstructive vs obstructive

    Non-Obstructive vs Obstructive

    • Non-obstructive variant of HCM is apical hypertrophic cardiomyopathy

      • Yamaguchi Syndrome or Hypertrophy

    • Obstructive variant historically known as Idiopathichypertrophic subaortic stenosis (IHSS) and Asymmetric septal hypertrophy (ASH)

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Symptoms hcm

    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


    Treatment

    Treatment

    • Limitation of extremely exertional activities

    • Beta blockers and Verapamil (calcium channel blocker)

      • Avoid diuretics

    • Sugical myomectomy

      • Removal portion of interventricular septum

      • Mortality of 1%

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Treatment1

    Treatment

    • Alcohol septal ablation

      • Alcohol ablation of the septal branches of LAD

      • Less invasive

    • Implantable cardiac defibrillator

    • Pacemaker

      • Induces asynchronous contraction of the left ventricle which reduces outflow obstruction

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Cardiovascular risks all causes

    Cardiovascular RisksALL Causes

    • SCD per year in healthy patients

      • 1 / 133,000 Men

      • 1 / 769,000 Women

    • AMI w/in 1 hour of exercise 2-10%

      • 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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Who should be screened

    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

    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


    Kidney renal

    Kidney/Renal

    • Incidence of renal trauma is 5-25%, but is mostly mild

    • Solitary kidney:

      • Pelvic, Iliac, Multicystic, Hydronephrotic, Uteropelvic jct abn’s >>> No Collision Sports!

      • Normal position:

        • Counsel and sign consent

        • Extra padding

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Hepato splenomegaly

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    The pre participation sports examination general special needs populations

    • 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

    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

    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 concussions1

    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


    Traumatic brain injury return to play np testing based

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Neuropsych testing

    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 ??


    Scat sideline concussion assessment tool

    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


    The pre participation sports examination general special needs populations

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Scat2

    SCAT2

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Impact univ of pittsburgh

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Cogstate sport

    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


    Chronic traumatic encephalopathy

    Chronic Traumatic Encephalopathy

    • 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

    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

    Treatment CTE

    • NONE!!!!!!!!

      • Treat symptoms

    • Prevention is currently the only available treatment option

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    The special needs population

    The Special Needs Population

    Special Olympics NJ

    NJ Academy of Family Physicians


    Special olympics

    Special Olympics

    • 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

    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

    Summer Sports

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Winter sports

    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)

    Prohibited Sports

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Organization of games

    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 ~ 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

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Common problems

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Complex problems

    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

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Atlanto axial instability1

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Atlanto axial instability2

    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 3-5 years

      • Unsure if indicated if initial evaluation normal

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Atlanto axial instability3

    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 instability4

    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 > have no symptoms

    • At this time screening is SO requirement

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Spinal cord injured athletes

    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

    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 regulation1

    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

    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

    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


    Treatment2

    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

    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

    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

    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

    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 impairment1

    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

    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

    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 athletes

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Insulin dependant diabetes

    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

      • > 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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Insulin adjustments

    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!!)


    Complications

    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


    Special concerns

    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

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Special concerns1

    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


    Healthy athletes initiative medfest

    Healthy Athletes InitiativeMedFest

    NJ Academy of Family Physicians

    &

    Special Olympics NJ


    Healthy athletes initiative

    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 2011: Over 600 athletes have been certified to participate that otherwise would have never had the opportunity

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Some pictures from medfest 1 before we start

    Some Pictures From MedFest 1:Before We Start…

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Registration

    Registration

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Vitals

    Vitals

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    History review

    History Review

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Heart lung

    Heart & Lung

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Orthopedic

    Orthopedic

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Ear nose throat

    Ear, Nose & Throat

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Check out

    Check out!

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


    Thank you

    Thank you!!

    Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


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