the pre participation sports examination general special needs populations
Download
Skip this Video
Download Presentation
The Pre-Participation Sports Examination General & Special Needs Populations

Loading in 2 Seconds...

play fullscreen
1 / 117

The Pre-Participation Sports Examination General & Special Needs Populations - PowerPoint PPT Presentation


  • 87 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' The Pre-Participation Sports Examination General & Special Needs Populations' - orea


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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

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
slide34
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

slide43

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

slide60
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

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

ad