The PreParticipation Sports Examination General

1
The Pre-Participation Sports ExaminationGeneral
Special Needs Populations

• Jeffrey A Zlotnick MD CAQ FAAFP
• Asst. Clinical Professor Family and Primary Care
  Sports Medicine
• UMDNJ - Robert Wood Johnson Medical School
• UMDNJ - New Jersey Medical School
• Philadelphia College of Osteopathic Medicine
• Medical Consultant Healthy Athletes
  Initiative
• Special Olympics NJ
• NJ Academy of Family Physicians

2
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

3
Primary Objectives

• Detect conditions that may limit participation
• Atlanto-axial instability in Downs
• Heart murmurs Innocent vs. HCM
• Detect conditions that may lead to injury
• Lack of physical conditioning, weak muscles
• Poor exercise tolerance, heat intolerance
• High amount of major joint problems ex
• Miserable Misalignment Syndrome
• Meet legal and insurance requirements

4
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

5
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

6
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

7
Methods

• Private office by Primary Care Physician
• Multi-station exam with different providers of
  various types (physicians, nurses, PAs)
• Each type has its advantages and disadvantages
• In-school physical
• Currently not in NJ to get athletes to have a
  Medical Home. However, there are exceptions

8
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

9
Private Office Disadvantages

• Many athletes dont have a PCP
• Limited time for appointments Time consuming
• Varying levels of knowledge and interest in sport
  specific problems
• Must be well versed in Sports-specific demands
• Greater cost Many cant afford
• Higher income athletes will tend to go to
  different specialists for each problem found
• Tendency for poor communication between the PCP
  and the school athletic staff
• Many un-indicated disallowed athletes

10
Multi-Station Advantages

• Cost-effective and easy to screen large numbers
  of athletes
• Specialized personnel at each station
• Usually 5-6 stations
• Good communication with the school athletic staff
  since the Coach ATs are usually part of the
  team

11
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

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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

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Multi-Station Optional

• Station
• Specific orthopedic exam
• Flexibility
• Body composition
• Strength
• Speed, agility, power, endurance, balance

• Personnel
• Physician
• Trainer or therapist
• Physiologist
• Trainer, coach, therapist, physiologist
• Trainer, coach, physiologist

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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!!

15
Key Questions

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

16
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?

17
Taking any Rxs, OTCs, Drugs?

• History of Rxs important to assess control
• Diabetes, Asthma
• Does the athlete require any emergency drugs that
  the coach/AT will need to know about AND how to
  use them!!
• Get information on birth control measures,
  menstrual history
• Amenorrhea in women athletes can lead to a high
  risk of stress fractures (Female Athletic Triad)
• Good way to introduce talk on STDs

18
Taking any Rxs, OTCs, Drugs 2

• Get information on OTC use as athletes tend to
  abuse these
• OTC asthma, decongestants, diet pills can cause
  increased heart rate and arrhythmia's
• NSAIDs can cause increased bleeding
• Laxatives (wrestlers) can cause electrolyte
  abnormalities
• Try to get history of illicit drug use
• Alcohol, tobacco, marijuana, steroids

19
Allergies?

• Drugs
• Know what can and CANT be given in case of an
  emergency
• Bees, Insects - important in outdoor sports
• Need to carry an EpiPen?

20
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

21
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

22
ANY History of Recurrent burners/stingers, or
transient quadriplegia?

• NEED Cervical spine films BEFORE being allowed to
  participate!!

23
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

24
Heat or muscle cramps?

• History of dizziness or passing out during
  activities in the heat
• Determines ability to tolerate heat or prolonged
  events
• Marathons

25
Difficulty Breathing?

• During or after activity?
• Seasonal allergies vs. asthma
• Also could be cardiac
• HCM
• Valvular disease
• Arrhythmia's

26
Special Equipment/Braces?

• Inspect for fit function
• Risk to other players?

27
Problems with Eyes/Glasses?

• Is athlete single-eyed
• Less than 20/50 as best in one eye
• Hx of orbital fractures

28
Sprains/ Strains/ Fractures/ Dislocations?

• Need to determine need for rehabilitation PRIOR
  to being allowed to participate

29
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??

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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)

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Keep in mind

• 90 of sudden death in athletes lt30 y/o is
  cardiovascular
• Syncope or near-syncope may be a sign of
  underlying hypertrophic cardiomyopathy
• Chest pain may be atherosclerotic
• Dyspnea on exertion may be asthma, valvular
  disease, or coronary artery disease
• Palpitations may be arrhythmia, WPW

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Key Components of the Physical Exam
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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

34
Eyes

• Absence of 1 eye or vision gt20/50 in the best
  eye AVOID COLLISION SPORTS!
• Anisicoria slight/baseline is normal and should
  be noted (1-2mm)
• Large difference needs neurological workup first!

35
Cardiovascular

• BP Use correct size cuff!!
• gt110/70 for lt10 y/o or gt120/80 for gt10 y/o must
  be evaluated (Latest JNC guidelines)
• Check pulses Symmetrical femoral and radial
  pulse is a good screen for Coarctation of the
  aorta
• Murmurs deep inspiration, valsalva, squatting
• Innocent, Mitral valve prolapse, Hypertrophic
  cardiomyopathy, Aortic sclerosis
• Arrhythmia EKG to evaluate
• 24 hour monitor

36
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

37
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_id10281nbr 005397stringconcussion
• Level of Evidence B - A well-designed,
  nonrandomized clinical trial. A non-quantitative
  systematic review with appropriate search
  strategies and well-substantiated conclusions

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Other

• Lungs look for symmetry of movement, listen for
  wheezes/rubs
• Abdomen check for organomegaly, tenderness,
  rigidity
• Skin check for rashes. growths

39
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/ab0023
  07.html
• Strength of Evidence Twenty-four trials (518
  participants) conducted in 13 countries between
  1976 and 1998 were included. All drugs were
  effective at attenuating the exercise-induced
  bronchoconstriction response but to varying
  degrees even within the same individual. Compared
  to anti-cholinergic agents, mast cell stabilizers
  were somewhat more effective at attenuating
  bronchoconstriction

40
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?)

41
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
• Refer to Figures 1-10 (pgs 22-27)
• Pre-participation Physician Evaluation 2nd
  Edition 1997
• The Physician and Sports Medicine,
• A Division of McGraw Hill Co. Minneapolis, MN
• (PDF files on NJAFP website)

42
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

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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?

44
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 (Table 7)
• Pre-participation Physician Evaluation 2nd
  Edition 1997
• The Physician and Sports Medicine
• A Division of McGraw Hill Co.
• Minneapolis, MN

45
Contact Non-Contact
46
Some Specifics
47
Acute Illness

• Individual assessment
• Generally accepted to limit activity during fever
• URIs and strenuous activity (re cycling) can
  cause significant impact on the immune system

48
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

49
MVP with

• PMHx of syncope
• Chest pain/tightness increased w/ activity
• FHx of sudden death
• Moderate to Severe regurgitation
• REASSESS!!
• HIGH RISK!!

50
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
• May participate in LOW intensity activities

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Cardiovascular Risks

• SCD per year in healthy patients
• 1 / 133,000 Men
• 1 / 769,000 Women
• AMI w/in 1 hour of exercise 2-10
• 2.1 10x higher than in sedentary patients
• SCD 6-164x greater than sedentary patients
• Recommend higher level of screening in high risk
  patients
• Circulation 2007 Exercise and Acute CV Events
  Placing Risks Into Perspective

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Who Should Be Screened?

• Low risk
• Men lt45 Women lt55
• Asymptomatic
• Meet no more than 1 risk factor
• Moderate risk
• Older than preceding
• 2 or more risk factors
• High risk
• Signs / symptoms of CVS, Pulmonary, Metabolic
  disease or family history of SCD

53
Visual Impairment

• Considered if singled-eyed or best vision in
  one eye gt20/50
• NO effective eye protection for
• Martial arts, Boxing, Wrestling gtgtgtgtDisallow!
• High risk
• Football, Baseball, Racquetball
• Eye guards exist but protection is limited

54
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_id4861nbr 3502ss6xl999
• Strength of Evidence Although the evidence for
  each recommendation is not specifically stated
  the evidence is drawn from reports from American
  National Standards Institute. Occupational and
  educational personal eye and face protection
  devices. Washington (DC) American National
  Standards Institute 2003 and American Society
  for Testing and Materials. Annual book of ASTM
  standards Vol 15.07. Sports equipment safety
  and traction for footwear amusement rides
  consumer products. West Conshohocken (PA)
  American Society for Testing and Materials 2003.
  

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Kidney/Renal

• Incidence of renal trauma is 5-25, but is mostly
  mild
• Solitary kidney
• Pelvic, Iliac, Multicystic, Hydronephrotic,
  Uteropelvic jct abns gtgtgt No Collision Sports!
• Normal position
• Counsel and sign consent
• Extra padding

56
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

57

• Hernia Only remove if symptomatic
• Gyn No restriction w/ single ovary
• Do look for menstrual irregularities
• Female athletic triad
• (Amenorrhea, anorexia, osteoporosis)
• Testicular Single may play all sports CUP!
• Undescended testes more serious
• Increased risk of Ca
• Sickle Cell
• Trait No restrictions altitudes lt4000 ft.
• Disease Very limited
• Even mild hypoxia can lead to sickling!!

58
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

59
Traumatic Brain Injury

• TBI classified by
• 1 Amnesia
• 2 Symptoms w/ activity and at rest
• Both physical and mental function
• 3 Loss of Consciousness
• NUMBER of events (damage is cumulative!)
• Neuropsych testing (pre-participation,
  post-injury)

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Traumatic Brain Injury

• Need to be aware of Post TBI Syndrome Second
  Impact Syndrome
• Pay close attention to subtle neuro signs and
  complaints of headache, poor concentration, dizzy
• Athlete must be symptom free w/ activity and at
  rest and back to baseline Neuropsych testing
  before being allowed to play
• Minor trauma can lead to rapid cerebral edema
• More common in younger / pre-adolescent athletes

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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

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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 ??

63
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

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65
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

66
Special Olympics

• Established early 1960s by Eunice Kennedy
  Shriver developed by the Joseph P Kennedy
  Foundation
• Mission To provide sports training
• competition for persons with mental
• retardation
• Winter summer events every 4 years
• Local, state, regional, national, international
• Local 300-600 athletes
• International 1500-6000 athletes
• 1st International Games were 1968 in Soldier
  Field, Chicago

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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

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Summer Sports

• Swimming diving
• Track field
• Basketball
• Bowling
• Cycling
• Equestrian
• Soccer

• Golf
• Gymnastics
• Powerlifting
• Roller skating
• Softball
• Tennis
• Volleyball

69
Winter Sports

• Alpine Skiing
• Cross-country skiing
• Figure skating
• Floor hockey
• Speed skating

70
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)

71
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 41
• Volunteers
• Support services
• Administration
• Physicians, nurses, PTs OTs, trainers
• Work directly with SO executive director

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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

73
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

74
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

75
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

76
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

77
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 gt 4.5 (5) mm are positive
• 17 of athletes w/ AAI
• Neurosurgical evaluation required before allowing
  any participation
• Reassessment every 3-5 years
• Unsure if indicated if initial evaluation normal

78
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

79
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 gt have no symptoms
• At this time screening is SO requirement

80
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

81
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

82
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

83
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

84
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)

85
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)

86
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

87
Cerebral Palsy

• Spasticity, athetosis, ataxia
• Progressively decreasing muscle/tendon
  flexibility strength gtgt Contractures
• Impaired hand-eye coordination
• Mental retardation
• Seizures
• Extreme risk for overuse injuries!
• 50 in wheelchairs
• Modification of events to accommodate
• Get inventive (Adaptive Sports Program)

88
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

89
Problems

• Overgrowth of stump is common
• Skin breakdown common in sports due to friction
  pressure
• Alteration center of gravity gtgt Problems with
  balance (10ly lower limb amputees)
• Hyperextension of knee lumbar spine
• Early detection is key 20 decreased sensation in
  limb
• Athletes may compete using prostheses but no
  other assistive device

90
Visual Impairment

• Partial sight to total blindness
• Legal blindness acuity lt 20/200, visual field lt
  200
• No related physical disabilities except due to
  lack of experience with certain activities
• Modifications to equipment, rules strategy may
  be required
• Tactile audio clues
• Tethers or guide wires
• Step stroke counting
• Guides

91
Hearing Impairment

• Tend not to consider themselves disabled
• Subculture of society
• Variations
• Mild threshold 27-40 dB
• Profound threshold gt 90 dB
• Behavioral disorders 20 communication challenges
• No related physical disabilities except due to
  lack of experience with certain activities

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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 gtgt Stabilizes neuromembranes
• Good control must be obtained prior to
  participation in activities
• Be prepared as with ALL athletes

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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
• gt 200 mg/dl Postpone take extra insulin to get
  glucose levels down 1st
• Exercise with elevated glucose will cause levels
  to RISE further which can lead to increased
  diuresis, dehydration, and keto-acidosis

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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
• lt 1hr water alone OK
• gt 1hr think Na replacement
• (Sport drinks remember they contain CHO!!)

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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 CHOs, glucagons
• Late onset hypoglycemia 6-28 hrs later
• Replace glycogen w/in 1 hr of activity
• Avoid activity near intermediate insulin peaks
• Use long-acting to avoid peaks
• Watch for Neuro-glypenic Syndrome

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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

97
Special Concerns

• Podiatric problems difficulty finding good
  athletic shoes that fit
• Pes planus
• Toenail fungus
• Tinea groin abscesses
• Orthostatic hypotension

98
Healthy Athletes InitiativeMedFest

• NJ Academy of Family Physicians
• Special Olympics NJ

99
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 2009 Over 500 athletes have been certified
  to participate that otherwise would have never
  had the opportunity

100
Some Pictures From MedFest 1Before We Start
101
Registration
102
Vitals
103
History Review
104
Heart Lung
105
Orthopedic
106
Ear, Nose Throat
107
Check out!
108
Thank you!!
109
Contact Information
Jeffrey A. Zlotnick, MD, CAQ, FAAFP New Jersey
Academy of Family Physicians 224 West State St
The Lutine House Trenton, NJ 08608 Phone
609-394-1711 Fax [phone] Email
Maddoc007_at_aol.com or Exec. Director Ray
Saputelli, CAE - ray_at_njafp.org Deputy Exec.
Director Theresa J Barrett, MS CMP -
theresa_at_njafp.org Office Manager Candida Taylor
candida_at_njafp.org