1. The Preparticipation Physical Exam James McKinley MD UTHCT Family Medicine Residency Program

2. Overview Introduction Goals and objectives The Exam itself Sudden death in athletes Clearance

3. PPE Monograph McGraw-Hill Healthcare Information 1-800-262-4729 http://books.mcgr aw-hill.com/cgi- bin/pbg/00714463 62

4. Introduction Purpose of PPE is to facilitate and encourage safe participation, not disqualify athletes..3-1.3% of athletes are denied participation 1-8. 3.2-13.9% require further evaluation 1-8.

5. Objectives Screen for conditions that may be life-threatening or disabling. Screen for conditions that may predispose to injury or illness (medical or musculoskeletal). Meet administrative requirements.

6. Remember “There is no solid evidence that a screening PPE will reliably identify important but clinically silent conditions (such as hypertrophic cardiomyopathy), yet the consensus panel feels that a comprehensive approach to the PPE uniformly applied seems to offer the best opportunity to meet this objective” 1. Until now.

7. University of Padua Study – JAMA 2006 22 Athletes and non-athletes 1979-2004, ages 12-35. Among athletes rate of sudden deaths fell by 89%. Rate among non-athletes did not change. Two important findings: –PPE is effective at recognizing unsuspected heart disease (first time). –Recognition reduces sudden cardiac deaths among athletes.

8. Padua Study-JAMA 2006 What it did not prove; –EKG’s are effective screening tool. The lowest annual death rate found in the study after screening was similar to the US rate among HS and college athletes between 1983-1993. The rate of sudden cardiac death before screening was higher than that of prior studies.

9. Secondary Objectives Determine general health. Serve as an entry point to the healthcare system for adolescents. –Less likely than any other age group. –5-10% have chronic condition requiring on going care. –CDC, SAM, AAP, AAFP, USPSTF all rec. annual routine health exam 9,10. Provide opportunity to initiate discussion on health-related topics.

10. The PPE Itself Frequency –Comprehensive PPE every 2 years in younger student athletes, every 2-3 years in older athletes. –Comprehensive PPE at entry into middle school, high school, or transfer to a new school. –Annual updates should include a comprehensive history, height, weight, blood pressure, problem-focused exam of concerns detected in history.

11. Reality Most states have their own requirements which we must follow. –UIL yearly exam.

12. Setting-Generally Two Scenarios The PCP’s office –Preferred, recommended More time, privacy, familiarity, ease of arranging referrals, more quiet. More cost, less available in smaller medical communities, some may not have PCP. Coordinated medical team exam

13. Coordinated Medical Team Waiting area: Sign-in, registration. Vitals station: Height, weight, vision, pulse, blood pressure. Office Exam: Hx review, exam performed by one physician per athlete. Specialty offices: Orthopedics, cardiology. Optional stages: P.T., Rehab, Education.

14. Screening Lab UA, CBC, chemistry profile, lipid profile, ferritin level, sickle cell trait, ECG, echocardiagram, exercise stress testing, spirometry. Not recommended. Screening test: Predictive value of test (influenced by prevalence), and ability to reduce morbity and mortality with the result.

15. Cardiac Screening Tests The Incidence of sudden cardiac death in athletes is 1:100,000 to 1:300,000 11,12. Felt by the PPE working group that a test would have to have extremely high sensitivity and specificity to merit the cost of nationwide implementation.

16. Cardiac Screening False positives from cardiac screening escalate costs. ECG and Echo studies yield mixed results. Better identification of high risk individuals when the tests are used for directed cardiac evaluation (a diagnostic test 13-19 ) rather than for screening.

17. Sudden Cardiac Death Most (95%) of sudden deaths in sports. Rare -.2-.5 per 100,000 adolescents/year. History – Exertional (during) syncope, chest pain, dyspnea, + fam. Hx sudden death. Physical Exam – Murmur: –Valsalva, standing – decreases venous return – increases murmur of HCM. –Squatting – increases venous return – decreases HCM murmur, increases flow or AS murmurs.

18. Hypertrophic Cardiomyopathy Reggie Lewis, Boston Celtics 1987- 1993, died during practice, 27 years old. Hank Gathers, University of Loyola- Marymount, died during a West Coast Conference college basketball game, died at age 23.

19. HCM Sudden death initial symptom 80%. Sx’s: Palpitations, syncope, chest pain, dyspnea on exertion P.E.: Murmur which increases with valsalva, decreases with squatting.

20. Congenital Coronary Artery Abnormalities Sudden death first sx 70%. Single right coronary artery. 40 years old. Anomalous origin or hypoplastic arteries.

21. Coronary Artery Disease Jim Fixx, author of the Complete Book of Running, 52 years old. Sergie Grinkov, Russian Olympic Skater, 28 years old. Daryl Kyle, Pitcher, St. Louis Cardinals, 33 years old. All suffered sudden death secondary to CAD>

22. Marfan’s Syndrome 2 of 4 major features –Family history –Cardiovascular abnormality –Musculoskeletal abnormality (arm span>height,kyphoscoliosis,ant. Thoracic deformity) –Ocular abn.-(ectopic lens,myopia) Flo Hyman, Captain US Olympic Volleyball, 1984. Died during a match, aortic dissection, Jan. 1986, age 32.

23. Sickle Cell Trait Usually benign. Strenuous exercise with high heat or altitude, sudden death can occur. –Hypoxemia – sickling of RBC’s, clogging coronary arteries, cardiac arrest. Precautions: avoid dehydration, gradual increase intensity of exercise (avoid max effort first day or two), cool clothes, caution in high temp/humidity/altitude. Stop exercise if cramping occurs!

24. Clearance Does the problem place the athlete at increased risk for injury or illness? Is another participant at risk for injury or illness because of the problem? Can the athlete safely participate with treatment (such as medication, rehab, bracing or padding)? Can limited participation be allowed while treatment is being completed? If clearance is denied only for certain sports or sport categories, in what activities can the athlete safely participate in?

25. Classifications 20 Sport by level of contact: –Contact or collision Football, basketball, hockey, boxing, soccer, rodeo. –limited contact: Baseball, cheerleading, field events, cycling, skating, skiing, gymnastics, volleyball, softball. –Noncontact: Bodybuilding, badminton, bowling, golf, track, swimming, field (throwing).

26. Classifications 20 Sports by strenuousness: –High to moderate dynamic and static demands: Boxing, wrestling, crew, cycling, football, rugby, hockey, sprints. –High to moderate dynamic and low static demands: Basketball, baseball, racquetball, soccer, swimming, tennis, volleyball. –High to moderate static and low dynamic demands: Field (throwing), gymnastics, martial arts, weight lifting, rodeo –Low dynamic and low static demands: Golf, Bowling, cricket, riflery

27. Determining Clearance Usually done case by case, must individualize. The PPE monograph contains a table of medical conditions and clearance suggestions (only 2 “no’s”). 36 th Bethesda Conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities, J Am Coll Cardiol 2005;45(8):1-64.

28. Success Stories John Kruk, testicular cancer found during PPE Successfully treated. Sportscaster now.

29. Success Stories Brett Butler, 16 years in majors. Throat cancer noted on PPE, 1996. Smokeless tobacco user. Motivational speaker, minor league coach.

30. Conclusion “The physician-athlete interaction associated with the PPE may serve as the foundation for a trusting relationship, help optimize the athlete’s long-term health, and, for many adolescent athletes, be their only contact with the healthcare system. Young athletes should know that the exam is in their best interest and will be conducted entirely confidentially 1 ”.

31. References 1 Preparticipation Physical Evaluation, third edition, 2005. The Physician and Sports Medicine, McGraw-Hill Healthcare. 2 Fuller CM: Cost effectiveness of screening of high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 2000:32(5) 887-890. 3 Klein JD, Slap GB, Elster AB, et al: Access to healthcare for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health 1992;13(2):162-170. 4 Carek PJ, Futrell M: Athletes’ view of the preparticipation physical examination. Arch Fam Med 1999;8(4):307-312. 5 Rosen DS, Elster A, Hedberg V, et al: Clinical preventive services for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health 1997;21(3):203-214. 6 Fuller CM, McNulty CM, Spring DA, et al: Prospective screening of 5615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 1997;29(9):1131-1138.

32. References 7 Lyznicki Jm, Nielsen NH: Cardiovascular screening of student athletes. Am Fam Physician 2000;62(4):765-774. 8 Koester MC, Amundson CL:Preparticipation screening of high school athletes: are recommendations enough? Phys Sportsmed 2003;31(8):35-38. 9 Medical evaluations, immunizations and records, in: NCAA Sports Medicine Handbook, ed 16. Indianapolis, National Collegiate Athletic Association, 2003, p 8. 10 United States Preventive Services Taskforce: The Guide to Medical Prevention Services, ed 2. Alexandria, Virginia, International Medical Publishing Inc, 1996. 11 MaronBJ, Shironi J, Poliac LC, et al: Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA 1996;276(3):199-204. 12 Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27(5):641-647.

33. References 13 Epstein SE, Maron BJ: Sudden death and the competitive athlete: perspectives on preparticipation screening studies. J Am Coll Cardiol 1986;7(1):220-230. 14 Feinstein RA, Colvin E, Oh MK: Echocardiographic screening as part of a preparticipation examination. Clin J Sport Med 1993;3(3):149-152. 15 Lewis JF, Maron BJ, Diggs JA, et al: Preparticipation echocardiographic screening for cardiovascular disease in a large, predominantly black population of collegiate athletes. Am J Cardiol 1989;64(16):1029-1033. 16 Maron BJ, Bodison SA, Wesley YE, et al: Results of screening a large group of competitive intercollegiate athletes for cardiovascular disease. J Am Coll Cardiol 1987;10(6):1214-1221. 17 Corrado D, Basso C, Schiavon M, et al: Screening for Hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339(6):364-369. 18 Maron BJ: Medical progress: Sudden death in young athletes. N Engl J Med 2003;349(11):1064-1075. 19 Glover DW, Maron BJ: Profile of preparticipation cardiovascular screening for high school athletes. JAMA 1998;279(22):1817-1819. 20 American Academy of Pediatrics Committee on Sports Medicine and Fitness: Medical conditions affecting sports participation. Pediatrics 2001;107(5):1205-1209.

34. References 21 36 th Bethesda Conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities, J Am Coll Cardiol 2005;45(8):1-64. 22 Corrado D, Basso C, Pavei A, et al, Trends in sudden cardiac death in young competitive athletes after implementation of a preparticipation screening program. JAMA Oct. 4,2006;296:1593-1601.