1. Pre-Participation Exam Chronic Medical Conditions John Colston DO, MS Chief Resident Pikeville Medical Center Integrated Family Medicine/Neuromuscular Medicine Adapted from presentation by Jamie Varney, MD

2. Chronic medical conditions Identified through history Identified through physical exam Relevance depends on type of sport Some require more evaluation Some may require medications Some may limit or exclude them from sports

3. Most important slide Each athlete is an individual Each condition is unique Clinical judgment is absolutely necessary

4. Common medical conditions

5. Cardiovascular conditions Pericarditis/myocarditis Valvular anomalies Hypertension Other structural defects/disease Irregular rhythms Vascular disease

6. Adolescent Hypertension 1 Normal SBP and/or DBP < 90 th percentile Prehypertension SBP and/or DBP > 90 th percentile but <95 th percentile SBP > 120 or DBP > 80 Stage 1 Hypertension SBP and/or DBP > 95 th percentile to 5 mmHg above 99 th percentile Stage 2 Hypertension SBP and/or DBP > 99 th percentile + 5 mmHg

7. Hypertension Should be screened for in all athletes Ideally BP in both arms at rest with appropriate cuff size Remember normal values are different for adolescents Need three separate occasions with elevated BP to diagnose

8. Hypertension Systolic and/or diastolic ≥ 95 th percentile is associated with higher risk for sudden death and complex arrhythmias Not necessarily proven in younger population

9. Hypertension Evaluate for Comorbid disease Evaluate for presence of secondary HTN Review meds/ OTC/ supplements/ drugs caffeine/ETOH/tobacco that may cause HTN

10. Hypertension Work-Up 1 Renal Function Electrolytes CBC Renal US Glucose / Lipids EKG Echo Retinal exam

11. Secondary Hypertension 1 Suspect if : Age < 10 Stage 2 HTN Stage 1 HTN with systemic signs Acute rise in BP over baseline No family History

12. Secondary Hypertension 1 Some Causes Medication Renal Disease Renal Artery Stenosis Coarctation of Aorta Obstructive Sleep Apnea Endocrine Disease Thyroid Cushing’s Aldosteronism Pheochromocytoma

13. Hypertension Treatment Weight Loss/Exercise/ Decreased Sodium Diuretics and beta-blocker prohibited by some governing bodies Diuretic may increase fluid and electrolyte abnormalities Beta Blockers may increase fatigue and decrease exercise tolerance If treatment needed ACE-Inhibitors /ARB’s and Calcium channel blockers are usually first choice if not contraindicated

14. Hypertension and Exercise 2,3 Stage 2 HTN should not exercise until controlled Stage 1 HTN with end organ damage should also be treated prior to exercise Careful with strength training or any other high static sports BP > 95 th % will likely need a more complete evaluation BP >90 th % requires periodic monitoring

15. Respiratory diseases Asthma Cystic fibrosis Smoking

16. Asthma Airway obstruction Typically reversible Airway inflammation Airway hyper-responsiveness Allergens Chemical irritants Viral infections Cold air Exercise

17. Symptoms Wheezing Chest tightness Shortness of breath Cough Allergic rhinitis and urticaria occur frequently as comorbid conditions

18. Diagnosis Symptoms consistent with diagnosis Spirometry FEV1 < 80% FEV1/FVC < 65% Reversibility with short acting Beta agonist FEV1 improvement > 11%

19. Treatment Education Patient, family, coaches, teammates Environmental control Avoid allergens Medication Stepwise approach

20. Exercise Induced Bronchoconstriction (EIB) 6 Typically occurs after 5-10 minutes of strenuous activity Generally broncodilation during exercise Bronchoconstriction typically last 30-60 minutes Followed by refractory period (up to 4 hours)

21. EIB Prevalence 4 7-20% of general population 6 Up to 80% of those with asthma have EIB Up to 40% of those with allergic rhinitis have EIB

22. Diagnosis of EIB May give trial of treatment if mild/moderate If suspected may do exercise test Rested and avoid medications prior 6-8 minutes on treadmill 85 % predicted heart rate Spirometry before and after exercise 1,3,5,10 and 15 minutes post 4 Positive test FEV1 drops 20% (15% in children) 6 FEF 25-75 > 35% drop 4 Peak flow rate > 10% drop 4 May also try other provocation tests

23. Prevention of EIB Warming up 30-60 minutes prior May induce symptoms but then get refractory period Cooling down May decrease episodes Nasal breathing Covering mouth in cold weather

24. Treatment of EIB Assess for underlying asthma and treat appropriately If solely EIB then may try prophylactic short acting Beta agonist 10-15 minutes prior If frequent exercise through day may need long acting Beta agonist Mast cell stabilizers and leukotriene receptor antagonist may also be beneficial as adjuncts Inhaled steroid not as effective unless has underlying asthma/ inflammatory component If so must have 2-4 weeks treatment before notice difference Treat allergies if indicated

25. Endocrine diseases Diabetes Thyroid

26. Diabetes Fasting glucose > 126 on two occasion Random glucose > 200 and symptoms Fatigue, polyuria, polydipsia, polyphagia 2 hr post prandial glucose > 200 with tolerance test

27. Evaluation of Diabetic Athlete 5 Duration (? > 10 yrs) Level of Control HBA1C Hospitalization (DKA) Hypoglycemic episodes Medication (?Insulin) Sequelae Retinal exam Neurologic exam Skin condition Nephropathy (Serum creatinine, Urine protein) Consideration of risk for Coronary Artery Disease Identification ? Medic Alert bracelet

28. Activity Selection Should avoid activities in which hypoglycemia could be life threatening Scuba Parachuting Rock climbing Underlying CAD or untreated retinopathy should discuss lower intensity activity Avoid foot trauma if have neuropathy Consider cycling or water activity Proper shoes and frequent exams/lubrication Consider timing of activity as more prone to hypoglycemia in evening

29. Initiation of Activity Consideration of stress testing Known CAD or risk factors Age > 35-40 Duration of Diabetes > 10-25 years Gradual introduction of activity to allow for adjustment of meals/insulin Should keep detailed diet/medication/exercise diary to allow for adjustments

30. Meal Planning Meal should be eaten 1-3 hours prior to any training/event Pre-exercise snack high in complex carbs Prolonged exercise should include 30-40 grams of carbs (15-20 for children) every 30 -60 minutes Plan to replace carbs within 30-60 minutes of exercise Increase caloric intake for 12-24 hours post exercise Exercising in cold may require more calories Encourage adequate fluid intake

31. Glucose Monitoring Before, during and after prolonged exercise Perhaps > 6 times a day Late night or 3AM glucose may be necessary for prolonged exercise if not routine activity If glucose > 300 or > 250 with ketones should avoid activity May lead to ketosis May also increase risk of dehydration If glucose <100 should eat snack prior

32. Insulin Pump Allows more flexibility of training/meal time May turn off and remove 1 hour before event May then need monitoring and bolus during prolonged event Be aware of possibility of dislodgement Antiperspirant may decrease sweating

33. Hypoglycemia Headache Hunger Dizziness Sweating Tremors Alteration in consciousness Pre event rise in stress hormones can mask or mimic symptoms

34. Hypoglycemia Mild (50-70) with mild symptoms Fruit juice Oral glucose tablets Supplement with complex carbs and protein Severe (<40) with alteration in consciousness Don’t delay treatment to check glucose Glucagon 1 mg SubQ or IM Oral or IV glucose Nothing orally if compromised ability to protect airway

35. Diabetes Summary Exercise has many benefits for patients with diabetes Several high level athletes perform well with diabetes Individual planning/ adjustment by patient and physician is necessary to find right training/meal/medicine regimen Education about disease / control / symptoms are a vital part to any exercise program for diabetics Others should be educated in how to recognize symptoms of hypo/hyperglycemia and how to manage an emergency situation Steps should be made to ensure availability of emergency medicines Glucagon Glucose tablets

36. Neurologic conditions Cerebral palsy Seizure disorder Headaches

37. Seizure Disorder and Sports 4 Individual plan based on Control Low risk if no seizures after 1 year on meds or 2 years off meds Type Focal lower risk than generalized Medication effects Reaction time/sedation Precipitating factors Hyperventilation Risk of activity Cautious of contact activity

38. Seizure Disorder and Sports 4 Restrict from Boxing (regardless of control) Scuba Other high risk sports as needed Close supervision or restriction Swimming/diving Archery /riflery Weight or power lifting/ strength training Sports involving heights Gymnastics

39. High Risk Sports with Seizures Boxing Diving Scuba Parachuting Rock climbing Hang Gliding Aviation Downhill skiing Motor racing Ski Jumping Rodeo Cycling

40. Rheumatologic conditions Juvenile rheumatoid arthritis Lupus Raynaud phenomenon

41. Hematologic/ID conditions Sickle cell disease HIV Hepatitis Cancer Bleeding disorders

42. Female Athlete Triad Disordered eating Altered menstruation Abnormal bone mineralization

43. Psychiatric conditions Eating disorders Anxiety Depression ADD/ADHD

44. Acute illness Fever GI complaints – Nausea/vomiting – Diarrhea URI UTI Skin infections

45. References 1.Mattoo, T., UpToDate. Definition and diagnosis of hypertension in children and adolescents. 8-2007. 2.AMERICAN ACADEMY OF PEDIATRICS: Medical Conditions Affecting Sports Participation. PEDIATRICS Vol. 121 No. 4 April 2008, pp. 841-848. 3.36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Journal of the American College of Cardiology Vol. 45, No. 8, 2005. 4.Mellion, M. et al. Team Physician's Handbook 3 rd edition. Hanley & Belfus Inc. 2002. 5.Safran, M. et al. Manual of Sport’s Medicine. Ch. 5 Endocrinology. Lippincott-Raven. 1998. 6.O’Byrne, P. UpToDate. Exercise-induced Bronchoconstriction. 9-2007.