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The Pre-Participation Sports Examination General & Special Needs Populations Jeffrey A Zlotnick MD CAQ FAAFP Asst. Clinical Professor Family and Primary.

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Presentation on theme: "The Pre-Participation Sports Examination General & Special Needs Populations Jeffrey A Zlotnick MD CAQ FAAFP Asst. Clinical Professor Family and Primary."— Presentation transcript:

1 The Pre-Participation Sports Examination General & 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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

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

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

10 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 & AT’s are usually part of the team

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

12 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

13 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  Trainer or therapist  Physiologist  Trainer, coach, therapist, physiologist  Trainer, coach, physiologist

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

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

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

20 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Concussion?  Traumatic Brain Injury (concussion) –High School 5.5% of injuries –College %  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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Difficulty Breathing?  During or after activity?  Seasonal: allergies vs. asthma  Also could be cardiac –HCM –Valvular disease –Arrhythmia's

26 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Special Equipment/Braces?  Inspect for fit & function  Risk to other players?

27 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Problems with Eyes/Glasses?  Is athlete “single-eyed” –Less than 20/50 as best in one eye  Hx of orbital fractures

28 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Sprains/ Strains/ Fractures/ Dislocations?  Need to determine need for rehabilitation PRIOR to being allowed to participate

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

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

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

32 Key Components of the Physical Exam

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

35 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Cardiovascular  BP: Use correct size cuff!!  >110/70 for 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

36 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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: &string=concussion  Level of Evidence: B - A well-designed, nonrandomized clinical trial. A non- quantitative systematic review with appropriate search strategies and well-substantiated conclusions

38 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Other  Lungs: look for symmetry of movement, listen for wheezes/rubs  Abdomen: check for organomegaly, tenderness, rigidity  Skin: check for rashes. growths

39 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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:  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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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: 2 nd Edition 1997 The Physician and Sports Medicine, A Division of McGraw Hill Co. Minneapolis, MN (PDF files on NJAFP website)

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

43 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians MOST IMPORTANT PART!! Determining Clearance MOST IMPORTANT PART!! 1 Does the problem put the athlete at greater risk for injury? 2 Is the athlete a risk to other players? 3 Can the athlete safely participate with treatment, rehabilitation, medicine, bracing or padding? 4 Can limited participation be allowed? 5 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: 2 nd Edition 1997 The Physician and Sports Medicine A Division of McGraw Hill Co. Minneapolis, MN

45 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Contact Non-Contact

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

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

48 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians MVP with:  PMHx of syncope  Chest pain/tightness increased w/ activity  FHx of sudden death  Moderate to Severe regurgitation REASSESS!! HIGH RISK!!

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

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

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

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

54 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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: 3502&ss=6&xl=999  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 Sports equipment; safety and traction for footwear; amusement rides; consumer products. West Conshohocken (PA): American Society for Testing and Materials; 2003.

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

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

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

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

61 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Traumatic Brain Injury Return 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

62 Neuropsych Testing  Standardized Assessment of Concussion Brain Injury Association of America 8201 Greensboro Drive Suite 611 McLean, VA /  Cost ??

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

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

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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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: athletes  International: athletes  1 st International Games were 1968 in Soldier Field, Chicago

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

68 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

69 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Winter Sports  Alpine Skiing  Cross-country skiing  Figure skating  Floor hockey  Speed skating

70 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)

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

72 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Pre-Participation Exam  Questionnaire: #1 tool –Done initially & yearly –Coaches must have an updated & reviewed questionnaire at ALL competitions – % 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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

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

80 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Spinal Cord Injured Athletes  Predisposed to injuries 2 0 to wheelchair use  Loss of motor & sensory function below the level of the injury  Lack of autonomic function –Thermoregulation –Autonomic dysreflexia

81 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Thermal Regulation  Seen 1 0 ly 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Thermal Regulation Body core temps that go to either extreme in hot & cold environments  Hypo but 1 0 ly extreme Hyperthermia  Need to be aware of: –Clumsiness / Erratic wheelchair control –Headache –Confusion or other mental status change –Dizziness –Nausea / vomiting

83 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Wheelchair Athletes  Usually other significant medical problems  1 0 ly 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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”)

88 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Problems  Overgrowth of stump is common  Skin breakdown common in sports due to friction & pressure  Alteration center of gravity >> Problems with balance (1 0 ly lower limb amputees)  Hyperextension of knee & lumbar spine  Early detection is key 2 0 decreased sensation in limb  Athletes may compete using prostheses but no other assistive device

90 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Visual Impairment  Partial sight to total blindness  Legal blindness: acuity < 20/200, visual field < 20 0  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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Hearing Impairment  Tend not to consider themselves disabled –“Subculture” of society  Variations: –Mild: threshold dB –Profound: threshold > 90 dB  Behavioral disorders 2 0 communication challenges  No related physical disabilities except due to lack of experience with certain activities

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

93 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Insulin Dependant Diabetes  Need to monitor glucose: –30 min before activity –Immediately before activity –Every min during activity  Ideal pre-exercise range is mg/dl –> 200 mg/dl: Postpone & take extra insulin to get glucose levels down 1 st –Exercise with elevated glucose will cause levels to RISE further which can lead to increased diuresis, dehydration, and keto-acidosis

94 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!!)

95 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Complications  Autonomic dysfunction –Avoid power lifting 2 0 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

96 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians  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 Special Concerns

97 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Special Concerns  Podiatric problems: difficulty finding good athletic shoes that fit –Pes planus  Toenail fungus  Tinea & groin abscesses  Orthostatic hypotension

98 Healthy Athletes Initiative MedFest NJ Academy of Family Physicians & Special Olympics NJ

99 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians 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 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Some Pictures From MedFest 1: Before We Start…

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

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

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

104 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Heart & Lung

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

106 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Ear, Nose & Throat

107 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Check out!

108 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Thank you!!

109 Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Contact Information Jeffrey A. Zlotnick, MD, CAQ, FAAFP New Jersey Academy of Family Physicians 224 West State St The Lutine House Trenton, NJ Phone: Fax: Exec. Director: Ray Saputelli, CAE - Deputy Exec. Director: Theresa J Barrett, MS CMP - Office Manager: Candida Taylor –


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