improving people’s lives through innovations in personalized health care the preparticipation...
TRANSCRIPT
Improving People’s Livesthrough innovations in personalized health care
The Preparticipation Physical Exam
Kelsey Logan, MD, MPH, FAAP, FACPOSU Sports Medicine
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I have nothing to disclose.
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Overview
Why do a PPE?
History components
Musculoskeletal exam
Medical exam Hot topics
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Published 2010
Collaboration between AAP, AAFP, ACSM, AMSSM, AOSSM, AOASM
Endorsed by AHA, NATA
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What’s it for?
PPE Objectives Screen for life-threatening or disabling conditions Screen for conditions that may predispose to injury or
illness
Get adolescents/young adults into the health care system
Determine general health
Discuss health and lifestyle issues
MEDICAL HOME!
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Other Goals
Fulfillment of legal and insurance requirements Establishing physician rapport with athletes Providing counseling to athletes Establishing a database and record-keeping systemArmsey et al, CJSM, 2004
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PPE Purpose
Most physicians think PPE is not meant to take place of yearly health maintenance exam by PCP Was never intended nor designed to replace regular
health maintenance exams
What do the athletes think? Most consider the PPE as an appropriate alternative
to full evaluation
Parents? Most perceive PPE as a complete medical evaluation
Greydanus et al., Med Sci Mon, 2004
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PPE Frequency
Varies
35 states require yearly exam – Ohio included
11 states require every other year exam
3 states require exam every year with interval questionnaire in non-exam years
Wingfield, CJSM, 2004
Recommended Every 2 years in younger athletes Every 2-3 years in older athletes Annual update: history questionnaire, focused exam if
needed
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Great Britain PPE’s not widely practiced Thought to be ineffective
Italy Aggressive approach Ages 12-35: annual medical clearance Detailed H&P, ECG, EST, PFT’s Echo required in professional soccer, boxing, cycling Physicians can be held accountable in criminal/civil
court for incorrect/missed diagnosis
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Who can/should perform the PPE?
Varies by state Ohio: MD, DO, DC (NP or PA with physician)
AAP recommends MD, DO having ultimate responsibility
Multiple consensus statements supporting MSSE 2000, AJSM 2000, MSSE 2001
Complete screen for problems potentially affecting participation or placing athlete at risk
Standardized forms help
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PPE Setting
The PCP has the advantage Allows for private discussion of sensitive topics Gives more time for patient education Allows for comprehensive ROS, more direct
questioning regarding family history Able to talk about psychosocial functioning/problems
? Disadvantage Knowledge of how any history/exam findings affect
the athlete in sport
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PPE Setting
If no PCP?
Station approach Can reduce costs for student-athletes Fosters line of communication between members of sports medicine team Allows participation from athletic trainers, team medical and orthopedic
staff, subspecialists Facilitates screening large number of athletes in relative efficiency
Optimize it! Physician medical coordinator – needs to sign off on all Get good history from parents Ensure privacy in exam areas; provide area for counseling Clear referral protocol to primary and subspecialty physicians Help athletes with needed follow-up Keep records
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Clearance
Clearance to play with no restrictions
Cleared to play following further evaluation, treatment, or rehabilitation
Not cleared to play certain types of sports Rare for athletes not to be cleared
1.9% of high school athletes ruled ineligible as result of the PPE Smith, Mayo Clin Proc, 1998
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Musculoskeletal abnormalities accounted for 43.4% of athletes not cleared
Cardiac abnormalities accounted for 18.9%
2 athletes with severe HTN
1 with syncope
6 with dizziness/near-syncope
1 after heart operation
None had family history of cardiac death
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Vision abnormalities accounted for largest population of Cleared with Follow-Up Recommended dispositions – 53.5%
Musculoskeletal problems accounted for 27.8%
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The Most Important Part of the PPE
History
Exam
History Wins!•88% of medical conditions identified by history alone•67% of musculoskeletal conditions identifiedChun, CJSM, 2006
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The History is the Cornerstone…is it reliable?
Athlete’s reliability should not be taken for granted
Inaccuracies may lead to unwarranted clearance
Carek, CJSM, 1999
Examined whether discrepancies exist between information given by parents and student athletes
Only 19.8% of histories were in complete agreement
Many discrepancies found in cardiovascular and musculoskeletal questions
Risser, Tex Med, 1995
Showed 33% HS athlete-parent agreement, 44% junior high
If station-based physicals used, encourage parental involvement in history form completion
In office-based physical, have parent present for review of medical history, family history
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History Components
Medical Recent/chronic problems Hospitalizations Surgical procedures Prescription/nonprescription medications Allergies or anaphylactic reactions to medications,
insects, foods, exercise
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History Components
Cardiac: family history, chest pain, (near) syncope
Skin: warts, fungus, blisters
Neurologic: HA, concussion, seizures
Heat Illness – heat cramps, dehydration, etc.
Use of Special Equipment
Asthma and seasonal allergies Prevalence of exercise-induced bronchospasm
10-35% of athletes Mick, Dimeff, CCJM, 2004
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History Components
Eyes Functionally one-eyed defined as having less than
20/40 corrected vision in one eye
Musculoskeletal system Sprains, strains, fractures, dislocations
Weight concerns
Psychosocial issues
Immunizations
Menstruation – screening for female athlete triad components oligo/amenorrhea, bony stress injury, disordered eating
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The Physical Exam
Important areas Blood pressure Vision screening Musculoskeletal screening Cardiovascular screening
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Orthopedic Screening
2-minute, 12 step EXAM:
Sensitivity: 50.8%
Specificity: 97.5% to identify orthopedic problems
HISTORY found to have 91.6% sensitivity
Gomez et al, AJDC, 1993
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The Musculoskeletal Exam/Issues
Take a history! Missed practice or games Do you wear a brace? Fracture (include stress fracture), dislocation History of imaging, injections, physical therapy
Exam If no previous injury or complaint, general screen
ROM, strength, muscle asymmetry Joint specific exam may be needed
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General Musculoskeletal Screen
General posture; symmetry
Neck range of motion
Resisted shoulder shrug and shoulder abduction
Shoulder range of motion
Elbow range of motion
Forearm/wrist range of motion
Clench fist, spread fingers
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Inspection of athlete from behind
Back flexion and extension
Duck walk
Heel, toe stance/walk
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Joint Specific Exams
Low yield in asymptomatic athletes without prior injury
Indicated by history and general screen findings
Think about what sports the athlete is doing and preparing to do – may help focus exams Ex: shoulder, elbow in baseball player
Symmetry
Range of motion of all joints
Stability of shoulders, elbows, knees, ankles
Further joint assessment if problem found
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Examples of Problems in Joint-Specific Exams
Spine: Scoliosis, pain on extension (think about spondylolysis)
Shoulder: decreased internal rotation, signs of rotator cuff impingement, multidirectional instability
Elbow: pain over medial elbow (apophysitis, UCL injury)
Hip: poor hamstring flexibility, pain on rotation, tenderness over apophyses
Knee: patellar malalignment, hypermobility
Foot: pes cavus, rigid flatfoot, severe pes planus
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Clearance Question
16 yo female sophomore soccer player, history of right ankle sprain in club soccer over summer
What things do you want to know? When did it happen? Prior injuries? Mechanism of injury? Time missed? Current symptoms? Use brace/tape?
Exam shows decreased balance right foot, mild laxity in ATFL; able to run forward, backward, laterally
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What do you do?
Is she cleared for soccer? Why?
Consider severity of injury, ability to compete safely
Consider demands of sport
Cleared
Cleared with
restrictions/recommendations
Not Cleared
Further advice?
Brace?
Rehab?
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Medical Exam
Follow up on history questions Ever been disqualified from sport?
1-2% of athletes ever DQ’d from sport Ever been hospitalized? Do you have any problems you see a doctor for? Put history in context of specific sport
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Hot Topics
Obesity Weight alone should not disqualify Want to get these kids moving!
66-78% more likely to be obese at age 35 if obese at age 18 NIH, 2000
MSK exam: focus on hips, knees Counsel on heat injury avoidance
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Supplements
Most athletes will not mention supplements on form Ask about ‘protein drinks’, recovery aids
Good intro for energy drink discussion Most athletes don’t know what the ingredients are Discuss potential side effects Some medications banned in sport
Many supplements tainted unknowingly: 15% may contain anabolic agents Geyer et al. Int
J Sports Med, 2004
NCAA banned drug list
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Sickle Cell Trait
Much press
NCAA: D1 testing mandatory, DII/III coming
No evidence screening prevents death
SCD: Avoid contact, collision sports, strenuous sports
Everyone should be asked about history of trait
Ask about history of heat illness
Appropriate counseling, individual clearance based on history
Deaths reported with strenuous activity with altitude or heat stress
Avoid exhaustive exercise while still acclimatizing
Avoid dehydration
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Concussion
History Personal history of concussion
53% by high school Field et al., J Ped, 2003
Many don’t recognize ‘concussion’
Length of recovery period, associated problems
Not just the number of injuries
Presence of chronic headaches, academic or learning issues
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Concussion Clearance
Never clear for contact sport if any symptoms present Ask about school, mood, sleep, headaches
When to DQ from sport? RARE (…Rare?) When a concussion does not resolve (PCS)
Physical, cognitive, emotional symptoms When concussions happen with less impact
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Cardiovascular Screening
Many questions on history section
75% of sudden death in athletes due to CV issues 80% of those in high school and college athletes Maron, Circulation, 2006
Higher occurrence in boys, African Americans
From Maron, JAMA, 1996
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Cardiovascular History
Should ask about
Chest pain
Syncope
Exercise tolerance
Palpitations
Heart murmur history
Elevated BP in past
Family history of cardiac problems
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CV Exam
Measure blood pressure
Listen for heart murmurs Supine, standing HCM murmur increases with standing, Valsalva
30-40% have murmur
Palpate radial and femoral pulses
Look for signs of Marfan syndrome Kyphoscoliosis, high palate, pectus, arm span greater
than height, etc.
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ECG, Echocardiogram
Very controversial AHA recommends against ECG, echo IOC, European Society of Cardiology, support
Italian experience Based on limited ability of History/PE to detect CV
abnormalities, adds 12 lead ECG Indicates 77% greater power for detecting HCM
compared with AHA recommendations Estimates 3x greater cost-effectiveness of Italian vs
US screening strategy for HCM Corrodo et al. European Heart Journal 2005
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Obstacles to Screening with ECG/Echo
Large population of athletes
Major cost-benefit considerations
Cannot eliminate risks of competitive sports
Large number of false positive/borderline results
False negatives where subtle but important lesions go undetected
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“Although we should continue our endeavors to identify better tests to detect athletes at risk, I think we would do the public a service to acknowledge that we simply cannot prevent the vast majority of sudden cardiac deaths that will affect (high school athletes). Giving the public an honest answer about the futility of our efforts in this regard may help lessen some of the anger and frustration over the tragedies that do occur.”Karl Fields, Medicine & Science in Sports & Exercise, 2002
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Summary
Station based PPE are efficient but may miss important psychosocial problems
History is extremely important (may be more so) than physical exam
Ideally, athlete should still go through office-based evaluation, even if station-based exam was done
Drive athletes toward health care Volunteer for sports physicals Get to know school teams, athletes Be involved in your community
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