Transcript of The Pre-Participation Sports Examination Jeffrey A. Zlotnick, MD CAQ FAAFP DABFP Family & Sports...
- Slide 1
- The Pre-Participation Sports Examination Jeffrey A. Zlotnick,
MD CAQ FAAFP DABFP Family & Sports Medicine Asst. Clinical
Professor Family and Primary Care Sports Medicine Rutgers - Robert
Wood Johnson Medical School Rutgers - New Jersey Medical School
Philadelphia College of Osteopathic Medicine Medical Consultant
Healthy Athletes Initiative Special Olympics New Jersey New Jersey
Academy of Family Physicians
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- Jeffrey A. Zlotnick, MD CAQ New Jersey 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
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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
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- 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 pectoral muscles
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- 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
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- 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
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- 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, 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
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- 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
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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
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- 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 & ATs are usually part of the team
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- 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
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- 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
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- 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
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- 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! Anecdotally information from
the athlete agrees with the parents less than half of the time!
Medicine & Science in Sports & Exercise: Volume 31(12)
December 1999p 1727
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- Key Questions Need to be asked or put on a questionnaire that
is reviewed
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- 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?
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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, renal damage Laxatives (wrestlers) can cause
electrolyte abnormalities Try to get history of illicit drug use
Alcohol, tobacco, marijuana, steroids
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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?
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- 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
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- 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
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- ANY History of Recurrent burners/stingers, or transient
quadriplegia? NEED Cervical spine films BEFORE being allowed to
participate!
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Concussion? 1.6 to 3.8 million sports-related TBIs occur each year
Concussion accounts for 6-10% of all sport related injuries Higher
risk among high school athletes in contact sports Langlois, 2006
TBI can be cumulative Cognitive Function (Punch Drunk) Memory
Ability to learn Reaction time Increased risk of Second Impact
Syndrome Primarily younger (pre-adolescent) athletes
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- 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
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- 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
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Special Equipment/Braces? Inspect for fit & function Risk to
other players?
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- 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
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- 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
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- 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??
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- 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)
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Keep in mind: 90% of sudden death in athletes
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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
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- 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!
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Cardiovascular BP: Use correct size cuff!! The strongest risk
factor for primary hypertension in children is elevated body mass
index. The USPSTF found inadequate evidence on the diagnostic
accuracy of screening for primary hypertension. The USPSTF also
found inadequate evidence on the effectiveness of treatment and the
harms of screening or treatment.
http://www.uspreventiveservicestaskforce.org/ 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
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- 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
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- 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:
http://www.guideline.gov/summary/summary.aspx?doc_id=10281&nbr=
005397&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
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- 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
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- 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:
http://www.cochrane.org/reviews/en/ab002307.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
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- 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?)
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- 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
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- 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 Cardiovascular screening (EKG, Echo) under investigation
for cost-effectiveness Screen only those at risk or positive
findings Vol 61, No 1 | January 2012 | The Journal of Family
Practice
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- 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?
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- 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
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Contact Non-Contact
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Some Specifics
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
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
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- 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
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- 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! Oxford Journals Medicine European Heart Journal Volume 26,
Issue 14 Pp. 1422-1445 Oxford JournalsMedicineEuropean Heart
JournalVolume 26, Issue 14 Oxford JournalsMedicineEuropean Heart
JournalVolume 26, Issue 14
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- 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
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Symptoms HCM Most are ASYMPTOMATIC until Sudden Cardiac Death (can
be the 1 st symptom) Symptoms with activity: Chest pain Shortness
of breath Lightedness Dizziness Loss of consciousness Children
often do not show signs of HCM After puberty
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Basketball Star's Sudden Death Brings Awareness of Deadly Heart
Disease By Dan O'Donnell Story Created: Mar 7, 2011 Story Updated:
Mar 8, 2011 MILWAUKEE - The shockwaves from high school basketball
star Wes Leonard's sudden death last week have reverberated from
Fennville, Mich. across the nation. An autopsy revealed that
Leonard suffered cardiac arrest brought on by dilated
cardiomyopathy (DCM), a condition more commonly referred to as an
"enlarged heart."
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Incidence HCM 0.2% to 0.5% of the general population All types of
HCM (Obstructive vs Non- obstructive) Appears in all racial groups
Sarcomeres (contractile elements) in the heart replicate causing
heart muscle cells to increase in size Results in the thickening of
the heart muscle Typically an autosomal dominant trait 50% chance
of passing trait
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Veneto Italy Study Claim 89% reduction in SCD by screening ALL
athletes with ECG in the PPE Actual numbers: 84 of 12,880 (0.65%)
screened had any significant ECG abnormalities Study was done
between 1979-2001 11 of that 84 (0.09% of the 12,880) had
significant pathology US athlete population alone is ~15 million
New findings higher familial incidence of HCM in Veneto Italy
population Pediatrics in Review November 2006; 27:418-424;
doi:10.1542/pir.27-11-418 European Heart Journal (2011) 32, 983990
doi:10.1093/eurheartj/ehq428 Peliccia et al, N Eng J Med 2008
V358(2) pp152-61
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Cardiovascular Risks ALL Causes 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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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Who
Should Be Screened for SCD Low risk: Men
- 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
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- 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:
http://www.guideline.gov/summary/summary.aspx?doc_id=4861&nbr=
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 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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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Kidney/Renal Incidence of renal trauma is 5-25%, but is mostly mild
Other injuries more common that renal Solitary kidney: Pelvic,
Iliac, Multicystic, Hydronephrotic, Uteropelvic jct abns
>>> No Collision Sports! Normal position: Counsel and sign
consent Pediatrics Vol. 118 No. 3 September 1, 2006 pp. 1019
-1027
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- 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
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- 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: (more later) Trait: No restrictions altitudes
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- Hearing Impairment Tend not to consider themselves disabled
Subculture of society Variations: Mild: threshold 27-40 dB
Profound: threshold > 90 dB Behavioral disorders 2 0
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 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 > 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
- Slide 125
- 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
Lantus: as above Liberal hydration < 1hr: water alone OK >
1hr: think Na+ replacement (Sport drinks: remember they contain
CHO!!)
- Slide 126
- 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 CHOs, glucagon
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
- Slide 127
- Parental Concerns Some athletes non-verbal Cannot describe
problems Some will hide problems Not unlike other athletes Older
athletes may demonstrate adolescent behavior & significant
psychiatric problems Some have parents/caregivers in their 70s Some
problems may be related to parental & caregiver burn-out
- Slide 128
- 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 comfortable & willing to care for SO athletes
Parental Concerns
- Slide 129
- Coaches need to be made aware of what medical problems athletes
have and what medications they are on Side effects SO PPE form
needs to be revised to include major medical problems Currently
form does not include this
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- Parental Concerns Podiatric problems: difficulty finding good
athletic shoes that fit Pes planus Toenail fungus Tinea & groin
abscesses Orthostatic hypotension
- Slide 131
- Parents Biggest Concern The athlete is NOT seen in isolation,
but rather within the family network
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- Conclusion Be aware of special needs but remember that Common
problems are common! Take the usual precautions as outlined
Participation is critical for these athletes Self esteem Enhances
physical development Requires a multidisciplinary approach
Physicians, nurses, athletic trainers, coaches PTs & OTs Most
important: the Athlete
- Slide 133
- Some Pictures From MedFest 1: Before We Start
- Slide 134
- Registration
- Slide 135
- Vitals
- Slide 136
- History Review
- Slide 137
- Heart & Lung
- Slide 138
- Orthopedic
- Slide 139
- Questions? Jeffrey A. Zlotnick, MD, CAQ, FAAFP
Maddoc007@aol.com New Jersey Academy of Family Physicians
www.njafp.org 224 West State St., Trenton, NJ 08608 Phone:
609-394-1711 ~ Fax: 609-394-7712 or Exec. Vice President: Ray J.
Saputelli, MBA, CAE ray@njafp.org Deputy Exec. Vice President:
Theresa J Barrett, PhD, CMP, CAE theresa@njafp.org Office Manager
& Membership Services: Candida Taylor candida@njafp.org
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- Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Questions