Colston y Gibbs. (1998). Analogy and Irony. Rebutal to 'Rebutal Analogy'.
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Pre-Participation ExamChronic Medical Conditions
John Colston DO, MSChief Resident
Pikeville Medical CenterIntegrated Family Medicine/Neuromuscular Medicine
Adapted from presentation by Jamie Varney, MD
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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
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Most important slide
• Each athlete is an individual• Each condition is unique• Clinical judgment is absolutely necessary
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Common medical conditions
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Cardiovascular conditions
• Pericarditis/myocarditis• Valvular anomalies• Hypertension• Other structural defects/disease• Irregular rhythms• Vascular disease
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Adolescent Hypertension1
• Normal • SBP and/or DBP < 90th percentile
• Prehypertension• SBP and/or DBP > 90th percentile but <95th percentile• SBP > 120 or DBP > 80
• Stage 1 Hypertension• SBP and/or DBP > 95th percentile to 5 mmHg above
99th percentile• Stage 2 Hypertension• SBP and/or DBP > 99th percentile + 5 mmHg
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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
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Hypertension
• Systolic and/or diastolic ≥ 95th percentile is associated with higher risk for sudden death and complex arrhythmias
• Not necessarily proven in younger population
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Hypertension
• Evaluate for Comorbid disease• Evaluate for presence of secondary HTN• Review meds/ OTC/ supplements/ drugs
caffeine/ETOH/tobacco that may cause HTN
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Hypertension Work-Up1
• Renal Function• Electrolytes• CBC• Renal US• Glucose / Lipids• EKG• Echo• Retinal exam
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Secondary Hypertension1
• Suspect if :• Age < 10• Stage 2 HTN• Stage 1 HTN with systemic signs• Acute rise in BP over baseline• No family History
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Secondary Hypertension1
•Some Causes• Medication• Renal Disease• Renal Artery Stenosis• Coarctation of Aorta• Obstructive Sleep Apnea• Endocrine Disease• Thyroid• Cushing’s• Aldosteronism
• Pheochromocytoma
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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
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Hypertension and Exercise2,3
• 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 > 95th % will likely need a more complete
evaluation• BP >90th % requires periodic monitoring
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Respiratory diseases
• Asthma• Cystic fibrosis• Smoking
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Asthma
Airway obstructionTypically reversible
Airway inflammationAirway hyper-responsiveness
AllergensChemical irritantsViral infectionsCold airExercise
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Symptoms
WheezingChest tightnessShortness of breathCoughAllergic rhinitis and urticaria occur frequently as
comorbid conditions
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Diagnosis
Symptoms consistent with diagnosisSpirometry• FEV1 < 80%• FEV1/FVC < 65%• Reversibility with short acting Beta agonist
FEV1 improvement > 11%
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Treatment
Education• Patient, family, coaches, teammates
Environmental control• Avoid allergens
Medication• Stepwise approach
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Exercise Induced Bronchoconstriction (EIB)6
Typically occurs after 5-10 minutes of strenuous activity
Generally broncodilation during exerciseBronchoconstriction typically last 30-60 minutesFollowed by refractory period (up to 4 hours)
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EIB Prevalence4
7-20% of general population6
Up to 80% of those with asthma have EIBUp to 40% of those with allergic rhinitis have EIB
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Diagnosis of EIBMay give trial of treatment if mild/moderateIf 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 post4
• Positive testFEV1 drops 20% (15% in children)6
FEF25-75 > 35% drop4
Peak flow rate > 10% drop4
May also try other provocation tests
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Prevention of EIB
Warming up• 30-60 minutes prior• May induce symptoms but then get refractory
period
Cooling down• May decrease episodes
Nasal breathingCovering mouth in cold weather
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Treatment of EIBAssess for underlying asthma and treat appropriatelyIf solely EIB then may try prophylactic short acting Beta
agonist 10-15 minutes priorIf frequent exercise through day may need long acting Beta
agonistMast cell stabilizers and leukotriene receptor antagonist may
also be beneficial as adjunctsInhaled 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
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Endocrine diseases
• Diabetes• Thyroid
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Diabetes
Fasting glucose > 126 on two occasionRandom glucose > 200 and symptoms
Fatigue, polyuria, polydipsia, polyphagia
2 hr post prandial glucose > 200 with tolerance test
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Evaluation of Diabetic Athlete5
• 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
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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
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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
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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
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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
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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
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Hypoglycemia
HeadacheHungerDizzinessSweatingTremorsAlteration in consciousnessPre event rise in stress hormones can mask or
mimic symptoms
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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
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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
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Neurologic conditions
• Cerebral palsy• Seizure disorder• Headaches
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Seizure Disorder and Sports4
• 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
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Seizure Disorder and Sports4
• 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
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High Risk Sports with Seizures
• Boxing• Diving• Scuba• Parachuting• Rock climbing• Hang Gliding
• Aviation• Downhill skiing• Motor racing• Ski Jumping• Rodeo• Cycling
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Rheumatologic conditions
• Juvenile rheumatoid arthritis• Lupus• Raynaud phenomenon
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Hematologic/ID conditions
• Sickle cell disease• HIV• Hepatitis• Cancer• Bleeding disorders
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Female Athlete Triad
• Disordered eating• Altered menstruation• Abnormal bone mineralization
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Psychiatric conditions
• Eating disorders• Anxiety• Depression• ADD/ADHD
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Acute illness
• Fever• GI complaints– Nausea/vomiting– Diarrhea
• URI• UTI• Skin infections
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References1. 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 3rd 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.