PREPARTICIPATION PHYSICALKATHY HALCOMB, EDD, APRN, FNP

DR. ALYCIA WALTY, MD

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OBJECTIVES▪ Review the goals and objectives of the pre-participation

evaluation.

▪ Discuss the necessary questions and physical assessment that should be included in the pre-participation examination.

▪ Describe criteria for clearing, restricting or not clearing a child for participation.

GOALS AND OBJECTIVES OF THE PRE-PARTICIPATION PHYSICAL

▪ Primary▪ Screen for conditions that may be life threatening or disabling▪ Screen for conditions that may predispose to injury or illness

▪ Secondary▪ Determine the general health▪ Serve as an entry point to the health care system▪ Provide an opportunity to initiate discussion on health related

topics

RISKS RELATED TO SPORTS PARTICIPATION

▪ Death▪ Rarely does participation in sport activities cause death▪ Sports related deaths most commonly are related to:

▪ head trauma▪ cardiac arrest▪ heat stroke

▪ Injuries▪ Over 7,000 children aged 0-19 were seen in ERs for sports and

recreational-related injuries per day in 2009▪ Many times these injuries are predictable and preventable

(CDC : National action planhttp://www.cdc.gov/safechild/NAP/overviews/sports.html)

INJURIES AND ATHLETIC ACTIVITIES

▪ Fractures

▪ Sprains

▪ Strain

▪ Overuse

ADVANTAGES OF SPORTS PARTICIPATION

▪ Prevention of chronic disease▪ Cardiovascular▪ Hypertension▪ Cancer▪ Obesity▪ Osteoporosis▪ Depression

▪ Mental health

▪ Promotion healthy lifestyle

CLASSIFICATION OF SPORTS

http://academicdepartments.musc.edu/surgery/divisions/pediatric/Classification_of_Sports_by_Contact.pdf

Date of download: 3/19/2014

Copyright © The American College of Cardiology. All rights reserved.

From: Task Force 8: Classification of sports

J Am Coll Cardiol. 2005;45(8):1364-1367. doi:10.1016/j.jacc.2005.02.015

Classification of sports. This classification is based on peak static and dynamic components achieved during competition. It should be noted, however, that higher values may be reached during training. The increasing dynamic component is defined in terms of the estimated percent of maximal oxygen uptake (MaxO2) achieved and results in an increasing cardiac output. The increasing static component is related to the estimated percent of maximal voluntary contraction (MVC) reached and results in an increasing blood pressure load. The lowest total cardiovascular demands (cardiac output and blood pressure) are shown in green and the highest in red. Blue, yellow, and orange depict low moderate, moderate, and high moderate total cardiovascular demands. *Danger of bodily collision. †Increased risk if syncope occurs.

Figure Legend:

TIMING AND FREQUENCY OF THE PPE

▪ Timing ▪ End of season or midsummer▪ 6 weeks prior to season

▪ Frequency▪ State by state mandate▪ School or organization directed▪ Included at least with yearly physical (AAP recommendation yrly physical from age 6-21 )

WHO CAN PREFORM THE PPE?

▪ MD/DO ▪ APRN▪ PA ▪ Chiropractor ▪ Athletic trainers

ETHICAL AND LEGAL CONCERNS

▪ HIPAA▪ Cleared or not cleared without medical information may

be shared with the coaches/school

▪ Sharing chronic medical conditions

▪ Ethical▪ Improper professional conduct▪ Restriction from participation

▪ Good Samaritan law and charitable immunity▪ The Volunteer Protection Act

THE HISTORY

▪ 76%-90% of diagnoses are based on medical history

▪ 88% of medical conditions and 67% of musculoskeletal conditions detected during the PPE

▪ ACCURATE INFORMATION is the key!!!!!

CARDIOVASCULAR PROBLEMS▪ The history

▪ Have you ever or nearly passed out DURING or AFTER exercise?▪ Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?▪ Does your heart ever race or skip beats (irregular beats) during exercise?▪ Have you ever been told that you have any heart problems (HTN, elevated lipids, heart murmur, heart

infection, Kawasaki disease)?▪ Ever have a test for your heart (ECG/EKG or echo)?▪ Do you get lightheaded or SOA more than expected during exercise?▪ Unexplained seizure?▪ Do you get more tired or SOB more quickly than your friends during exercise?▪ Has any family member or relative died of heart problems or unexpected or unexplained sudden death

before age 50?▪ Any family history heart problems?▪ Any family history of unexplained fainting, seizures or near drowning?▪ Any family history of Marfan’s, cardiomyopathy, dysrhythmias?

SUDDEN CARDIAC DEATH

▪ More common in males (ranges 5:1 to 9:1)

▪ >40% occurs in African-American males

▪ Occurs most frequently in basketball and football

STRUCTURAL/FUNCTIONAL/ELECTRICAL

▪ Hypertrophic cardiomyopathy

▪ Coronary artery anomalies

▪ Myocarditis

▪ Arrhythmogenic Right Ventricular Cardiomyopathy

▪ Aortic Rupture/Marfan Syndrome

▪ Aortic Stenosis

▪ Coronary Artery disease

▪ Ion Channel Disorders

HYPERTENSION

▪ Adults▪ Pre-hypertensive (120-139/80-89)▪ Hypertensive stage 1 (140-159/90-99)▪ Stage 2 (160/100 or greater)

▪ <18yrs of age▪ BP measurements in 90-95% of age, gender and height based norms

▪ Children▪ Work-up

▪ Glucose, creatinine, electrolytes, lipids, TSH, hematocrit, ECG, urinalysis▪ Those with stage 2 or any end target organ involvement may not be cleared until BP

evaluated, treated and controlled

CARDIAC PHYSICAL EXAMINATION

▪ Auscultation▪ Supine and standing

▪ Palpation femoral arteries▪ Delay pulse compared to radial

▪ Look for Marfan’s (Ghent criteria)

▪ BP in sitting position

CENTRAL NERVOUS SYSTEM

▪ Concussion history: ▪ Have you ever had a head injury or concussion?▪ Have you ever had a hit or blow to the head that caused confusion,

prolonged HA, or memory problems?

▪ Risk for:▪ Second impact syndrome▪ Postconcussion syndrome▪ Permanent neurological deficits

CONCUSSION HISTORY

History

▪ How many previous head injuries?

▪ How did occur?

▪ What symptoms?

▪ How long did each last?

▪ Was there retrograde or posttraumatic amnesia?

▪ How long they held from practice?

▪ Did they miss any competitions?

▪ Difficulties in class?

▪ What were their grades typically like?

▪ How long take to feel 100% normal?

▪ Are they any other dings/hits to head?

Exam

▪ Cranial nerve

▪ Speech

▪ Gait

▪ Rhomberg

▪ Pronator drift

▪ Mental status examination

▪ 3 word recall

▪ Nine months forward then backward

▪ Digit sequencing forward and backward

CENTRAL NERVOUS SYSTEM

▪ Headaches▪ Do you have headaches with exercise?

▪ Seizures▪ Do you have history of seizures?

▪ Stingers or burners▪ Have you had numbness, tingling, or weakness in your arms or legs

after being hit or falling?

▪ Cervical Cord Neuropraxia▪ Have you ever been unable to move your arms or legs after being

hit or falling?

ASTHMA

▪ History▪ Do you have asthma?

▪ Do you cough, wheeze, or have difficulty with breathing during or after exercise?

▪ Have you ever used an inhaler or taken asthma medication?

▪ Is there anyone in your family who has asthma?

RESPIRATORY ASSESSMENT

▪ Resting PFT not enough

▪ Pre and post beta-agonist with recreational activities

▪ Pre and post-exercise spirometry

GENERAL MEDICAL QUESTIONS

▪ Have you ever been denied or restricted participation in sports?

▪ Do you have any on going medical conditions?

▪ Have you ever spent the night in the hospital?

▪ Please list all medications and over the counter medications and supplements you are taking?

▪ Do you have any allergies?

▪ Have you ever had surgery?

▪ Where you born without or are you missing a ….(paired organ)?

MEDICAL CONDITIONS

▪ Diabetes- need glucose control▪ High risk activities

▪ Sickle-cell trait▪ Increase risk death strenuous activities, high heat and altitudes

▪ Blood borne pathogens▪ No restrictions

▪ Mononucleosis▪ Splenic rupture not likely after 21 day illness▪ Light activities 4th week▪ Full activity at week 5

▪ Obesity▪ Increased risk developing heat illnesses

EYE DISORDERS▪ History

▪ Have you had any problems with your eyes or vision?▪ Have you had any eye injuries?▪ Do you wear glasses or contact lens?▪ Do you wear protective eyewear such as goggles or a face shield?

▪ Exam▪ Vision acuity of 20/40 or better in at least one eye – good vision▪ If best corrected vision in one eye is less than 20/40 – must wear

protective eye goggles

▪ AAO recommendation for athletes who are functionally one-eyed must not participate in boxing, wrestling or full-contact martial arts

GASTROINTESTINAL

▪ Missing paired organ▪ Cleared- sport specific

▪ Malabsorption syndromes▪ Cleared sport specific

▪ Hernia▪ Not a limitation from participation

▪ Organomegaly▪ Chronic enlargement- sport specific

▪ Diarrhea▪ Unless mild- not cleared for participation

GENITALIA

▪ Tanner staging

▪ Missing testicle▪ Incidence injury to testicle low

▪ Protection

DERMATOLOGICAL

▪ History:▪ Do you have any rashes, pressure sores, or other skin problems?▪ Have you had a herpes or MRSA skin infection?

▪ Specific dermatological conditions:▪ Herpes gladiatorum▪ Tinea▪ Impetigo▪ Molluscum contagiosum▪ Warts▪ MRSA

MUSCULOSKELETAL▪ History:

▪ Have you ever had an injury to bone, muscle ligament or tendon that caused you to miss a practice or a game?

▪ Have you ever had broken bone or dislocated joint?▪ Have you ever had an injury that required x-ray, MRI or CT scan, injection therapy,

brace?▪ Have you ever had a stress fracture?▪ Have you ever been told that you have or have you had an x-ray for neck instability or

atlantoaxial instability? (Downs syndrome or Dwarfism)▪ Do you regularly use brace orthotics or other assistive device?▪ Do you have bone, muscle or joint injury that bothers you?▪ Do any of your joints become painful, swollen, feel warm or look red?▪ Do you have a history of juvenile arthritis or connective tissue disease?

MUSCULOSKELETAL EXAM

▪ ROM

▪ Gross muscle strength

▪ Muscle asymmetry

▪ Ligamentous laxity▪ Beighton Hypermobility Criteria

▪ Passive dorsiflexion of metacarpophalangeal joint beyond 90 degrees▪ Passive apposition of the thumb to the flexor aspect of the forearm▪ Hyperextension of the elbow beyond 10 degrees▪ Hyperextension of the knees beyond 10 degrees▪ Forward flexion of the trunk with knees fully extended so that the palms of the hands rest

flat on the floor

▪ Scoliosis

FEMALE ATHLETE

▪ Have you ever had injury to a bone, muscle, ligament or tendon that caused you to miss practice or a game?

▪ Have you had any broken bones or dislocation?

▪ Have you ever had a stress fracture ?

▪ Have you had a head injury?

▪ Do you worry about your weight?

▪ Are you trying to gain or lose weight?

▪ Are you on a special diet or do you avoid certain types of foods?

▪ Have you ever had an eating disorder?

▪ Have you ever had a menstrual period?

▪ How old were you when you had your first menstrual period?

▪ How many periods have you had in the past 12 months?

CONDITIONS FEMALE ATHLETES ARE AT HIGH RISK DEVELOPING▪ ACL

▪ Recurrent dislocation of the patella

▪ Patellofemoral pain syndrome

▪ Idiopathic scoliosis

▪ Concussion

▪ Distal forearm fractures

▪ Athlete triad

▪ Eating disorders

▪ Vitamin D deficiencies

CLEARANCE CONSIDERATIONS

▪ Cleared for all activities

▪ Cleared with recommendations

▪ Not cleared- clearance status to be reconsidered after completion of further evaluation, treatment or rehabilitation

▪ Not cleared for certain types of sports or from any sports

▪ <2% of individuals are restricted from participation

IMPLICATIONS OF NOT CLEARING

▪ Psychological

▪ Physical

▪ Legal

ABSOLUTE CONTRAINDICATIONS FOR PARTICIPATION

▪ Carditis

▪ Fever

HEALTH PROMOTION: IMMUNIZATIONS

HEALTH PROMOTION: ANTICIPATORY GUIDANCE

▪ Stress, depression and feeling safe

▪ Tobacco use

▪ Alcohol

▪ Anabolic steroids

▪ Supplements

▪ Acute illness