Transcript Pre-Participation Physical Examination

‫‪1‬‬
‫دکتر باقری مقدم‬
‫‪88/9/17‬‬
Pre-Participation Physical
Examination
A Principle Tool for Injury
Prevention
What is a PPE?
• A tool for injury prevention, used to gather medical
information about athletes to ensure that they are
ready to participate in sports
• The athlete’s initial exposure to the sport’s medicine
team
Principles Governing PPE
• Collects medical info about athlete to
ensure readiness to participate in a sport
• Design of PPE should allow assessment of
risk factors & detect any disease &/or
injury that might create problems
• Each question should be understandable
• Ensure instruments used are properly
calibrated
• Each instrument used in PPE should be
valid & reliable
Goals of PPE
(Kibler, 1990)
• Provide an objective, sport-specific
musculoskeletal exam
– Obtain (-) information that alters participation
– Obtain (+) information to decrease injury
potential & increase performance
• Provide a reproducible record for
comparison in the future
• Provide baseline data for sport-specific
conditioning
Timing & Frequency of PPE
• Timing
– Researchers say to perform PPE 4-8 weeks prior to start
of season
• Allows time to f/u on evals, rehab, etc.
– Some say at beginning of season
– Some say in the season prior to start (i.e. May/June for fall
sports)
• Frequency
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Beginning of each sport season
Beginning of each year
At new level of competition (high school)
Health history update each year
Personnel
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General practice physician
Orthopedist
Cardiologist
Athletic trainer
Exercise physiologist
Psychologist
School nurse
Strength coach
formats of the examination
• Mass screening
• locker room
• Individual exams
Components of PPE
HISTORY
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chronic medical illnesses,
surgical history
allergies
current medications
groups disagreed on questions related to cardiovascular,
neurologic, musculoskeletal, and weight issues.
Preparticipation Physical Examination Task Force
HEENT
eye exam
Any differences in pupil size (anisocoria)at baseline
visual acuity.
An athlete should have corrected vision of 20/40 or better if engaging in collision and contact
sports
Protective eyewear
single eye
contraindication to participation boxing and wrestling
mouth
evidence of bulimic activity and/or
tobacco
A high, arched palate :Marfan’s syndrome
ear
ruptured tympanic membrane
risk factor for participation in swimming and diving
Cardiovascular PPE?
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Risk of sudden death in young athlete:
1/100,000
Men>women
USA:HCM
Age
risk
Italy:ARVD
geographical diff.
Germany:Myocarditis
China:Marfan
• Silent cardiovascular abnormalities
• Such deaths among athletes are unexpected, dramatic, and
often elicit community calls for preventive measures
• Beta blockers in sport is limitted
• Defibrilator is nessesary
goal
• early identification of structural cardiac
disease associated with sudden death
• reduction of the risk of disease progression
associated with athletic training and
competition.
Etiologies of sudden unexplained cardiac
death in children and adolescents.
Structural and
Functional Abnormalities
Primary Electrical
Abnormalities
Acquired Lesions
Congenital Heart Disease
HCM
LQTS
Commotio cordis
Aortic valve stenosis
ARVD
Brugada syndrome
Drug abuse
Postoperative congenital
heart disease
Coronary artery
abnormalities
Wolff-Parkinson-White
syndrome
Atherosclerotic coronary
artery disease
Coarctation of the aorta
Primary pulmonary
hypertension
Ventricular
tachycardia/fibrillation
Myocarditis
Heart block
Dilated cardiomyopathy
Marfan syndrome with
aortic dissection
Recommendations and guidelines
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The American Heart Association(AHA)
the Bethesda Conference
the Italian Guidelines (COCIS)
European Society of Cardiology(ESC)
International Olympic Committee(IOC)
the Bethesda Conference
AHA Cardiovascular PPE
Recommendations
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1st yr at institution/high school:
- Comprehensive personal and family history
- physical examination by qualified examiner
- CV PPE every 2 years after initial screening
- During intervening years: history
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Rewritten in 1998 for collegiate athletes:
Each year after initial CV PPE:
- history
- blood pressure measurement
PPE Cardiovascular tests
• The AHA states it is not necessary to recommend the
use of highly expensive cardiovascular disease tests
such as: electrocardiography, echocardiography or
graded exercise testing
• HOWEVER, they do not discourage the use of these
tests
Personnel of CV PPE
• Recommended by AHA:
– healthcare worker with medical background to
reliably obtain a CV history, perform a physical exam
and recognize cardiovascular disease.
– preferably a licensed physician
• Non-physician healthcare workers must establish a
formal certification in cardiovascular examinations
The American Heart Association(AHA) and European Society
of Cardiology recommendations
Family and Personal History
Physical Examination
1. Premature sudden cardiac death
9. Heart murmur (supine/standing )
2. Heart disease in surviving relatives less than 50
years old
3. Heart murmur
10. Femoral arterial pulses (to exclude coarctation
of aorta)
4. Systemic hypertension
11. Stigmata of Marfan syndrome
5. Fatigue
12. Brachial blood pressure measurement (sitting)
6. Syncope/near-syncope
7. Excessive/unexplained exertional dyspnea
8. Exertional chest pain
Stigmata of Marfan syndrome
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Kyphosis
High arched palate
Pectus excavatum
Arachnodactyly
Arm span > height 1.05:1 or greater
Mitral Valve Prolapse
Aortic Insufficiency
Myopia
Lenticular dislocation
the Italian Guidelines (COCIS)
• 12-lead electrocardiogram (ECG)
• history
• physical examination
investigations
• ECG
• echocardiography
• cardiac magnetic resonance imaging (CMR)
• exercise testing
• ambulatory Holter ECG recording
• implanted loop recorder tilt table examination
• electrophysiologic testing with programmed stimulation
• Diagnostic myocardial biopsy
• genetic testing
CV PPE
• ECG
 ECG alterations in elite athletes are mostly T wave
changes, ST segment elevation, and increases in R and/or
S wave voltage
 showing ECG abnormalities strongly suggestive of HCM,
with diffuse symmetric and pronounced T wave inversion,
associated with increased R or S wave voltages or deep Q
wave
 A few others showed ECG patterns suggestive of ARVC
with T wave inversion in V1 to V3 (or V4
 sensitivity 50%, positive predictive value 7%
• Echocardiography
 HCM:
 asymmetric left ventricular (LV) wall thickenin
 a maximal LV end-diastolic wall thickness of 15 mm
or more (or on occasion, 13 or 14 mm)
 valvular heart disease (e.g., mitral valve prolapse and
aortic valve stenosis)
 aortic root dilatation
 mitral valve prolapse in Marfan or related syndromes
 LV dysfunction and/or enlargement (evident in
myocarditis and dilated cardiomyopathy)
• some important diseases may escape detection
despite expert screening methodology. For
example, the HCM phenotype may not be
evident when echocardiography is performed
in the pre-hypertrophic phase (i.e., a patient
less than 14 years of age)
• Annual serial echocardiography is
recommended in HCM family members
throughout adolescence
Athletes with Cardiovascular
conditions
• referred to a cardiovascular specialist for further
evaluation and/or confirmation
• refer to 36th Bethesda Conference guidelines
– Written in 2005 by American College of Cardiology
– Recommendations for determining eligibility for
competition in athletes with cardiovascular
abnormalities
(Maron, 2005)
Judgment of Participation
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The American Academy of Pediatrics states:
Along with specialist and Bethesda guidelines, should
consider:
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risks of participation
the advice of knowledgeable experts
current health status
the level of competition, position and sport
availability of effective protective equipment
sport can be modified?
ability of the athlete and parents to understand and accept
risks involved in participation
Judgment of Participation
• How strenuous the sport is, is another factor that
should be considered for athletes with
cardiovascular problems
• A strenuous sport places many demands on the
cardiovascular system
CARDIAC
Exercise Stress Test
• High Risk Individual
• Generally no indication for individual
planning mild to moderate exercise
BRUCE PROTOCOL
Stage 1
Stage 2
Stage 3
Stage 4
Mets
Stage 5
Mets
Stage 6
Mets
Stage 7
Mets
0-3 min
3-6 min
6-9 min
9-12 min
1.7 mph
2.5 mph
3.4 mph
4.2 mph
10% grade 5.0 Mets
12% grade 6.8 Mets
14% grade 9.4 Mets
16% grade
13.3
12-15 min
5.0mph
18% grade
16.6
15-18 min
5.5 mph
20% grade
19.5
18-21 min
6.0 mph
22% grade
22.7
6 Minute Walk Test
 purpose: This test measures aerobic fitness
 equipment required: measuring tape to mark out the
track distances, stopwatch, chairs positioned for resting.
 procedure: The walking course is laid out in a 50 yard
(45.72m) rectangular area (dimensions 45 x 5 yards),
with cones placed at regular intervals to indicate
distance walked. The aim of this test is to walk as
quickly as possible for six minutes to cover as much
ground as possible. Subjects are set their own pace (a
preliminary trail is useful to practice pacing), and are
able to stop for a rest if they desire.
6 Minute Walk Test
 purpose: This test measures aerobic fitness
Athletic Heart Syndrome
• Normal Adaptations to Exercise
Athletic Heart Syndrome
• Endurance training
– Increased left ventricular chamber size
Athletic Heart Syndrome
• Strength training
– Increased left ventricular mass
Athletic Heart Syndrome
• Arrhythmia
•How slow is too slow?
Athletic Heart Syndrome
• Why is there bradycardia?
– Heart is more efficient with each beat
– Greater muscle mass, greater chamber size
– More blood pumped per beat
The American Heart Association(AHA) and European Society
of Cardiology recommendations
Family and Personal History
Physical Examination
1. Premature sudden cardiac death
2. Heart disease in surviving relatives less than 50 years old
9. Heart murmur (supine/standing )
3. Heart murmur
10. Femoral arterial pulses (to exclude coarctation of aorta)
4. Systemic hypertension
5. Fatigue
11. Stigmata of Marfan syndrome
6. Syncope/near-syncope
7. Excessive/unexplained exertional dyspnea
8. Exertional chest pain
12. Brachial blood pressure measurement (sitting)
PULMONARY
• Exercise-induced asthma
Participation is allowed for all sports if
the asthma is under control. Only athletes
with severe asthma will need restrictions
on activity
• primary spontaneous pneumothorax
ABDOMEN
• Organomegaly
An acutely enlarged liver or spleen is a
contraindication to collision/contact or
limited-contact sports
Infectious mononucleosis can cause acute
splenomegaly(3 weeks)
• young female athletes is the presence of a
gravid uterus.
NEUROLOGIC
• past history of concussions
second impact syndrome,
• History of a seizure disorder
• Burners/stingers or pinched nerves
• transient quadriplegia
‫جدول راهنماي بازگشت بيماران به فعاليت ورزشي( كانتو)‬
‫دومنب تكان مغزي‬
‫درجه‬
‫اولنب تكان مغزي‬
‫درجه اول‬
‫‪ 1‬هفتهيب عالمت باشد بس از ‪ 2‬هفته تروص رد‬
‫‪ 1‬هفتهيتم العيب‬
‫درجه دوم‬
‫‪ 2‬هفتهيب عالمت باشد بس از ‪ 1‬ماه تروص رد‬
‫سومنب تكان مغزي‬
‫در صورت يب عالميت فصل‬
‫بعدي‬
‫در صورت يب عالميت فصل‬
‫ف اييتم العيب بعدي‬
‫‪ 1‬هفته لص‬
‫بعدي‬
‫درجه سوم‬
‫ا ماه دعب از ‪ 1‬هفتهيب در صورت يب عالميت‬
‫فصل بعدي‬
‫عالميت‬
‫تا اخر ر مع از ورزش هاي‬
‫رقابيت منع مي شود‬
MUSCULOSKELETAL
• In general, clearance is denied to an athlete
with a musculoskeletal injury who has
• persistent effusion or edema
• loss of functional ability,strength that is
less than 85 to 90% of the unaffected side,
• decreased range of motion
• Spinal conditions that are cause for
disqualification include:
• symptomatic spondylolysis
• spondylolisthesis
• functional cervical spinal stenosis
• spear tackler’s spine
• herniated discs with cord compression
spear tackler’s spine
• congenital
narrowing of
the canal the
spinal cord
passes through
(foramen
magnum)
• the second is
injury to the
spine due to
trauma
RISK INCREASES WITH:
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Congenital narrowing of the spine at the neck.
Activities that have a high risk of trauma to the neck.
Arthritis of the spine.
High risk sports, such as football, rugby, wrestling,
hockey, auto racing, gymnastics, diving, martial arts, or
boxing.
Poor neck strength and flexibility.
Previous neck injury.
Poor tackling technique.
Wearing poorly fitted or padded protective equipment.
DERMATOLOGIC
herpes simplex, impetigo,boils, scabies, and
molluscum contagiosum.
When an athlete is contagious, participation
in sports that involve mats (such as
wrestling, gymnastics,and martial arts) as
well as contact/collision sports or limitedcontact sports should not be allowed
GENITOURINARY
• single kidney
be assessed on an individual basis
“flak” jacket
• single testicle
protective cup
The athlete and parents must be informed
of the risks of injuryor loss to the
remaining testicle
ROUTINE SCREENING
TESTS
• Routine laboratory tests such as urinalysis
or complete blood count, are not
recommended
• the history or physical examination
raises concerns, then further tests should be
ordered