Transcript 2012 Wexner Medical Center Template Getting Started in

The Preparticipation Physical Exam
Kelsey Logan, MD, MPH, FAAP, FACP
OSU Sports Medicine
Improving People’s Lives
through innovations in personalized health care
 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 system
Armsey 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%
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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 identified
Chun, 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?
OSU Sports Medicine
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
OSU Sports Medicine
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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sportsmedicine.osu.edu
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