Pre-Participation ExamChronic Medical Conditions

John Colston DO, MSChief Resident

Pikeville Medical CenterIntegrated Family Medicine/Neuromuscular Medicine

Adapted from presentation by Jamie Varney, MD

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

Most important slide

• Each athlete is an individual• Each condition is unique• Clinical judgment is absolutely necessary

Common medical conditions

Cardiovascular conditions

• Pericarditis/myocarditis• Valvular anomalies• Hypertension• Other structural defects/disease• Irregular rhythms• Vascular disease

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

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

Hypertension

• Systolic and/or diastolic ≥ 95th percentile is associated with higher risk for sudden death and complex arrhythmias

• Not necessarily proven in younger population

Hypertension

• Evaluate for Comorbid disease• Evaluate for presence of secondary HTN• Review meds/ OTC/ supplements/ drugs

caffeine/ETOH/tobacco that may cause HTN

Hypertension Work-Up1

• Renal Function• Electrolytes• CBC• Renal US• Glucose / Lipids• EKG• Echo• Retinal exam

Secondary Hypertension1

• Suspect if :• Age < 10• Stage 2 HTN• Stage 1 HTN with systemic signs• Acute rise in BP over baseline• No family History

Secondary Hypertension1

•Some Causes• Medication• Renal Disease• Renal Artery Stenosis• Coarctation of Aorta• Obstructive Sleep Apnea• Endocrine Disease• Thyroid• Cushing’s• Aldosteronism

• Pheochromocytoma

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

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

Respiratory diseases

• Asthma• Cystic fibrosis• Smoking

Asthma

Airway obstructionTypically reversible

Airway inflammationAirway hyper-responsiveness

AllergensChemical irritantsViral infectionsCold airExercise

Symptoms

WheezingChest tightnessShortness of breathCoughAllergic rhinitis and urticaria occur frequently as

comorbid conditions

Diagnosis

Symptoms consistent with diagnosisSpirometry• FEV1 < 80%• FEV1/FVC < 65%• Reversibility with short acting Beta agonist

FEV1 improvement > 11%

Treatment

Education• Patient, family, coaches, teammates

Environmental control• Avoid allergens

Medication• Stepwise approach

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)

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

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

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

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

Endocrine diseases

• Diabetes• Thyroid

Diabetes

Fasting glucose > 126 on two occasionRandom glucose > 200 and symptoms

Fatigue, polyuria, polydipsia, polyphagia

2 hr post prandial glucose > 200 with tolerance test

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

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

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

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

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

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

Hypoglycemia

HeadacheHungerDizzinessSweatingTremorsAlteration in consciousnessPre event rise in stress hormones can mask or

mimic symptoms

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

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

Neurologic conditions

• Cerebral palsy• Seizure disorder• Headaches

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

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

High Risk Sports with Seizures

• Boxing• Diving• Scuba• Parachuting• Rock climbing• Hang Gliding

• Aviation• Downhill skiing• Motor racing• Ski Jumping• Rodeo• Cycling

Rheumatologic conditions

• Juvenile rheumatoid arthritis• Lupus• Raynaud phenomenon

Hematologic/ID conditions

• Sickle cell disease• HIV• Hepatitis• Cancer• Bleeding disorders

Female Athlete Triad

• Disordered eating• Altered menstruation• Abnormal bone mineralization

Psychiatric conditions

• Eating disorders• Anxiety• Depression• ADD/ADHD

Acute illness

• Fever• GI complaints– Nausea/vomiting– Diarrhea

• URI• UTI• Skin infections

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.