The Pre-Participation Sports Examination General & Special Needs Populations Jeffrey A. Zlotnick,...

The Pre-Participation Sports Examination

General & Special Needs Populations

Jeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFPFamily & Sports Medicine

St. Luke’s University Health NetworkJim Thorpe, Bethlehem, PA

Assistant Clinical Professor Family and Primary Care Sports MedicineUMDNJ – Robert Wood Johnson Medical School

UMDNJ – New Jersey Medical SchoolPhiladelphia College of Osteopathic Medicine

Medical Consultant – “Healthy Athletes Initiative” Special Olympics NJ

NJ Academy of Family Physicians

Jeffrey A. Zlotnick, MD, CAQ NJ Academy of Family Physicians

The Pre-Participation Exam (PPE) Primary goal is to evaluate the health and

safety of the athlete Objective is to be INCLUSIVE, not to try to

exclude participation NOT a substitute for the regular health

examinations by the Primary Care Physician


Primary Objectives Detect conditions that may limit

participation– Atlanto-axial instability in Down Syndrome

– Heart murmurs: Innocent vs. Hypertrophic Cardiomyopathy (HCM)

Detect conditions that may lead to injury– Lack of physical conditioning, weak muscles

– Poor exercise tolerance, heat intolerance

– High number of major joint problems: “Miserable Misalignment Syndrome”

Meet legal and insurance requirements


Secondary Objectives Assess athlete’s general health

– May be the ONLY opportunity you have to see this patient and discuss issues such as immunizations, substance abuse, and birth control

Counsel athlete on health-related issues Assess growth & development

– Tanner staging can be helpful where less mature athlete is playing against a more mature athlete: HIGH risk for injury in contact sports (Exam can be embarrassing)

Assess fitness level & performance– Help identify weaknesses that may increase chances of injury

(e.g., swimmers with weak pectoral muscles)


Timing

Best if performed at a MINIMUM of SIX weeks before practice starts

Gives time to identify & correct problems noted on exam


Frequency

Vary from before each season to every “few” years (“few” is variable)

Optional: short interval history and go after specific changes or problems

Once yearly is most popular


Methods

Private office by Primary Care Physician Multi-station exam with different providers

of various types (physicians, nurses, PAs) Each type of station has advantages and

disadvantages In-school physical

– Currently not required in NJ to get athletes to have a “Medical Home.” However, there are exceptions.


Private Office – Advantages

PCP knows the PMHx, the FHx, Immunizations Less likely to overlook problems Young athletes will be more willing to discuss

sensitive issues with a known person Easier and less embarrassing to do GU exam (if

indicated)

Less chance for abnormalities to be overlooked and not addressed


Private Office – Disadvantages Many athletes do not have a PCP Limited time for appointments: time consuming Varying levels of knowledge and interest in sport

specific problems– Must be well versed in sports-specific demands

Greater cost: many cannot afford– Higher income athletes will tend to go to different specialists for

each problem found

Tendency for poor communication between PCP and school athletic staff– Many un-indicated disallowed athletes


Multi-Station – Advantages

Cost effective and easy to screen large numbers of athletes

Specialized personnel at each station– Usually 5 to 6 stations

Good communication with school athletic staff since the coach & athletic trainers are usually part of the team


Multi-Station – Disadvantages Requires a large amount of space Hurried, noisy, with minimal privacy

– Difficult for GU exam, heart murmurs

Continuity of care easily lost, problems noted are NOT followed up upon

Lack of communication with parents Particular consultant may put unreasonable

demands on an athlete Varying levels of training of school

physicians


Multi-Station – Requirements

Station Sign-in, Ht/Wt, vital

signs, vision History review,

physical (medical, orthopedic, & neurological) assessment/clearance

Personnel Coach, trainer, nurse,

volunteer Physician


Multi-Station – Options

Station Specific orthopedic exam Flexibility Body composition Strength Speed, agility, power,

endurance, balance

Personnel Physician Trainer or therapist Physiologist Trainer, coach, therapist,

physiologist Trainer, coach,

physiologist


MEDICAL HISTORY IS KEY!

Statistics show that a good history will identify 63% to 74% of medical problems

Anecdotal information from the athlete agrees with the parents less than half of the time

Reference: Medicine & Science in Sports & Exercise. 1999;31(12): 1727.

Key Questions

The following questions need to be asked or put on a questionnaire that

is reviewed


Ever been treated in a hospital or had surgery? Important to know number and severity of

Traumatic Brain Injuries (concussions) Determine if certain medical conditions are

under control enough to allow or limit participation– Diabetes, asthma

Has enough time passed to allow for healing and rehabilitation after surgery?


Taking any Rx or OTC Drugs? History of Rx’s important to assess control

– Diabetes, asthma Does the athlete require any emergency drugs that

the coach/AT will need to know about AND how to use them?

Get information on birth control measures & menstrual history– Amenorrhea in women athletes can lead to a high

risk of stress fractures (Female Athletic Triad)– Good way to introduce talk on STDs


Taking any Rx or OTC Drugs? Get information on use of OTC drugs

because athletes tend to abuse these:– OTC asthma, decongestants, & diet pills can

cause increased heart rate and arrhythmias– NSAIDs can cause increased bleeding– Laxatives (wrestlers) can cause electrolyte

abnormalities Try to get history of illicit drug use

– Alcohol, tobacco, marijuana, steroids


Allergies?

Drugs– Know which drugs can and CAN’T be given in

case of an emergency Bees & insects – important in outdoor

sports– Need to carry an EpiPen®?


Skin Problems or Rashes?

Mainly looking for herpes, scabies, lice, & molluscum contagiosum

Impetigo, herpes, and other conditions can be spread by mats, helmets, & towels

Acne and other atopic conditions can be exacerbated by clothing or equipment


History of Head Injury, LOC, Seizure, “Burners or Stingers?” History of seizure (epilepsy?) Loss of consciousness (LOC) & headache Hx

important to determine ability to resist Traumatic Brain Injury (TBI) & risk for Second Impact Syndrome

Burners/stingers are brachial plexus injuries– Usually resolve but are occasionally permanent

Cervical cord neuropraxia with transient quadriplegia is rare– Associated with cervical stenosis, congenital fusions,

cervical instability, disc problems

ANY History of Recurrent Burners/Stingers or Transient

Quadriplegia?

NEED cervical spine films BEFORE being allowed to

participate!


Concussion? Concussion accounts for 6% to10% of all sport Concussion accounts for 6% to10% of all sport

related injuriesrelated injuries– Higher risk among high school athletes in contact sports (Langlois Higher risk among high school athletes in contact sports (Langlois

2006)2006)

1.6 to 3.8 million sports-related TBIs occur each 1.6 to 3.8 million sports-related TBIs occur each yearyear

TBIs can be cumulative– Cognitive function (“Punch Drunk”)– Memory– Ability to learn– Reaction time

Increased risk of Second Impact Syndrome – Primarily in younger (pre-adolescent) athletes


Heat or Muscle Cramps?

History of dizziness or passing out during activities in the heat

Determines ability to tolerate heat or prolonged events– Marathons


Difficulty Breathing?

During or after activity? Seasonal allergies vs. asthma Also could be cardiac

– HCM– Valvular disease– Arrhythmias


Special Equipment/Braces?

Inspect for fit & function Risk to other players?


Problems with Eyes/Glasses?

Is athlete “single-eyed”– Less than 20/50 as best in one eye

Hx of orbital fractures


Sprains, Strains, Fractures, or Dislocations?

Need to determine need for rehabilitation PRIOR to being allowed to participate


Other Questions Medical problem or injury since last

evaluation (periodic exam)? Immunizations up to date?

– Td, Hep B, MMR, Meningitis

Women: Date of first and last menses; longest time between menses?

Family use of tobacco, alcohol, street drugs?– How about yourself?


Most Important Questions Ever passed out or became significantly

dizzy during/after exercise? Ever have chest pain during/after exercise? Do you tire more quickly than your peers? Hx of increased BP or heart murmur? Hx of heart racing/skipping beats? FHx of sudden death before age 50? Hx of concussion (Traumatic Brain Injury)


Keep in Mind 90% of sudden death in athletes <30 y/o is

cardiovascular Reference: Spotlight on sudden cardiac death. Cardiovascular Research. 2001:50(2):173-176.

Syncope or near-syncope may be a sign of underlying hypertrophic cardiomyopathy

Chest pain may be atherosclerotic Dyspnea on exertion may be caused by

asthma, valvular disease, or coronary artery disease

Palpitations may be arrhythmia, WPW

Key Components of the Physical Exam

Height & Weight Compare to growth charts for age/sex

– Body fat: male 5% to 10%; female 12% to 15% Very thin: Ask about diet, weight loss, body image

(r/o anorexia, bulimia) Optional: Body composition

– Skin fold calipers easiest

– Electronic scales

– Total immersion more accurate Good time to discuss weight in athletes where

weight is important– Wrestling, ice skating, gymnastics


Eyes

Absence of 1 eye or vision >20/50 in the best eye: AVOID COLLISION SPORTS!

Anisicoria: slight/baseline is normal and should be noted (1-2mm)

Large difference needs neurological work-up first


Cardiovascular System BP: Use correct size cuff!

– >110/70 mmHg for <10 y/o or >120/80 mmHg* for >10 y/o must be evaluated (*Latest JNC guidelines)

Check pulses: symmetrical femoral and radial pulse is a good screen for coarctation of the aorta

Murmurs: deep inspiration, valsalva, squatting – Innocent, mitral valve prolapse, hypertrophic

cardiomyopathy, aortic sclerosis Arrhythmia: EKG to evaluate

– 24 hour monitor

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

Neurological

Baseline testing: Neuropsych testing– Memory, Cognitive function– Ability to learn– Orientation

VERY useful if athlete receives TBI– Presence of post-concussive symptoms– More accurate for determining return to play– Can demonstrate loss of baseline function


Practice Recommendation Anyone with traumatic brain injury and a recorded

Glasgow Coma Scale of 13 or less at any stage after the first 30 minutes OR who received a CT scan of the head as part of their initial assessment should be routinely followed up with, as a minimum, a written booklet about managing the effects of traumatic brain injury and a phone call in the first week after the injury

Approved Source: National Guideline Clearinghouse Website: http://www.guideline.gov/summary/summary.aspx?doc_id=10281&nbr=

005397&string=concussion Level of Evidence: B - A well-designed, nonrandomized clinical trial. A non-

quantitative systematic review with appropriate search strategies and well-substantiated conclusions.


Other

Lungs: look for symmetry of movement, listen for wheezes/rubs

Abdomen: check for organomegaly, tenderness, rigidity

Skin: check for rashes and growths


Practice Recommendation

In a population of stable asthmatics short acting beta-agonists, mast cell stabilizers, or anti-cholinergics will provide a significant protective effect against exercise-induced broncho-constriction with few adverse effects

Approved source: Cochrane Database Website: http://www.cochrane.org/reviews/en/ab002307.html Strength of Evidence: Twenty-four trials (518 participants) conducted in 13 countries

between 1976 and 1998 were included. All drugs were effective at attenuating the exercise-induced bronchoconstriction response but to varying degrees even within the same individual. Compared to anti-cholinergic agents, mast cell stabilizers were somewhat more effective at attenuating bronchoconstriction.


GenitourinaryMale: Hernia? Testes both descended? Single: should counsel about collision sports

Female: Pelvic exam not necessary part of basic exam Do w/ Hx of severe menstrual irregularities,

primary or secondary amenorrhea

Both: Maturity & development (self rating?)

Musculoskeletal

Need to assess major muscle groups and joints via a screening exam

Follow up closely on any abnormalities noted– Decreased ROM, function– Hyper-flexibility


Laboratory Testing Traditionally: UA dip for protein/glucose

– Non-pathologic proteinuria VERY common– U-glucose NOT reliable & unproven in large

studies for DM screening Same for CBC, Hct, Fe, Ferritin, Sickle trait Cardiovascular screening (EKG, Echo) under

investigation for cost-effectiveness Screen only those at risk or positive findings Reference: Exercise-induced Proteinuria? The Journal of Family Practice. 2012;61(1):23-26.


Determining ClearanceMOST IMPORTANT PART!MOST IMPORTANT PART!1 Does the problem put the athlete at greater risk for

injury?2 Is the athlete a risk to other players?3 Can the athlete safely participate with treatment,

rehabilitation, medicine, bracing or padding?4 Can limited participation be allowed?5 If clearance is denied, are there other activities

that the athlete can safely participate in?

Clearance is based on AAP Committee on Sports Medicine Recommendations for Participation in Competitive Sports Based upon the amount of contact/collision

and intensity of exercise


Contact Non-Contact

Contact/ Collision

Limited Contact/ Collision

Strenuous Moderate Non- Strenuous

Boxing Field Hockey Football Ice Hockey Lacrosse Martial Arts Rodeo Soccer Wrestling

Baseball Basketball Bicycling Diving Field Sports Gymnastics Horseback Riding Skating Skiing (all) Softball Squash/Handball Volleyball

Aerobic Dance Crew Fencing Discus, Javelin, Shot put Running Track Swimming Tennis Weight lifting

Badminton Curling Table tennis

Archery Golf Riflery


Some Specifics


Acute Illness

Individual assessment Generally accepted to limit activity during

fever URIs and strenuous activity (e.g., cycling)

can cause significant impact on the immune system


Cardiovascular Abnormalities

May Dispose to Sudden Death!May Dispose to Sudden Death! Mild hypertension: No restrictions Moderate to severe hypertension: need

assessment and possible treatment Benign functional murmurs: No restriction Mild mitral valve prolapse: No restriction


MVP with:

PMHx of syncope Chest pain/tightness increased w/ activity FHx of sudden death Moderate to severe regurgitation REASSESS! HIGH RISK!HIGH RISK!Reference: Recommendations for competitive sports participation in athletes with cardiovascular disease. European Heart

Journal. 2005;26(14):1422-1445.


Hypertrophic Cardiomyopathy(HCM, IHSS)

Most common cause of sudden death in athletes Usually find:

– Marked LVH (*Need to differentiate from normal LVH in conditioned athletes)

– Significant L outflow obstruction & Arrhythmias, both increased by activity

– PMHx of syncope or FHx of sudden death in a young relative

May participate in LOW intensity activities


Symptoms HCM Most are ASYMPTOMATIC until Sudden

Cardiac Death (can be the 1st symptom) Symptoms with activity:

– Chest pain– Shortness of breath– Lightheadedness– Dizziness– Loss of consciousness

Children often do not show signs of HCM– After puberty


Basketball Star's Sudden Death Brings Awareness of Deadly

Heart Disease

By Dan O'Donnell Story Created: Mar 7, 2011 Story Updated: Mar 8, 2011

MILWAUKEE - The shockwaves from high school basketball star Wes Leonard's sudden death last week have reverberated from Fennville, Mich. across the nation.An autopsy revealed that Leonard suffered cardiac arrest brought on by dilated caridomyopathy (DCM), a condition more commonly referred to as an "enlarged heart."


Incidence HCM

0.2% to 0.5% of the general population– All types of HCM (obstructive vs non-

obstructive) Appears in all racial groups Sarcomeres (contractile elements) in the

heart replicate causing heart muscle cells to increase in size– Results in the thickening of the heart muscle

Typically an autosomal dominant trait– 50% chance of passing trait


Cardiovascular RisksALL Causes SCD per year in healthy patients

– 1/133,000 Men– 1/769,000 Women

AMI w/in 1 hour of exercise 2% to 10%– 2.1 – 10x higher than in sedentary patients

SCD 6-164x greater than sedentary patients Recommend higher level of screening in

high risk patientsReference: Exercise & acute CV events placing the risks into perspective: a scientific statement from the

AHA Council on Nutrition, Physical Activity, & Metabolism and the Council on Clinical Cardiology. Circulation. 2007;115(17):2358-68.


Who Should Be Screened? Low risk:

Men <45 Women <55 Asymptomatic Meet no more than 1 risk factor

Moderate risk: Older than preceding 2 or more risk factors

High risk: Signs/symptoms of CVS, pulmonary, metabolic

disease or family history of SCD


Visual Impairment

Considered + if singled-eyed or best vision in one eye >20/50

NO effective eye protection for – Martial arts, boxing, wrestling >>>>Disallow!

High risk:– Football, baseball, racquetball

Eye guards exist but protection is limited


Practice Recommendation Functionally 1-eyed athletes and those who have had an eye injury or

surgery must not participate in boxing or full-contact martial arts. (Eye protection is not practical in boxing or wrestling and is not allowed in full-contact martial arts.)

Approved Source: National Guideline Clearinghouse Website: http://www.guideline.gov/summary/summary.aspx?doc_id=4861&nbr=

3502&ss=6&xl=999 Strength of Evidence: Although the evidence for each recommendation is not

specifically stated the evidence is drawn from reports from American National Standards Institute. Occupational and educational personal eye and face protection devices. Washington (DC): American National Standards Institute; 2003 and American Society for Testing and Materials. Annual book of ASTM standards: Vol 15.07. Sports equipment; safety and traction for footwear; amusement rides; consumer products. West Conshohocken (PA): American Society for Testing and Materials; 2003.


Kidney/Renal Incidence of renal trauma is 5% to 25%, but

is mostly mild– Other injuries more common that renal

Solitary kidney:– Pelvic, iliac, multicystic, hydronephrotic,

uteropelvic jct abn’s >>> No Collision Sports!– Normal position:

Counsel and sign consent

Reference: Single kidney and sports participation: perception versus reality. Pediatrics. 2006;118(3): 1019-1027.


Hepato/Splenomegaly

Liver: determine primary cause (e.g., mono)– OK to return once organ reduces size

Spleen: Acute splenomegaly associated with HIGH risk of rupture with minimal provocation!

Chronic splenomegaly: need to assess and treat individually


Hernia: Only remove if symptomatic Gyn: No restriction w/ single ovary

– Do look for menstrual irregularities– Female athletic triad

(Amenorrhea, anorexia, osteoporosis)

Testicular: Single may play all sports: CUP!– Undescended testes more serious

Increased risk of Ca

Sickle Cell:– Trait: No restrictions altitudes <4000 ft– Disease: Very limited

Even mild hypoxia can lead to sickling


Neurological Problems

Burners/Stingers: Can play once asymptomatic– Recurrent: need atlanto-axial evaluation

Transient Quadriplegia: NOT associated w/ increased risk of permanent quadriplegia– However, MUST be evaluated

Orthopedist or Neurosurgeon


Traumatic Brain Injury(Concussions)

TBI classified by– #1 Amnesia– #2 Symptoms w/ activity and at rest

Both physical and mental function

– #3 Loss of consciousness – NUMBER of events (damage is cumulative!)– Neuropsych testing (pre-participation, post-

injury)


Traumatic Brain Injury(Concussions) Need to be aware of Post TBI Syndrome &

Second Impact Syndrome– Pay close attention to subtle neuro signs and complaints

of headache, poor concentration, dizzy

– Athlete must be symptom free w/ activity and at rest and back to baseline Neuropsych testing before being allowed to play

Minor trauma can lead to rapid cerebral edema– More common in younger/pre-adolescent athletes


October 29, 2010 Friday

"It was just a routine play. I don't think there was anything special," Orrick told the Miami County Republic after the game. "I think he just hit the ground pretty hard with his head. He came on the sideline and told one of my assistants, 'my head is really hurting.' He sat down on the bench. He then stood up, but his legs went underneath him and collapsed there."

NBC Action News also reports that Stiles was taking part in his first game since returning from a concussion suffered in early October. Stiles' father confirmed this to the Kansas City Star, noting that his son suffered a concussion during the homecoming game earlier in the month, but was cleared to play Thursday.

Reference: Al Spivak AOL News 10/30/2010

http://www.fanhouse.com/2010/10/30/nathan-stiles-kansas-high-school-football-player-dies-

after-in/

Nathan Stiles 17 y/o

Spring Hill HS, Kansas City


Return to Play: NP testing based

Administer BEFORE starting any sports– Mainly contact sports

Studies demonstrate good correlation between reported symptoms and changes in neuropsych testing at 2 hours

However, correlation is lost at 48 hours to 2 weeks Most athletes returned to baseline in 2-4 weeks More accurate at aiding in determining return to

play than patients reports of symptoms Other more advanced computer-based

systems for determining return to play

Neuropsych Testing

Standardized Assessment of ConcussionBrain Injury Association of

America

8201 Greensboro Drive

Suite 611

McLean, VA 22102

703-761-0750 / 800-444-6443

Cost?


SCAT: Sideline Concussion Assessment Tool Developed by Prague Group 2004 Symptom score sheet post-injury Mental function assessment in several areas Not a full neuro-psych test Does have some baseline to compare with

post-injury



SCAT2


ImPACT: Univ of Pittsburgh

Computerized system to evaluate concussion management and safe return to play

Battery of scientifically validated neuro-cognitive testing on large populations– Does not require baseline testing for individual athlete

– Does not allow for individual variation

Expensive! Already in use at the professional level, some colleges

& high schools– Becoming more available for on field management


CogState Sport Also computer based system Requires a baseline

– Data submitted to secure online server After injury, athlete can be re-tested from

any web-connected computer & able to compare scores

CogState also does analysis on pre- and post- tests– Reports by Email


Return to Play

Based on Zurich protocols published in Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008

Clinical Journal of Sport Medicine. 2009;19(3): 185-200.


Chronic Traumatic Encephalopathy (CTE)

Found most commonly in athletes with multiple head “injuries”– Can be an accumulation of multiple small “hits” & not

all causing symptoms 73% of pro football players with CTE died in

middle age (mean 45 y/o) 64% of deaths have been from

– Suicide– Abnormal erratic behavior– Substance abuse


Symptoms CTE

Cognitive changes (69%)– Memory loss/dementia

Personality/Behavioral changes (65%)– Aggressive/violent behavior– Confusion– Paranoia

Movement abnormalities (41%)– Parkinsons (Dementia pugilistica)– Gait/Speech problems


Treatment CTE

NONE! Treat symptoms Prevention is currently the only available

treatment option

The Special Needs Population

Special Olympics NJ



Special Olympics (SO) Established early 1960’s by Eunice Kennedy

Shriver & developed by the Joseph P Kennedy Foundation

Mission: To provide sports training &

competition for persons with mental

retardation Winter & summer events every 4 years Local, state, regional, national, & international

Local: 300-600 athletes International: 1500-6000 athletes

1st international games were 1968 in Soldier Field, Chicago


Eligibility

At least 8 y/o & identified as having:– Mental retardation by an agency or professional– Cognitive delays– Learning or vocational problems requiring

special designed instruction No maximum age limits Training programs can begin at 6 y/o


Summer Sports

Swimming & diving Track & field Basketball Bowling Cycling Equestrian Soccer

Golf Gymnastics Powerlifting Roller skating Softball Tennis Volleyball


Winter Sports

Alpine skiing Cross-country skiing Figure skating Floor hockey Speed skating


Prohibited Sports

Any sport w/ direct 1-on-1 competition

Considered dangerous for mentally retarded athletes

Wrestling Shooting Fencing Ski jumping

Javelin Vault Triple jump Platform diving Trampoline Biathlon Boxing Rugby Football (US)


Organization of Games Levels of participation

– Age, Sex, Ability– “Developmental” sports for those w/ severe limitations

Coaches– Special education teachers, athletic instructors, parents– Extensive knowledge of the physical & mental

characteristics of each athlete– Low ratio athlete/coaches ~ 4:1

Volunteers– Support services

Administration– Physicians, nurses, PT’s & OT’s, trainers– Work directly with SO executive director


Pre-Participation Exam Questionnaire: #1 tool

– Done initially & yearly

– Coaches must have an updated & reviewed questionnaire at ALL competitions

– 44% to 71% of problems that can affect ability to compete are identified by questionnaire

Physical– Initially & every 3 years

– Athletes develop new problems Htn, visual problems, concussions, surgery…

– Identifies approximately 29% problems


Common Problems

Visual: 25%– Refractive, cataracts, myopia, blindness

Hearing: 8% Seizures: 19% Medical: 6% (similar to general population)

– 30% use medications Emotional & behavioral

– Much higher than general population


Complex Problems Atlanto-axial instability

– Most common & most controversial Spinal cord problems

– Injuries* Meningomyelocele Spinal bifida Hydrocephalus

Cerebral palsy Wheelchair athletes Amputees (congenital & acquired) Visual & hearing impairment Seizures Type 1 Diabetes


Atlanto-Axial Instability Up to 15% of athletes have Down syndrome All have abnormal collagen that leads to increased

ligamentous laxity and decreased muscle tone Annular +/- Transverse ligament of C1 (Axis)

stabilizes articulation of the odontoid process of C2 (Atlas) w/ C1

Laxity may allow forward translation of C1 on C2 causing compression of the cervical spinal cord

Reference: Participation by Individuals with Down Syndrome Who Have Atlantoaxial Instability. Special Olympics. www.specialolympics.org. Accessed 12/10/12. http://sports.specialolympics.org/specialo.org/Special_/English/Coach/Coaching/Basics_o/Down_Syn.htm


Atlanto-Axial Instability Reports of athletes with Down syndrome

experiencing spontaneous subluxation & catastrophic spinal cord injury during surgery requiring intubation (anecdotal)

Also with blows to the head and major falls 2% experience symptoms related to AAI

– Abnormal gait, neck pain, limited C-spine ROM, spasticity, hyper-reflexia, clonus, sensory deficits, upper motor neuron signs

Asymptomatic AAI is of major concern– Highest risk between 5 to 10 years of age


Atlanto-Axial Instability SO requires C-spine x-rays in neutral,

hyper-extension and hyper-flexion Evaluation of the Atlantodens interval &

spinal canal at C1-C2 Intervals > 4.5 (5) mm are positive

– ~ 17% of athletes w/ AAI Neurosurgical evaluation required before

allowing any participation Reassessment every 3 to 5 years

– Unsure if indicated if initial evaluation normal


Atlanto-Axial Instability Participation allowed in most events except:

– Butterfly stroke– Diving starts in swimming– Pentathlon– High jump– Equestrian sports– Artistic gymnastics– Soccer– Squat lifts– Alpine skiing


Atlanto-Axial Instability American Academy of Pediatrics & Comm.

on Sports Medicine & Fitness concluded “potential but unproven value”

Current literature does NOT provide evidence for or against screening– Long term longitudinal studies are lacking

Natural history of AAI is unknown 85% of patients w/ AAI 5mm or > have no

symptoms At this time screening is SO requirement


Spinal Cord Injured Athletes

Predisposed to injuries 20 to wheelchair use Loss of motor & sensory function below the

level of the injury Lack of autonomic function

– Thermoregulation– Autonomic dysreflexia


Thermal Regulation

Seen 10ly in lesions above T-8 Loss of vasomotor responses Hypothalamus response limited by loss of

impulse from below the injury Reduced venous return from the paralyzed

muscles below the injury Impaired sweating below lesion reduces

effective body area for evaporative cooling


Thermal Regulation

Body core temps that go to either extreme in hot & cold environments

Hypo but 10ly extreme Hyperthermia Need to be aware of:

– Clumsiness/Erratic wheelchair control– Headache– Confusion or other mental status change– Dizziness– Nausea/vomiting


Prevention Acclimatization of athletes 2 weeks prior Daily posting of temp & heat stress index

– Combination of solar & ambient heat and relative humidity

Systematic schedule of fluid intake– Before, during & after events

Daily weights Availability of resuscitative and

transportation services


Autonomic Dysreflexia Occurs in injuries above T-6 Loss of inhibition of the Sympathetic NS

– Sweating above lesion

– Hyperthermia

– Acute hypertension

– Cardiac dysrhythmias

Multiple triggers– Bowel & bladder distention

– Pressure sores

– Tight clothing

– Acute fractures

– Environmental (temperature)


Treatment Remove athlete from activity Remove sensory stimulus

– Clothing– Bladder catheterization/bowel evacuation– Cooler/warmer environment

Transport to hospital may be necessary– Uncontrolled hypertension or dysrhythmia

Usually self-limited Watch for self-induced (“Boosting”)


Wheelchair Athletes Usually other significant medical problems 10ly Overuse injuries to wrist & shoulders

– Rotator cuff impingement/tendonitis

– Biceps tendonitis

Fractures to the hands & wrists– Epiphyseal plate weakest point

– Lower extremity fractures infrequent

Pressure sores– Due to increase pressure & lower blood flow

– Insidious onset due to lack of sensation

– Tx: Custom seats, moisture absorption, padding


Cerebral Palsy Spasticity, athetosis, ataxia Progressively decreasing muscle/tendon

flexibility & strength >> Contractures Impaired hand-eye coordination Mental retardation Seizures Extreme risk for overuse injuries! 50% in wheelchairs Modification of events to accommodate

– Get inventive (“Adaptive Sports Program”)


Athletes w/ Amputations Indications for amputation:

– Circulatory problems: Necrosis or infarction

– Life threatening: cancer, infection

– Congenital deformity rendering limb insensate

Upper limb more common in younger Length of limb preserved to protect epiphysis Appliances are smaller & require frequent

adjustments to accommodate growth Prostheses are abused & need repair/adjustment Skin breakdown/ Phantom limb pain is less

frequent in younger athletes


Problems

Overgrowth of stump is common Skin breakdown common in sports due to

friction & pressure Alteration center of gravity >> Problems with

balance (10ly lower limb amputees) Hyperextension of knee & lumbar spine Early detection is key 20 decreased sensation in

limb Athletes may compete using prostheses but no

other assistive device


Visual Impairment Partial sight to total blindness

– Legal blindness: acuity < 20/200, visual field < 200

No related physical disabilities except due to lack of experience with certain activities

Modifications to equipment, rules & strategy may be required– Tactile & audio clues– Tethers or guide wires– Step & stroke counting– Guides


Hearing Impairment Tend not to consider themselves disabled

– “Subculture” of society Variations:

– Mild: threshold 27-40 dB– Profound: threshold > 90 dB

Behavioral disorders 20 communication challenges

No related physical disabilities except due to lack of experience with certain activities


Seizures Common in athletes with developmental

disabilities Familiarity with meds & side effects

– Attention span & cognitive impairment

Decreased potential for seizures w/ exercise– Metabolic acidosis due to lactate buildup & incomplete

respiratory compensation

– Decreased pH >> Stabilizes neuromembranes

Good control must be obtained prior to participation in activities

Be prepared as with ALL athletesReference: Howard GM, Radloff, M, Sevier TL. Epilepsy and sports participation. Current Sports Medical Reports.

2004 Feb;3(1):15-9.


Insulin Dependent Diabetes Need to monitor glucose:

– 30 min before activity– Immediately before activity– Every 30-45 min during activity

Ideal pre-exercise range is 120-180 mg/dL– > 200 mg/dL: Postpone & take extra insulin to

get glucose levels down 1st

– Exercise with elevated glucose will cause levels to RISE further which can lead to increased diuresis, dehydration, and keto-acidosis

Insulin Adjustments Moderate exercise:

– AM activity reduce Reg by 25%

– PM activity reduce Reg by 25% as well as NPH or Long Acting

Strenuous or Long Term:

– AM activity reduce Reg by 50%

– PM activity reduce Reg by 50% as well as NPH or Long Acting

Insulin pumps or Glargine: as above Liberal hydration

– < 1hr: water alone OK

– > 1hr: think Na+ replacement (Sport drinks: remember they contain CHO!!)


Complications Autonomic dysfunction

– Avoid power lifting 20 bradycardia & syncope

– Increased hot & cold intolerance Hyperglycemia: treat & watch for KA Hypoglycemia

– Tremors, sweating, palpitations, pallor, hunger

– Long acting CHO’s, glucagons Late onset hypoglycemia: 6-28 hrs later

– Replace glycogen w/in 1 hr of activity

– Avoid activity near intermediate insulin peaks

– Use long-acting to avoid peaks

– Watch for Neuro-glypenic Syndrome


Some problems out of scope of practice for Family Physicians:– Dental disease– Complex Cardiac problems– Advanced Orthopedic problems– Ophthalmic problems

Need to establish referral network of physicians

Part of “Healthy Athlete’s Initiative” SOI

Special Concerns


Special Concerns

Podiatric problems: difficulty finding good athletic shoes that fit

– Pes planus Toenail fungus Tinea & groin abscesses Orthostatic hypotension


Special Concerns: Communication Disorders

Elective mutism

– Children usually 3-5

– Have the ability to speak +/- use language, but refuse to except under certain circumstances, or only to certain individuals

Hearing impairment

– Seen at young age with delayed or abnormal speech & language development

– Can be mild, moderate, severe & uni- or bilateral


Autism Pervasive developmental disorder with significant

impairment in – Socialization

– Communication

– Sensory/motor development

7:10,000 births Associated with

– Mental retardation

– Seizure disorders

– Psychiatric disorders


Approach to the patient

Approach slowly Speak in a slow clear voice Try to maintain eye contact

– Be aware too much may cause the patient to withdraw

Use hand gestures along with language Let the patient touch

– E.g., stethoscope, otoscope, splints, your hands Watch the patient & caretaker for clues

Healthy Athletes InitiativeMedFest


&

Special Olympics NJ

MedFest ProgramSONJ and NJAFP March 9, 2003: the first MedFest occurred

in Lawrenceville, NJ. This model has been copied by a number of other organizations

August 2005: an agreement was signed between SOI and AAFP

March 2012: Almost 1000 athletes have been certified to participate that otherwise would have never had the opportunity



Some Pictures From MedFest 1:Before We Start…


Registration


Vitals


History Review


Heart & Lung


Orthopedic


Ear, Nose & Throat


Check out!


Thank you!!


Contact InformationJeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFPNew Jersey Academy of Family Physicians224 West State StreetTrenton, NJ 08608Phone: 609-394-1711 ~ Fax: 609-394-7712

MedFest Coordinator and NJAFP Office Manager: Dr. Zlotnick – [email protected] Candida Taylor – [email protected]

NJAFP Executive Vice President:Ray Saputelli, MBA, CAE – [email protected]

Deputy Executive Vice President:Theresa J. Barrett, MS, CAE – [email protected]

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The Pre-Participation Sports Examination General & Special Needs Populations Jeffrey A. Zlotnick,...

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