Pre-participation Exams for College Athletes

1. Pre-participation Exams for College Athletes Jessica D. Higgs, M.D. Director of Health Services and Sports Medicine Bradley University May 29, 2012 ACHA 2012 Annual Meeting

2. Background • Over 370,000 NCAA athletes • 60,000 NAIA athletes • Over 50,000 NJCAA athletes

3. NCAA • NCAA sports medicine handbook (adopted by NAIA) • A pre-participation medical evaluation should be required upon a student-athlete’s entrance into the institutions intercollegiate athletics program. This initial evaluation should include a comprehensive health history as defined by current CDC guidelines and relevant physical exam, with strong emphasis on cardiovascular, neurologic, and musculoskeletal evaluation. After the initial medical evaluation, an updated history should be performed annually. Further pre-participation physical exams are not believed to be necessary unless warranted.

4. NJCAA • PHYSICALEXAMINATION • All student-athletes participating in any one of the NJCAA certified sports must have passed a physical examination administered by a qualified health care professional licensed to administer physical examinations, prior to the first practice for each calendar year in which they compete Section 9, NJCAA Eligibility criteria

5. AHA • AHA modified 1996 recommendations for screening every two years for collegiate athletes. Revision recommends cardiovascular screening as part of initial exam and in subsequent years an interim history and blood pressure measurement should be made. Circulation, 2007

6. Background • Poor sensitivity and specificity • Has no future predictive value • No study exists that demonstrates a PPE based on history and physical exam alone is effective in preventing or detecting athletes at risk for sudden death • Evidence category D, expert opinion

7. Objectives • List the primary and secondary objectives in doing a pre-participation physical • Identify red flags from the history and physical that would prompt further evaluation for cardiac concerns • Describe key components in the evaluation of a concussion history • Discuss the different options available for “clearing” an athlete

8. Primary Objectives • Screen for conditions that may be life-threatening or disabling • Screen for conditions that may predispose to injury or illness • Meet administrative requirements

9. Secondary Objectives • Determine general health • Serve as an entry point to health care system • Provide opportunity to initiate discussion on other health topics

10. History • Most important element of the PPE • History alone detects 88% of medical conditions and 67% of musculoskeletal conditions during a PPE • Questions unproven • Difficulties in obtaining accurate medical history Clinical Journal of Sports Medicine, 2006

11. Clearance • 3.1-13.9% of athletes require further evaluation before final clearance status is determined • 4 categories • Cleared for all activities without restriction • Cleared with recommendations for further evaluation or treatment • Not cleared – clearance status to be reconsidered after completion of further evaluation, treatment, or rehabilitation • Not cleared for certain types of sports or for any sports Mayo Clinic Proc, 1998

12. Clearance • When abnormality found consider the following • Does problem increase risk of injury or illness for athlete • Are other participants at risk • Can they safely participate with treatment • Can limited participation be allowed while treatment being completed • If clearance is denied for some sports, are other sports safe • Particular sport issues should be considered

13. Sports Classification • Contact • Strenuous

15. Cardiovascular • Have you ever passed out or nearly passed out DURING or AFTER exercise? • Have you ever had discomfort, pain, or pressure in your chest during exercise? • Does your heart race or skip beats during exercise? • Has a doctor ever told you that you have high blood pressure, high cholesterol, a heart murmur, a heart infection? • Has a doctor ever ordered a test for your heart? • Do you get lightheaded or feel more short of breath than expected during exercise? • Have you ever had an unexplained seizure? • Do you get more tired or short of breath more quickly than your friends during exercise? • Has anyone in your family died of heart problems or had any unexpected or unexplained sudden death before age 50? • Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? • Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? • Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

16. Cardiovascular Red Flags • Exertional chest pain • Exertional syncope or near-syncope • Unexplained seizures • Excessive dyspnea or fatigue disproportionate to the level of exertion • History or current finding of a murmur • History or current finding of hypertension • Family history of death prior to age of 50 in 1st or 2nd degree relative

17. Cardiovascular • First sign of cardiac abnormality….. SUDDEN DEATH • AHA purpose for screening • Recommends some form of PPE for college age athletes • Ethical, legal, and medical grounds • 36th Bethesda conference

18. Incidence • Exact incidence of SCD in athletes is unknown • Current estimate is between 1:25,000 to 1:200,000 • In Italy 1:25,000 prior to national screening program • US military recruits 1:9000 • More common in males, African-Americans, and basketball and football athletes JAMA 1996 Annals of Internal Medicine 2004

19. Sudden Death NCAA

20. Sudden Cardiac Death Hosey e al, Sudden Cardiac Death, Clinics in Sports Medicine, 2003

21. Hypertrophic Cardiomyopathy • Accounts for about one-third of sudden cardiac deaths in US athletes younger than 30 years • LV wall thickness of 16mm or more (normal <12, borderline 13-15mm) • Inherited autosomal dominant disorder • Typically develops in early adolescence to young adulthood • Only 21% of athletes who died of HCM had signs or symptoms 36 months prior to their death • Characteristic murmur is harsh systolic ejection murmur that increases with Valsalva and diminish with lying supine (present about 25% of time) JAMA 1996

22. Hypertrophic cardiomyopathy • ECG with be abnormal in 95% of patients with HCM • Prominent Q waves • Deep negative T waves • Dramatic increases in QRS voltage with ST depression or T-wave inversion • Echocardiography remains the standard for diagnosis of HCM Circulation 1982

23. Coronary Artery Anomalies • Accounts for 17% of cases • Less than half of SCD cases have prodromal symptoms • Exertional syncope, chest pain, palpitations • Transthoracic echo NEJM 2003

24. Myocarditis • Accounts for 6% of SCD in US athletes • Coxsackievirus B implicated in 50% of cases • Also echovirus, adenovirus, influenza, and chlamydia pneumoniae • Prodromal viral illness followed by progressive exercise intolerance, dyspnea, cough, and orthopnea • ECG – diffuse low voltage, ST-T wave changes, heart block, or ventricular arrhythmias • Labs – leukocytosis, elevated ESR, C-reactive protein, elevated myocardial enzymes • Echocardiogram Circulation 2007

25. Arrhythmogenic Right Ventricular Cardiomyopathy • 4% of SCD in United States • 22% in Veneto region of northeastern Italy • 68% of athletes had prodromal symptoms • Syncope, chest pain, palpitations • Physical exam is normal • ECG • Precordial T-wave inversion, epsilon wave, prolongation of QRS, or RBBB • Echocardiogram Circulation 2007 NEJM 1998

26. Cardiovascular • Marfan syndrome • Cardiovascular complications are major cause of morbidity and mortality • Risk of aortic rupture or dissection increases during adolescence • Ghent criteria

27. Others • Aortic Stenosis • Coronary Artery Disease • Ion Channel Disorders • Long QT being most common

28. Cardiovascular • Hypertension • Elevated BP reported in 6.4% of athletes • Increase in body size • Use of appropriate charts and cuffs • Careful evaluation for secondary causes including CMP, hematocrit, UA and ECG Medicine and Science of Sports and Exercise 2004

29. Physical Exam • Auscultation for murmurs • Both supine and standing positions (or with valsalvamanuever) • Palpation of femoral pulses to exclude aortic coarctation • Examination for the physical stigmata of Marfansyndrome • A brachial artery blood pressure taken in the sitting position

30. EKG Discussion

31. EKG - Pro • Makes the clinical evaluation more effective • Poor incidence/prevalence data • 1:200,000 or 1:25,000 or 1:43,000 • False positive rate claims too high • Claim up to 20% new tool from University of Washington has data to significantly reduce • Similar to mammograms • Cost • Similar to HIV, HPV screening • Feasibility • YH4L here in Chicago perfect example of mass screening AMSSM 2012

32. EKG - Con • No argument that increases the potential dx of HCM, AV accessory pathway, RVCM, Burgada, LQTS • Unknown prevalance • What is the magnitude? • Does more harm that good? • Inappropriate invasive and expensive studies • Unnecessary athletic restriction • Is asymptomatic same as symptomatic? • Italy’s best rate is our current rate of SCD AMSSM 2012

33. Neurologic Conditions • Have you ever had a head injury or concussion? • Have you been hit in the head and been confused or lost your memory? • Have you ever had a seizure? • Do you have headaches with exercise? • Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? • Have you ever been unable to move your arms or legs after being hit or falling?

34. Definition A trauma-induced alteration in mental status that may or may not be accompanied by a loss of consciousness Neurology 1997

35. Definition Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathological, and biomechanical injury constructs that may be used in defining the nature of concussive head injury include: May be caused by direct blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to head Rapid onset of short lived impairment of neurological function that resolves spontaneously Neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury Graded set of clinical syndromes that may or may not involved loss of consciousness Grossly normal structural neuroimaging studies

36. Prevalence 300,000 to 2 million sports related concussions annually 40,000 in high school level Football accounting for 63% Sports with highest incidence of concussion in high school Football, ice hockey, soccer, wrestling, basketball, field hockey, baseball, softball, volleyball Estimated that 36% of college students will report a history of multiple concussions Collins et Al, JAMA 1999 Collins et al, Neurosurgy 2006

37. Observable Symptoms Loss of consciousness Poor coordination Impact seizure Gait unsteadiness Slow to answer questions Easily distracted Vacant stare Retrograde amnesia Posttraumatic amnesia (anterograde) Unusual or inappropriate emotions Vomiting Slurred speech Personality changes Inappropriate or decreased playing ability

38. Reported Symptoms Headache Nausea Dizziness Double or blurred vision Sensitivity to light and noise Ringing in ears Feeling “foggy” Amnesia Changes in sleep pattern Impaired concentration Irritability

39. Pathophysiology “metabolic mismatch” Cells exposed to changes in intracellular and extracellular environment Results in hyperglycolysis Increased Na/K ATP-ase activation Decreased cerebral vascular flow Possibly due to accumulation of endothelial Ca

40. Post-concussive Syndrome • Condition arising after a “head injury” that produces deficits in three areas of CNS functioning • Somatic (neurological) • Psychological • Cognitive • Occurs in 38% to 80% of people who experience “mild head trauma” • Majority of people recover fully in 4-6 months • Only 7-15% have symptoms 1 year after injury

41. Post concussive Syndrome • Cognitive • Verbal and nonverbal memory impairment, attention deficit • Somatic • Headache, dizziness, blurred vision, sensitivity to light or sound • Psychiatric • Personality changes, irritability, anxiety, and/or depression, apathy • Female gender, socioeconomic status, 40+, psychological disorder, prior head injury, headache history

42. Second Impact Syndrome • Believed to occur when an athlete who has sustained a head injury sustains a second one prior to complete resolution of the first • Athlete may walk of the field, then collapse, become semi-comatose, dilate pupils, and respiratory failure • Believed to be due to loss of auto-regulatory function of the brain’s blood supply • Precise incidence cannot be determined • More than 50% mortality and 100% morbidity

44. Concussion History • How many previous head injuries has the athlete experienced? • How did it occur? • What type of symptoms? • How long did each last? • Was there retrograde or posttraumatic amnesia? • How long were they held from practice? • Did they miss any competitions? • Did they have difficulty in their classes? • Were their grades typical for them that semester? • How long did it take them to feel 100%? • Are there other hits to the head that were not considered concussions?

45. Neurologic Conditions • Seizures • Athletes with good seizure control can participate in both collision and contact sports • Hx of new onset or after head injury deserves further review • Headaches • Burners or stingers • 52% college football players annually • Determine isolated or recurrent • Cervical cord neurapraxia • Cervical spine radiographs

46. Neurologic Conditions • Cervical cord neurapraxia • Cervical spine radiographs

47. Medical History • Has a doctor ever denied or restricted your participation in sports for any reason? • Only 1-2% of athletes completely disqualified • Do you have an ongoing medical condition? • Big picture of athletes general health • Assess control and affect of sport

48. Drugs and Supplements • Are you currently taking any prescription or nonprescription (over the counter) medicines or pills? • Double check medical history • Affect performance or banned from certain sports

49. Allergies and Anaphylaxis • Do you have allergies to medicines, pollens, foods, or stinging insects? • DO THEY CARRY EPI-PEN???

50. Paired Organs • Were you born without or are you missing a kidney, an eye, a testicle, or any other organs? • In general, absence of a paired organ does not limit the athlete from competing • Risks and ramifications of injury to remaining organ must be discussed