Improving People’s Lives through innovations in personalized health care

1. The Preparticipation Physical Exam Kelsey Logan, MD, MPH, FAAP, FACP OSU Sports Medicine Improving People’s Lives through innovations in personalized health care

2. I have nothing to disclose.

3. Overview • Why do a PPE? • History components • Musculoskeletal exam • Medical exam • Hot topics

4. Published 2010 • Collaboration between AAP, AAFP, ACSM, AMSSM, AOSSM, AOASM • Endorsed by AHA, NATA

5. 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!

6. 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

7. 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

8. 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

9. 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

10. 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

13. 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

14. 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

15. 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

16. Musculoskeletal abnormalities accounted for 43.4% of athletes not cleared Cardiac abnormalities accounted for 18.9% 2 athletes with severe HTN 1 with syncope 6 with dizziness/near-syncope 1 after heart operation None had family history of cardiac death

17. Vision abnormalities accounted for largest population of Cleared with Follow-Up Recommended dispositions – 53.5% Musculoskeletal problems accounted for 27.8%

18. 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

19. 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

20. History Components • Medical • Recent/chronic problems • Hospitalizations • Surgical procedures • Prescription/nonprescription medications • Allergies or anaphylactic reactions to medications, insects, foods, exercise

21. 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

22. 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

23. The Physical Exam • Important areas • Blood pressure • Vision screening • Musculoskeletal screening • Cardiovascular screening

24. 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

25. 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

26. 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

27. Inspection of athlete from behind • Back flexion and extension • Duck walk • Heel, toe stance/walk

28. 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

29. 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

30. 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

31. 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?

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Cardiovascular History Should ask about Chest pain Syncope Exercise tolerance Palpitations Heart murmur history Elevated BP in past Family history of cardiac problems

40. 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.

41. 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

42. 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

43. “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

44. 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

45. sportsmedicine.osu.edu