Transcript Title Page - Adolescent Health

Boston University School of Medicine asks all individuals involved in the development and
presentation of Continuing Medical Education (CME) activities to disclose all relationships with
commercial interests. This information is disclosed to CME activity participants. Boston
University School of Medicine has procedures to resolve apparent conflicts of interest. In
addition, presenters are asked to disclose when any discussion of unapproved use of
pharmaceuticals and devices is being discussed.
I, Albert C. Hergenroeder, MD have no commercial relationships to disclose.
Preparticipation Sports
Examination
Albert C. Hergenroeder, M.D.
Section of Adolescent Medicine
and Sports Medicine
SAHM Workshop 2015
Pediatrics
Goals
•The audience will understand the purposes and
administration of the preparticipation sports
examination (PPE)
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Objectives. The audience will be
able to discuss:
1. Purposes of the PPE/what form to use
2. Distinguishing PPE from annual visit
3. Administering the PPE
4. Key historical data
5. Most common complaints
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Objectives (cont’d). The
audience will be able to discuss:
6. Sudden death in sports
7. Key PE findings
8. Musculoskeletal exam
9. Laboratory evaluation
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#1 Objectives of the PPE
•Primary
‐Screen for life-threatening or disabling conditions
‐Screen for conditions that may predispose to injury or
illness
•Secondary
‐Determine general health
‐Serve as an entry point to health system
‐Opportunity to initiate discussion of health related topics
PPE 4th Edition AAP
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What form to use?
•American Academy of Family Physicians,
American Academy of Pediatrics, American
College of Sports Medicine. Preparticipation
Physical Evaulation. 4th Edition. Elk Grove.
American Academy of Pediatrics; 2010. (PPE 4)
•Added personal and family history questions
designed to identify rare channelopathies.
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How often does a PPE need to be
done? Who can do it
•80% states require an annual PPE.
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Caswell 2015
#2 PPE ≠ Annual evaluation
•Not comprehensive
•Does not address HEADDS
•Assumptions
‐Most athletes are healthy
‐Most have had previous medical evaluations
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#3 Administration
•Plan 6 weeks before season starts
‐May, prior to leaving school
•Station approach
‐More sensitive
•One provider doing evaluation
‐Faster and more holistic
•Know how you will handle work-ups and
disqualifications
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#4 History – most sensitive data
•Current injuries
•Menstrual history
•Injuries last year
•Weight changes
•Cardiac questions
•Recent illness
•Medical problems
•PMH
•Meds
•Concussion symptoms
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#5 What are the most common
complaints by athletes at the
PPE?
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(+) history reported at PPE
•Musculoskeletal
20%
•Concussion
5%
•Dizziness, fainting,
frequent headache, Sz
3%
•Current meds
3%
Durant 1992
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#6 Unexpected
sudden death in
athletes
Pediatrics
U.S National Registry of
Sudden Death in Athletes
U. of Minnesota, 1987 - 2006
Pediatrics
513/1866 unable
to ascribe
cause of death
Pediatrics
Deaths in sports from
cardiovascular or related causes
•Incidence is not known
Kaltman. NHLBI 2011
•75 – 100 sudden cardiac deaths in young
athletes/year in the U.S.
Maron 2009, 2012
•11% in females
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Public health context
•2,700 16-19 yo killed in MVA in US (2010)
CDC
•2,436 15-19 yo killed by guns in US (2009)
‐~ 2/3 homicide
Children’s Defense Fund
‐~ 1/3 suicide
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Sudden unexpected death
1-40 year olds
•25-40% are autopsy negative
•25-35% of these could be challenopathies
‐Most common LQTS
Drezner 2013
•27 (53%) of states have not updated their PPE
forms to include questions designed to screen for
channelopathies, from PPE4
Caswell 2015
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Abnormal ECG findings suggestive of primary electrical disease
Ventricular pre-excitation PR interval <120 ms with a delta wave (slurred upstroke in the QRS complex) and wide
QRS (>120 ms)
Long QT interval*
QTc ≥470 ms (male)
QTc ≥480 ms (female)
QTc ≥500 ms (marked QT prolongation)
Short QT interval* QTc ≤320 ms
Brugada-like ECG pattern High take-off and downsloping ST segment elevation followed by a negative T wave in
≥2 leads
in V1–V3
Profound sinus bradycardia
<30 bpm or sinus pauses ≥3 s
Atrial tachyarrhythmias Supraventricular tachycardia, atrial-fibrillation, atrial-flutter
Premature ventricular
contractions
Drezner 2013
≥2 PVCs per 10 s tracing
Ventricular arrhythmias Couplets, triplets, and non-sustained ventricular
tachycardia
Note: These ECG findings are unrelated to regular training or expected physiological adaptation to exercise, may
suggest the presence of pathological cardiovascular disease, and require further diagnostic evaluation.
*The QT interval corrected for heart rate is ideally measured with heart rates of 60–90 bpm. Consider repeating
the ECG after mild aerobic activity for borderline or abnormal QTc values with a heart rate <50 bpm.
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Sudden Cardiac Death in Sports
•Previous symptoms
‐Passing out when training
‐Chest pain
‐Irregular heart rate
•These symptoms preclude exercise until evaluated
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Cardiac syncope more likely if 1 of 4
factors (100% identified)
•Family history of:
‐Syncope; Heart problems (arrhythmias, congenital heart
disease, and cardiomyopathies); Sudden death in family
members younger than 50.
•Exertional syncope
•Abnormal PE or ECG
Tretter 2013; similar Ritter 2000
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Cardiac syncope less likely to have
•Previous syncope
•Prodromal symptoms (dizzy, visual, auditory
changes, nausea, diaphoresis)
•Trigger event
•Vasovagal more likely if standing for long time
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If cardiac history is positive
•Preclude from sports participation regardless of PE
•EKG
•ECHO
•Stress test with 12 lead EKG
•Event capture/holter monitor
Circulation 2004 36th Bethesda Conference
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Should screening ECG be part of
the PPE?
•30% won’t be identified by screening, including
ECG: coronary artery anomalies, some HCM,
dilated aorta, and dilated cardiomyopathy
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Should screening ECG be part of
the PPE?
•Corrado et al 2006
‐1982 law requiring PPE and 12 lead ECG
‐89% reduction in annual incidence of SCD 1979 – 2004
‐Intervention not just ECG: more meticulous PPE screening;
‐Elite Italian athletes, 24 yo, AA not included
‐MDs put in jail for missing ARVC
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Veneto vs. Minnesota
•No difference in rates of SCD over the 1993 – 2004
period
Maron 2009
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Should screening ECG be part of
the PPE?
•NHLBI report – not enough data to recommend
routine screening
•AHA does not endorse routine ECG screening
Circulation 2012
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Public pressure to “do
something”
•“Fortunately there is much more to do than wring
out hands in endless debate….
•Using the most accurate detection methods – a
combination of EKG and MRI - our mobile van has
screened 500 athletes and other students…
•We also know that sitting on the sidelines & doing
nothing while tragedy continues to strike is not at
Leader in the Texas Medical Center, Houston Chronicle 3/20/11
option.”
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Continued pressure to screen
•Local clinic in Texas is screening patients with
ECGs and having parents of youth who have died
as speakers for their testimonials.
•Advocating for legislation that if a player passes
out, has dizziness, they have to have a work-up
before clearance
‐Legislating medical decision making
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Can the PPE predict EIB?
•NO
•Allergic rhinitis, asthma or EIB was found in 11/24
subjects with EIB diagnosed by spirometry Hallstrand
TS 2002
•PE not helpful in PPE
•12% of athletes with EIB were using short acting ß2
•If short acting ß2 > 2x/week, use ICS
Boulet 2015
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#7 Key PE findings
•Physical examination
‐Height
‐Weight
•Overweight or underweight?
•What to do about >> 95% and < 5%?
‐Case by case
‐>> 95% concern about deconditioning
‐< 5% concern about malnutrition
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Predicting stress fx in female runners
•5.4% over 11 months (prospective)
•Prior fracture was 6x risk of stress fx over 12
months
•Menarche > 15
•BMI < 19
•Prior participation in dance or gymnastics
Tenforde 2013
‐Each increased risk 2-3x
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#7 Key PE findings (cont’d)
•Pulse
‐Resting < 40 beats per minute or > 120
•Temperature
‐Don’t exercise if temp > 100.8 o C
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#7 PE findings – ↑BP (cont’d)
•“Athletes found to have stage 2 hypertension or
findings of end organ damage should not be
allowed to participate in any competitive sport until
their bp is further evaluated, treated, and under
control, at which time eligibility for participation can
be reevaluated.”
•Limited evidence shows no greater risk of acute
events with strenuous dynamic or static exercise
PPE AAP 2010
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Age
Severe ↑BP ♂
(2010): >5 mm
above 99% for
height = 50%
Severe ↑BP ♀
(2010): >5 mm
above 99% for
height = 50%
12
137/95
136/94
14
142/96
139/96
17
149/100
142/97
> 18
160/100*
4th Task Force 2004; 36th Bethesda; JNC7*
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Classification of sports according to cardiovascular demands (based on combined static and
dynamic components).
Demorest 2010
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©2010 by American Academy of Pediatrics
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Relevance to football, other sports
•“In certain sports and team positions, bulk and
body mass are valued, expected, and promoted.
This practice should not be encouraged because of
the health risks associated with obesity…”
Demorest, et al AAP Policy Statement 2010
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Hypertension during weight
lifting
•Experienced weight lifters
•Intraarterial catheter, brachial artery
•Double leg press - Mean 355/281 mm Hg
MacDougal 1983 MSSE
•Single arm curls - Mean 293/230
•With large muscle groups contracting at great
force, SBP can exceed 300 mm Hg; DBP > 200.
MacDougal 1985 JAP
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#7 Key PE findings (cont’d)
•Limited PE
‐Visual acuity
•Best correct 20/40 or uncorrected < 20/200
•Corrective eyewear
‐Cardiac – lying and standing
‐Organomegaly
‐Paired organs
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#8 Musculoskeletal exam
•Musculoskeletal exam
‐2 minute exam
‐Done by a qualified health care provider
‐History more useful in predicting injury Garrick 2004
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#9 Laboratory evaluation
•Routine U/A and CBC not indicated
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Summary
PPE is not the same as an annual exam
Key historical data
Musculoskeletal
Cardiac – check to see if you have the PPE4
Sudden death
Cardiac >> Asthma and heat stroke
Pay attention to presyncope, palpitations
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Summary (cont’d)
•EIB cannot be predicted during PPE
•Stress fractures in females are higher if menarche
> 15, BMI < 19, previous stress fracture and prior
participation in dance or gymnastics
•Targeted PE: vs, eye, cardiac, paired organs
•No lab data indicated for all – case by case
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