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  • athletic screenings

    1 of 1 DOCUMENT

    Copyright 2003 Gale Group, Inc.
    ASAP
    Copyright 2003 Dowden Health Media, Inc.

    Journal of Family Practice

    February 1, 2003

    SECTION: No. 2, Vol. 52; Pg. 127; ISSN: 0094-3509

    IAC-ACC-NO: 97724146

    LENGTH: 4678 words

    HEADLINE: A thorough yet efficient exam identifies most problems in school
    athletes; Applied evidence: research findings that are changing clinical
    practice.

    BYLINE: Carek, Peter J.; Mainous, Arch G., III

    BODY:

    Practice recommendations

    * A complete medical history, preferably from the student and a parent, will
    reveal approximately 75% of problems affecting initial athletic participation
    (D).

    * For asymptomatic athletes with no previous injuries, a 90-second screening
    musculoskeletal test will detect 90% of significant musculoskeletal injuries
    (A).

    * A routine screening need not include noninvasive cardiac testing or
    laboratory tests such as urinalysis, blood count, chemistry profile, lipid
    profile, ferritin level, or spirometry (B).

    Is the preparticipation physical examination the best way to determine
    whether a student athlete can participate fully in his or her chosen sport? This
    examination has become the standard of care for the over 6 million high school
    and college students. While most athletes pass the exam without significant
    medical or orthopedic abnormalities being noted, it often detects conditions
    that may predispose an athlete to injury or limit full participation in certain
    activities. We describe an efficient approach to the
    preparticipation examination.

    Although many organizations have adopted the preparticipation exam there has
    been considerable debate on its content and usefulness. (l-4) Nevertheless,
    sponsoring institutions continue to require the medical evaluation prior to
    competition in organized athletics, so family physicians should be knowledgeable
    about the objectives and limitations of the exam.

    The American Academy of Family Physicians, the American Academy of
    Pediatrics, the American Medical Society for Sports Medicine, the American
    Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of
    Sports Medicine established the Preparticipation Physical Examination Task
    Force. The recommendations of this task force serve as a guide for the physician
    conducting these examinations for high school and collegiate athletes. (5,6)

    * ASSESSING RISKS OF MORTALITY AND MORBIDITY

    The mortality associated with athletic participation is most often the
    result of sudden cardiac death, which occurs in about 0.5 per 100,000 high
    school athletes per academic year and is most commonly due to hypertrophic
    cardiomyopathy. (7,8) Screening for predisposing conditions is limited by the
    low prevalence of relevant cardiovascular lesions in the general youth
    population, the low risk of sudden death even among persons with an unsuspected
    abnormality, and the large number of school athletes. (7-9)

    An estimated 200,000 children and adolescents would have to be screened to
    detect the 500 athletes who are at risk for sudden cardiac death and the 1
    person who would actually experience it. (10) Even when cardiac abnormalities
    are detected, the findings leading to disqualification are most often rhythm and
    conduction abnormalities, valvular abnormalities, and systemic hypertension,
    which are not the cardiac abnormalities usually associated with sudden cardiac
    death in athletes. (11,12)

    The majority of sudden deaths are associated with 4 sports: football,
    basketball, track, and soccer. Approximately 90% of athletic-field deaths have
    occurred in males, mostly high school athletes. (7,13)

    More frequently than mortality, athletic participation places the individual
    at risk for acute injury or worsening of an underlying medical condition. These
    conditions are most commonly musculoskeletal, cardiovascular, or ophthalmologic
    (Table 1). (5,9,21)

    Nine studies of the preparticipation exam done between 1980 and 1999 show
    general agreement on the rates at which it qualifies (84.8% to 96.6%), qualifies
    with conditions (3.1% to 13.9%), and disqualifies students for sports
    participation (0.2% to 2.6%). (14-22)

    * WHAT SHOULD THE MEDICAL HISTORY INCLUDE?

    The examining physician should obtain a medical history from each
    participant (strength of recommendation [SOR]: D). A complete medical history
    will identify approximately 75% of problems that will affect initial athletic
    participation and serves as the cornerstone of the exam. (14,19) Most conditions
    requiring further evaluation or restriction will be identified from the medical
    history. Rifat and colleagues (21) noted that a complete medical history
    accounted for 88% of the abnormal findings and 57% of the reasons cited for
    activity restriction. The Preparticipation Physical Evaluation Task Force has
    developed a history form that emphasizes the areas of greatest concern. (5)

    In particular, examining physicians should ask regarding risk factors and
    symptoms of cardiovascular disease (Table 2). You should confirm a positive
    response to any of these questions, and conduct further evaluation if necessary.
    Unfortunately, most athletes with hypertrophic cardiomyopathy do not report a
    history of syncope with exercise or a family history of premature sudden cardiac
    death due to the disease.

    Musculoskeletal injury is a common cause for disqualification of an athlete.
    (14,19,21) The most common injury to restrict participation is a knee injury,
    with an ankle injury the next most common. (23) The strongest independent
    predictor of sports injuries is a previous injury (odds ratio [OR]=9.4) and
    exposure time (OR=6.9). (24) DuRant and colleagues (23) found that a previous
    knee injury or knee surgery was significantly associated with further knee
    injuries during the subsequent sports season when compared with individuals who
    did not report previous knee injury or surgery (30.6% vs. 7.2%, P=.0001).

    Additional historical information has been recommended for inclusion (SOR:
    D). For example, the examining physician should question the athlete about
    wheezing during exercise. Due to the high rate of recurrence and potential for
    long-term adverse effects, he or she should also obtain a history of previous
    concussions. Other issues to be addressed include presence of a single bilateral
    organ and use of performance-enhancing medication. Finally, physicians should
    question female athletes regarding their menstrual history and other symptoms or
    signs of the female athletic triad (eating disorder, amenorrhea, and
    osteoporosis).

    Always carefully review the information provided by the athlete and his or
    her parents. In 2 separate studies, minimal agreement was found between
    histories obtained from athletes and parents independently. (19,25) We do not
    know which source provides the most accurate history; therefore, both the
    parents and student athlete should be questioned.

    * WHAT SHOULD THE PHYSICAL EXAMINATION INCLUDE?

    A complete physical examination is not necessary (SOR: D). (5) The screening
    physical examination should include vital signs (ie, height, weight, and blood
    pressure) and visual acuity testing as well as a cardiovascular, pulmonary,
    abdominal, skin, genital (for males), and musculoskeletal examination. Further
    examination should be based on issues elicited during the history.

    Cardiovascular examination

    The cardiovascular examination requires an additional level of detail.
    Perform auscultation of the heart initially with the patient in both standing
    and supine position, and during various maneuvers (squat-to-stand, deep
    inspiration, or Valsalva's maneuver), as these maneuvers can clarify the type of
    murmur.

    Any systolic murmur grade III/VI or louder, any murmur that disrupts normal
    heart sounds, any diastolic murmur, or any murmur that intensifies with the
    previously described maneuvers should be evaluated further through diagnostic
    studies (echocardiography) or consultation prior to participation. Sinus
    bradycardia and systolic murmurs are commonly found, occurring in over 50% and
    between 30% and 50% of athletes, respectively; they do not warrant further
    evaluation in the asymptomatic athlete. (26) Third and fourth heart sounds are
    also commonly found in asymptomatic athletes without underlying heart disease.
    (26,27)

    Noninvasive cardiac testing (eg, electrocardiography, echocardiography, or
    exercise stress testing) should not be a routine part of the screening
    preparticipation exam (SOR: B). (7) These tests are not cost-effective in a
    population at relatively low risk for cardiac abnormalities and cannot
    consistently identify athletes at actual risk. (28-32) For example, a
    substantial minority of subjects (11%) were found to have a clinically
    significant increased ventricular wall thickness, which made clinical
    interpretation of the echocardiographic findings difficult in individual
    athletes. (28) Furthermore, some patients with hypertrophic cardiomyopathy are
    able to tolerate particularly intense athletic training and competition for many
    years, and even maintain high levels of achievement without incurring symptoms,
    disease progression, or sudden death. (29)

    Echocardiography and stress testing are the most commonly recommended
    diagnostic tests for patients with an abnormal cardiovascular history or
    examination. With the assistance of clinical information, echocardiography is
    able to distinguish the nonobstructive hypertrophic cardiomyopathy from the
    athletic heart syndrome. (33)

    Musculoskeletal examination

    A screening musculoskeletal history and examination in combination can be
    used for asymptomatic athletes with no previous injuries (Table 3) (SOR: A).
    (34) An accurate history is able to detect over 90% of significant
    musculoskeletal injuries. The screening physical examination is 51% sensitive
    and 97% specific. (34) If the athlete has either a previous injury or other
    signs or symptoms (ie, pain; tenderness; asymmetries in muscle bulk, strength,
    or range of motion; any obvious deformity) detected by the general screening
    examination or history, the general screening should be supplemented with
    relevant elements of a site-specific examination.

    Additional forms of musculoskeletal evaluation are often performed for
    athletes to determine their general state of flexibility and muscular strength.
    While various degrees of hyperlaxity, muscular tightness, weakness, asymmetry of
    strength or flexibility, poor endurance, and abnormal foot configuration may
    predispose an athlete to increased risk of injury during sports competition,
    studies have failed to demonstrate conclusively that injuries are prevented by
    interventions aimed at correcting such abnormalities. (35-37)

    Role for lab tests?

    Studies do not support the use of routine laboratory or other screening
    tests such as urinalysis, complete blood count, chemistry profile, lipid
    profile, ferritin level, or spirometry as part of the exam (SOR: B). (38-41)

    * DETERMINING CLEARANCE

    Occasionally, an abnormality or condition is found that may limit an
    athlete's participation or predispose him or her to further injury. In these
    cases, the examining physician should review the following questions: (5)

    1. Does the problem place the athlete at increased risk for injury?

    2. Is another participant at risk for injury because of the problem?

    3. Can the athlete safely participate with treatment (ie, medication,
    rehabilitation, bracing, or padding)?

    4. Can limited participation be allowed while treatment is being completed?

    5. If clearance is denied only for certain sports or sport categories, in
    what activities can the athlete safely participate?

    Physicians should base clearance to participate in a particular sport on
    previously published guidelines, such as the recommendations by the American
    Academy of Pediatrics, the 26th Bethesda Conference, and the American Heart
    Association. (7,43,44) Participation recommendations are based on the specific
    diagnosis, though multiple factors such as the classification of the sport and
    the specific health status of the athlete affect the decision. (44)

    * APPROACH TO THE PATIENT

    While current research demonstrates that the preparticipation physical
    examination has no effect on the overall morbidity and mortality rates in
    athletes, these exams may fulfill other objectives. Furthermore, no harmful
    effects of these examinations have been reported, and the exam has become
    institutionalized in the athletic and sports medicine community. As such,
    physicians should base their evaluation on the best available evidence using the
    standard form shown in "Preparticipation physical evaluation for athletics." (6)
    (A copy of the Preparticipation Physical Evaluation form can be found at
    www.jfponline.com.) This may require that the physician work with local school
    systems to assure that they understand what constitutes an appropriate
    examination.

    To assist future patient care decisions and research efforts, a standardized
    preparticipation physical examination with an associated form similar to the
    evaluation recommended by the Preparticipation Physical Evaluation Task Force
    should be uniformly implemented throughout the country. The use of consistent
    clearance criteria as recommended by the Preparticipation Physical Evaluation
    Task Force or the American Academy of Pediatrics ("Medical conditions and sports
    participation," also available at www.jfponline.com) should be used, studied,
    and revised as needed. (5,44)

    In addition to the exam, physicians should consider exploring other aspects
    of sports participation to assist athletes in reducing the risk of injury.
    Rules, equipment, or other factors may have a greater effect on decreasing the
    mortality and morbidity associated with athletic participation. A marked
    decrease in cervical spine injuries occurred following the rule change in
    football banning deliberate "spearing"--the use of the top of the helmet as the
    initial point of contact in making a tackle. (41)

    TABLE 1



    Medical and orthopedic conditions

    resulting in additional evaluations



    Lively,

    Rifat, 1995 * 1999

    ([dagger])



    n=2,574 n=596



    Pass with Follow-up

    follow-up Fail with or

    and/or follow-up restriction

    restriction (2.6%) (14.1%)

    (12.6%)



    Medical (% of overall total) 76.6 74.1 55.4

    Cardiovascular 18.3 35.0 63.0

    Dermatologic 6.8

    Endocrinologic 0.4

    Ear, nose, and throat 9.6 2.5

    Gastrointestinal 0.9 2.2

    Genitourinary 9.6 12.5 8.7

    Gynecologic 4.4

    Infectious 0.4 6.5

    Neurologic 6.5

    Ophthalmologic 26.0 25.0 6.5

    Psychological 2.2

    Pulmonary 14.2 2.5

    Other ([double dagger]) 13.7 22.5

    Total medical (%) 100.0 100.0 100.0

    Orthopedic (% of overall total) 23.4 25.9 44.6

    Ankle/Foot 14.9 7.7 2.7

    Back/Neck 22.4 14.3 5.4

    Elbow 5.4

    Hand/Wrist 1.5 10.9

    Knee 41.8 7.1 43.2

    Leg 5.4

    Shoulder 27.0

    Nonspecific pain/injury 19.4 71.4

    Total orthopedic (%) 100.0 100.0 100.0



    * Studied junior high and high school students. Two individuals

    failed (nonspecific pain/injury).



    ([dagger]) Studied college-aged students. One individual

    failed (complicated pregnancy).



    ([double dagger]) "Other" includes abdominal pain, allergy,

    bruising, chest pain, chronic/recurrent illness, dizziness/

    syncope with exercise, surgery (recent).



    TABLE 2



    Questions to help discern cardiovascular risk



    Have you ever passed out during or after exercise?

    Have you ever been dizzy during or after exercise?

    Have you ever had chest pain during or after exercise?

    Do you get tired more quickly than your friends during exercise?

    Have you ever had racing of your heart or skipped heartbeats?

    Have you ever had high blood pressure or high cholesterol?

    Have you been told you have a heart murmur?

    Has any family member or relative died of heart problems or of

    sudden death before age 50?

    Have you had a severe viral infection (for example, myocarditis or

    mononucleosis) within the last month?

    Has a physician ever denied or restricted your participation in sports

    for any heart problem?



    TABLE 3



    The "90-second" musculoskeletal screening examination



    Instruction Observations



    Stand facing examiner Acromiclavicular joints: general

    habitus

    Look at ceiling, floor, over both Cervical spine motion

    shoulders, touch ears to

    shoulder

    Shrug shoulders (resistance) Trapezius strength

    Abduct shoulders to 90[degrees] Deltoid strength

    (resistance at 90[degrees])

    Full external rotation of arms Shoulder motion

    Flex and extend elbows Elbow motion

    Arms at sides, elbows at Elbow and wrist motion

    90[degrees] flexed; pronate and

    supinate wrists

    Spread fingers; make fist Hand and finger motion, strength,

    and deformities

    Tighten (contract) quadriceps; Symmetry and knee effusions, ankle

    quadriceps effusion relax

    "Duck walk" away and towards Hip, knee, and ankle motions

    examiner

    Back to examiner Shoulder symmetry; scoliosis

    Knees straight, touch toes Scoliosis, hip motion, hamstring

    tightness

    Raise up on toes, heels Calf symmetry, leg strength

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    Corresponding author: Peter J. Carek, MD, MS, Associate Professor,
    Department of Family Medicine, Medical University of South Carolina, 9298
    Medical Plaza Drive, Charleston, SC 29406. E-mail: [email protected].
    Knowledge is power ... Stay informed!
    YOU can make a difference - all you have to do is try!

    Dx age 12 current age 46 and counting!
    lost: 5 family members to HCM (SCD, Stroke, CHF)
    Others diagnosed living with HCM (or gene +) include - daughter, niece, nephew, cousin, sister and many many friends!
    Therapy - ICD (implanted 97, 01, 04 and 11, medication
    Currently not obstructed
    Complications - unnecessary pacemaker and stroke (unrelated to each other)

  • #2
    Re: athletic screenings

    Furthermore, some patients with hypertrophic cardiomyopathy are
    able to tolerate particularly intense athletic training and competition for many
    years, and even maintain high levels of achievement without incurring symptoms,
    disease progression, or sudden death. (29)

    Where exactly are these people getting their info I thought one of the first things you stopped with HCM was competitive sports.


    2

    I don't know but I think someone might have been "cracking smoke" when they made that statement!
    Just my two cents

    Mary S.

    Comment


    • #3
      Re: athletic screenings

      Mary, you're too funny!! But I agree. Now, if only I could read Japanese and figure out what these guys are arguing about....

      Reenie

      ****************
      Husband has HCM.
      3 kids - ages 23, 21, & 19. All presently clear of HCM.

      Comment


      • #4
        Re: athletic screenings

        Mary, there maybe some validity in that statement.
        My symptoms did not appear until 20 - 21 years of age.
        Prior to that I played hockey, football, baseball and track and field and was participarting at a fairly high level of training, I was also running 5 miles several times a week.
        Whenever I read about another athelete suddenly dying I thank my lucky stars because it could very well have been me.
        However in the years I was competing I did not know I had HCM, and I did, as many other have, survive.
        Once I was diagnosed I had to stop all that and now do only moderated exercise.
        Every great thing that has ever happened since the beginning of time has started as a single thought in someones mind.
        So if you are capable of thought then you are capable of great things
        Good luck and stay well.
        Glen

        Comment


        • #5
          Re: athletic screenings

          Originally posted by Glen Beamish
          Mary, there maybe some validity in that statement.
          My symptoms did not appear until 20 - 21 years of age.
          Prior to that I played hockey, football, baseball and track and field and was participarting at a fairly high level of training, I was also running 5 miles several times a week.
          Whenever I read about another athelete suddenly dying I thank my lucky stars because it could very well have been me.
          However in the years I was competing I did not know I had HCM, and I did, as many other have, survive.
          Once I was diagnosed I had to stop all that and now do only moderated exercise.
          I think the what they maybe saying is that some with HCM and does not know can survive many years without incident
          Every great thing that has ever happened since the beginning of time has started as a single thought in someones mind.
          So if you are capable of thought then you are capable of great things
          Good luck and stay well.
          Glen

          Comment


          • #6
            Re: athletic screenings

            Originally posted by Glen Beamish
            Originally posted by Glen Beamish
            Mary, there maybe some validity in that statement.
            My symptoms did not appear until 20 - 21 years of age.
            Prior to that I played hockey, football, baseball and track and field and was participarting at a fairly high level of training, I was also running 5 miles several times a week.
            Whenever I read about another athelete suddenly dying I thank my lucky stars because it could very well have been me.
            However in the years I was competing I did not know I had HCM, and I did, as many other have, survive.
            Once I was diagnosed I had to stop all that and now do only moderated exercise.
            I think the what they maybe saying is that some with HCM and do not know can survive many years without incident
            Every great thing that has ever happened since the beginning of time has started as a single thought in someones mind.
            So if you are capable of thought then you are capable of great things
            Good luck and stay well.
            Glen

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            • #7
              Re: athletic screenings

              Originally posted by Glen Beamish
              Originally posted by Glen Beamish
              Originally posted by Glen Beamish
              Mary, there maybe some validity in that statement.
              My symptoms did not appear until 20 - 21 years of age.
              Prior to that I played hockey, football, baseball and track and field and was participarting at a fairly high level of training, I was also running 5 miles several times a week.
              Whenever I read about another athelete suddenly dying I thank my lucky stars because it could very well have been me.
              However in the years I was competing I did not know I had HCM, and I did, as many other have, survive.
              Once I was diagnosed I had to stop all that and now do only moderated exercise.
              I think what they maybe saying is that some with HCM and do not know can survive many years without incident
              Every great thing that has ever happened since the beginning of time has started as a single thought in someones mind.
              So if you are capable of thought then you are capable of great things
              Good luck and stay well.
              Glen

              Comment


              • #8
                Re: athletic screenings

                Geeeez, looks like I was trying to hog this posting, sorry.
                Every great thing that has ever happened since the beginning of time has started as a single thought in someones mind.
                So if you are capable of thought then you are capable of great things
                Good luck and stay well.
                Glen

                Comment


                • #9
                  Re: athletic screenings

                  I passes several athletic screenings and competed in gymnastics for close to 10 years plus played softball and track. Nothing happened to me thank goodness, but when I see the info about echo's not being worth the expense I always think... what if it was you or your child, wouldn't it be worth it. Of course I wasn't diagnosed then, but I suspect that I had it during that time period because that's the same time period I passed out on the roller coaster. Of course it's only speculation on my point. Still the main concern is for those who have it and don't know it and participate in sports without having the knowledge.

                  Amy N.

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