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The Preparticipation Physical Exam

The Preparticipation Physical Exam. Jennifer A. Southard, MD, MSc Saint Alphonsus Medical Group Family Medicine and Sports Medicine NP Idaho Fall Conference August 24 , 2013. Objectives. Discuss purpose and timing of PPEs Give Overview of PPE Review 3 key areas: CV, Ortho, Neuro

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The Preparticipation Physical Exam

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  1. The Preparticipation Physical Exam Jennifer A. Southard, MD, MSc Saint Alphonsus Medical Group Family Medicine and Sports Medicine NP Idaho Fall Conference August 24, 2013

  2. Objectives • Discuss purpose and timing of PPEs • Give Overview of PPE • Review 3 key areas: CV, Ortho, Neuro • Identify conditions which warrant further investigation prior to allowing participation • Discuss populations of athletes with special considerations • Discuss clearing athletes for participation

  3. Purposes of the PPE Objectives of the PPE Primary Objectives 1. Screen for conditions that may be life-threatening or disabling 2. Screen for conditions that may predispose to injury or illness Secondary Objectives 1. Determine general health 2. Serve as an entry point to the healthcare system for adolescents 3. Provide opportunity to initiate discussion on health-related topics

  4. What the PPE is NOT: • PPEs should NOT replace routine health care or comprehensive physicals • The PPE is a screening tool to determine fitness for athletic participation • The PPE often takes place in a format which does not allow adequate time for anticipatory guidance • The PPE often takes place in a format which does not provide adequate privacy to discuss confidential issues

  5. Frequency and Timing of the PPE • Ideally do PPEs 4-6 weeks before athlete’s season to allow for eval/treatment of problems • NFHS: PPE necessary - but leaves to states to mandate & standardize • NCAA recommends & most institutions require annual exams • Youth / club sports - no formal requirements

  6. Effectiveness of PPE • Unknown as to: • Effectiveness of PPE as a screening tool • Lack of efficacy data for PPE • Little effect on morbidity & mortality • Ability of PPE to affect outcomes • Detect risk for catastrophic events

  7. Is the PPE a good screening tool? • Significant burden of disease in population • Preclinical stage is detectable and prevalent • Early detection improves outcome (mortality) with acceptable morbidity • Screening tests are acceptable to population, inexpensive, and relatively accurate • Effective treatment available for detected disease

  8. Approaches to the PPE • Historically: the HHH exam • Hi, how are ya? • Heart • Hernia

  9. Approaches to the PPE • Office Based: maximizes privacy, allows single examiner to complete entire exam, but inefficient for large groups of people. Recommended method • Locker-Room Approach: allows for one examiner to complete each part of the PPE but is also inefficient for large groups and does not allow for privacy • Station-Based: requires multiple examiners, each doing a different part of the exam. Improves efficiency and privacy

  10. The History and Physical AAFP AAP ACSM AMSSM AOSSM

  11. PPE: The History • History forms are very helpful • athletes and parents should jointly complete a history form prior to the PPE • Review form: 75% of issues detected through Hx alone • Web based history forms may be more convenient for the athletes (ePPE) • Preparticipation form recommended by the AAFP, AAP, AMSSM, and AOSSM is available in the Preparticipation Physical Evaluation, 4th ed. 2010.

  12. The Cardiovascular History • Screening for conditions that predispose to Sudden Cardiac Death • Most common cause of SCD in US athletes <30 is HCM

  13. AHA GuidelinesCirculation, 2007 • Personal History of: • Exertional chest pain • Syncope/near-syncope • Excessive fatigue • Prior murmur • Elevated BP • Family history of: • Premature CV Death • CV disease <50yo • Specific conditions (ie Marfans, Long QT, HCM, etc) Maron BJ et al. Circulation 2007;115:1643-1655

  14. AHA Guidelines • A positive finding on >=1 element on history is sufficient to warrant further CV investigation • Might include ECG, ECHO, Stress test or referral to cardiology

  15. The Neurologic History • At each PPE, athletes should be asked about previous neurologic problems: • Prior concussions • Previous neck injuries • Previous history of stingers/burners • Seizure history • Current neurologic symptoms (numbness, tingling, weakness, etc.) • Current learning/emotional problems

  16. Neurologic History • Consider baseline neurocognitive studies in athletes who have a history of: • Multiple concussions • School performance problems • ImPACT testing available to all Boise Public HS students, free, or $15 via STARS

  17. The Musculoskeletal History • Complete history of musculoskeletal injuries is important • Operations • Time lost from play • Prior rehab • Ongoing musculoskeletal complaints • Require a more complete history • Deserve detailed evaluation

  18. Screening for the Female Athlete Triad • All female athletes should be screened for the Female Athlete Triad WHAT MAKES UP THE FEMALE ATHLETE TRIAD???

  19. Provider Knowledge • 240 health care professionals (physicians, medical students, physical therapists, athletic trainers and coaches) were surveyed to determine their knowledge and comfort in treating the condition • Results • 48% of physicians, 43% of therapists, 38% of trainers, 32% of medical students and 8% of coaches could identify all 3 components • Only 9% of physicians felt comfortable treating the disorder Troy K, Hoch A, Stavrakos, J. Awareness and comfort in treating the female athlete triad: are we failing our athletes? Wisconsin Medical Journal. 2006;105(7): 21-24.

  20. Female Athlete Triad History • Not a new entity – various components have been noted for years • Defined in 1992 by American College of Sports Medicine • ACSM developed a Position Statement in 1997 • revised statement in 2007

  21. 1997 ACSM Position Statement • Syndrome that can develop in physically active girls and women with three interrelated components: • Disordered eating • Amenorrhea • Osteoporosis Otis CL, Drinkwater B, Johnson M, et al. American College of Sports Medicine Position Stand: The female athlete triad. Med Sci Sports Exerc 1997; 29(5): i-ix.

  22. The Female Athlete Triad Today • 2007 ACSM Definition (Renamed components) • Disordered Eating • Menstrual Dysfunction • Low Bone Mineral Density (BMD) • Greater emphasis on the full spectrum of behaviors and conditions within a given disorder. • The original version focused more on the extreme end point of each disorder. • Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

  23. Who is at Risk? • “Potentially all physically active girls and women could be at risk for developing 1 or more components of the Triad” • Sports that emphasize low body weight • Subjective scoring of performance (figure skating) • Endurance sports (distance running) • Body contour-revealing clothing (track, cheerleading, volleyball) • Weight categories (wrestling, horse racing) • Emphasis on prepubertal body habitus (gymnastics) • Male athletes are also at risk for disordered eating and anorexia nervosa

  24. Prevalence • Disordered Eating: 8% - 62% depending on population studied. • More prevalent in sports that emphasize lean physique BUT seen in all sports • Athletes 2.6x more likely than non-athletes to manifest DE Sx • Burckes-Miller et al: Study 695 NCAA Div I athletes • 3% met criteria for anorexia nervosa • 21% bulemia Burckes-Miller ME, Black DR. Male and female college athletes: prevalence of anorexia nervosa and bulimia nervosa. Athl Train J NatlAthl Train Assoc. 1988;23: 137-140.

  25. Prevalence • Menstrual Dysfunction: 6% - 79% depending on definitions used in study • Prevalence of secondary amenorrhea in adult female collegiate athletes reported at 14-66% compared to 2-5% of the general population • Low Bone Mineral Density: 22% - 50% (mainly osteopenia) Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13: 405-18.

  26. Prevalence of the Triad • Only 3 studies have examined all 3 disorders using direct measures of BMD in female athletes (DEXA) • The prevalence of all three components simultaneously: 0.4% - 2.2%. • Although prevalence small, presence of any of the three should warrant further provider investigation Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

  27. Etiology • In the 1970’s low body weight or low body fat was thought to be the primary cause of amenorrhea • Exercise-stress hypothesis • Deficit in energy availability

  28. Hypothalamic Dysfunction • Disruption of hypothalamic-pituitary-ovarian axis • Decrease in pulsatileGnRH disrupts pituitary secretion of LH and FSH • Disruption of LH and FSH pulsatility shuts down stimulation to the ovary, ceasing production of estradiol

  29. What causes hypothalamic dysfunction? • Deficit in energy availability

  30. Energy Availability • Dietary energy intake minus exercise energy expenditure OR • The amount of dietary energy remaining after exercise training to support physiological processes Loucks A & Nattiv A. The female athlete triad. Lancet 2005; 366:549-550.

  31. Disordered Eating • Includes a wide spectrum of unhealthy eating behaviors • Skipping meals or limiting calorie intake • Restricting certain foods such as those high in fat or protein • Binge eating or purging • Diet pills, laxatives, diuretics • Anorexia nervosa • Bulimia nervosa

  32. Disordered Eating • May be intentional or unintentional • Lose a few pounds before an event • “Inadvertently failing to balance energy expenditures with adequate energy intake”

  33. 2007 ACSM Definition:Menstrual Dysfunction • Includes the full spectrum of menstrual irregularities. • Luteal suppression • Anovulation • Oligomenorrhea • Amenorrhea • Primary – redefined by American Society of Reproductive Medicine as absence of menstruation by 15 years of age in girls with secondary sex characteristics • Secondary – absence of 3 consecutive cycles Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

  34. Menstrual Dysfunction • Prevalence studies • Wide range (2-35%) of prevalence estimates can be explained by methodologic differences among studies • differences in athletic populations studied • failure to control for OCP use • assessment and definition of menstrual dysfunction • Despite differences, menstrual dysfunction is more prevalent in sports that emphasize leanness • Menstrual dysfunction is NOT a normal part of training! Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

  35. 2007 ACSM Definition: Low Bone Mineral Density • Emphasis has been placed on the full spectrum of bone health. • Low bone mass • Stress fractures • Osteoporosis • Bone strength is characterized by bone mineral content and density as well as quality of bone • Bone quality refers to the process of bone turnover Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

  36. Bone Health • Estrogen suppresses osteoclast activity • Female athletes have higher BMD than nonathletic counterparts UNLESS they have menstrual dysfunction • Bone density declines in proportion to the number of menstrual cycles missed • Myburgh and colleagues showed a direct correlation between time spent amenorrheic and number of stress fractures • Low bone mineral density may be irreversible resulting in a lifetime lower bone density • Multiple studies show irreplaceable bone loss after 3 years amenorrhea • Risk of stress fractures is two-four fold higher in athletes with menstrual disturbances compared to those without

  37. Bone Health • Females gain more than 50% of skeletal mass during adolescence and reach peak bone mass between 18 and 25 years of age • Young women menstrual dysfunction during these years are at risk for losing 2% of bone mass annually instead of gaining 2-4%

  38. Bone Density • Consider DEXA for the following: • Amenorrheic > one year • BMI < 19 • Documented history of stress fracture Lo B, Hebert C, McClean A. The female athlete triad, no pain, no gain? Clinical Pediatrics 2003; 42(7) 573-580.

  39. How Should Athletes be evaluated for the Triad?

  40. Evaluation Options • History Questionnaire (easy and effective) • All • Blood Tests (measure ovarian steroid hormones) • High Risk • Dual Energy X-ray Absorptiometry (DEXA) • High Risk

  41. History • Female Athlete Triad Coalition Screening Questionnaire (ACSM and IOC): • 12 Questions • Sensitivity 91.5% • Specificity 74.2% • False Positive 25.8 % • False negative 38.5% Black DR, et al. Physiologic Screening Test for Eating Disorders/Disordered Eating Among Female Collegiate Athletes. Journal of Athletic Training. 2003:38; 4; 286-297.

  42. IHSAA PPE Questions (3/12 similar questions) • When was your first menstrual period? • When was your last menstrual period? • What was the longest time between periods last year?

  43. 9 questions not on IHASS PPE • Do you worry that you have lost control over how much you eat? • Do you make yourself vomit, use diuretics or laxatives after you eat? • Do you currently or have you ever suffered from an eating disorder? • Do you ever eat in secret? • Have you ever had a stress fracture?

  44. 9 questions not on IHASS PPE • Are you unhappy with your weight? • Are you trying to gain or lose weight? • Has anyone recommended you change your weight or eating habits? • Do you limit or carefully control what you eat?

  45. Laboratory Evaluation • CBC, CMP, ESR, Ferritin, VitB12, Folate, UA • EKG and/or echocardiogram if abnormal cardiac exam • TSH • Pregnancy test for amennorhea • LH, FSH to rule out premature ovarian failure • Prolactin to rule out pituitary tumor • Consider imaging • If hirsutism, free testosterone, DHEA-S, 17-hydroxy-progesterone to screen for adrenal or ovarian tumors • Progesterone Challenge • Medroxyprogesterone 5-10 mg for 5-10 days Lo B, Hebert C, McClean A. The female athlete triad, no pain, no gain? Clinical Pediatrics 2003; 42(7) 573-580.

  46. Treatment Goal • Restore reproductive and metabolic hormones by increasing energy availability • Increase energy intake • Reduce energy expenditure • Weight gain of 1-2 kilograms (or 2-3%) or 10% decrease in exercise load in either duration or intensity is often sufficient to reverse reproductive dysfunction! Loucks A & Nattiv A. The female athlete triad. Lancet 2005; 366:549-550

  47. Treatment Options • Educate • Correct energy deficit • Increase calories by 10% per week until target is reached. • Decrease activity levels to assist in correcting energy deficit. • Limit weight gain to 1-2 pounds per week

  48. Treatment Options • Add Calcium and Vit D supplement • Treatment for osteoporosis with bisphosphonates and calcitonin has not been tested in younger patients, nor patients with female athletic triad

  49. Hormone Therapy • No published longitudinal studies available on long term benefits of HRT to slow or reverse loss of BMD • Longest studies currently available 60 months • Several good studies show irreplaceable bone loss occurs after three years of amenorrhea • Minimal 4-11% BMD increases have been noted in women with hypothalamic amenorrhea on oral contraceptives • increases in BMD of 6-17% have been seen with spontaneous reversal of amenorrhea • Increases slow to 3% following year and plateau at BMD well below normal for age Goodman, L & Warren, M. The female athlete and menstrual function. Adolescent and Pediatric Gynecology. 2005;17(5): 466-470.

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