I am about to embark upon a controversial subject which has been debated among physicians and other health care providers for years. The issue of what should be considered necessary when examining competitive athletes prior to clearing them to participate in their sport and what tests may be appropriate and useful in providing the healthcare for the competitive elite athlete. Unfortunately many physicians were never athletes themselves and most athletes do not go on to become doctors. This is not to suggest that a physician that has never been an athlete themselves cannot be an excellent sports medicine physician. I only suggest that the common experience of the life-long athlete/physician serves to create a unique bond and understanding of empathy between the athlete/patient and the experienced well trained sports medicine physician. In short I raise these questions? If all other variables are equal such as training and experience, who will garner more credibility when addressing the healthcare issues of a competitive athlete Who will be trusted as relating to the problems an athlete may encounter? The average physician who does not exercise and may be overweight or the physician who is a fit, lifetime athlete and may in fact still be competing in sports?
The physician caring for the competitive athlete need know that the mind of the athlete is different than that of the common non-athlete patient. For one I have clearly experienced the pain tolerance of the athlete to exceed that of most non athletes. Athletes, in general are highly motivated individuals and my experience has been that they are highly compliant patients with regard to their treatment plan in context of getting over sickness or injury. Furthermore recent research suggests that the competitive athlete may possess a mental advantage in situations beyond the sports field or ice for that matter. Recent research at the University of Illinois at Urbana-Champaign found that overall, elite athletes did show faster response times in tasks outside the context of athletics.
What is to follow is my recommendations, some based on sound scientific evidence some based on my twenty five years of clinical experience in caring for athletes and my lifetime of experience as an athlete, coach and patient.
All competitive athletes should have a primary physician. Their captain, quarterback or go to guy. It is really not important if their physician is a primary care doctor, internal medicine doctor or orthopedic surgeon. It's more important that their physician is trained and experienced in caring for this unique group of patients. Many Sports Medicine doctors have either trained in sports medicine fellowships or have many years of experience as team doctors or both. As sports science continues to evolve it is important that the athlete chooses a physician who is active in teaching at a medical school, residency or sports medicine fellowship and continues his or her education through conferences, symposia and continuing medical education credit. In either case, a recommendation from other athletes or teams and or physicians may serve the athlete well.
When first interviewing the athlete a good history should be obtained and is paramount. Document all history of injuries, hospitalizations, head trauma, concussions, loss of consciousness and a family history of sudden cardiac death. Interrogate the athlete concerning episodes of loss of consciousness, chest pain, palpitations, racing heart rate at rest or during exertion. These may be clues to underlying cardiac disease. I support the recommendations of the American College of Cardiology and their approach to pre-participation cardiovascular examination of the competitive athlete with one addition. I am a proponent of cardiac ultrasound (echocardiography) to assess every athlete for anatomic and congenital heart abnormalities including but not limited to bicuspid aortic valve, Hypertrophic Cardiomyopathy, Mitral Valve Prolapse and Concentric Left Ventricular Hypertrophy. Cardiac ultrasound is noninvasive, inexpensive and easy to perform and provides a great deal of information. It also may disclose an anatomic abnormality which would preclude an athlete from participating and therefore may also save a life.
4 Steps for Diagnosing Cardiovascular Abnormalities in Competitive Athletes
1. Use the 12-point American Heart Association Recommendations for Screening for Cardiovascular Abnormalities in Competitive Athletes, (below)
2. An Electrocardiogram
3. Conduct more advanced testing in certain individuals based on what you believe you will find. (i.e., echocardiography, exercise and cardiopulmonary stress testing, ambulatory arrhythmia monitoring, advanced imaging such as cardiovascular computed tomography or magnetic resonance imaging or angiography to assess for congenital anatomic abnormalities)
4. Apply 36th Bethesda guidelines determining eligibility to participate, available at www.acc.org/qualityandscience/clinical/bethesda/beth36/index.pdf
1. Exceptional Chest Pain
2. Unexplained syncope/near syncope #
3. Excessive exceptional and unexplained shortness of breath/fatigue associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in 1 or more relatives
7. Disability from heart disease in a close relative <50 years of age
8. Specific knowledge of certain cardiac conditions in family members: hypertrophic Cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan Syndrome, or clinically important arrhythmias
9. Heart Murmur ++
10.Femoral pulses to exclude aortic coarctation
11.Physical Stigmata of Marfan Syndrome
12.Brachial Artery Blood Pressure (sitting position)
*Parental verification is recommended for high school and middle school athletes
# judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion
++ Auscultation should be performed in both the supine and standing positions (or with valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction
Source: Marron, BJ., et al (2007) Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and metabolism: Endorsed by the American College of Cardiology Foundation. Circulation 1151643-55.
The modern athlete scarcely resembles that of the athlete of a generation ago. Considering the advances in nutrition, improvements in training methods, athlete conditioning, strength and advancement in equipment athletes are bigger, faster, stronger and more highly skilled. Since the size of the playing field or ice surface has not changed in any major sports this has created less time and space for the athlete to operate translating into an epidemic of traumatic brain injuries (TBI, concussion). For this reason I see the first encounter with the competitive contact sport athlete a natural opportunity to perform baseline neurocognitive and neurophysical testing.
Baseline neurocognitive (ImPACT@*) and neurophysical (Biodex Balance-SD) testing in the competitive athlete at risk for traumatic Brain Injury (TBI) or concussion provides an objective scientifically validated measure of neurocognitive (brain) and neurophysical function. ImPACT takes approximately 20 minutes to complete. The program measures multiple aspects of cognitive functioning in athletes, including: Attention span, working memory, sustained and selective attention time, response variability and non-verbal problem solving.
ImPACT can be administered by an athletic trainer, school nurse, athletic director, team doctor or psychologist, provided that they have completed training in the administration of the test. Post-concussion care and the management of concussion should only be administered by a trained medical professional. Given the inherent difficulties in concussion management, it is important to manage concussions on an individualized basis and to implement baseline testing and/or post-injury neurocognitive testing. This type of concussion assessment can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion.
Maintaining postural balance involves complex coordination and integration of multiple sensory, motor and biomechanical components. Sensory feedback from visual, vestibular and somatosensory systems is not properly processed during the first few days after concussion; the motor limb of neurological function should be assessed along with the neurocognitive domain of function. The Clinical Test of Sensory Integration of Balance (CTSIB) can be easily and quickly tested utilizing the Biodex Balance-SD. The combination of ImPACT and Biodex Balance-SD can be accomplished in experienced specialized centers in less than forty five minutes. These two examinations should be considered the cornerstone of proper concussion management, enabling the TBI specialist with the objective tools to guide appropriate safe return to play timing.
In addition to history, physical examination cardiovascular screening including EKG and Echocardiography, ImPACT@ Testing and Biodex Balance-SD Testing I am a proponent of general blood serology's including a complete blood count, comprehensive metabolic profile including liver and kidney function, thyroid function studies, serum estrogen and testosterone levels in appropriate gender and age patients.
Muscle strength testing and measurement of (REE) Resting Energy Expenditure and (VO2Max) Anaerobic threshold can be performed in Junior, Collegiate and Professional athletes if the medical staff plans to track their athletes fitness levels throughout the season. I do not necessarily think these studies should be universally applied to all youth athletes but suggest that these modalities of testing are extremely useful to track any athlete's progress during a strength training or aerobic conditioning program.
* ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the first, most-widely used, and most scientifically validated computerized concussion evaluation system.
Developed in the early 1990's by Drs. Mark Lovell and Joseph Maroon, ImPACT is a 20-minute test that has become a standard tool used in comprehensive clinical management of concussions for athletes of all ages. ImPACT Applications, Inc. was co-founded by Mark Lovell, PhD, Joseph Maroon, MD, and Michael (Micky) Collins, PhD.
Biodex Balance-SD provides dynamic balance assessment of single-leg and two-leg stance. It is used to assess overall dynamic stability and balance for pre-season baseline, injury pre-disposition or return to activity. In addition, use for balance and proprioceptive training.
Dr. Salvatore Trazzera, a Board Certified Cardiologist and Sports Medicine Physician has rapidly established himself as the athletes and fitness conscious individual's physician. His life long experience as a competitive athlete combined with his extensive medical training, knowledge and clinical experience provide an uncommon combination of skills which allow him to relate to his athletes in a way unique to few physicians. As owner and supervising team physician of professional, Jr. A and youth hockey programs for NYTEX Sports, Suffolk PAL and the Texas Brahmas of the Central Hockey League he has introduced a concussion prevention and management program utilizing state of the art clinical neurocognitive (ImPACT@) and neurophysical (Biodex Balance SD@) assessment. This program will help to guide athletes to safer timing of return to play minimizing recurrent and long term injury further decreasing post concussive cognitive impairment. www.farmingdaleheart.com
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