So today, Dr. David Bernhardt will be lecturing on the PPE during COVID-19 and a little bit on disqualifying conditions. We're fortunate to have him. He's board certified in pediatrics and did all of his training at Wisconsin Madison, but he's the fellowship director there as well as a team physician. He mainly works with men's basketball, women's volleyball, and cross country and track, and was formerly on the MSM board of directors, but he's heavily involved with the writing of the PPE book. So we're definitely fortunate to have him lecture us today, done a lot of publications on the cardiovascular screening related to the PPE, PPE in general. And then I'll go ahead and submit your, let me do some housekeeping before we start. Mute, submit your questions in the chat, and again, this is an adjunct to the fellowship education, what are, what's already going on in your fellowship program and to help assist with the CAQ exam preparation. And my name is Heather Saffel. I was a fellow representative at Emory this past year, and then I'm now going to be faculty at the South Bend Notre Dame Fellowship. And without further ado, I'll let Dr. Bernhardt go ahead and get started. All right. Thank you, Heather. You're welcome. Stop sharing. Okay. I think we're rolling. So I don't have any conflicts of interest, I don't think. I do want to point out that normally in a lecture format like this, it would be much easier if we could all interact. But I think due to the awkwardness of trying to see questions and answer them during a talk while doing online lecturing, it becomes a significant challenge. So at the end, I will definitely stay on to answer any and all questions that you have the courage to ask in front of others, or you can just send a text chat and I'm happy to answer them that way. So hopefully everybody will get their questions answered by the time we're done today. The other thing I would encourage everybody, and I'm sure you've heard this before from other people who are speaking, who have significant involvement with AMSSM, is get involved. So you can get involved in lots of different committees now through AMSSM and the websites. But definitely when you finish your fellowship, please get involved in any and all committees, whether it's policymaking, advocacy, writing groups, research, education. That's the only way this organization grows, is with diversity and others' ideas. So I highly, highly encourage everybody to get involved. Now, uh-oh, let's see, there we go. So today we're going to talk about pre-participation screening. And although the advertisement today was going to be that we were going to talk about just disqualifying conditions, I'm actually going to talk more about pre-participation screening during the COVID pandemic. And the reason for that is that I think the talk gets kind of boring and dry if we just stick to the stuff that you can read through the monograph, and probably that many of you are used to doing in terms of pre-participation evaluation at your local high schools and colleges. And the other reason is that there, I think, are unique things to talk about related to the COVID pandemic. So although I don't have any conflicts of interest in terms of financially, I do want to point out that I was a co-author or a co-editor for both the pre-participation evaluation monograph fourth and fifth editions with Bill Roberts out of the University of Minnesota. And you know, I learned just as much from working with Bill and all of the other co-authors from the six different organizations that participated in the writing as I did from just being an editor. But just that personal interaction and getting to hear others' ideas was very educational. In addition, it should be pointed out in terms of the monograph that there were other contributors that were not part of the groups that we used independently, and I'll talk about some of the unique features of the monograph as we go through today's talk. So it'll be sort of a combined talk of the traditional PPE, and then I was also fortunate to be asked to be a writer on an AMSSM statement that's been submitted for publication on interim guidance on the pre-participation physical exam for athletes during the SARS-CoV-2 pandemic. The thing to keep in mind is, you know, we submitted this for publication probably no less than four weeks ago, and I would argue that things changed so quickly with COVID that some of what we submitted may be out of date by now. And so when you read it, make sure that you say, is this really still true? And you should be doing that for anything that you read, whether it's policy or guidelines, but really make sure that there's evidence for why we're doing something and question dogma. So the objectives when you leave here today are that you should be able to state the objectives for the pre-participation exam, which really have not changed since the onset of the pandemic. So the objectives of why we're doing the pre-participation exam are the same. You should be able to understand and explain to patients and families issues related to COVID when you are screening athletes related to sport participation in terms of whether or not they've been sick or tested positive for COVID. You should be able to understand the mental health concerns related to physical isolation during a pandemic, along with the mental health concerns that you have in terms of just athletes in general. And then like I just stated, understand that we are learning literally on the fly. Nobody's been through any of this before in our organization. Even the old timers in our organization were all dead if they were around during the Spanish flu. So in terms of learning on the fly and policies and procedures and whether you're having sport, not having sport, are subject to change when dealing with a pandemic. And I think that's something that we're all learning as we go. So in terms of introduction, the introduction today in terms of the PPE in general and the PPE during a pandemic is that all of us were taught in medical school to do no harm. And the goal of clearance is to mitigate risk. So you are trying to mitigate risk for the individual athlete who is your primary responsibility, but you're also trying to mitigate risk for any institution that you may be associated with, whether that's a high school, a professional or collegiate sports team. In addition, when we're trying to mitigate risk in the time of a pandemic, some of the decisions that are being made at this time are being made extrapolating data from an inpatient population where the patients were very sick because they were sick enough to get hospitalized, some of them even in an intensive care unit and some of them for months. And we're basing our clinical decisions for an outpatient athletic population on research and clinical experience of those inpatients. And that may or may not be the right thing to do. But I think if we're trying to mitigate risk, we're trying to decide on what is a reasonable risk that we can live with in terms of allowing an individual to participate in sport and trying to mitigate risk in terms of should sport take place at all in the middle of a pandemic. And we can discuss that more in detail if you want at the end. So like I said, one of the goals when you leave here today is to know what the goals of the pre-participation evaluation are independent of being in a pandemic. And so the goals of the PPE as stated in the monograph are to determine the general physical and psychological health of the athlete. Number two is to evaluate the athlete for conditions that may be life-threatening or disabling. Number three is evaluate for conditions that may predispose the athlete to injury or illness. And number four is to serve as an entry point into the healthcare system for student athletes who have not established a medical home. So nowhere on this slide does it say anything about a goal being to disqualify an athlete. And although the advertisement for today's talk was about disqualification, there's nothing in here about disqualifying because the overall goal of the PPE is to promote safe participation in sport. And we'll talk about that in a second. The goals of the pre-participation evaluation in the face of a COVID pandemic are to guide the athlete and family again in terms of safe participation in sport, to hopefully minimize their risk of contracting the disease, understand that exercise is medicine and exercise can be beneficial for everybody, whether they are an athlete or not, during a pandemic for both physical and mental health reasons. And so we still want to promote exercise, but we might not want to promote the sport they are likely wanting to participate in. And then the final goal is to return the athlete to play in a safe manner post-COVID infection. Again, nowhere on this slide is there anything about disqualifying an athlete being the major goal of the pre-participation evaluation. So the overall goal for AMSSM as a society in terms of exercise is medicine, whether you are participating in the back of the pack or the front of a pack of a mass participant event, whether you're taking care of a high school athlete who's playing at the varsity level, whether you're taking care of a high school or middle school or elementary school athlete who's participating at a club level in an organized sport, whether you're taking care of a collegiate or professional athlete, whether you're taking care of kids who are doing more what I would call freestyle sports, skateboarding, snowboarding, downhill skiing, jumping on trampolines, mountain biking, or whether a kid is just playing at recess, the overall goal is to promote the health and safety of that athlete in training and competition. And I would argue that everybody that I just talked about is an athlete by that definition. In terms of evidence related to the pre-participation evaluation, the evidence is very limited. And as it states on this paragraph from the monograph, there is a lot of work that needs to be done to validate the pre-participation evaluation tool, history tool that we all use, evaluate the content of the questions, the process of doing the pre-participation evaluation, who is disqualified and not disqualified, how good the tool is, what the cost is. And we need to consider that right now, a lot of what we're doing is based on expert opinion and not necessarily a lot of science. And so there are a lot of gaps in terms of the pre-participation evaluation that we will talk about at the end. But important questions do remain in terms of whether it's worth doing at all. So in terms of controversies, does the pre-participation evaluation identify conditions that truly do affect the health and safety of the athlete? Is there evidence that people who undergo the pre-participation evaluation have less morbidity and mortality? What is so special about the high school collegiate or professional athlete that we make everybody go through this at least once at the onset of their athletic career at each level to determine clearance? And why is this not considered the standard of care for everybody if we just said that almost everybody listed on that slide of active people, why don't we make everybody go through a pre-participation evaluation prior to having them participate in sport? So all of the four questions I listed there are sort of follow-up related to what the goals that we talked about for the pre-participation evaluation are. And I think each goal has questions, and I don't know that they have answers. So in terms of just starting with some COVID issues, and is it safe for people to participate in sports? There are lots of factors to consider related to the safety of participant or of participation. So is the athlete fit? And are they asymptomatic? Have they been during this downtime when we've had them not necessarily exercising regularly or leaving it up to them individually to do it? Are they fit in terms of starting to participate? I think there was a lot in social media among my colleagues and now your colleagues as fellows this summer in terms of the number of kids that people were seeing in their office with shoulder and elbow complaints where they had not been throwing a lot, and then they got clearance to play in some youth baseball tournaments, and probably loaded their ulnar collateral ligament or their proximal humeral thysis too quickly, and didn't receive guidance from anybody in terms of how much they should throw, and I have a return to play program, and then they wondered why they were sore. So what is really the athlete's fitness level, and what is their risk in terms of participation? Are there accommodations that we can make in terms of decreasing their risk related to COVID? Is that potentially wearing a mask, different ways of playing the sport? So as an example, the youth tennis players around here are playing where each player has their own three balls that they only touch with their hands, and if the ball ends up on their opponent's side of the net, the opponent is supposed to flick it back to them using their racket, not their hand. So now you have six balls strewn around the court instead of three, but theoretically you're decreasing your risk because nobody's touching the other person's balls. In terms of venue analysis, are you going to have the venue with or without spectators? Who else is going to be there? How much are you going to screen everybody? Where are you going to screen them? When are they going to get screened? So Heather and I were talking before my talk today about the local professional soccer team in our area. So there's an agreement among at least the USL, the United States Soccer League, and we're in the second level of that league, that everybody's using the same lab, and everybody is supposed to get tested once a week on the Tuesday or Wednesday before a weekend game, and they have to have a negative result within seven days. Well, that means they tested negative four or five days before their match, and you have to be using a lab that's reliable. Well, last week, I was tested, so I covered the game last weekend, I was tested literally 10 days before our match, I didn't get my result back for seven days, and they lost five of our athletes' lab tests, and they were still likely allowed to play. Well, what's the quality and reasoning for doing that kind of testing in COVID? What's the reliability? So how really controlled is your venue when you're sending your athletes back to play? Understand what local statistics are and local rules are. There are obviously what people are calling hotspots around the country, and is it safer to play in rural Montana or rural Idaho than it is in the middle of New Jersey or Arizona or Texas right now? And so you have to think about that. You have to think about how you're going to get to the venue. You know, if you have a positive athlete, and they all rode on the same bus with the windows up, probably everybody on the bus is going to be a contact, and therefore you're going to lose a whole team in terms of quarantine. So you have to think about that. And ultimately, I think things will return to normal when we have a vaccine, and the majority of our country is participating in a national vaccine program to hopefully eradicate this illness from our country, as doing physical distancing and social isolation doesn't seem to be making much of an impact at this point, likely due to noncompliance. So in terms of safe exercise, exercising outdoors is likely very safe. Exercise where you're not sharing equipment is likely very safe. And exercise where you can physically distance from one another is likely very safe. For the cross-country runners, I joke that if you're leading the race, it's probably pretty safe. If you're competing in the middle of the pack, we don't know. In terms of contact or collision sport, again, what is the testing availability, and how reliable is the testing, and what is the turnaround time? Are you able to contact race? What's the disease burden in your community? What's the overall health of the athlete? And are there ways to mitigate risk, not only for the athlete, but for team contact and collision sports? You have to look out for the coaches, the officials, and administrators who might be also attending the events. So, switch gears a little bit to go back to the PPE in terms of what we've talked about. We talked about in terms of trying to incorporate the pre-participation evaluation into the routine health supervision visit for all children starting at age six, and that they should go through this pre-participation questionnaire at least every two to three years. There's a definite priority that in the majority of cases, these pre-participation evaluations should be done in the medical home related to medical record access, confidentiality, the primary care provider knowing the patients well. And we do talk about in the monograph about making sure the kids come in every year and try and focus on different things every year related to anticipatory guidance and safety, child development, and adolescent risk outside of sport as well. Well, what do we do during the pandemic when we've shut down clinics and access to outpatient clinics and pediatricians, family medicine physicians, nurse practitioners, PAs that do primary care is not necessarily readily available? Well, the National Federation of State High Schools released a recommendation in April of this year that said that athletes who had undergone a pre-participation evaluation as an example their freshman year, and if your school would then require them again as a junior, those kids could get a one-year extension and not have to have that second pre-participation evaluation done until their senior year, if that makes sense. And at the time, I was like, well, that's awesome. You know, it's tough to get these kids in. When we were starting to allow more access in our clinics, there were other priorities rather than the student athlete in terms of kids who needed to catch up on their immunizations. This seemed to be a reasonable recommendation. But then you started reading more about the heart-related issues in some of the college athletes that are suffering from COVID, and then you're like, well, man, if there's an athlete out there who's suffered from COVID and we're giving them a one-year extension and they're not checking in with their providers, maybe we're actually putting them at risk, and maybe we shouldn't be following these guidelines. So I don't know if this guideline really should be the recommendation that we all have related to our student athletes in the community who have suffered from COVID or have an injury that hasn't been evaluated. So I think at the local level, the athletic trainers who are hopefully still working in the high schools, which is a totally different issue, but as a priority, the athletic trainers that are working in the schools should probably be reviewing this, and those kids who have had COVID infections or have an injury that still needs to be evaluated, those kids probably should be sent back to their physician for ultimate clearance, and only the kids who have a completely negative history should be warranted or should be allowed to have this extension. So that's the why I asked, is this wise? The main point of emphasis that's new in the pre-participation fifth edition is mental health screening, and I can tell you that I get more questions about this than any other part of the monograph, and that's because people don't read the monograph. They just want to use the form. So I would encourage everybody to get a copy of the monograph and look at it in detail in terms of disqualifying conditions and issues related to mental health and transgender athletes and the whole thing. But in terms of what generates the most questions, mental health screening. So the four questions that are on the pre-participation evaluation pertaining to mental health are listed right here, and this is copy and pasted right from the monograph. Over the last two weeks, how often have you been bothered by any of the following problems? And if they answer a score of greater than or equal to three in either subscale, questions one and two combined, or questions three and four combined, then that is positive, and what do we do with a positive answer on any of the history questions related to the pre-participation evaluation? We ask more questions. This is just meant to be a screening tool. So if you have somebody who answers positive, you need to figure out how bad is it, and so we will talk about that, but in terms of mental health, the other part of mental health related to COVID is that there are significant mental health concerns, and my colleague here in Madison, Tim McGuine, along with other people's names you might recognize, Stephanie Klether-Meese, who spoke at your fellow conference earlier this year, Dr. Reardon, who's a psychiatrist who's very well-known nationally and internationally, and you know, fortunately for us, we have her here at the university. Allison Brooks and Drew Watson, who are both very involved in the MSM, they did a collaborative study looking at the impact of school closures on sport cancellations on the health and well-being of adolescent athletes, and the main thing that showed up was the mental health issues related to physical distancing and social isolation, and the groups that were most affected were girls and then the kids who participated in team sports, kids who participated in individual sports, likely because they can continue to do it, they can go out for a run, they can go for a bike ride, they can probably at least swim in a lake, if nothing else, they did relatively well, but the kids who really were affected were the kids who were not participating in sport, and I think it's even more important then to screen for mental health issues in those kids. So when somebody screens positive on mental health screening, take more history, and that would include either having them complete a more detailed screening questionnaire like the GAD-7 or PHQ-9, going through a typical, you know, what is their home life like, what is school like, are they at risk for AODA issues, and then assessing them in terms of risk for self-harm and suicide, the final S in the heads, are they going to harm themselves or harm others. And then after you take a more detailed history, figure out what you're going to do, whether that's to refer them to a mental health provider, which might be a psychologist for cognitive behavioral therapy, refer them to a psychiatrist for a more detailed assessment. If you're comfortable taking care of them in your own office, figure out if you're going to be able to provide that care, and consider medications if the symptoms warrant. In terms of mental health tips, I'm not going to go over all this in detail. I have blatantly stolen this from another psychiatrist in the area when I asked for an e-consult, which is available at least in EPIC and our electronic medical records, so I can ask for an electronic consult from a specialist, and she was nice enough to share these tips with me in terms of handouts that you might want to use for your athletes who are having difficulty. So it's all about things that psychiatrists and psychologists would recommend related to sort of meditation, mindfulness related to breathing, relaxation, grounding activities, encouraging them to do something productive, the importance of exercise, and the other things that they can do to keep themselves busy. In the time of COVID, I think it is important for these kids who have a lot of downtime to try and keep a schedule, which allows them to be in more self-control. Trying to stay away from the news or social media or listening to depressing podcasts for long amounts of time doesn't also help the situation. I can tell you that from personal experience, and trying to take breaks and switch activities frequently during the day. So all of that is on the handout. The other, and the slides will be available, as Andy will allude to, through AMSSM Collaborate later. There are also fitness centers that are offering free online classes, and there's a link through a USA Today article related to the fitness centers nationally that are offering free online classes that you can give to your students and student-athletes if they're suffering mental health-wise. Apps that you can use are listed here. I think most of us are likely familiar with Calm and Headspace, but there are others. And I think those have definitely been shown to be helpful in terms of mindfulness, and I would encourage people to use those. Now, on to other factors related to the pre-participation evaluation. Sudden cardiac death and the pre-participation screening. We know that the prevalence of sudden cardiac death is very, very small. And we know that in countries where they utilize EKG as part of the screening to detect those rare cardiac conditions that can lead to sudden cardiac death, the use of EKGs uniformly has lowered the incidence of sudden death in those communities, specifically a small area in Italy, to the baseline levels that we have commonly seen in our country and other countries. So, AMSSM and the monograph that we wrote has really said if you have the resources to detect some of these rare conditions, an EKG is likely the best study to choose. But remember, not everybody has access to screening EKGs in terms of access with somebody who knows how to read these in athletes. In addition, we don't have a lot of good outcomes data from large randomized control studies. So, I think it is okay when you're doing the pre-participation evaluation to use sort of a patient-centered shared medical decision-making approach in terms of whether or not you're going to get an EKG. And you may target higher risk populations, such as the Division I collegiate basketball population as an example, and do EKGs more on the high-risk populations, and not do EKGs on the lower-risk populations. And there is the reference in terms of the AMSSM position statement related to sudden cardiac death screening that is listed there that people can look at. The thing to keep in mind, the graph in the lower corner, is if you look at the risk of death related to homicide in the dark green, suicide in the lighter green, and then unintentional death in the very small light gray bar, you can see where you should likely spend more of your time in terms of screening if you're going to prevent sudden death. And sudden unexpected death related to homicide and suicide is much, much more common than the unexpected unintentional death related to participating in sport. Related to COVID, we have learned more recently about myocarditis associated with COVID. The pathophysiology of this is likely similar to other forms of myocarditis where the virus itself can infect the cell or cause an inflammatory response and then scarring of cardiac tissue. It can also affect the heart by producing a pericardial effusion. All of this then can lead to potential arrhythmias and risk of sudden death. I listened last week to an educational rather than depressing podcast, and the educational podcast was called The Young Athlete. It's produced by Mark Halstead out of Washington University. He had Andy Peterson, who's the head team physician at Iowa on the podcast, along with an infectious disease expert from St. Louis University and a cardiologist from Emory. And I think that part of the podcast that I liked, which is what I was questioning in my own mind, if we are using cardiac MRI to be the definition of myocarditis in these people who have COVID, what if we did cardiac MRIs on everybody who had other viral infections? Because it's such a sensitive tool, would we be finding other people who are asymptomatic who have findings on their MRI of myocarditis? So as it was pointed out in the podcast, you know, people who have enterovirus in the summer or influenza in the winter, if we required all of them to undergo a cardiac MRI, would we have similar findings? And so at this point, I can tell you that there are universities around the country who are now requiring all student athletes who test positive for COVID and have symptoms to undergo screening markers such as troponins, BNPs, CRP, SED rate. They're required to undergo an EKG, an echo, and a cardiac MRI before they are cleared to participate. Whether that's a good use of money, whether that's best for the athlete, whether that really needs to be done on everybody is not clear. And I think it is a huge research opportunity that people are participating in. And at least in the Big Ten, there's two universities that are considering becoming sort of a warehouse looking at the data downstream as we collect it to determine are these kids really at risk and how many are really affected. So the picture here is of the Boston Red Sox pitcher Eduardo Rodriguez who suffered from COVID and was diagnosed with myocarditis. For those who you think the disease is not that bad, his description based on an article in the USA Today is that he felt horrible. And there are people who have significant symptoms. There are people who are actually, you know, we obviously know are dying from this. But there are many of those people who are outpatients who, when they're symptomatic, they feel horrible. And he felt, according to his quote, that he was 100 years old. It took him about 10 days before he was able to do any light throwing. He was ultimately diagnosed with myocarditis. According to the USA Today article, he is expected to make a full recovery. But they don't feel he has time during this baseball season to recover. And therefore, he will not be pitching to the Red Sox. And therefore, he will not be pitching during the shortened Major League Baseball season. In terms of recommendations for exercise in athletes based on symptoms and COVID-19, again, there are lots of expert opinions, but not a lot of research. So some of this is related to recovery from influenza and other viruses. Some of it could be extrapolated from how we sort of guide people back after mono and other issues. But the main point is to do this gradually so that if they do have symptoms, you can catch them and then potentially do other testing or just try and improve their fitness more slowly and not subject them to injury. So in this article published in the European Journal of Preventive Cardiology earlier this year, if you were positive for COVID symptoms and had a positive test result, their recommendations for self-isolation are listed 7 to 14 days. And obviously, in our country, the recommendation is the last 72 hours of that self-isolation period you need to be asymptomatic. You want to refrain from exercise until you've been symptom-free for seven days. They want you to consider clinical assessment in the appropriate environment, including blood tests such as troponins and CRPs. And if positive for troponins, then consider a 12 lead EKG, echo, and cardiac MRI. And then if you have evidence for myocarditis or pericarditis, treat them accordingly. If they are negative for COVID symptoms but a positive test result, again, refrain from exercise for seven days from the test result. And if symptom-free after this period, consider graduated return to training and return to normal. And this all seemed awesome until some of the universities in the Big Ten were reporting that even people who are positive test negative symptoms were having evidence of myocarditis on the cardiac MRIs that they were doing routinely. So I don't know if this guideline should continue for everybody or not. And I think that's what we're going to try and answer. If people are positive for COVID symptoms and negative for in terms of COVID testing, I think it is okay to repeat the COVID testing because it might be a false negative, especially if you're doing it early in the course of the illness. Manage them like you would anybody else with a viral respiratory illness. And if there's a high index of suspicion, again, repeat the COVID testing. And if you're really worried that they have COVID and a negative test, I think it's okay to sort of follow the guidelines that are listed up in the top part of the table. There are other articles that are out there with slightly different recommendations, but I think the bottom line is anybody who has symptoms based on, unfortunately, inpatient more than outpatient experience at this point should be worked up more thoroughly than we probably were doing early on. If they've already returned to sport with all the negative testing and they're exercising full out, I think they've likely passed what you would call a stress test. And I don't know that you have to do further testing for that group of people. In terms of vulnerable populations, when you're doing your pre-participation evaluation during the time of COVID, they are listed here. People with chronic kidney disease, COPD, immune compromised state, especially from solid organ transplant, people who have significant obesity, serious heart conditions, sickle cell disease, but not sickle cell trait, and people with type 2 diabetes. All of them have been shown to be vulnerable in terms of if they were to get the disease, having poorer outcomes, and therefore trying to keep them self-isolated and not allowing them to return to team contact, collision sports that are considered higher risk makes a lot of sense to me. In terms of the qualifications of the examiner, let's see how we're doing on time, we're doing well. So qualifications of the examiner, should this be different during the time of the pandemic? So the qualifications of the examiner traditionally is that it has to be a physician or an advanced practice provider, an NP or a PA. I don't know that just because you're a physician, you're qualified to do this pre-participation evaluation. If you're a neurosurgeon, an orthopedic surgeon, you don't do primary care on a routine basis, I definitely would rather have an advanced practice provider who does primary care on a regular basis be my provider for the pre-participation evaluation. I think it is essential to have clinical training in terms of knowledge and expertise to conduct the evaluation. I think you wanna have knowledge about COVID. You wanna be able to address the broad range of problems and you wanna be able to determine medical eligibility. For that reason, there's areas of the country where they do allow chiropractors to do this. I don't necessarily think that qualifies in terms of being able to provide this type of primary care and medical decision-making, especially in the pandemic. And I think that should be considered in terms of who's clearing these people to participate in sport. I do think it's important to seek consultation whenever you have a question. I think it's good to have shared decision-making related to disqualification. And do remember that it's less than 1% of the people that you're ultimately gonna disqualify. And the reason that you're mainly gonna disqualify them is because they have a condition that is either going to put them at significant risk of complications related to a previous injury that has not completely healed or recovered from, or you're gonna disqualify them because they have a condition that may lead them to being at risk for sudden cardiac death. In terms of group-based examinations, group-based examinations are unreasonable during a pandemic. We do these station-based type examinations routinely at the college level, at the high school level, we might do them as a last resort to help with access for kids so that we don't wanna have this pre-participation evaluation be an obstacle for them to participate. But I think in the time of a pandemic, having a whole bunch of kids come to a waiting room all at one time, sit there and wait to be called, going from station to station with a group of volunteers does not make any sense. At the college level, we are not doing any group physicals this year, and it's much more appointment-based, and the coaches have to understand that their athletes may not be cleared in a weekend. So the pre-participation evaluation does provide medical background for shared decision-making. That shared decision-making should be based on history and physical exam, and then case-finding studies. So whether that's an EKG, an echo, a cardiac MRI, but there should be some reason with data to back that up. Oftentimes, you're gonna have a subspecialist weigh in on some of that shared decision-making, and you wanna have the family involved early because this is an important decision that's gonna affect these athletes for the rest of their life. In terms of determining medical eligibility, there are five categories that you can determine medical eligibility. The most common is gonna be that the athletes are gonna participate in all activities without restriction. This is not black and white, all or none. There may be times where we clear them for all activities with recommendations for further evaluation, such as just checking a blood pressure, something pretty innocuous. It may be that they can't participate in any activities until further testing is completed or rehab is completed. It may be that you can let them participate in lower-risk sports, such as golf, but not higher-intensity sports based on the condition that you find. Again, like I said, it's gonna be a very, very, very small percent that are completely disqualified from participating in any sport or physical activity. On the medical eligibility form, you're gonna check a box that says what your ultimate disposition is. But when you're communicating, especially at the high school level, you're sharing medical information if you do anything beyond checking that box. So you're not gonna necessarily communicate with the school what the specific condition is unless you get permission from that student athlete and their family. The other part of determining medical eligibility on the forms is that there is a statement about rescinding clearance, so that if you find something later, you can rescind clearance and temporarily or permanently disqualify that athlete at a later date. It used to be that that statement was not on the clearance forms, and then you might find something, such as an athlete with a horseshoe kidney or some other cardiac condition, and you had cleared them, you wouldn't be able to disqualify them until they came back for a pre-participation evaluation the next time they were due, which would allow them to continue to participate. And you'd be like, well, most of these families will make a reasonable decision, not true. So it's good to have a statement in there about rescinding clearance and make sure that everybody's aware of that. So in terms of research gaps, talking to a fellowship group here, these are opportunities for you as you go through your career, so that I'm not giving this same talk 10 years from now at the, you know, right before my retirement. So in terms of top research gaps, do these pre-participation evaluations change the mortality rate of a target population? Are individuals excluded from sport participation necessarily lives saved by screening? Are abnormalities found at the pre-participation evaluation for a target population different than those found during routine health supervision visits and therefore should be done separately? Are these abnormalities that are found clinically meaningful and are outcomes modifiable? In other words, if you found that somebody has hypertrophic cardiomyopathy, that might be clinical meaningful, but if you tell them that they can't participate in a high school or college activity, but then they go and play recreational basketball and die while playing recreational basketball, have you really modified their outcome? Do pre-participation evaluation requirements adversely affect sports participation rates? And are those participation rates disproportionately affecting individuals at socioeconomic or medical disadvantage? Do requirements for follow-up testing for abnormalities lead to harm, potentially finding other problems? Do they reduce participation or disproportionately affect individuals on the basis of race, socioeconomic factors, or availability of medical resources? And what is the relative importance of each of the questions on the questionnaire in preventing or modifying morbidity or mortality from sport participation? Are adolescents who have their PPE performed somewhere other than their primary medical home, such as a group physical, otherwise receiving routine comprehensive or preventive care? What is the accuracy of a pre-participation evaluation for detecting known or suspected conditions that may affect risk or participation status? And are there any physical exam or functional movement tests that actually prevent or reduce injury to warrant inclusion in the universal screening? At this point, I don't know that we have anything that are going to be effective in terms of amenable to the routine primary care provider who receives what I would describe as relatively inadequate education from a musculoskeletal standpoint during their medical school training. So what findings from screening tests performed as part of the PPE are discovered in truly asymptomatic individuals at really no increased risk for suddenly dying. And then the final question, that's really a hot question that's been around for a long time and there has been a little bit of traction trying to get this off the ground, but not enough nationally, is does trying to regionally or nationally store electronic PPE findings, whether that's positive answers on a questionnaire or physical exam findings, reduce fragmentation of the medical record, improve follow-up on abnormal results, reduce errors, reduce legal risk, and come with a data storage base so that you can determine some of the sensitivity and specificity questions and findings related to this screening type of pre-participation tool that we are all using. So what have we learned today? We've learned today, hopefully, that the PPE is not an evidence-based exam. We've hopefully learned that the best place to do the PPE is in the medical home. At this point, history and physical exam should drive case-finding studies rather than screening everybody with an EKG or ECHO or whatever other cardiac tool you might wanna use. It's unclear whether EKG screening, ECHO, and cardiac MRI should be done on everybody who has status post-COVID infection. I think it's important as we do in almost anything medically that we have shared medical decision-making to determine medical eligibility. And the final thing we tried to point out is there are lots of research opportunities and we don't know much more than, unfortunately, we did four years ago or five years ago when I did the monograph number four. So I think these are the references that I have that are out there related to sports participation and COVID. I don't have the pre-participation monograph up, but if you Google pre-participation monograph edition five, it is available through the American Academy of Pediatrics and I think it was the publisher of the monograph because we needed some place to publish it and they do publish things, whereas AMSSM doesn't have really a publication arm that published textbooks and that kind of thing. So that's why we chose the American Academy of Pediatrics in terms of who we collaborated with. And the monograph is mainly targeted towards the middle school, high school, and college level athletes. So I think we'll get rid of that and it's time for any questions. I can't really see the questions, I think, unless I stop sharing, maybe I can chat. So if people wanna ask questions verbally and I can go into the chat, we can go there. So Anne, go ahead, Heather. I don't see any questions just yet, which was the case last week as well. So I ask a couple of questions. Excellent, it's always good to be a prepared host and moderator. But definitely for any fellow or faculty on, please feel free to share your questions in the chat or unmute yourself if you're brave enough to talk. But I'll go ahead and I reached out to a couple of fellows yesterday too to see if there were any questions they would like me to ask. One question that came up was, and you might not know percentages with this, but what would you, as far as cardiovascular screening in your exam or others that you know of, what would you say are some of the more sensitive tests and high yield in the physical exam maneuvers? Okay, so I think the answer to that is that there is no super sensitive cardiovascular test that is going to make the diagnosis. The most common cause of sudden cardiac death, as hopefully everybody knows, is hypertrophic cardiomyopathy. The majority of people with hypertrophic cardiomyopathy have a non-obstructive pattern of the disease. Therefore, they're gonna have a fairly normal exam or they may have a very, very subtle murmur. The best case example I can give related to that is we used to do pre-participation evaluations on every University of Wisconsin football player every year. And so, and we would do them, the upper classmen, we would do, because they'd already been cleared the years before, we did them right after a workout where they would hold their fall camp, which is at a local seminary area near Madison. And there was a kid where the resident could literally hear this huge murmur right after he worked out, like grade four. You could have your stethoscope tilted on its side and easily still hear the murmur. And when we sent him in the next day to see the cardiologist, because obviously there was something wrong with his heart, there was no murmur at all. And the cardiologist looked at us like we had a third eye. And he turned out to have pretty bad cardiomyopathy on his echo and his career was over. And so the findings on the physical may be variable in terms of when the person has worked out and how hydrated they are and what their cardiac output is and whether they have a fever. But a lot of these people are gonna have a negative physical exam. And so I wouldn't rely on anything physical. I would argue that the most sensitive thing to do for something that you're gonna see obviously on a physical exam is know the criteria for making a diagnosis of Marfan syndrome that you can make without a stethoscope. And then they are at risk and there's guidelines in terms of how often you should look at their aortic dimension before you clear them for participation. I don't know if that answers your question well enough, but that's my two cents. Yes. And I don't see any other questions in the chat just yet, but I'll ask another question. A lot of times, or at least last year, even when I was a fellow, I was kind of instructed, mass physicals are tough. You're limited by time and you don't have that many providers. And so you wanna do it. And I know with COVID, we're not doing those as much, but still wanna bring up mass physicals in case they're still going on even after COVID. Are there any things that you really wanna focus on with your history or exam and not, like don't let time affect, like the key points to really hit with those? So the mass physicals are really challenging. So if you have to get 40 or 50 kids done, like we sometimes do for the uninsured in our area in a night, you're not gonna be allowed to spend a lot of time. And so you need to make sure that the form that you are using, which is available online for free without buying the monograph, you have the student athletes use that form and make sure that form is filled out with hopefully a parent who knows their history. So one thing that has been shown in research in the past is that especially at the high school level and probably even at the college level, kids don't know their medical history and they for sure don't know their family history really well. So making sure that as the person who's checking those kids out, you are reviewing that history in detail. And if there is a positive answer, you're going through follow-up questions and not just trying to rush them through. The other part of it that I think is really important from a public health standpoint is to do this in conjunction with either a public health nurse or a school nurse, where at least in the state of Wisconsin, there's a large database for kids who live in Wisconsin and you can track their immunizations and have immunizations available when you do this. So at least you're giving them the vaccines that they need, whether that's a meningococcal vaccine, their tetanus, their HPV, have everything there so that you're doing at least a little bit of comprehensive care and you're not gonna have time to do any of the anticipatory guidance. And the other thing I would say with group physicals like this, especially for the high school kids, is you're only there to clear people who are absolutely perfect. If there's any question, you don't clear them, you bring them back, you get the test done that you need to, and then you clear them. Don't feel pressure that you have to clear them that night. That makes sense. That was a good last highlight point. Well, thank you so much for the awesome lecture. I see one thing in the chat. Oh, yes. So hello, Mavish. The question is about whether you, whether I have thoughts about reviewing the concussion history. So what does that conversation look like? If they've had a concussion and they, I usually go through how many concussions have they had, what was the timeframe between concussions? Did they fully recover between concussions? Are they having any symptoms related to persistent headaches, dizziness, headaches with exercise, dizziness with exercise? And then are they completely normal per parent's report? Are there academically functioning at the level they used to prior to the concussion? And are they having any processing problems? And by that, I mean, can they do the same amount of academic load as they could prior to their concussion in the same efficient manner that they used to do it? So I had a kid who had had two or three previous concussions, went to a local high school, and he was a good three or four months out from his injury. And he was gonna go to MIT. His dad was an engineer who had graduated from MIT. He had a 4.0 GPA at the local high school here. And he would say, I just can't do my college level calculus as fast as I normally could. Everything else was fine. For a kid like that, who has that much insight and knows that he's not doing it as quickly as he could, to me, that's still having symptoms. And you're not gonna clear a kid until they're completely asymptomatic. And whether that's because he's anxious related to his history of a head injury, and that's why he's not doing it as quickly, or whether he just has a lot of insight, I'm not gonna take that chance. Okay, thanks. Thank you for the question. Good question. I don't see any other questions in the chat, but thank you for the lecture. It was definitely informative, especially in the wake of COVID and all those extra things to think about. I also, please fill out the survey if you haven't yet, that Andy posted in the chat. And then I also wanna just mention that next week we'll be lecturing on sideline emergencies and C-spine injuries next Tuesday, August 25th, 1 p.m. Eastern Standard Time and 10 a.m. for the Pacific Coast. Any last things you wanna say, David? No, I'm good. Thank you everybody for attending today. It's beautiful here in Madison, and hopefully everybody can get outside and exercise at the end of the day a little bit. So have a good day, everybody. Thanks for having me, Heather. Thank you, take care.

3rd Edition, CASE 34

3rd Edition

Metabolic/Medical Conditions

pre-participation evaluations

COVID-19

disqualifying conditions

mental health screening

shared medical decision-making

sudden cardiac events

medical homes

myocarditis

evidence-based application