Sports Physicals – PediaCast 424
- Dr Jim MacDonald and Dr Peter Kriz visit the PediaCast Studio as we consider the pre-participation sports physical. What makes this visit different than a well-child exam? What are the important components and where should the exam take place? Plus, we talk conditioning, injury rehabilitation, cardiac screening and concussions. We hope you can join us!
- Sports Physicals
- Pre-Participation Exams
- Athletic Conditioning
- Injury Rehabilitation
- Cardiac Screening
- Sports Medicine – Nationwide Children’s Hospital
- The Sports Medicine Center – University Orthopedics (Providence, RI)
- Summer Conditioning – PediaCast 171
- Physical Fitness and Resistance Training – PediaCast 212
- Sports Nutrition – PediaCast 385
- Sports Nutrition and Low Energy Availability – PediaCast CME 41
- Early Aerobic Exercise Speeds Concussion Recovery (Study)
- Concussion Update – PediaCast 362
- Sports-Related Concussion – PediaCast CME 33
- Refining the Sports Physical – PediaCast CME 05
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It is Episode 424 for February 20th, 2019. We're calling this one "Sports Physicals". I want to welcome all of you to the program. We are turning our attention back to sports medicine this week as we consider the sports physical.
And you may be asking yourself how in the world is he going to fill an entire program about sports physicals? I mean, you go, they do the exam, they fill up the paperwork, and you're good to go. Unfortunately, that is exactly how the sports physical goes in many places, they're quick and easy. You get the paper signed and that's it.
However, if that has been your experience, your student athlete is getting short-changed because there are many important components of the sports physical, also known as the pre-participation exam. And during the course of this program, we will be shortening that often to PPE. You think, "Just call it sports physical." But we're going to be taking to a couple of sports medicine doctors and they're used to calling it the pre-participation exam.
And then they shorten it to PPE, and that's just naturally what's going to come out of their mouths. So we're all in the same page, PPE is pre-participation exam, also known as the sports physical.
And there's a lot of things that can get overlooked when these examinations are done hastily. So it's important for the medical provider to sit down with your child or your teenager and talk about the sport that he or she is interested in playing or participating in, addressing the unique needs of that particular sport, asking about past injuries including concussions, any illnesses that can impact sports like asthma.
Is injury rehabilitation necessary and what sort of conditioning is beneficial before playing this particular sport? A cardiac or heart screening is also important to make sure there aren't any risk factors for sudden death while playing sports and to see if more of a cardiac workup would need to be done.
Sometimes, a baseline neurocognitive can be helpful if there is a high risk for concussion while playing the desired sport. And then, of course, a complete physical examination by an expert who cares for student athletes is important with an emphasis on the musculoskeletal exam.
And then, there's a lot of anticipatory guidance to consider. That's a pediatric industry term for health coaching. You want to talk about nutrition and using food as fuel to power the body, getting proper amounts of sleep, early signs of heart disease or exercise induced asthma so you know what to watch for. And then, what do you do if a concussion occurs. That's an important thing to know before an injury.
Also, balancing sports with academics and family life, screening for anxiety, depression, and other mental health concerns, which are actually quite common in all students including athletes.
So there's a lot that really should go into the sports physical. So much so that this exam really should be in addition to your child's well checkup because there are so many different topics that you want to cover during the annual physical. The sports physical is different, it's specialized and an important part of caring for the health and wellbeing of student athletes.
Now, because there's a lot of things that we want to talk about, immunizations and growth and development, during the regular physical. We want to talk about screen time and gun safety and lots of different that go into the well checkup compared to the sports physical. If you schedule each of those once during the year, then your kids being seen by someone every six months and can really give you the guidance on health and wellbeing that you need.
So we're going to approach today's episode with a couple of audiences in mind. First, those who take care of kids. So about 20% of our audience is medical providers. And so for those of you in the crowd, what components should you include in the sports physical? I've touched on many of them already but we'll talk in much more detail.
And then, our primary audience, really, about 80% of here is for parents who have student athletes. What can you expect at the visit? For those of you who have had a recent pre-participation exam and you're thinking, wow, I really did get short-changed. We did not talk about past injuries and conditioning and nutrition, concussion, heart problems, juggling multiple sports, staying fit between sports seasons, and fitting sports into the bigger picture of academics and family life.
If you missed those pearls of wisdom during your cursory bargain sports physical, we are going to include some of that guidance here today to help your student athlete achieve a higher level of health wellness and fitness. And for the medical providers in the crowd, this will give you some great ideas for talking points during the pre-participation visit.
To help me with this topic, I have a couple of terrific studio guests joining me. Dr. Jim MacDonald is a sports medicine physician here at Nationwide Children's Hospital. And Dr. Peter Kriz is a sports medicine physician at University Orthopedics in Providence, Rhode Island, and he's affiliated with Brown University Medical School.
Before we get to them, I do want to remind you that PediaCast is on Facebook. We're also on Twitter and Instagram. Facebook and Twitter, every day, we really try to provide some interesting articles for you. What's in the news right now that parents could benefit from reading whether it's related to a lot of stuff in the news here lately has been about measles because we have another measles outbreak. So we're kind of heavy on that covering it because that's what the mainstream media is covering right now.
And it's an important topic. Also, a huge increase in the amount of vaping among high school students. I mean, like almost 80% increase compared to this time last year. So just an explosion of vaping, so we've been covering that quite a bit.
We also cover some blog posts by other pediatricians. Just some recent examples, How to Help Your Teens Sleep or Exercise More, how to motivate them.
Also, children of anti-vaxers are, when they're teenagers, asking how they can get vaccinated without their parents' knowledge. In general, definitely in Ohio, to vaccinate someone who's less than 18, you got to have parent's permission. And I think that's probably true in most states, probably all states, but I can't say that for sure. I know it's true in Ohio.
But we are seeing some 18-year-olds. Because pediatricians generally will see folks until they're 21 who do come in. And once you're 18, there is medical privilege between a teenager and the physician. So some 18-year-olds are coming in wanting their vaccines, when they're parents didn't want them to have them in the past. So it's an article that talks about that.
Americans take the pain of girls less seriously than boys. That's the recent one that we shared.
Chronic school absence is a better predictor of failure. Actually, it's a better predictor than test scores. And this is an important problem because about 10% of all American children are chronically absent from school, which really does have an effect on their future.
And then, many fruit juices contain lead and other heavy metals.
So lots of stuff in the news. That's some recent things. Again, you can find those articles, we share them every day on Facebook and Twitter. Just search for PediaCast and join us there. And we'll get you lots more information than just what we have in the podcast.
Also on Instagram, less on the information side there and more on the fun side, just some pictures into the studio including today's recording. So if you want to see what our sports medicine experts look like, you can check PediaCast on Instagram. We'll have in-studio pictures. But also just what my family's up to.
My wife and I go to the movies a lot and see movies. And so I try to put a lot of movie review. I am not an expert movie reviewer by any chance. It's usually a sentence or two, and the movie rated on a one to five clap board system. If you're wondering what in the world that is, just check out PediaCast on Instagram.
Also, I want to remind you that the information we present in the podcast each and every week is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
So let's take a quick break and then I will be back with Dr. Jim MacDonald and Dr. Peter Kriz to talk about sports physicals. That's coming up right after this.
Dr. Mike Patrick: I am joined in the studio by Dr. James MacDonald. He is a sports medicine physician at Nationwide Children's Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine.
We also have a visiting professor with us, Dr. Peter Kriz, from Rhode Island. He's a sports medicine physician with university orthopedics in Providence and an associate professor in the Division of Sports Medicine at Brown Medical School.
They're both experts at caring for student athletes which includes providing sports physicals. That' what we're here to talk about today, the pre-participation examination for sports.
So let's give a warm PediaCast welcome to Dr. Jim MacDonald and Dr. Peter Kriz. Thanks so much to both of you for being here today.
Dr. James MacDonald: Great being here.
Dr. Peter Kriz: Thank you for having us.
Dr. Mike Patrick: Yes, absolutely. I appreciate you guys taking time out of your busy day to join us. So, Dr. MacDonald, let's start with you, what exactly is a pre-participation exam or sports physical? What is that?
Dr. James MacDonald: So let me just really quickly say, so the pre-participation exam, sometimes in our world, we start shortening to PPE. So if I start using that phrase over and over again, hopefully that will make some sense to you all.
Dr. Mike Patrick: Yes, so PPE, pre-participation exam which is a sports physical.
Dr. James MacDonald: Sport physical, exactly. So it's basically a chance for a young athlete and parents to connect primarily with a physician to determine their fitness readiness and health as they enter a sports season.
I would actually say probably the biggest heart of the "physical" is the interview. It's the history. The history-taking, oftentimes, it takes place before the event when the physician is with the parent or the patient. In other words, there's a lot of paperwork that's usually associated with a PPE that needs to be filled out properly, completely. That's probably at least half of what the PPE is.
There's paperwork, history, physical. So we can go over some of the details of what the physical is but then a determination of "Yes, off you go, you're going to have a great season" versus "Hmm, there's something that may not be right in terms of your overall health," for participating in basketball, football, et cetera.
Dr. Mike Patrick: Is there a good time period before the sport that you would want to get this done? Is there something that you do the week before you start? Or do you give it a month in case there's some things you might need to do?
Dr. James MacDonald: Sounds like you know something about it, Mike. So in some sense is there's no perfect time, but you're balancing out, you want a time lead. So in other words, if your season's let's say November, doing it maybe in March is enough lead time that in a young person, their medical world may change. So that's probably too much.
But you're exactly right, a week before doesn't give any lead time to "Hey, the season's starting, oops. Now, the doctor doing the PPE thinks my son or daughter needs these and these and these things to determine if they're safe."
So I tell you the way a lot of school districts will do it is, and I'm mostly familiar with Bexley. If anyone's listening, Bexley, Ohio will say do it in June for the season starting in August. So I would say a month or two is probably the right answer.
Dr. Peter Kriz: I was going to say six weeks I think is the accepted answer.
Dr. James MacDonald: Ah, there we go.
Dr. Peter Kriz: The idea I think a lot of it boils to the availability and the scheduling for physician and what they have available as well. And so oftentimes, as you're heading to the fall months and the fall season, there's not as much availability.
Dr. Mike Patrick: As I was doing show prep for this particular episode, I came across a document from 2010. And please correct me if there's an updated one. This is a joint statement from the American Academy of Family Physicians and the American Academy of Sports Medicine. And they put out some goals. Just goals for a pre-participation exam.
And they said, to maximize safe participation, you want to be able to play safely. Identify medical conditions that could become that could become life threatening, so like heart disease.
Identify medical problems that require a treatment plan. Chronic medical conditions, so things like hypertension.
Identify medical problems which could interfere with performance like exercise-induced asthma, although that might require a treatment plan as well.
Identify and rehabilitate old injuries. Remove unnecessary restrictions on participation. So maybe there had been some restrictions that were a little overly zealous and maybe we could remove some of those.
And then, to provide the anticipatory guidance on things like concussion, nutrition, sleep, those sorts of things. Is that still kind of the big idea here? And I had the advantage to have the document in front of me.
Dr. James MacDonald: Yeah, I know.
Dr. Peter Kriz: Moving forward, that is the most recent edition. That's the 2010 monograph, so I think I'll probably refer to that as the PPE monograph later in the talk as well. But that's absolutely correct.
Dr. Mike Patrick: Okay. And then, Jim, how often should this take place? So do you need one for every sport that you participate in? Or is one a year enough? Or like one in middle school, one in high school? How often?
Dr. James MacDonald: Once a year is the standard. So if you had it at one point in the year, that's most school district will recognize that for the entirety of the school sports, whether you play three sports, four sports, whatever.
Dr. Mike Patrick: Yeah, but if you would have some specific problem come up before you start a second sport, there's nothing wrong with seeing a physician again to sort of check in and address those.
Dr. James MacDonald: Yeah, you know what? It's interesting. Peter, you weigh in. That absolutely can happen. I mean, I don't necessarily think of that as the PPE. But there are absolutely are things that can happen during the school year, maybe between seasons or in season that will render the determination let's say in June that you're good to go, like null and void.
In other words, you had an ACL injury. You have a concussion. You're at least temporarily out. And so, absolutely, there'll be some licensed professional, usually doctor, who needs to step in and go, "Now, you're cleared from that and now you're back to play." So like a mini-PPE, sort of mini-reassessment, so to speak.
Dr. Mike Patrick: Yeah, on a case by case basis.
Dr. Peter Kriz: I'll say it's also probably best, if we're talking about a high school athlete, to check with your athletic director at that school. Because oftentimes, it may be, the calendar year versus the academic year, sometimes they provide a grace period. They'll make it 13 months the physical's good for, just so that you're not scrambling at the last minute to get it.
Dr. Mike Patrick: Yeah, that makes sense.
Dr. James MacDonald: That's a great point.
Dr. Mike Patrick: And I think a question that probably comes up really often is can a yearly well checkup with a primary care doctor, so your annual physical with your pediatrician, your family practice doctor, can that count for this?
Dr. James MacDonald: It can, I think with some caveats. And as just as a disclaimer, like Jim, before I gotten and went back into the sports medicine fellowship, I was a general pediatrician for eight years. So I did these frequently.
And so, I think if we're looking at standardizing the PPE, using the monograph and going through it and doing a focused physical exam, which is going to particularly include a cardiovascular screen as well as an orthopedic screen, is going to be part of that.
I think, oftentimes what… I'll give my state of Rhode Island as an example, I know this happens in multiple states. You have the school camp sports form which is not the PPE monograph form that we're talking about. That is utilized because it also includes immunization information and other things that are important, vision screening and things.
And so, most states don't. Typically, there's not a uniformed standardized form that is used. You can use the PPE monograph, but most states don't, if you look at that.
I think the other thing that you find is that unfortunately, if you look nationally, about 30% to 90% of adolescents, their PPE is substituted for the well child exam. So they're not seeing their physician for truly an annual checkup. They're coming for their sports physical.
Dr. Mike Patrick: And to just sort of public service announcement out there for parents, I mean, you can really be an advocate for your child to get both of these things done because there's a whole separate of anticipatory guidance, things that we would want to talk about. And you just can't really fit all of that into one visit. Otherwise, you're really short-changing the medical experience and health and wellness guidance that you would get.
So just my own personal opinion would be even if it could count for one or the other, that maybe every six months, go in and focus on well stuff and then focus on sports another time. What do you guys think of that?
Dr. James MacDonald: I agree. I'd imagine this is true for Dr. Kriz, as well. I'm primarily doing PPEs now, not well child physicals. I pay next to no attention to say vaccine status when I'm doing a PPE. And that's the kind of anticipatory guidance you're referring to that's crucial to most of our young people, at least just one among many things in terms of the work that is done for the annual physical as separate from the sports physical.
Dr. Mike Patrick: And you know, you think about academics and mental health. And I know those things are important to think about in context of sports, but you're probably not going to spend as much time on those things as you would. You know, "Are you having aches and pains?" And "How are you doing conditioning and fitness?" and those sorts of questions.
Dr. James MacDonald: Yeah, I think to do it well, to do both well, you really need about 60 minutes. And I think that is the challenge with this. Can it be done in a primary care setting? It really should not be taking the place of the annual well child visit.
Dr. Mike Patrick: Yeah. And then the other caveat that I kind of thought of, and this is just coming from the lens of like you guys, I have an experience of practicing primary care pediatrics for quite some time in the past. And I would say that primary care docs, if you're going to do this, have a low threshold for sending someone to see sports medicine. If there's anything that you don't feel comfortable with, if there's questions that come up with the family, old injuries recently rehabilitated, understand what your limitations are and refer.
Dr. James MacDonald: Yes, agree.
Dr. Mike Patrick: And then, the next question that I think a lot of parents have is if you're not doing it at your regular doctors, where do you do this? We're really lucky here to have a very advanced sports medicine program that folks can get involvement. But that's not true in every community. And then, you see urgent care centers offering sports physicals. And the supermarket clinics offering them. And then sometimes, they have them at school. Is there a best and maybe things to avoid?
Dr. Peter Kriz: Yeah, no, all are great points and points I was planning to bring up as well. So I think we can all agree that the best place is the medical home with your primary care physicians. For a number a reasons, you got an established physician-to-patient relationship there. You've got access to their complete medical record, which we oftentimes do not have even bits and pieces of in another scenario.
It's a comfortable environment. You can conduct a thorough exam. It's focused but thorough. I think one of the challenges that I will bring up when you're doing this in a group setting or at a sports medicine clinic is if we're really going to do the PPE correctly, we should be assessing femoral pulses and are testicles descended? Is there inguinal hernia?
And in this day and age, with what we've seen particularly in a number of sports, I think those are things that sometimes people will glean over just because they aren't comfortable doing as a physician or provider. But it's also not something that is comfortable for the patient unless you have a chaperon, which is always important to have.
And so, getting back to it, I think if you've got an established rapport with an student athlete, and you've seen them for five, seven, ten years, and you've done this year after year at the exams, it's going to be something they're more comfortable with. So I think it's a more appropriate setting.
Having said that, I think certainly orthopedic groups, sports medicine groups do this very well where you're doing station based exams. And it's a very efficient process.
And I certainly would dissuade families from going to the MinuteClinics and the urgent cares for a number of reasons. Ultimately, I think it comes down to if there's some level of procrastination. That's what where you're left with a week before your season starts.
Dr. Mike Patrick: And you're really going probably get short-changed because… I mean there aren't going to be exceptions. There may be a particular provider at a particular clinic who has looked at the monograph and really has a well thought out PPE. But that's going to be the rare exception and pretty much not the rule.
Dr. James MacDonald: Mike, may I just…
Dr. Mike Patrick: Yeah, yeah.
Dr. James MacDonald: This is related to this, but I would just, for all the parents listening out there. Both Dr. Kriz and I are parents, too. Both of us have children in sports. Tied into making those decisions as to where, and my shared concerns about things like the MinuteClinics is that to look at this PPE as a very, very important part of your child's overall health and their experience in athletics.
To not look at it as some hurdle or speed bump that you have to go over, that you want to have done it the cheapest amount with the least amount of time invested. Because that takes away from its intent. I mean, we're talking about some serious issues that sometimes come up that I think you're probably going to touch on like, "My child have a heart problem on the field." If you look at it through that lens, you look at it with the importance it needs to be treated.
And I think that's the strong argument for see your regular pediatrician, go to sports medicine, go to the authorized provider by your high school. And that most high school athletic directors will be able to tell you what that is or the dates that those will happen.
But not to look at this a week before the sport, "I'm going to MinuteClinic," bang, bang, "It's done," and Johnny's out on the field because that's short-changing your child.
Dr. Mike Patrick: Yeah. You may check the box but you're not going to really deal with problems that could potentially interfere with performance and health, and those things.
Dr. James MacDonald: Yes.
Dr. Mike Patrick: So walk us through what a pre-participation exam ought to look like, just so parents can compare this with their other experiences and kind of gauge, "Hey, am I getting a thorough exam? Or maybe I should look elsewhere the next time this rolls around." In short, what is optimal?
Dr. James MacDonald: So, the first is to use standardized forms which in Ohio can come on paper, now being done by many school districts electronically. Many of the school districts will require the parents and children to fill out forms before they come in for their PPEs, when they're done in the school setting, which is usually a station based setting that Dr. Kriz in referring to. And that's paperwork that can be downloaded from computers and printed out for instance and filled out, or can actually be done electronically.
As I said earlier in the talk, that's one of the biggest parts of PPE. It starts before the PPE and that's where typically it's parents. Some us joke when I'm with a child, and I'm looking at this like, "Wow, this handwriting is really great! Is it yours?" And they're, "Nah, no, it's mom's." "It's dad's." But it's going through the child's entire history and family history.
So questions that come up are like, "Do you have a relative who had an unexplained death, let's say age 40?" Most children won't know that. They won't know that Uncle Bob was like that, but the parents will. And so, the parents filling out these questions that range from if it's a girl's menstrual history to boys and girls cardiac history, et cetera, that's the beginning, the paperwork part.
If you want me to continue walking through, so the other really, really big parts are there's always a cardiovascular exam part. And that includes pulse and blood pressure. It ideally includes what Dr. Kriz is referring to, not just the standard, "We're getting it in your arms," but we're checking femoral pulses in your legs as well. Because that informs certain medical conditions, heart, blood vessel conditions that your child may have. Listening to the heart and lungs.
And then there is a very, at least in Ohio, pretty standard brief orthopedic exam that's done in a global sense, but also based on questions that you've answered. Like "Oh, you may have had a fracture a year ago." "You may have had a fracture a year ago." "You may have had this surgery on this shoulder last season."
Oftentimes, it involves a targeted exam to the body part that was involved and more intense questioning. Because again, you're trying to determine, is the shoulder injury cleared and are they ready to go back to soccer or whatever?
Dr. Mike Patrick: So really a much more thorough musculoskeletal exam that you would probably do in a well checkup.
Dr. James MacDonald: Yes.
Dr. Peter Kriz: The monograph includes the targeted orthopedic exam. It's about two-minute exam to complete. It's very quick to do and it assesses range of emotions, strength, stability of joints. Also, course strength which is important in a lot of young athlete.
Dr. James MacDonald: And we do a brief abdominal exam, skin exam, and neurological exam. Those tend to be briefer than the ortho and cardiovascular exams.
Dr. Mike Patrick: Now, a little bonus, because our audience is probably 80% parents, but about 20% pediatricians and family practice doctors do listen to this particular podcast. So when you're talking about the femoral pulses, I would imagine you're looking like at coarctation of the aorta would have a diminished femoral pulse. What other specific conditions are you thinking about?
Dr. Peter Kriz: That's the big one for femoral pulses. I think the other part of the exam that should be done and sometimes should be devoted to is listening for murmurs both in a supine and a standing position. While they are rare, we're talking about causes, sudden cardiac death. Hypertrophic cardiomyopathy is one that may have a louder murmur in a standing position versus supine. But it's again, oftentimes, not present.
But I do think we should take the time and have a thorough assessment of that as part of the exam, and not just the orthopedic targeted exam. It really is both components that are really focused on.
Dr. Mike Patrick: Yeah, absolutely.
Dr. James MacDonald: I have something to add. Dr. Kriz just said, and then this goes back again where's the ideal setting for this. Imagine, if you're in the pediatrician's office, which I'm unnecessarily to all you pediatricians out there is saying always super quiet. But it's arguably the closed door, arguably more quiet than you're doing it in a high school cafeteria or gym or you name it. Listening for those murmurs can be very hard in the mass PPE setting that exists.
I went a couple of years ago where the PPE was being done. And bam, practice was being done adjacent. I guarantee you if there were a heart murmur that day, I would not have been able to hear it. You're less likely to have that happen in a private pediatrician's office.
Dr. Mike Patrick: What about the EKG?
Dr. James MacDonald: Well, you touched on a really important subject, not recommended typically in United States. Though I would say in many settings now that maybe it wouldn't be actively discouraged, but the general idea would go like this. The American Heart Association has a 14-point exam cardiovascular exam and history-based screen.
The intent especially for the physicians listening is to determine if the person you're seeing might be at higher risk of a cardiovascular incident than your average patient. So that would be things like listening for those murmurs, hypertension. They've said yes to a family history of sudden unexplained death. So buried in that are concerns ranging from hypertrophic cardiomyopathy, prolonged QT syndrome to you name it.
In those people, it may deemed that we get an EKG because that would enhance issues of sensitivity and specificity, like how likely will my EKG if positive be connected to this person having true disease? All commerce, if they don't need one or more of those 14-point recommendation, like have the wrong answer so to speak, in United States are recommended not to give EKGs because the chance of things like, number one, the cost, the workup of it, the number of false positives. Most bodies still making decisions in the United States are actively recommending against it.
Dr. Mike Patrick: A lot of folks who would be doing these aren't experts at reading EKGs, and so you get the machine interpretation. But when the cardiologists looks at it, they're like, "No, no, this is very normal, it's not a problem." But yet, by the time you got in to see the cardiologist to get that done, you may be talking a month. And then, that could also delay conditioning and getting involved in this sport.
Dr. Peter Kriz: And even in that situation, there's going to be disagreement among the experts about the findings on that EKG. And so, it's very challenging. It's contentious topic in sports medicine. And a lot of this has come out of data in Italy with a specific type of congenital heart disease, which is not necessarily something that we can extrapolate here to the United States, where there's kind of a different makeup of cardiovascular disease, particularly premature cardiovascular disease or congenital heart disease.
And so, I'll show you the few statistics. So they've done some mathematical models out of the UK using that Italian data and this is one of the issue. So to prevent one sudden cardiac death per year with EKG screening, you would exclude 800 athletes on the basis of false positive results on EKG. So that's another issue.
Another concern is that an EKG is not going to detect coronary artery anomalies as well. So you will pick up a number of conditions.
Another challenging condition is something called the athletic heart or the athlete's heart where you have enlargement of the left ventricle just because it's very muscular and that can have EKG abnormalities that are very hard sometimes to discern from pathology.
Dr. James MacDonald: If I may add to what Dr. Kriz has said, so if you were nevertheless still any death prevented is better than allowing continued just the way we're doing things. And you're still either didn't agree or you're heard Dr. Kriz just said, but nevertheless I think this is important. So I'm behind EKG. What he's mentioning with the coronary anomalies for instance is well then you'd also be interested in adding on an echocardiogram. Because if you're going to really do this, you've got to do the history and physical and an EKG and an echo.
And I suspect Dr. Kriz nor I have those numbers right off the top of our head, but then you're talking about astronomical costs.
Dr. Mike Patrick: And really, the system can't take that if you had to do an echocardiogram on every student athlete. There's just not enough echo machines and appointment times.
Dr. Peter Kriz: Particularly for universal screening, that's what we're talking. For training and everyone, if you take a targeted approach and this is also contentious, because you could, and I'll share some more statistics. So we know there's some sub-populations that have higher risk of sudden cardiac disease. And this is out of a review I recall, I'll give props to Dr. Bill Roberts and Chad Asplund and Fran O'Connor.
But they provided the relative risks of certain cardiac disease in certain athletic population group. So for an NCA Division 1 basketball player, the relative risk is about 15 times than of the general population in the United States. NCA Black male athletes, it's about three and a half times that of the general population. And then NCA Black athletes altogether, about two and a half.
So you can see where if you went to targeted screening, it's going to raise some ethical and discriminatory issues. And is that fair? And so, I think that's a big part of the discussion, would it be more cost effective to do targeted screening?
Dr. Mike Patrick: And I think that's also puts folk's mind at ease, that this is coming from sports medicine experts. But I've also asked the same question to one of our cardiologist on the PediaCast CME program. We talked about sports physicals a few years ago. And she basically said the same thing that you guys are saying.
And her job is to look at EKGs all day long, she's an EKG expert. And she was all for the targeted screening, not universal EKG. So we're hearing it from the sports medicine folks, from the cardiology folks. So those on primary care, that really is the standard.
Dr. Peter Kriz: Yes.
Dr. James MacDonald: Yeah.
Dr. Mike Patrick: And then, neurocognitive testing. So I'm going to hit all the controversial topics here.
Dr. James MacDonald: Yeah, right, right.
Dr. Mike Patrick: So as we think about concussions and there are some brain testing that can be done to see when folks are ready to go back, should they have a baseline neurocognitive screening at the PPE?
Dr. Peter Kriz: Great question. If you ask me five years ago, I would say certainly, yes. I'm starting to question that for a number of reason. I think it's cost, number one. Who's paying for that test, it's not free. The licensure is not cheap for those of us that have them. It really boils down to what age.
So the current test, and there are four or five different manufacturers of computer-based neurocognitive testing. We'll just throw it out there. We're going to use one specific brand. But most of them are valid over the age of 13. So that's a question that we get asked all the time. Should my ten-year-old have a baseline? My answer is no, it's just that the test isn't really valid.
There are some pediatric versions that certain manufacturers have put out, but I don't think they have the same body of normative data to compare the one that's for 13 and older. And so, I think if someone who's 13 and older who is a playing a contact or collision sport, there may be tilting on getting a baseline because we're comparing their data to themselves when they get injured versus normative data. But I think as I've gone on in practice, you can still compare their results in normative data. So it's not essential, I think money is better spent in other places, personally.
Dr. Mike Patrick: And when you say normative data, you just mean like an average of what a big population of folks would perform if they didn't have a concussion.
Dr. Peter Kriz: Yeah, I'm using a medical term.
Dr. Mike Patrick: That's okay.
Dr. James MacDonald: It would be that idea of when we're doing blood tests, what we define as normal or abnormal are comparing or looking at normative data sets. I mean, when we'd say, "Hemoglobin A1c is above a certain number, therefore you have diabetes," that's drawing a line in the sand based on datasets. So one can do that same thing with the neurocognitive tests.
I'll just add on to something Dr. Kriz was alluding to, is there's a lot of concern about issues of the stability of the testing, reliability, validity, learning effects. The more you take it, the more you're able to do better. That cast a lot of question on even the idea of a baseline testing.
I mean, it sounds great. Like, "Test me, Jim, then you know what I'm doing in August. So if I get lit up on the football field in October and I've declined, oh, that must mean something." You potentially could decline because you had a bad nigh sleep the night before. You could potentially improve because you've taken the test through. There's enough wiggle room that a lot of people have people questions about, just how solid are those baseline numbers.
Dr. Peter Kriz: Yeah, I've got two comments to add on to what Jim said. So athletes have learned that they can sandbag the test. So they can do poorly on it. And sometimes, it's very hard even with the internal measures to test to determine whether someone sandbagged or not. So reaction time can help you a little bit and some of the other components on the testing.
So that's one of the main issues that we're concerned about. I'm just blanking on my second point. I'll come back in two seconds.
Dr. Mike Patrick: So when you say sandbagging, so they're trying to do worse than they really could do. So that then when they have a concussion, it looks like they're back to their baseline. That's tricky.
Dr. Peter Kriz: I thought of my second point. So the other point that I definitely have issue with is, one of the manufacturers just received FDA approval for the test to be performed at home, in their home environments. So not supervised or monitored. So there are going to be a lot of distractions. If you're a 15-year-old at home with your phone trying to take one of these computerized tests, and is it really going to be a valid test?
I think those of us that if we're going to do baseline testing, I'd like it to be in a more controlled supervised setting.
Dr. Mike Patrick: The remainder of our time, we're just going to go kind of rapid fire on some of what we call anticipatory guidance sort of stuff. So just general health and wellness information that student athletes ought to know.
The good news is with this is that our sports medicine program is so robust and loves to be on PediaCast that we have done a ton of sports medicine shows. And all of these topics, we have whole shows devoted to them. So I just want the most important things and then, in the Show Notes, we're going to put links to episodes that actually going to tons of detail, probably more so than you would in a PPE.
But what are the nuggets? What are the really important take-home points? I wanted to start with just sort of conditioning and injury prevention. And Dr. Kriz, what do you recommend? What do parents need to know to sort of prevent injury in terms of conditioning before a sports season? What ought kids be doing?
Dr. Peter Kriz: I think this is really essential and has been neglected for some time, partly because free play is no longer in the equation. Physical education classes are less in the equation. So I think a number of "athletes" when we assess some in the office, some of their core strength, they're weak. They may have strength in the skills that they need to perform their sport, but from a cross-training standpoint, they have weak hip muscles and things that really do need to be addressed.
So I think it's one thing to participate, but to have some success in your sport, I think it needs to be part of the equation. And I think starting a program at least 6 weeks, ideally 6 to 12 weeks before your season is probably the time to do it.
And we're not talking that it doesn't have to be an expensive program, but something where you're doing some body weight activities, maybe with some dumb bells, kettlebells. And there are a lot of things that you can do ideally with some supervision, whether that's a physical therapist, athletic trainor. If you're lucky enough to have access to strengthening conditioning, great. But it doesn't have to be some expensive model.
Dr. Mike Patrick: A couple of episodes folks would may be interested in, we did one on summer conditioning. That's PediaCast 171 with Dr. Tom Pommering and Kerry Waple. And then, Jim, you did one with me on physical fitness and resistance training. That's PediaCast 212 with another visiting professor, Dr. Avery Faigenbaum.
Dr. James MacDonald: Yes.
Dr. Mike Patrick: And that was a fantastic episode and still in the archives. So I'll put links to both of those in the Show Notes.
And then, Jim, what about nutrition and sleep?
Dr. James MacDonald: Yeah, so if I had to say nuggets, it would be for the nutritionist, eat breakfast and listen to the one you've done with Jess and Dr. Fischer, correct?
Dr. Mike Patrick: Yes. So that one was actually one of our CME podcasts, which parents are welcome to listen to, but we did go into a lot of detail on the syndrome of low energy availability or what used to be called female athlete triad.
Dr. James MacDonald: That's right.
Dr. Mike Patrick: And so, that was Episode 41 on the PediaCast CME side. But I did a show just with Jess Buschmann, she's our sports dietitian. That was Episode 385 and that one was aimed at parents. So it's like an hour of talking about sports nutrition.
Dr. James MacDonald: So you'll get so much useful information listeners if you go to that one. Jess is such an amazing resource. But in truth, I'd say if I just keep it simple right now in this talk with two big messages, have your child eat breakfast. That will set the stage for good nutrition throughout the day. Doesn't guarantee it, but sets the stage as opposed to you're already behind the eight ball. They're running the door, they haven't eaten breakfast.
Then they're going to be snacking. Who knows how good the snacks are? They'll be potentially under-fuelling or over-fueling because they're chasing low blood sugar. It starts with breakfast and an adequate breakfast.
As far as sleep goes, there's a huge and growing body of evidence looking at how important sleep is for both athletic performance and injury prevention. It's changing almost by the week. And the overall body of evidence is proper sleep is a huge component to injury prevention and athletic performance.
So again, if I said, what does that boil down for my parents and their kids? It starts with having a really good sleep environment in the house. They should have no screens in their room. The screen thing has gotten out of control specifically in the bedrooms. That will tend to disrupt your child's sleep.
So if you just said, one thing is like, "Sure you can use your screens. They need to be off and not on in your room," as a starter for getting good sleep, I'd say you're pointing in the right direction.
Dr. Mike Patrick: Yeah. If you want to motivate your kid, tie it into performance.
Dr. James MacDonald: Right, right, yeah. But spot on to that, because a lot of times we're finding that they go fingers and glove, the injury prevention and sports performance. And you're absolutely right, the selling point for most athletes will not be, nobody wants the ACL tear, but that's not what's going to motivate them. What's going to motivate them, "Oh, my god, you're saying I'm going to get faster because I have stronger hamstring? Sure, let's go for it!" And that will get them to do both things.
Dr. Peter Kriz: Yeah, I think the screens in the bedroom, sometimes it's not the screens. It's the ringer on the phone that's vibrating on the dresser that's keeping them up and disrupting sleep. So a good rule is to maybe put those on the parent's dresser or down the kitchen and have something where when you go to bed, it's just out of your bedroom.
Dr. Mike Patrick: And then back to the nutrition, the PediaCast 385 with Jess Buschmann, we talked about those kids who are hungry in the morning. Like what are some good breakfast for them? Or picky eaters, just some really great ideas for fueling you, but thinking about food as fuel when you're a student athlete, so I definitely recommend those. And we'll have links to those in the Show Notes.
Dr. James MacDonald: Mike, one more thing. You mentioned, Jess, because she hammers this all the time, and there is a connection between nutrition-sleep and it's this, remember energy is not caffeine, energy is calories. Caffeine energy drinks are a hoax. They're not going to get the energy you want and they'll disrupt your sleep. So if your child is doing a lot of energy drinks, please have them stop it.
Dr. Mike Patrick: And it used to be a rite of passage for female athletes, you kind of lose your period during sports season. That's not a good thing. So if your child stops having their period while they're playing sports, it means they're not fueling their body and they really need to see a provider. And a sports nutrition expert would be perfect if you have that resource in your community.
I want to switch over to concussions. And it seems like even in the last ten years, the guideline just keep changing. So what's the current thinking especially on concussion recovery?
Dr. Peter Kriz: Sure, I was going to just hit on that nugget. We were just having a conversation about this last night at dinner is this idea of active rehabilitation now. So there's been some literature that's come out that has shown that prolonged periods of cocoon therapy, so staying out of school for a week, staying in a dark room, are probably more deleterious than they are beneficial. And that athletes actually have more expedite recovery if they start more of an active rehabilitation.
So what does that mean? I mean, maybe starting to go some half days at school two to three days after your injury, if you're during the school year. I mean, it's okay to read. It's okay to do a few math problems. It's okay to jump on a stationary bike. You could do some planks, do some pushups, some pull-ups, and body weight activities because it probably will… And John Letty who is at the University of Buffalo has just come out with some, and he's really the leader in this field, but in terms of active rehabilitation.
So I think that's the big change. Any of the time we go out and give talks about concussion to the community including pediatricians, they get confused. Because I think many still are recommending that there's this period of complete cognitive and physical rest. And it's really maybe two to three days.
But also, you have to tailor to the individual. There are going to be some individuals based on their concussion history or other confounding things that may require a little bit longer period before your start introducing activity.
Dr. Mike Patrick: And one thing that has not changed is the advice that while you're recovering from a concussion, you don't want to put yourself at risk for another head injury during that process, right?
Dr. Peter Kriz: Absolutely.
Dr. Mike Patrick: So really, you want to avoid contact sports. I mean, active rehabilitation of these things. We're talking aerobic activity or weight training but not where you could collide.
Dr. Peter Kriz: Well, I think we're tailoring it to their sports because I think you also have engaged the athlete a little bit. If they think they're going to be out of their sport for two three months, I think we try to include that in the recommendations. And it's a stepwise return to play, but sometimes we'll let them do a couple stages of that return to play. That's all non-contact.
But maybe if you're a hockey player, we'll let you do some off-ice work with the pucker or training ball, so that you're working on your stick handling. Or in some events, yeah, we'll let you on ice with the helmet with no one else on the ice and work on some power skating and things, some edgework. But in general, yes, that's really the key here is try to avoid re-injury during that recovery period.
Dr. Mike Patrick: And for the providers in the crowd, I'm going to put a link to, and maybe this was the article that you were alluding to, Early Aerobic Exercise Speeds Concussion Recovery. And it basically showed the young athletes recovered more quickly from sports related concussion with an early progressive exercise regimen. And it was a 103-patient randomized trial. So it was a nice study.
Dr. Peter Kriz: Very nice.
Dr. Mike Patrick: And I'll put a link to it in the Show Notes for anyone who's interested in seeing that.
And then, Dr. Kevin Walter from Children's Hospital Wisconsin was on this program. And we did a concussion update, that was PediaCast 362. And our own Dr. Steven Cuff did a CME episode on sports related concussion. That was CME Episode 33. And again, all of these links will be in the Show Notes so folks can listen.
Dr. Peter Kriz: One final comment, I think one of the reasons why it works is athletes oftentimes have a reactive depression with their concussions. So, exercise, as most of us know elevates the mood, and it really is really important to prevent that reactive depression if you can and allow the anxiety that comes with concussion. So I think exercise can mitigate a lot of that.
Dr. Mike Patrick: What are your feelings on multiple sports? So a lot of kids, "I can't decide. Do I want to do basketball?" Just saw a girl the other day, basketball and volleyball, those are her two big sports. What do you think of that?
Dr. Peter Kriz: I think it's great. I think most of us would prefer a model where kids play multiple sports and not just year-round sports, single sport specialization model that unfortunately I think most communities in the United States have gone to.
Multiple sports has built in cross-training. You're using different muscle groups. You have recovery. Anytime I see a year-round runner who's running cross country, indoor and outdoor track, they've gone to regional and states and nationals. And they're already in with their next season, there's no period of recovery.
So to some extent, and that's not multiple sports because running is one sports, you're at higher risk for overused injury. But your body needs these downtimes and to use different muscle groups. And certainly, that applies to head injuries. If you're playing three helmeted sports a year, then you're going to be more prone to repeat concussions.
I've thought about this a lot recently. I think the challenge in the economy of youth sports though is most sports are now three-season sports. And every coach wants their sport to be the primary sport, right? So what we see is this caravan of kids that are finishing one practice and getting in the car and go into the next practice. So, and that's happening more and more frequently. And some of that is economically based.
The other challenge is that what used to be town leagues or recreational leagues have kind of been sapped of their elite players if we use that word. So what's left of the kids are just playing rocks, it's just not a high level of competition. So I think the attrition rate for them is higher than it used to be, too.
And so, a lot of us would like to see a kind of come back into middle rather than the extremes, whether that's high school sports or just really well designed town leagues. I think there is the pendulum swing a little bit, but we're fighting the micro-economics of these sports.
Dr. Mike Patrick: Yeah, so ideally, from a health standpoint, multiple sports but with some time in between to sort of recover. And what should that time ideally look like? So we call it a rest, but that doesn't mean you'll become a couch potato, right?
Dr. James MacDonald: Right. We go back to your idea of pre-season summer conditioning. The idea would be I think Dr. Kriz mentioned that in his discussion. It's transitioning say out of your sport of volleyball and then perhaps doing weight training. Perhaps doing, "It's summer, and I'm going to be in the pool. I'm going to swim. I know I am a volleyball player, but I'm going to run for a couple of weeks and train for the town 5k," or something like that. It would be for an athlete, encourage to stay active but in a diversified fashion.
And just one other thing about the multiple sports, you just do have one wrinkle. And also beware there are down sides to sports specialization. There are a potential upsides to diversified sports, but remember to avoid over-scheduling. I can't tell how many people I see who did the basketball-volleyball simultaneously.
So you mentioned, it's one thing is like, "Oh, I did basketball and I'm learning the volleyball season and I'm doing this beach volleyball. Now, I'm basketball," versus "I'm doing basketball and volleyball on top of each other."
Those people, you have to start being aware that they're having too many hours. Even granted, they're in two different sports, they're getting over-scheduled. And that can be its own problem.
Dr. Peter Kriz: The other point that experience had shown me too is that you have to look at the whole family. So is the family focusing on the start athlete and the siblings are being neglected? Maybe they aren't involved in sports or other activities because the top athlete in the family is on all of these travel programs on a weekend.
So I think the overarching goal for all of us is lifelong fitness, right? And I think part of that needs to be more inclusive, too.
Dr. Mike Patrick: There was actually a study that I came across in prepping for another show maybe a year ago or so that looked at mental health and how scheduled kids were. And that the more that parents got involved in the scheduling, the less things they actually did and the better their mental health. So if you let kids just, "Do what you want to do, sign up for what you want to sign up for," but really it's better if parents say, "Well, let's pick and choose and figure out what's going to fit best with the whole family schedule."
Dr. James MacDonald: Yeah, it's the helicopter parenting phenomena a lot of us struggle with. I think sometimes when people are asking me for my specific advice, I say I look at maybe your parent role is be that maybe that nudge and maybe be the floor for your child. So have an expectation, say, "Now, you're an middle school athlete, I'm expecting you to do one sport or one activity." "Oh, good, you're going into this school newspaper," "You're going to do theater," as opposed to nothing.
And let them be the ones driving the bus that "Oh, I'm going to do theater and journalism. And I'm going to do two sports." As opposed to like a lot of us parents will be the kind of the ceiling as opposed to the floor. Like, "Oh, we're going to send you to karate. Or you're going to do your piano lessons. Oh, you're going to do this and this and this," and not have the child participate in those decisions.
I think that's where you start getting into problems. But I think having a reasonable minimum expectation of "We're hoping you do this and do this."
Dr. Mike Patrick: Yeah, kind of work on it together rather than one person definitely driving it. And then, what about integrating sports with academics and then social family life? You can't do sports 24/7, right? I mean, that's not healthy either.
Dr. Peter Kriz: It isn't. No, I think that's unfortunately where we've gotten to. And I think academics always should be the top priority. I think there's a lot of myth out there in terms of the percentage of kids that have gone on and earned Division 1 or Division 2 NCAAs scholarships. It's about 2% if you look at all sports. Some sports a little higher than others.
But I think what most people don't realize is most of those are not full scholarships, they're partial scholarships. It's not that much money and people are spending hundreds of thousands of dollars sometimes the journey from age 5 to 18 through a single sport oftentimes.
And so, I think family life has been compromised a little bit. I firmly believe that that's something we don't sit at any dinner anymore because we're running out the door to get Johnny to their third practice of the day or something else.
And so, I think academic sports, they should really be in the extracurricular activity. Unfortunately, where we are now, I think they've taken the front seat a little bit more than some of these other things that… And we're trying to build young men and women, right? I mean, it's really the goal of sports and other activities. And we should now emphasize sports, music and art and all these other things are equally important and should be in the mix, in the equation.
Dr. James MacDonald: Please recognize too, listeners. Dr. Kriz already alluded to some social justice issues. There's some compelling literature that shows it's the kids in the families who come from higher socioeconomic classes that are the ones who are at risk for overuse injuries. They are the ones that are the ones that are at risk for over-scheduling.
Unfortunately, a lot of the folks in our community, and hopefully some people listening on the other end of things, there are families who may be struggling on lower socioeconomic scales. They don't have the means to have their kids do this and these and these things. And that's its own shame and problem. But to some extent from an injury point of view can be protective. Like, "I'm in a school where my kid can only do one sport. That's all I can afford." Ironically, that may be semi-protective for you.
So some of what we're talking about right now is honestly a rich person's problem. When we're talking about the travel and this and that, obviously, a lot of that, that's out of reach of a lot of families.
And then, again, that takes away from the ultimate intention, I think, from most of these interscholastics sports is, "Let's get kids active. Let's start set the table for a lifetime of physical activity." It cuts in both ways, actually.
Dr. Mike Patrick: Yeah, absolutely. Good stuff.
So as we kind of wrap up our time together, Dr. Kriz, if you'd just let us know a little bit about your sports medicine program. We have listeners all across the country and every US states. I know we have listeners in Rhode Island. So tell us about the Sports Medicine Center at University Orthopedics.
Dr. Peter Kriz: Sure. I'm in the Division of Sport Medicine within the Department of Orthopedics at University Orthopedics. It's kind of a private/academic group. So we're affiliated with Brown University and we have our academic titles there.
We have a state-of-the-art facility that's been open less than a year now. We have about 35 to 40 orthopedic surgeons and non-operative physicians that manage a variety of conditions, musculoskeletal conditions, obviously in the sports medicine side of the house. We do other things such as concussion management and sports performance and ultrasound guided injections and things like that.
But one of my interests and passions is also injury prevention. I've had the opportunity to work with our interscholastic league in Rhode Island and work on some meaningful rule changes to reduce injury.
Dr. Mike Patrick: Great. And we'll put a link to your program so that folks can find that easily. And then, Jim, enlighten everyone about the sports medicine program here at Nationwide Children's.
Dr. James MacDonald: Well, you know, it's growing so much I sort of lose track to be honest with you. I believe we have eight or nine centers around Columbus, roughly sort of in the center and around the ring to help people from a geographic point of view. We have two that are very large, free-standing centers where we'll do physical therapy. We do something called motion analysis, fancy term for how's your kid throwing right and can we change what they throw so they don't get injured?
We're, I believe, nine physicians now and offer everything from, yes, concussion care, musculoskeletal care, ultrasound, guided injections, testing for exercise induced asthma, testing for vascular diseases.
As I said, we're big, we're growing. We love being part of the Nationwide Children's family. Love your program. As you said, a lot of us come on and we're very grateful for that.
But we, I think to a person, the doctors in this division are just really happy to be in Columbus, really happy seeing any of the listeners out there, your kids. And hopefully they'll stay out of the clinics. Hopefully, they won't get injured, but we're there for you if you need us.
Dr. Mike Patrick: That's right. And we have great athletic trainors.
Dr. James MacDonald: Oh, yeah.
Dr. Mike Patrick: We mentioned…
Dr. James MacDonald: Like 40-plus something now. I can't keep track of it anymore.
Dr. Mike Patrick: And they're in the schools and then of course, we have sports dietitians and sports psychologists and really well developed program.
Dr. James MacDonald: That's exactly right.
Dr. Mike Patrick: And we'll put a link to our program as well. And then, all of those other episode of PediaCast where we really delve into those specific topics in a lot more detail.
All right, well, Dr. Jim MacDonald and Dr. Peter Kriz, I really have enjoyed having you on today to talk about sports physicals. Thanks so much to both of you for stopping by.
Dr. James MacDonald: Thanks, Mike.
Dr. Peter Kriz: Thanks for having us.
Dr. Mike Patrick: We are back with just enough times to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that.
Also thanks to our guests, Dr. Jim MacDonald and Dr. Peter Kriz. Dr. MacDonald is sports medicine physician here at Nationwide Children's and Dr. Kriz works with the University Orthopedics group, affiliated with Brown University Medical School in Providence, Rhode Island.
Really appreciate both of them stopping by and talking to us about the pre-participation exam, better known as sports physicals. Don't forget, you can find PediaCast in all sorts of places. We are in the Apple podcast app, iTunes, Google Play, iHeartRadio, Spotify, most mobile podcast apps you can find for iOS and Android.
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