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The Athlete With Academic Performance Issues |
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The Athlete With Academic Performance Issues
George C. Phillips, MD, CAQSM
September 18, 2003
Case Presentation
n
16-year-old male, sports physical
n
Football (OL, DL, LB), wrestling
n
Left shoulder pain for 3-4 months, moderately compliant with
physical therapy
n
Limitation in overhead weightlifting
Adolescent Health
n
As many as 78% of adolescents use sports physical as their only
healthcare visit
n
Guidelines for Adolescent Preventive Services (GAPS)
n
Parental concern for decline in grades last semester – not doing
well on tests and not turning in homework
Questions for the
Athlete
n
School performance
u
Effort, time, organization, tests/assignments, class
participation
n
Job performance
n
Family relationships
n
Peer relationships
n
Athletic performance
Case Presentation
n
School – mostly tests and homework, not disruptive in class
n
Job – new job recently, no problems
n
Family – aggressive behavior toward mother, one episode of
hitting
n
Peers – no reported problems
n
Athletics – no reported problems
Differential
Diagnosis
n
Left shoulder pain
u
Rotator cuff injury
u
Anterior subluxation
u
Posterior subluxation (OL/DL/wrestler)
u
Labral injury
u
Malingering/Secondary Gain
Differential
Diagnosis
n
Poor academic performance
u
Attention-deficit disorder (ADD)
u
Learning disability (LD)
u
Oppositional-defiant disorder (ODD)
u
Major depressive disorder
u
Anxiety disorder
u
Bipolar disorder
u
Conduct disorder
Case Presentation
n
History
u
Diagnosed previously with ADD (ADHD)
u
Used stimulant medications, but self-discontinued 2-3 years ago
u
Shoulder pain improved with PT
n
Exam
u
Pain/no weakness with ROM, impingement tests
u
(+) apprehension/relocation test (anterior)
u
Contralateral sulcus sign (guarded L)
Diagnosis
n
Left shoulder pain
u
Anterior subluxation, secondary rotator cuff strain
u
Noncompliance with rehabilitation program
n
Poor school performance, with dysfunctional family relationships
u
ADD
u
ODD, LD
Management
n
Referral to PT – rotator cuff program
n
Limit overhead weightlifting, otherwise clear to participate
n
Referral to ADHD Clinic
u
Psychological evaluation and testing
u
Evaluation by physician with expertise in ADHD
Rehabilitation
n
How did rehabilitation go for this patient?
n
Were there specific problems that could be addressed by altering
your typical therapy regimen?
Treatment
n
Stimulant medications (amphetamines)
u
Ritalin (methylphenidate)
u
Dexedrine
u
Concerta
n
NCAA restrictions on use of amphetamines
u
Is there an alternative non-banned substance?
n
Wellbutrin (bupropion) – studies show equal efficacy to
methylphenidate
Psychological
Evaluation
n
Memory
n
Visual-Spatial/Motor
n
Attention/Concentration
u
Difficulty inhibiting a repeated motor response
n
Behavior/Adjustment
u
Obsessive/compulsive, depressive symptoms
u
Inattention, anxiety
The Rest of the
Story…
n
ADHD diagnosed in 1992 – Ritalin
n
1997 – Ritalin, Elavil (mood, sleep)
n
Elavil switched to Paxil (mood worse)
n
Dexedrine and Paxil
n
Paxil discontinued; Dexedrine increased
n
Clonidine added (impulsivity)
u
All changes in less than one year
The Rest of the
Story…
n
April 1998 – stable on Dexedrine, Clonidine
n
November 1998 – also diagnosed with a learning disability and ODD
n
December 2000 – changed from Dexedrine to Wellbutrin (compliance
issues, no clear benefit noted from Dexedrine by patient)
n
June 2001 – last visit to Psychiatry
The Rest of the
Story…
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Medications self-discontinued in 2001-2002
n
No followup with psychiatry, counseling, or primary care
physician
n
Grades dropped, more irritable, more aggressive behaviors,
disorganized school-work, fails to complete assignments
n
Parents expected simple refill of Wellbutrin at sports physical
(after 2 yrs w/o followup)
ADHD - Problems
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Distractibility
n
Hyperactivity
n
Difficulty organizing tasks
n
Difficulties with self-control
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Learning disabilities
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May need longer time or more repetitions to learn
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Inconsistency is common
u
Know it one day, forgotten the next day
ADHD - Strategies
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Routines and schedules
n
Limit distractions
n
Divide tasks into smaller parts
n
Contract with patient using incentives
n
Work for a specific amount of time
n
Catch the
patient doing something good!
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