You are in: eMedicine Specialties > Sports Medicine > Introductory Topics in Sports Medicine Athletes With DisabilitiesArticle Last Updated: Apr 9, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation Gerard A Malanga is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation Coauthor(s): Jessica Bloomgarden, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Rosemarie Filart, MD, MPH, Fellow, Department Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Jenfu Cheng, MD, Pediatric Physiatrist, Children's Specialized Hospital Editors: Joseph P Garry, MD, Director of Sports Medicine and Sports Medicine Fellowship, Associate Professor of Family Medicine and Exercise and Sport Science, Department of Family Medicine, East Carolina University Brody School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Author and Editor Disclosure Synonyms and related keywords: adapted sports, Special Olympics, wheelchair athletics/sports, individuals with paraplegia, Paralympics, spinal cord injury, SCI, paralysis and sports INTRODUCTIONSection 2 of 10
  Adapted sports were introduced in the mid 20th century as a tool for the rehabilitation of injuries in war veterans.1, 2, 3 Over time, adapted sports have grown in popularity. People with disabilities now can participate on the recreational level as well as the international competitive level. In many sports, such as archery, athletes who are disabled can participate side-by-side with athletes with able bodies. Adapted equipment also allows athletes with disabilities to engage in other activities. Organized activities for individuals with disabilities date back to 1888 when the first Sports Club for the Deaf was established in Berlin, Germany. In 1924, the first international competition for athletes with physical disabilities, the International Silent Games, was held in Paris, France. Wheelchair sports were developed at the Stokes Mandeville Hospital in Stokes-Mandeville, England, in the mid-1940s. The first Stoke Mandeville Games for the Paralyzed, which had 16 participants in wheelchair basketball, archery, and table tennis, were held in 1948. The First Winter Paralympic Games were held in 1976 and were hosted in Ornskoldsvik, Sweden. The events were composed of Nordic and Alpine skiing. As with the increased number of events added to the summer Paralympic Games, events such as speed skating, sit skiing, sledge racing, and sledge hockey were added to subsequent winter games. In the Lillehammer Paralympic Games, held in Norway in 1994, events for athletes with cerebral palsy were added. In 1998, events for participants with mental disabilities were added to the winter games in Nagano, Japan. Legislation Legislation has helped to stimulate the development of adapted sports in the United States. In 1973, the Rehabilitation Act stated that no person could be excluded from participation in any program or activity that received federal financial assistance. This law made physical education academic programs and intramural and interscholastic sports programs at colleges and universities accessible to participants with disabilities. The Amateur Sports Act (1978) and the Olympic and Amateur Sports Act (1998) recognized athletes with disabilities as part of the Olympic movement. As a result, 7 organizations of disability sports hold membership in the US Olympic Committee (USOC): USA Deaf Sports Federation (formerly American Athletic Association of the Deaf), Disabled Sports USA, Dwarf Athletic Association of America, Special Olympics (domestic and international), US Association of Blind Athletes, and Wheelchair Sports USA (formerly National Wheelchair Athletic Association). In 1990, the Americans with Disabilities Act (ADA) was passed into law, providing increased access for persons with disabilities to employment, transportation, public accommodations, state government, local government, and telecommunications. In general, this access facilitates the involvement of people with disabilities in athletic pursuits and the venues where they are held. For children and adolescents, the 1990 Individuals with Disabilities Education Act (IDEA) is particularly relevant. The purpose of the IDEA is to assure access to public education for children with disabilities. This law specifically requires that children with disabilities have access to adapted physical education. PARTICIPATION FOR PEDIATRIC PATIENTSSection 3 of 10
The development of junior-level activities and competition can be measured only in a few short decades. Wheelchair Sports USA created a junior division in the early 1980s for participants aged 6-18 years. Other organizations, such as the National Wheelchair Basketball Association and the USA Deaf Sports Federation also created junior divisions. National organizations, such as the Boy Scouts, the Girl Scouts, and local leagues of Little League Baseball, have increased accessibility to their programs for children with disabilities. As discussed above, legislation such as the 1990 IDEA mandated the establishment of adapted physical education programs for children who could not participate fully in mainstream physical education classes without adaptations. Sports and physical fitness activities have been used as forms of therapy for the pediatric population. Horseback riding (hippotherapy) has been used for many years as a therapeutic modality to help improve strength, balance, posture, range of motion (ROM), and self-image in children with disorders affecting muscle tone, strength, or motor skills. Pool therapy is also used with children to increase muscle strength, ROM, coordination, and endurance, as well as to decrease tone. In addition, compliance with therapies may be difficult with children; therefore, delivering therapy disguised as recreation may be helpful. CLASSIFICATION SYSTEMSSection 4 of 10
Classification systems are important in adapted sports to ensure the fairest environment for competition, and they are designed to allow participants to compete on equal terms with each other. This stratification prevents individuals with less severe disabilities from dominating the competition. In sports for athletes with able bodies, classification is common. For example, weight classes are used in boxing, wrestling, and weight lifting. Multiple classifications systems exist. Some classification systems are based on the medical diagnosis. Others are based on the level of function. In other sports, such as archery, competitors who are disabled and those who are not disabled are integrated fully. A detailed discussion of the different classifications systems for each sport is beyond the scope of this article. BENEFITS OF EXERCISE AND SPORTSSection 5 of 10
The spectrum of benefits of exercise and sports for athletes with disabilities spans the distance from psychosocial to physiologic realms.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 The participants develop an improved self-concept, psychosocial attitude, social awareness, social reintegration, perception of well-being, and health. Recreational enjoyment is also obtained. Exercise has been found to improve mood, especially in those individuals who are affected more severely by disabilities. The physiologic benefits of participating in sports are well known. Studies on athletes who are disabled provide similar physiologic findings.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Athletes with disabilities demonstrate increased exercise endurance, muscle strength, cardiovascular efficiency, and flexibility; improved balance; and better motor skills compared with individuals with disabilities who do not participate in athletics. Athletes with spinal cord injury have an increase in bone density above the level of injury, and individuals with amputations who participate in athletics have improved proprioception and increased proficiency in the use of prosthetic devices.14, 15 Athletics also have an impact on general health. Individuals who are disabled but active have fewer cardiac risk factors, have higher high-density lipoprotein (HDL) cholesterol, and are less likely to smoke cigarettes than those who are disabled and nonactive. Athletes with paraplegia are less likely to be hospitalized, have fewer pressure ulcers, and are less susceptible to infections than nonactive individuals with paraplegia. MEDICAL CONSIDERATIONS OF ADAPTED SPORTSSection 6 of 10
The role of the healthcare provider for athletes who are disabled is to be knowledgeable of the individual's primary disability and to assist in their safe participation in sports for the achievement of athletic goals. Performing a preparticipation examination (PPE) and being knowledgeable about participation maintenance and disability-specific conditions are essential to the safety of the patient. The PPE and participation maintenance are discussed in this section; disability-specific conditions are addressed in the following section. The PPE Before participating in athletics, the athlete with a disability has to have completed acute rehabilitation, must understand the disability, must set sport-specific goals, and must communicate with a health care provider familiar with the medical aspects of the disability.3, 16, 17, 18, 19, 20, 21, 22, 23 A PPE performed by a qualified healthcare provider is often required before participation. The specific elements required in the PPE are determined by the sport, the level of the participation, the athletic organization, the clinical indications, and the athlete. This published information is obtained from the respective athletic teams, schools, and organizations and, hence, is used by the examiner to tailor the PPE accordingly. The objectives of the examination include the following:
In general, components of the PPE include a disability and sports-specific history and physical examination. In addition to the standard components of a history, the elements of the history for an athlete with a disability should also include the athletic goals of the individual, the predisability and present level of training and sports participation, information on any over-the-counter (OTC) agents taken, presence of impairments, past family cardiopulmonary history, level of functional independence for mobility and self-care, and needs for adaptive equipment. The elements of the disability and sports-specific physical examination are tailored for the individual. Sensory deficits, neurologic deficits, joint stability and ROM, muscle strength, flexibility, skin integrity, medications, and adaptive equipment must be assessed. For the athlete who is disabled, assess the functional limitations of his or her body in both the affected and unaffected anatomic areas. Evaluate the patient's mobility with a wheelchair or any assistive devices that will be used for sports participation. Also evaluate his or her general cognition, memory, and judgment. During the musculoskeletal examination of an athlete who uses a wheelchair, evaluate the stability, flexibility, and strength of the commonly injured sites (eg, shoulder, hand and wrist, lower extremities [LEs]) as well as the trunk. During the musculoskeletal examination of an individual who has had an LE amputation, assess the stability, flexibility, and strength of the trunk, as well as the hip girdle and the unaffected and affected LE, with or without the prosthesis. Cardiovascular and pulmonary examinations are vital to any PPE and can identify conditions that can cause cardiopulmonary collapse or disease progression. Suggested guidelines for cardiovascular screening of the athlete are available from the American Heart Association, American College of Cardiology, and American College of Sports Medicine.20, 23 For example, in the case of detected heart murmurs, the athlete is informed and is referred to his/her primary physician for consideration of an electrocardiogram (ECG) and echocardiogram before the beginning of the sports season and before entry into training. A PPE is performed upon entry into sports and should be repeated at least every 2-3 years. An interim follow-up before each sport season may be necessary if the athlete's health condition changes. Participation maintenance The key to continued participation and recreational enjoyment is remembering that safety is integral to good training and play. Therefore, strategies to prevent injury are emphasized. Musculoskeletal injury is the most common injury reported among athletes who are disabled. A prevailing preventive strategy for musculoskeletal injury is sports-specific conditioning, along with preexercise stretching and warm-up as well as postexercise cool-down and stretching. Musculoskeletal injuries, as well as fatigue and exhaustion, can be reduced by assuring adequate nutrition and fluid status.24 Instruction in the use of proper protective and adaptive equipment and clothing also is important. In addition, the location where the sporting event is to be held should be evaluated before each training and play for potential hazards, such as falls, and for access and maneuverability of the adaptive equipment. Training athletes who are disabled on specific fall techniques (ie, safe methods for falling and recovering from a fall) can prevent potential injuries. This part of the athlete's education can be performed by a trained physical therapist. For example, an athlete who uses a wheelchair should be taught techniques for how to protect the head and neck in the event of a fall from a wheelchair, how to prevent ejection from the wheelchair upon a fall, and how to recover to an upright position in an energy-efficient way with a locked wheelchair. DISABILITY-RELATED MEDICAL CONDITIONSSection 7 of 10
Environment Thermoregulatory dysregulation is a common condition for a number of neurologic disabilities such as spinal cord injury (SCI), MS, brain injury, and stroke. For these disabilities, thermoregulatory dysregulation is a condition whereby the thermoregulatory system is impaired neurologically, resulting in heightened difficulties with acclimatization to either a cold or hot environment.2, 23, 25, 26, 27, 28, 29 Hence, the play environment heavily influences the schedule for training and for the sporting event, whether the sport is played indoors or outdoors. In individuals who are neurologically intact, body temperature is regulated by the interplay coordinated by the autonomic nervous system, thermal receptors, cardiopulmonary system, and skeletal muscle contraction. The hypothalamus is the thermoregulatory center. The afferent system to the hypothalamus is provided by peripheral and central thermal receptors; the efferent signal descends primarily through the brainstem to the thoracolumbar division of the autonomic nervous system. The efferent system coordinates adjustments in cutaneous blood flow, sweating, venous return, and skeletal muscle-generated metabolic heat. Circulating vasoactive substances and local mechanisms are known to play a role in thermoregulation in response to the ambient temperature. For patients with SCI, thermoregulatory dysregulation is a significant aspect in participation of sports. This dysregulation has been described at the level of the afferent and efferent systems with autonomic dysfunction and sensory deficits and at the thermoregulatory center with the impaired response to the hypothalamus regulation. Individuals with a neurologic injury level of T6 and above are most vulnerable to complications related to heat or cold stress. Thermoregulation dysfunction may occur in persons with central nervous system (CNS) lesions along the thermoregulatory system, such as in the hypothalamus or brainstem, as observed in individuals with cerebral palsy or in individuals following a stroke or brain injury. Individuals with MS may have CNS and/or spinal cord lesions; therefore, impairment of the thermoregulation system may also be observed in cases of MS. In addition, among individuals with MS, the propensity of fatigability with activity increases the risk for intolerance to environmental stresses. With advanced age, an athlete with a neurologic physical disability may experience greater intolerance to environmental stresses than an individual without the disability. This change may occur in the setting of a previous state of immobility, premorbid deconditioning, medication effects, and concomitant age-related medical problems including autonomic dysfunction, altered control in cutaneous vasodilation, impaired renal function, reduced stroke volume and cardiac output, reduced total body water, obesity, or altered vital capacity (VC). If the individual enters into recreational athletics without previous experience and is deconditioned at the onset of training, the intolerance is even more prominent. A program geared toward a gradual acclimation is advisable. Medications may potentiate environmental intolerance. Adjustments may need to be made in the medication, the dose, and/or the dosing regimen, depending on the intensity of the activity. For example, diuretics can increase the risk of dehydration, especially when coupled with intense exercise. Other medications include anticholinergics, neuroleptics, antihistamines, and beta-blockers. Prevention is the key to management. Daily assessment of the individual's training and sporting environment should guide scheduling. Clothing featuring the appropriate fit and durability is emphasized, with the selection of lightweight, light-colored garments for hot climates and insulated, layered garments for cold climates. Adequate nutrition and hydration is particularly important for players in competitive games and outdoor sports. An enclosed facility such as a tent provides an area for rest and protection during breaks and for first-aid administration. Education is vital for the athlete and game officials to prevent, identify, and provide initial management of heat-related and cold-related illnesses. In addition to prevention and recognition, medical personnel should be familiar with advanced treatment of these conditions. Heat-related illness includes a spectrum of conditions (eg, heat-induced peripheral edema, heat cramps, heat exhaustion, hypotonic fluid-induced hyponatremic collapse, heat syncope, heat stroke) (see Table, below). Heat edema results from local peripheral vasodilation, sweating, and increased sodium and water retention, leading to the development of peripheral edema. Heat edema resolves over several days during acclimatization. The term heat cramps refers to the muscular spasm associated with prolonged exercise in heat, thought to result from ongoing negative sodium balance related to endurance activities in those who are unacclimated. Although resolution is observed with minimal conservative treatment, heat cramps may portend heat exhaustion when treatment is not administered and the athlete is not monitored for the development of further signs and symptoms of heat-related illness. Heat exhaustion is a serious condition resulting from severe dehydration and/or hyponatremia. Tachycardia, high core temperature, dry mucous membranes, and hypotension are observed. Sweating may be reduced. If not treated, this condition may progress to heat stroke. Heat syncope results from impaired CNS perfusion due to reduced cardiac output from reduced venous return associated with heat-induced peripheral vasodilation and blood pooling in the extremities. If an alternative etiology of the syncope is suggested, the differential diagnosis for syncope in the athlete with a neurologic disability should be considered, depending on the individual's medical history and clinical presentation. The etiology may be cardiovascular, pulmonary, or associated with an acute CNS event. Heat stroke is a medical emergency and does not resolve spontaneously. This condition results from thermoregulation failure and presents with an extremely elevated core body temperature and electrolyte and metabolic derangements. Mental status changes are key clinical clues. The Table provides a summary of the heat-related illnesses.
Cold-related illness can be seen with swimming, during inclement weather in summer sports, or during winter sports. The predominant condition is hypothermia.25 Hypothermia, by definition, occurs when the core temperature is below 95°F (35°C). Assess the degree of severity of the cold-related illness. A mild condition can be treated with slow external rewarming techniques. A moderate or severe condition requires close monitoring of the condition and warrants immediate transfer for more extensive medical attention. Until emergency services are available, initial treatment is instituted, involving removal of the athlete from the cold environment and passive external rewarming techniques. Spasticity Spasticity is defined as the velocity-dependent increase in resistance of muscle tone believed to be due to increased motoneuronal excitability and enhanced stretch-evoked synaptic excitation of motoneurons from an upper motor neuron injury. When not controlled, the clinical result is reduced mobility and ability to perform activities of daily living (ADL). The individual may report an inability to operate a manual wheelchair, ambulate, fit clothing properly, or perform transfers and ADL. An increased risk of contractures, skin breakdown, and pain accompany spasticity. Moreover, training and sporting events may become unsafe with the potential propulsive force of involuntary muscle spasms causing, for example, falls out of the wheelchair, difficulty in ambulation with forward movement, and reduced control of balance. Spasticity is observed in varying degrees among patients following SCI, stroke, and brain injury and among individuals with MS. Control of spasticity is preferred when the athlete's play and functional ability are affected. Management is achieved through noninvasive means with pharmacologic treatment, positioning, or bracing. Pharmacologic options depend on the patient and the severity of the tone. Administration of medications is performed best under the advisement of a physician who is familiar with spasticity treatment. The medication's side effect profile and dosage should be reviewed, as alertness, cognition, and motor strength can be affected adversely at therapeutic dosages. The choice, route, and dose of the medication should be reviewed with the choice of optimal administration to produce the fewest side effects with the greatest control. When indicated, bracing of the affected extremities may include tone-reducing upper-extremity or lower-extremity braces. For athletes who use wheelchairs, wheelchair positioning and modified components can reduce triggering muscle spasms and provide increased support in case of a triggered spasm.13, 30, 31 Trials can be performed to determine the optimal wheelchair system for the athlete. Depending on the location and severity of the spasticity, these trials can be conducted with one or a combination of items, including modification of the front rigging, adjustment of the footplates, adjustment of the angle of the seat with the back support, and/or addition of a lap belt or chest, thigh, knee, ankle, and/or foot straps.31, 32 Osteoporosis In addition to the primary and secondary osteoporosis risk factors, osteoporosis in those who are neurologically disabled is observed to be associated with one or a combination of factors, including immobility, decreased muscular strength and weight-bearing activities, age, predisposition, and medications. In this population, varying degrees of osteoporosis commonly are encountered among athletes with a motor-complete SCI and/or advanced age. The impact on the ability to play is notable because of an increased risk of fractures over osteoporotic areas. Preventive strategies against complications are essential for the management of osteoporosis among these athletes. Pharmacologic treatment includes the recommendation of calcium and vitamin D as initial agents. The addition of bisphosphonates to treat documented osteoporosis is indicated. Modifications to equipment are prudent. For athletes who use wheelchairs, liberal chair padding provides increased protection in case of falls and reduces the stress with axial loading. Fall prevention techniques are also implemented. These techniques include assessing the play environment for potential obstruction to safe mobility and ambulation; providing advanced training in safe mobility on uneven surfaces, stairs, and sport-specific environments; and ensuring optimal treatment for sensory deficits, such as updated prescription lenses that are fitted for sports activity. In addition, it is important to assess the individual athlete's needs, as well as to provide athlete and caregiver education about the routine evaluation of the integrity, functional utility, and sport-specific applicability of the athlete's equipment, including adaptive equipment, wheelchair, ambulatory equipment aids, and/or protective gear. Repairs, adjustments, and new equipment are considered to reduce the risk of falls and ensure safe play. Musculoskeletal injuries Musculoskeletal injuries are the most frequently reported medical problem within the competitive arenas.33, 34, 35, 36 The shoulder was the most commonly injured area of the body in the Paralympic 1996 summer games for the athletes of Disabled Sports USA and Wheelchair Sports USA.37 Overall, from 1990-1996, among US athletes with disabilities participating the Paralympics and World Championship Games, the most commonly reported musculoskeletal injuries were the thorax/spine (13.3%), the shoulder (12.8%), and the lower leg/ankle and toes (12%).38 For athletes with amputations and other ambulatory athletes, LE injuries were the most commonly treated condition. For athletes using wheelchairs, UE injuries were the most commonly treated condition. Little information has been published regarding the prevalence of injury among participants in all winter sports. Depending on the sport and the nature of the athlete's disability, as well as the method of reporting, varying prevalences of anatomic sites of injury are indicated in the literature. Preventive strategies are essential to reduce the number of musculoskeletal injuries. Elements of management have been discussed previously. This section focuses on one of the elements (ie, sport-specific conditioning). This specific type of conditioning provides the athlete with an individualized program that prepares him/her for the sport's unique metabolic and biomechanical demands, injury risks, and level of fitness. The overall program goal is to improve performance and prevent injury. The conditioning program begins with the identification of the athlete's goals and choice of sport. Each program is geared to the individual's level of fitness upon entry. With general athletic fitness as the foundation, training for the higher level of fitness needed for that given sport incorporates flexibility, muscular strength, muscle balance, aerobic endurance, speed, agility, and sport-specific skills. Conversely, for individuals with neurologic disabilities, overtraining is a major concern. These athletes are predisposed to chronic repetitive strain and overuse injuries because of the reliance on the remaining functional limb(s). For athletes with SCI using wheelchairs, chronic shoulder injuries are common occurrences that may, in large part, be due to overuse and overtraining. Hence, it is important to strike a balance between carrying out the appropriate training program and overtraining. Precautions to prevent fatigue are also presented for athletes with MS and neuromuscular disorders. The training program is divided into phases (eg, off season, preseason, early season, late season). The program may be gradual in intensity and of longer duration for the elite athlete, in comparison with the recreational athlete whose play season is often shorter. Pressure sores A pressure sore is the disruption in skin integrity due to unrelieved pressure. Unrelieved pressure can cause local ischemia and subsequent tissue damage. Interruption in skin integrity can be associated with prominent bony surfaces, which are more likely to encounter pressure forces, poor skin integrity, and friction that is generated by shearing forces. The skin lesion is graded upon the depth of tissue involvement. The following classifications are according to the National Pressure Ulcer Advisory Panel39:
For individuals who use a wheelchair for mobility, the most common areas at risk for pressure sores include the sacrum and coccyx, ischial tuberosity, posterior knee, foot, and shoulder blade. For the individual who wears a prosthesis, the skin areas in contact with the prosthesis and suspension are at risk. Athletes with sensory deficits are most at risk for the development of pressure sores related to training or play. Other risk factors include activity-related shearing; axial forces generated against the skin; and poor transfer techniques, pressure relief techniques, seating and/or prosthetic systems, skin integrity, or skin care. Athletes who use a wheelchair and athletes who have had an amputation are at risk because of a combination of these factors. Prevention and early intervention are important to management of pressure sores.39, 40 Skin checks and pressure-relieving techniques should be performed on a regular basis. For athletes who use a wheelchair, weight shifts are the predominant pressure-relieving technique taught during rehabilitation. Weight shifts from a seated position are performed by pushing up off the surface or by leaning forward or laterally. The SCI clinical practice guidelines recommend that weight shifts be performed every 15-30 minutes to reduce the effect of prolonged pressure. Education is directed toward assuring the adequate type, condition, and fit of adaptive devices; implementing proper transfer techniques; monitoring of disrupted skin integrity areas; and treating pressure sores early to prevent progress.39, 40 For athletes who use wheelchairs, alternative adjunctive preventive strategies include methods to reduce friction forces and moist skin environments. These strategies can be achieved by choosing moisture-wicking clothing, an adequate custom-fitted wheelchair cushion, and sufficient padding over potential areas of breakdown. Sitting times may need to be restricted in severe cases. For the athlete with an amputation, adjunct strategies include a proper prosthetic fit and an adequate suspension system, as well as assessment for a silicone liner, adequate cushioning with socks and padding, and sport-specific biomechanics training with the prosthesis. Avoiding a moist skin environment over the residual limb reduces the risk of skin breakdown. Syncope Syncope is the complete loss of consciousness and postural tone with recovery. A near-syncopal event represents an altered level of consciousness rather than a complete loss of consciousness. The evaluation indicates the need for assessment and treatment on an emergency basis. The main categories of the differential diagnosis include vascular, cardiac, neurologic, and miscellaneous etiologies. The differential diagnosis is lengthy and beyond the scope of this article. This section only highlights several conditions. The most worrisome etiology is cardiogenic syncope, leading to cardiac arrest from arrhythmias, myocardial ischemia, or myocardial infarction. Hence, it is important to identify accessible emergency medical services and a hospital before a training session or game. Sudden cardiac death is a separate entity defined as a nontraumatic unexpected cardiac event resulting in cardiac arrest and death within 6 hours of a previously witnessed healthy state. For the pediatric population, this phenomenon has been associated with congenital cardiac anomalies, hypertrophic cardiomyopathy, increased cardiac mass, Marfan syndrome, myocarditis, long QT syndrome, severe valvular disease, use of drugs, severe bronchospasm, and coronary artery abnormalities (less commonly). For the adult population, the occurrence of sudden cardiac death is associated primarily with coronary artery disease, but it can also be associated with hypertropic cardiomyopathy, increased cardiac mass, severe valvular diseases, conduction abnormalities, severe bronchospasm, and drug use. The most common etiology of syncope in the athlete is neurocardiogenic syncope (vasovagal or neurally mediated hypotension syncope). A specific trigger usually is identified and can be a cough, micturition, bowel evacuation, or a stressful event. Neurocardiogenic syndrome involves a reflex-mediated vascular condition. Tilt-table testing administered by a cardiologist can reproduce this condition. Pharmacologic intervention may be warranted. Syncope or near-syncopal events that are readily reversible in the athlete include heat-related illness, hypovolemia due to dehydration, and hypoglycemia. These conditions are treated accordingly. The differential diagnosis of syncope in athletes who are disabled include neurologic physical disability-related syncope or near-syncopal events, which may result from a number of conditions, including hypovolemia, orthostatic hypotension, seizure, transient ischemic attacks (TIAs), or stroke.41, 42, 43 These conditions are treated accordingly. Management involves preventive measures such as local mechanical support (the application of supportive pressure-gradient stockings and abdominal binders when the patient is in an upright position). If these conservative measures fail, pharmacologic interventions are considered and include agents such as sodium chloride tablets or midodrine. Autonomic dysreflexia Autonomic dysreflexia (AD) is a medical emergency resulting from the massive reflex sympathetic discharge occurring in patients with SCI at or above the splanchnic outflow at the T6 level or among those with brainstem lesions.44 The clinical picture is an unopposed sympathetic discharge below the lesion and prevailing parasympathetic outflow above the lesion. Noxious stimuli are the triggers of AD. Therefore, in the presence of a trigger, an individual with an SCI at or above T6 may present with AD. Clinical signs of AD include sympathetically induced elevated systolic blood pressure greater than 20 mm Hg above baseline, severe peripheral vasoconstriction, and piloerection below the lesion, and parasympathetic-induced profuse sweating and skin flushing due to the vasodilation. The individual commonly complains of a severe headache, nasal congestion, and feelings of apprehension. The complications of unresolved AD are the same as for other hypertensive crises: stroke, seizure, arrhythmias, myocardial infarction, and death. Triggers for AD include some form of noxious stimuli, most commonly of a genitourinary (eg, urinary tract infection, bladder distention) or gastrointestinal (eg, constipation) origin. Other etiologies that may be encountered on the field include infection, sunburn, contact with sharp objects, tight garments, an ingrown toenail, fracture, appendicitis or other abdominal pathology, malpositioning, and disrupted skin integrity from numerous etiologies. The initial management focuses on the identification and removal of the trigger, which usually results in its resolution. Elevating the head and trunk to more than 30° is an initial maneuver to decrease the high blood pressure. Assessing for adequate bladder drainage and an aggressive bowel evacuation, loosening tight garments, adjusting the athlete's position, and performing a full skin examination are essential in identifying the cause of AD. The athlete's blood pressure is monitored every 5-10 minutes until it normalizes to the patient's baseline. If the systolic blood pressure does not resolve spontaneously, pharmacologic intervention is warranted until the trigger is identified and treated. The initial choice is nitropaste applied to the skin, commonly on a UE, the chest wall, or the forehead. Doses are elevated until resolution is achieved. A hypertensive urgency or emergency may develop if these conservative measures fail. In these cases, emergency medical services are required to transfer the athlete for an in-hospital evaluation. The athlete, coach, and officials should be familiar with preventive strategies as they can address many of the potential triggers. These strategies include assuring a functioning and secure bladder drainage system, regular bowel evacuation, routine skin examination, well-fitted adaptive devices, proper clothing, sunburn protection, and proper positioning (eg, wheelchair seating system for athletes who use wheelchairs). Boosting Boosting is the colloquial terminology for self-induced AD, which is identified as a performance-enhancing technique.45, 46The term boosting refers to a technique potentially employed by athletes with an SCI at the T6 level or above. The clinical result is similar to that produced by ergogenic aids. Consequently, boosting has been prohibited because of its unethical use in competitive sports. In theory, the performance-enhancing physiologic mechanism has been attributed to increased cardiopulmonary effects, oxygen utilization, and noradrenaline release. Reported methods for boosting by some athletes include temporarily occluding one's own urinary catheter, ingesting great amounts of fluids before the sporting event to distend the bladder, tightening garments, and prolonged sitting, thus inducing nociceptive stimuli. The complications of a prolonged boosting trial are the same as for AD in general (eg, stroke, seizure, arrhythmias, myocardial infarction, death). Education of medical personnel, coaches, and officials about this performance-enhancing technique is essential to its detection. Discouraging the use of practices intended to induce symptoms of AD is important. Assessing the athlete's condition before and during sporting events can help to detect such dangerous practices. ADAPTIVE EQUIPMENT FOR SPORTSSection 8 of 10
Prosthetics and orthotics The use of specialized prosthetics and orthotics designed for specific activities significantly can increase the quality of athletic experiences for athletes who are disabled.14, 15 These devices allow these individuals to be more physically active and perform at higher proficiency levels. The development of prosthetic limbs has been significant over the years, with the introduction of many variations for different activities. The correct choice of a prosthetic limb is essential for optimal performance. For example, many people who ambulate throughout the household and community can use a solid-ankle cushion heel (SACH) prosthetic foot efficiently, whereas most athletes use the newly developed dynamic-response prosthetic foot (Ossur Americas, Aliso Viejo, Calif; Otto Bock Healthcare GmbH, Minneapolis, Minn). The dynamic-response foot deforms under a load but retains the memory of its prestressed configuration to return it to its original shape upon removal of the load. These dynamic response feet are subdivided further into articulated and nonarticulated groups. Articulated feet use axial joints to provide articulation, rather than only on-heel deformation. They can accommodate uneven surfaces better than unarticulated feet and, therefore, are useful in sports such as golf. Suspension design becomes a very important consideration in sports, particularly in running events. Silicone suspension systems with locking mechanisms or supracondylar suspension with an additional neoprene sleeve are common configurations.Some sports may not incorporate foot designs at all. Swimmers may prefer a prosthesis with an attached fin. Prostheses used in water may also be designed to fill with water to prevent buoyancy. This feature is particularly important in sports such as scuba diving. Elastomeric skins are also available to cover conventional prostheses to provide protection from minor water exposure. Like an attached fin for swimmers, other specialized terminal devices are available for specific sports. A pedal binding system can be used to attach a prosthesis to bicycle pedals. Prostheses for rock climbing come in various shapes and sizes to accommodate different features in the rock. The prosthesis can also be covered with a high-friction sole to increase purchase to the rock. Countless variations of specialized equipment have been developed, and innovation has continued to open doors for athletes with disabilities. Specialized wheelchairs Wheelchair design has advanced with the increased specialization of athletics for individuals who are disabled. The athlete needs to choose the chair carefully to acquire the characteristics necessary to participate and excel in their sports. As new needs arise, development of new equipment is needed. Wheelchairs are divided into 4 general categories, as follows31:
General sport chairs are often used as a primary chair for everyday use. They generally have no armrests but have strong braking systems and relatively large handrims. They may also have small caster wheels in the front to improve the ease of turning. Motorized chairs are used by athletes who are affected with more severe disabilities. Motorized chairs can be significantly more expensive than manual chairs, but they do allow participation by athletes who are unable to propel a general sport chair. Throwing chairs are used in field events. They are more rigid and stable, allowing better throwing of a club, shot, discus, and javelin. Throwing chairs usually do not have wheels. Racing chairs often lack maneuverability but do offer the capacity to generate greater speeds. Racing chairs often have only 3 wheels and usually offer a lower body position, larger wheels, more camber for stability, and a longer wheelbase. Rules define the parameters of allowable wheelchair design for each sport; however, within these parameters, a wheelchair optimally must be fitted and designed for each athlete, as well as each sport. Advanced wheelchair design allows athletes who are disabled to participate effectively in countless physical sports and endeavors. Other specialized equipment Equipment design is often limited only by imagination and motivation. Adapted rock-climbing equipment has allowed individuals with paraplegia to ascend rock faces that are 3000 feet high. Patients with tetraplegia have developed sailboat-operating systems that use the sip-and-puff method. These pieces of equipment often represent one-of-a-kind innovations but often become more widespread as they are adapted by more participants. SPORTS AND EVENTSSection 9 of 10
Sports and events As a general rule, adapted sports are designed to depart as little as possible from the original versions. Below is a brief overview of a selection of adapted sports as well as contact information.
The following organizations can provide further information on sports and sports-related activities for individuals with disabilities:
REFERENCESSection 10 of 10
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