Eunice Shriver organized a program of physical fitness for individuals with mental impairment in 1968. This program, Special Olympics, has grown tremendously in size: it is international and involves over 2.2 million athletes, pediatric through older adult ages. Eligibility for participation requires the individual to be at least 8 years of age (for competitions) and have intellectual ability significantly below average for biological age and social culture, as measured by formal assessment, or significant learning or vocational problems owing to cognitive delay that require or have required specially designed instruction. More information can be obtained from Special Olympics’ website: www.specialolympics.org. Special Olympics is typically considered to be the competition, that is, the Summer Special Olympic Games, held by the organization. There is also a Skills Program that is available and detailed in a written format for several summer and winter sports. This is an 8-week training program, 3 days per week with goals and assessment tools. These guides/skill programs are available from Special Olympics International and assist those who wish to be active but do not actually wish to compete in the Games.

Special Olympics uses a system called “divisioning” versus a medical or functional classification system, in order to match the skills of similar competitors in a sport. Age, sex, and ability are used to create a score. Each division has three to no more than eight competitors or teams. Within a division, the top and bottom scores may not exceed each other by more than 10%. In team sports, 4 to 5 sport-specific skills are evaluated in every team member. These scores are summated to create the team score for divisioning.

Special Olympic athletes have a higher rate of abnormalities on screening evaluation (1) than able-bodied athletes;
such as gastrointestinal disorders, visual impairment and congenital heart conditions. A high incidence of visual problems has been sited in these athletes (2). Of 905 participants at the 1995 Special Olympics World Summer Games, refractive errors, poor distance acuity, and strabismus were among the vision anomalies (2).

Congenital heart conditions are present in up to 50% of athletes with Down syndrome (3). The most common congenital heart disease in western medicine literature is atrioventricular septal defect. A recent retrospective study in Saudi Arabia (4) found a similar frequency (61.3%); however, ventricular septal defect was the most common congenital heart anomaly they reported. There has also been an increased association of obesity and high cholesterol in athletes with Down syndrome (5). Some of these conditions can limit participation in sports (6), depending on the type of activity. Sports injuries in mentally challenged athletes are similar to those that occur in nonimpaired athletes and are sport specific (7).

Clinical issues potentially uncovered on pre-participation examination can include decreased neck range of motion (ROM), abnormal gait, ligamentous laxity, neurological symptoms, seizure history, and sensory symptoms. There is a reported 8.7% incidence of scoliosis in these athletes (8). The athlete may also report being easily fatigued during activity. Atlantoaxial instability is of higher incidence in Down syndrome than in nonchallenged athletes. Most athletes with atlantoaxial instability are asymptomatic (9). Lateral cervical x-rays with flexion and extension views are required in the Special Olympics screening program in all athletes with Down syndrome. There is controversy regarding using the “atlanto-dens interval” as criteria for competition in sports (10,11). The American Academy of Pediatrics suggests that presence of atlantoaxial instability be considered a contraindication for contact sports (6).

There are several groups of athletes with physical impairment as their athletic classification. Examples of the different groups of physically challenged athletes include wheelchair athletes, athletes with cerebral palsy (CP), les autres (meaning “the others”, which includes those with various disabilities such as muscular dystrophies, multiple sclerosis [MS], etc.) and athletes with limb difference or deficiency. Hearing impaired and visually impaired are not exclusive to physically challenged competitions as many compete in athletic competitions without physical impairment as a qualification, for example, hearing impairment in wrestling. They are eligible, according to the National Collegiate Athletic Association (NCAA), “…if they qualify for a team without any lowering of standards for achievement…and do not put others at risk.” Those hearing impaired athletes that compete in the physically challenged arena demonstrate a hearing impairment of greater than 55 db loss in the better ear as their qualification.

Among the physically challenged athletes, there are classification systems developed to remove bias based on innate level of function. These systems have considered classification based on medical diagnosis alone, functional ability, and a hybrid model considering issues of function and the medical diagnosis. These systems attempt to place persons with a particular impairment on equal functional terms with other competitors. An example is noted in comparing medical and functional classification systems of les Autres athletes:

Some sports have sport-specific classification, such as alpine skiing (Table 22.1).

Figure 22.1 shows an athlete with limb deficiency using outriggers for assistance. Some of the classification systems, for Athletics (Track and Field) in Limb deficiency or difference, and, for physical condition of movement impairment/CP, are given in Tables 22.2 and 22.3. The presence of physically challenged competitions does not limit the involvement of some physically challenged athletes in able-bodied arenas. A few examples including physically challenged athletes in able-bodied arenas are archery and wrestling (athletes with hearing loss). Jim Abbott, a well-known athlete, competed as a professional major league baseball pitcher with a congenital limb deficiency of his right hand.

These classification systems are frequently revised and it is important to know the system in place for the particular
competition of your athletic patient. The corresponding governing sports body can assist in clarifying any classification changes. They are typically used in sanctioned competitions but not as strictly followed for local events. International competition involves the following disabilities: paraplegia, amputation, locomotor disorders, CP, mental impairment, visual impairment, and hearing impairment. In the Atlanta Paralympics there were 3,500 athletes from 120 nations; most of these were athletes with limb deficiencies (12).

There are several sports organizations associated with physically challenged athletes. Some examples are: National Disability Sports Alliance (NDSA) formerly known as the United States Cerebral Palsy Athletic Association, United States Les Autres Sports Association (USLASA), and Dwarf Athletic Association of America (DAAA). There are also single sport organizations, such as the National Foundation of Wheelchair Tennis (NFWT), that are open to people with all types of physical impairments who use wheelchairs for sports. This organization works with United States Tennis Association (USTA) wheelchair tennis committee to achieve opportunities for competition in tennis. Internationally, there are the International Paralympic Committee (IPC), the International Stoke Mandeville Wheelchair Sports Federation (ISMWSF), and the International Sports Organization for the Disabled (ISOD), among others. The rules and regulations can vary between local, national and international competitions. In treating athletes training for competitions, be aware of what regulations may be in place for competition and classification.

Through the course of development (in congenital acquired impairments), or rehabilitation after a change in physical function (such as traumatic spinal cord injury (SCI)), the team of medical professionals are supportive and encourage the patient to pursue an active lifestyle. There are pre-participation examinations readily available in the able-bodied sports arena. Some of these also address questions to consider in physically- and mentally challenged athletes (13). These can also be used as guides for the physically challenged, however there are additional considerations
during the pre-participation evaluation. These medical issues are covered in more detail in other texts (14). The medical team during acute rehabilitation phases is attuned to these issues. However, some physically challenged athletes do not turn to competitive sports until after several years following their injury. It is important to gather additional information in the history and determine the presence of co-morbidities in these athletes. In a study reviewing medical comorbidities in long-term SCI individuals, the most prominent included urinary tract infection (UTI), spasticity, and hypertension—regardless of the severity of the SCI (15). Typical historical questions to review the pre-participation assessment are noted in Table 22.4. Laboratory studies must be considered in the context of concurrent medical conditions. For example, an athlete with SCI may have elevated C-reactive protein and interleukin-6 due to the bladder management program or skin breakdown; these can also be elevated in metabolic syndrome of able-bodied athletes (16,17). Potential participation limitations in physically-challenged athletes are listed in Table 22.5.

In this population, there are many medications that are used to treat problems related to various physical impairments. For example, anti-convulsants may be used for treatment of central pain, phantom limb pain, spasticity, and mood disturbances in athletes with a brain injury. Antidepressants and neuromodulation medications such as bromocriptine, baclofen, and methylphenidate are also commonly utilized. The intrathecal baclofen pump (a gamma aminobutyric acid-B [GABA-B] agonist) may be used to manage spasticity. Modafinil has been used in individuals with MS to address fatigue. The World Anti-Doping Code (WADC) applies to the physically challenged athlete in competitive arenas (18). Some of the medications used in treatment of the athlete’s physical impairment may be on the prohibited list, such as modafinil, selegiline, or methylphenidate. It is important to understand the principles of the WADC and to stay updated on the list of prohibited substances as these are reviewed and updated. Therapeutic use exemption process, on a sport- and case-specific basis, is in place for those athletes, who may need a prohibited substance to manage their medical condition and which does not offer a competitive advantage.

Medical clearance of the athlete for sport is one step; however, this athletic population may also have adaptive equipment requirements. Equipment can be sport specific, such as a quad rugby wheelchair or field event chair. It can involve modification of an everyday prosthesis, as in different terminal devices for athletes with limb deficiencies. In the general recreational, non-competitive arena, there are other types of adaptive equipment such as a swim fin for a person with lower extremity deficiency. When evaluating equipment needs, it is important to utilize a team approach as prosthetic advances for limb deficient athletes and wheelchair modifications for sports require an understanding of the sport and benefits of a particular modification or component.

Wheelchair seating and customizing is individualized. There are different seating systems, depending on the needs of the athlete and sport. Figure 22.2 shows one type of racing wheelchair. In distance racing, some options are the kneeling cage, upright cage, or kneeling bucket. Selection depends on the comfort of the athlete, the amount of torso control and the presence of joint contractures. Optimal positioning for efficient racing stroke is very important. Efficient upper extremity motion in stroke mechanics may decrease overuse injury incidence in the shoulder. There are specialized chairs for basketball, tennis and quad rugby; the latter a hybrid of the other court sport wheelchairs.