© Springer International Publishing AG 2018Arthur Jason De Luigi (ed.)Adaptive Sports Medicinedoi.org/10.1007/978-3-319-56568-2_5
5. Medical Considerations in Adaptive Sports
Uniformed Services University, Department of Family Medicine, Bethesda, Maryland, USA
US Army, Fort Benning, Columbus, GA 31904, USA
All athletes, including adaptive athletes, may have medical conditions and injuries that impact their ability to participate in sports. However, injuries and illnesses for an adaptive athlete can pose a unique and complex challenge for physicians. To provide quality care during competition and training, physicians should be familiar with common medical conditions in athletes in each of the six disability categories: wheelchair athletes, athletes with amputations, athletes with cerebral palsy, visually impaired athletes, athletes with intellectual impairment, and athletes classified as les autres .
Pre-participation Physical Examination
A thorough pre-participation evaluation (PPE) is critical to determining the health status of any athlete. The PPE screens for injuries or medical conditions that may place an athlete at risk of further injury . In contrast to the 1–3% incidence of sport-significant abnormalities found in able-bodied athletes, in Special Olympians the incidence is closer to 40% . The standard recommendation is that the evaluation be performed at least 6 weeks in advance of competition to allow adequate opportunity for any identified health concerns to be addressed, and lead time is particularly critical in athletes with disabilities where complex equipment and widely diverse medical issues are more likely to be present. In addition to the standard aspects of the PPE for able-bodied athletes, there are additional considerations for the sports medicine physician when evaluating adaptive athletes. The current PPE monograph endorsed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine includes a supplemental history form for the adaptive athlete in addition to the recommended history and physical examination form for able-bodied athletes . A similar PPE monograph recently proposed by a team of sports medicine specialists in Canada is based on the International Olympic Committee consensus statement and includes a more comprehensive format for the adaptive athlete. Some of these additional recommendations include assessment of functional daily activities and evaluation of orthoses and other adaptive devices . Current recommendations are that a PPE be performed upon entry into sports and should be repeated at least every 2–3 years, depending on the age and participation issues of the athlete. An interim evaluation (often just a brief history and blood pressure) prior to each sport season may be necessary to determine if the athlete’s health condition has changed .
The medical team involved in the longitudinal care of the adaptive athlete should perform the PPE, since as knowledge of baseline functioning is critical to proper recommendations and protections for the athlete. Physicians should complete the PPE in a systematic and comprehensive fashion and should avoid the common mistake of becoming overly focused on the athlete’s impairment/disability and overlooking other medical and pre-participation issues. The evaluation of an adaptive athlete often requires a multispecialty team approach. For example, a physician specializing in sports medicine and a spinal cord injury specialist may work together to jointly assess an individual with spinal cord injury (SCI) and safely clear them for participation.
The sport, level of participation, athletic organization, clinical indications, and medical conditions of the athlete determine the required elements of the PPE. The PPE should provide information to guide the athletic organizer, athlete, trainer, coach, and team physician toward safe participation for the athlete .
The PPE should achieve the following objectives :
Identify conditions that require further evaluation before training, require close supervision during training, or may predispose them to injury
Determine the athlete’s general health and fitness level
Counsel the athlete on health-related issues and methods for safe participation
Cardiovascular and pulmonary evaluations seek to identify conditions that may lead to disease progression or sudden cardiopulmonary collapse. Suggested guidelines for cardiovascular screening of the athlete are available from the 36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities [4, 6].
Additional elements of the PPE for adaptive athletes should include an assessment of pre-disability health, present level of training, current medications and supplements used, presence of impairments, level of functional independence for mobility and self-care, history of prior sports participation, and anticipated needs for adaptive equipment. Assessment of sensory deficits, neurologic impairment, and joint stability, range of motion (ROM), muscle strength, and skin integrity are even more important in the population of adaptive athletes compared to able-bodied athletes. An evaluation of the athlete-equipment interface is critical to a proper PPE. For instance, during the musculoskeletal examination of an athlete who uses a wheelchair, the physician should evaluate the stability, flexibility, and strength of the commonly injured body sites (e.g., shoulder, hand and wrist, and lower extremities) as well as the trunk. Special attention should be made during the PPE for skin breakdown on insensate pressure areas (e.g., buttocks and back) as well as sites that come in contact with orthotics/prosthetics. A careful history of heat/cold injuries and changes in neurologic function should also be solicited .
Additional musculoskeletal testing is recommended for limb-deficient athletes due to amputations or congenital deformity. The musculoskeletal examination of an individual, who has had a lower extremity (LE) limb deficiency, should assess the stability, flexibility, and strength of the trunk, as well as the hip girdle and the unaffected and affected LE with and without the prosthesis. For individuals with upper extremity (UE) limb deficiency, the stability, flexibility, and strength of the shoulder girdle must be assessed in the unaffected and affected extremity with and without prosthesis, in addition to a trunk and LE evaluation .
Careful evaluation of the athlete’s wheelchair, prosthetics, orthotics, and assistive/adaptive devices should also be performed prior to competition. This is usually facilitated by consultation with the individual’s orthotist, prosthetist, or other healthcare specialists with experience in this area .
In summary, pre-participation evaluation of the adaptive athlete should encompass all the aspects of the able-bodied clearance exam but with additional attention paid to key areas of unique concern to that individual athlete. A comprehensive, systematic, and multidisciplinary team approach is critical to identifying and managing both disability-related and non-disability-related conditions in the adaptive athlete.
Physicians covering adaptive sporting events experience a high volume of visits to the medical treatment area and significant acuity of medical conditions. For instance, 82% of participating athletes at a recent Paralympic Games utilized provided medical services most for prior existing medical conditions . The general medical conditions and category-related injuries that adaptive athletes experience are covered here in this chapter, while sport-specific considerations and injury patterns are covered separately and in greater depth in the following chapters.
Spinal Cord Injuries
Most wheelchair athletes have spinal cord injuries; however, athletes with a deficiency of multiple limbs due to amputations or congenital deformity, cerebral palsy, polio, or other neurologic disorders are eligible to compete in this category. The conditions experienced by athletes with spinal cord injuries may be applicable to other wheelchair athletes, depending on the extent of trunk and upper extremity function, level of sensation, and preservation of bowel and bladder function .
The extent of the thermoregulatory impairment is directly related to the level of SCI. Loss of motor and sensory function as well as lack of control of autonomic function (dysautonomia) can inhibit cardiovascular and thermoregulatory functioning. Loss of blood flow regulation via the CNS, loss of temperature sensation, and inability to sweat or shiver below the level of injury prevent autonomic control of temperature regulation. Therefore, depending on the environmental conditions, these athletes are at much higher risk of both hypothermia and hyperthermia. Event medical support teams should be aware of wet clothes and prolonged pool time even in normal ambient temperatures. In warm environments precooling and cooling strategies during competitions can reduce thermal strain and improve functional capacity .
As many athletes with SCI are often insensate below the level of injury, the examiner needs to pay particular attention looking for occult injuries (pressure sores, fractures, dislocations, and visceral injuries). Prolonged pressure over bony prominences combined with shearing forces from activity and moist, insensate skin can cause local tissue ischemia and injury. Athletes in wheelchairs who have a pressure ulcer should not be cleared for sports participation until there is complete healing of the wound . Frequent monitoring is key to pressure sore prevention. Prevention tactics include skin checks, shifting of weight every 15 min to relieve pressure, the use of appropriately fitting seat cushions, and maintenance of a dry environment. Cold weather injuries (frostbite) are of particular concern as athletes with spinal cord injuries have impaired sensation and require frequent visual monitoring [8, 10].
Autonomic dysreflexia (AD) is a medical emergency caused by unregulated sympathetic outflow due to interruption of neural pathways after spinal cord injury at or above the level of T6. Noxious stimuli below the level of injury can cause reflexive sympathetic activity that cannot be modulated by supraspinal centers of control, resulting in high levels of sympathetic activity below the level of injury and incomplete parasympathetic compensation above the level of injury. Symptoms include headache, skin flushing, piloerection, and diaphoresis above the level of spinal cord injury . If suspected the athlete should be immediately removed from competition or activity. Treatment should include sitting the person upright, removing restrictive clothing, and searching for the source of the noxious stimulus, which is commonly a distended bladder or impacted colon, pressure sores, or other injury . Transportation to an appropriate facility for further management should be a strong consideration. For acute blood pressure control, chewable nifedipine or nitro paste can be used . Most athletes know the danger of intentionally causing AD, which is banned by the International Paralympic Committee. Therefore, the practice “boosting,” which is an effective ergogenic aid , is rarely employed.
Wheelchair athletes (WCA) are at a significantly increased risk of upper extremity entrapment neuropathies, with the most common being carpal tunnel syndrome with reported prevalence rate of greater than 50% . Prevention techniques include maintaining a relaxed rather than a firm grip to minimize the increases in intracarpal pressures experienced during propulsion. Use of padded gloves for skin protection is a common practice; however, it may not be effective at preventing carpal tunnel syndrome. Perhaps the second most common upper extremity neuropathy observed in WCA is ulnar neuropathy at Guyon’s canal or the cubital tunnel which may cause pain and weakened grip strength. Racquet sports may place WCA at increased risk. Counterforce braces, emphasis on proper technique, and use of appropriately tensioned racquets may assist with prevention of ulnar neuropathy .
Orthostatic hypotension (OH) occurs in most SCI patients and is caused by decreased sympathetic efferent activity in the vasculature below the level of the injury resulting in venous pooling. Symptoms include light-headedness and dizziness; syncope may occur if uncorrected. Prevention includes lower limb compression stockings and abdominal binders, maintenance of hydration, and salt supplementation . Non-pharmacologic prevention should be attempted before the use of pharmacologic agents for wheelchair athletes who experience orthostatic hypotension. Pharmacologic treatment with World Anti-Doping Agency (WADA) banned stimulants (midodrine, fludrocortisone, or ephedrine) are often helpful but would disqualify the athlete from competition . For a list of banned substances visit the WADA website (www.globaldro.com). Each organization has specific guidance regarding therapeutic use exemptions (TUE) for medications banned by WADA. TUE forms are available on the WADA website (www.wada-ama.org).
Wheelchair athletes are susceptible to the same overuse injuries experienced by able-bodied athletes. However, their reliance on upper limbs for mobility and activities of daily living places significant importance on recognizing, treating, and preventing upper limb injuries. Their functional impairment is magnified compared with able-bodied athletes as relative rest to allow injuries of the upper limb to heal may not be possible. Additional treatment considerations should include splinting, orthotic prescriptions, home and equipment modifications, and additional assistance with home care. Sometimes admission to an inpatient facility is required to allow proper rest of the extremity.
Following traumatic brain injury (TBI), SCI, burns, and arthroplasty, heterotopic ossification (HO) or pathologic bone formation may develop around major joints and restrict range of motion. Up to 36% of patients with spinal cord injuries may develop HO . Common areas affected are the hip joints, but the knee, elbow, and shoulder may also be impacted [10, 13]. Restricted motion and the presence of hardened bone within soft tissues can increase the risk of pressure sores and entrapment neuropathy.