CHAPTER 37

Pediatric Athletes With Disabilities

Types of Disabilities

• Physical disabilities affect physical functioning, for example, spinal cord injury or amputation.

• Intellectual disabilities affect intellectual functioning and adaptive behavior, for example, intellectual disability associated with Down syndrome or fragile X syndrome.

• Other conditions affect sensory systems, for example, blindness or low vision affecting vision or deafness or hard of hearing affecting hearing.

Social Versus Medical Model of Disability

• Medical model of disability focuses on the disability itself from a medicalized approach and is now outdated.

• Biopsychosocial model of disability (“International Classification of Functioning, Disability and Health,” published by the World Health Organization) focuses on an individual’s level of health, emphasizing how the health condition interacts with environmental factors, personal factors, participation, body functions, and structure to affect the individual’s overall health and quality of life, rather than focusing on the health condition alone.

• Using this framework, the health care professional can help improve quality of life for children with underlying health conditions by working on various factors, including environmental factors such as access to adaptive physical activity programs.

Physical Activity Guidelines

• As they are able, youth with disabilities should meet the same guidelines for physical activity as youth without disabilities (eg, 60 minutes per day of moderate to vigorous aerobic activity).

• Youth with disabilities experience the same health benefits from physical activity as seen in the general population, including improved cardiovascular health, decreased obesity or overweight, and improved mental health.

• Despite this, youth with disabilities tend to be less physically active than youth without disabilities.

• Youth with disabilities should be encouraged to participate in physical activities. This chapter describes the specific precautions, restrictions, and guidelines that should be followed when counseling youth with specific disabilities and health conditions about safe participation in sports and physical activities.

Sports Participation

• Children and adolescents with disabilities should be encouraged to participate in organized sports.

• Sports participation holds many benefits for children and adolescents with disabilities.

— Physical benefits: improved cardiovascular fitness and decreased systolic blood pressure

— Psychosocial benefits: improved quality of life and socialization

• Participation options

— In the general population, alongside peers who do not have disability, such as the following:

■A child with an upper extremity congenital limb deficiency may play softball one-handed.

■A child with a lower extremity congenital limb deficiency may play baseball using a prosthetic leg.

— Through sports organizations for individuals with disabilities

■Para sports, “sports in parallel,” which are specifically for individuals with physical disabilities or blindness or low vision.

❖ Adaptive sports, such as wheelchair basketball or wheelchair tennis, are included within the term para sports, but are specifically sports that are adapted from general sports.

❖ There are some para sports, such as goalball, that exist only for athletes with disabilities rather than being adapted from general sports.

❖ The most elite level of para sports for people with physical or visual disabilities is the Paralympics, which occurs in parallel to the Summer and Winter Olympics.

■The most elite level of sports for deaf or hard of hearing athletes are the Deaflympics, which are international sporting events that occur as Winter and Summer Games.

■Special Olympics

❖ Large international organization focused on sports and health for individuals with intellectual disabilities.

❖ Sports are from novice to elite level. Divisions are determined by ability level.

❖ Elite competitions occur at the Special Olympics USA Games and Special Olympics World Games.

❖ Unified Sports is a subset of Special Olympics sport competition in which integrated teams composed of athletes with and without intellectual disability compete together on the same team.

Important Considerations for Some Selected Disabilities

SPINAL CORD INJURY

• Injury to the spinal cord from trauma, infection, inflammation, or tumor that causes weakness, sensory impairments, neurogenic bowel, neurogenic bladder, and/or thermoregulation impairments.

• Autonomic dysreflexia

— Medical emergency resulting in uninhibited increased blood pressure due to a noxious stimulus below the level of spinal cord injury (Figure 37-1)

— Individuals with spinal cord injury at T6 level or above are at highest risk.

— More common in those with more complete injuries (affecting sacral nerves, resulting in impaired rectal sensation and control)

— Treatment is emergently addressing the noxious stimulus. Sometimes antihypertensive medications are also needed.

— Boosting is when an athlete intentionally creates a noxious stimulus (eg, clamping a Foley catheter) to cause autonomic dysreflexia for the adrenal rush in an effort to enhance performance.

Figure 37-1. Pathophysiology of autonomic dysreflexia. Abbreviation: SCI, spinal cord injury

From Dubon ME, Rovito C, Van Zandt DK, Blauwet CA. Youth para and adaptive sports medicine. Curr Phys Med Rehabil Rep. 2019;7:104–115. © 2019. Reprinted with permission from Springer Nature.

■Dangerous practice because autonomic dysreflexia can result in dangerously fast and significant increases in blood pressure that can cause stroke or, in some cases, death

■Banned by sporting organizations

• Sensory impairments: Sensation can be decreased or absent below the level of injury.

— This puts individuals at risk for skin wounds, blisters, and sunburn.

— Important consideration with sports equipment and environment management

■Make sure adequate shade is provided and sunblock is used.

■Important to have custom fit for athlete’s equipment, such as sports wheelchair or sled hockey

• Low bone mineral density: Individuals with decreased weight bearing are at risk for low bone mineral density and pathologic fractures.

— Precautions should be taken to decrease risk, such as proper positioning and support during passive stretching techniques.

• Spasticity: velocity-dependent increase in muscle tone

— May interfere with muscle function, in which case it can be treated with stretching, medications, or procedures (eg, botulinum toxin injections)

— Sometimes, spasticity is not functionally interfering or may even be beneficial (eg, case in which an athlete with lower extremity spasticity has better stability due to spasticity).

• Neurogenic bladder: impaired ability to control how the bladder stores or empties urine

— Typically, individuals with neurogenic bladder due to spinal cord injury require the use of catheterization for bladder emptying.

— These athletes will need to carry supplies with them and may be on a strict schedule, so coaching staff should allow for an individual to take catheterization breaks during practice, games, and tournaments.

— There is an increased risk of urinary tract infections, which may present with different symptoms such as increased autonomic dysreflexia episodes or increased spasticity.

• Neurogenic bowel: impaired ability to control how the bowel empties stool

— Typically, individuals with neurogenic bowel due to spinal cord injury require the use of enteral medications and often suppository, enema, or digital rectal stimulation for bowel emptying.

— The athlete may need to bring bowel program supplies to travel tournaments, especially multiday, out of state tournaments.

• Thermodysregulation: impaired ability to regulate body temperature

— Athletes should be dressed for the weather and take appropriate warming or cooling measures to prevent hyperthermia or hypothermia.

■Warming: Wear appropriate clothing for the climate.

■Cooling: Use cooling mist, take appropriate breaks, maintain hydration, and wear appropriate clothing.

CEREBRAL PALSY

• Cerebral palsy (CP) is a category of permanent neurologic conditions resulting from an injury or insult to the fetal or infant brain that is not progressive and results in motor impairments.

• Cognitive impairments, seizures, spasticity, dystonia, and/or low bone mineral density may also occur (see Chapter 61, Cerebral Palsy).

• Skin breakdown can occur due to decreased mobility, but impaired skin sensation is not classically associated with CP.

• Some individuals with CP may be at risk for seizures.

— A consensus guideline by the International League Against Epilepsy Task Force on Sports and Epilepsy divides sports into 3 categories based on potential risk of injury or death should a seizure occur (Box 37-1; Table 37-1).

■Group 1 sports: no significant additional risk

■Group 2 sports: moderate risk to the persons with epilepsy but not to bystanders

■Group 3 sports: high risk for persons with epilepsy and, for some sports, also for bystanders

Box 37-1. Categorization of Sports by Level of Risk of Injury or Death for Persons With Epilepsy, or for Bystanders, Should a Seizure Occur During the Event

Abbreviation: PWE, persons with epilepsy.

Adapted from Capovilla G, Kaufman KR, Perucca E, Moshé SL, Arida RM. Epilepsy, seizures, physical exercise, and sports: A report from the ILAE Task Force on Sports and Epilepsy. Epilepsia. 2015;57(1):6–12.

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