Periodic Health Evaluations in the Adaptive Athlete

The periodic health evaluation (PHE) is a tool used to assess, monitor, and identify barriers to safe participation in sport. Currently, there are no standards associated with the PHE in the adaptive sport population. These athletes have a higher prevalence and a wide variety of health problems while also having delayed access to appropriate health care. This article provides education and standardized considerations of the PHE for adaptive athletes. With guidance, health care providers are more prepared to perform comprehensive and clinically appropriate care to this at-risk population, while also promoting safe participation in sport for the adaptive athlete population.

Key points

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Current existing periodic health evaluation (PHE) forms need revision to be more specific in standardizing comprehensive but practical evaluations specific to different adaptive athlete populations.
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Healthcare providers should acquire adequate knowledge on medical issues associated with commonly seen medical conditions and impairments in adaptive sports to consider appropriate PHE components.
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Have the adaptive athlete’s underlying medical condition and sport-specific demands in mind when performing the PHE.

Abbreviations

ADLs	activities of daily living
AWDs	athletes with disabilities
CNS	central nervous system
DEXA	dual-energy x-ray absorptiometry
ECG	electrocardiogram
GI	gastrointestinal
GU	genitourinary
HCPs	health care providers
HSP	hereditary spastic paraplegia
IDDs	intellectual and developmental disabilities
ISNCSCI	International Standards for Neurologic Classification of Spinal Cord Injury
PHE	periodic health evaluation
VP	ventriculoperitoneal

Introduction

Participation in adaptive sports has been shown to improve both physical and mental health with athletes with disabilities (AWDs). While participation has been shown to be correlated with higher life expectancy, it also results in a higher rate of musculoskeletal issues. Due to the adaptive athlete population’s diversity of medical conditions, some of which may be complex, and wide variety of clinical presentations, it is difficult to formulate a standardized periodic health evaluation (PHE) that is applicable to all AWDs. ^,^, Compared to able-bodied athletes, adaptive athletes have a higher prevalence and wide variety of health problems and participate in sports to more advanced age. ^, The adaptive athlete population is also at higher risk for delayed access to appropriate health care services for medical issues related to their impairments. ^, Thus, it is essential for health care providers (HCPs) to understand the pathophysiology of athletes’ conditions and impairments prior to sport participation, as this will also guide much of the PHE process and frequency.

The PHE is a tool that can be performed to assess, monitor, and identify barriers to safe participation in these athletes. The main goal of the PHE is to perform a comprehensive assessment of an athlete’s current health status and risk of future injury or disease, which also includes assessment of how an athlete’s adaptive equipment (if applicable) fits and impacts their health and risk of injury. Therefore, it is important to standardize the PHE process. The PHE serves to establish a relationship with an HCP, gain understanding of an athlete’s health conditions, and minimize health complications throughout their sport participation, which is essential for all athletes.

Current standards of practice and forms for periodic health evaluation for athletes with disabilities

Several PHE tools are available in the current literature, but there is no globally accepted standardized screening form available for adaptive athletes. Current PHEs for adaptive athletes vary significantly in the following aspects :

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Impairment category
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Timing: preseason, immediate postseason, and change in the level of participation
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Time intervals between PHEs: ranging from annually to every 3 years
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Personnel: performed by an individual or multidisciplinary health care members
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Availability of resources

There is a standard PPE form that has been developed 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 the American Osteopathic Academy of Sports Medicine. It is also endorsed by the National Athletic Trainers’ Association and the National Federation of State High School Associations. With this form, there is a supplemental form for AWDs, addressing additional considerations for medical history when evaluating AWDs. The Special Olympics also has a dedicated form to assess medical aspects specific to athletes with intellectual and developmental disabilities (IDDs) for their events. In addition, Special Olympics has another medical evaluation form for athletes with IDDs that was created specifically for the Special Olympics MedFest, which is available with detailed history taking, assessing symptoms associated with underlying syndromes, as well as detailed physical examination per organ system. ^,

Recently, a group of adaptive sports medicine global experts published a position statement on the specific parameters for inclusion in the PHE for adaptive athletes. This focuses on medical issues related to different impairments and underlying medical conditions, as well as nutritional and sport-specific demands. Mental well-being and safeguarding are also addressed in this statement. The development of a standardized, comprehensive, yet practical, PHE for adaptive athletes should be prioritized in the near future to ensure HCPs are consistent and consider relevant medical issues that are prevalent in specific adaptive athlete populations.

Common impairments and medical conditions seen in adaptive sports

There are a wide variety of medical conditions and impairments that may be seen in the adaptive athlete population. Table 1 outlines commonly seen medical conditions in adaptive sports, and common impairments associated with these medical conditions. Knowledge of medical conditions and their commonly associated impairments is helpful when considering what areas of the PHE to focus on, in specific adaptive athlete populations.

Table 1

Impairments associated with each common medical condition ^,^,

Common Medical Condition Examples	International Paralympic Committee Eligible Impairment Types
	Physical Impairments								Visual Impairment	Intellectual Impairment
	Ataxia	Athetosis	Hypertonia	Impaired Muscle Power	Impaired Passive Range of Movement	Leg Length Difference	Limb Deficiency	Short Stature	Visual Impairment	Intellectual Impairment
Achondroplasia					+/−			+
Albinism									+
Amputation/limb deficiency (acquired or congenital)					+/−		+
Arthrogryposis				+/− (Dependent on type of arthrogryposis)	+	+/−
Brachial plexus permanent injury				+	+/−
Brain injury	+/−	+/−	+ (In most cases, depends on brain anatomic sites impacted)	+ (In most cases, depends on brain anatomic sites impacted)	+/−	+/− (Particularly if brain injury happened during development)			+/− (Depends on brain anatomic sites impacted)	+/− (Depends on brain anatomic sites impacted; brain injury would have to be before 18 y/o for intellectual impairment to be eligible)
Cerebral palsy	+/−	+/−	+ (In most cases)	+	+/−	+/−			+/− (Depends on brain anatomic sites impacted)	+/−
Club foot				+/−	+
Down syndrome										+
Dystrophinopathies (eg, muscular dystrophies)				+	+/−
Intellectual disability (noted before 18 y/o) without any other associated medical condition										+
Limb difference				+/−	+	+/−	+/−
Multiple sclerosis	+/−		+/−	+	+/−				+/−
Peripheral nerve permanent injury				+	+/−
Polio				+	+/−
Spina bifida				+	+/−			+/−		+/−
Spinal cord injury			+/−	+	+/−
Spinal muscular atrophy				+	+/−
Vision loss from many different disease processes									+

+: Impairments always present in these medical conditions.

+/−: impairments that are sometimes seen in these medical conditions.

Expert recommendations for periodic health evaluation history, physical examination, and special investigations

There are many components to consider for history questions to ask, physical examination techniques to perform, and special investigations to pursue for further diagnostic evaluation when performing the PHE. Areas on which to focus are dependent on the athlete’s medical history and impairment type. Table 2 lists standard medical history questions to ask all adaptive athletes during their PHE, while Table 3 lists standard physical examination areas or techniques to perform in all adaptive athletes. Table 4 lists special investigations to consider in all adaptive athletes during or after their PHE.

Table 2

Standard medical history questions for all athletes ^,^,^,^,

Demographics	• Name • Date of Birth • Sex • Residence Location
Sport	• What sports do you participate in (including primary sport)? • What are your main sport events? • What is your classification sport class? (Applies to Paralympic sports only)
General medical	• Do you have any concerns you would like to discuss with your health care provider? • Has a provider ever denied or restricted your participation in sports for any reason? • What are your current or active medical conditions? ○ Are these medical conditions stable or progressive? ○ What is the etiology of your medical conditions? (eg, if you have limb deficiency, what was the etiology? If congenital, was it associated with a syndrome? If acquired, was there a disease process or issues that led to amputation? If you have cerebral palsy (CP), was it associated with an in utero stroke? Prematurity? Brain injury or pathology before the age of 2 year old? Was MRI of brain performed to ensure consistency with diagnosis and made sure the athlete did not have other “CP mimicker” medical conditions that get misdiagnosed as CP?) • Do you have any current illness or ongoing health concerns? • Past medical conditions • Surgical history • Current medications • Current supplements and vitamins • Allergies and reaction type • Were you ever advised not to participate in sport due to health-related concerns? • Exercise precautions related to medical conditions • How many days have you missed sport practice or competition in the past 12 mo due to injury or illness?
Impairment characteristics	• What impairments do you have? • What is the etiology of your impairment (ie, what underlying medical conditions do you have that are associated with your impairment)? • Is/are your impairment(s) congenital or acquired? ○ If acquired, when and how was it acquired? • Is/are your impairments stable or progressive?
Cardiovascular	• Do you have a personal history of ○ Discomfort, pressure, tightness, or pain in your chest during exercise? ○ Lightheadedness, shortness of breath, or feeling more tired than your teammates or friends during exercise? ○ Heart racing, fluttering in your chest, or skipping beats (irregular beats) during exercise? ○ Heart issues, heart disease, high blood pressure, stroke, or blood clots? ○ Passing out or nearly passing out during or after exercise? • Has a doctor ever requested a test for your heart (eg, electrocardiography (ECG) or echocardiogram) ? • Do any of your family members have genetic heart disorders or rhythm disorders? • Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 y (including drowning or unexplained car accident)? • Has any family member had a pacemaker or an implanted defibrillator before age 35 y?
Respiratory	• Do you have a personal history of ○ Postnasal drip, hay fever, or runny nose due to allergies? ○ Any difficulty breathing, wheezing, coughing, diagnosis of asthma, or vocal cord dysfunction?
GI	• Do you have a personal history of ○ Heartburn, constipation, nausea, abdominal pain, diarrhea, blood in stools, or change in bowel habits?
GU	• Do you have a personal history of ○ Urinary tract infections? If yes, ▪ What antibiotics have been effective for treatment in the past? ▪ Do you have history of antibiotic resistance? Which antibiotics have you developed a resistance to in the past?
Hematologic/oncologic	• Do you have a personal history or family history of ○ Anemia, abnormal bleeding, blood clots, sickle cell trait/sickle cell disease, or any other blood disorders? ○ Cancer?
Metabolic/nutritional/endocrine	• Do you have a personal history of ○ Low levels of iron, vitamin D, magnesium, vitamin B12, or folate? ○ Diabetes, high cholesterol, thyroid, or other endocrine issue? ○ Heat or cold-related illnesses? Have you ever become ill while exercising in hotter environments? Or developed cold injuries such as frostbite? ○ Other hormonal abnormalities? • Are you on a special diet or do you avoid certain types of foods or food groups? • Are you trying to or has anyone recommended that you gain or lose weight?
Dermatologic	• Do you have a personal history of ○ Regular skin infections, skin rashes, or eczema?
Neurologic	• Do you have a personal history of ○ Seizure/seizure disorder/epilepsy (type of seizures, when was last seizure, on medication for seizures)? ○ Previous concussions or head injuries (when, how, and time to full recovery)? ○ Regular headaches or migraines? ○ Numbness, tingling, paresthesias, or weakness in your extremities? Or inability to move an extremity after being hit or falling?
Musculoskeletal	• Do you have a personal history of ○ Low bone mineral density? ○ Fractures? ○ Stress fracture, bone, joint, ligament, or muscle injury preventing sport participation? ○ Arthritis, osteoarthritis or joint pain, swelling, or redness not related to injury?
Psychiatric/mental health	• Do you have a personal history of ○ Mental health conditions (eg, anxiety, depression, posttraumatic stress disorder, bipolar disorder, and so forth)? ○ Difficulty or issues with sleeping? ○ Concerns about your weight, body composition, or eating habits? ○ Eating disorder?
Miscellaneous	• Do you have a personal history of ○ Vision or hearing issues? ○ Injured, decayed, missing, or filled teeth? ○ Missing organ (eg, eye, spleen, kidney, testicle, and so forth )? ○ Pain on a regular basis? ○ Problems with traveling? ○ Special diet or avoiding certain foods (eg, vegan, vegetarian, lactose intolerance, and so forth) ? • Vaccination history (especially as relevant to potential travel destinations if traveling with adaptive sports team as medical staff) • Lifestyle habits (eg, smoking, alcohol, and recreational drug use)
Baseline function—independence levels and/or assistance needed	• Mobility ○ Do you walk? If yes, all of the time, or part of the time? ▪ If part of the time, in what situations do you walk? ○ What assistive devices or adaptive mobility equipment do you use (eg, manual wheelchair, power assist for manual wheelchair, power wheelchair, walker or gait trainer, cane, and so forth) ? ▪ If you use adaptive devices, when do you use these (eg, for longer distances, in areas where they need more stability such as pool deck or uneven terrain, and so forth) ? ○ What adaptive equipment do you use for sport participation (if any)? ○ Do you have any issues with air travel with motorized equipment and batteries for adaptive equipment? • How do you perform transfers? (Assess independence level and how) • Do you need assistance with your activities of daily living (ADLs)? ○ If you need assistance with ADLs, please describe what assistance you need with which ADLs • Review independence level and assistance needed with other essential functions relative to the athlete’s sporting context (eg, athlete may need assistance with setting up certain sporting equipment)
Female individuals	• Have you ever had a menstrual period? • How old were you when you had your first menstrual cycle? • When was your most recent menstrual period? • How many menstrual cycles have you had in the past 12 mo? • Are you on a form of contraceptive (eg, oral contraceptive, intrauterine device, other)? If yes, which one? • Do you have any menstrual cycle concerns or disturbances? • Do you have a painful bulge or hernia in the groin area?
Male individuals	• Do you have a history of injury to your testicles, hernia or swelling around the testicles, or surgery for an undescended testicle? • Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

Table 3

Standard physical examination for all athletes ^,^,^,^,

Vitals/Intake	• Height • Weight • Calculated body mass index • Temperature • Heart rate • Blood pressure (supine and sitting) • Respiratory rate • Pulse oximetry
General	• General appearance
Head/neck	• Head • Eyes: Visual acuity and peripheral visual fields • Ears: External appearance and otoscopic examination • Nose • Oropharynx • Dental: number of teeth missing, filled, decayed • Throat
Lymphatic	• Palpation of lymph nodes
Cardiovascular	• Heart auscultation (supine, standing, and valsalva) • Peripheral pulses • Check for edema of limbs
Respiratory	• Respiratory effort appearance • Lung auscultation
Abdomen	• Appearance (eg, distension) • Auscultation • Palpation
Neurologic	• Muscle strength (manual muscle testing) • Sensation (light touch and pin prick) • Deep tendon reflexes • Other/primitive reflexes (eg, Babinski and Hoffman) • Balance • Coordination
Musculoskeletal	• Spine • Upper limbs • Pelvis • Lower limbs • Joint range of motion • Anatomic differences (eg, limb differences, scoliosis, and so forth) • Inspection, palpation, and special tests as appropriate (focused examination if specific issues with certain musculoskeletal issues noted in history)
Dermatologic	• General head to toe examination
Function	• Observe and evaluate mobility including gait (if ambulatory) with assistive devices they normally use, or wheelchair mobility • Assess equipment, orthosis, and prosthesis fit