The Challenged Athlete

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The Challenged Athlete
Military Sports Medicine Fellowship
Every Warrior an Athlete

• Kevin deWeber, MD, FAAFP
• Director,
• Primary Care Sports Medicine Fellowship
• Acknowledgments to Dr. Mark Williams

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Objectives

• Review classifications of disabilities
• Describe PPE requirements
• Discuss epidemiology of injury and illness
• Describe unique medical issues
• Prepare for medical coverage of Special Olympics
  events

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Types of disabilities (challenges)

• Physical challenges
• Intellectual disabilities
• Subaverage intellectual functioning and marked
  impairment in adaptive behavior
• Sometimes both coexist

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Physical Disability Classification

• Wheelchair athletes
• Cerebral palsy
• Les autres (the others)
• Limb deficiencies
• Hearing impairment
• Vision impairment

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U.S. Paralympics

• Governing body for sporting competition in those
  with physical disabilities
• U.S. Paralympics, a division of the U.S. Olympic
  Committee, is dedicated to becoming the world
  leader in the Paralympic sports movement, and
  promoting excellence in the lives of persons with
  physical disabilities. U.S. Paralympics website

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Paralympic Sports

• Archery
• Basketball
• Boccia
• Curling
• Cycling
• Equestrian
• Fencing
• Goalball
• Judo
• Powerlifting
• Rowing

• Rugby
• Sailing
• Shooting
• Skiing (alpine and Nordic)
• Sled Hockey
• Soccer
• Swimming
• Table Tennis
• Tennis
• Track Field
• Volleyball

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Mental Retardation

• In the United States
• 100,000 born each year with mental retardation
• 7 times more prevalent than blindness
• 7 times more prevalent than deafness
• 10 times more prevalent than physical disability
• 12 times more prevalent than cerebral palsy
• 35 times more prevalent than muscular dystrophy

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• Special Olympics is an international nonprofit
  organization dedicated to empowering individuals
  with intellectual disabilities to become
  physically fit, productive and respected members
  of society through sports training and
  competition. Special Olympics offers children and
  adults with intellectual disabilities year-round
  training and competition in 30 Olympic-type
  summer and winter sports. Special Olympics
  website

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Mission

• To provide sports training and competition for
  persons with mental retardation age 8 through
  adulthood
• Children ages 5-8 may participate in training,
  but not compete

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Special Olympics activities

• Sports training and competition for children and
  adults exist in each state of the U.S.
• Clinics, camps,
• Games held at local, regional, state, national,
  and international levels

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Special Olympics Games

• First International Special Olympics - 1968
• 2005 Special Olympics World Winter Games
  
• 1,800 athletes, 84 countries
• 2003 World Summer Games
• 6,500 athletes, 150 countries
• Over 2.2 million athletes worldwide

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Goals

• Physical fitness
• Social development
• Acceptance into larger society

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Eligibility

• Identified by an agency or professional as having
  mental retardation OR
• Have a cognitive delay as determined by
  standardized measures OR
• Have significant learning or vocational problems
  due to cognitive delay which require specially
  designed instruction

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Levels of Participation

• Divisioning
• Gender
• Age
• 8-11, 12-15, 16-21, 22-29, 30
• Ability
• Athletes scored based on ability in specific
  skills
• Goal 3-8 participants/teams of similar ability
  in each event

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Official SportsWinter and Demonstration

• Badminton
• Golf
• Powerlifting
• Table tennis
• Team handball

• Alpine skiing
• Cross country skiing
• Figure skating
• Floor hockey
• Speed skating

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Official SportsSummer

• Aquatics (swimming and diving)
• Track and field
• Basketball
• Bowling
• Cycling
• Equestrian

• Gymnastics
• Roller skating
• Softball
• Tennis
• Volleyball
• Soccer

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PreparticipationPhysical Evaluation Requirements

• History and physical exam required on entry
• Update every 1-3 years, depending on state
• Requirements not standardized
• Special Olympic Games PPE lt 12 months
• New exam required when a new problem develops
  that could pose a risk for the athlete during
  sports participation

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Preparticipation Evaluation

• PPE must be tailored to address their special
  needs
• Office-based exam preferred
• Frequency of abnormal findings
• Diagnoses often associated with clusters of
  abnormal findings
• Enhanced interpersonal communication

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Additional History Needed

• Testicle (absence?)
• Kidney (absence ?)
• Urinary catheters?
• Communication issues

• Level of independence
• Wheelchair
• Motor impairment
• Prosthetic equipment
• H/O autonomic dysreflexia

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PPE Special Concerns

• Communication
• Many Special Olympics athletes have expressive
  and receptive language deficiencies
• 5 of athletes are non-verbal
• May be unable to describe symptoms clearly
• Utility of PPE Questionnaire at events
• Available to medical provider for review
• Must be kept updated and brought to all
  competitions

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Exam Abnormalities in Non-Disabled Athletes vs
Special Olympians

• Nondisabled athletes 0.3 3 have disqualifying
  abnormalities
• Special Olympians- 39 have abnormalities
• Not necessarily all disqualifying.

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Sports Significant Disabilities

• McCormick, Ivey, et al 1988
• 80 athletes in Special Olympics sports PPE
• 39 had sports significant abnormalities
• Vision worse than 20/40 13
• Seizures 13
• Cardiac arrhythmia
• Cyanotic heart disease

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Sports Significant Disabilities

• Hudson (Physician Sportsmedicine 1988)
• 176 Preparticipation Physical Exams
• Age 5-20 years
• Visual acuity of 20/30 or worse 40
• Decreased LE Flexibility 31
• Clonus 12
• Spasticity 8
• Heart murmur 5
• Scoliosis 3

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Sports Significant Disabilities Hudson
(Physician Sportsmedicine 1988)Medical
Diagnoses in History ()

• Seizure 23
• Down Syndrome 16
• Cerebral Palsy 15
• Hydrocephaly 4
• Meningomyelocele 4

• Multifocal leukoencephalopathy 1
• Progressive Sz d/o 1
• Sickle Cell dz 1
• Muscular Dystrophy 1
• Renal anomalies 1

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Conditions Encountered on Pregame Medical Exam of
1512 Competitors at U.K. Special
Olympics,1989Robson, Br. J. Sports Med.
24225,1990

• Down Syndrome 417
• Epilepsy 239
• Cardiac lesion 88
• Cerebral palsy 33
• Asthma 24
• Hypothroidism 22
• Hemiparesis 11

• Severe vision dist 11
• Diabetes 10
• Hydrocephalus 9
• Ataxia 7
• Microcephaly 6
• Paraplegia 5
• Phenylketonuria 3

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Physical Exam

• Abdominal, including hernia and testicular check
• Screening orthopedic, including scoliosis
• Focused orthopedic
• Screening neurologic

• Height and Weight
• Blood pressure
• Visual Acuity
• Eye,ear, nose, throat
• Cardiorespiratory auscultation

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Visual Exam

• About 1/3 will have abnormality
• Poor visual acuity most common
• Others
• Refractive errors
• Astigmatism
• strabismus

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Physical Exam

• Routine general exam
• Focus on areas that most often reveal problems
• Musculoskeletal
• Cardiovascular
• Neurological
• Derm (wheelchair, prosthetics)
• Functional Assessment

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Musculoskeletal Examination

• Wheelchair athlete attention to shoulder, wrist
  and hand
• Amputees attention to back and lower extremities
• Downs
• attention to c-spine exam
• Hip and knee exam, instability common
• Cerebral palsy
• contractures, strength, muscle imbalances
  attention to hips,
• knees, ankles and feet which have high rates of
  overuse injuries.

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Down SyndromeMajor Musculoskeletal Disorders

• Metatarsus Primus Varus
• Problem with shoe fit
• Hallux Valgus
• Patellar Instability
• Scoliosis
• Slipped Capital Femoral Epiphysis
• Most due to defect in collagen synthesis,
  resulting in generalized ligamentous laxity

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Down Syndrome Cervical Spine Abnormalities

• Atlantoaxial Instability
• Occiput-C1 Instability
• Odontoid Dysplasia (6 of Down patients)
• Hypoplasia of posterior arch of C1
• Spondylolysis and Spondylolisthesis of
  midcervical vertebrae
• Precocious Arthritis of C4-C6

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Atlantoaxial Instability (AAI)

• Up to 15 of Down syndrome have a laxity of the
  transverse ligament of C-1 (atlas) which
  stabilizes the articulation of the odontoid
  process of C-2 (axis) with C-1
• If excessively lax, C-1 may spontaneously sublux
  forward on C-2 resulting in compression of the
  cervical spinal cord

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Atlantoaxial Instability

• 10- 20 of Down syndrome individuals have
  asymptomatic AAI
• 1-2 have symptomatic AAI

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Atlantoaxial Instability Diagnosis

• Lateral x-ray of the cervical spine in flexion,
  neutral, and extension
• Look at Atlas-Dens Interval (ADI)
• Distance between anterior ramus of C-1 and the
  dens of C-2
• Should not exceed 4.0mm
• All Down syndrome athletes must receive a
  diagnostic x-ray of the c-spine before entering
  Special Olympics participation

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Normal ADI in neutral position.
Increased ADI in flexion.
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Normal note no increase in ADI with flexion.
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AAI note increase in ADI with flexion
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Cardiovascular Exam

• Cardiac murmurs are common
• Grade2/6 or softer and systolic no further
  evaluation
• Diastolic murmur or systolic 3/6 or louder
  further evaluation
• Blood pressure

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Down SyndromeCardiac Lesions

• Endocardial Cushion Defect
• Ventricular Septal Defect
• Less Commonly
• Secundum Atrial Septal Defect
• Tetralogy of Fallot
• Patent Ductus Arteriosus
• 36th Bethesda Conference standards apply

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Ventricular Septal Defect

• History of failure to thrive and dyspnea on
  exertion
• Murmur holosystolic and loudest in the 3rd and
  4th left interspaces
• Work-up and any necessary intervention prior to
  participation
• Fairly common in Down Syndrome
• May cause problems during Sports events

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Endocardial Cushion Defect

• Embryologic precursors of the atrioventricular
  canal, mitral and tricuspid valves
• Defects of valves

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Neurologic examination

• Nerve entrapment disorders
• Especially common in wheelchair athletes
• Cerebral palsy evaluate sport-specific movements
• MS check for ataxia, weakness, fatigue,
  spasticity, sensory function
• Downs signs of AAI
• Abnormal gait, incoordination , sensory deficits,
  spasticity, hyperreflexia, clonus, UMN or
  posterior column deficits

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Skin Examination

• Wheelchair athletes prone to skin injuries
• Abrasion, blisters, pressure ulcers (look in
  those difficult places)
• Amputees remove prostheses, look for abrasions,
  blisters, rashes, pressure ulcers

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Functional Assessment

• Overall mobility
• Use of prosthetics
• Use of wheelchair
• Evaluate sport-specific tasks

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Lab Tests and X-rays

• Down Syndrome- lateral C-spine in neutral,
  flexion, and extension
• Seizure disorders- monitor therapeutic drug
  levels
• Risk in swimming, diving, gymnastics, skiing,
  speed skating, and equestrian events
• Other tests as indicated by each condition

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Minimize RiskMaximize Participation

• Many benefits of athletics and competition
• Must identify potential problems
• Must encourage physical activity for individuals
  with disabilities
• If an athlete is disqualified from chosen sport,
  help determine alternate sport
• Provide positive reinforcement and encourage a
  healthy lifestyle

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Atlantoaxial Instability and Athletics

• Sports related collision or contact may lead to
  subluxation or dislocation at the atlantoaxial
  joint
• Spinal cord compression can lead to fatigue when
  ambulating, or to upper motor neuron and
  posterior column signs
• Gait disturbances, progressive loss of
  coordination, spasticity, hyperreflexia, clonus,
  or toe-extensor reflex

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Atlantoaxial Instability and Athletics

• Refer for neurosurgical consultation
• Avoid activities at risk for hyperextension,
  radical flexion, or direct pressure on the neck
  or upper spine
• butterfly stroke, diving, pentathlon, high jump,
  equestrian sports, gymnastics, soccer, squat
  lift, alpine skiing, and any warm-up exercise
  placing undue stress on the head and neck
• Non-contact sports OK with parental consent

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Epidemiology of Injury and Illness in Special
Olympians
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Injury rates for Team USA at the First
International Special Olympics Winter Games, 1993

• Alpine skiing 20/28 71
• Floor hockey 11/35 31
• Speed skating 7/28 25
• Figure skating 3/29 10
• Cross country skiing 1/28 4

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International Summer Special Olympics, 1983 (2150
Athletes)

• Behavior/psych 26
• Seizure 22
• Dental injury 15
• Closed head/ neck 12
• Fracture/dislocation 8

• Heat illness 302
• Abrasion/lac 287
• Sprain /strain 280
• GI illness 115
• Respiratory illness 70

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Hawaii Special Olympics Summer Games, 1993-96

• Batts, Glorioso, Williams. The Medical Demands of
  the Special Athlete. Clin J Sport Med 1998
  822-25.
• Medical attention rate of 3.87 per year
• 58 injuries
• 42 medical conditions

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Hawaii Special Olympics Summer Games
INJURIES (n52) MEDICAL COND (n38)

• Abrasion 16
• Muscle cramp 14
• Sprain/strain 8
• Contusion 7
• Laceration 4
• Blister 2
• Nail avulsion 1

• GI complaint 6
• Heat injury 5
• Epistaxis 5
• Infection 5
• Seizure 4
• Headache 4
• Injection 3

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Hawaii Special Olympics Summer Games INJURY SITES

• Lower extremity 50 (knee 13)
• Upper extremity 30
• Chest/Abd 8
• Face 6
• No site listed 6

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Hawaii Special Olympics Summer Games

• Track and Field 55.6
• Softball 35.6
• Aquatics, dance, training 8.8
• No reported injuries for wheelchair events,
  powerlifting, or tee ball

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Study Comparison

• Birrer McCormick Robson Hawaii
• Time 2yr 1yr 1yr 4yr
• Athlete 2056 777 1512 2326
• Treated 4.2 3.5 13 3.8

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Disabled Athlete Injury Rates

• Hoeberigs (1990) Wheelchair 47.5
• Richter (1991) Paralympics 60
• Ferrara (1992) Wheelchair, Blind and
  Cerebral palsy 32

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Able-Bodied Athlete Injury Rates

• Zacicznyj (1980) 6 school aged child
• Backx (1989) 10.6 school aged child
• Garrick (1981) 39 high school athletes
• Requa (1981) 85 high school track and
  field injuries to the lower extremity
  

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Hawaii Special Olympics Winter Games (unpublished)

• Approx. 3.2 injury rate
• 66 of injuries in Basketball
• 15 of injuries from non-sports
• 56 of injuries either strain/sprain or abrasions
• No injuries in ice skating

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Medical Coverage of Special Olympic Events

• Medical professionals
• Physicians, nurses, EMTs, physical therapists,
  athletic trainers
• Equipment- Basic first aid, ACLS, oxygen
• Medical Aid Stations
• Communication
• Transportation
• Ambulance, golf carts

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Medical Coverage Safety Precautions

• Protect from the heat and sun
• Environment and weather
• Acclimate to altitude, temperature, humidity
• Fluids
• Encouraged by coaches, volunteers, health care
  teams
• Personal medications available

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Medical Coverage Prevention

• Training- muscular and cardiovascular
  conditioning
• Protective gear - eyewear
• Seizure precautions
• A seizure while in or around water
• Equestrian events, gymnastics, alpine skiing

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Conclusion

• Prior knowledge of injury patterns experienced by
  Special Olympians will improve medical coverage
  of games
• The spirit with which these athletes compete is
  no different than that of a true Olympians

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Conclusion

• Although injury rates are higher in disabled
  athletes and able-bodied athletes, the types of
  injuries sustained by the special athlete are
  similar
• Sport specific injuries are similar to all
  athletes

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Questions?