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The Challenged Athlete

Military Sports Medicine Fellowship. The Challenged Athlete. “Every Warrior an Athlete”. Kevin deWeber, MD, FAAFP Director, Primary Care Sports Medicine Fellowship Acknowledgments to Dr. Mark Williams. Objectives. Review classifications of disabilities Describe PPE requirements

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The Challenged Athlete

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  1. Military Sports Medicine Fellowship The Challenged Athlete “Every Warrior an Athlete” Kevin deWeber, MD, FAAFP Director, Primary Care Sports Medicine Fellowship Acknowledgments to Dr. Mark Williams

  2. 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

  3. Types of disabilities (challenges) • Physical challenges • Intellectual disabilities • Subaverage intellectual functioning and marked impairment in adaptive behavior • Sometimes both coexist

  4. Physical Disability Classification • Wheelchair athletes • Cerebral palsy • “Les autres” (“the others”) • Limb deficiencies • Hearing impairment • Vision impairment

  5. 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

  6. 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 Paralympic Sports

  7. 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

  8. “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

  9. 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

  10. 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

  11. 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

  12. Goals • Physical fitness • Social development • Acceptance into larger society

  13. 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

  14. 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

  15. Alpine skiing Cross country skiing Figure skating Floor hockey Speed skating Badminton Golf Powerlifting Table tennis Team handball Official SportsWinter and Demonstration

  16. Aquatics (swimming and diving) Track and field Basketball Bowling Cycling Equestrian Gymnastics Roller skating Softball Tennis Volleyball Soccer Official SportsSummer

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

  18. 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

  19. Level of independence Wheelchair Motor impairment Prosthetic equipment H/O autonomic dysreflexia Testicle (absence?) Kidney (absence ?) Urinary catheters? Communication issues Additional History Needed

  20. 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

  21. 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.

  22. 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

  23. 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%

  24. 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 Sports Significant DisabilitiesHudson (Physician & Sportsmedicine 1988)Medical Diagnoses in History (#)

  25. 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 Conditions Encountered on Pregame Medical Exam of 1512 Competitors at U.K. Special Olympics,1989Robson, Br. J. Sports Med. 24:225,1990

  26. Height and Weight Blood pressure Visual Acuity Eye,ear, nose, throat Cardiorespiratory auscultation Abdominal, including hernia and testicular check Screening orthopedic, including scoliosis Focused orthopedic Screening neurologic Physical Exam

  27. Visual Exam • About 1/3 will have abnormality • Poor visual acuity most common • Others: • Refractive errors • Astigmatism • strabismus

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

  29. 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.

  30. 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

  31. 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

  32. 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

  33. Atlantoaxial Instability • 10%- 20% of Down syndrome individuals have asymptomatic AAI • 1-2% have symptomatic AAI

  34. 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

  35. Normal ADI in neutral position. Increased ADI in flexion.

  36. Normal: note no increase in ADI with flexion.

  37. AAI: note increase in ADI with flexion

  38. 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

  39. 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

  40. 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

  41. Endocardial Cushion Defect • Embryologic precursors of the atrioventricular canal, mitral and tricuspid valves • Defects of valves

  42. 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

  43. 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

  44. Functional Assessment • Overall mobility • Use of prosthetics • Use of wheelchair • Evaluate sport-specific tasks

  45. 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

  46. 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

  47. 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

  48. 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

  49. Epidemiology of Injury and Illness in Special Olympians

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