The Challenged Athlete and Special Olympics

1. Military Sports Medicine Fellowship The Challenged Athlete and Special Olympics “Every Warrior an Athlete” Cole R Taylor, MD Primary Care Sports Medicine Fellow Special thanks to Dr. Kevin deWeber

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

3. Benefits of Sports in Challenged Athletes • Increased endurance, strength and flexibility • Improved CV Function • Improved balance and coordination • Psychological benefits • Number of years in sports shows strong correlation to functional abilities in children with mild/moderate MR (Ghosh, 2012)

4. Types of disabilities • Physical disabilities • Intellectual disabilities • Subaverage intellectual functioning and marked impairment in adaptive behavior • Sometimes both coexist

5. Spectrum of Disabilities • Intellectual Disability • Amputations • Cerebral palsy • TBI, SCI • Genetic or Neuromuscular • Hearing/Vision impairment

6. Classification of Disabilities • Functional Classification System (FCS) • Provides number based on abilities • Divisions/Grouping based on prior performance

7. 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

8. Paralympics • 6 Major Categories • Amputee, CP, Intellectual Disabilities, Vision Impaired, Wheelchair, Les Autres (MS, Dwarfism) • Summer Games 2012 • 20 sports, 500 events • Winter Games • 5 Sports, 64 events

9. 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

10. “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

11. 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

12. Special Olympics Activities • Serves more than 2.5 million people in 180 countries • Events arranged at local, state, national, and international levels

13. Special Olympics Games • First International Special Olympics - 1968 • 2009 World Winter Games - Boise • Nearly 3000 athletes, 85 countries • 2011 World Summer Games - Athens • More than 6000 athletes, 170 countries

14. 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

15. 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

16. Deaflympics • Many deaf individuals do not consider themselves disabled • For Deaflympics, must have significant hearing loss in both ears and use of any type of hearing device is prohibited in warm-up or competition

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 • Consider physical ability, mental status, level of competition, maturity, equipment • Common Pitfall • Diagnostic Overshadowing (overlook common medical issues with focus on disability) • Office-based exam by medical professionals who are involved in the longitudinal care of these athletes is preferred

19. 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

20. History of seizures? Controlled? Hearing or vision loss? Any CV disease? History of heatstroke or heat exhaustion? Hx of fractures/dislocations PPE Medical History

21. PPE Medical History • Prosthetics/equipment required • Urinary issues (ex: indwelling catheter) • Pressure sores or ulcers • Levels of prior competition • Current level of independence and mobility • Medication usage • Special diet? • History of autonomic dysreflexia

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. Down Syndrome 417 Epilepsy 239 Cardiac lesion 88 Cerebral palsy 33 Asthma 24 Hypothyroidism 22 Hemiparesis 11 Severe vision Im 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

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

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

27. 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.

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

29. Specific Condition Considerations • Down Syndrome • Intellectual Disability • IQ 35-70 • Collagen Defects • Ligamentous laxity • Congenital Heart Disease • Vision/Hearing Deficits

30. Down SyndromeMusculoskeletal 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

32. 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

33. Atlantoaxial Instability (AAI) • Up to 15% those with Down Syndrome • 1-2% have symptomatic AAI • Laxity of the transverse ligament of C-1 (atlas) which stabilizes the articulation of the odontoid process of C-2 (axis) with C-1 • C-1 can spontaneously sublux forward on C-2 resulting in compression of the spinal cord

35. Atlantoaxial Instability: Diagnosis • Atlas-Dens Interval (ADI) • Distance between anterior ramus of C-1 and the dens of C-2 • All Down syndrome athletes must receive a lateral x-ray of the cervical spine in flexion, neutral, and extension before entering Special Olympics participation (2012 ITE question) • Special Olympics consider any ADI of 5 mm or more to be disqualifying for certain sports

37. AAI: note increase in ADI with flexion

38. 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

39. 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

40. 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

41. Spinal Cord Injury (SCI)Considerations • Thermoregulation • Especially with lesions above T8 • Impaired sweating, venous pooling, meds • Autonomic Dysreflexia • SCI above T6 • Noxious stimuli below lesion leads to sympathetic response with loss of inhibition • Self limiting but can be deadly (dysrhythmia)

42. “Boosting” with Autonomic Dysreflexia • Self-Induced • Drink large amounts of fluid, strap legs tightly, clamp catheters • Has been shown to reduce race time • Considered an ergogenic aid and is not sanctioned

43. Wheelchair Athlete Considerations • Overuse injuries in shoulders and wrists are most common • Carpal tunnel reported in 50-75% of wheelchair athletes (Groah, 2000) • Skin breakdown (often asymptomatic) • This is also a big concern in amputee athletes

44. Cerebral Palsy Considerations • Progressively decreasing flexibility leads to overuse syndromes • Flexion contractures with decreased flexibility leads to chronic back pain or spondylolysis • 50% in wheelchairs

45. Cerebral Palsy ITE Question • What is different about a CP athlete? • There are no lesions involving the reflexes/lower motor neurons (it is a central lesion) • Cardiopulmonary training will improve VO2 max in CP athlete as well • Rapid muscle stretching triggers excessive reflex activity via Upper Motor Lesion

46. 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

47. 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

48. Epidemiology of Injury and Illness in Special Olympians

49. 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%

50. Heat illness 302 Abrasion/lac 287 Sprain /strain 280 GI illness 115 Respiratory illness 70 Behavior/psych 26 Seizure 22 Dental injury 15 Closed head/ neck 12 Fracture/dislocation 8 International Summer Special Olympics, 1983 (2150 Athletes)