Medical care to Paralympic Athletes

1
Medical care to Paralympic Athletes

• Dr I. Stuart Miller Dip Sport Med FFSEM(UK)
• Clinical director
• Bath University Sport and Exercise Medicine
• CMO ParalympicsGB

2
Disability Hide away or celebrate talent

• It is impossible to change everyone's
  perceptions on the subject of disabled sport
• Daily Telegraph journalistGareth A Davies
• Care of Paralympic athletes is it rocket
  science or just a need to explore perceptions?

3
Paralympic games a rationale

• The Paralympic Games are a powerful demonstration
  of the vitality and achievements of disabled
  persons world-wide
• -Kofi Annan, United Nations Ex-Secretary General
  (letter dated 7 September 2004

4
Paralympic athletes role models and ambassadors

• The Paralympics are one of the worlds most
  prominent events where people with disabilities
  show their tremendous talent and energy. We take
  this opportunity to admire the skill and
  determination of these athletes, but at the same
  time we must reflect upon the fact that globally,
  too many people with disabilities do not enjoy
  even the most basic human right.
• -Dr. Etienne Krug, Director of the WHO
  Department of Injuries and Violence
  Prevention,International Paralympic Symposium on
  Disability Rights

5
History of the Paralympic Games

• 1948 Guttmans Stoke Mandeville Games in the UK
  taking part
• 1960 First Paralympic games in Rome with 23
  countries and 400 athletes
• 1988 First true linked Modern Paralympic games in
  the same venue as the Olympic Games (Seoul)
• 2000 Sydney Paralympics 127 countries and 4000
  athletes took part with global TV coverage of
  1.1billion. (except the USA!)

6
The increasing Global participation

• 2004 Paralympic games
• Cumulative TV audience worldwide 1.862 billion
• IPC revenue in 2004 was 4.67million
• IPC annual report 2004
• 2008 Paralympics
• 140 countries
• Global cumulative audience of 3.8billion
• IPC Press release -9.12.08

Number of countries
Number of competitors
7
The sports and classification within Paralympic
sports
8
The Paralympic summer sports programs

• Archery
• Athletics (track and field)
• Boccia
• Cycling
• Equestrian
• Football 5-a-side
• Football 7-a-side
• Goalball
• Judo
• Powerlifting

• Rowing
• Sailing
• Shooting
• Swimming
• Table Tennis
• Volleyball (sitting)
• Wheelchair basketball
• Wheelchair fencing
• Wheelchair rugby
• Wheelchair tennis

9
Disability Groups

• Based on historical precedence and sport
  development
• Wheelchair athletes/Spinal injured
• Cerebral palsy
• Blind or visually impaired
• Amputees
• Les Autres
• Intellectual disability (suspended)
• Deaf (Not part of the Paralympic movement)
• There is likely to be significant change either
  very soon for London 2012 or in time for 2016
  ability based

10
Classification- setting a level playing field

• Comparison with able bodied classification- eg
  boxing weights/age/experience
• Classification considered by each sport as either
• Disability specific
• e.g. athletics
• Involves a structured assessment blind, amputee
  lower limb etc
• Functional classification
• swimming
• static and dynamic evaluation- apparently
  different disabilities within classifications
• Confirmed (C), Review (R) or New (N)
  classification

11
Limitation to classification

• General public do not understand
• Banding is either
• too broad to allow some to compete on a level
  playing field
• Too narrow creating too many categories
• Complex to manage, open to abuse? If challenged
  may result in a good athlete/medal potential
  being unable to qualify in a more difficult
  category
• Where possible it should be functional and not
  alterable by training.
• Consideration should also be given to equipment
  to prevent technology wins cf F1 racing.

12
Specific medical issues with disability groups
13
What should we expect when treating disabled
athletes?

• The great worry amongst therapists and doctors is
  that injuries and illness will be very high or
  unduly complex
• injury rates are broadly comparable to able
  bodied counterparts at 9.1/1000
• Patterns of injury vary a little with the
  different sports
• more upper limb injuries in wheelchair users
• increase in lower limb trauma in visually
  impaired athletes
• Ferrara MS and Connie L. Peterson CL Injuries to
  Athletes With Disabilities - Identifying Injury
  Patterns Sports Med 2000 Aug 30 (2) 137-143
• FerraraMS,Buckley WE. Athletes with disabilities
  injury registry. Adapt Phys Act Q 1996 13 50-60

14
Musculo-skeletal Injuries

• Nick Webborn BPA data on file Athens
  Paralympics

15
Illness in Disability athletes

• Can be a little more challenging sometimes due to
  co-morbidities e.g.
• Epilepsy in CP
• Pressure sore management
• UTI
• Autonomic dysfunction
• Nick Webborn BPA data on file

16
Specific problems encountered in disability groups

• Spinal injured
• Cerebral palsy
• Amputee athletes
• Visually impaired

17
Spinal Lesion

• Cause- an insult that affects the functioning of
  the nerves of the spinal column
• congenital problems such as
• Spina bifida or
• acquired injury such as
• Spinal injury fracture / dislocation (rugby
  diving RTA
• Transverse myelitis
• Tumour
• Infection
• Polio

18
Spinal Injury
19
Causes of Spinal Injury
20
Defining Injury Level

• Complete or incomplete?
• ASIA classification (American spinal injuries
  Association )
• Quadriplegiatetraplegia
• A-D (A complete D power 3/5)

21
Spinal Cord Injured Athletes

• Motor loss
• Sensory loss
• Pressure sores
• Lack of awareness of injury
• care when transferring
• Loss of autonomic control
• Bladder
• Bowel
• Sweating
• Effects on cardiac function in exercise
• (T1-4 sympathectomises)
• Respiratory function

• Temperature control
• Dehydration
• UTI / stones
• Autonomic dysreflexia (at or above T6)

22
Dysreflexia

• Sensory (pain) impulses enter the cord below
  lesion and sympathetic nervous system responds to
  local spinal reflexes with an excessive discharge
  which is uncorrected by feedback loop.

BP
HR
23
Signs Symptoms

• Pounding headache.
• Nasal congestion.
• Blurred vision.
• Appearance of spots in the patient's visual
  fields.
• Profuse sweating and flushing of the skin above
  the level of the lesion, especially in the face,
  neck, and shoulders, or possibly below the level
  of the lesion.

• Bradycardia
• Elevated blood pressure
• Cardiac arrhythmias, atrial fibrillation,
  premature ventricular contractions, and
  atrioventricular conduction abnormalities.
• Piloerection or goose bumps above or possibly
  below the level of the lesion.

24
Why is it important?

• Autonomic dysreflexia has been regarded as a
  medical emergency because of the severe rises in
  blood pressure that can occur with recorded
  values in excess of 300 mmHg.
• Reported complications in the medical literature
  include seizures, cerebral haemorrhage, cardiac
  arrhythmia and death.
• In the hospital setting it is treated as a
  medical emergency.

25
Causes of Autonomic Dysreflexia

• Intentional
• Clamping catheter.
• Tight leg straps.
• Genital trauma.
• Prolonged sitting in racing chair.

• Unintentional
• UTI
• Blocked catheter
• Constipation
• Urinary calculi
• Anal fissure
• Skin infection or injury
• Pressure area

26
Boosting

• The practice of precipitating a dysreflexic state
  by noxious stimuli
• Perceived increase in exercise capability.
• Belief that boosted state could be controlled.
• Treadmill exercise capability improved.
• Increase in simulated race times of 9.7 in
  boosted state. - Burnham et al. Clin. J. Sports
  Med. Vol.4 1994.
• Equivalent in able-bodied performance
• 1 second off 100m record.
• 4 seconds off 400m record.
• 12 minutes off marathon record.

27
Managing thermoregulation in Spinal Cord Injury

• Above the lesion
• sweating may be excessive (Sweat rate above level
  of lesion - can increase x 6)
• Drips off - ineffective for heat loss
• Below the lesion
• Basal sweat rate is unaffected by activity or
  ambient temperature

Level of lesion
28
Risks of heat to Wheelchair Athletes

• Increases in core temperature up to 40.5 deg.
• Increases in heart rate.
• Risk of dehydration still likely to occur.
• Risk of heat illness increased and impairment of
  athletic performance.
• Most affected athletes Tetras (high lesion)

29
Managing thermoregulation

• Hydration strategies
• pre-cooling strategies
• interventions during competition
• Cooling vests, head and hand emersion, use of fans

30
Time to Exhaustion
31
Core Temperature
32
Risks in cold environments

• Inability to shiver below spinal lesion
• Lack of locomotor effort
• Lack of feeling in peripheries may lead to cold
  injury
• Difficulty changing in and out of cold weather
  gear

33
Other Factors Limiting Performance of spinal
injured athletes

• May be peripheral rather than central
• Local fatigue despite sufficient availability of
  blood and O2 -muscle fatigue in muscles not
  designed for endurance exercise.
• Inadequate venous return of blood to the heart
  due to deficient skeletal muscle pump activity
  and impaired sympathetic vasoregulation
• SCI T1-4 or above - sympathectomised myocardium.
  HR max 110-130
• Unopposed sympathetic input may cause relative
  bronchospasm

34
Wheelchair use

• Type of wheelchair- sports design
• Disabled facilities- is wheelchair access
  available?
• Propulsion issues
• Injury specific patterns

35
Influence of disability on propulsion

• Lower spinal cord injury
• Higher position
• Ability to flex and extend trunk
• High thoracic injury
• Lower flexed position
• Inability to extend trunk
• wheelchair racing
• Fencing

36
Amputee or Limb Deficiency

• Congenital e.g. developmental
• or
• Acquired
• Disease e.g. tumour, vascular disease
• Trauma RTA, workplace injury

37
Amputees

• Can compete with or without prosthesis or in
  wheelchair

38
Amputee Considerations

• Alignment
• Impact loading on stump prosthesis interface
• Choke syndrome- venous pooling
• Residual limb problems- overuse injury muscle
  imbalance
• Biomechanical issues (prosthetic limb may be made
  short to allow easier toe clearance)
• Phantom limb pain
• Technology development and costs
• Is the technology too good to compete with able
  bodied athletes?

39
Oscar Pistorius and cheetahs- media hype or real
opportunity?

• Oscar Pistorius was ruled ineligible to compete
  at the Olympic Games because his prosthetic limbs
  give him an unfair advantage.
• Their statement said the double amputee's
  "cheetah" blades were technical aids in clear
  contravention of IAAF rules, effectively banning
  the South African, 21, from competing against
  able-bodied athletes.
• Times online 14 Jan 2008
• Successful appeal proved there was no benefit
  when comparing pre and post injury athletes and
  rates of exhaustion/VO2Max

40
Cerebral Palsy

• A non-progressive but not unchanging disorder of
  movement and/or posture, due to an insult or
  anomaly of the developing brain.
• Classification can be according to the type of
  movement disorder and/or by the number of limbs
  affected.

41
Classification

• Movement Disorder
• Spastic cerebral palsy
• Choreo-Athetoid cerebral palsy
• Mixed-type cerebral palsy
• The classifications of movement disorder and
  number of limbs involved are usually combined
  (e.g. spastic diplegia).
• Half compete in wheelchairs

42
Cerebral Palsy Sport

• Common problems
• Prejudice and misconception
• Co-morbidity
• epilepsy
• visual defects
• deafness
• intellectual impairment
• Spasticity
• Dependency and psychology (not often in elite
  sport!)
• Issues around spasticity, training and
  classification

• Common sports
• CP athletics track and field
• CP football
• Boccia
• Cycling

43
Physical interventions

• Reduce excessive muscle tone
• Maintain or improve range of movement and
  mobility
• Increase strength and co-ordination
• Improve comfort.
• Stretching to maintain the full ROM of a joint,
  keeping it mobile.
• Strengthening Spasticity often leads to loss of
  strength in both the spastic muscles and
  surrounding ones.

44
To treat or not to treat in CP

• The temptation is to correct abnormality
• Increased tone in one area may improve stability
• Classification issues more significant and
  controversial

45
Visually Impaired

• Injuries commonly related to falls (PWC)
• Unfamiliar environments when competing
• May require able bodied guides.
• Difficulty monitoring fluid balance

• Sports
• Track and field athletics
• Goalball
• VI/Blind football
• Judo
• Cycling
• Swimming

46
Les Autres

• Congenital disorders - e.g. spondylo-epiphyseal
  dysplasia, Stickler syndrome
• Limb deficiencies
• Muscular dystrophies
• MS
• Ankylosis or arthritis of major joints

• Choice of sport
• dependant on disability

47
The role of the medical team
48
Medical team role

• Treatment of acute injuries and illnesses
• Managing ongoing medical illness and disability
• Manage psychological aspects of performance
• Maximise potential for performance
• Monitor and evaluate interventions and potential
  problems
• Minimise the effects of travel and competition
  abroad

49
The Paralympic perspective on medical care

• The athletes have a disability
• Co-morbidities eg epilepsy
• Managing spinal injury complications such as
  dysreflexia and thermoregulation
• Knowledge of biomechanics as applied to
  wheelchair athletes and others eg amputees
• Managing prejudice and misconceptions.
• Managing success and failure

50
Medical Team - Use of Time
N.Webborn Athens 2004
51
Travelling with Athletes with a disability
52
Travel Problems

• Pressure sores
• Dehydration (may lead to UTI)
• DVT
• Epilepsy
• Oedema
• Autonomic dysreflexia
• Time zone issues bowel regimes, blind (how
  does this affect jetlag)
• Loss of normal support network

53
Travelling with a team- Getting on a plane

• Are there enough staff to assist at the airport
  with luggage and equipment?
• Extra luggage including wheelchairs (both day to
  day and competition chairs)
• Moving around in the cabin to address issues
  such as going to the toilet?
• Choice of seat.
• Number of wheelchair users
• Is there a plan what to do about bladder care
  needs?
• Is the athlete fluid restricting as it is
  difficult to move around and they may be trying
  to avoid the need to go to the toilet. (Thus
  increasing the risk of urinary tract infection)

54
In the host country

• Is there adapted transport?
• Is the environment suitable for the disabled?
• Is there an acceptance of disability within the
  society?
• Is the infrastructure suitable for athletes with
  a disability? Are hospitals equipped to deal with
  spinal injured patients understanding the need
  for pressure area care etc?
• Are the competition or training venues
  accessible?

55
At the hotel

• Is the hotel appropriately equipped to deal with
  disability athletes?
• Wheelchair users needs,
• Reduced lower limb mobility eg amputees or
  cerebral palsy
• Visually impaired
• Are there suitable facilities in the room to
  allow for space to move in a wheelchair or attend
  to bathroom needs?

56
Travelling with visually impaired athletes

• Is the hotel room easy to find?
• Consider signage in Braille or other low vision
  aids to augment the hotel signage where needed
• Carry out a sighted walk through the hotel and
  surroundings to identify risks. This may include
  high visibility strips on steps, signage to alert
  of obstruction, or even removing decorative
  plant pots from corridors!
• Ensure obstructions in hotel rooms are kept to a
  minimum
• Ensure the support team are all aware, willing to
  help and know how to guide the visually impaired.

57
Summary

• Paralympic sport is to me awe inspiring and a
  privilege to work with.
• Disability brings its own challenges to both the
  athlete and the medical teams
• Managing medical aspects of disability is not
  difficult but requires a good depth of knowledge
  of biomechanics, medicine, psychology and general
  sports medicine
• Also a sense of humour and an understanding of
  the athlete and what it means to have both a
  disability and a skill.

58
Thank you