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Paralympic.ppt - WCSO

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					 Medical care to Paralympic
          Athletes




Dr I. Stuart Miller Dip Sport Med FFSEM(UK)
                 Clinical director
Bath University Sport and Exercise Medicine
             CMO ParalympicsGB
Disability – Hide away or
celebrate talent
• “It is impossible to change
  everyone's perceptions on the
  subject of disabled sport”
  Daily Telegraph journalist
   Gareth A Davies

  Care of Paralympic athletes – is it
   rocket science or just a need to
   explore perceptions?
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
Paralympic athletes – role
models and ambassadors
• The Paralympics are one of the world’s
  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
History of the
Paralympic Games
•1948 Guttman’s 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!)
    The increasing Global         140



    participation                 120

                                  100

                                     80


• 2004 Paralympic                    60

                                     40

  games                              20

                                              0
                                                  1960         1968     1976    1984    1992   2000

• Cumulative TV audience                                 Number of countries
  worldwide 1.862 billion
• IPC revenue in 2004 was
                                                   4
                                                  3.5
                                                   3
  £4.67million                                    2.5




                                  Thousands
•    IPC annual report 2004                        2
                                                  1.5


• 2008 Paralympics                                 1
                                                  0.5
                                                   0
• 140 countries                                         1960     1968    1976    1984   1992   2000



• Global cumulative                                       Number of competitors
  audience of 3.8billion
•    IPC Press release -9.12.08
The sports and classification
  within Paralympic sports
The Paralympic summer
sports programs
• Archery                • Rowing
• Athletics (track and   • Sailing
  field)                 • Shooting
• Boccia                 • Swimming
• Cycling                • Table Tennis
• Equestrian             • Volleyball (sitting)
• Football 5-a-side      • Wheelchair
• Football 7-a-side        basketball
• Goalball               • Wheelchair fencing
• Judo                   • Wheelchair rugby
• Powerlifting           • Wheelchair tennis
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
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
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.
Specific medical issues with
     disability groups
    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
 Musculo-skeletal Injuries
500                                                          Bursa
                                             445
450                                                          Laceration/pressure sores
400                                                          Fractures
350                                                          Haematoma
300
                                                             Joint dysfunction
250
                                                             Ligament injury
200
                                                             Muscle strain/tear
150        120
                                                             Spinal segmental
                            90                     90
100                                                          dysfunction

                      40                50                   Tendon injury
50                                                      35
      20         10              8                           Other
 0
                           No. of Rxs

      •Nick Webborn – BPA data on file Athens Paralympics
    Illness in
    Disability
    athletes                                                  Psychological
                                                                              Other
                                           Skin Infection
• Can be a little more
  challenging                     Neurological
  sometimes due to                                                                        URTI

  co-morbidities e.g.
• Epilepsy in CP
• Pressure sore                   Insect Bites

                                                                                         Heat related
  management
• UTI                                              GU
                                                            G-E               Epilepsy
• Autonomic                                                       GI - non-
                                                                  infective
  dysfunction

•    Nick Webborn – BPA data on
     file
Specific problems encountered in
         disability groups




          Spinal injured
         Cerebral palsy
        Amputee athletes
        Visually impaired
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
Spinal Injury
Causes of Spinal Injury
Defining Injury
Level

           • Complete or incomplete?
           • ASIA classification
             (American spinal injuries
             Association )
           • Quadriplegia=tetraplegia
           • A-D (A complete D power
             3/5+)
Spinal Cord Injured Athletes
• Motor loss
• Sensory loss                •   Temperature control
   • Pressure sores
   • Lack of awareness of
                              •   Dehydration
     injury                   •   UTI / stones
   • care when transferring
                              •   Autonomic dysreflexia
• Loss of autonomic
  control                         (at or above T6)
    Bladder
    Bowel
    Sweating
• Effects on cardiac
  function in exercise
   • (T1-4
     sympathectomises)
• Respiratory function
                        Sensory
                        (pain)
     Dysreflexia   BP
                        impulses
                        enter the cord
HR                      below lesion
                        and
                        sympathetic
                        nervous
                        system
                        responds to
                        local spinal
                        reflexes with
                        an excessive
                        discharge
                        which is
                        uncorrected
                        by feedback
                        loop.
    Signs & Symptoms
 Pounding headache.           Bradycardia
 Nasal congestion.            Elevated blood
 Blurred vision.               pressure
 Appearance of spots in       Cardiac arrhythmias,
  the patient's visual          atrial fibrillation,
  fields.                       premature ventricular
 Profuse sweating and          contractions, and
  flushing of the skin          atrioventricular
  above the level of the        conduction
  lesion, especially in the     abnormalities.
  face, neck, and              Piloerection or goose
  shoulders, or possibly        bumps above or
  below the level of the        possibly below the level
  lesion.                       of the lesion.
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.
Causes of Autonomic
Dysreflexia
 Unintentional               Intentional
     UTI                           Clamping catheter.
     Blocked catheter              Tight leg straps.
     Constipation                  Genital trauma.
     Urinary calculi               Prolonged sitting in
     Anal fissure                   racing chair.
     Skin infection or injury
     Pressure area
 ‘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.
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   Level of lesion
     for heat loss
• Below the lesion
• Basal sweat rate is
  unaffected by activity
  or ambient
  temperature
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)
Managing thermoregulation

• Hydration strategies
• pre-cooling strategies
• interventions during
  competition
• Cooling vests, head and
  hand emersion, use of fans
Time to Exhaustion
                                30                        *            *
  Number of sprints completed
                                28
                                26
                                24
                                22
                                20
                                18
                                16
                                14
                                12
                                10
                                        Control       Precooling      During

                                * significantly greater than Control (p<0.05)
   Core Temperature
                     38.2               CON
                     38.0               PRE
                     37.8
C)


                                        DUR
o




                     37.6
Core Temperature (




                     37.4
                     37.2
                     37.0
                     36.8
                     36.6
                     36.4
                     36.2
                     36.0
                     35.8
                     35.6
                     35.4
                            -26   -22    -18   -14   -10   -6    -2     2   6   10   14   18    22   26
                                                           Time (min)
                                   Precooling manouver      Warm up                       ISP
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
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
Wheelchair use
• Type of wheelchair-
  sports design
• Disabled facilities- is
  wheelchair access
  available?
• Propulsion issues
• Injury specific patterns
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
Amputee or Limb
Deficiency
• Congenital e.g.
  developmental
       • or
• Acquired
     • Disease e.g.
       tumour,
       vascular
       disease
     • Trauma – RTA,
       workplace injury
Amputees

• Can compete
  with or without
  prosthesis or in
  wheelchair
 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?
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
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.
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
Cerebral Palsy
Sport
• Common problems
• Prejudice and
  misconception
• Co-morbidity
   •   epilepsy                  • Common sports
   •   visual defects
   •   deafness
   •                        • CP athletics track
       intellectual impairment
• Spasticity                  and field
• Dependency and            • CP football
  psychology (not often in
  elite sport!)             • Boccia
• Issues around spasticity, • Cycling
  training and
  classification
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.
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
Visually Impaired
• Injuries commonly
  related to falls
  (PWC)
• Unfamiliar          • Sports
  environments        • Track and field
  when competing        athletics
• May require able    • Goalball
  bodied guides.      • VI/Blind football
• Difficulty          • Judo
  monitoring fluid    • Cycling
  balance
                      • Swimming
Les Autres
• Congenital
  disorders - e.g.
  spondylo-epiphyseal
  dysplasia, Stickler
  syndrome
• Limb deficiencies
• Muscular
  dystrophies              • Choice of
                             sport
• MS
• Ankylosis or arthritis   • dependant on
  of major joints            disability
The role of the medical team
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
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
 Medical Team - Use of
 Time
                      Other   Musculo-
                       3%     skeletal
                              54%
Massage -
pre & post
   23%




              Medical
             conditions
                20%           N.Webborn –
                              Athens 2004
Travelling with Athletes with a
           disability
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
 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)
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?
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?
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.
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.
Thank you

				
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