SIDELINE AND EVENT MANAGEMENT
Preparing for Events for Physically Challenged Athletes Lauren M. Simon, MD, MPH, FACSM1 and David C. Ward, MD2
Abstract The participation in sports for physically challenged athletes continues to expand in multiple domains from recreational, novice, and competitive to elite competitions such as the Paralympics. Physically challenged athletes have various disabilities such as visual impairments, spinal cord injuries, amputations, cerebral palsy, or other neuromuscular impairments and have different levels of functional ability within these broad categories. The spectrum of medical illnesses and musculoskeletal injuries seen with sports is similar to that of able-bodied athletes; however medical teams caring for athletes with disabilities need to be familiar with medical risks such as skin breakdown, thermoregulation problems, dehydration, autonomic dysreflexia, infections, orthotic and prosthetic issues, and psychiatric comorbidities that may be encountered. The medical team preparation for events involving physically challenged athletes should include obtaining appropriate medical supplies, ensuring disability-compatible access to medical areas, and preparing for emergency extraction from adaptive equipment.
Introduction Physically challenged and able-bodied athletes participate in recreational and organized sports activities for fitness, health, emotional well-being, and competition. The number of physically challenged athletes participating in sports and the opportunities to participate have increased substantially over the past few decades. For example, the inaugural Olympic-style games for elite athletes with disabilities (which were the precursor to the modern Paralympic Games) occurred in Rome in 1960 and had 400 athletes. In contrast, the London 2012 Summer Paralympic Games had over 4300 participants. Physically challenged athletes have various impairments and have different levels of functional ability with these impairments. Medical teams preparing to care for athletes with 1 Primary Care Sports Medicine, Family Medicine, Loma Linda University, Loma Linda, CA; and 2Family Medicine, Loma Linda University, Loma Linda, CA
Address for correspondence: Lauren M. Simon, MD, MPH, FACSM, Primary Care Sports Medicine, Family Medicine, Loma Linda University, 25455 Barton Road Suite 209 B, Loma Linda, CA 92354; E-mail: [email protected]. 1537-890X/1303/163Y168 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
disabilities at sporting and recreational events need to be familiar with risks for medical problems such as infections, skin breakdown, temperature regulation problems, autonomic dysreflexia (AD), adaptive equipment, and prosthetic issues that may be encountered. The medical team also should prepare appropriate medical supplies, provide event-specific medical and musculoskeletal care, ensure disability access to medical areas, and prepare for emergency extraction from adaptive equipment. The nature of the athletes’ disabilities, the type of event (single sport, multisport, endurance sport), level of competition, number of participants, and sport-specific risks need to be considered in the medical coverage plan.
Classification There is a wide range of physical impairments seen in physically challenged athletes. In order to have equitable competition, athletes with disabilities can be classified so that those with similar functional abilities are competing with each other (18). Classification is a process in which a single group of entities is ordered into a number of smaller units based on common observable properties (20). Medical professionals caring for physically challenged athletes may cover events with athletes who have a broad range of impairment, variable functional ability, and multiple disabilities participating in the same sport and should be prepared to meet the diverse needs of these athletes. Medical staff should be aware of more formal classification systems used by sports federations. Earlier classifications were medically based classes of disabilities: amputee, cerebral palsy, visual impairment, spinal cord injury/disability (SCI), intellectual disability, and les autres (a group with impairments not covered by other groups such as muscular dystrophy). As sports for persons with disability evolved from extension of rehabilitation to more organized sports, classifications evolved to more functional classifications such as the International Paralympic Committee (IPC) classification code (19Y21) adopted by the IPC in 2007 and used as the overall classification of Paralympic sports. There are Current Sports Medicine Reports
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10 eligible impairment types used in IPC classification (hypertonia, athetosis, ataxia, impaired muscle power, loss of muscle strength, impaired passive range of motion, loss of limb, limb deficiency, low vision, and intellectual impairment). The sport/impairment is denoted by a letter and number. The lower the number, the greater impact the athlete’s impairment has on his/her ability to compete. Knowledge of the athletes’ sport classes at the events can help the medical team prepare their coverage. The IPC code uses the International Classification of Functioning, Disability, and Health terminology and taxonomy to describe impairment groups (20,21,25). Of note, in a particular sport, there may be athletes with differing physical disabilities such as a Paralympic athlete with L2 SCI with paraplegia and an athlete with double above-knee amputation competing in the same wheelchair racing class (class T54) since their impairment for the particular sport is similar (20). The classification systems are sport specific and are developed by the international federations governing the sport. Injury and Illness Epidemiology There is a paucity of published studies on the incidence of injury and illness in athletes with disabilities to use to help prepare for medical coverage needs for events with physically challenged athletes. Injury studies on athletes with disabilities are confounded by lack of consistent injury definition or types of athlete impairments (9). In the study on the athlete injuries sustained at the 2010 Winter Paralympic Games, Webborn et al. (22) listed the incidence proportion (IP) (percentage of athletes with injury) for the 120 injuries in 505 athletes as 23.8% (95% confidence interval (CI), 20.11Y27.7), with 40.8% of the injuries classified as acute traumatic-onset injuries. Initially able-bodied athletes and those with disabilities appeared to have similar injury patterns (7Y9) in an epidemiologic review by Ferrara and Peterson (9) that included athletes with disabilities who participated in the Summer Paralympic Games (9). Injury pattern was disability and sport related. Upper extremity injuries were more common in wheelchair athletes, and lower extremity injuries were more common in ambulatory athletes (9). In the London 2012 Summer Paralympic Games, daily injury and illness data were obtained prospectively by using a web-based injury and illness surveillance system and an electronic medical data capture system (5). The definition for reporting injury or illness was ‘‘any athlete who received medical attention regardless of the consequences, with respect to absence from competition or training.’’ ‘‘Injury’’ was defined as ‘‘any newly acquired injury and exacerbations of preexisting injury that occurred during the 14-d precompetition and competition period.’’ From this cohort of 3565 athletes from 160 of the 164 countries present (representing 85% of the athletes), prospective injury and illness surveillance data for the competition period were extracted and showed that there were no differences between incidence rates (IR) of injury and illness (5,24). The IR of injury during the competition period was 12.1/1000 athlete days, with IP of 11.6% (95% CI, 11.0%Y13.3%), and the IR of illness was 12.8/1000 athlete days (95% CI, 11.7Y13.9), with IP of 10.2%. Upper extremity injuries 164
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represented the highest IP (35%), with shoulder injuries being the most common (IP, 17%). The most commonly affected systems for illness were the respiratory system (27.4%), the skin and subcutaneous system (18.3%), and the gastrointestinal system (14.5%). Nonrespiratory illnesses (in sum) were more common than respiratory illnesses in athletes with a disability (5). This study found that patterns of injuries and illnesses in Paralympic athletes were different from those in able-bodied athletes, with upper limb injuries (shoulder, elbow, wrist, and hand) more common than lower limb injuries and nonrespiratory illnesses (including urinary tract infections) showing higher prevalence in the Paralympic athletes than that in able-bodied athletes (5). During the study period, 10.9% of the Paralympic athletes studied presented with an injury and 10.2% presented with an illness (5). In comparison, 11% of the athletes presented with at least one injury and 7% of the athletes presented with at least one illness during the ablebodied London 2012 Summer Olympic Games (6). Preparing for Events: General Considerations Preparedness for events involving physically challenged athletes is similar to sideline preparedness practiced by team physicians and involves ‘‘identification of and planning for medical services to promote the health and safety of athletes, limit injury and illness, and provide medical care at the site of practice or competition’’ (11). Event physicians should hold an unrestricted medical license to practice medicine (1,12) and follow all applicable laws regarding medical licensure and special credentials if they are traveling to a venue in another state or country outside their licensure area. The medical professionals should have strong knowledge of musculoskeletal injuries, medical and psychological issues affecting athletes, and provision of sports venue emergency care (e.g., acute fracture management, head injuries, cardiac emergencies, AD, and thermoregulatory illnesses) and be trained in cardiopulmonary resuscitation and use of automated external defibrillators (AED) (11,12). Ideally some members of the event medical staff should be trained in advanced cardiac life support (ACLS) and advanced trauma life support. The medical team should develop and maintain medical and event records in paper or electronic format and follow the privacy principles of the Health Insurance Portability and Accountability Act in the United States or applicable laws for medical privacy and medical reporting in other countries. Hazardous Conditions Another consideration of particular importance when preparing for events with physically challenged athletes is competition site preparation such as inspecting the competition site to reduce injury risks (e.g., uneven ground, wires, sand, or debris particularly dangerous with use of cycles or lower limb prostheses), communication plan to link medical personnel, medical sites and emergency personnel, provision of adequate hydration fluids for athletes and medical staff, and preparation of a hazardous condition plan (HCP) (1). Event Preparation: Challenged Athletes
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Hazardous conditions pose a risk to the event participant beyond the inherent risk of the activity and include environmental conditions such as temperature extremes, lightning, poor air quality, or high wind speed. There should be a predetermined plan for these conditions including modifying, suspending, or canceling activities. One example of acute HCP implementation occurred in October 2013 when the large DisAbility Sports Festival at California State University V San Bernardino was postponed when Santa Ana wind gusts exceeding 40 mph threatened the safety of participants and staff. Emergency Action Plan Rehearsal Preparation and practice are critical components of providing optimal medical care for events with physically challenged athletes. The event medical director should be involved in developing and directing the emergency action plan (EAP) and medical venue organization. Special attention must be given to providing physically accessible care for those with disabilities (e.g., wheelchairs, crutches, prostheses). It is important to rehearse the EAP and plans for standard and emergency communication with athletes with hearing or visual impairment (e.g., use of white marker boards, personnel with sign language skills, written or Braille communication, and assigned personnel to assist those athletes). The medical team/emergency medical service (EMS) personnel should be familiar with and do simulation practice for medical injuries and injured athlete extraction from equipment that may be used in the sporting event (e.g., paracycles, wheelchairs, adaptive skis, and throwing chairs). The medical team also may be caring for able-bodied athletes (e.g., sited athlete on tandem cycle or sited athlete leading visually impaired athlete in a marathon) at events for physically challenged athletes. On-Site Medical Personnel The medical personnel required on site vary depending on the type of event, sport, level of competition, and sports federation rules. Events involving potential for high-speed crashes such as wheelchair rugby are venues where EMS presence is advised. Some of the international paralympic sports federations mandate ambulances and physicians on site for emergency care, whereas other venues may have personnel such as sports physical therapists. The medical team also should be aware of what level of assistance may be provided to an athlete (e.g., a hand cyclist who falls over while secured in his cycle) without incurring penalty or disqualification of the athlete. Psychological Comorbidity and Event Preparation Sports participation can foster independence, improve socialization opportunities, and build self-confidence in physically challenged athletes. In addition to providing general psychological support at sporting events, plans should be made to address the psychological needs of some challenged athletes who may experience posttraumatic stress disorder (PTSD) (e.g., some paralyzed veterans) and may experience PTSD exacerbations at sporting events (e.g., from firework displays or gunshots in track events). It is important to educate the athletes about when and where such activities may occur. Designating ‘‘quiet rooms’’ where athletes can www.acsm-csmr.org
retreat is helpful for athletes who may react adversely to overstimulation in venues. Adaptive Equipment and Prostheses Some physically challenged athletes have several prostheses such as those for daily activities and others for competition (e.g., running limb or cycling limb), and the prostheses have varying levels of technology and cost. Factors such as travel to events, changes in temperature and humidity, large venue distances to ambulate, and changes in training routine potentially may affect the ‘‘fit’’ or skin integrity at the prosthetic socket interface between the medical device and the athlete. It is very helpful to have access to orthotists and prosthetists to address the adaptive needs of the athletes and have personnel familiar with wheelchair or paracycle repairs at events for physically challenged athletes using this equipment. During event planning, it is important to prepare a security plan for the athletes’ adaptive equipment (e.g., prostheses, paracycles, wheelchairs) at competition and medical venues for athletes receiving care or who may require medical transport. Venue Supplies The type of medical equipment and supplies needed at the sporting event and specific venues will vary based on the type of events, number of competitors, anticipated injury, and illness risks for the participants. For example, in wheelchair events, upper extremity injuries predominate (7), so splint and skin injury supplies should be included at those venues. Blood pressure cuffs should be available at wheelchair events to monitor for AD when clinically suspected. General Supplies at the Main Medical Station General supplies at the main medical area are listed in Table 1 and ideally should include a contained shelter with partitions (e.g., useful for privacy when looking for sacral skin breakdown or decubiti on insensate athletes with SCI), physical equipment, communication devices, power and water sources, and tubs for heat injuries (1,3). Since it can be challenging to get an athlete with spinal cord impairment in and out of a deep immersion tub, alternative methods include placing the athlete into a low plastic child’s pool or placing the athlete in a waterproof tarp (e.g., on a frame made of substance such as sprinkler PVC pipe or holding the sides up to form a taco shape around the athlete) while cooling them. In the preevent and event day checks, it is important to make sure that there is an accessible working hose or other water sources. Care should be taken with the power source for the medical station to make sure that wires and cords are positioned out of the way and taped down (duct or electrical tape) where they will not be a hazard to participants (e.g., visually impaired athletes and those using adaptive equipment) or staff. In addition to providing power for the medical instruments, the power supply should be able to safely charge the athletes’ adaptive equipment as needed when receiving care (e.g., motorized wheelchairs). When traveling to foreign venues, it is important to make sure that Current Sports Medicine Reports
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Table 1. Main medical venue general supplies for events with physically challenged athletes.
General Supplies
Specific Items
Comments
Contained shelter with physical supplies
Building, enclosed tent or trailer, partitions
Partitions for privacy (e.g., for skin survey for sacral decubiti)
Examination tables with table coverings Blankets Adjustable stretchers
Lifting athletes with SCI
Trash receptacles, sharps container
Contaminated waste disposal
Disability accessible toilet and sink
Medical venue toilet
Portable or fixed
Power source
For medical equipment and charging adaptive equipment
Check compatibility for foreign travel sites.
Proper lighting
Tape down cords and wires for safety (e.g., duct tape, electrical tape)
Separate toilet for doping control
Communication devices
Water source
Optional diagnostic or therapy equipment
Weather-related items: heaters, fans, cooling equipment
Important with thermoregulatory issues in disabled athletes
Hose, sinks
Hand hygiene (soap and soapless)
Water, ice, plastic bags for ice
Hydration, swelling reduction, heat injuries
Immersion tubs, tarps
Heat injuries
Portable ultrasound, hydrocollator, interferential unit, neuromuscular electrical stimulator
Useful for multiday events or when physical therapists are on medical treatment team
the proper electrical adaptors are used so that the medical equipment functions without getting damaged. Medical Supplies Medical supplies that are desirable to have at the event main medical station are listed in Table 2. There should be an organized system to contain the supplies and make them readily identifiable and accessible at the point of care (e.g., utility cabinets with labeled drawers, compartmentalized tackle boxes, or other specialized storage kits). Particular care should be taken to use latex-free medical equipment and supplies (including blood pressure cuffs, stethoscope tubing, catheters, gloves, bandages, and others) as there is a high prevalence (25%Y65%) of latex allergy in persons with myelomeningocele spinal cord impairment (16,17). Standard medical supplies and medications The standard medical supplies and medications for the main medical station at events for physically challenged athletes are listed in Table 2 and include many of those that are listed in Sideline Preparedness for the Team Physician: A Consensus Statement V 2012 Update (11). The supply categories include medical equipment, cardiopulmonary, ophthalmic, wound, bone, soft tissue, and skin supplies, and recommended medication classes. World Antidoping Agency prohibited list and medications In order to avoid potential disqualification and/or sanction of an athlete from medication use, it is essential for the medical staff to check the World Antidoping Agency (WADA) prohibited status of any medication they plan to 166
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use for a competitive athlete unless it is a medical emergency. The athletes are held responsible for what goes into their bodies. Some medications are prohibited completely, and others are permitted only for specific sports or permitted only ‘‘out of competition,’’ not ‘‘in competition.’’ Some medications require a therapeutic use exemption. Some medications that are not prohibited may have restrictions on the route of dosing or quantity (e.g., wheelchair rugby athlete on baclofen muscle relaxant may use orally, but there are restrictions on injectable usage). The prohibited list undergoes changes, so it is imperative to check the current status of the medication use for the athlete’s specific sport. Useful Web sites to check medication status include the Global Drug Reference Online (http://www.globaldro.com) for information about medications and substances sold in the United Kingdom, Canada, the United States, and Japan and the WADA site (http://www.wada-ama.org). Bone and soft tissue injury and skin supplies Supplies to care for fractures, sprains, lacerations, contusions, abrasions, and skin breakdown are listed in Table 2. Due to risk of skin breakdown (especially on residual limbs or over bony prominences in athletes using wheelchairs), bacterial and fungal skin infections in some athletes with SCI (and urinary tract infections, particularly in athletes with urinary catheters), the medical supplies should include a selection of antibiotics and antifungal medication or access to pharmacy services for medicine provision. Wheelchair athletes are particularly at risk for inner arm abrasions/friction burns. In addition to a standard selection of bandages and medical tape, other items to reduce Event Preparation: Challenged Athletes
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Table 2. Main medical venue medical supplies for events with physically challenged athletes.
Medical Supplies
Specific Items
Comments
Equipment
Blood pressure cuff stethoscope, otoscope/ ophthalmoscope, gloves (sterile and nonsterile)
Latex free preferred
Glucometer
Dextrose 50% in water, glucose replacement
Rectal thermometer with covers
When indicated
Cervical collar, back board with straps Eye kit
Ocular anesthetic, eyewash, fluorescein strips, blue light, eye chart/card, eye patch/shield, ocular antibiotic Cotton-tipped applicators
Intravenous fluid and administrative supplies
Normal saline, lactated Ringer’s
Large bore 14Y16 angiocatheters
Cardiopulmonary supplies
Airway management items: stethoscope, intubation equipment, airway kit, mouth to ventilation mask, oxygen, oxygen saturation monitor, short-acting beta-agonist inhaler AED
Some venues may have these items provided by on-site EMS
Aspirin Prepackaged epinephrine 1:1000 Nitroglycerin ACLS supplies Wound supplies
Gauze, medical tape, adhesive and nonadhesive bandages, butterfly bandages, scissors, scalpels, wound irrigation solution, needles, syringes, local anesthetic, sutures/suture instruments, skin staplers, medical wound adhesive, povidone-iodine and alcohol swabs, silver nitrate sticks, blister and burn supplies, silver sulfadiazine, wound packing material
Additional skin supplies
Bandages, transparent film dressings, bioocclusive dressings, other decubitus supplies
Care for skin breakdown (e.g., in athletes with SCI)
Moleskin, self-adhesive silicone pads, skin lubricant, polyethylene foam
Pressure and friction reduction, padding
Bone and other soft tissue injury supplies
Crutches, braces, splinting supplies, elastic bandages, medical and athletic tape
May have casting supplies for multiday events or as needed
Medication classes
Antibiotics (oral, topical, injectable, ophthalmic)
Urinary tract infection in athletes with SCI
Antifungal, antiviral
Skin infections
Analgesics, anti-inflammatories, antihistamines, antiemetics, antacids, glucose replacement, muscle relaxants, anticonvulsants
Check all medicines against WADA list.
pressure or friction include latex-free moleskin, selfadhesive silicone pads, and polyethylene foam. For events involving water transitions such as triathlon, it is important for the athletes’ hands to be totally dry before applying gloves to reduce risk of blistering and skin breakdown. It can be helpful to have talcum powder on site in those events for athletes to use as needed once their hands are dry (2).
Medical Concerns Although many of the injuries sustained by physically challenged athletes are acute soft tissue injuries, there are www.acsm-csmr.org
medical concerns that the medical team should be familiar with. In addition to skin breakdown risks, athletes with SCI are at risk for heat or cold injuries since they have poor ability to tolerate extreme temperatures or regulate body temperature (2). Hyperthermia risk occurs due to impaired sweating and impaired control of peripheral blood flow below level of spinal cord lesion, so less evaporative cooling occurs (14). Hyperthermic athletes require immediate cooling (3). Athletes with SCI also are at risk for hypothermia from loss of skeletal muscle mass and activity, resulting in reduced ability to generate body heat through Current Sports Medicine Reports
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shivering. Some athletes with cerebral palsy are also at risk for thermoregulatory problems, especially hypothermia (with winter or water sports) if they have associated hypothalamic dysfunction. Neurogenic bladders predispose some athletes with SCI to urinary tract infections, which may present atypically with subtle signs of increased spasticity or lethargy. Amputee athletes with upper extremity amputations are more likely to have cervical and thoracic spine injuries, whereas lower extremity amputees are more likely to have lumbar back pain due to musculoskeletal imbalances (4). AD and boosting AD is a medical emergency that is seen usually in individuals with SCI above the T6 level that occurs when a noxious stimulus below the level of the SCI results in uncontrolled sympathetic discharge that can lead to severe hypertension, myocardial infarction, cerebral hemorrhage, or other severe complications (23). Symptoms of AD include abnormally high blood pressure, sweating, goose bumps, facial and neck flushing, and diaphoresis (14). ‘‘Boosting’’ is an intentional induction of AD (e.g., overfilling bladder catheter, sitting on a sharp object, or applying a tight leg strap) (10,14,15) to improve athletic performance and is banned by the IPC (13). Initial treatment includes removing the offending stimulus and sitting the athlete upright for orthostatic blood pressure reduction. Conclusions Individuals with disabilities participate in multiple levels of recreational and competitive sports. When preparing for events for physically challenged athletes, it is essential for the medical team to be familiar with the nature of the athletes’ impairments, the sport, and disability-related risk factors for injury and illness in order to organize needed supplies, EAP, and provide optimal care for the athletes’ health and safety. The authors declare no conflicts of interest and do not have any financial disclosures.
References 1. American College of Sports Medicine. Mass participation event management for the team physician: a consensus statement. Med. Sci. Sports Exerc. 2004; 36:2004Y8. 2. Black SA. Triathlon participation for the physically challenged athlete: medical considerations. Curr. Sports Med. Rep. 2007; 6:195Y9.
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3. Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional heat stroke in competitive athletes. Curr. Sports Med. Rep. 2005; 4:309Y17. 4. Dec KL, Sparrow KJ, McKeag DB. The physically-challenged athlete: medical issues and assessment. Sports Med. 2000; 29:245Y58. 5. Derman W, Schwellnus M, Jordaan E, et al. Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEBIISS) for team medical staff. Br. J. Sports Med. 2013; 47:420Y5. 6. Engebretson L, Soligard T, Steffan K, et al. Sports injuries and illnesses during the London Summer Olympic Games 2012. Br. J. Sports Med. 2013; 47:407Y14. 7. Ferrara MS, Buckley WE, McCann BC, et al. The injury experience of the competitive athlete with a disability: prevention implications. Med. Sci. Sports Exerc. 1992; 24:184Y8. 8. Ferrara MS, Palutsis GR, Snouse S, Davis RW. A longitudinal study of injuries to athletes with disabilities. Int. J. Sports Med. 2000; 21:221Y4. 9. Ferrara MS, Peterson CL. Injuries to athletes with disabilities: identifying injury patterns. Sports Med. 2000; 30:137Y43. 10. Harris P. Self-induced autonomic dysreflexia (‘boosting’) practised by some tetraplegic athletes to enhance their athletic performance. Paraplegia. 1994; 32:289Y91. 11. Herring SA, Kibler WB, Putukian M. Sideline preparedness for the team physician: a consensus statement-2012 update. Med. Sci. Sports Exerc. 2012; 44:2442Y5. 12. Herring SA, Kibler WB, Putukian M. Team physician consensus statement: 2013 update. Med. Sci. Sports Exerc. 2013; 45:1618Y22. 13. IPC Handbook. (April 2009) International Paralympic Committee. Retrieved December 2013. 14. Klenck C, Gebke K. Practical management: common medical problems in disabled athletes. Clin. J. Sport Med. 2007; 17:55Y60. 15. McGrath M. Paralympic athletes who harm themselves to perform better. Available from: http://www.bbc.co.uk/news/science-environment-19325756 16. Patel DR, Greydanus DE. Sport participation by physically and cognitively challenged young athletes. Pediatr. Clin. North Am. 2010; 57:795Y817. 17. Randolph C. Latex allergy in pediatrics. Curr. Probl. Pediatr. 2001; 31: 135Y53. 18. Tweedy SM, Vanlandewijck YC. International Paralympic Committee position stand V background and scientific principles of classification in Paralympic sport. Br. J. Sports Med. 2011; 45:259Y69. 19. Van de Vliet P. Paralympic athlete’s health. Br. J. Sports Med. 2012; 46: 458Y9. 20. Vanlandewijck Y, Thompson W. The Paralympic Athlete: Handbook of Sports Medicine and Science. West Sussex (United Kingdom): Wiley-Blackwell; 2011, p. 19Y30, 217Y30. 21. Webborn N, Van de Vliet P. Paralympic medicine. Lancet. 2012; 380:65Y71. 22. Webborn N, Willick S, Emery C. The injury experience at the 2010 winter paralympic games. Clin. J. Sport Med. 2012; 22:3Y9. 23. Wheeler G, Cumming D, Burnham R, et al. Testosterone, cortisol and catecholamine responses to exercise stress and autonomic dysreflexia in elite quadriplegic athletes. Paraplegia. 1994; 32:292Y9. 24. Willick SE, Webborn N, Emery C, et al. The epidemiology of injuries at the London 2012 Paralympic Games. Br. J. Sports Med. 2013; 47:426Y32. 25. World Health Organization. International Classification of Functioning, Disability, and Health. Geneva (Switzerland): 2001.
Event Preparation: Challenged Athletes
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Preparing for Events for Physically Challenged Athletes Lauren M. Simon, MD, MPH, FACSM1 and David C. Ward, MD2
Abstract The participation in sports for physically challenged athletes continues to expand in multiple domains from recreational, novice, and competitive to elite competitions such as the Paralympics. Physically challenged athletes have various disabilities such as visual impairments, spinal cord injuries, amputations, cerebral palsy, or other neuromuscular impairments and have different levels of functional ability within these broad categories. The spectrum of medical illnesses and musculoskeletal injuries seen with sports is similar to that of able-bodied athletes; however medical teams caring for athletes with disabilities need to be familiar with medical risks such as skin breakdown, thermoregulation problems, dehydration, autonomic dysreflexia, infections, orthotic and prosthetic issues, and psychiatric comorbidities that may be encountered. The medical team preparation for events involving physically challenged athletes should include obtaining appropriate medical supplies, ensuring disability-compatible access to medical areas, and preparing for emergency extraction from adaptive equipment.
Introduction Physically challenged and able-bodied athletes participate in recreational and organized sports activities for fitness, health, emotional well-being, and competition. The number of physically challenged athletes participating in sports and the opportunities to participate have increased substantially over the past few decades. For example, the inaugural Olympic-style games for elite athletes with disabilities (which were the precursor to the modern Paralympic Games) occurred in Rome in 1960 and had 400 athletes. In contrast, the London 2012 Summer Paralympic Games had over 4300 participants. Physically challenged athletes have various impairments and have different levels of functional ability with these impairments. Medical teams preparing to care for athletes with 1 Primary Care Sports Medicine, Family Medicine, Loma Linda University, Loma Linda, CA; and 2Family Medicine, Loma Linda University, Loma Linda, CA
Address for correspondence: Lauren M. Simon, MD, MPH, FACSM, Primary Care Sports Medicine, Family Medicine, Loma Linda University, 25455 Barton Road Suite 209 B, Loma Linda, CA 92354; E-mail: [email protected]. 1537-890X/1303/163Y168 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
disabilities at sporting and recreational events need to be familiar with risks for medical problems such as infections, skin breakdown, temperature regulation problems, autonomic dysreflexia (AD), adaptive equipment, and prosthetic issues that may be encountered. The medical team also should prepare appropriate medical supplies, provide event-specific medical and musculoskeletal care, ensure disability access to medical areas, and prepare for emergency extraction from adaptive equipment. The nature of the athletes’ disabilities, the type of event (single sport, multisport, endurance sport), level of competition, number of participants, and sport-specific risks need to be considered in the medical coverage plan.
Classification There is a wide range of physical impairments seen in physically challenged athletes. In order to have equitable competition, athletes with disabilities can be classified so that those with similar functional abilities are competing with each other (18). Classification is a process in which a single group of entities is ordered into a number of smaller units based on common observable properties (20). Medical professionals caring for physically challenged athletes may cover events with athletes who have a broad range of impairment, variable functional ability, and multiple disabilities participating in the same sport and should be prepared to meet the diverse needs of these athletes. Medical staff should be aware of more formal classification systems used by sports federations. Earlier classifications were medically based classes of disabilities: amputee, cerebral palsy, visual impairment, spinal cord injury/disability (SCI), intellectual disability, and les autres (a group with impairments not covered by other groups such as muscular dystrophy). As sports for persons with disability evolved from extension of rehabilitation to more organized sports, classifications evolved to more functional classifications such as the International Paralympic Committee (IPC) classification code (19Y21) adopted by the IPC in 2007 and used as the overall classification of Paralympic sports. There are Current Sports Medicine Reports
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10 eligible impairment types used in IPC classification (hypertonia, athetosis, ataxia, impaired muscle power, loss of muscle strength, impaired passive range of motion, loss of limb, limb deficiency, low vision, and intellectual impairment). The sport/impairment is denoted by a letter and number. The lower the number, the greater impact the athlete’s impairment has on his/her ability to compete. Knowledge of the athletes’ sport classes at the events can help the medical team prepare their coverage. The IPC code uses the International Classification of Functioning, Disability, and Health terminology and taxonomy to describe impairment groups (20,21,25). Of note, in a particular sport, there may be athletes with differing physical disabilities such as a Paralympic athlete with L2 SCI with paraplegia and an athlete with double above-knee amputation competing in the same wheelchair racing class (class T54) since their impairment for the particular sport is similar (20). The classification systems are sport specific and are developed by the international federations governing the sport. Injury and Illness Epidemiology There is a paucity of published studies on the incidence of injury and illness in athletes with disabilities to use to help prepare for medical coverage needs for events with physically challenged athletes. Injury studies on athletes with disabilities are confounded by lack of consistent injury definition or types of athlete impairments (9). In the study on the athlete injuries sustained at the 2010 Winter Paralympic Games, Webborn et al. (22) listed the incidence proportion (IP) (percentage of athletes with injury) for the 120 injuries in 505 athletes as 23.8% (95% confidence interval (CI), 20.11Y27.7), with 40.8% of the injuries classified as acute traumatic-onset injuries. Initially able-bodied athletes and those with disabilities appeared to have similar injury patterns (7Y9) in an epidemiologic review by Ferrara and Peterson (9) that included athletes with disabilities who participated in the Summer Paralympic Games (9). Injury pattern was disability and sport related. Upper extremity injuries were more common in wheelchair athletes, and lower extremity injuries were more common in ambulatory athletes (9). In the London 2012 Summer Paralympic Games, daily injury and illness data were obtained prospectively by using a web-based injury and illness surveillance system and an electronic medical data capture system (5). The definition for reporting injury or illness was ‘‘any athlete who received medical attention regardless of the consequences, with respect to absence from competition or training.’’ ‘‘Injury’’ was defined as ‘‘any newly acquired injury and exacerbations of preexisting injury that occurred during the 14-d precompetition and competition period.’’ From this cohort of 3565 athletes from 160 of the 164 countries present (representing 85% of the athletes), prospective injury and illness surveillance data for the competition period were extracted and showed that there were no differences between incidence rates (IR) of injury and illness (5,24). The IR of injury during the competition period was 12.1/1000 athlete days, with IP of 11.6% (95% CI, 11.0%Y13.3%), and the IR of illness was 12.8/1000 athlete days (95% CI, 11.7Y13.9), with IP of 10.2%. Upper extremity injuries 164
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represented the highest IP (35%), with shoulder injuries being the most common (IP, 17%). The most commonly affected systems for illness were the respiratory system (27.4%), the skin and subcutaneous system (18.3%), and the gastrointestinal system (14.5%). Nonrespiratory illnesses (in sum) were more common than respiratory illnesses in athletes with a disability (5). This study found that patterns of injuries and illnesses in Paralympic athletes were different from those in able-bodied athletes, with upper limb injuries (shoulder, elbow, wrist, and hand) more common than lower limb injuries and nonrespiratory illnesses (including urinary tract infections) showing higher prevalence in the Paralympic athletes than that in able-bodied athletes (5). During the study period, 10.9% of the Paralympic athletes studied presented with an injury and 10.2% presented with an illness (5). In comparison, 11% of the athletes presented with at least one injury and 7% of the athletes presented with at least one illness during the ablebodied London 2012 Summer Olympic Games (6). Preparing for Events: General Considerations Preparedness for events involving physically challenged athletes is similar to sideline preparedness practiced by team physicians and involves ‘‘identification of and planning for medical services to promote the health and safety of athletes, limit injury and illness, and provide medical care at the site of practice or competition’’ (11). Event physicians should hold an unrestricted medical license to practice medicine (1,12) and follow all applicable laws regarding medical licensure and special credentials if they are traveling to a venue in another state or country outside their licensure area. The medical professionals should have strong knowledge of musculoskeletal injuries, medical and psychological issues affecting athletes, and provision of sports venue emergency care (e.g., acute fracture management, head injuries, cardiac emergencies, AD, and thermoregulatory illnesses) and be trained in cardiopulmonary resuscitation and use of automated external defibrillators (AED) (11,12). Ideally some members of the event medical staff should be trained in advanced cardiac life support (ACLS) and advanced trauma life support. The medical team should develop and maintain medical and event records in paper or electronic format and follow the privacy principles of the Health Insurance Portability and Accountability Act in the United States or applicable laws for medical privacy and medical reporting in other countries. Hazardous Conditions Another consideration of particular importance when preparing for events with physically challenged athletes is competition site preparation such as inspecting the competition site to reduce injury risks (e.g., uneven ground, wires, sand, or debris particularly dangerous with use of cycles or lower limb prostheses), communication plan to link medical personnel, medical sites and emergency personnel, provision of adequate hydration fluids for athletes and medical staff, and preparation of a hazardous condition plan (HCP) (1). Event Preparation: Challenged Athletes
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Hazardous conditions pose a risk to the event participant beyond the inherent risk of the activity and include environmental conditions such as temperature extremes, lightning, poor air quality, or high wind speed. There should be a predetermined plan for these conditions including modifying, suspending, or canceling activities. One example of acute HCP implementation occurred in October 2013 when the large DisAbility Sports Festival at California State University V San Bernardino was postponed when Santa Ana wind gusts exceeding 40 mph threatened the safety of participants and staff. Emergency Action Plan Rehearsal Preparation and practice are critical components of providing optimal medical care for events with physically challenged athletes. The event medical director should be involved in developing and directing the emergency action plan (EAP) and medical venue organization. Special attention must be given to providing physically accessible care for those with disabilities (e.g., wheelchairs, crutches, prostheses). It is important to rehearse the EAP and plans for standard and emergency communication with athletes with hearing or visual impairment (e.g., use of white marker boards, personnel with sign language skills, written or Braille communication, and assigned personnel to assist those athletes). The medical team/emergency medical service (EMS) personnel should be familiar with and do simulation practice for medical injuries and injured athlete extraction from equipment that may be used in the sporting event (e.g., paracycles, wheelchairs, adaptive skis, and throwing chairs). The medical team also may be caring for able-bodied athletes (e.g., sited athlete on tandem cycle or sited athlete leading visually impaired athlete in a marathon) at events for physically challenged athletes. On-Site Medical Personnel The medical personnel required on site vary depending on the type of event, sport, level of competition, and sports federation rules. Events involving potential for high-speed crashes such as wheelchair rugby are venues where EMS presence is advised. Some of the international paralympic sports federations mandate ambulances and physicians on site for emergency care, whereas other venues may have personnel such as sports physical therapists. The medical team also should be aware of what level of assistance may be provided to an athlete (e.g., a hand cyclist who falls over while secured in his cycle) without incurring penalty or disqualification of the athlete. Psychological Comorbidity and Event Preparation Sports participation can foster independence, improve socialization opportunities, and build self-confidence in physically challenged athletes. In addition to providing general psychological support at sporting events, plans should be made to address the psychological needs of some challenged athletes who may experience posttraumatic stress disorder (PTSD) (e.g., some paralyzed veterans) and may experience PTSD exacerbations at sporting events (e.g., from firework displays or gunshots in track events). It is important to educate the athletes about when and where such activities may occur. Designating ‘‘quiet rooms’’ where athletes can www.acsm-csmr.org
retreat is helpful for athletes who may react adversely to overstimulation in venues. Adaptive Equipment and Prostheses Some physically challenged athletes have several prostheses such as those for daily activities and others for competition (e.g., running limb or cycling limb), and the prostheses have varying levels of technology and cost. Factors such as travel to events, changes in temperature and humidity, large venue distances to ambulate, and changes in training routine potentially may affect the ‘‘fit’’ or skin integrity at the prosthetic socket interface between the medical device and the athlete. It is very helpful to have access to orthotists and prosthetists to address the adaptive needs of the athletes and have personnel familiar with wheelchair or paracycle repairs at events for physically challenged athletes using this equipment. During event planning, it is important to prepare a security plan for the athletes’ adaptive equipment (e.g., prostheses, paracycles, wheelchairs) at competition and medical venues for athletes receiving care or who may require medical transport. Venue Supplies The type of medical equipment and supplies needed at the sporting event and specific venues will vary based on the type of events, number of competitors, anticipated injury, and illness risks for the participants. For example, in wheelchair events, upper extremity injuries predominate (7), so splint and skin injury supplies should be included at those venues. Blood pressure cuffs should be available at wheelchair events to monitor for AD when clinically suspected. General Supplies at the Main Medical Station General supplies at the main medical area are listed in Table 1 and ideally should include a contained shelter with partitions (e.g., useful for privacy when looking for sacral skin breakdown or decubiti on insensate athletes with SCI), physical equipment, communication devices, power and water sources, and tubs for heat injuries (1,3). Since it can be challenging to get an athlete with spinal cord impairment in and out of a deep immersion tub, alternative methods include placing the athlete into a low plastic child’s pool or placing the athlete in a waterproof tarp (e.g., on a frame made of substance such as sprinkler PVC pipe or holding the sides up to form a taco shape around the athlete) while cooling them. In the preevent and event day checks, it is important to make sure that there is an accessible working hose or other water sources. Care should be taken with the power source for the medical station to make sure that wires and cords are positioned out of the way and taped down (duct or electrical tape) where they will not be a hazard to participants (e.g., visually impaired athletes and those using adaptive equipment) or staff. In addition to providing power for the medical instruments, the power supply should be able to safely charge the athletes’ adaptive equipment as needed when receiving care (e.g., motorized wheelchairs). When traveling to foreign venues, it is important to make sure that Current Sports Medicine Reports
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Table 1. Main medical venue general supplies for events with physically challenged athletes.
General Supplies
Specific Items
Comments
Contained shelter with physical supplies
Building, enclosed tent or trailer, partitions
Partitions for privacy (e.g., for skin survey for sacral decubiti)
Examination tables with table coverings Blankets Adjustable stretchers
Lifting athletes with SCI
Trash receptacles, sharps container
Contaminated waste disposal
Disability accessible toilet and sink
Medical venue toilet
Portable or fixed
Power source
For medical equipment and charging adaptive equipment
Check compatibility for foreign travel sites.
Proper lighting
Tape down cords and wires for safety (e.g., duct tape, electrical tape)
Separate toilet for doping control
Communication devices
Water source
Optional diagnostic or therapy equipment
Weather-related items: heaters, fans, cooling equipment
Important with thermoregulatory issues in disabled athletes
Hose, sinks
Hand hygiene (soap and soapless)
Water, ice, plastic bags for ice
Hydration, swelling reduction, heat injuries
Immersion tubs, tarps
Heat injuries
Portable ultrasound, hydrocollator, interferential unit, neuromuscular electrical stimulator
Useful for multiday events or when physical therapists are on medical treatment team
the proper electrical adaptors are used so that the medical equipment functions without getting damaged. Medical Supplies Medical supplies that are desirable to have at the event main medical station are listed in Table 2. There should be an organized system to contain the supplies and make them readily identifiable and accessible at the point of care (e.g., utility cabinets with labeled drawers, compartmentalized tackle boxes, or other specialized storage kits). Particular care should be taken to use latex-free medical equipment and supplies (including blood pressure cuffs, stethoscope tubing, catheters, gloves, bandages, and others) as there is a high prevalence (25%Y65%) of latex allergy in persons with myelomeningocele spinal cord impairment (16,17). Standard medical supplies and medications The standard medical supplies and medications for the main medical station at events for physically challenged athletes are listed in Table 2 and include many of those that are listed in Sideline Preparedness for the Team Physician: A Consensus Statement V 2012 Update (11). The supply categories include medical equipment, cardiopulmonary, ophthalmic, wound, bone, soft tissue, and skin supplies, and recommended medication classes. World Antidoping Agency prohibited list and medications In order to avoid potential disqualification and/or sanction of an athlete from medication use, it is essential for the medical staff to check the World Antidoping Agency (WADA) prohibited status of any medication they plan to 166
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use for a competitive athlete unless it is a medical emergency. The athletes are held responsible for what goes into their bodies. Some medications are prohibited completely, and others are permitted only for specific sports or permitted only ‘‘out of competition,’’ not ‘‘in competition.’’ Some medications require a therapeutic use exemption. Some medications that are not prohibited may have restrictions on the route of dosing or quantity (e.g., wheelchair rugby athlete on baclofen muscle relaxant may use orally, but there are restrictions on injectable usage). The prohibited list undergoes changes, so it is imperative to check the current status of the medication use for the athlete’s specific sport. Useful Web sites to check medication status include the Global Drug Reference Online (http://www.globaldro.com) for information about medications and substances sold in the United Kingdom, Canada, the United States, and Japan and the WADA site (http://www.wada-ama.org). Bone and soft tissue injury and skin supplies Supplies to care for fractures, sprains, lacerations, contusions, abrasions, and skin breakdown are listed in Table 2. Due to risk of skin breakdown (especially on residual limbs or over bony prominences in athletes using wheelchairs), bacterial and fungal skin infections in some athletes with SCI (and urinary tract infections, particularly in athletes with urinary catheters), the medical supplies should include a selection of antibiotics and antifungal medication or access to pharmacy services for medicine provision. Wheelchair athletes are particularly at risk for inner arm abrasions/friction burns. In addition to a standard selection of bandages and medical tape, other items to reduce Event Preparation: Challenged Athletes
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Table 2. Main medical venue medical supplies for events with physically challenged athletes.
Medical Supplies
Specific Items
Comments
Equipment
Blood pressure cuff stethoscope, otoscope/ ophthalmoscope, gloves (sterile and nonsterile)
Latex free preferred
Glucometer
Dextrose 50% in water, glucose replacement
Rectal thermometer with covers
When indicated
Cervical collar, back board with straps Eye kit
Ocular anesthetic, eyewash, fluorescein strips, blue light, eye chart/card, eye patch/shield, ocular antibiotic Cotton-tipped applicators
Intravenous fluid and administrative supplies
Normal saline, lactated Ringer’s
Large bore 14Y16 angiocatheters
Cardiopulmonary supplies
Airway management items: stethoscope, intubation equipment, airway kit, mouth to ventilation mask, oxygen, oxygen saturation monitor, short-acting beta-agonist inhaler AED
Some venues may have these items provided by on-site EMS
Aspirin Prepackaged epinephrine 1:1000 Nitroglycerin ACLS supplies Wound supplies
Gauze, medical tape, adhesive and nonadhesive bandages, butterfly bandages, scissors, scalpels, wound irrigation solution, needles, syringes, local anesthetic, sutures/suture instruments, skin staplers, medical wound adhesive, povidone-iodine and alcohol swabs, silver nitrate sticks, blister and burn supplies, silver sulfadiazine, wound packing material
Additional skin supplies
Bandages, transparent film dressings, bioocclusive dressings, other decubitus supplies
Care for skin breakdown (e.g., in athletes with SCI)
Moleskin, self-adhesive silicone pads, skin lubricant, polyethylene foam
Pressure and friction reduction, padding
Bone and other soft tissue injury supplies
Crutches, braces, splinting supplies, elastic bandages, medical and athletic tape
May have casting supplies for multiday events or as needed
Medication classes
Antibiotics (oral, topical, injectable, ophthalmic)
Urinary tract infection in athletes with SCI
Antifungal, antiviral
Skin infections
Analgesics, anti-inflammatories, antihistamines, antiemetics, antacids, glucose replacement, muscle relaxants, anticonvulsants
Check all medicines against WADA list.
pressure or friction include latex-free moleskin, selfadhesive silicone pads, and polyethylene foam. For events involving water transitions such as triathlon, it is important for the athletes’ hands to be totally dry before applying gloves to reduce risk of blistering and skin breakdown. It can be helpful to have talcum powder on site in those events for athletes to use as needed once their hands are dry (2).
Medical Concerns Although many of the injuries sustained by physically challenged athletes are acute soft tissue injuries, there are www.acsm-csmr.org
medical concerns that the medical team should be familiar with. In addition to skin breakdown risks, athletes with SCI are at risk for heat or cold injuries since they have poor ability to tolerate extreme temperatures or regulate body temperature (2). Hyperthermia risk occurs due to impaired sweating and impaired control of peripheral blood flow below level of spinal cord lesion, so less evaporative cooling occurs (14). Hyperthermic athletes require immediate cooling (3). Athletes with SCI also are at risk for hypothermia from loss of skeletal muscle mass and activity, resulting in reduced ability to generate body heat through Current Sports Medicine Reports
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shivering. Some athletes with cerebral palsy are also at risk for thermoregulatory problems, especially hypothermia (with winter or water sports) if they have associated hypothalamic dysfunction. Neurogenic bladders predispose some athletes with SCI to urinary tract infections, which may present atypically with subtle signs of increased spasticity or lethargy. Amputee athletes with upper extremity amputations are more likely to have cervical and thoracic spine injuries, whereas lower extremity amputees are more likely to have lumbar back pain due to musculoskeletal imbalances (4). AD and boosting AD is a medical emergency that is seen usually in individuals with SCI above the T6 level that occurs when a noxious stimulus below the level of the SCI results in uncontrolled sympathetic discharge that can lead to severe hypertension, myocardial infarction, cerebral hemorrhage, or other severe complications (23). Symptoms of AD include abnormally high blood pressure, sweating, goose bumps, facial and neck flushing, and diaphoresis (14). ‘‘Boosting’’ is an intentional induction of AD (e.g., overfilling bladder catheter, sitting on a sharp object, or applying a tight leg strap) (10,14,15) to improve athletic performance and is banned by the IPC (13). Initial treatment includes removing the offending stimulus and sitting the athlete upright for orthostatic blood pressure reduction. Conclusions Individuals with disabilities participate in multiple levels of recreational and competitive sports. When preparing for events for physically challenged athletes, it is essential for the medical team to be familiar with the nature of the athletes’ impairments, the sport, and disability-related risk factors for injury and illness in order to organize needed supplies, EAP, and provide optimal care for the athletes’ health and safety. The authors declare no conflicts of interest and do not have any financial disclosures.
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3. Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional heat stroke in competitive athletes. Curr. Sports Med. Rep. 2005; 4:309Y17. 4. Dec KL, Sparrow KJ, McKeag DB. The physically-challenged athlete: medical issues and assessment. Sports Med. 2000; 29:245Y58. 5. Derman W, Schwellnus M, Jordaan E, et al. Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEBIISS) for team medical staff. Br. J. Sports Med. 2013; 47:420Y5. 6. Engebretson L, Soligard T, Steffan K, et al. Sports injuries and illnesses during the London Summer Olympic Games 2012. Br. J. Sports Med. 2013; 47:407Y14. 7. Ferrara MS, Buckley WE, McCann BC, et al. The injury experience of the competitive athlete with a disability: prevention implications. Med. Sci. Sports Exerc. 1992; 24:184Y8. 8. Ferrara MS, Palutsis GR, Snouse S, Davis RW. A longitudinal study of injuries to athletes with disabilities. Int. J. Sports Med. 2000; 21:221Y4. 9. Ferrara MS, Peterson CL. Injuries to athletes with disabilities: identifying injury patterns. Sports Med. 2000; 30:137Y43. 10. Harris P. Self-induced autonomic dysreflexia (‘boosting’) practised by some tetraplegic athletes to enhance their athletic performance. Paraplegia. 1994; 32:289Y91. 11. Herring SA, Kibler WB, Putukian M. Sideline preparedness for the team physician: a consensus statement-2012 update. Med. Sci. Sports Exerc. 2012; 44:2442Y5. 12. Herring SA, Kibler WB, Putukian M. Team physician consensus statement: 2013 update. Med. Sci. Sports Exerc. 2013; 45:1618Y22. 13. IPC Handbook. (April 2009) International Paralympic Committee. Retrieved December 2013. 14. Klenck C, Gebke K. Practical management: common medical problems in disabled athletes. Clin. J. Sport Med. 2007; 17:55Y60. 15. McGrath M. Paralympic athletes who harm themselves to perform better. Available from: http://www.bbc.co.uk/news/science-environment-19325756 16. Patel DR, Greydanus DE. Sport participation by physically and cognitively challenged young athletes. Pediatr. Clin. North Am. 2010; 57:795Y817. 17. Randolph C. Latex allergy in pediatrics. Curr. Probl. Pediatr. 2001; 31: 135Y53. 18. Tweedy SM, Vanlandewijck YC. International Paralympic Committee position stand V background and scientific principles of classification in Paralympic sport. Br. J. Sports Med. 2011; 45:259Y69. 19. Van de Vliet P. Paralympic athlete’s health. Br. J. Sports Med. 2012; 46: 458Y9. 20. Vanlandewijck Y, Thompson W. The Paralympic Athlete: Handbook of Sports Medicine and Science. West Sussex (United Kingdom): Wiley-Blackwell; 2011, p. 19Y30, 217Y30. 21. Webborn N, Van de Vliet P. Paralympic medicine. Lancet. 2012; 380:65Y71. 22. Webborn N, Willick S, Emery C. The injury experience at the 2010 winter paralympic games. Clin. J. Sport Med. 2012; 22:3Y9. 23. Wheeler G, Cumming D, Burnham R, et al. Testosterone, cortisol and catecholamine responses to exercise stress and autonomic dysreflexia in elite quadriplegic athletes. Paraplegia. 1994; 32:292Y9. 24. Willick SE, Webborn N, Emery C, et al. The epidemiology of injuries at the London 2012 Paralympic Games. Br. J. Sports Med. 2013; 47:426Y32. 25. World Health Organization. International Classification of Functioning, Disability, and Health. Geneva (Switzerland): 2001.
Event Preparation: Challenged Athletes
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