PAULA JONES Physiotherapist

To consider general good practice when treating/communicating with athletes who have disabilities = ‘Disability Awareness’

To discuss specific considerations when treating athletes with –

- Spinal cord injury- Cerebral palsy- Visual Impairments- Amputations- Dwarfism

19 Paralympic Summer Sports Athletics, Archery, Wheelchair Basketball,

Boccia, Cycling, Equestrian, Fencing, Football, Goalball, Judo, Powerlifting, Wheelchair Rugby, Rowing,Sailing, Shooting, Swimming, Table Tennis, Tennis, Volleyball

4 Paralympic Winter SportsAlpine Skiing, Ice sledge HockeyNordic Skiing, Wheelchair curling

Upbringing Cultural, social and religious background Previous experiences of education Previous life experiences Personality Experience of discrimination The onset of the impairment Whether or not the impairment is progressive

Most athletes with disabilities lead independent lives, have jobs and families and are used to international travel for holidays, work etc.

Don’t assume you know whether, when and what help a disabled athlete needs.

Don’t make assumptions about an athlete’s level of impairment

based on a previous experience of an athlete with the same type of impairment.

Ask athletes if they want assistance rather than assuming they need it, and if they accept, ask for an explanation of how you can help.

  Don’t assume that someone with one disability also has others.

Don’t feel you have to avoid certain words – people with disabilities fit into the normative society where normative words are used.

When talking to a wheelchair user try to sit across from them. Do not lean on the wheelchair. Wheelchair users consider the chair to be part of their body and personal space. Avoid crouching down like you would to a child.

Don’t move wheelchairs / mobility aids without asking permission first.

Speech impairment or a lack of speech does not necessarily indicate an inability to understand – allow the individual to speak at their own pace and finish what they are saying.

Ask about equipment, aids or techniques they may use to assist them in daily living – wheelchairs, crutches, and braces are visible but prostheses, ileostomy or colostomy devices and breathing assistance devices may not be.

Experience their world – try a sports chair, join in training.

 

On greeting the athlete, make sure you first introduce yourself.

Speak naturally – don’t avoid visually descriptive language such as ‘see you later’.

Don’t pet a guide dog without the owner’s permission. They should generally be ignored.

On first entering the treatment room orientate the athlete to the location of the treatment couch etc.

If you leave the room, inform the athlete you are leaving.

If treating the athlete on a couch, keep one hand in contact with the athlete as you move around the couch for reassurance.

If you need to guide a person with a visual impairment, allow them to take your arm above the elbow, and inform them of any curbs, steps up or down, ramps, doorways etc.

May or may not use a white cane – symbol canes are just held to indicate visual impairment, long canes to assess stairs, curbs etc. A white cane with a red stripe indicates hearing impairment as well.

Do not move an athlete’s white cane without asking prior permission.

Causes:- Traumatic injury - severing of cord or bruising. Viral infections. Toxic conditions.

Major symptoms:-  Loss of muscle function and/or loss of sensation

below level of the lesion. May be full or partial loss.

Associated conditions:- Incontinence (loss of innervation to bladder/bowels). Pressure sores (poor circulation and skin breakdown

in weight-bearing areas). Sporadic limb spasticity and joint contractures. Residual pain around injury site.

Associated Conditions cont .... UTIs (urinary tract infections) – importance of

hydration. Impaired regulation of heart rate, blood pressure and

body temperature (ANS dysfunction). Risk of osteoporosis in legs (non-weight-bearing). DVT (through inactivity/sitting). Hederotopic ossification (excessive laying down of

bone in soft tissues around joints especially below level of SCI).

Increased risk of hypertension, atherosclerosis and cardiovascular disease.

Exercise hypotension (low BP from blood pooling in legs).

Autonomic Dysreflexia

By spinal root level of lesion - e.g. injury at first lumbar level is referred to as L1.

By type of cord lesion -(a) complete - paralysis or loss of sensation in the muscles innervated below the level of the lesion.(b) incomplete - paresis (partial paralysis) which leaves some spinal cord function intact and therefore allows some movements or sensations in muscles innervated below the level of the lesion. May not be equal on each side.

By body parts affected - (a) paraplegia - at or below the level of upper abdominals (T1) – the person has full use of the upper extremities including hands but there is neurological impairment to the lower extremities and often part of the trunk.

(b) quadriplegia (tetraplegia) - at the cervical level, involving all four limbs and trunk although does not necessarily mean no use of arms.

Level C4 is the highest level lesion that a person can sustain and remain alive without breathing support.

Transfer ability – plinthe height, assistance needed or not? May need help to lift hips and legs through to achieve prone. If no abdominal control, need assistance to lower into supine.

May need to empty / adjust leg bag, tubing, slacken clothing to prevent blockages – see autonomic dysreflexia

Treatment position - ? treat in chair or on plinthe.- at comps athlete may prefer to be treated in chair between events

May need to adapt traditional treatment techniques to apply in chair e.g. mobilisations in sitting / forward lean sitting, nags and snags, acupuncture, soft tissue release. Use of theraband/tubing in chair.

SCI athletes only sweat above level of lesion so need to avoid overheating/dehydration during training / competition.

S+C – Be aware resting heart rate in quads much lower. MHR 100-125 bpm therefore target training heart rate much lower at 65-91bpm. T1-T6 also lower but not as much. Below T6 – comparative to able bodied.

Assess extent of sensation to assist in treatment awareness – may have odd pattern of sensation.

Frequently develop muscle imbalances from prolonged sitting posture.

Watch for overuse injuries if there is an increased requirement for self-propelling – happens at events depending on location of training / comp facilities, food areas, accommodation.

Strengthen lower trapezius, rhomboids and external rotators to avoid rounded shoulders, and neck and back extensors to avoid forward head and rounded back.

Strengthen shoulder girdle and scapular musculature to avoid shoulder impingement and rotator cuff injuries e.g. when performing overhead work

  Stretch tight muscles e.g. anterior neck, shoulder and trunk; internal rotators and

adductors of arm/shoulder; hip and knee flexors; plantarflexors.

N.B. Increased ROM in some muscles may be undesirable because tightness has functional benefits e.g. overstretched, non-functional back extensor muscles make it difficult to maintain upright posture.

Tenodesis - allows quadriplegics who do not have a functional grasp to passively pull the fingers into flexion by extending the wrist.

Therefore DO NOT stretch wrist and finger flexors simultaneously with quads otherwise you will decrease their hand function. 

Serious life-threatening condition. Occurs in a high % of patients with lesions at or above the 6th

thoracic vertebra (T6). Can occur at any time after injury Result of uncontrolled reflex sympathetic activity causing

significant rise in blood pressure. Stimulus/cause should be identified. Prompt action must be taken to reduce the blood pressure

and to remove the cause. Autonomic dysreflexia occurs when there is an irritating

stimulus below the level of the injury.

Autonomic nervous system (ANS) functions at an unconscious reflex level. Regulates the internal environment of the body.

Made up of Sympathetic (SNS) + Parasympathetic (PNS) SNS - provides stimulus response to stress, activity and injury. Resulting nerve impulses travel up the spinal cord but are blocked on

reaching the injury level. Impulses cannot reach the brain but activate a reflex which increases

SNS response. Results in vaso-constriction - leads to the development of high blood

pressure. Brain indirectly appreciates the change in the blood pressure through

nerve receptors in the heart and aorta but cannot influence changes below the level of the injury.

Concomitant vaso dilatation of blood vessels seen as flushing and blotching of the skin in upper half of the body and face, nasal congestion and pounding headache.

1. Bladdere.g. over distension, blocked catheter, kinked tubing, full leg bag, urinary tract infection, bladder stones.Bladder dysfunction is the most common cause of autonomic dysreflexia.2. Bowele.g. Constipation, digital evacuation, rectal examination.3. Pressure Sores.5. Electro-Ejaculation.6. Pregnancy and Labour.7. Sexual Activity.8. All other conditions with pain below lesion – fractures, wounds, burns.Physio induced possible causes - acupuncture, cold therapy, positioning on plinthe, soft tissue / joint work below level of lesion – rarely clinically needed. Would not advise ice baths in SCI athletes with lesions T6 and above. Care with ice baths below T6 due to altered thermoregulation.

Symptoms • Pounding headache • Feeling of doom, anxiety & apprehension • Profuse sweating • Tightness in chest.

Signs • Flushing and/or blotching above level of cord lesion • Hypertension and bradycardia • Pupillary dilatation • Cardiac dysrhythmia Above lesion: • Pallor initially • Flushing head and neck • Sweating in area above and around the lesion.

Below lesion: • Cold peripheries • Pilo erection • Contraction of bladder and bowel • Penile erection & seminal fluid emission.

Note: Under normal circumstances a tetraplegic person

may have a low blood pressure (e.g. 90/60mm.Hg). A rise to “normal” level of 120/80mm.Hg. may represent a significant elevation.

Immediately sit the patient up to lower BP 

Remember until bladder or abdo distention is alleviated, sting up to 90 degrees could cause further pressure so make symptoms worse.

Summon medical help Check catheter and tubing for kinks or empty leg bag Check for bladder and lower bowel distension  Check for tight clothing, abdominal strap, leg bag strap, shoe, brace etc. Give medication of choice if patient normally takes this.- may be sublingual Nifedipine 5 mg pierced, bitten or chewed. Treatment

may be repeated up to four doses (40mg) over one hour.- GTN Spray If possible monitor blood pressure every five minutes during the episode

A non-inherited, non-progressive disorder resulting from damage to the brain which occurs at or around birth or during the first year of infancy.

Lesion in the upper motor neurons within the brain - regulate neuromuscular function, control muscle tone and spinal reflexes.

Primitive reflexes may persist throughout life.

Lesion never worsens and as the central nervous system matures, the condition stabilises.

  CP is primarily a motor deficit. Other disorders may be present,

including:- Convulsive disorders- Cognition disorders- Perceptual and motor disorders- Visual difficulties- Speech and language difficulties- Orthopaedic problems

 Anatomical classification

Monoplegia - One limb is affected, usually an arm Paraplegia - Lower extremities and hip region are affected Hemiplegia - Limbs on one side of the body are affected Triplegia - Three limbs are affected, usually both legs and one

arm Quadriplegia - All four limbs and the trunk are affected. Neck

and facial muscles may also be involved Diplegia - More involvement in lower limbs than upper limbs.

Neuromotor classification Spastic CP Athetoid CP Ataxic CP

70% of all CP cases. Fixed lesion in the motor portion of the cerebral cortex. Increased muscle tone (hypertonicity) - most often affecting flexor

and internal rotator muscles . If hypertonicity is not controlled, contractures may permanently

shorten resting muscle length and cause joint deformities .

- shoulders: flexed, adducted, internally rotated - forearms: pronated - elbows/wrists/fingers flexed - hips: flexed, adducted, internally rotated - knees flexed - feet: plantarflexed, everted

Increased by - stress, emotional arousal, cold weather, fatigue, posture, positioning, stretching and fast movements. 

20-30% of cases. Can often accompany spasticity.

Involves a lesion to the extrapyramidal cells in the basal ganglia.

Primary symptom is slow, nonrhythmical, random and involuntary writhing or jerking movements, often expressed in head, neck and facial muscles as well as limbs (e.g. pill rolling).

   Characterised by continual state of involuntary movement and

fluctuations in muscle tone from hypotonus to hypertonus (distonia: abnormal muscle tone)

  Stress, increased effort or emotional arousal may increase

abnormal movement patterns

Dysarthria (difficulty with speech) often associated with athetosis

Affects 5-10% of cases.  Involves a lesion to the cerebellum.  Primary symptoms are:- poor body balance (especially with upright posture).- impaired gait with uncertain, staggering movements.- decreased trunk control and lack of co-ordination - usually

walk with a wide-based gait to compensate.

Muscles are hypotonic.  May be impaired kinaesthetic sense which affects

judgment of posture, centre of gravity and body relationships to external objects.

Depending on type of CP, strength and tone may be different on each side.

Stretch tight, spastic muscles. May be difficult to hold static stretches if athetoid or ataxic.

Strengthen antagonists (usually extensors) as these are often weak.

Care with overtraining - risk of increasing tone due to post training soreness and fatigue.

Consider location of training venues to avoid long transit journeys between – again will affect fatigue and tone

  Avoid cold or noisy treatment environments as may increase spasticity.

Use slow, large movements to decrease muscle tone/spasticity. Rapid movements will increase tone.

  Use mind/breathing e.g. “think about straightening your arm as you breathe out”.

Be aware of primitive reflexes – may need to adapt positioning.

NB - Don’t introduce soft tissue massage pre-event unless you know how it will affect their tone - Athletes frequently rely on their tone to perform.

 

Defined as an individual with an adult height of 4ft 10 in or shorter as a result of medical or genetic factors

Over 250 different types of restricted growth conditions.

Skeletal dysplasias - characterized by intrinsic abnormalities in growth/remodelling of cartilage and bone.

Two main categories, disproportionate and proportionate.

Disproportionate - commoner of the two. Results in average size torsos with shorter arms and legs – cause is from skeletal dysplasia, the failure to develop bone either inherited or due to gene mutation.

Proportionate - short in statureMain cause due to pituitary gland dysfunction (growth hormone deficiency)

Most common – 80% of Dwarf population Occurs all races equal frequency Equal frequency male/female. Standing height below 1/3rd percentile both sexes-

male 132cms, female 125cms. Sitting height normal.

Normal life expectancy Gross motor development is frequently delayed.

Disproportionate short stature - normal trunk length, narrow thoracic cage.

Rhizomelic limbs (shortened), skin folds Hyperlordotic muscle tone Hypermobilty of most joints Genu Varum - lateral tibial torsion Large head – prominent forehead Midface hypoplasia (underdevelopment)

Radiological Findings - Contracted skull base – small foramen magnum - compression Short pedicles Short femoral neck Flat roofed acetabular Narrow sacro-iliac groove

Lumbo-sacral spinal stenosis – most common 90% adults Craniocervical junction compression 10% infants Spinal deformities – thoracolumbar kyphosis, kyphoscoliosis. Cervical atlanto-axial instability (less in achondroplasia) Premature degenerative changes – frequently need joint

replacements hips and kness Joint hypermobilty – knees, ankles, dislocation and trauma. Joint hypomobility- elbows ext +rot, hip ext. Respiration – sleep apnoea, cardiopulmonary exercise capacity.

prevalence of pneumonia Hydrocephalus Neurological symptoms – due to anatomical abnormalities, or

stretching of nerves e.g. ankle pain from peroneal nerve Fibromyalgic symptoms – trigger points, trochanteric bursitis.

Treatment couches – height Strapping – hypermobile joints, excess skin folds,

short limbs Need to maintain joint range for sporting function

e.g. powerlifting cannot have in excess of 20° loss of elbow extension

Congenital - Limb may be absent at birth, or malformed at birth and

subsequently removed to provide a better fit for a prosthesis (artificial limb)

Dysmelia = absence of a complete limb Phocomelia = absence of middle segment of limb with

distal portions attaching to joint e.g. hands attached to shoulders or feet attached near hips

Acquired -  circulatory malfunction causing loss of blood supply to limb

and resulting death of affected tissue e.g. diabetes cancerous tumours serious infections  trauma (work-related/RTA/severe burns) 

General Contractures and decreased ROM  Impaired sensation and skin damage Phantom pain Upper Limb Deformities of the spine especially scoliosis with upper

extremity amputations Removal of dominant hand/arm can create awkward

movement patterns and lack of co-ordination Reduced efficiency and stability in locomotion; balance may

be affected Postural imbalances through displaced centre of gravity

Lower Limb - Increase in energy expenditure with prosthesis Decreased control of dynamic balance Altered gait pattern and decreased gait efficiency

(AK especially through using hip to hitch) Removal of dominant leg can create awkward

movement patterns and lack of co-ordination Postural imbalances Speed, lateral agility, stair-climbing and jumping

efficiency all affected Fixation in thoracic region

General - Stump care – watch for breakdown of stump with overtraining / new

training methods Balance re-education – sit fits, WII FitUpper extremity - Trunk and postural exercises to focus on midline control e.g.

strengthen back extensors and lateral flexors on that side to compensate for leaning towards heavier complete side

Lower extremity - Tight trunk/hip/knee flexors and adductors in AKs – encourage lying

on stomach to stretch Hip hitching on swing phase when walking, can lead to excessive

lordosis and thoracic fixation > low back pain Strengthen core - lower abdominals/gluts/pelvic floor. Pilates.

Consult your best resource – the athlete. Know key features of the disability and associated

conditions e.g. Autonomic dysreflexia, altered thermoregulation in SCI’s

Consider treatment environment – temperature, safety, plinthe height, treatment position.

Appropriate application of sports massage - timing Don’t be afraid to try things – most

treatments/training techniques with able bodied athletes can be adapted.

Thank you