Education Columns

Seth VanZant, MSII; Laurie Woodard, MD; Michelle Hummel; Eric Coris, MD

In the United States, it is estimated that more than 3 million athletes with physical and cognitive disabilities participate in organized athletic programs. This number continues to grow with an increasing number of recreational leagues and programs tailored to athletes with disabilities.^1,2 For individuals with disability, participation in sports can have a dramatic impact. Socially, participation can improve self-confidence and self-esteem, enable the athlete and his/her family to be integrated into a support system, and allow for a sense of independence and accomplishment.¹ Physically, sports can improve performance in activities of daily living, build strength and endurance, and prevent painful degenerative decline.³ Emotionally, athletes report decreased feelings of anxiety and depression and an overall greater life satisfaction.^1,4

Prior to participating in organized sports, athletes should obtain clearance through a standardized pre-participation physical exam (PPE). When performing a PPE for athletes with disabilities, it is important to tailor your evaluation to the athlete’s syndrome-specific conditions and provide a thorough history and physical exam to ensure safe participation. The term disability covers a wide spectrum of conditions and syndromes: physical (eg, amputation), neurological (eg, spinal cord injuries, traumatic brain injury), sensory (eg, vision and hearing loss), and developmental/genetic (eg, cerebral palsy, autism). Performing the PPE with mindfulness and consideration of these patients’ unique conditions can grant individuals with disability safe participation in sports and the benefits associated with exercise and recreational activity.

The following are special considerations for the PPE when obtaining a health history and performing the head-to-toe physical exam for athletes with disability:

History

• Which sport(s) does the patient desire to play?
• Is the disability congenital or acquired? If acquired, for how long?
• Does the participant use assistive devices (eg, for mobility or communication)?
• How does the disability affect activities of daily living (eg, what tasks can be completed independently, which require assistance, and who provides assistance)?
• Have there been any recent changes in coordination and mobility (eg, wheelchair users are more prone to overuse injuries, pressure sores, and premature osteoporosis)?
• Does the patient have bowel and bladder control?
• Which medications is the patient taking (eg, anticonvulsants can prolong the QT interval)?
• Are there syndrome-specific concerns related to the athlete’s condition (eg, autonomic dysreflexia, thermoregulation in those with spinal cord injuries, atlantoaxial instability in athletes with Down syndrome, sensory defects, cardiac and seizure disorders in patients with intellectual developmental disability)?⁵

Physical Exam

• Check for undiagnosed hearing, vision, and dental problems.
• Check blood pressure in both arms and auscultate heart in supine and sitting positions since congenital heart disease is much more common in patients with developmental conditions.
• Perform a complete neuromuscular exam to check strength, tone, and range of motion; modify this exam for individuals with balance or mobility impairments.
• Assess the condition of skin and closely inspect feet, especially in athletes with developmental disabilities.

Assessment

• Does the athlete have the physical, social, and mental capacity to safely participate in their desired sport(s) (remember the sport(s) may be adapted to their needs)?
• Are there any condition-specific concerns that require particular consideration (eg, seizure control if sport involves water or heights, thermoregulation impairments if participating outside, atlantoaxial instability if contemplating high impact sports)?⁵

The American Academy of Family Physicians, along with other specialty organizations, has developed the PPE History Form, Examination Form and the Athlete With a Special Needs Supplemental History Form.6 These resources can be used as guide for teaching learners to perform a PPE for athletes with disabilities and can be found at the following web link: http://www.aafp.org/afp/2015/0901/afp20150901p371-onlineonly.pdf

References

1. United Nations. Sport and persons with disabilities: fostering inclusion and well-being.
   Patel DR, Greydanus DE. Sport participation by physically and cognitively challenged young athletes. Pediatr Clin N Am 2010;57:795-817.
2. Kurkowski K, Chandra S. The preparticipation athletic evaluation. Am Fam Physician 2000;61:2683-90.
3. Sahlin KB, Lexell J. Impact of organized sports on activity, participation and quality of life in people with neurologic disabilities. PMR 2015:1-8.
4. Klenck C, Gebke K. Practical management: common problems in disabled athletes. Clin J Sport Med 2007;17(1):55-60.
5. Bernhardt DT, Roberts WO, eds. American Academy of Family Physicians, American Academy of Pediatricians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. PPE: Preparticipation physical evaluation, 4th edition. Elk Grove Village, IL: American Academy of Pediatrics 2010:154.