PT Classroom - Sports and Children with Physical Disabilities ׀ by Marķa A. Ocasio-Silva, MD & Kathryn Greaves, MPT

 

Kathryn Greaves graduated from UW- Madison with her Master of Physical Therapy degree. Her training in physical therapy includes pediatrics, orthopedics, sports medicine, vestibular and women’s health. While attending Madison, she was also a member of the UW- Madison Women’s hockey team. Kathryn is currently a physical therapist at Children's Hospital of Wisconsin.


Sports and Children with Physical Disabilities

The physical, mental and social benefits derived from sports participation for all ages and abilities are widely accepted. Research examining the influence of physical activity, exercise and sports participation on individuals with and without disabilities shows sports:

• Increase muscle strength and flexibility.
• Improve exercise endurance and cardiovascular efficiency.
• Enhance balance, motor development and motor skills.
• Support self-concept and body awareness.
• Help develop sportsmanship.
• Promote a positive environment for friendship.


Sports participation promotes social interaction, peer acceptance and development of social skills and self-esteem in both able-bodied and disabled children. Participation also can teach able-bodied children to be sensitive to those who are different.

In spite of these benefits, children with physical disabilities are less likely to engage in these activities than their able-bodied peers. Disabled children often have limited access to recreational activities, sports participation, knowledgeable coaches or adapted fitness leaders, and competent, active role models with similar disabilities capable of providing both instructional and motivational feedback.

In 2002, the Centers for Disease and Control Prevention, the Surgeon General and the President's Council on Physical Fitness identified concerns related to the lack of physical activity in the daily lives of Americans with physical disabilities and the negative impact this has on their primary and secondary medical conditions. Research shows that children with disabilities are at an increased risk for developing:

• Obesity.
• Poor cardiopulmonary endurance.
• Muscle atrophy.
• Joint contractures.

Rates of obesity are especially high in children with Down syndrome, muscular dystrophy, spina bifida and spinal cord injury, making adaptive sports and recreation of significant importance. However, participation by these children in sporting activities may bring about unique issues and injuries. Pediatric physical medicine and rehabilitation and pediatric orthopedics are specialties that can assist in screening, prevention and treatment to ensure safety with participation to gain maximum effects.

Adapted sports programs are being organized in many communities, either in an integrated (athlete participates with others who have no disabilities) or segregated (athlete participates only with other athletes with disabilities) environment. These programs give children with disabilities increased opportunity to achieve the main goal of adapted sports – independent participation. There are two major adaptive sports movements:

• Paralympics – for people with physical disabilities.
• Special Olympics – for people with intellectual disabilities.


Both of these movements have grown dramatically since their initiation, reflecting an increased awareness of the abilities of people with disabilities. There have been increases in competitive opportunities for disabled children to participate at recreational, local and regional events. Legislation also has helped stimulate the development of adaptive sports in the U.S. Yet, with increased participation and competition come unique issues and injuries pertaining to the physically challenged child.

Children in general have different bone structure, open growth plates and decreased ability to withstand heat stresses compared to adults. Physicians need to be mindful of these differences. The American Academy of Pediatrics recommends that every athlete without a disability have a preparticipation examination at least once a year, but little has been published about guidelines for athletes with disabilities. Although it is recommended to use the standard PPE, it is important to take into account the particular co-morbidities associated with a disabled child's primary impairment. The PPE goals for disabled children are the same as for the typically developing child, including:

• Identifying musculoskeletal conditions that could make sports participation unsafe.
• Screening for underlying illnesses.
• Recognizing pre-existing injury patterns.
• Devising rehabilitation programs to prevent recurrences.

PPEs for disabled children should include all the components of the standard PPE. The physical exam also should include all organ systems, with special focus on those affected by the child's disability. It should evaluate general cognition, memory and judgment. The physical exam should consider not only the disability; it also should be sports specific. Following are examples of what to look for during a physical exam.


Subjective/history
Athletic goal of the individual.
• Current level of training and sports participation.
• Impairment and level of functional independence for mobility and self-care.
• Orthosis, assistive devices, adaptive equipment or prosthesis.
• Emotional, psychiatric or behavioral problems. (This is extremely important as children should not be cleared for sports that could be hazardous to themselves or others. Examples include weight lifting and archery.)
• Past history, including sports-associated lesions. (Injury incidence and patterns are similar for athletes with and without disabilities. However, location of injury appears to be disability and sports dependent. For example, wheelchair sports participants have more upper extremity injuries while ambulatory children tend to have more lower extremity injuries.)
• Medications. (For example, anticholinergics may cause thermoregulation problems and muscle relaxants may cause sedation.)
• Review of systems. (Consider presence of external devices for bladder drainage or for bowel evacuation, wound dressings and pressure sores, etc.).

Objective
Always evaluate affected and unaffected extremities, with and without prosthesis, braces or other devices. Evaluate the patient's mobility with a wheelchair or any assistive devices that will be used for sports participation, checking equipment for fit and wear. In addition:

• Assess for skin integrity, especially in patients with spina bifida, spinal cord injury or amputations and those who participate in wheelchair sports.
• Watch for upper extremity overuse in wheelchair users and lower extremity overuse in cerebral palsy patients who ambulate.
• Review joint stability and range of motion, flexibility. (Down syndrome patients may have knee and hip problems due to hypotonia and generalized ligamentous laxity; cerebral palsy patients may experience issues with tightness and strains.)
• Measure muscle strength.
• Evaluate muscle tone, deep tendon reflexes and Babinski reflex. (Down syndrome patients should have hypotonia. If upper motor neuron signs are found on the physical exam, atlanto-axial instability (AAI) needs to be ruled out.)
• Check for sensory and neurologic deficits.
 

Special tests are ordered depending on the history and the physical exam. The only mandatory special test is AAI screening for Down syndrome patients who participate in sports that place stress on the head and neck. The highest risk for AAI is between ages 5 and 10. Cervical radiographs – including lateral, flexion and extension views – need to be ordered. An atlanto-dens interval of more than 4.5 mm is abnormal and requires further evaluation.

Assessment/recommendations
The Committee on Sports Medicine and Fitness of the American Academy of Pediatrics has devised a classification system based on contact level and the stress of the activity. This system guides physicians when recommending which sports are safe, with very few conditions excluding a child from all sports activities. Physicians should be sure to:

• Assess the physical and intellectual capabilities of a patient to participate in a given sport.
• Educate disabled athletes and caregivers about the potential risks related to their given diagnosis.
• Recommend prevention measures and/or adapted activities based on developmental skills and challenges.


Pediatric physical medicine and rehabilitation physicians have an understanding of anatomy and development that allows accurate evaluation and goal-directed treatment.

Through the use of an adaptive sports program, these physicians can assist in evaluating sports injuries and devising rehabilitation programs for adaptive sports athletes. They also can help provide specific sporting recommendations and assist in providing the PPE yearly to all children with disabilities who plan to participate in sports. Pediatric physiatrists also have a unique role in adapted sports as their knowledge and training reflect a great understanding for thedisabled child and the associated possible complications secondary to their primary impairment. Children with disabilities should look to their adaptive sports program for pre-injury prevention strategies, after-injury rehabilitation and sport-specific training each season to determine rehabilitative needs and ensure safe participation.

Conclusion
Physical activity and sports participation enhances disabled children's health and well-being. Regular exercise and participation in sports by these children is as important as it is for their able-bodied counterparts. Professionals working with children with disabilities should actively promote participation in sports and recreation activities. Prior to participation, children with disabilities should be evaluated by a physician who has understanding of childhood disabilities to identify sports commensurate with their abilities.

 

Last revised: August 4, 2010
by Kathryn Greaves, MPT

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