Athletes with Disabilities & Adaptive Sports Medicine – PediaCast 434
- Physical fitness and sports participation benefit everyone, including those challenged by disability. Adaptive sports medicine supports disabled athletes by anticipating need, providing help and connecting families with essential resources. Dr Jonathan Napolitano and Ashley Davidson visit the studio as we explore this important topic. We hope you can join us!
- Athletes with Disabilities
- Adaptive Sports Medicine
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.
It is Episode 434 for June 12th, 2019. We're calling this one "Disabled Athletes and Adaptive Sports Medicine." I want to welcome all of you to the program.
Summer is in full swing, at least in terms of school breaks and warm weather and kids playing outside. I mean, technically it's still spring but we are close enough to call it summer, right? Just another week or two on the calendar.
My point is this, it is a terrific time to turn off those screens, head outside, and play, engage in some vigorous physical activity. And then, it's not just your kids. Get out there and have fun with your kids. We all need to be more physically active and this is a great time of the year to do that and participate in the sports.
Now, we all know that being a couch potato can have serious health consequences. Well, physical activity does our bodies and brains a whole lot of good. We've heard that message over and over, and there's a reason we hear it over and over -- because it's true.
It's also an easy enough thing to say for those of us who are able-bodied, right? I mean, "Hey, we need to get outside and be more active." Just do it. Easy enough to do. But what about those who are challenged by physical and mental disabilities?
Well, physical activity and sport participation is good for everyone. It does the body and the brain good regardless of the overall condition of our bodies and our brains. It lessens the risk of obesity and heart disease and high blood pressure and type II diabetes and improves energy levels.
It can fend off depression. It gives us a sense of accomplishment and belonging. It can strengthen friendships. Lots and lots of good comes from physical activity and sports participation.
But those who are challenged with disabilities, they're going to need support and resources that able-bodied folks sort of take for granted as they strive for fitness and participation.
So that's the focus of our episode today as we consider athletes with disabilities and the medical professionals who support them. That help often comes in the form of an adaptive sports medicine program.
We have one such program here at Nationwide Children's and a couple of our experts from that program will be joining us shortly including sports medicine physician, Dr. Jonathan Napolitano, and certified athletic trainer, Ashley Davidson.
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Let's take a quick break. We'll get our guests settled into the studio and then return to talk about athletes with disabilities and adaptive sports medicine. That's coming up right after this.
Dr. Mike Patrick: Dr. Jonathan Napolitano is a sport medicine physician at Nationwide Children's Hospital and an assistant professor of Pediatrics and Physical Medicine Rehab at the Ohio State University College of Medicine. He serves as director of our Adaptive Sports Medicine Program, which supports athletes and others with disabilities as they strive for fitness and overcome the hurdles of sports participation.
Ashley Davidson is also in the studio. She is a certified athletic trainer at Nationwide Children's and also supports young athletes challenged by disabilities. Thank you both so much for visiting us today.
Dr. Jonathan Napolitano: Thanks for having us.
Ashley Davidson: Thank you.
Dr. Mike Patrick: Yeah. I really appreciate you taking time out of your busy schedules to join us.
So, Dr. Jonathan, let's start with you. What exactly is adaptive sports medicine. I know this is something that when you first told me about it, I hadn't really heard of this. We certainly want to raise awareness. Tell us what it is and why is it important.
Dr. Jonathan Napolitano: Yeah, really great question. You're not alone in what is adaptive sports medicine. It's a unique specialty that really focuses on the prevention, evaluation, and treatment of injuries and athletes who are participating with some form of physical disability. That participation can be with or without modifications, meaning in an adaptive sport.
Those modifications can be something in changing the sports as a whole -- for example, participating in a wheelchair versus on your feet -- or a modification to the equipment that you're using. For example, Ashley and I have a friend who is professional race car driver competes against able-bodied race car drivers, uses modifications within his car, so on a level plain field.
What those modifications can be really differs from the sport and then when you get up to the Paralympic level, there's a classification skill that allows everyone to compete on the same level playing field.
That adaptive sports medicine specialty requires really a unique background to have an understanding of someone's underlying disability as well as their functional abilities, but really keeping the focus on the injury and the return to play, not being overwhelmed by what that background is.
So for me, my background is as you mentioned, I'm an assistant professor of Physical Medicine and Rehabilitation where I was treating in the hospital patients with new spinal cord injuries, stroke, limb loss and getting them back to normal life.
Followed that training with sports medicine fellowship here at Nationwide Children's where I focus on return-to-play programs and body biomechanics. So combining that has given me a unique perspective. Ashley as a similar background where starting as an athletic trainer but some unique experiences in spinal cord injury program as well.
Dr. Mike Patrick: And I think it's so important to realize how those two things come together because there's so much emphasis placed on the adaptation that's going to help them do their sports and kind of put them at a level playing field, as you say. But then there's still all the other stuff of conditioning and injury prevention. And then, when there are injuries, treating those and rehabilitation and just like any other athletes, sort of keeping them in top-notch performance.
Dr. Jonathan Napolitano: That's correct.
Dr. Mike Patrick: Exercise and sports, of course, is important for everyone including those with disabilities. There are 53 million adults in the United States with a disability and only 53% of them report at least one 10-minute bout of aerobic activity per week compared to 74% of able-bodied adults. And that's a real health challenge for these folks.
Ashley, just remind us, what are some of the benefits of physical activity and participation on organized sports that we may take for granted but it's really important for these folks who are challenged by movement?
Ashley Davidson: Right. And it's very important obviously for everybody with physical activity but especially those that might have a little bit more barriers to that to be able to stay more active in an evolved program, but there's obviously the physical health, as well as emotional and social benefits of it.
So with physical health, obviously, it's going to help increase cardio pulmonary fitness, cardiac and skeleton muscle endurance, strength, flexibility. And then also, just like everybody else, decrease obesity, heart disease, stroke, type II diabetes.
But then also, more importantly, sometimes, it's going to help with those emotional and social benefits. So less depression, feeling they're more involved with their peers, higher self-esteem, higher self-worth, more independent as well when they feel like they're able to do more and get that strength to be able to be more involved. And then social, like I said with inclusion of peers and just having more those relationships with abled bodies, as well as those with their similar abilities as well.
Dr. Mike Patrick: And there's not only the barrier of the specific disability that folks have but there are other barriers then that kind of go along with that disability, things like low energy. They may have weight gain because they've not been as active as others in the past. What are some of those things and how do you overcome sort of beyond just the disability?
Ashley Davidson: Correct. You touched on a few of those, but depending on what it is that their disabilities are, a lot of times they're dealing with a lot of chronic pain, either depending on if they're in on those wheelchairs and have some type of amputee, with different type of that they're having to use for support. But also because they do rely on either overuse of those arms.
Sometimes, they're threatened by maybe more injury to them, so that might be a barrier. They're just nervous to get more involved because of what that possible risk is with that.
Sometimes, just the expertise of the staff around them to help them become more physically active and give them that type of support that they need to be able to be more active and some type of things that they're interested in trying.
There sometimes lack of accessible environments. So depending on where they live, they might not always have that close surrounding resource to go to see what it is that they're able to become more involved in.
It could be lack of transportation. They don't have those means to get there quickly, easily on a more consistent basis or sometimes they just have that type of worry. Or it could also be just like with a lot of other people, financial cost and the time to be able to get out and do those type of things.
Dr. Mike Patrick: And this is something, again, that so many of us take for granted. And think about all those different little barriers, and it really takes a village to help. And it's not just the sports medicine people, but family members and other people who are competing in the same sport, and coaches and athletic trainers. It just takes so many people really to help remove those barriers, right?
Ashley Davidson: Correct, yeah.
Dr. Jonathan Napolitano: The community, as well. Dr. Mike, you had mentioned, what is adaptive sports medicine? It's important for us to continue to promote this that these options are available. When Nationwide Children's started our program, we looked to the community and many of these programs were already in place.
This year marked the sixth, I believe sixth year that Ohio High School Athletic Association has had a seated division for wheelchair sports. And so, there is more and more commonality and more and more accessibility of these opportunities. This is just another great opportunity, being on PediaCast, to share those opportunities.
Dr. Mike Patrick: I wanted to focus in particular just on obesity because we hear so much that there is a population issue with obesity. There's just so high of prevalence and can affect health in so many ways. Just kind of touch upon, Dr. Jonathan, what is obesity? What things go along with it and how big of a problem is this with those disabilities?
Dr. Jonathan Napolitano: Certainly. We see obesity as a problem across our children, regardless of their functional abilities or disabilities. But this becomes an even more important issue in those with mobility limitations. If you think about the added weight of being able to transfer back and forth, the added weight of using a wheelchair, the added weight of what that place is on your own body, as well as that of your caregivers.
And that's just functionally. When we look at the medical challenges of obesity, we look at the dyslipidemia or cholesterol challenges, those with sugar modifications or management and diabetes. And so it leads to a whole host of health problems as well.
It wasn't long ago than when we talk about neurologic injuries like spinal cord injury, that the number one causes of death where wound care, infections, kidney problems or pneumonia. Those things related to their disability. As medical care has advanced, that's all under control. And, really, the causes of death in this community as that the same of that of the able-bodied population where heart disease, stroke, and cancer is the most important.
Therefore, promoting that activity to combat obesity is really important. You mentioned the statistics about only 53% of patients with disabilities get some form about 10 minutes of physical activity in the whole week. The American Academy of Pediatrics recommends 60 minutes a day for kids. We're not meeting that in our able-bodied kids but we're certainly not meeting that in the disabled population.
Dr. Mike Patrick: And so such a big problem and by increasing awareness and just trying to provide opportunities for folks with disabilities to have more activity and be active and encourage that and participate with them is just so important.
Walk us through the history of the Paralympic Movement and tell us how popular that is today. I found it fascinating. I'm kind of history buff and so looking at the history of this was pretty interesting.
Dr. Jonathan Napolitano: It really is neat. We see it now, right? It's commonplace now. When we're watching TV, we see commercials and advertisements and all that for the Paralympic Movement. But it's not new. It's been there and it's just been growing and recently gathering a lot of traction.
Really, the first thoughts of competitive competition in this population is back after World War II when there were veterans games. Started in 1948 in England bringing all of those soldiers who had limb loss, spinal cord injuries, other injuries that were acquired in the war and yet these soldiers all had that competitive nature and wanted to compete in sports.
So, those initial games in 1948 was the start of that. It has since grown. The first official inaugural Paralympic competition was in 1960 in Rome. The first Winter Olympics were in 1976 in Toronto. But up until that point, it was a whole separate bid to bid on the Paralympics. It wasn't the same year as the Olympics. It wasn't the same location. And so that wasn't as structured as what where we are today.
So it wasn't until 1988 with the Seoul, Korea Olympics that bid was a combined bid and Korea won the award to have both the Paralympics and the Olympics following that same year and it has continued to grow from that.
The initial Paralympic Games in Rome in 1960, 400 athletes from 23 different countries. And then, recently here, Rio was our last Summer Games. We had 159 different nations participating with over 4,000 athletes, 22 different sports. The PyeongChang Winter Olympics here, the most important thing that we've found about that was NBC Sports provided 96 hours of televised coverage. So that's where it is popularity and this interest has continued to grown. We see it year-round, not just every four years now.
Dr. Mike Patrick: And in 2020, the Tokyo Games, they're going to be right there alongside, same venues and all that again, next year. So that will be an exciting thing to watch.
What sporting events then, Ashley, do these athletes general compete in? What do those look like?
Ashley Davidson: I think what Dr. Napolitano was saying with how it's great, how much publicized it is now, so you can realize the vast majority of what all these athletes are able to compete in.
A lot of times, maybe we thought before it's a lot wheelchair-based but it's a lot of different impairments. So they have a lot of abilities to be able to go down and try different events. A big one is football 5-a-side. So that's actually with vision impairment where they're wearing blindfolds and the ball has a bell in it. So they're kind of working along that with soccer-related type activities.
There's also something called goal ball where they're sitting on the ground and they're just going for that ball, same type of thing, vision impairment. There's the basic ones like the wheelchair basketball, rugby, tennis. They're swimming, so a lot of upper body impairment as well as different level of lower body.
There's athletics which is the track and field. It can be like regarding wheelchair-based, as well as those of amputees. There's a lot of different availability to be able to go out and compete. There's rowing, so that could be whether they're using lower body versus upper body.
Like I said, they have done a great job as far as making different modifications to allow these individuals to compete and be very successful in this sporting events to stay active and all that.
Dr. Mike Patrick: And even in the winter games, alpine skiing, snowboarding, cross-country skiing, wheelchair curling, and ice sledge hockey. What is ice sledge hockey?
Ashley Davidson: That's actually great because we have a local ice sled hockey that we do a lot of events with. So to really get the kids in that sled and they have different type of sport with those key sticks and they're able to, it's amazing. I think that Dr. Napolitano went out and did a little competition with different local sled hockey around here just competing. But yeah, they're in their sleds. They're just agile ability to move around the ice and have fun.
Dr. Mike Patrick: That sounds like fun.
Ashley Davidson: Yeah, it's great.
Dr. Mike Patrick: What then is the role of adaptive sports medicine in supporting these athletes? What does it look like on a daily basis? What sort of things are you doing with them?
Ashley Davidson: We're here to provide resource. Because, like I said, there's a lot of different community partnerships around that provide this type of services, but a lot of times these individual athletes aren't aware of this.
So we're trying to share this information with them, trying to mentor them and encourage them to participate in this type of activities to increase that physical activity, just the wellness of them as individual in itself and then assist with education. And providing those resources and getting them connected, and then being then a resource too. If they do become injured. to keep them active in those type of environment as well.
Dr. Mike Patrick: And…
Dr. Jonathan Napolitano: I'm sorry. There's a certain amount of conditioning with that, too. When I see somebody in clinic who is interested in participating in a new sport, I will send them to Ashley, our functional rehab program or physical therapy program to start training the body in those unique different skills from the body standpoint. Again, I mentioned Ohio High School Seated Division, so that there's not a classification there.
I have people who will compete at that level who are normally ambulatory and has never used a wheelchair before. However, their functional impairment limits their ability to do that. Developing their shoulder strength to use a chair appropriately is part of that transition in that training that we can provide as well.
Dr. Mike Patrick: Because just like anyone else, muscles that you haven't used in a while or you're using in a different way than you have before is going to put a lot of strain on them and you can see a lot of soft tissue, muscular skeletal kind of injuries with that. Speaking of injuries, Ashley, what are some of the most common injuries that you see in these folks?
Ashley Davidson: A lot of injuries are similar to our able-bodied but it just depending on overuse base-type stuff because they are going to use a lot of those upper body muscles movements as compared to able-bodied. But it's just a difference in the pattern. Like I said, a lot of the upper extremity is greater than lower extremity-based injuries.
And you can also see a lot of more trauma. So, wheelchair rugby, you're going to see a lot more bruising, broken bone just because that has such much, much more impact for that type of sport.
Within the shoulder itself, there's a lot of more imbalances due to that poor posture, the positioning fit technique that they're in those provided wheelchairs for the sports. A lot of times what we're looking for is just to help them improve that posterior type work because they are constantly in that anterior movement, just surrounded posterior type. So just trying to help improve that.
Because they are doing a lot much more of that propulsion move if they are in that wheelchair, you're going to see a lot more rotator cuff because it's a lot of overuse or different type of tendinopathies as well.
So obviously, with those pushing type movements, so using a lot more of those biceps, you're going to see that a little bit more in that area. And then, different issues with the wrist because they're using a lot of that to either help balance depending on they have different lost strands or just different things that they might need to assist them to become more able with that.
You're also going to see some type of impingements or bursitis through the acromial, just different areas in the shoulder. Elbow-type injuries where you can also have like peripheral nerve stuff with carpal tunnel and different other nerve and tracts types of things.
Dr. Mike Patrick: Lots of opportunity for injury and sprains and strains and deep broken bones. Dr. Jonathan, what are some special consideration for those with spinal cord injuries?
Dr. Jonathan Napolitano: It's a unique population that just like each of these different groups has a wide variety of what ability and limitations there are. And so, the most important thing when looking at spinal cord injury is determining that level of impairment, and that's determined through that spinal cord level. Your physician at the time of your injury will help you figure that out. And what that gives us information and it's not only what are your functional abilities with your muscle control and strength, but also what are your physiologic limitations.
So depending on where that level is in the spine that there are physiologic changes. For example, you may not be able to attain a maximum level of heart rate with exertion as I may be able to when running. For example, like your heart rate will max out at only 80 beats per minute, whereas I'm up to 160 or 180 while I'm running.
Other things that are different in this group physiologically is temperature regulation. So someone who is not able to feel sensation may have additional challenges of staying cool when they're out at a track and field meet and those need to be incorporated as well.
And finally, the most important in the spinal cord injury group is really the physiologic response to pain. If I stab my toe, I can appreciate that as toe pain and my body treat it as such. However, if that sensation is impaired below there, whether it's pain, whether it's a sore, whether it's an injury, the body does not interpret that in the same way that you and I do.
And therefore, it has a unique pain response that can really be life threatening, where the heart rate is affected, the blood pressure can shoot sky high. And that put you at risk of stroke, visual challenges. So it's really important to be aware of changes and sensation and changes in physiologic concerns.
Dr. Mike Patrick: And this is something where I think education then must be really important for family members who maybe at sporting events, certainly for coaches, the athletic trainers that are working with these people. Talk about a little bit about how you educate families about this.
Dr. Jonathan Napolitano: Certainly. Because it is so serious, education is key. It's important to acknowledge the fact that we are promoting activity and inclusion while also understanding the limitations and what to look out for.
While this response is unique, going back to the stubbed toe injury, it's not what you or I feel. However, it is a unique sensation for that individual. And while it's difficult to appreciate everything and to diagnose yourself as to what's going on, when you're feeling different and you're feeling unique and something's changed, it's important that you stop what you're doing. And that you can present to your physician if those things are continued to be noticed or those things persist because they can be an emergent situation.
Dr. Mike Patrick: And then, when they do have that sensation and they stop what they're doing, does that then immediately correct the problem? Or is there more that needs done to intervene?
Dr. Jonathan Napolitano: Really great question because it's a huge spectrum. Autonomic dysreflexia, as it's called, can be anything from a simple as a stubbed toe to it can be an appendicitis. So it can be a chronic insulting event that you're having a pain response to that needs to be worked up and differentiated by a physician.
Typically, what we look at on the field or in participation as the first things that are done, it's loosening restrictive clothing, inspecting the skin for any skin changes or lesions, looking for evidence of a broken bone or things like that. Because then, yes, if we remove that insulting event, then those physiologic responses improve immediately. However, if we're continuing to look for what that is, that can persist and that's where we get into medical trouble.
Dr. Mike Patrick: We talk about spinal cord injuries. What about those who have lost limbs? I'm sure that's also a large number of folks that you see.
Dr. Jonathan Napolitano: Certainly. And again, back to the classification level and back to my biggest point about those spinal cord injury, again, the most important thing when we're looking at limb loss is the level of that limb loss. Because depending on where that level is not only discusses and promotes certain functional abilities but it also challenges you as far as what that response to training can be.
For example, someone with a baloney amputation with advances and technology has pretty similar energy expenditure and similar speed when running to someone with full two legs. And so, that's really unique where someone with a higher level above knee or hip level injury has a significant energy expenditure impairment. So, being aware of where that level is and timing up what your limitations can be.
The most important thing when we look at the limb loss community though is the same things that we're seeing in our able-bodied community. When Ashley is treating our able-bodied athletes in our rehab program, the biggest thing that she's seen are loss of range emotion and flexibility, as well as trauma or pressure from time of sports.
When you're using a prosthesis, it's important that you have full range emotion and flexibility at your hip and at your hamstrings to promote that full gait cycle. But then, it's also important to inspect your skin because just as a marathon runner is at risk of blister and skin changes there, as is of prosthetic user.
Dr. Mike Patrick: And not only the site of the prosthesis but also, I mean, there's a lot of opportunity for mechanical rubbing friction that can cause ulcerations. And if you combine that especially in someone with the spinal cord injury that may not have sensation at that level, it may not know that they have skin injury. It's going to be really important to notice those, right?
Dr. Jonathan Napolitano: Uh-huh. The changes with skin, it's really a big overlap with sensation impairment and fit of the device that you're using whether it is a prosthesis, whether it is a track chair for wheelchair user because the fit and function of that will affect your competition but also your maximum function.
How much can you push if this fits appropriately? And if it fits poorly, you go down that pathway of pressure source. Pressure source in this population whether limb loss of spinal cord can be a huge problem. Whereas the marathon runner gets a blister on their toe, they can just change their footwear for a little bit of time.
This prosthetic user needs their prosthesis for functional mobility. A wheelchair user if they have a pressure sore is unable to continue to sit in that wheelchair. So we're talking about an impairment where we're now bedridden or off of our prosthesis or out of our chair for prolonged period of time while that insensate skin can heal or repairs.
So it's really important, education-wise, that we're discussing with athletes first of all, proper fit of their devices but then also inspection. Just because they can't feel the skin in that region, it's important that they're using either mirrors or assistance where a caregiver can help them, but constantly inspecting skin after activity to make sure that there's no overuse or extra friction and wear.
Dr. Mike Patrick: Other than making sure that things are fitting properly, are there other things that you can do to protect the skin that maybe able-bodied folks wouldn't need to think about?
Dr. Jonathan Napolitano: Yeah. So fit within those devices is really important. There are different types of modifications and pads that can be chair-specific or sport-specific to make sure that you have that added padding.
Some people use a barrier cream. I guess I wouldn't say avid but I'm a cyclist and using the barrier cream can prevent sores when spending a lot of time in the saddle, on a bike, and similar barrier cream can be helpful in these individuals, too.
Dr. Mike Patrick: Great. Ashley, folks may have heard of the Paralympic Movement have seen images of this alongside of the Olympics. But we've also heard about the Special Olympics. How do the Special Olympics differ from the Paralympic Movement?
Ashley Davidson: Great question. So with the Special Olympics, a little bit different just because they're designed more for children than adults with more intellectual disabilities. But they're still try to encompass the importance of promoting inclusion in that physical activity with those around them.
But a lot of times, these are the athletes, more have diagnosis of Down syndrome. There's Fragile X syndrome, autism, and then there's also a little bit more with as far as sometimes you'll see them with cerebral palsy, Apert syndrome.
Like I said, there's a lot of diagnosis within that but more focus on those with intellectual disabilities but they're still wanting to compete, stay active, and be more involved.
And with these, there's 5 million athletes from 172 countries with the Special Olympics as well. It's still a very growing important program for those staying active but just a little bit different as far as who is all involved in the Special Olympics.
Dr. Mike Patrick: And when you look at the local level and the national level, it's like over 100,000 events per year with the Special Olympics. There's really lots of opportunity for folks to get involved with this.
Ashley Davidson: Yeah, definitely. Like I said, it's great how everything is growing and booming. And just having that inclusion and the importance of getting these individuals because they're wanting to have that opportunity and they're just as competitive to be able to do that but just to give them that platform to be able to compete is what's so important.
Dr. Mike Patrick: Now, in addition to the yearly events, they also have something sort of like the Olympics with Summer Games and Winter Games. Tell us about those.
Dr. Jonathan Napolitano: Sure. There are a lot of local different programs through that where you're competing. Here in Central Ohio, Columbus City schools is affiliated with these special Olympics. and so they do local events here whether playing basketball. They're doing some track and field events. But then as that continues to grow, there is that platform for national participation and competition.
It is inclusion-based and the resources for that are incredible. The process to get from the local to the national level isn't as structured as that in the Paralympic community but there is that pathway to get there in that platform to show off your abilities and your accomplishments. And so, that's what's really most important is just that there is that inclusion to get there as well.
Dr. Mike Patrick: And Summer and Winter Games, too.
Dr. Jonathan Napolitano: Correct.
Dr. Mike Patrick: You talked about Down syndrome, folks, being one of the big participants in Special Olympics. What challenges do folks with Down syndrome face as they get active and participate?
Dr. Jonathan Napolitano: Down syndrome is a very common diagnosis that we see. It's approximately I think 1 in 800 newborns will be diagnosed with Down syndrome. The effect there is that we know a lot about that syndrome and the limitations that exist.
So most importantly there is well establishment with the primary care physician who can continue to monitor the host of comorbidities that are associated with Down syndrome.
Some of those challenges really we spoke earlier about obesity, when we look at those patients or those individuals with Down syndrome, anywhere between 23% and 70% of someone with Down syndrome will be obese, which is a significant reason again to promote physical activity.
But other challenges besides obesity are the impaired physiology as well. Up to a half of patients with Down syndrome will have some type of cardiac challenge, either structural or electrical. So it's important that they're established with the cardiologist to evaluate those things.
But there are also, when we think of more of my realm and Ashley's realm, the functional limitations, too. So patients with Down syndrome have a lot of hyper mobility in their joints that leads them at risk of dislocation. So our focus is more on structural stability, strengthening the muscles around the joint to limit that dislocation risk.
But then, the higher concern there is when dislocations can become even more severe so that instability can extend into the cervical spine as well. So instability or laxity within the ligaments of the neck can lead to catastrophic injuries. And therefore, it's important to continue to monitor for symptoms of changes in neurologic status.
What those things include is changes in sensation, changes in bile and bladder control, changes in strength through weakness. If there are changes that are noticed developing new or something that you had not seen prior, it's important that you get those evaluated and checked up by your primary care doctor to evaluate for participation. Especially in the high-risk sports which I consider in the Special Olympics consider gymnastics, equestrian, back strokes in swimming, butterfly strokes where you're putting a lot of stress on the cervical spine.
And so, to continue to make sure that you have that heath to participate. But even if you aren't cleared for that high-risk sport, you're still able and cleared to compete in track and field and basketball and stuff.
Dr. Mike Patrick: Just so folks can have a visual, you have seven vertebrae in your neck and the first one and the second one is in particular where there can be instability. And if those bone slip, then it can cause a problem with the spinal cord. And so that's something that we'd be very worried about.
Other than symptoms, is there screening that you do for these folks to make sure that they have stability? And is that an important thing to do? I actual was surprised to read that. It's a little controversial, right?
Dr. Jonathan Napolitano: Certainly is. Really good question because this has changed throughout time. Initially, when we look at the instability within that cervical spine or that upper level of the cervical spine, it was recommended to evaluate that instability with cervical spine X-rays. Then the question became, "Well, when do we repeat an X-ray?" and "How often do we do an X-ray?"
And so, initially, Special Olympic required all participants to have a cervical spine film on file. It did not require them to be repeated, just on file. That was initially endorsed by the American Academy of Pediatrics.
And then, we look for the research behind that as to why do we need to require that and they found that no one with asymptomatic instability went on to have a symptomatic cervical spine injury from sport participation.
And so, as you continue to follow that, we look at disqualification based on our radiographic finding at a point in time was not as helpful as the symptom reporting.
And so now, the American Academy of Pediatrics have removed their recommendations and endorsement for cervical spine films. However, it's still written in the Special Olympics dogma to continue to have something on file at least at a point in time.
Dr. Mike Patrick: Which then become something that could be a barrier to participation from someone who may not even have had a problem because they didn't have symptoms associated with it. Kind of like screening EKGs where if we do a screening EKG on everyone, we're going to keep some people from participating who really could participate. And so, they don't have that opportunity.
Dr. Jonathan Napolitano: Yeah, that's very important, and the inclusion is the most important part. At Nationwide Children's Hospital, with Columbus City Schools, we help them with their pre-participation physicals.
And our message there when we're bringing those athletes through is that we're promoting inclusion and understanding that it's not a cleared or not cleared but it can be cleared with restrictions. Someone who has symptoms or concerns of instability, we are clearing them for participation in running sports. However, not in the high-risk sports.
Dr. Mike Patrick: Ashley, let's say that I have a child with Down syndrome and they are interested in participating in Special Olympics. They could just call, make an appointment with sports medicine? Is that how you get in and see folks?
Ashley Davidson: As far as the pre-participation examination takes off? With the Down syndrome, like what Dr. Napolitano was saying, with the Columbus Schools, we set up a big overall. We try to bring them all in at once to be able to get all those type of physicals.
And then besides that, I believe it's more through like their primary care with getting their physicals prior too, but we try to at least give them that resources. So that they can all come through and have a specialized here with our physicians, here at Nationwide Children's Hospital, to be able to provide those service so that we can get them those resources or clear them with some of those type of activities that they can perform in a safe position.
Dr. Mike Patrick: And any of these families, whether we're talking about Down syndrome or folks with disabilities that are interested in participating in sports like the Paralympic Movement, those folks can get in touch with you guys fairly easily?
Ashley Davidson: Yeah. We're very excited about our new Adaptive Sports Medicine Program here at Nationwide Children's Hospital. So those families or individuals with those type of athletes or children that want to become more involved or just have questions, save resources, you can visit the Nationwide Children's Hospital website and then search for the Adaptive Sports Medicine Program. And that will kind of give you all the information as far as where those clinics are located, when they can be seen, the physicians.
Because Dr. Napolitano is the one who treats with those adaptive sports medicine if they're having injuries or having different difficulties, needing those evaluations, more imaging. Place proper referrals as far as if they need athletic training to give them those rehabilitation to get them back out to sports specific activities, whether it be PT or within our Play Strong program because we can get those.
Just give them those important resources. And when they come into the clinic, they're going to get a good check-in and healthy history involved by an athletic trainer and then a thorough physical examination by Dr. Napolitano. And like he said, any type of imaging that's necessary, resources that are important, just to keep them active and provide them with all those necessary information.
And then, what's also really important is sports nutrition as well because when they're creating more of this energy that they're using, they're going to need the right fuel to kind of build upon that just to keep them within the activity level.
Dr. Mike Patrick: Sometimes you don't know what you need until you visited an expert and they say, "Hey, why don't you see these folks and these folks." And then, suddenly, things are much more improved and you didn't even know they could be, right?
Dr. Jonathan Napolitano: That's right.
Dr. Mike Patrick: It's great having all those resources available to us here at Nationwide Children's.
You mentioned the adaptive sports medicine program webpage and we'll put a link to that in the Show Notes for this Episode 434 over at pediacast.org. We'll also have links to the International Paralympic Committee if you'd like to learn more about those programs, also the Special Olympics website.
And then we have a couple of blogposts that Dr. Napolitano had written. One is Shoulder Pain and Injury in the Adaptive Athlete. Another, The Importance of Activity for Kids with Physical Disabilities. Those are great things to read and to share with your online audience that each of you haven in our audience.
Also, Dr. Jonathan, just tell us about Sports Medicine in general at Nationwide Children's. What other services do you folks offer?
Dr. Jonathan Napolitano: It's growing and growing. We have now nine different physicians and we go across the city providing resources and access for patients.
We see patients all the way from the age of 5 through 25, so we're seeing young adults as well. And our access is for those who are injured, whether it's playing sports, whether it's at band camp at summer. And we're looking at primary focus to return to play.
In addition to our musculoskeletal clinics, we also have sports related concussion clinics. So those who are looking at getting back into sports but who have had suffered a head injury, there's a certain program in place for that. But our access really is widespread throughout the city and we look forward to seeing all of your kids.
Dr. Mike Patrick: Great, great. Well, we really appreciate both of you stopping by the studio today and telling us all the Adaptive Sports Medicine Program. Dr. Jonathan Napolitano, physician with Sports Medicine, and Ashley Davidson, certified athletic trainer, also at Sports Medicine, thank you so much to both of you for being here today.
Dr. Jonathan Napolitano: Thanks for the time. I appreciate it.
Ashley Davidson: Thank you for having us.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Thanks once again to our guests, Dr. Jonathan Napolitano with Sports Medicine and Ashley Davidson, certified athletic trainer also here at Nationwide Children's Hospital.
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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.