Sports injuries at the Rio de Janeiro 2016 Summer Paralympic Games: use of diagnostic imaging services.

OBJECTIVE: To describe the occurrence of imaging-depicted sports-related injuries (bone, muscle, tendon, and ligament injuries) during the Rio 2016 Summer Paralympic Games. METHODS: Descriptive data on all imaging examinations by using radiography, ultrasonography (US), and MRI were collected and retrospectively analyzed centrally by five musculoskeletal radiologists according to imaging modality, country of origin of the athletes, type of sport, type of disability, and type and location of injury. RESULTS: We report 109 injuries in 4378 athletes. A total of 382 radiologic examinations were performed in 261 athletes, including 118 (31%) radiographic, 22 (6%) US, and 242 (63%) MRI examinations. Para athletes from Africa had the highest utilization rate (20.1%, 67 out of 333). Athletes from Europe underwent the most examinations with 29 radiographic, 12 US, and 66 MRI examinations. The highest utilization rate of imaging modalities by sport was among Judo para athletes (16.7%, 22 out of 132). Most injuries were reported in athletics discipline (37.6%, 41 out of 109). Most injuries were also reported among para athletes with visual impairment (40 injuries, 36.7% of all injuries). Bone stress injuries were most common among para athletes with visual impairment (6 out of 7). Para athletes with visual impairment were also more prone to bone stress injuries than traumatic fractures, unlike para athletes with neurologic and musculoskeletal impairments. CONCLUSIONS: Imaging was used in 6.0% of para athletes. MRI comprised 63% of imaging utilization. Identification of patterns of injuries may help building future prevention programs in elite para athletes. KEY POINTS: • The highest imaging utilization rates were found among para athletes competing in Judo, sitting volleyball, powerlifting, and football. • Utilization of diagnostic imaging at the Rio 2016 Paralympic Games demonstrated similar trends to what was observed at the Rio 2016 Olympic Games. • Comparison of the rate of imaging-depicted injuries between Olympic and Paralympic athletes is limited due to inherent differences between the two athlete populations and the manner in which injury risk in the Paralympic athlete varies dependent on impairment type, which is not the case for the Olympic athlete.

Low energy availability, menstrual dysfunction, and impaired bone health: A survey of elite para athletes.

INTRODUCTION: The Female Athlete Triad (Triad) is a syndrome describing three interrelated conditions: low energy availability (LEA), menstrual dysfunction, and low bone mineral density (BMD). Relative Energy Deficiency in Sport (RED-S) expands the Triad to include multiple physiologic consequences of LEA in both sexes. The purpose of this study is to determine the prevalence of factors associated with the Triad/RED-S in an elite para athlete population. METHODS: Athletes were U.S. elite para athletes training to qualify for the 2016 or the 2018 Paralympic Games. Participants completed an online questionnaire characterizing nutrition, menstrual status (in females), bone health, and awareness of the Triad/RED-S. RESULTS: The athletes were 260 elite para athletes (150 male, 110 female). While few reported prior eating disorder (3.1%), 32.4% had elevated Eating Disorder Examination Questionnaire (EDE-Q) pathologic behavior subscale scores. Most athletes (95 male, 65 female) were attempting to change their body composition or weight to improve performance. Forty-four percent of premenopausal females had oligomenorrhea/amenorrhea. Bone stress injury was reported in 9.2% of athletes; of these, 54.5% (n = 12) had low BMD. Less than 10% of athletes reported awareness of the Triad/RED-S. CONCLUSIONS: Factors associated with the Triad/RED-S are present in an elite para athlete population, regardless of sex or sport type. Awareness of the Triad/RED-S in para athletes is low. The consequences of LEA in para athlete populations are poorly understood. However, the high prevalence of factors observed suggests value in advancing screening tools and education efforts to optimize health in this population.

Pain Management in Athletes With Impairment: A Narrative Review of Management Strategies.

OBJECTIVE: To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population. DATA SOURCES: A comprehensive literature search was performed linking pain with terms related to different impairment types. MAIN RESULTS: There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete. CONCLUSIONS: It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.

Prescribing Exercise to Individuals with Disabilities: What Are the Concerns?

It is well known that individuals with disabilities, constituting 15% to 20% of the adult population, experience a disproportionate risk of cardiometabolic disease and are more likely to live sedentary lifestyles when compared with their able-bodied peers. Although many complex factors likely lead to these disparities, targeted exercise programs can be influential in improving the health outcomes of this population. Additionally, it is important to keep several factors in mind when tailoring the exercise prescription for individuals with varied types of disability, given unique factors related to medical history, mobility, and community barriers. By safely engaging individuals with disabilities in exercise programs, clinicians can promote inclusion while making a significant contribution to health outcomes, ensuring that the principles of "Exercise is Medicine" are accessible to individuals of all abilities.

Diversity, Equity, and Inclusion Curriculum Embedded in a Physical Medicine and Rehabilitation Residency Program.

ABSTRACT: Diversity, equity, and inclusion initiatives are continuing to have increased importance in medical training, including rehabilitation medicine. Although resident-led curricula have been integrated into medical education in other training programs, to our knowledge, this the first report focusing on integrating these topics into resident education for a physical medicine and rehabilitation program. We created a didactic curriculum for our rehabilitation residents that included: quarterly lectures on diversity, equity, and inclusion topics followed by small group discussions. Each session also included an article that was included in the discussion. The sessions used both anonymous presurvey and postsurvey data to assess the efficacy of our initiative. Our initial data showed that our quarterly sessions created a safe and comfortable environment for discussing diversity, equity, and inclusion topics. In addition, our session specific data supported that increased awareness of diversity, equity, and inclusion disparities with rehabilitation and medicine was achieved. Our committee used the data and feedback to create further iterations of this initiative within our program, and we believe that this is a model that can be adopted by other physical medicine and rehabilitation residencies.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023.

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Testing for boosting at the Paralympic games: policies, results and future directions.

BACKGROUND: 'Boosting' is defined as the intentional induction of autonomic dysreflexia (AD) by athletes with a spinal cord injury (SCI) at or above the level of T6 for the purpose of improving sports performance. Boosting has been shown to confer up to a 9.7% improvement in race time. Additionally, to compete in a hazardous dysreflexic state, whether intentional or unintentional, would present an extreme health risk to the athlete. For these reasons, the International Paralympic Committee strictly bans the practice of boosting, and has developed a protocol to test for its presence. METHODS: Testing was performed at three major international Paralympic events. Education regarding the dangers of AD was provided to athletes and team staff. Testing was conducted on athletes from the relevant sport classes: Athletics (wheelchair racing classes T51/T52/T53) and Handcycling (H1). Key parameters included the athlete's demographics (gender, country of origin), classification and blood pressure measurements. An extremely elevated blood pressure was considered to be a proxy maker for AD, and a systolic blood pressure of ≥180 mm Hg was considered a positive test. RESULTS: A total of 78 tests for the presence of AD were performed during the three games combined. No athlete tested positive. The number of athletes tested, by classification, was: 6 in Athletics T51, 47 in Athletics T52, 9 in Athletics T53 and 16 in Handcycling H1. Of those tested, the average systolic and diastolic blood pressures were 135 mm Hg (range 98-178) and 82 mm Hg (range 44-112), respectively. All athletes were compliant with testing. No athletes were withdrawn from competition due to the presence of AD. DISCUSSION: Testing for the presence of AD in paralympic athletes with SCI prior to competition has been carried out for the first time at three major international paralympic competitions. There have been no positive tests thus far. Knowledge gained during these early testing experiences will be used to guide ongoing refinement of the testing protocol and the development of further educational initiatives.

The epidemiology of injuries at the London 2012 Paralympic Games.

BACKGROUND: The characteristics and incidence of injuries at the Summer Paralympic Games have not previously been reported. A better understanding of injuries improves the medical care of athletes and informs future injury prevention strategies. OBJECTIVE: The objective of this prospective cohort study was to characterise the incidence and nature of injuries during the London 2012 Summer Paralympic Games. METHODS: Injury information was obtained from two databases. One database was populated from medical encounter forms completed by providers at the time of assessment in one of the medical stations operated by the Organising Committee. The second database was populated daily with information provided by team medical personnel who completed a comprehensive, web-based injury survey. RESULTS: The overall injury incidence rate was 12.7 injuries/1000 athlete-days. Injury rates were similar in male and female athletes. The precompetition injury rates in women were higher than those in the competition period. Higher injury rates were found in older athletes and certain sports such as football 5-a-side (22.4 injuries/1000 athlete-days). Overall, 51.5% of injuries were new onset acute traumatic injuries. The most commonly injured region (percentage of all injuries) was the shoulder (17.7%), followed by the wrist/hand (11.4%), elbow (8.8%) and knee (7.9%). CONCLUSIONS: This is the largest and most comprehensive epidemiological report examining injuries in Paralympic athletes. Injury rates differ according to age and sport. Upper limb injuries are common. The knowledge gained from this study will inform future injury surveillance studies and the development of prevention strategies in Paralympic sport. The Epidemiology of Injuries at the London 2012 Paralympic Games.

Factors associated with illness in athletes participating in the London 2012 Paralympic Games: a prospective cohort study involving 49,910 athlete-days.

BACKGROUND: The incidence and factors associated with illness in Paralympic athletes have not been documented. AIM: To determine the factors associated with illness in athletes participating in the London 2012 Paralympic Games. METHODS: A cohort of 3565 athletes from 160 of the 164 participating countries in the London 2012 Paralympic Games were followed over a 14-day period (precompetition period=3 days, competition period=11 days; 49 910 athlete-days). Daily illness data were obtained from (1) teams with their own medical support who completed a daily illness log (78 teams, 3329 athletes) on a novel web-based system and (2) teams without their own medical support through the local organising committee database (82 teams, 236 athletes). Illness information from all athletes included age, gender, type of sport and the main system affected. MAIN OUTCOME MEASUREMENT: Incidence rate (IR) of illness (illness per 1000 athlete-days) and factors associated with IR (time period, gender, age and sport). RESULTS: The IR of illness was 13.2 (95% CI 12.2 to 14.2). The highest IR of illness was in the respiratory system, followed by the skin, digestive, nervous and genitourinary systems. The IR in the precompetition period was similar to that in the competition period, but the IR was significantly higher in athletics compared with other sports. Age and gender were not independent predictors of illness. CONCLUSIONS: Illness is common in Paralympic athletes and the main factor associated with higher IR of illness was the type of sport (athletics).

Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff.

BACKGROUND: In this study we describe (1) the implementation of a novel web-based injury and illness surveillance system (WEB-IISS) for use by a team of physicians at multisport events and (2) the incidence and characteristics of injuries and illness in athletes during the London 2012 Paralympic Games. METHODS: Overall, 3565 athletes from 160 of the 164 participating countries were followed daily over a 14-day period, consisting of a precompetition period (3 days), and a competition period (11 days) (49 910 athlete-days). Daily injury and illness data were obtained from teams with their own medical support (78 teams, 3329 athletes) via the WEB-IISS, and without their own medical support through the London Organising Committee of the Olympic Games and Paralympic Games database (82 teams and 236 athletes). RESULTS: There were no differences between incidence rates (IR) of injury and illness, or between the precompetition and competition periods. The IR of injury during the competition period was 12.1/1000 athlete-days, with an incidence proportion (IP) of 11.6% (95% CI 11.0% to 13.3%). Upper limb injuries (35%), particularly of the shoulder (17%) were most common. The IR of illness during the competition period was 12.8/1000 athlete-days (95% CI 12.18 to 1421), with an IP of 10.2%. The IP was highest in the respiratory system (27.4%), skin (18.3%) and the gastrointestinal (14.5%) systems. CONCLUSIONS: During the competition period, the IR and IP of illness and injury at the Games were similar and comparable to the observed rates in other elite competitions. In Paralympic athletes, the IP of upper limb injuries is higher than that of lower limb injuries and non-respiratory illnesses are more common.

Challenges and Opportunities in Academic Physiatry: An Environmental Scan.

ABSTRACT: Environmental scans determine trends in an organization's or field's internal and external environment. The results can help shape goals, inform strategic decision making, and direct future actions. The Association of Academic Physiatrists convened a strategic planning group in 2020, composed of physiatrists representing a diversity of professional roles, career stages, race and ethnicity, gender, disability status, and geographic areas of practice. This strategic planning group performed an environmental scan to assess the forces, trends, challenges, and opportunities affecting both the Association of Academic Physiatrists and the entire field of academic physiatry (also known as physical medicine and rehabilitation, physical and rehabilitation medicine, and rehabilitation medicine). This article presents aspects of the environmental scan thought to be most pertinent to the field of academic physiatry organized within the following five themes: (1) Macro/Societal Trends, (2) Technological Advancements, (3) Diversity and Global Outreach, (4) Economy, and (5) Education/Learning Environment. The challenges and opportunities presented here can provide a roadmap for the field to thrive within the complex and evolving healthcare systems in the United States and globally.

Global Alliance for the Promotion of Physical Activity: the Hamburg Declaration.

Non-communicable diseases (NCDs), including coronary heart disease, stroke, hypertension, type 2 diabetes, dementia, depression and cancers, are on the rise worldwide and are often associated with a lack of physical activity (PA). Globally, the levels of PA among individuals are below WHO recommendations. A lack of PA can increase morbidity and mortality, worsen the quality of life and increase the economic burden on individuals and society. In response to this trend, numerous organisations came together under one umbrella in Hamburg, Germany, in April 2021 and signed the 'Hamburg Declaration'. This represented an international commitment to take all necessary actions to increase PA and improve the health of individuals to entire communities. Individuals and organisations are working together as the 'Global Alliance for the Promotion of Physical Activity' to drive long-term individual and population-wide behaviour change by collaborating with all stakeholders in the community: active hospitals, physical activity specialists, community services and healthcare providers, all achieving sustainable health goals for their patients/clients. The 'Hamburg Declaration' calls on national and international policymakers to take concrete action to promote daily PA and exercise at a population level and in healthcare settings.

Patterns of Athlete Medication Use at the 2018 PyeongChang Paralympic Games: A Descriptive Cohort Study.

OBJECTIVE: Medication use among elite athletes has received growing attention over the past decades. However, only limited studies have focused on para athletes, and trends in medication use among this cohort remain unclear. The aims of this study were (1) to describe the pattern of medication use in elite Paralympic athletes, with a particular focus on analgesics, (2) to analyze whether medications declared by athletes were included in the 2018 World Anti-Doping Agency's prohibited list and monitoring program, (3) to report on a variety of novel supplements, and (4) to review whether athlete analgesic needs will be met by the new Olympic & Paralympic Model Formulary. DESIGN: This is a retrospective, descriptive cohort study. RESULTS: Of all athletes who underwent doping control, 21% declared the use of an analgesic medication. Athletes with limb deficiency and para snowboarders declared the most analgesic medications in their respective categories. It was determined that 84% of the athletes' analgesic medication needs were provided from the new Olympic & Paralympic Model Formulary. CONCLUSIONS: Analgesic use among athletes who participated at the 2018 PyeongChang Winter Paralympics was high. Para snowboarders and athletes with limb deficiency declared the most analgesics. The new Olympic & Paralympic Model Formulary adequately addressed the medication needs of the athletes attending the 2018 games.

Shoulder Pain, Function, and Ultrasound-Determined Structure in Elite Wheelchair-Using Para Athletes: An Observational Study.

PURPOSE: This study aimed to determine the relationship between shoulder pain, physical examination, and tissue pathology in manual wheelchair users competing in elite sport. METHODS: Eighty elite para athletes who used a manual wheelchair for daily mobility were recruited from international track (n = 40), field (n = 19), and powerlifting (n = 21) competitions. Athletes were surveyed regarding shoulder pain history and symptoms (Wheelchair User's Shoulder Pain Index (WUSPI)), whereas independent blind observers measured signs (Physical Examination of the Shoulder Scale (PESS)) and tissue pathology (Ultrasound Shoulder Pathology Rating Scale (USPRS)). Relationships between measures for the total cohort and for subgroups defined by sporting discipline were calculated. RESULTS: A large proportion of athletes reported a history of upper limb pain (39% dominant and 35% nondominant). For the total cohort, WUSPI score was 22.3 ± 26.9, PESS score was 7.4 ± 6.7, and USPRS score was 5.2 ± 4.0. There were no USPRS score differences between athlete subgroups; however, track athletes had lower WUSPI and PESS scores, especially compared with field athletes. The first principal component explained most of the variance in the WUSPI and PESS, which were strongly correlated (r = 0.71), and the second orthogonal component explained the USPRS, which did not correlate with either the PESS (r = 0.21) or WUSPI (r = 0.20). Subgroup analysis showed that track athletes had lower symptom scores for a given physical examination score. CONCLUSIONS: Elite para athletes who use manual wheelchairs for daily mobility have a high prevalence of shoulder symptoms, positive signs on physical examination, and ultrasound-determined tissue pathology. Ultrasound-determined tissue pathology does not correlate with symptoms or signs. This information can help to guide clinicians in managing shoulder problems in this athlete population at high risk of injury.

Telemedicine During COVID-19 for Outpatient Sports and Musculoskeletal Medicine Physicians.

INTRODUCTION: The global pandemic due to SARS-CoV-2 has resulted in an expansion of telemedicine. Measures of quality and barriers for rapid use by patients and physicians are not well described. OBJECTIVE: To describe results from a quality improvement initiative during a rapid adoptive phase of telemedicine during the pandemic. DESIGN: Patient and physician satisfaction with synchronous audiovisual telemedicine visits was measured during the early adoptive phase (6 April 2020-17 April 2020) within the division of sports medicine in an academic Physical Medicine and Rehabilitation (PM&R) department. Patients were invited to participate in a quality improvement initiative by completing an online survey at the end of a telemedicine visit. Physicians completed a separate survey. PRIMARY OUTCOME MEASURES: Patient measures included visit type, duration of encounter, quality, and satisfaction. Physicians reported on experiences performed telemedicine. RESULTS: Surveys were completed by 119 patients (293 telemedicine encounters, response rate 40.6%) and 14 physiatrists. Telemedicine was utilized primarily for follow-up visits (n = 74, 70.6%), and the most common duration was 15 to 29 minutes. Patients rated their telemedicine visit as "excellent" or "very good" across measures (91.6%-95.0%) including addressing concerns, communication, developing a treatment plan, convenience, and satisfaction. Value of completing a future telemedicine visit was measured at 84.9%. Most reported estimated travel time saved was in excess of 30 minutes. Rate of no-show was 2.7%. Most physicians (57.1%) had no prior experience with telemedicine visits, and most were comfortable performing these visits after completing 1 to 4 sessions (71%). Nearly all physicians (92.9%) rated their telemedicine experience as very good or excellent. The key barrier identified for telemedicine was technical issues. All physicians reported plans to perform telemedicine visits if reimbursement continues. CONCLUSIONS: In summary, rapid expansion of telemedicine during the COVID-19 pandemic was well-received by a majority of patients and physicians. This suggests feasibility in rapid expansion of telemedicine for other outpatient sports medicine practices.

More Than Just a Game: The Public Health Impact of Sport and Physical Activity for People With Disabilities (The 2017 DeLisa Lecture).

Although people with disabilities make up a large proportion of our global population and are known to be disproportionately impacted by sedentary lifestyles leading to chronic disease, programs promoting physical activity often fail to address their unique needs. Both environmental and attitudinal factors also act as barriers to full participation. In this context, increasing evidence shows the positive impact of physical activity and sport on outcomes related to physical health, mental health, community participation, and, in some cases, neurorecovery for people with disabilities. Thus, participation should be seen not only as a medical intervention but also as a rights-based issue. We, as physiatrists, can be agents of change by promoting concepts of universal design and inclusion in physical activity and sport programs.

Bone Health in Adaptive Sports Athletes.

Adaptive sports athletes represent a growing population within the athletic community worldwide. Given potential cardiometabolic and psychosocial benefits of adaptive sports participation, the impact on bone health and injury risk in adaptive athletes is of increasing clinical interest. Impaired bone health as a result of low energy availability has been well described in able-bodied athletic women and, more recently, men as part of the female athlete triad and Relative Energy Deficiency in Sport (RED-S). However, the applicability of these models to adaptive athletes remains unclear given altered physiology and biomechanics compared with able-bodied counterparts. Thus, a literature review was completed to characterize the influence of adaptive sports participation and associated risk factors for impaired bone health in this unique population. To date, limited investigations demonstrate a consistent, positive effect of sports participation on bone health. Risk factors for impaired bone health include low energy availability and micronutrient deficiency.

Prevalence and Anatomical Distribution of Bone Stress Injuries in the Elite Para Athlete.

Bone stress injury is a common overuse injury in athletes. Risk factors for bone stress injury in athletes include the female athlete triad (triad); this has not been evaluated in para athletes. The aim of this study was to identify risk factors, prevalence, and anatomical distribution of bone stress injury in para athletes. A cross-sectional online survey on health characteristics and previous fractures including bone stress injury was completed by para athletes training for the 2016 or 2018 Paralympic Games. Two hundred sixty para athletes completed the survey (659 invited, response rate = 40%). Half reported previous fracture, and bone stress injury was reported in 9.2% of all athletes. Twenty-four athletes (11 men and 13 women) sustained one or more bone stress injury, including 13 athletes with two bone stress injuries. No risk factors of the triad, disability type, or duration of disability were associated with bone stress injury. Injuries were most common in the metatarsals (n = 8) and hand/wrist (n = 7). In an elite para athlete population, locations for bone stress injury included both the upper and lower limbs. Clinically, para athletes presenting with pain localized to bone require further workup to evaluate for bone stress injury particularly for pain in both upper and lower limbs. Further research is required to identify risk factors for bone stress injury in para athletes.