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SPORTS MEDICINE DISABILITY SPORT
The use of urinary sheath drainage can protect the athlete from accidents that result in this reflex voiding. Complete lesions below T12 lead to
a lower motor neuron flaccid paralysis, as the reflex loop is interrupted by division of the nerves in the cauda equina, arising from the conus of the spine at this level. In this case, the bladder has no sensation and continues to fill and then overflow, causing dribbling incontinence and potentially backflow and damage to the kidneys. However, this can be reasonably managed by regular intermittent self-catheterisation. Bowel function follows a similar pattern to bladder function, with reflex bowel movement in upper spinal injury and flaccid paralysis in lower spinal lesions below T12. A strict routine is important in order to maintain bowel function; this routine may be upset when crossing time zones or when confronted by the increased risk of gastroenteritis when travelling. Reflex bowel movements are best
managed by stimulating the bowel to move with a stimulant enema or digital stimulation. Stools should be soft but well formed. When faced with a flaccid paralysis,
it is often better to ensure that the faeces are pellet-hard. Management is through manual evacuation by the patient.
Thermoregulation Work in preparation for the heat of the Far East proved that temperatures among rugby players in wheelchairs (the vast majority of whom have high spinal lesions) rose to above 40°C when competing. This is due in most part to the lack of the athletes’ ability to sweat. Cooling strategies that worked most effectively included the following: n Use of cooling fans and water sprays n Wetting the hair and head, combined with use of fans n Emersion of the hands and wrists in cold water n Use of cooling vests (prior cooling, however, may reduce the athlete’s temperature to suboptimal level for good muscle function). An inability to shiver and move
around may affect the athlete’s ability to maintain body heat in the cold and should not be forgotten (9).
Skin and pressure area care The ability of the athlete with spinal injury to protect the skin is impaired by the inability to feel uncomfortable areas and the lack of movement, which naturally redistributes load. Skin may be further compromised as autonomic and sensory loss produces dry and unprotected “neurogenic skin”. Nursing input is valuable in maintaining the health of the athlete. Skin damage may result from the
following: n Excessive pressure against bony areas for prolonged periods of time n Skin damage caused by abrasions from objects: – Clothing design, eg. buttons and studs on trousers and skirts, thick bulky seams, belts, shoes, tight stockings (including anti-DVT stockings)
– Objects placed in pockets, eg. keys and coins – Catheter connectors and clamps
n Shearing of skin, particularly during transfers or in sporting activities.
Treatment involves removing the insult and protecting the skin for long enough for it to heal, while managing secondary complication such as skin infection and abscess formation.
ATHLETES WITH CEREBRAL PALSY Cerebral palsy arises following an insult to the brain prenatally, perinatally or immediately after birth and results in a wide range of cerebral damage. Athletes with cerebral palsy have often overcome a lot of prejudice and misconception from people around them, who assume that because they have difficulties in activities of daily living they lack intelligence or a sense of humour. Anyone spending a few hours with the Boccia team will soon dispel these myths!
Various types of cerebral palsy are seen (10). Spastic cerebral palsy (70–80% of all people with cerebral palsy) presents with upper motor neuron symptoms of increased tone, often in a characteristic distribution of spasticity.
In athetoid/dyskinetic cerebral
palsy (10–15% of all people with cerebral palsy), extrapyramidal signs predominate, with poor regulation of tone and postural control, difficulty with coordination, athetoid movements and chorea. There may be difficulty with speech and swallowing. A scissoring gait and spastic foot deformity such as equinovarus can complicate mobility. Ataxic cerebral palsy is seen in less than 5% of all people with cerebral palsy. These types are subdivided further
according to the extent of the body affected: n Tetraplegic (10–15%): all four limbs are equally affected n Diplegic (30–40%): lower limbs are more affected n Hemiplegic (20–30%): one side is affected. Cerebral palsy is rarely monoplegic.
Co-morbidity, in addition to the obvious motor deficits, may include the following: n Higher incidence of epilepsy n Cognitive impairment (seen most commonly in spastic tetraplegia) n Contractures and joint pains from abnormal tracking and muscle balance around joints n Pulmonary complications (predominantly from aspiration)
THE INJURY AFFECTS THE ATHLETE AS A WHOLE
THERE NEEDS TO BE A REALISATION OF HOW
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