SPORTS CARE

understand the potential seriousness of the complications of dehydration.

The development of dependent oedema with prolonged air travel is well known. Simulated cabin pressurisation has experimentally shown that a 12-hour journey may account for more than 1 litre of fluid retention in able-bodied subjects (2). Athletes with paralysis are more likely to develop dependent oedema due to the loss of the potential muscle pump improving venous return. This may result in increased pressure areas with footwear leading to ulceration and the oedema is generally slower to recover than in able-bodied subjects. The use of diuretics is banned in competi- tive sport and so this avenue of therapeutic management is not available.

Athletes with lesions below L1 are likely to have lower motor neu- ron lesions with associated flaccidity and generalised decrease in tone, further exacerbating the venous return. As these athletes have no muscle spasm, they are also likely to have very little padding on the sacrum and ischium and will be particularly prone to pressure damage, although all athletes with reduced sensation should be considered high risk.

There is increasing awareness of the phenomenon of deep vein thrombosis and pulmonary embolism following air travel (3,4). A study of 254 patients with deep vein thrombosis and/or pulmonary embolism identified 44 patients who developed symptoms during or after air travel (5). Risk factors identified included a history of previous deep vein thrombosis (34%), presence of chronic disease or malignancy (25%) and hormone therapy (16%). The authors also speculate about the role of cabin related risk factors including, low humidity, hypoxia, the diuretic effect of alcohol, insufficient fluid intake, smoking, ‘coach’ position, and immobilisation. For the athlete with a severe dis- ability the immobilisation component is accentuated. Aspirin treatment prophylactically has been shown to reduce the incidence of deep vein thrombosis following surgery and following immobilisation for lower limb injury (6). It has also been suggested by some travel clinics that aspirin should be taken prophylactically prior to prolonged air travel and this is certainly an option, providing the athletes/staff have no other contra- indications. This would appear to be a relatively cheap and safe way of preventing potentially fatal complications as there are case reports in the literature of cerebral thrombosis following air travel (7).

Sitting in a cramped position may also affect spasticity in athletes with spinal lesions above L1/2, frequent alterations in passive positioning and passive movements may help. Increases in pain from various chronic conditions also may occur with prolonged sitting and adequate analgesics should be available bearing in mind doping regulations. Fortunately in recent years the relaxation of restrictions of analgesics has made pain management easier. The permitted use of codeine, dihydrocodeine and dextropropoxyphene allows the physician more options in pain management.

Another condition associated with this group of athletes is auto- nomic dysreflexia. This tends to occur in lesions of T6 or above and is commonly caused by a blockage of the catheter a urinary tract infection or the potential for dehydration that was described

8 2 TABLE 2: COMPLICATIONS OF LONG HAUL TRAVEL

■ Dehydration ■ Urinary tract infection/calculi ■ Pressure sores ■ Oedema ■ DVT ■ Autonomic dysreflexia ■ Exacerbation of chronic pain ■ Epilepsy

earlier. It may also be precipitated by the pain or discomfort that occurs during long haul travel. The nociceptive input causes an excessive, uncorrected discharge of the sympathetic system, which in turn, causes severe hypertension, headache, sweating, skin blotching and general malaise. This condition has been asso- ciated with seizures, cerebral haemorrhage and death and should therefore be considered as a life threatening emergency (8,9). The initial management must include identification and removal of the cause of the painful stimulus and reduction of the blood pressure by the use of sublingual Nifedipine. It is important that the physi- cian accompanying the team has medication ready to treat this phenomenon should it occur.

Autonomic dysreflexia has received press attention in recent times because some athletes have been intentionally inducing this state to improve sporting performance with a technique known as ‘boosting’ (10). Deliberate introduction of a nociceptive stimulus by for example twisting the scrotum or interfering with the catheter to induce bladder distension, is obviously extremely dan- gerous and is banned by the International Paralympic Committee.

When travelling to hot or cold climates, it is important for the medical support team to know that athletes with cord lesions will not be able to regulate their temperatures as effectively as able bodied athletes. Sweating and skin vasodilation will not occur appropriately below the level of the lesion. If evaporation and hence cooling can only take place at the shoulders and head, clearly the athlete will be extremely compromised in a hot and humid climate. If the situation is further exacerbated by dehydra- tion or damaged skin due to sunburn, it is highly likely that heat illness will occur. In order to prevent this, education programmes should be undertaken prior to travel and athlete agreements drawn up in relation to fluid intake, alcohol consumption, sunbathing, recreational activities and the use of protective clothing. In cold climates, athletes should be taught to check extremities regularly and ensure adequate warm and waterproof clothing is used.

The majority of injuries sustained by wheelchair athletes involve the neck and shoulders and upper limbs generally. It is difficult to sit in a wheelchair and maintain a good posture and as a result a forward head position is often adopted, leading to irritation of zygoapophyseal joints and nerve roots and inactivity of the local cervical stabilising muscle systems. We have found that prophy- lactic postural re-education and training of the deep neck flexors and other local stabilising muscles can help to prevent this prob- lem, but it is also important that physiotherapists working with these athletes are highly trained in manual therapy. Shoulder pain

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