Dr. Taron Davis presents "Adaptive Sports Medicine" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
All right, thank you very much. It gives me my pleasure to introduce Doctor Taron Davis. Uh He is a pediatric psychiatrist here at U CS F. He earned his medical degree at Saint Louis University School of Medicine. He completed a combined residency in pediatric and physical medicine and rehabilitation at the University of Colorado School of Medicine. He cares for young people with amputations or limb deficiencies and for those who have issues with physical function resulting from brain or spinal cord injuries as well as rheumatic disorders, cancer, neurological conditions or musculoskeletal conditions. So, with that Doctor Davis. All right, good morning. Uh My name is Ron Davis and I am here to talk to you about um physical activity and sports participation in, in Children with um disabilities. Um I have no financial disclosures. The learning objectives for today are to describe benefits and uh special consideration for physical activity, recreation and sports, for Children with disabilities. To discuss an approach uh to pre partici patient examination um for Children with disabilities and to provide an overview of some various uh adaptive sports uh and, and address common injuries related to youth athletes with disabilities. So, uh I included um this first slide as just a primer of some of the uh legislative work that went in that uh went into having a more um equitable uh society for people with disabilities. Uh And also included the image below um as a kind of a reference point to um uh um compared to uh the recent um societal uh conversation we've been having in recent years about equity and inclusion. Um As we turn to look at um how society equity can impact people with um physical uh uh disabilities. And so, thinking about equality being, you know, giving someone with a wheelchair or a bicycle um that they uh cannot, is not adapted to them versus uh equity where there are um uh adaptability for people with different um a abilities to uh fit best, fit their, their current function. So I think it's important to recognize the intersectionality between diversity, equity and inclusion initiatives. Um The fight for civil rights and inclusion of individuals with disabilities um in our society. And um in many ways, individuals with disabilities, uh both physical and cognitive find themselves excluded from many aspects of modern li living um recreation and physical being a key focus for this talk today. So, um physical activity, uh so one in five people with disa uh are um have disabilities in the US. And so, um that's about 20% of the general population for uh the pediatric uh population that includes about 8% of Children um under the age of 15 and um 21% of Children um from the age of 15 to, to 21 identify um uh as uh with some sort of disa physical disability. And so, uh for many years now, there's been uh an, an understanding that physical activity is beneficial um um for the pop or the US population and including Children with uh um disabilities. So, some of those benefits and participation of exercise, sports and recreation include um in uh feeling of inclusion, um cardiovascular conditioning, function, mental health. And so, um despite these benefits, uh Children with disability, face barriers to participation and have lower levels of fitness redo reduce uh rates of participation in higher prevalence of overweight and obesity compared to their um uh typical, typically developing peers. Um an early participation in sports and recreation helped to improve local motor skills, um object con control uh and make it so that Children are more likely to be able to participate in um uh sports and recreation activities into the future. The early participation in sports and recreational activities is associated with um uh higher quality of life, uh improved social skills skills and um connection with peers and and improved self confidence. So, um within specific populations, what we know. So for Children with cerebral palsy, there's been evidence that shows uh engaging with an early physical activity program is associated with improved body um bone mineral density. And so that includes um um weight bearing on the floor quadruped prone activities for um Children with uh um lower G MS CS levels, um all the way to standing programs um and uh and early engagement with physical physical therapists on walking. Um with the, the use of developmentally appropriate equipment for um Children with higher G MS CS levels, um activity. Uh uh Children with um more motor ability have uh a higher quality of life when they are engaged with physical activity, with um with, with age appropriate peers. And that's compared to those and with um who are not engaged with within physical activity for Children with cerebral palsy. And then for boys with Duchin muscular dystrophy, um bicycle programs and upper extremity programs uh training have been associated with slower deterioration of function and improved motor function ability. Uh So, for us, as providers, um we wanna consider what are the barriers and what are some of the facilitators for getting Children with disability engaged in recreation and sports activities. And so um really wanna focus on awareness and access. Um So increasing our awareness, increasing our education and increasing our and decreasing some of our, our bias and ignorance towards uh what, what we might expect someone's um interests or ability to engage with different sports or recreational activities. Um And uh to uh consider um the other barriers such as cost. Uh what are the, what, what is the accessibility um and what kind of specific programs might be available um within a, within a population for facilitation. So oftentimes uh health care providers might be the first um person to interact with a patient or family um to consider what amount of physical activity uh the child is engaged in. And so our role is to um is to uh begin to have that early conversations about um physical activity and I included to the left um AAA um a handout or a document from the College of Sports Medicine, which is a physical activity vital sign. And it's a, a quick screening um assessment that asks uh that you could use with any uh child or family that ask how many days per week an individual is participating in physical activity. Um And uh whether that's moderate or, or vigorous and gives uh example or example, language of what moderate activity looks like and what vigorous activity looks like. And then it also asks how many minutes per week um um a child or a patient would be active in physical activity and to begin that early conversation uh uh to see what the level of interest for individuals and families are and engaging in um sports and recreation in regards to um the pre participation, physical. So um it's a um so physical, the, the conversation begins early. Uh you want to and think about what the um uh current function of the child is, what their current activity level looks like and what their interest is um and participating in sports and recreation activities. So, um early identification of disability and impairment are important so that you can um direct uh early interventions, whether that be with physical occupational therapists um um to help support um developmental delays, exploration of uh the child and family's knowledge and motivation and feelings regarding physical activity and, and movement. Um You can refer to uh specialists to support and refine and promote physical um ability, skills and boost that way and boosting confidence, which may allow for uh increased engagement and interest in sports participation for the child. Um During that pre participation assessment, you're also considering um what are other comorbidities, whether um whether there are any other medical conditions to be considered for the child or any um uh conditions specific to um the primary disability that you might need to consider? Also considering the demands of the sport um especially uh for some conditions like um down syndromes where if there's an Ax Atlanto axial instability um where you might, where you might have to direct um a that Children participate in, in noncontact sports. And then um is there a way to adapt that sport or modify that sport to meet the child's need? And so as you might imagine, um it takes a village. So given the complexity of pre participation evaluations for Children with disabilities, um they don't always occur in a single context of one office visit. They can occur in context of talking with coaches, um other other um therapists, um physical education teacher, uh school nurses, um and thinking about adaptive um adaptive equipment and technology specialists like orthotist and prosthetics to best come up with a plan and a way to facilitate a child's participation in uh sports and recreation activity. So, um we talked a little bit about, yeah, the adapted looking at um what the child's physical literacy um might be at the pre participation exam, thinking about their ability, their desire and their confidence and exploring that with the family. I'll briefly talk about um some, I highlight some high um topics about uh the physical exam before moving on to thinking about some specific uh populations uh with that um within uh the sports or Children with disability and um the way to engage their um physical exam and think about uh common conditions that occur. So um you are doing some preliminary screening of vision, hearing cardiovascular health and then thinking about neurologic function. So the ways that uh movement disorders like ataxia spasticity or, or sensory dis dis differences might affect uh a child's participation um doing an overview of dermatological conditions or skin injury, especially in Children who um uh might be looking to participate in wheelchair, wheelchair sports or for the athletes with um uh it may be an amputation to look at um the health of the residual limb. Uh before engaging in any sports. And then um there are some specific musculoskeletal skeletal um conditions that I highlighted here such as um contracture, um an ax and um instability and then uh limb differences. And so um the uh risk assessment and association for uh each condition may be, may be varied. And so um it takes, you'll take time to consider each. So some associated injuries that uh will look at. So, first starting with spinal cord injuries. So for um the population of Children with spinal cord injuries, thinking about the skin integrity, um Children with spinal cord injuries due to their uh sensory impairment are at increased risk for uh skin injury and breakdown, including pressure, um ulcers. And so I highlighted some of the common areas including the oxo Samuel tubes, heels and feet. Um Risk factors include um the time in uh one position without pressure, relief friction at bracing straps or tight fitting clothes and moisture. And so, um that's one consideration for the spinal cord injury population. Next, thinking about temperature and thermal regulation, dysfunction. So, uh a condition of Pike Yother Mia which is an inability to maintain temperature, um can result in environmental fevers. Uh placing an athlete at high risk for hyperthermia during exercise. Risk factors include uh high thoracic Cervi uh and cervical spinal cord injuries management um includes hydration and cooling blankets, um and um maintaining appropriate dress for the um the sport and then one very important and emergent uh uh condition for individuals with spinal cord injury. Um participating in sports is the condition of auto anomic dyslexia. So, um anomic dyslexia can occur when a noxious stimuli below the level of the spinal cord injury, um results in sympathetic uh response and subsequent vasal constriction leading to hypertension and parasympathetic output um by the vagus nerve. Uh and then that causes bradycardia, but that parasympathetic output can't pass below the level of the lesion of the spinal cord. And so there's a mismatch of the autonomic nervous system. Um inputs. Uh individuals who are at risk include Children um with lesions at the level at T six or above. Some uh are as low as T 10 are still at risk for symptoms of auto autonomic dyslexia. The management for ad would be to lie the player flat to remove the um no, any noxious stimuli. Um get them out of the wheelchair, unclamp, a foley and loosen any um tight fitting clothes like waistbands. And then I wanted to highlight that for um some uh individuals um participating in sports uh with spinal cord injury. There's a phenomenon called boosting and boosting is utilized by um um uh by athletes to deliberately trigger anomic dyslexia, creating they will create a noxious stimuli. Usually um clamping their uh indwelling catheter or tightening a leg strap to increase their sympathetic outflow um thereby uh um kind of um uh giving them an adrenaline boost and this is banned by all of the major organized sports committees. So um turning to uh other specific conditions that occur for uh um within the population of Children with disability participating in sports. So, uh in, in intertwined with um these athletes uh or wheelchair athletes um is the idea of equipment and so improper equi in improper fitting equipment or equipment in disrepair, um place the athlete at risk uh of injury or overuse um, injury. Um And so you want to, uh, have familiarity with, uh if, with, with durable medical equipment or have a, um, a someone certified to evaluate for specific seating, um and specific equipment for the, the sport that the child is interested in participating in. And so there are a number of adaptive types of wheelchairs um for uh for skiing, for uh um for basketball playing, um for rugby that would all need to be kind of a specialized fit for a child, um who is interested in um, participating in that sport. And so it just kind of highlights, uh some of the uh variations that right might be, uh might go into considering a fit. So whether the seats too narrow or too wide, this where the place placement of the wheels. Um So if they're too far back, um, the, the, the player has to extend their, their arm and shoulder back, further increasing, um, the strain on the rotator cuff, which can lead to overuse injuries in the future. And so, um, uh, as important as the health of the athlete is. So, so also is the importance of the quality and um uh um of the, the equipment that they're using similarly thinking for wheelchair athletes. Um, some of the places that they might be more at risk for injury, um for a wheelchair, uh for an athlete using a wheelchair, um, they're at highest risk for upper extremity injury and overuse injuries of those muscles. Um that often include so hand, wrist, elbows and shoulders, they're also at increased risk for peripheral nerve entrapment. Um So, carpal tunnel syndromes, ulmer, neuropathy and um uh as I mentioned, rota rotator, cough, tendinopathy, and impingement for individuals with limb differences and amputation. Um The vast majority of pediatric um uh limb different or amputations are, are sorry, limb differences is congenital, congenital and then for amputations, they're often acquired. Um The two or a few things that I highlighted for um uh conditions to consider for individuals with limb differences and amputations were um overgrowth of youth uh of the um of the bone. And so youth with amputations uh continue to grow their long um through their long bone um through at risk of terminal overgrowth and penciling um which can cause skin injury. So, uh the x-ray, they are highlighting the terminal overgrowth uh of the fibular. Um the distal fibula um and then kind of uh impinging and poking at risk for poking through the skin there. And then, so other skin traumas that have happened to do with contact with the uh terminal limb to um the prosthetic device and um phantom limb pain, which can occur. And then neuroma which can develop at the end of the of the limb. This next slide just highlights um again, the importance of equipment. So uh really um doubling back on some of the comments about um the importance of fit quality and um uh and, and having specialist take a look at um uh athletes use, utilizing their limbs. Um for the sake of time, I'll cut jump through some of the terminology, but it uh just kind of talks through um the, the relevant terms for thinking about para ale and then pointing highlighting here just that there are some international organizations in the, the main two being uh the Special Olympics and the Paralympics. The next slide also um kind of delineates between what, what are some of the differences between Paralympic athletes and Special Olympic athletes, which I'll allow you to look at, at a, at on your, at your leisure. And I'll move on to um uh raising awareness of some of the local um resources or national and local resources for uh Children with disabilities, interested in, in sports and recreation. So, the National Center for Health and Physical Activity and Disability um is a really great resource for providers uh looking to educate themselves and have uh an increased language about ways to talk to um patients about sports participation with disability. Um It provides uh um articles, handouts, uh and videos that describe um that provide specific details and exercise programs. Um for uh for individuals with disabilities, I highlighted um of their youtube channel which has um kids adaptive yoga. Um And then I also included uh a handout that for uh this discover accessibility fitness where they have a um um a multi page uh pamphlet or booklet uh for individuals in wheelchairs of how to uh interact with uh weight, weight and fitness equipment in a gym. And then um the association of uh children's processes Ortho orthotist uh clinics. Um I included this resource because it has um a AAA part of their site uh is includes camps and um um um recreational activities that uh Children can um can participate in. And it has uh many of which have grant and scholarship funding and our local resource here. So BP Bay Area Outreach recreational program is similarly um is a wonderful resource for Children um and families interested in engaging uh and learning more about how to, how to increase the activity level for um their child with disability. And then, uh also here at U CS F, there are uh multiple camps and resources uh put on um through throughout the academ or throughout the year. Um Some more more recent were uh rock climbing adaptive rock climbing event. Um They did an adaptive um uh um basketball session with uh the Golden State Warriors and they did a um I think it was a 1 to 5 K run um for uh or trot. So the takeaways for today were um so don't underestimate um and evaluate uh to assess and reassess uh for a chi a child's ready readiness uh to participate in sports or physical uh or recreation activity um to help facilitate uh uh and facilitation can take a village to consider disease specific conditions for the participant to beware of overuse injury and um uh prevention strategies and then familiarize yourself with local and regional and national resources. Um So I wanna thank uh a co, a former colleague of mine, Stephanie who um uh who is the head of the team physician uh um for the U Sas Paralympic Swimming team. And um helped me um develop slides for this talk.