In January of 2013, the U.S. Department of Education’s Office for Civil Rights (OCR) released a statement underscoring its responsibility to enforce Section 504, a Federal law protecting the rights of individuals with disabilities in programs and activities that receive Federal financial assistance.
OCR emphasized that students with disabilities who cannot participate in the school’s existing extracurricular athletics program should still have an equal opportunity to receive the benefits of athletics; therefore, the school should create additional opportunities for those students.
We have always known that participation in athletic activities provides important benefits to all high school students, including improvements in academic performance, teamwork and leadership skills, fitness, and socialization.
In an effort to provide more opportunities for students with disabilities, schools are increasingly creating disability-specific teams (e.g., wheelchair basketball, track and field).
Coaches and administrators – and school nurses and athletic trainers if schools are fortunate enough to have them – should be aware of the unique medical and musculoskeletal challenges that may be encountered by some of their student-athletes with disabilities. Awareness of these challenges will enable athletic administrators to prepare for a safe and rewarding experience for the athlete.
Medical Considerations for Student-Athletes with Physical Disabilities
The Pre-Participation Exam (PPE)
Prior to participation in interscholastic athletics, the student with physical disabilities must be examined by a physician and cleared for participation. Consideration of the specific physical disability, the desired sport and the student’s medical history should be considered in tandem.
The fourth edition of the Preparticipation Physical Evaluation monograph, reviewed and recommended by six national medical societies, has an entire chapter devoted to the athlete with special needs, as well as a supplemental history form. Critically important is a medical card with parental/guardian signatures giving permission to participate and be treated, contact information, and specific activity limitations and medical needs by the student. The medical card must accompany the student at all practices and competitions. The PPE must be completed yearly or as required for all athletes by the respective state high school association.
Medical Coverage and Preparation
• The minimum level of coverage is to have one or more coaches who hold a current certification in CPR and training in first aid. The ideal medical team would include a certified athletic trainer (ATC) and a physician with a background in sports medicine and experience in working with athletes with physical disabilities. The athletes’ families may be able to assist with finding appropriate medical coverage as needed.
• Emergency action plans (EAPs) that are already in place at schools should be reviewed, modified and appended as necessary to reflect any special needs. Additional items should be considered for the sideline first aid kit (e.g., specialized skin supplies like silicone blister pads, foam for padding) and for the sideline or medical venue, depending on the event and type of athletes competing (e.g., accessible bathroom facility or accessible portable toilet and sink).
Specific Medical Concerns
• The most serious illness that can happen to athletes with a spinal cord injury (SCI) at the 6th thoracic spine (T6) or higher is autonomic dysreflexia, which results in extreme high blood pressure and headache and is usually a medical emergency.
• Student-athletes with SCI at T6 or higher have a challenging time regulating their body temperatures in both warm and cold environments, and are at greater risk of hypothermia and hyperthermia (heat illness).
• The loss of more than one limb in amputees changes the ratio of surface area to body volume, and these student-athletes may also find it difficult to regulate their body temperatures.
• Spasticity, an uncontrollable contracting of muscle groups and limbs, is common in individuals with SCI and with cerebral palsy (CP).
• Skin problems including an increased risk of pressure sores and ulcers, and skin infections, can be seen in amputees and student-athletes competing in wheelchairs.
• Neck and upper back injuries in upper extremity (UE) amputees are common due to UE imbalance and unequal movements. Fifty percent of UE amputees also show overuse injuries in the unaffected arm (e.g., rotator cuff tendinitis, tennis elbow).
• Low back and sacroiliac joint (SI joint) injuries are seen in lower extremity (LE) amputees due to leg length imbalance and altered biomechanics. Low back pain is experienced in 62 percent of below-knee amputees and in 81 percent of above-knee amputees.
• Wheelchair student-athletes experience neck and shoulder pain mainly during wheelchair racing due to racing mechanics, and weight placed primarily through the UE. Carpal tunnel symptoms and other nerve conditions are also common.
The medical needs of student-athletes participating in adaptive sports are similar in many aspects to the needs of student-athletes without disabilities. With increased awareness, pre-emptive planning and skillful coordination of available resources, schools can adequately address any potential medical situations with confidence.
Crandell, David M. “Special Considerations in the Disabled Athletes.” Clinical Sports Medicine: Medical Management and Rehabilitation (2007): 117-30
Klenk C, Gebke K. Practical Management: Common Medical Problems in Disabled Athletes. Clin J Sports Med 2007:17: 55-60
“The Athlete with Special Needs.” PPE: Preparticipation Physical Evaluation, Fourth Edition (2010): 131-9, 164.
Simon LM and Ward DC. Preparing for Events for Physically Challenged Athletes. Curr Sports Med Reports 2014; 13: 163-8
Wind WM, Schwend RM, Larson J. Sports for the physically challenged child. JAAOS 2004; 12: 126-137.
Cindy J. Chang, M.D. has been the head team physician at the University of California, Berkeley and was chief medical officer for Team USA at the London Olympics. She is a member of the NFHS Sports Medicine Advisory Committee. Doug Rempe is president/founder of ReActive Physical Therapy in Cincinnati Ohio, and has been a physical therapist/athletic trainer with USA Paralympics since 2007. Kevin Charles is executive director of the Delaware Interscholastic Athletic Association and was president of the NFHS in 2012-13.