Sports Medicine: Just the Facts

CHAPTER 100 • THE DISABLED ATHLETE 591

the level of the SCI injury causing a sympathetic reflex

that perpetuates uncontrolled by the central nervous

system. This can be a life-threatening condition.

• Common noxious stimuli, which may serve as trig-
  gers, include pressure sores, infections, heterotopic
  ossification (HO), tight clothing, soft tissue injuries,
  fractures, bladder distension, and constipation.


• Initial symptoms include facial flushing, headache,
  hypertension, sweating, tachycardia, and bradycardia.
  If left untreated the condition may lead to seizure or
  even death.
  •Treatment should begin with sitting the patient
  upright, then finding and eliminating the cause of the
  noxious stimulus. Sublingual nifedipine, nitropaste,
  or other fast acting short duration hypotensive agents
  may be needed if the systolic blood pressure does not
  respond to initial management.


• Some athletes may try to use this condition to enhance
  their performance by increasing norepinepherine
  release and improving oxygen utilization. This is
  commonly referred to as “boosting” and is dangerous
  to the athlete’s health.

HETEROTOPIC OSSIFICATION

• Individuals with traumatic brain, spinal cord, or burn
  injuries are at risk for developing HO typically in the
  soft tissue surrounding large joints or fractures.
  •Typical symptoms include pain, warmth, and erythema.


• Diagnosis is made by bone scan early in the disease
  process and later by plain radiographs. Treatment
  includes NSAIDs, etidronate, or radiation. Surgical
  excision should only be considered once ossification
  has completed.

SPASTICITY

• Spasticity is an increase in resistance of muscle tone
  from an upper motor neuron injury.


• Spasticity can result in reduced mobility and ability to
  perform activities of daily living(ADL), and may lead
  to increased risk of pain, skin breakdown, and con-
  tractures.


• Multiples medications are currently available to help
  manage spasticity. They include baclofen, tizanidine,
  diazepam, dantrolene, clonidine, and botulinum toxin
  injections. All have side effects and therefore should
  be screened during the athletes PPA.


• Increases in spasticity may be the first indication of an
  underlying problem such as bowel or bladder disten-
  sion, infection, pressure sore, fracture, HO, or other
  injury.

OSTEOPOROSIS

• Osteoporosis is a common occurrence in neurologi-
  cally disabled athletes.


• Risk factors for osteoporosis include advanced age,
  female sex, thin body habitus, White race, immobility,
  decreased weight-bearing activities, paralysis, alco-
  hol, tobacco, caffeine, and some medications.
  •Wheelchair athletes are at increased risk for fracture
  after a fall. Practitioners should therefore have a lower
  threshold for obtaining radiographs on disabled ath-
  letes.


• Adequate padding is essential for wheelchair athletes,
  and all athletes should be taught proper fall techniques
  to prevent injury.


• Calcium and vitamin D supplementation are recom-
  mended for prevention. Bisphosphonates can be used
  when osteoporosis is documented.

DEEP VENOUS THROMBOSIS

•Venous stasis resulting from paralysis increases the

risk of deep venous thrombosis (DVT). The risk is

even greater during a period of hypovolemia or hypo-

viscosity as seen with blood doping or erythropoietin

(EPO) use. DVT may lead to thrombophlebitis or pul-

monary embolism.

• Symptoms of DVT may include lower extremity
  swelling, erythema, increased spasticity, or autonomic
  dysreflexia; however, signs and symptoms may be
  deceiving therefore the practitioner should always
  maintain a high index of suspicion. Pulmonary
  embolism(PE) may present as shortness of breath,
  chest pain, or even fever.


• Diagnosis is made by doppler ultrasound or venogram.
  Treatment includes anticoagulation medications.

SYNCOPE

• Syncope is the complete loss of consciousness and
  postural tone. The differential diagnoses include dis-
  orders divided into vascular, cardiac, neurologic, and
  miscellaneous categories.


• The most common etiology of syncope in the athlete
  is neurocardiogenic syncope (vasovagal or neurally
  mediated hypotension syncope).


• The differential diagnoses of syncope in athletes who
  are disabled include neurologic physical disability-
  related syncope or near-syncopal events, which may
  result from a number of conditions, including hypov-
  olemia, orthostatic hypotension, seizure, transient
  ischemic attacks(TIAs), or stroke.