Scott Webb (Host): Much like sports for able-bodied participants, Adaptive Sports have their own unique barriers, injuries and concerns. And joining me today to discuss Adaptive Sports are Dr. Andrew Hills and Dr. Binnan Ong, both of whom work with Adaptive Sports athletes to help treat injuries and more.  This is the Franciscan Health Doc Pod. I'm Scott Webb.

It's great to have you both here today. We're gonna talk through how to care for athletes to participate in Adaptive Sports and exactly what does that mean Adaptive Sports. And I was telling Dr. Hills I have a little bit of experience my daughter refereed an Adaptive Sports PE basketball game and the whole school was there and it was very cool but I'm definitely not an expert. You guys are. So we'll start with you Dr. Hills. What are Adaptive Sports?

Andrew Hills, DO: They're kind of like our sports for able bodied people but like the term adaptive, you kind of modifying the sport to promote inclusion for individuals with disability. Because, the main goal here is we want everybody to be able to participate in the sport if they want to. It really promotes that inclusion, physical fitness and improves everyone’s quality of life when they participate. So these sports are modified by rule changes. We add certain equipment or we change how the rules of the sport to kind of change how it's overall played. Like our typical sports, these organizations can be played at a variety of levels similar to Adaptive, PE Classic can range from anywhere from like recreational league to something very competitive. We know we recently just had the Olympics so I mean it can get all the way to the point where you're participating internationally in the para games and it's something that’s really grown over the last few decades. It kind of all started, I would say in England. They've always had a historic push for Adaptive Sports. They were the ones that first allowed it to be part of the Olympic games. It started in 1948 in London Olympics. They had sixteen patients who were World War II veterans at that time with spinal cord injuries. But then it took a whole nother turn when London hosted the Olympics Games again in 2012. Because then they had 4,000 adaptive athletes at those Paralympic games. So it's crazy how much Adaptive Sports have grown over the years.

Host: All right so we get a sense there of what it is exactly or what they are and you know how much they've grown. Dr. Ong are there still though some barriers of getting into Adaptive Sports?

Binnan Ong, DO: Let me give you guys a little context. You know I'm a rehabilitation doctor. So my job very often is to work alongside orthopedic surgeons, neurologists, any other specialty that's taking care of a disease. And my job is to try to maximize their function both you know inside the home, in their day to day lives as well as trying to get them back into the community. And so when we're talking about Adaptive Sports, a lot of the barriers to getting into Adaptive Sports comes first from getting them comfortable you know in their day to day life. And then kind of moving out from there. So you know I'll give a few examples here but, you know if we have someone like that's an amputee for instance, right, they may be dealing with things like phatom pain Their prosthesis may not fit well. They may not have been trained how drive with their prosthesis. You know maybe there's mental health issues about self-consciousness about how they look with their prosthesis or if they were involved in accident you know maybe they have some PTSD issues from the accident that lost you know their limb.

Host: Yeah.

Binnan Ong, DO: Or if we take another condition like you know strokes, spinal cord injuries, brain injuries which I kind of have a subspecialty in. You know that population may have difficulty feeding themselves, managing their bowel and bladder.

 And so if they're not comfortable with those conditions and managing them, they're not gonna want to leave the home to go to a sports event and participate with other people. And you know even if they are comfortable in their home life, there's a lot of unique problems of getting outside the house right. So how do you transport a wheelchair or a powerchair especially that you know may weigh a couple pounds.

Host: Right.

Binnan Ong, DO: Ah, or if they have a wheelchair, can that wheelchair get through the sand to get down to a beach so they can do some Adaptive kayaking, can it get through some wooded areas if they want to get back into Adaptive hunting. There might be special equipment needs and stuff that they'll have to navigate to participate. And you know some of this I will mention this because it's um it comes up a lot a lot of people get put off because they're like well I want to do this or that but I need this equipment and you know I'm not working. I'm on fixed income because you will have all these problems. And there are resources to help people with that you know and Dr. Hills and I are familiar with those resources whether that be grant programs or you equipment that might be better suited you know are certain budget levels and you know things like that. So, sometimes a big, big barrier isn't necessarily the condition that the patient has, but really just never being hooked up with the resources and being given the exposure to Adaptive Sports and you know how to make that happen.

Host: Yeah it's interesting right. So there's some obvious perhaps physical barriers, maybe some mental barriers, you're saying financial and otherwise, just folks knowing about these things being connected with the right resources. Wondering Dr. Hills are there some unique risks or injuries like these unique sort of forces and mechanisms of injury in different sports whether we're talking wheelchair sports, joint laxity, overuse, residual limb sores. I have a whole list here. Just wondering if you can talk through some of this for us.

Andrew Hills, DO: And I would say like similar to or more likeable body sports, you know injuries are somewhat unique based off the sport that's being played. So it is somewhat of a broad

 topic. I would say there is maybe a slight trend maybe more towards the overuse injuries as a para athlete, just as Dr. Ong is kind of talking about some of those additional like physical barriers they have to come from transportation. You are reliant on like if you're an amputee, You're reliant more maybe on your upper body, therefore you're putting more stresses across those joints.

 If you are participating in wheelchair basketball, you know it's predominantly controlling the wheelchair with your upper extremities, your arms there so again, you're putting a lot of additional stresses across that shoulder whereas someone who is able to use bot their arms and legs, they can kind of dissipate those forces across their joints. So you know they're, those tend to be a little bit more overuse injuries in Adaptive Sports. But again the sport definitely does matter. So you know I mentioned wheelchair basketball and when you get to some of these more competitive leagues its very much a like contact sport.

Host: Right.

Andrew Hills, DO: Ahm, you know they're ramming into each other, they're tipping over. There's risk for fractures and concussions. Similar you know we got a recent, our first snow here recently so

Host: Mm-hmm.

Andrew Hills, DO: you know our Adaptive Sports from a winter standpoint. You know

they're adding a lot more speed and potential for impact with these like Adaptive skiing risk which again brings in the increased risk of fractures and concussions. So overall, definitely more I would say overuse, but at the same time, we definitely still see the acute injuries depending on the sport.

Host: Yeah I've watched some wheelchair basketball. You know so like I mentioned my daughter's a basketball player for her, especially being an outside shooter much of the time, you know it's all about her legs, you know and building up her leg strength and being able to jump over defenders and shoot over them and then I've watched wheelchair basketball and thought how do they do that?

their arms must be so strong and then as you say really all levels of basketball are contact sports whether people realize that are not.

But especially in wheelchairs. I've seen a lot of that ramming into each other, knocking each other over. It's pretty violent and it's fun to watch and I'm sure it's fun for them to participate but as you say there can be some injuries right.

Dr. Andrew Hills: Exactly one hundred percent.

Host: and Dr. Ong want to have you talk through things like osteoporosis, autonomic dysreflexia, pressure ulcers, plasticity, those types of things from your perspective.

Binnan Ong, DO: You know Dr. Hills mentioned that there's a lot of unique forces on a patient you know depending on the sport they playing. But depending on their disease, you know whatever is causing their disability, they might be at kind of increased risk to have certain problems compared to a normal athlete. So if you have someone who for instance is maybe a paraplegic who maybe hasn't walked you know in a year or more, who uses a wheelchair to get around; their bones can develop osteoporosis. They become brittle and soft. And so things that normally wouldn't cause a fracture to an able bodied person, will cause a fracture, right. If you catch an arm and a jersey and it twists your arm you know just a little bit too hard, or if you tip out of your wheelchair, you know, that fall may only be one or two feet or something like that, but it, for someone that has brittle bones, right, that alone can cause fractures.

Host: Yeah.

Binnan Ong, DO: And so you when you are clearing people for sports, right like most regular sports physicals don't include a bone density scan ah to check on things like that right, ah to know what your risk is and maybe get it treated before you participate in a sport. There are kind of other global symptoms that have similar implications right. So people that have a lot of numbness for instance, right, may not be able to feel their skin. They may be in bed a lot of time. They may have wounds and like bedsores and stuff like that. So when you take these patients and you put them into a sporting event where there's now more friction, more pressure and stuff like that, that may increase their risk of developing sores or worsen ones that they already have. So that might be unique considerations that have to take place about you know how do you pad this or that. How do you maybe modify what they do to, to distribute the forces differently. I would say those are kind some unique things and then in terms of competitive sports, you know there are a lot of conditions that can cause involuntary muscle movements right. Or joint contractures where your arm can' t you know fully bend or straighten and things like that. So if you're really trying to compete at a competitive level and you're trying to do like a throwing sport or something like that, you're not gonna be able to throw in the most optimal manner right and that can limit your competitive edge. And so doctors like you know Dr. Hills and I, you know we, we're trying find ways to overcome each of these unique barriers and how normalize people's body mechanics and function as much as possible.

Host: Yeah I see what you mean. Wondering Dr. Hills how does sports med and PMR optimize performance and prevent injury, you know specifically when it comes to tailoring those treatments to disease specific deficits.

Andrew Hills, DO: I think that's one of the big things I like to emphasize especially in this population. You know we're throwing out the term like Adaptive ahm and for me from like a medicine like foundational standpoint, not a whole lot actually in my mind kind of changes, yes there some unique aspects but for me, the thing no matter if you're an adaptive athlete or any patient I'm seeing in the office; prevention is really the first place we need to focus on. Cause if we can prevent the injury from even happening, that's the key thing. Especially in this population because if you do have an injury, you know they already have these impairments so adding an additional injury to it can definitely change not only their quality of life, but just being able to independently complete their activities of daily living. So we've been talking a lot about like you know wheelchair basketball and things like that. So, people who are dependent on a wheelchair; we definitely want to optimize their positioning in the chair to decrease that increased forces across that shoulder joint. So, one example we do that so you know we do place the the rear axle of the chair kind of slightly behind the athlete's center gravity. It does allow the athlete to have a little bit better grasp and propulsion just to kind of make mechanics a little bit more efficient there. The wheelchairs have a more of an angle to it so the, at the base, it's wider and then it's a little bit more narrow at the top. There's a biomechanical term, it's called camber. Which again increases kind of the responsiveness to their hands in regards to turning, provides better stability and again as we've been mentioning with the contact aspect you know it does allow your opponent not to be able to get as close to you which is kind of nice from that standpoint.

And then some of the unique things with amputees is really making a big focus on how does their prosthetic fit. It truly needs to be a snug and perfect fit. Any movement at the skin where that prosthetic is kind of meeting the skin, can result in increased pain, blisters, open wound if there's any extra movement and we do need to be flexible though as they're participating because you know as we are sweating and you know their limb can actually change shape as the competition's kind of moving along, so we gotta be flexible and be able to kind of you adapt to those more moist environments as they are kind of in the middle of the competition. They may need to add a extra layer or sock to their limb to kind of recreate that kind of snug fit throughout the competition to again to prevent some of the extra movement, to injury in the first place. And for me, you know that's the key thing especially in this population is it's all about preventing the injury before it happens.

Host: Right. Certainly you can treat the injuries after they happen, but in a perfect world, ideally we're preventing them as much as possible so I'm sure education is key. Uh, Dr. Ong mentioned earlier having the proper resources or the amount of resources of course. Dr. Ong, wondering what a multidisciplinary approach looks like when we think about Sports Medicine specialist and a Physical Medicine physician you know working together, a part of that team. How does that work?

Binnan Ong, DO: You know there's a lot of overlap between you know what I do and what Dr. Hills does and honestly with a lot of other specialties as well. It require a lot of coordination to kind of get patients to function at their best in all settings. You know I kind of mentioned earlier about how patients function inside the home and things like that right so you know when Dr. Hills and I you know work together,I kind of focus on a lot of those barrier you know to get patients out to the sport, right? Can they get dressed, can they get in a car, can they drive, are their medical issues kind of optimized to participate in the sport. Then Dr. Hills can kind of take over if there's sport specific injuries and you know we can always collaborate as well. If there's special equipment that a patient needs, right, that kind of has to take into consideration what those needs are inside the home and what those needs are in that specific sport. Likewise sometimes if a patient has a sports injury, that injury may carry over into how they're going to function at home. If they fracture a leg, yes they can't participate in a sport but how are they going to get out of bed and get in their wheelchair and get downstairs or things like that, right. I think you know, patients are best served if they have multiple doctors kind of paying attention to all these various things.

Host: So l want to finish up with you Dr. Hills. Talk through, I want to understand the special olympics and paralympics like are those the same things, or are they sort of the same, somewhere in the middle. Are those the same things or are there some differences?

Andrew Hills, DO: You said kind of somewhere in the middle. I like that answer. In general, I mean both of them are important and they both have similar missions. They want to promote that inclusion and provide physical fitness opportunities for individuals with impairments that affect their daily life.  There is a difference between the two though ahm Special Olympics, it does tend to be a little bit more focused on individuals who have intellectual impairments.

Scott Webb: Okay.

Andrew Hills, DO: Where you see more of the Paralympics is traditionally focused more on the physical impairments but again that's why I like to say you know with your questioning it's kind of somewhere in the middle because if you actually look at the paralypics, they actually have certified raters for your impairment and they divide your impairment into ten different categories. And eight of those ten categories are actual physical impairments but they do one of the ten does include an intellectual component to it so there definitely is some overlap between the two. So mostly it's an over simplification but special olympics does tend to be a little bitmore intellectual impairments, whereas paralympics does a little bit more physical.

Host: Yeah good to understand that they're different but there is some overlap, there is some you know meeting in the middle a little bit. This has been really good stuff today, really educational. I just want to thank you both for your time. These are the ones that are for me you know I get to a certain age in my fifties and I think I probably know everything now right and then I, I talk to a couple experts, multidisciplinary teammates if you will and I go yeah you know what there's so much i don't know so it's why it's great to have experts have you on so thank you both.

Andrew Hills, DO: Yeah thank you for having us.

Binnan Ong, DO: Yeah thanks.

Host: And to learn more about Dr. Andrew Hills or Dr. Binnan Ong, visit franciscanhealth.org and type their name into the search bar.

Host: And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.