Working with athletes with disabilities paula jones

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  • Dwarfism: is a condition characterized by short stature. Technically, that means an adult height of 4 feet 10 inches or under, according to the advocacy group Little People of America (LPA). can be caused by any one of more than 200 conditions, most of which are genetic. The most common type, accounting for 70% of all cases of short stature, is called achondroplasia. can and most often does occur in families where both parents are of average height. In fact, 85% of children with achondroplasia are born to average-size parents. Dwarfism isn't: an intellectual disability. A person who has dwarfism is typically of normal intelligence. a disease that requires a "cure." Most people with the condition can live long, fulfilling lives. a reason to assume someone is incapable. Little people go to school, go to work, marry, and raise children, just like their average-size peers. No consensus of correct terminology – little people, short stature, dwarf all mentioned in the literature .
  • Primordial Dwarfism is a category of disorders with many subtypes. The exact definition can vary from one type to another, but all are defined primarily by extreme short stature at birth. Unlike many other forms of Dwarfism, Primordial Dwarfism differs in that all of the bones and organs of the body are proportionally smaller than in an average person. When looking at a picture of an individual with Primordial Dwarfism, it can actually be difficult to realize how much smaller than an average person they are, unless there is something else in the photo to use for comparison.
  • The standardized mortality ratio is increased for all age groups by a factor of 2.27 over that of the general population.children younger than 4 years, death most commonly occurs due to brain stem compression, which causes sudden death. 5-24 years, central nervous system and respiratory abnormalities are the common causes of death. 25-54 years, cardiovascular problems are the most frequent causes of death. Hypotonia is very evident from early on.  Motor development is delayed.  (See Table 1.)  Head control may not develop until seven to nine months of age because it takes longer to develop the muscular strength needed to control the overly large head. Table 1:  SKILLS ACHIEVED BY 90% OF CHILDREN ACCORDING TO THE DENVER DEVELOPMENTAL SCREENING TEST MilestonesAverage Child Child with Achondroplasia Smile2 to 2.5 mo2 to 3 mo Head Control4 to 7 mo7 to 9 mo Roll Over5 to 6 mo6 to 8 mo Sat with Propping 6 to 7 mo 7 to 9 mo Sit Alone 9 to 11 mo11 to 14 mo Crawl10 to 11 mo11 to 13 mo Pull up to Stand 11 to 14 mo14 to 18 mo Stand with Support 12 to 16 mo16 to 21 mo Stand Alone15 to 18 mo18 to 23 mo Walk with Support14 to 18 mo18 to 22 mo Walk Alone 17 to 22 mo22 to 30 mo Babbling Sounds 6 to 7 mo6 to 10 mo Said Momma/Dada 9 to 12 mo12 to 17 mo Said 2 Word Phrase15 to 20 mo20 to 30 moSaid Short Sentence24 to 25 mo25 to 36 mo Has the hypotonia increased?  It should gradually resolve as the muscles mature.  However if it worsens or there is presence of sleep apnea, there may be a compression of the cervical spine.  A common complication of achondroplasia is a narrowing of the foramen magnum, causing compression of the cervical spine.  This needs to be surgically corrected. As the child develops head control and begins sitting, a kyphosis of the lumbar spine can occur.  This may be corrected with a small back brace (Knight brace).  The Knight brace (Figure 1) is made with and adjustable soft abdominal shield.  This soft abdominal shield allows for abdominal breathing, which is very typical in achondroplasia The Knight Brace is most beneficial if worn between the ages of 8 to 18 months of age and should be used when the child is in the upright position.  If the kyphosis is not corrected, wedging of the vertebrae may occur leading to significant problems later in life Achondroplasia does not effect the development of soft tissue.  The muscle size is actually the same size as an average child's muscle would be.  However, it is less efficient because of the shorter distance over which it is stretched. During early childhood, there will most likely be a bowing of the legs.  This is caused by a faster growth rate of the fibula than that of the tibia the extensor muscles are weak and lengthened, while the flexors are short and stronger.  There is often an anterior pelvic tilt that may increase with age.  This can cause compression in the lumbar spine.  Eventually, the youngster may need to stop and squat while ambulating or standing.  This is one of the indications that spinal stenosis is occurring Early years:   Neurological symptoms from stenosis of spinal cord and foramen magnum   Thoraco-lumbar kyphosis   Delayed motor milestones Childhood:   Joint laxity (subluxed humerus)   Bowing of the lower extremities   Anterior pelvic tilt Teen years:    Lumbar stenosis    Independence in ADLs    Obesity
  • Stenosis of the spinal canal and intervertebral foramen leads to symptoms such as low back pain, leg pain, dysesthesia, paresthesia, paraparesis, incontinence, and neurogenic claudication. Claudication may present as vague symptoms of aching or tiredness of the lower extremities induced by walking or standing. Symptoms may progress with a sensation of tingling and numbness and, eventually, weakness. Often, the pain is alleviated if the patient assumes a squatting position or bends forward. More than 50% of patients experience symptoms of lower extremity radiculopathy from nerve root compression or cauda equina syndrome . The mean age of onset of back or lower extremity symptoms is 26 years; one third of patients are younger than 15 years at onset. Symptoms due to abnormal curvature of the spine (eg, kyphosis, lordosis, scoliosis) may be present, such as deformity, back pain, respiratory dysfunction, neurologic involvement, or symptoms of spinal stenosis. The incidence of kyphoscoliosis may be as high as 33-50% in adults. However, the curve magnitude is generally less than 30° and generally does not require treatment. Spinal deformities are the most common and potentially disabling problems. 10,11,12 Spinal canal stenosis and stenosis of the intervertebral foramen are secondary to short thickened pedicles, interpedicular narrowing, thickened laminae, intervertebral disc herniation, degenerative spondylolysis, excessive lumbar lordosis, or anterior wedging of the vertebral bodies from thoracolumbar kyphosis. Sensory deficits, posterior column dysfunction, lower and upper motor neuron signs, and signs of neurologic claudication may be present. Signs of lower extremity radiculopathy from nerve root compression or cauda equina syndrome are present in more than 50% of patients. Four clinical syndromes may be observed: 1. Single or multiple disc lesions: usually in the lumbar region and presenting with a cauda equina lesion. 2. Generalized spinal stenosis: often beginning in the lumbar region with an intermittent claudicant history. Later the upper limbs become involved and a quadriparesis develops. 3. Severe thoraco-lumbar kyphosis with spinal block: clinically a progressive kyphosis with associated cord signs. 4. Foramen magnum insufficiency: compression of the medulla and upper cervical spine due to a small foramen magnum and a proximally placed atlas and axis.

Transcript

  • 1. PAULA JONES Physiotherapist
  • 2.
    • To consider general good practice when treating/communicating with athletes who have disabilities = ‘Disability Awareness’
    • To discuss specific considerations when treating athletes with –
    • Spinal cord injury
    • Cerebral palsy
    • Visual Impairments
    • Amputations
    • Dwarfism
  • 3.
    • 19 Paralympic Summer Sports
    • Athletics, Archery, Wheelchair Basketball, Boccia, Cycling, Equestrian, Fencing, Football, Goalball, Judo, Powerlifting, Wheelchair Rugby, Rowing,
    • Sailing, Shooting, Swimming, Table Tennis, Tennis, Volleyball
    • 4 Paralympic Winter Sports
    • Alpine Skiing, Ice sledge Hockey
    • Nordic Skiing, Wheelchair curling
  • 4.
    • Upbringing
    • Cultural, social and religious background
    • Previous experiences of education
    • Previous life experiences
    • Personality
    • Experience of discrimination
    • The onset of the impairment
    • Whether or not the impairment is progressive
  • 5.
    • Most athletes with disabilities lead independent lives, have jobs and families and are used to international travel for holidays, work etc.
    • Don’t assume you know whether, when and what help a disabled athlete needs.
    • Don’t make assumptions about an athlete’s level of impairment based on a previous experience of an athlete with the same type of impairment.
    • Ask athletes if they want assistance rather than assuming they need it, and if they accept, ask for an explanation of how you can help.
    •  
    • Don’t assume that someone with one disability also has others.
    • Don’t feel you have to avoid certain words – people with disabilities fit into the normative society where normative words are used.
  • 6.
    • When talking to a wheelchair user try to sit across from them. Do not lean on the wheelchair. Wheelchair users consider the chair to be part of their body and personal space. Avoid crouching down like you would to a child.
    • Don’t move wheelchairs / mobility aids without asking permission first.
    • Speech impairment or a lack of speech does not necessarily indicate an inability to understand – allow the individual to speak at their own pace and finish what they are saying.
    • Ask about equipment, aids or techniques they may use to assist them in daily living – wheelchairs, crutches, and braces are visible but prostheses, ileostomy or colostomy devices and breathing assistance devices may not be.
    • Experience their world – try a sports chair, join in training.
    •  
  • 7.
    • On greeting the athlete, make sure you first introduce yourself.
    • Speak naturally – don’t avoid visually descriptive language such as ‘see you later’.
    • Don’t pet a guide dog without the owner’s permission. They should generally be ignored.
    • On first entering the treatment room orientate the athlete to the location of the treatment couch etc.
    • If you leave the room, inform the athlete you are leaving.
    • If treating the athlete on a couch, keep one hand in contact with the athlete as you move around the couch for reassurance.
    • If you need to guide a person with a visual impairment, allow them to take your arm above the elbow, and inform them of any curbs, steps up or down, ramps, doorways etc.
    • May or may not use a white cane – symbol canes are just held to indicate visual impairment, long canes to assess stairs, curbs etc. A white cane with a red stripe indicates hearing impairment as well.
    • Do not move an athlete’s white cane without asking prior permission.
  • 8.
    • Causes:-
    • Traumatic injury - severing of cord or bruising.
    • Viral infections.
    • Toxic conditions.
    • Major symptoms:-  
    • Loss of muscle function and/or loss of sensation below level of the lesion. May be full or partial loss.
    • Associated conditions:-
    • Incontinence (loss of innervation to bladder/bowels).
    • Pressure sores (poor circulation and skin breakdown in weight-bearing areas).
    • Sporadic limb spasticity and joint contractures.
    • Residual pain around injury site.
  • 9.
    • Associated Conditions cont ....
    • UTIs (urinary tract infections) – importance of hydration.
    • Impaired regulation of heart rate, blood pressure and body temperature (ANS dysfunction).
    • Risk of osteoporosis in legs (non-weight-bearing).
    • DVT (through inactivity/sitting).
    • Hederotopic ossification (excessive laying down of bone in soft tissues around joints especially below level of SCI).
    • Increased risk of hypertension, atherosclerosis and cardiovascular disease.
    • Exercise hypotension (low BP from blood pooling in legs).
    • Autonomic Dysreflexia
  • 10.
    • By spinal root level of lesion - e.g. injury at first lumbar level is referred to as L1.
    • By type of cord lesion -
    • (a) complete - paralysis or loss of sensation in the muscles innervated below the level of the lesion.
    • (b) incomplete - paresis (partial paralysis) which leaves some spinal cord function intact and therefore allows some movements or sensations in muscles innervated below the level of the lesion. May not be equal on each side.
    • By body parts affected - 
    • (a) paraplegia - at or below the level of upper abdominals (T1) – the person has full use of the upper extremities including hands but there is neurological impairment to the lower extremities and often part of the trunk.
    • (b) quadriplegia (tetraplegia) - at the cervical level, involving all four limbs and trunk although does not necessarily mean no use of arms.
    • Level C4 is the highest level lesion that a person can sustain and remain alive without breathing support.
  • 11.
    • Transfer ability – plinthe height, assistance needed or not? May need help to lift hips and legs through to achieve prone. If no abdominal control, need assistance to lower into supine.
    • May need to empty / adjust leg bag, tubing, slacken clothing to prevent blockages – see autonomic dysreflexia
    • Treatment position - ? treat in chair or on plinthe.
    • at comps athlete may prefer to be treated in chair between events
    • May need to adapt traditional treatment techniques to apply in chair e.g. mobilisations in sitting / forward lean sitting, nags and snags, acupuncture, soft tissue release. Use of theraband/tubing in chair.
  • 12.
    • SCI athletes only sweat above level of lesion so need to avoid overheating/dehydration during training / competition.
    • S+C – Be aware resting heart rate in quads much lower. MHR 100-125 bpm therefore target training heart rate much lower at 65-91bpm. T1-T6 also lower but not as much. Below T6 – comparative to able bodied.
    • Assess extent of sensation to assist in treatment awareness – may have odd pattern of sensation.
  • 13.
    • Frequently develop muscle imbalances from prolonged sitting posture.
    • Watch for overuse injuries if there is an increased requirement for self-propelling – happens at events depending on location of training / comp facilities, food areas, accommodation.
    • Strengthen lower trapezius, rhomboids and external rotators to avoid rounded shoulders, and neck and back extensors to avoid forward head and rounded back.
    • S trengthen shoulder girdle and scapular musculature to avoid shoulder impingement and rotator cuff injuries e.g. when performing overhead work
    •  
    • Stretch tight muscles e.g. anterior neck, shoulder and trunk; internal rotators and adductors of arm/shoulder; hip and knee flexors; plantarflexors.
    • N.B. Increased ROM in some muscles may be undesirable because tightness has functional benefits e.g. overstretched, non-functional back extensor muscles make it difficult to maintain upright posture.
    • T enodesis - allows quadriplegics who do not have a functional grasp to passively pull the fingers into flexion by extending the wrist.
    • Therefore DO NOT stretch wrist and finger flexors simultaneously with quads otherwise you will decrease their hand function .  
  • 14.
    • Serious life-threatening condition.
    • Occurs in a high % of patients with lesions at or above the 6th thoracic vertebra (T6).
    • Can occur at any time after injury
    • Result of uncontrolled reflex sympathetic activity causing significant rise in blood pressure.
    • Stimulus/cause should be identified.
    • Prompt action must be taken to reduce the blood pressure and to remove the cause.
    • Autonomic dysreflexia occurs when there is an irritating stimulus below the level of the injury.
  • 15.
    • Autonomic nervous system (ANS) functions at an unconscious reflex level. Regulates the internal environment of the body.
    • Made up of Sympathetic (SNS) + Parasympathetic (PNS)
    • SNS - provides stimulus response to stress, activity and injury.
    • Resulting nerve impulses travel up the spinal cord but are blocked on reaching the injury level.
    • Impulses cannot reach the brain but activate a reflex which increases SNS response.
    • Results in vaso-constriction - leads to the development of high blood pressure.
    • Brain indirectly appreciates the change in the blood pressure through nerve receptors in the heart and aorta but cannot influence changes below the level of the injury.
    • Concomitant vaso dilatation of blood vessels seen as flushing and blotching of the skin in upper half of the body and face, nasal congestion and pounding headache.
  • 16.
    • 1. Bladder
    • e.g. over distension, blocked catheter, kinked tubing, full leg bag , u rinary tract infection , b ladder stones.
    • Bladder dysfunction is the most common cause of autonomic dysreflexia.
    • 2. Bowel
    • e.g. Constipation , d igital evacuation , r ectal examination.
    • 3. Pressure Sores.
    • 5. Electro-Ejaculation.
    • 6. Pregnancy and Labour.
    • 7. Sexual Activity.
    • 8. All other conditions with pain below lesion – fractures, wounds, burns.
    • Physio induced possible causes - acupuncture, cold therapy, positioning on plinthe, soft tissue / joint work below level of lesion – rarely clinically needed.
    • Would not advise ice baths in SCI athletes with lesions T6 and above. Care with ice baths below T6 due to altered thermoregulation.
  • 17.
    • Symptoms
    • • Pounding headache
    • • Feeling of doom, anxiety & apprehension
    • • Profuse sweating
    • • Tightness in chest.
    • Signs
    • • Flushing and/or blotching above level of cord lesion
    • • Hypertension and bradycardia
    • • Pupillary dilatation
    • • Cardiac dysrhythmia
    • Above lesion :
    • • Pallor initially
    • • Flushing head and neck
    • • Sweating in area above and around the lesion.
  • 18.
    • Below lesion:
    • • Cold peripheries
    • • Pilo erection
    • • Contraction of bladder and bowel
    • • Penile erection & seminal fluid emission.
    • Note:
    • Under normal circumstances a tetraplegic person may have a low blood pressure (e.g. 90/60mm.Hg). A rise to “normal” level of 120/80mm.Hg. may represent a significant elevation.
  • 19.
    • Immediately sit the patient up to lower BP 
    • Remember until bladder or abdo distention is alleviated, sting up to 90 degrees could cause further pressure so make symptoms worse.
    • Summon medical help
    • Check catheter and tubing for kinks or empty leg bag
    • Check for bladder and lower bowel distension 
    • Check for tight clothing, abdominal strap, leg bag strap, shoe, brace etc.
    • Give medication of choice if patient normally takes this.
    • may be sublingual Nifedipine 5 mg pierced, bitten or chewed. Treatment may be repeated up to four doses (40mg) over one hour.
    • GTN Spray
    • If possible monitor blood pressure every five minutes during the episode
  • 20.
    • A non-inherited, non-progressive disorder resulting from damage to the brain which occurs at or around birth or during the first year of infancy.
    • Lesion in the upper motor neurons within the brain - regulate neuromuscular function, control muscle tone and spinal reflexes.
    • Primitive reflexes may persist throughout life.
    • Lesion never worsens and as the central nervous system matures, the condition stabilises.
    •  
    • CP is primarily a motor deficit. Other disorders may be present, including:
    • Convulsive disorders
    • Cognition disorders
    • Perceptual and motor disorders
    • Visual difficulties
    • Speech and language difficulties
    • Orthopaedic problems
  • 21.
    •   Anatomical classification
    • Monoplegia - One limb is affected, usually an arm
    • Paraplegia - Lower extremities and hip region are affected
    • Hemiplegia - Limbs on one side of the body are affected
    • Triplegia - Three limbs are affected, usually both legs and one arm
    • Quadriplegia - All four limbs and the trunk are affected. Neck and facial muscles may also be involved
    • Diplegia - More involvement in lower limbs than upper limbs.
    • Neuromotor classification
    • Spastic CP
    • Athetoid CP
    • Ataxic CP
  • 22.
    • 70% of all CP cases.
    • Fixed lesion in the motor portion of the cerebral cortex.
    • Increased muscle tone (hypertonicity) - most often affecting flexor and internal rotator muscles .
    • If hypertonicity is not controlled, contractures may permanently shorten resting muscle length and cause joint deformities .
    • - shoulders: flexed, adducted, internally rotated
    • - forearms: pronated
    • - elbows/wrists/fingers flexed
    • - hips: flexed, adducted, internally rotated
    • - knees flexed
    • - feet: plantarflexed, everted
    • Increased by - stress, emotional arousal, cold weather, fatigue, posture, positioning, stretching and fast movements. 
  • 23.
    • 20-30% of cases. Can often accompany spasticity.
    • Involves a lesion to the extrapyramidal cells in the basal ganglia.
    • Primary symptom is slow, nonrhythmical, random and involuntary writhing or jerking movements, often expressed in head, neck and facial muscles as well as limbs (e.g. pill rolling).
    •   
    • Characterised by continual state of involuntary movement and fluctuations in muscle tone from hypotonus to hypertonus (distonia: abnormal muscle tone)
    •  
    • Stress, increased effort or emotional arousal may increase abnormal movement patterns
    • Dysarthria (difficulty with speech) often associated with athetosis
  • 24.
    • Affects 5-10% of cases.
    •  
    • Involves a lesion to the cerebellum.
    •  
    • Primary symptoms are:
    • - poor body balance (especially with upright posture).
    • - impaired gait with uncertain, staggering movements.
    • decreased trunk control and lack of co-ordination - usually walk with a wide-based gait to compensate.
    • Muscles are hypotonic.
    •  
    • May be impaired kinaesthetic sense which affects judgment of posture, centre of gravity and body relationships to external objects.
  • 25.
    • Depending on type of CP, strength and tone may be different on each side.
    • Stretch tight, spastic muscles. May be difficult to hold static stretches if athetoid or ataxic.
    • Strengthen antagonists (usually extensors) as these are often weak.
    • Care with overtraining - risk of increasing tone due to post training soreness and fatigue.
    • Consider location of training venues to avoid long transit journeys between – again will affect fatigue and tone
    •  
    • Avoid cold or noisy treatment environments as may increase spasticity.
    • Use slow, large movements to decrease muscle tone/spasticity. Rapid movements will increase tone.
    •  
    • Use mind/breathing e.g. “think about straightening your arm as you breathe out”.
    • Be aware of primitive reflexes – may need to adapt positioning.
    • NB - Don’t introduce soft tissue massage pre-event unless you know how it will affect their tone - Athletes frequently rely on their tone to perform.
    •  
  • 26.
    • Defined as an individual with an adult height of 4ft 10 in or shorter as a result of medical or genetic factors
    • Over 250 different types of restricted growth conditions.
    • Skeletal dysplasias - characterized by intrinsic abnormalities in growth/remodelling of cartilage and bone.
    • Two main categories, disproportionate and proportionate .
  • 27.
    • Disproportionate - commoner of the two. Results in average size torsos with shorter arms and legs – cause is from skeletal dysplasia, the failure to develop bone either inherited or due to gene mutation.
    • Proportionate - short in stature
    • Main cause due to pituitary gland dysfunction (growth hormone deficiency)
  • 28.
    • Most common – 80% of Dwarf population
    • Occurs all races equal frequency
    • Equal frequency male/female.
    • Standing height below 1/3 rd percentile both sexes-male 132cms, female 125cms. Sitting height normal.
    • Normal life expectancy
    • Gross motor development is frequently delayed.
  • 29.
    • Disproportionate short stature - normal trunk length, narrow thoracic cage.
    • Rhizomelic limbs (shortened), skin folds
    • Hyperlordotic
    •  muscle tone
    • Hypermobilty of most joints
    • Genu Varum -  lateral tibial torsion
    • Large head – prominent forehead
    • Midface hypoplasia (underdevelopment)
    • Radiological Findings -
    • Contracted skull base – small foramen magnum - compression
    • Short pedicles
    • Short femoral neck
    • Flat roofed acetabular
    • Narrow sacro-iliac groove
  • 30.
    • Lumbo-sacral spinal stenosis – most common 90% adults
    • Craniocervical junction compression 10% infants
    • Spinal deformities – thoracolumbar kyphosis, kyphoscoliosis.
    • Cervical atlanto-axial instability (less in achondroplasia)
    • Premature degenerative changes – frequently need joint replacements hips and kness
    • Joint hypermobilty – knees, ankles, dislocation and trauma.
    • Joint hypomobility- elbows  ext +rot, hip  ext.
    • Respiration – sleep apnoea,  cardiopulmonary exercise capacity.  prevalence of pneumonia
    • Hydrocephalus
    • Neurological symptoms – due to anatomical abnormalities, or stretching of nerves e.g. ankle pain from peroneal nerve
    • Fibromyalgic symptoms – trigger points, trochanteric bursitis.
  • 31.
    • Treatment couches – height
    • Strapping – hypermobile joints, excess skin folds, short limbs
    • Need to maintain joint range for sporting function e.g. powerlifting cannot have in excess of 20° loss of elbow extension
  • 32.
    • Congenital -
    • Limb may be absent at birth, or malformed at birth and subsequently removed to provide a better fit for a prosthesis (artificial limb)
    • Dysmelia = absence of a complete limb
    • Phocomelia = absence of middle segment of limb with distal portions attaching to joint e.g. hands attached to shoulders or feet attached near hips
    • Acquired -  
    • circulatory malfunction causing loss of blood supply to limb and resulting death of affected tissue e.g. diabetes
    • cancerous tumours
    • serious infections 
    • trauma (work-related/RTA/severe burns) 
  • 33.
    • General
    • Contractures and decreased ROM 
    • Impaired sensation and skin damage
    • Phantom pain 
    • Upper Limb
    • Deformities of the spine especially scoliosis with upper extremity amputations
    • Removal of dominant hand/arm can create awkward movement patterns and lack of co-ordination
    • Reduced efficiency and stability in locomotion; balance may be affected
    • Postural imbalances through displaced centre of gravity
  • 34.
    • Lower Limb -
    • Increase in energy expenditure with prosthesis
    • Decreased control of dynamic balance
    • Altered gait pattern and decreased gait efficiency (AK especially through using hip to hitch)
    • Removal of dominant leg can create awkward movement patterns and lack of co-ordination
    • Postural imbalances
    • Speed, lateral agility, stair-climbing and jumping efficiency all affected
    • Fixation in thoracic region
  • 35.
    • General -
    • Stump care – watch for breakdown of stump with overtraining / new training methods
    • Balance re-education – sit fits, WII Fit
    • Upper extremity -
    • Trunk and postural exercises to focus on midline control e.g. strengthen back extensors and lateral flexors on that side to compensate for leaning towards heavier complete side
    • Lower extremity -
    • Tight trunk/hip/knee flexors and adductors in AKs – encourage lying on stomach to stretch
    • Hip hitching on swing phase when walking, can lead to excessive lordosis and thoracic fixation > low back pain
    • Strengthen core - lower abdominals/gluts/pelvic floor. Pilates.
  • 36.
    • Consult your best resource – the athlete.
    • Know key features of the disability and associated conditions e.g. Autonomic dysreflexia, altered thermoregulation in SCI’s
    • Consider treatment environment – temperature, safety, plinthe height, treatment position.
    • Appropriate application of sports massage - timing
    • Don’t be afraid to try things – most treatments/training techniques with able bodied athletes can be adapted.
    • Thank you