Making sure young athletes are fit to compete in Special Olympics

By Mathew W. Lively, DO

The preparticipation examination of these young athletes must address some important concerns beyond those of the usual PPE. Here's what you need to keep in mind.

Special Olympics, Inc., is an international organization that was established in 1968 to provide year-round sports training and athletic competition for people who are mentally retarded. The organization has grown to serve more than 1 million athletes in more than 150 countries, conducting Special Olympics competitions at local, state, national, and international levels. Athletes participating in Special Olympics are required to have a preparticipation physical examination (PPE) at the time of their initial certification for eligibility. Although guidelines for conducting PPEs in nondisabled athletes have been established, few guidelines are available to help physicians conduct sports physicals specifically for disabled athletes. To facilitate medical screening of young athletes for participation in Special Olympics, this review describes the eligibility requirements and risks and offers advice drawn from the broad literature concerning the content of PPEs for Special Olympics participants.

Who is eligible to compete?

Special Olympics is open to all persons with mental retardation or a closely related developmental disability that results in functional limitations in both general learning and adaptive skills.¹ Developmental limitations, however, cannot be based solely on a physical, behavioral, or emotional disability or a specific learning or sensory disability.¹ Participants must be at least 8 years of age. Tables 1 and 2 list Special Olympics summer and winter sports.

TABLE 1
Special Olympics summer sports

Official sports

Aquatics

Athletics (track and field)

Basketball

Bowling

Cycling

Equestrian sports

Soccer

Golf

Gymnastics

Power lifting

Roller skating

Softball

Table tennis

Tennis

Volleyball

Popular sports

Badminton

Bocce

Sailing

Team handball

TABLE 2
Special Olympics winter sports

Alpine skiing

Cross-country skiing

Figure skating

Floor hockey

Speed skating

Athletes who want to compete in Special Olympics must register with the organization and complete a standardized application. The application includes a health information section that requires certification from a licensed medical professional that he or she has examined the athlete and has not found medical evidence that would preclude the athlete's participation. This certification and physical examination is valid for life unless a significant change in condition occurs—except for athletes competing in regional or world games, who must have a medical examination within the year preceding the competition.¹ Although Special Olympics, Inc., does not require a yearly PPE, local accredited programs are required to seek follow-up medical advice annually for athletes who program officials believe have undergone a significant change in health since initial certification.¹

Performing a complete PPE once every three or four years with a limited annual reevaluation is consistent with the current PPE recommendations for nondisabled athletes at all levels of competition.² However, the American Heart Association recommends that nondisabled athletes at the high school, but not collegiate, level have a repeat cardiovascular examination every two years.³

Athletes with a blood-borne infection who meet the other criteria for eligibility can compete in all Special Olympics events. During competitions, universal precautions must therefore be followed for every exposure to blood, saliva, and other bodily fluid.¹

What are the risks of participation?

Some health-care providers may hesitate to certify disabled athletes for sports participation for fear that athletic competition is dangerous. Others may avoid providing medical coverage for Special Olympics competitions for similar reasons. The reality, however, is that Special Olympics events carry a lower risk of injury than similar activities by nondisabled athletes.⁴

Between 2.8% and 3.9% of Special Olympics athletes require medical attention during competition.^4–6 Most medical encounters are for trauma-related injury, not medical conditions.^4,5,7 The most common injuries are minor sprains and strains, contusions, and abrasions, typically on the lower extremities.^4,5,7,8 Track and field events appear to result in the most injuries, partly because they have the largest number of participants.^4,6

The most common reason other than injury for seeking medical attention is abdominal pain caused by indigestion.^2,7 After abdominal pain, the conditions that most often require medical care are seizures in predisposed persons and heat illness.^4,7 Sunburn and conjunctivitis resulting from sun block in the eyes have also occurred often in some competitions.^4,5 Overall, most injuries in Special Olympics competitions are minor, and many medical problems can be prevented if athletes receive careful and prudent attention during the games.

What are the components of the PPE?

The guidelines for conducting a PPE that have been published jointly by several medical organizations² do not address the particular concerns of disabled athletes. Because most athletes who compete in Special Olympics have an underlying medical condition, the PPE for those athletes often has to deal with issues that do not occur in nondisabled athletes. Down syndrome is one example. Special Olympics, Inc., has drawn up guidelines for screening athletes with Down syndrome, which are discussed below.

The PPE for all athletes entails obtaining a medical history, physical examination, and appropriate laboratory studies. For disabled athletes, particular attention should be given to the visual, cardiovascular, musculoskeletal, and neurologic systems because most abnormalities encountered in Special Olympics participants occur in these areas.^9,10

Medical history. A thorough medical history is vital; approximately 70% of abnormal findings are uncovered during this component of the examination.^11,12 A parent or guardian who is familiar with the athlete's medical history must be present to obtain the most accurate answers to questions. The health information section of the Special Olympics certification form contains questions concerning the athlete's personal medical history but does not inquire about a family history of medical problems. General PPE guidelines recommend that questions concerning a family history of sudden death, significant cardiovascular disease, or the occurrence of certain cardiovascular conditions (hypertrophic cardiomyopathy, long QT syndrome, important arrhythmias) be included in the screening of athletes.^2,3 Such questions should also be a routine part of the PPE for disabled athletes. Current medications, allergies, and the status of immunizations (especially against tetanus) are other important elements of the medical history that should be documented on the examination form.

Vision. Eye examinations of Special Olympics athletes have revealed a high prevalence of vision abnormalities—mostly poor visual acuity and monocular vision.^10,13 Also of concern is that 41% of Special Olympics athletes in one study reported no previous eye examination before their PPE.¹³ A visual acuity test using a Snellen chart or a modified acuity card should be performed routinely for athletes who are undergoing a sports physical.

Current sports participation guidelines recommend that an athlete with a best corrected acuity of less than 20/40 in one eye should be considered functionally one-eyed and wear eye protection during sports that carry a high risk of ocular injuries (Table 3).^2,14 Special Olympics events in this category include badminton, basketball, softball, handball, soccer, floor hockey, and tennis.

TABLE 3
High-risk Special Olympics sports

Risk of eye injury

Badminton

Basketball

Floor hockey

Handball

Soccer

Softball

Tennis

Risk to athletes with atlantoaxial instability

Alpine skiing

Diving

Equestrian sports

Gymnastics

High jump

Pentathalon

Soccer

Swimming (butterfly stroke and events involving diving starts)

Athletes who require eye protection should wear sports goggles with polycarbonate lenses.¹⁵ Athletes who wear glasses and compete in sports that have a low risk of eye injury can use street-wear frames that meet American National Standards Institute (ANSI) standard Z87.1 with polycarbonate or CR-39 lenses and a strap that secures the frame to the head.¹⁵ Attention to eyewear is important because 30% of Special Olympics athletes have been shown to wear standard glasses during competition.¹³

Cardiovascular system. Cardiovascular disorders are the most common cause of sudden death in nondisabled athletes.¹⁶ This fact takes on added significance for Special Olympics athletes because of the high prevalence of congenital heart defects in this population. Approximately 15% of athletes competing in Special Olympics have Down syndrome,⁸ and 40% to 50% of persons with this disorder have congenital heart disease.¹⁷ Extra diligence is required, therefore, when assessing the presence or absence of symptoms, functional capacity, and any associated conditions in athletes who have a history of congenital heart disease. Most of these athletes need clearance from a cardiologist before participating in sports.

Cardiac murmurs are common in healthy athletes; most do not need an extensive evaluation. An asymptomatic athlete without a family history of heart disease and an isolated systolic murmur grade 2/6 or softer requires no further cardiac evaluation.¹⁸ However, an athlete with any diastolic murmur, a systolic murmur grade 3/6 or louder, or a murmur that increases in intensity with the Valsalva maneuver must be further evaluated before participating in sports.²

Musculoskeletal system. Motor deficits are common in many genetic disorders, and some Special Olympics athletes use braces or wheelchairs, which can restrict the examiner's ability to perform a complete orthopedic evaluation. Nevertheless, an effort should be made to evaluate the athlete's overall joint mobility and function and to look for scoliosis. Any reported history of a prior orthopedic injury mandates an assessment of the affected area to ensure that no residual laxity or weakness is present that may predispose the athlete to further injury.

Athletes with Down syndrome present a unique musculoskeletal concern because of the possibility of atlantoaxial instability (AAI). Approximately 15% of children with Down syndrome have AAI, and almost all are asymptomatic.¹⁹ People with AAI are at increased risk of spinal cord injury during certain activities.

Special Olympics, Inc. has formulated guidelines for screening and participation of athletes with Down syndrome.¹ The guidelines require a full radiologic examination (including flexion and extension views) of the cervical spine for such athletes who want to participate in equestrian sports, gymnastics, diving, swimming events that involve diving starts or the butterfly stroke, pentathlon, high jump, soccer, and alpine skiing. Athletes with documented AAI are excluded from participation in these sports unless they meet the following two conditions:

• The athlete, or a parent or guardian of a minor athlete, confirms in writing his or her decision to participate in the activity regardless of the risks.

• Two licensed medical professionals certify in writing that they have explained the risks of participation to the athlete and his or her parent or guardian and that AAI does not, in their medical judgment, preclude the athlete from participating in the restricted activities.¹

The Special Olympics certification form includes a notice of the radiologic requirement for Down syndrome athletes and a section in which to document the presence or absence of AAI.

Neurologic system. Because many athletes who compete in Special Olympics have some form of neurologic deficit, a detailed preparticipation neurologic examination is important. Spasticity associated with cerebral palsy or another central nervous system disorder may restrict joint range of motion and limit an athlete's ability to perform certain activities. Although symptomatic AAI is rare, neurologic manifestations of the condition include easy fatigue, abnormal gait, neck pain and limited mobility, incoordination, spasticity, hyperreflexia, clonus, and other upper motor neuron signs and symptoms.^19,20 The importance of a neurologic exam is underscored by the fact that persons with Down syndrome who suffer an AAI–related catastrophic spine injury often have had weeks or years of prior neurologic symptoms.¹⁹

Seizure disorder is second only to Down syndrome as the most common medical disorder reported in Special Olympics athletes,^5,21 and seizures are a frequent reason that athletes require medical care during competition. It is rare, however, for someone to suffer a seizure while exercising; the majority of activity-related seizures occur after exercise has stopped.²² A well-controlled seizure disorder does not preclude participation in any sport, but close supervision of seizure-prone athletes during aquatic sports is recommended.^2,14,22 Athletes with a poorly controlled seizure disorder should be restricted from aquatic and power lifting sports, as well as sports that carry an increased risk of falls (gymnastics, equestrian events, cycling, skiing).^2,14,22

Although no documented evidence exists that repetitive minor head trauma during contact sports increases seizure frequency, most authorities recommend that athletes who suffer frequent seizures avoid contact and collision sports.^2,22 Because hyperthermia can trigger seizures, extra caution should be taken to ensure athletes get adequate hydration and rest during competitions in a hot, humid environment.

Laboratory testing and imaging. With the exception of cervical spine radiographs in certain athletes with Down syndrome, no routine laboratory or radiologic screening tests are recommended. Routine laboratory testing during a PPE has not been shown to be cost-effective or necessary.^2,18 The need for laboratory or radiologic testing should be based on the results of a complete history and physical examination.

Opportunity with few risks

Special Olympics provides the opportunity for athletes with mental retardation to compete in sporting events at local, state, national, and international levels. These athletes are required to have a complete preparticipation examination, which must be repeated if their health status changes. The risk of injury associated with participating in Special Olympics is lower for these athletes than the risk of injury to nondisabled athletes in similar events, and most injuries sustained during competition are minor. The PPE for Special Olympics athletes should consist of a detailed medical history and a physical exam that focuses on the visual, musculoskeletal, and neurologic systems because many athletes have an abnormality in one or more of these areas.

REFERENCES

1. Special Olympics, Sports Rules Advisory Committee: Official Special Olympics Summer Sports Rules 2000–2003, revised ed. Washington, D.C., Special Olympics, Inc., 2000, pp 8–12

2. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine: Preparticipation Physical Evaluation, ed 2. Minneapolis, Minn., McGraw-Hill Co., 1997

3. American Heart Association: Cardiovascular preparticipation screening of competitive athletes. Circulation 1996;94:850

4. Batts KB, Glorioso JE, Williams MS: The medical demands of the special athlete. Clin J Sport Med 1998;8:22

5. Birrer RB: The Special Olympics: An injury overview. The Physician and Sportsmedicine 1984;12:95

6. McCormick DP: Injury and illness surveillance at local Special Olympics games. Br J Sports Med 1990;24:221

7. Gelena HJ, Epstein CR, Lourie RJ: Connecticut State Special Olympics: Observations and recommendations. Conn Med 1998;62:33

8. Perlman SP: Special Olympics athletes and the incidence of sports-related injuries. Journal of the Massachusetts Dental Society 1994;43:44

9. Hudson PB: Preparticipation screening of Special Olympics athletes. The Physician and Sportsmedicine 1988;16:97

10. McCormick DP, Ivey FM, Gold DM, et al: The preparticipation sports examination in Special Olympics athletes. Tex Med 1988;84:39

11. Goldberg B, Saranti A, Witman P, et al: Preparticipation sports assessment: An objective evaluation. Pediatrics 1980;66:736

12. Lively MW: Preparticipation physical examinations: A collegiate experience. Clin J Sports Med 1999;9:3

13. Block SS, Beckerman SA, Berman PE: Vision profile of the athletes of the 1995 Special Olympics World Summer Games. J Am Optom Assoc 1997;68:699

14. American Academy of Pediatrics Committee on Sports Medicine and Fitness: Medical conditions affecting sports participation. Pediatrics 2001;107:1205

15. American Academy of Pediatrics Committee on Sports Medicine and Fitness, American Academy of Ophthalmology Committee on Eye Safety and Sports Ophthalmology: Protective eyewear for young athletes. Pediatrics 1996;98:311

16. Maron BJ, Shirani J, Poliac LC, et al: Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA 1996;276:199

17. Hayes A, Batshaw ML: Down syndrome. Pediatr Clin North Am 1993;40:523

18. Tanji JL: The preparticipation exam—Special concerns for the Special Olympics. The Physician and Sportsmedicine 1991;19:61

19. American Academy of Pediatrics: Atlantoaxial instability in Down syndrome: Subject review. Pediatrics 1995; 96:151

20. Cope R, Olson S: Abnormalities of the cervical spine in Down syndrome: Diagnosis, risks, and review of the literature with particular reference to the Special Olympics. South Med J 1987;80:33

21. Robson HE: The Special Olympic Games for the mentally handicapped—United Kingdom 1989. Br J Sports Med 1990;24:225

22. Sirven JI, Varrato J: Physical activity and epilepsy. What are the rules? The Physician and Sportsmedicine 1999;27:63

DR. LIVELY is assistant professor of medicine and pediatrics, West Virginia University, Morgantown, W.Va.

What is the difference between Special Olympics and Paralympic Games?

Although some athletes who qualify for Special Olympics may also qualify for the Paralympic Games, the two organizations are separate entities with separate competitions. The Paralympic Games are made up largely of athletes with a physical disability (such as spinal cord injury, amputation, visual impairment, and cerebral palsy) and do not require that participants be mentally retarded or have a developmental disability.

 

Mathew Lively. Making sure young athletes are fit to compete in Special Olympics. Contemporary Pediatrics 2003;1:101.