Suzy Kim, M.D. Medical Director, St. Jude Centers for Rehabilitation & Wellness Spinal Cord...

Handcycling InjuryParacycling

Suzy Kim, M.D.Medical Director, St. Jude Centers for Rehabilitation & WellnessSpinal Cord Injury & Neurologic RehabilitationRancho Los Amigos National Rehabilitation CenterUSC Keck School of MedicineTeam Physician, USOC Olympic and Paralympic Teams

AAPM&R Adaptive Sports Medicine Symposium, October 1, 2015

Disclosure

Suzy Kim, M.D. is on the Speakers Bureau

for Allergan Neurosciences

Acknowledgements

United States Olympic Committee, Sports Medicine (USOC)US ParalympicsUS Paralympic Paracycling Team

Union Cycliste Internationale (courtesy photos)

History

Chief Complaint: Right lower leg road rash following

handcycle crash on course during training ride at Nationals

History of Present Illness 26 y/o M handcyclist (H3

classification) with T8 motor complete paraplegia (T8 AIS B SCI)

During a sharp turn on the course, right leg came out of foot rest and twisted ankle under front wheel causing isolated rollover crash

Athlete reports a strong sudden right hip and knee flexion spasm pulled right leg out of foot rest

Anatomy of Competition Handcycle

Rear Wheels

Backrest

Headrest

Gear shiftersDraft bar

Fork

Fixed frame

Arm cranks

Footrests & strap

Hand pedals

Competition Handcycling (H1-H3)

Photo courtesy of UCI

History of Present Illness

From baseline, increased frequency of bilateral lower extremity spasms –primarily flexion based x 1 week prior to competition

Few episodes of urinary incontinence between scheduled intermittent catheterizations

Mild malaise, denies fever or chills

History…

Spasticity Baseline: episodic lower extremity

clonus and spasms. Not functionally limiting. Not taking any anti-spasmodic medications

Triggers: position changes. does not occur during wheelchair transfers, not painful. Changes with UTI or constipation

Alleviators: self ROM, WB with standing frame.

History…

Neurogenic bladder Scheduled clean intermittent

catheterization q4-6 hours depending on fluid intake

Receives botox injections q 6 months (last 3 months ago)

Ditropan XL 5mg daily

Past Medical & Surgical HistoryStable T8 AIS B SCISpinal ependymoma causing cord

compression at T10. Dx 2006 s/p tumor resection No surgical fusion or instrumentation

Neurogenic bladder Neurogenic bowelNo history of fractures since SCIMild neuropathic pain at NLI and below

No pain medications

Functional History

Mobility Primary manual wheelchair user Independent community mobility, transfers without

sliding board Activities of daily living

Independent at wheelchair level Independent driving adapted car with hand controls Independent bladder/bowel management

Community Lives with wife in single level wheelchair accessible

home Employed as a financial planner Travels independently-national/international

Physical Exam (on site)

Inspection No gross deformities, superficial road rash of right lower

proximal lateral leg, focal edema right ankle w/o ecchymosis. Generalized atrophy proximal and distal lower extremities

Palpation No bony deformities, knee joint laxity, crepitus, knee

effusions. 2+ edema over right lateral malleolus and dorsal foot

ROM Soft end range with PROM hip extension with 15 degrees

hip flexion tightness bilaterally. Full PROM knee flexion & extension. Ankle dorsiflexion subtalar neutral with PROM with knee extension and +15 with knee flexion

Physical exam (off site)

Neurologic Spastic paraplegia: L2-S1 myotomes 0/5 , T8

sensory level Clonus and spasms easily triggered by any

tactile stimuli or ROM Fair dynamic trunk control

Special Tests** Knee instability: (-) pivot shift, anterior &

posterior drawer, Lachman’s, McMurray’s, patellofemoral tests

Ankle instability: (-) talar tilt, anterior drawer

Differential Diagnoses

Photo courtesy of UCI

Differential Diagnosis

Cause of crash: Course conditions Athlete performance error Faulty competition equipment-handcycle Uncontrolled lower extremity spasms

Change in spasticity: Noxious stimuli: UTI, occult fracture, pressure

ulcers, constipation Fracture of femur, tibia, fibula Knee sprain Ankle sprain

Diagnostics: pelvis/hip x-ray

Diagnostics: Femur & tib/fib x-ray

Diagnostics: foot & ankle x-ray

Definitive Diagnoses

Photo courtesy of UCI

Diagnoses

1. Superficial soft tissue injuries – right lower lateral leg road rash

2. Mild right ankle inversion sprain3. New/acute UTI 4. Spasticity exacerbation: Increased

lower extremity spasms due to acute UTI

Initial Treatment

Local wound careUrinalysis and culturePain control

Phenazopyridine (pyridium) 200 mg tid RICE: NSAIDs, edema compression

Empirical cephalexin 500 mg bid for UTI

Handcycle adjustments Thigh and footstraps

Spasticity treatment options

PROM Focal NMES

(neuromuscular electrical stimulation) quadriceps and hamstrings to “fatigue” spastic muscles

Discussion

Injury Prevention

ILLNESS INJURYTreat underlying illness!Optimize daily managementUnique considerations for para-

athletes Impaired sensation Atypical pain responses (ie. spasticity,

AD) High risk low velocity fractures of

paralyzed limbs Pre-existing abnormalities**high index of suspicion

Photo courtesy of US Paralympics

Performance Implications

Symptom checklist UTI Change in spasticity/AD Skin check

Hydration w/ UTI & neurogenic bladder

Treatment limitations in competitionAthlete, coach, staff education to

seek early medical attention

Follow Up Treatment (when home) Continue local wound care Follow up UTI treatment Spasticity management Bone health:

Baseline DEXA scan/bone density

Vitamin D 25-hydroxy level

Consider FES leg ergometry Continue weight-bearing in

standing frame Calcium/Vit D supplements

✔

Photo courtesy of RTI

Questions?suzykimmd@gmail.com

Photo courtesy of US Paralympics

Thank you.

Photo courtesy of US Paralympics