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Medical Considerations for the Wheelchair Tennis Athlete

By Erin Andrede, MD


Wheelchair tennis is just one of a number of adaptive sports opportunities for individuals with a range of neuromuscular conditions. Since its beginnings in the 1970s, it has gained significant popularity, and the number of clinics and tournaments is increasing [1]. Although the rules of wheelchair tennis and able body tennis are

largely similar, there are a few key differences between wheelchair tennis and able body tennis. The main differences are that the wheelchair athlete is allowed two bounces to hit the ball, and the athlete may use a manual or power wheelchair for mobility [1]. The medical care for the wheelchair athlete is also similar to the care for the able bodied athlete, but there are key considerations for the wheelchair athlete. Depending on the

underlying neuromuscular condition, a few of these key considerations include mobility needs, upper extremity injuries, thermoregulation, autonomic dysreflexia, neurogenic skin, and neurogenic bladder.


MOBILITY NEEDS: As mentioned, a variety of neuromuscular conditions may impact the functional mobility of an individual. Some of the more common underlying medical conditions of the wheelchair athlete include spinal cord injury, stroke, amputation, cerebral palsy, and spina bifida. The use of a wheelchair can help improve the mobility of an individual. Depending on the type of injury, a manual wheelchair or power wheelchair may be more appropriate for the athlete. For example, if an athlete can not propel a manual wheelchair in a functionally significant way, he or she could utilize a power wheelchair [1]. Additionally, not all wheelchair athletes use a manual wheelchair for all of their mobility. Some individuals may have sufficient strength or balance to ambulate

household or short community distances using a walker or other assistive device. In order to mobilize distances more quickly and safely, they may choose to use a manual wheelchair to play tennis. Athletes should be seen by a certified wheelchair specialist to fit them appropriately. Back rest height, weight of the chair, camber or angle of the wheels, and many other factors must be considered. From a safety perspective anti-tippers or suspension systems should be assessed dependent on the functional abilities of the athlete [2].


Tennis, with the overhead reaching and leaning, can pose a risk to one tipping backward. Anti-tippers can be added to a wheelchair to help prevent the athlete from tipping over backward. Those athletes who do not use a manual wheelchair for their daily activities or are new to wheelchair tennis should strongly consider using anti-tippers, see Figures 1 and 2 [2]. For those athletes with poor trunk control or balance, waist restraints can help secure the athlete to the chair. Spasticity or other lack of muscle control may also necessitate the use of straps to secure one’s legs to make sure they stay on the footplate [2].





UPPER EXTREMITY INJURIES: The wheelchair athlete often requires the use of the upper extremities to not only play tennis, but for mobility and other aspects of functional independence. For this reason, it is crucial to immediately evaluate and manage upper extremity pain and injuries. The wheelchair tennis athlete is prone to similar injuries as the overhead or throwing athlete, most commonly including rotator cuff impingement and bicipetal tendinitis [3]. The athlete may also be prone to other injuries such as median or ulnar neuropathies, lateral epicondylitis, or arthritis [3]. The key concept to keep in mind is that a wheelchair athlete may rely on his or her upper extremities to maintain his or her independence. New upper extremity pain or weakness may impact the ability to perform transfers, to mobilize, and to perform other aspects of self-care. For this reason, one should encourage prompt management of new pain.


THERMOREGULATION: Heat related illness threatens the athlete and can lead to dangerous conditions such as hyperthermia, heat exhaustion, or heat stroke. All athletes are prone to these conditions, but an individual with impaired autonomic regulation is at a particular risk as the ability to regulate temperature may be compromised. For this reason, since the body’s mechanisms to regulate temperature are impaired, one will need to utilize environmental cooling methods such as shade, fans, and ice [3]. When using ice to cool one’s core temperature, given that some individuals may have impaired sensation, it is important to monitor for cold-induced injuries.


AUTONOMIC DYSREFLEXIA: Autonomic dysreflexia is a condition unique to individuals who have a spinal cord injury. Specifically, those athletes with an injury level at T6 or above are susceptible. It is caused by loss of descending central sympathetic control and hypersensitivity of receptors below the level of the lesion [4]. Typically, some type of noxious stimulus, such as a new skin lesion, will cause an uncontrolled sympathetic response. Common signs and symptoms of autonomic dysreflexia include headache, sweating, flushing, hypertension, bradycardia or tachycardia, piloerection, and pupillary constriction. The condition can be life threatening secondary to dangerous hypertension leading to cerebrovascular hemorrhage, seizure, myocardial infraction, or even death [4]. The initial management involves sitting the patient upright and loosening tight clothing, identifying and removing the noxious stimulus, and monitoring and controlling blood pressure. Of note, an individual with a spinal cord injury may have a baseline resting blood pressure in the 90-100 systolic range. For this reason, elevations of blood pressure 20-40 mm Hg above baseline are characteristic of an episode of AD. Medication management is typically initiated for a blood pressure of >150 systolic [3].


NEUROGENIC SKIN: Many wheelchair athletes have altered sensation and innervation to the skin, which poses a significant risk for development of skin lesions. A few common area of skin breakdown are the sacrum and ischium because they are areas of high pressure while sitting. Many athletes use custom cushions to help relieve these high-pressure areas. Other vulnerable areas include the heels, ankles, and feet [5]. Especially

during long matches, the athlete will need to make sure to perform pressure offloading and skin checks should be performed routinely. Areas of non-blanching erythema are concerning because they are stage I ulcers [4].


NEUROGENIC BLADDER: Bladder management often poses a challenge for the wheelchair athlete. Bladder management options can vary from individuals using an indwelling foley catheter to performing an intermittent self-catheterization program. Individuals with a neurogenic bladder are at risk for urinary tract infections for a

variety of reasons including hygiene, bladder spasms, or altered anatomy. Adequate hydration, good hygiene, and proper emptying of the bladder can help prevent urinary tract infections [4]. Individuals with chronic conditions may have altered bladder anatomies, such that their storage capacity is decreased, and may require more frequent restroom visits. Urinary tract infections can present in atypical ways, and the athlete may have more generalized reports of malaise, increased spasticity, bladder spasms, or having a fever [3]. If suspicious of a urinary tract infection, one should notify the individual’s primary provider and pursue further evaluation with urinalysis and urine culture.


These key considerations - mobility needs, upper extremity injuries, thermoregulation, autonomic dysreflexia, neurogenic skin, and neurogenic bladder are important medical considerations for the wheelchair athlete. By being aware of these issues, the tennis medicine provider can better serve the wheelchair athlete and help keep them healthy both on and off the court.



 

REFERENCES:

1. ITF Wheelchair Tennis Regulations. 2015 [cited 2015 November 13, 2015];

2. Instructing Wheelchair Tennis. 2011 [cited 2015 November 13, 2015];

3. Klenck, C. and K. Gebke, Practical management: common medical problems in disabled athletes. Clin J Sport Med, 2007. 17(1): p. 55-60.

4. Braddom, R.L., Physical Medicine and Rehabilitation. 2010: Elsevier Health Sciences.

5. Naugle, K., C. Stopka, and J. Brennan, Medical Conditions in Athletes With Spinal-Cord Injuries. ATHLETIC THERAPY TODAY, 2006. 11(3): p. 37-39.

6. Invacare® Top End® ProTM Tennis Wheelchair Online Brochure. [cited 2015 November 13, 2015]; Available from: http://www.topendwheelchair.com/TopEnd_Media/TopEndProductDocuments/12-507rev1214_ProTennis_Sellsheet.pdf.

7. Pressure Ulcer Category/Staging Illustrations. 2015 November 13, 2015 [cited 2015 November 13, 2015]; Available from: http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/.

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