and the chair of our Adaptive Athletes in Sport Community Group. We're really excited to be able to have convened this panel for tonight's discussion. We hope everyone has a lot of questions because this is an area of interest, I think that's bringing us all together because we know that there is a need for it and a lot of opportunity for growth in adaptive sports medicine. So I appreciate everyone's interest in joining. I'm gonna go ahead and share my screen here. All right, so just like to go ahead and introduce our speakers. So I mentioned that I'm at the University of Michigan. I'm a clinical assistant professor in PMNR. I'm also the director of our adaptive sports program at the Lieutenant Colonel Charles S. Kettles VA Medical Center in Ann Arbor. I serve on the national medical team for the National Veteran Wheelchair Games. And I also help run our University of Michigan adaptive and inclusive sports experience, which is our therapeutic program for adaptive sports and recreation. I also wanted to introduce on our panel, we have Alex Sink, who is the deputy chief of PMNR at Minneapolis VA Medical Center, and is the newly appointed acting chief of the Spinal Cord Injury Center there as well. I'm in a clinical affiliate of the sports medicine at the University of Minnesota. And he also has served on the national medical teams for both the National Veterans Wheelchair Games and the National Veterans Golden Age Games. So really excited to have him present tonight as well. Also joining us is one of our residents at the University of Michigan, Dr. Deanna Brinks. And she has an interest in adaptive sports medicine and sports medicine will be applying for fellowship and really excited to have her join as well. And also Mike Ulein, who is a clinic associate professor of emergency medicine at the medical, through the Medical College of Wisconsin, and is also at the Clement J. Zablocki VA Medical Center in Milwaukee. He has numerous hats, including he's been on the national medical team for the National Veteran Wheelchair Games, has been the medical director for the National Veterans Golden Age Games. And I would say his longest running hat is 10 years plus as a team physician for the US National Sled Hockey Team. So we're very, very excited to have him present as well. So enough with the introductions. And if I forgot anything, you guys can mention anything else that you want to share. So our session objectives tonight, one is to identify safety considerations when recommending a participant or recommending a patient to participate in adaptive sports and recreation. Also to provide concussion screening in wheelchair athletes, understanding the differences from current standard protocols. We're also going to be reviewing understanding how autonomic completeness and the hidden dangers of boosting can be problematic in adaptive sports. And lastly, identify common emergencies that occur in adaptive sports and how best to prepare. So I'll be reviewing first off is a pre-participation adaptive sports screening. I have one disclosure, it is a non-paid disclosure. I work for a benefits corporation in research and education called the Adaptive Sports Movement. So our objectives for this portion of the talk is to review medical comorbidities in adaptive sports participants, to discuss the elements of a medical evaluation, discuss diagnostic screening tests, review equipment prescription considerations, review training considerations, and also to review coding and billing. So when we're thinking about adaptive sports athletes, of course, we're thinking there's a baseline medical condition that requires adaptation for participation in recreation and sport. We know that there are associated comorbidity factors that could be significant for that participant. Complications may be unique. Injuries can certainly affect function and the equipment may be necessary, obviously, for their sport or activity. So this is taken from the CDC's website regarding health and disability. And I had stated previously, there's a lot of comorbidity as we know, but it's really interesting to see how much of a jump there is between people with disabilities and those without in the categories of obesity, smoking, heart disease, and diabetes. So I just wanted to highlight that when we're doing a baseline evaluation to think about these higher risk factors. So certainly having an individualized evaluation is important depending on what the participant or person is interested in, thinking about their diagnosis, whether there's a prognosis, if this is a fixed in time singular injury versus a changing condition that causes their disability, thinking about functional ability, their limitations and goals. And when I'm going through, and a lot of these elements that I'm talking about, I've put together through standardized pre-participation sports evaluations, also the elements that go into the medical portion of the forms required for our national VA adaptive sports events, and really thinking about how to put it all together in one evaluation. So in the HPI, I like to include adaptives, of course, the activities that they're currently participating in, any other activities outside of that, thinking about functional history, classification history, if they have prior participation, because that obviously could change over time as function can as well, and that would affect classification, participation and training history. So thinking about how often they're doing it, how long is the training and how intense it is, certainly thinking about their durable medical equipment, because that certainly can affect the day to day, the functioning off the field, thinking about all that is required to even get to the event and after, and as well as obviously adaptive sports equipment, transportation and storage is a huge consideration, and then the person's individual goals. So when I think about activity history, certainly thinking about weekly physical activity history is important to consider. This is taken from the Exercise is Medicine website where it gives really great information regarding soliciting activity history and from the guidelines for Americans for exercise. And this is, again, taken from a couple of different sources and really it's asking about when we're thinking about moderate to high intensity activity, so on average, you would ask how many days a week, somebody might engage on average, how many minutes do they engage in this? And then total activity. Now, obviously it becomes more specific once you're thinking about somebody who is already engaged in a sport or several sports. In regards to review of systems, cardiopulmonary health really wanted to highlight that and emphasize that with consideration for chest pain, dizziness, lightheadedness, you know, any history of syncope or dyspnea with or without the activity. Certainly any kind of pain that may occur with or without activity. Skin is a, you know, important consideration thinking about, you know, wounds, skin breakdown, or prior history of this with certain activities. And then also we would think about maybe seizure history. So thinking about cardiopulmonary risk, when you're thinking about somebody who is, you know, with a disability, depending on their diagnoses, they might have a congenital cardiac defect, which would require, you know, more screening, increased risk for a sudden cardiac death, you know, as a possibility and consider, you know, you might consider stress testing or doing echocardiogram. I know also this is even greater if we're thinking about somebody going to altitude. And I know for our winter sports, we do an EKG, you know, at it's really with higher cardiovascular risk or the person's personal history that might necessitate having that done prior to competition. In past medical history, certainly, you know, thinking about someone's heat illness or cold intolerance, you know, whether I, and haven't really, you know, when we're talking in our space of AAPMNR, we're thinking primarily physical disability, but certainly we should, you know, pay attention to vision or hearing deficits, cardiovascular disease, autonomic dysreflexia history, which we'll be going into more detail further in the session. Sickle cell or hematologic diseases, metabolic diseases, renal, neurogenic bladder and bowel, concussion. Again, we'll be going into more detail on that. Stress fractures, muscle tendon injuries and skin rash, kind of just running the full gamut. Regards to past surgical history, obviously, you know, with the cardiac risk factors, you would want to know if somebody had had a pacemaker, a defibrillator, hernia surgeries, spinal surgeries, any orthopedic, you know, injuries and surgeries as well. And then thinking about skin considerations, you know, we talked about pressure wounds, you know, certainly rash from heat or friction, you know, equipment surfaces. So things that may not be a factor in, you know, day-to-day tasks could become more of an issue, obviously with repeated motion and under, you know, heat, stress, you know, sport activity. Thinking about bladder and bowel management in relation to participation, obviously that participant will have a fluctuation of fluid intake that impacts, you know, their bladder or bowel program potentially. The catheterization frequency could change based on, you know, their habits of hydration surrounding, you know, a sport. And then thinking about timing of the bowel program in relation to scheduled events. So it's a logistical consideration, certainly medical consideration. And then thinking about equipment, obviously knowing the components and what function they provide and any functional limitation that may be involved. Cleaning and maintenance of those components, inspection with every use, and appropriate skincare and protection in relation to those. So these were the guidelines I was talking about when I was referencing the history about the weekly activity. So training considerations, you know, think about that pre-injury functional level. When you think about the activities, daily activity, recreation, competition, you know, really meeting that participant where they're at. Environment, it's obviously, you know, an important thing to take in consideration depending on, you know, geographically where the person lives and their baseline level of exercise. So in our assessment and plan, you know, we're thinking, you know, is this person medically eligible for sports without restriction? Are they medically eligible for sport without restriction, but further evaluation is needed? Are they medically eligible for certain sports listed, you know, on their form? Thinking about, you know, what they're asking for to participate in, not medically eligible for any sports, right? That you would say, I'm not sure if I can give you clearance, but we would need to do more evaluation or they're really not, you know, safe to participate. Some of the other things that I like to include, you know, another way you could phrase it is medical clearance for various adaptive sports, if it's very general. If you feel like there's no contraindication or concern relative to participating in that adaptive sport or activity. Other words that you could, you know, include in your assessment and plan, you know, there's no contraindication to the prescribed equipment, the selected equipment and accessories are appropriate. I think this is really important to include regardless of your payer source. So if the person is needing guidance or, you know, recommendation for equipment that might be more appropriate for them, you know, obviously you might take into account their actual training and coaching, but if this is something that you are able to determine, you know, yourself in discussion with the patient, you know, that patient may be seeking a grant, you know, application, you know, for charity. And it's really important that they have the medical documentation to help back up their request so it can be really beneficial to them. So I think it's really helpful to document that. Also that patient has received comprehensive education about their equipment or participation, and then following up to reevaluate, you know, any further needs or discussing further opportunities to engage in adaptive sports. So lastly, I'd like to quickly go over coding and billing. So some of the things you can include, obviously you can have your primary diagnosis, which might be spinal cord injury or amputation, et cetera. And then additionally, you would have, you can have a secondary code for encounter or examination for participation in sport, can have exercise counseling and also lack of physical exercise. I actually am really interested about, you know, the utilization of the lack of physical exercise, because I think baseline, especially if you have people who are new to adaptive sports, that this would probably be a uniform code that you would see consistently, which would really kind of help, you know, I think explain the reason for our place in this process to have somebody, to facilitate somebody to participating. So just an example of billing and coding. So providers, you know, we certainly need to have everything in there. Our coding, billing and documentation. So, you know, again, the ICD-10 for the primary diagnosis, plus those other things, including lack of exercise. Sometimes I'll throw, you know, obesity in there or diabetes or whatever health, you know, comorbidity that exercise would be impacting. So you can also include those too. Again, just an example that obviously, you know, this is a pretty comprehensive evaluation. To me, this is a little bit different than if you were to do, say like a high school, you know, physical where you're just in an otherwise healthy individual kind of checking off that they're, you know, okay to play. So it could be more involved, you know, up to a level four potentially, depending on what you're doing for the patient. And then certainly I think it's important to talk about the time, just because you are, you could be spending a lot of time explaining, especially to somebody who's new to adaptive sports. And so this is certainly something that is just an example of a pre-participation physical evaluation that you can see, you know, how they have it broken down. So I don't know if, you know, anyone in the audience is doing, you know, physicals for sport, but for able-bodied sport, but this is just, I think, a nice way to look and see all the elements we've kind of talked about of how you can include a lot of these elements that relate to somebody who has a disability. And just wanted to share some things because, you know, these pictures are folks that I feel like I have had an impact on in their participation and really facilitating them to engage in adaptive sports and recreation. So I think that might be all, yep. And then I just have to put a real quick plug. We do have one session where I am presenting for exercise in the exercises medicine community on Wednesday. That'll be recorded from three to 6 p.m. I'll be talking about advocacy and adaptive sports and what happens after exercise prescription. And then we have an in-person networking event on Friday, October 21st in Baltimore from 8 to 9 a.m. And I hope to see some of you there. All right, I'll stop share. All right. So Alex, I'll pass the baton to you. All right, am I live? Perfect, all right. Well, thank you for everyone for joining us tonight. Really excited to join you from afar. It's one of the beauties of the COVID times, being able to find better ways to connect all the time. So tonight I have the privilege of talking to you about concussion screening in a wheelchair athlete. I have no financial disclosures, but the topics today are my personal interpretations and may not reflect that of Uncle Sam's. I do have a brief disclaimer too, that this discussion tonight is not to teach you how to perform a standard concussion assessment, but rather to elevate your understanding of it in a wheelchair athlete. So our objectives today are going to be to really kind of provide you a focused review of the factors that influence the concussion evaluations in your wheelchair athlete, and to highlight the special considerations that you have in this special patient population, as well as to enhance your understanding and improve your confidence with performing these assessments. I always like to go kind of back to the epidemiology. It kind of helps me understand why we're talking about this. When we look at the relative amount of sports-related concussions that are occurring annually in the U.S., it's estimated to be somewhere between two and four million incidents per year. However, really that data is really kind of focused on our able-bodied athletes. It may not be inclusive of our wheelchair athletes or adaptive sports. And while the recognition of sports-related concussions has really improved for all athletes, there remains a lack of available data on our wheelchair athletes. Our International Paralympic Committee has been putting forth efforts to try to correct this. And one way that they've been doing that is by implementing or introducing concussions into their injury and illness surveillance system. And they've been doing that since the 2016 Summer Paralympics at Rio, which incidentally didn't have any concussions reported. But the limited amount of data that we have available really may be skewed due to non-reporting, as demonstrated by Wessels and her colleagues in 2012. So during that year, what they did was they followed a wheelchair basketball team over a single season. And at the conclusion of the season, they sent out a survey study. And from that, they were able to find that our wheelchair athletes may be as susceptible to the same tendencies as our able-bodied athletes. And so what they discovered of all the athletes that they surveyed, about 6% of them reported concussion during that season. Of those that reported a concussion, only 44% of them, or sorry, I guess 56% of them reported their concussion, meaning 44% did not. Of those that reported their concussion, over half of them continued to play despite recognizing that they had symptoms of concussion. So even though we're getting the word out and education and further encouraging our athletes to report concerns of concussion to us may help improve some of these issues, really being here tonight and taking advantage of these educational sessions to better prepare ourselves to recognize concussions in this wheelchair athletes will hopefully pay big dividends. So when I'm thinking about concussion screening, now there's two main components to it. And so you have your history and your physical exam. Your history can include your observed as well as reported information. So what you see and what the patient reports to you, what they experience, or maybe what you also get from other bystanders if you didn't see it for yourself. And then within our physical exam, the neuro exam can incorporate your system screening, or sorry, your symptom screening, your cognitive assessment, your vestibular testing, and your balance testing. In this table that I prepared for you, we have the primary inclusion criteria for all of our national veteran sports programs. And as you can see, they represent a very diverse patient population for which traditional concussion screening tests are not appropriate. And that's because most of those standard screening tests are really based off our neurotypical patients. When you consider those who are able to, or eligible to participate in your wheelchair sports or adaptive sports, they really have a far further spanning kind of spectrum of physical abilities and cognitive functions, or cognitive abilities. And so you have to be considerate of what tests you may use for your concussion screening to make sure that you're testing the people appropriately. For instance, if you had a person who was of low vision, if you were to perform a convergence testing on them or perform a balance test, it wouldn't be a good selection because it wouldn't be reflective of what they're actually capable of doing. These are shortcomings of traditional concussion screening tests have been highlighted by the works of Kissick and Weaver. And they've also been further emphasized by Lee et al in his recent publication. When you are looking at this table here, it kind of shows you the SCAT-5 edition and the five components of it, as well as the potential challenges facing these traditional tests. And what you could see is that even though the SCAT-5 is arguably the most used concussion screening tool in the United States if not the world, it really falls short of being able to adequately assess our wheelchair athletes. And this is due to a combination of factors. One, maybe a patient has medication that they're taking that could alter either the sensorium a little bit, maybe their balance. The patients may have preexisting sensory abnormalities or differences. And also if a person has a speech impediment or significant impairment, or if they're aphasic, we won't be able to adequately assess them with these traditional tests. This is really why baseline testing is so important. And in 2021, there was a consortium of experts in the fields of brain injury and adaptive sport that came together virtually because of COVID. And what they did was they put forth this first position statement of concussion near paraspore group. And in this statement, they strongly advocated that baseline testing for concussion is part of your pre-participation evaluation that Dr. Tinney was discussing. And within it, we should really kind of make sure that we're establishing points of reference for each individual's baseline function, for their auditory function, balance, cognition, physical abilities, their verbal and visual abilities as well. This is acutely important in this patient population as there are no normative values for which we can compare to for your different wheelchair sports. When you're performing or trying to design your own baseline testing, you should keep in mind that this can actually take much more time and maybe more resource intensive than performing it in your neurotypical populations because you're gonna have to use different strategies and tools in order to perform or in order to assess the same functions. So as you design your protocol, make sure that your testing is appropriate, meaning that you're testing the right things for the right people and that it's reproducible for your athlete population. And what I mean by reproducible is that this is something that you're gonna be able to bring to the sideline and perform or in the training room. If you're not able to do that, it's really not gonna assist you in your concussion screenings. As you are kind of putting together your design, you can make sure that your protocols are going to be standardized for your patient population. So if you have the same team like Dr. Uline does with sled hockey, you can keep the same one. But if you're seeing a lot of different people with a lot of different medical issues for different sports, you may have to be flexible and start to mix and match a little bit, but just try to remain structured and consistent in your approach. If you don't know where to start, the National Veterans Wheelchair Games Concussion Management Plan that's published in the Concussion Management for Wheelchair Athletes book can be a really great starting place, or you could just use it. So one of our main components of our concussion screening is your symptom evaluation. And the table that you see on the far right, this is a modified version of the SCAT-5s. And so this is the expanded symptom evaluation checklist, again, used in the National Veterans Wheelchair Games Concussion Management Plan. It was modeled after SCAT-5, but it is expanded and includes spasms, which may be more relevant to our wheelchair athletes. So as you're performing your symptom evaluation for your baseline screening, you should really be cognizant of a few different factors that may be affecting your wheelchair athletes. For one, on average, they report a higher number of symptoms than their comparative non-adaptive collegiate athletes. Other factors that may play a role here too are that if an athlete has a history of brain injury, whether it be traumatic or related to MS or a stroke or something like that, they too have a higher association of increased symptom reporting. And when you think of our spinal cord injury population, about 60% of them actually have an incumbent history of brain injury. So there's a lot of factors that may play into effect here of why you may see a higher score. When considering other wheelchair athlete specific tools, we have our WES or Wheelchair Error Scoring System. This mirrors the BESS or the Balance Error Scoring System from which it was based upon. And this is a modified tool that has been established to assess postural stability and balance in our wheelchair athletes. It's undergone preliminary reliability and validation testing. And has shown good practical use so far. It is performed very similar to what you do for BESS. You have three positions that are each performed for 20 seconds, both with the athlete's eyes open and closed. And as you can see on the far left of the screen, we have our athlete sitting on a firm, stable surface. And if they do well with that, we will progress them into a unstable surface and that could be either like a BOSU ball or maybe like a raised high density foam. That's gonna make them a little bit more unstable, really having them to engage their core to stay upright. And then the last position is actually ask the patient to perform a wheelie. And before you have them perform this, you should really make sure one, that this is an appropriate test. And so ask the person if they use a manual wheelchair as their normal mode of transportation throughout the day. If they don't, like for instance, if they're an amputee, they may prefer to actually perform the BESS examination. You should also ask them if they feel confident and comfortable performing wheelie. If they do not, you shouldn't perform it. If they do, you should still have the appropriate amount of staff on hand to spot them in case they lose their balance. Your sideline evaluation. So this is really kind of what we're all performing the baseline testing for. It's in order to be prepared for this moment. And so if the need arises and there's a concern of a possible concussive event or injury, then we'll perform this. And the purpose of it isn't really to do a full concussion screening. It's not to diagnose a patient with concussion, but it's to determine if a person needs the full concussion screening. And it's also to determine if you need to expedite medical care in an urgent situation. So within this, you should be performing your focus history and neuro exam, and your level of scrutiny and degree of concern should really be adjusted according to what you witnessed, what someone else reported, and what you're seeing or hearing from the patient. Your training room evaluation is going to be a little bit different. So this is where you are trying to make a determination. And I'll repeat that. You are trying to make a determination. This is not whether a person has a concussion or not, or a diagnosis. This is, you're trying to decide whether a patient can play or not. So a go, no-go situation. This is where your baseline testing that you performed before is going to come into play about reproducibility. You want to be able to perform those established comparative tests for your athletes. So in the more quiet, kind of secure environment of the training room, you should be able to get a more reflective examination of the athlete's true performance on these neurocognitive testing and evaluations. Depending on what you're seeing on the examination, you may determine that you need to perform serial examinations for close follow-up. You may determine that further workup is needed, whether it's going to the emergency department for imaging, or if they need to be seen by someone else at a later time that's non-urgent. And then this will also be a time when you may start to make decisions regarding return to activity progression. If the person is doing well and you're just not sure if they had a concussion, you may ask them to be reassessed by their team athletic trainer if they have one, or see you again in clinic before proceeding with elevated levels of activity. So in summary, the baseline testing really allows you to know your patient and team well. And this is important because wheelchair athletes represent a large and diverse spectrum of individuals with complex medical considerations. When designing your baseline testing for your team or athletes, make sure that the tests are going to be appropriate and reproducible. Your side-on evaluation should really be consistent with your baseline testing. This also includes your training room assessments. And this is all because baseline concussion testing may aid you in navigating the complex concussion evaluations as well as diagnosing and treating it with enhanced confidence. It's also going to aid you in those return to X decisions, meaning play, school, work, whatever activity or issue it is that they want to get back to. So I just want to acknowledge quickly that the images were primarily from our Department of Veterans Affairs and the National Veteran Sports Programs and Special Events. The other images were appropriately attributed on their respective slides. Here's my references for you. Thank you for being here tonight. And I also want to thank the Academy, the Department of Veterans Affairs and University of Minnesota for enabling me to be here and speaking with you. Please reach out and connect, collaborate so that we can change the world together. Sorry, it's stopped on me. I can't do it right now. Are you guys able to get- Are you able to stop share? No, it's not coming up right now. It might be that Dr. Brinks, if you're able to- I'm trying to share mine, I can boot you out. Please do. It says I cannot. All right, we'll ask. Here it goes, okay. Oh, here we go. Okay, great. All right, we'll pass on the baton to Dr. Brinks. Thank you very much, Dr. Zink. See if I can figure this out again. All right, do you see just my slides now? Cool. So as Dr. Cheney mentioned earlier, I'm Deanna Brinks, I'm a current PGY-4 at the University of Michigan. And I will be kind of taking a dive into autonomic dysfunction and boosting in athletes with spinal cord injury. Unfortunately, I don't have any financial interests to disclose. So just a brief overview of what I'm gonna be talking about. I'm gonna kind of briefly describe autonomic dysfunction kind of broadly in spinal cord injury. And then we're gonna jump more specifically into autonomic dysreflexia and its management, both in SCI and in athletes, then orthostatic hypotension, again, kind of risk factors management. I'm gonna touch just briefly on sports classification as it relates to autonomic dysfunction. And then lastly, I'm gonna talk about boosting. So the extensive autonomic dysfunction in spinal cord injury is related to the level of autonomic completeness of injury. It affects multiple systems, including cardiovascular, respiratory, temperature regulation, and blood pressure control. Looking specifically at cardiovascular control, individuals with spinal cord injury have been found to have a lower maximal heart rate. However, heart rate is actually higher in spinal cord injury when exercising compared to able-bodied controls. However, cardiac output and stroke volume are 25% lower in spinal cord injury compared to able-bodied controls. And so this tachycardic response in spinal cord injury while they're exercising is not able to compensate for that decreased stroke volume and cardiac output ultimately remains lower. Folks with spinal cord injury have also been found to have lower VO2 max, but not surprisingly, VO2 max is higher in athletes than in non-athletes when looking specifically at the spinal cord injury population. And athletes with spinal cord injury have also been found to have a lower peak power. Looking at respiratory control, there's a lower forced expiratory volume or FEV in spinal cord injury compared to able-bodied controls. FEV is reduced in paraplegic and even more so in tetraplegic individuals when compared to able-bodied controls. And the higher level of the spinal cord injury, the lower the respiratory rate due to decreased innervation of the respiratory muscles. Looking at temperature regulation, this is affected specifically in spinal cord injuries that are at T8 and above. The higher level and more complete spinal cord injuries have less afferent input and efferent output leading to more thermal strain. They have decreased input to the hypothalamic nucleus, which is the thermoregulatory center in the brain, which leads to increased risks of hyperthermia as well. Finally, with the decreased autonomic control, they get decreased vasomotor changes to regulate that cutaneous blood flow and sweating, leading to decreased sweating below the level of injury and ultimately increased risk of hyperthermia. So that's just kind of a review of those systems. This presentation specifically is gonna focus more on blood pressure control, particularly, as I mentioned earlier, autonomic dysreflexia and orthostatic hypotension. So autonomic dysreflexia, or AD, as I'll refer to it throughout most of the presentation, is defined as an abnormal overreaction of the autonomic nervous system to a stimulus. It's caused by imbalanced reflex sympathetic discharge and injuries above the splanchnic outflow. That splanchnic outflow is a T5 to L2. AD occurs in up to 90% of individuals with cervical or high thoracic spinal cord injury. And so those athletes with a spinal cord injury at T6 and above are at risk for AD. The characterizing symptom of AD is sudden onset hypertension, which is defined as a systolic blood pressure that's 20 to 40 over baseline. It is important to note that in spinal cord injury, that baseline blood pressure is lower. So a normal appearing blood pressure might actually be autonomic dysreflexia in your spinal cord injured athlete. So in addition to that sudden onset hypertension, there are multiple other associated symptoms that an athlete may experience while having AD. I made this little man here to kind of point out these symptoms. So common things are anxiety, headache, blurred vision, diaphoresis above the level of injury, nasal congestion, pilar erection, bradycardia. Bradycardia is not always there and you can actually sometimes be tachycardic despite the kind of classic bradycardia from that parasympathetic output. So in looking at the mechanism of autonomic dysreflexia, it's caused by noxious stimulus below the level of spinal cord injury, which triggers a sympathetic response resulting in vasoconstriction and a subsequent increase in blood pressure. The aortic and carotid baroreceptors respond to this increase in blood pressure by signaling the basal motor center in the brainstem. This then triggers parasympathetic response resulting in bradycardia and vasodilation above the level of the injury. In the absence of a spinal cord injury, we can appropriately respond to that sympathetic response to maintain homeostasis. However, in spinal cord injury, the brainstem is unable to communicate through the injured spinal cord to decrease that sympathetic outflow and allow for vasodilation of the splanchnic bed. So this results in persistent sympathetic response below the level of injury and a parasympathetic response above the level of injury until that noxious stimulus is removed. So when we look at the consequences of AD, this is a medical emergency. You can think of it like a code in a spinal cord injury. When left untreated, AD can lead to retinal hemorrhage, cerebral hemorrhage, seizure, cardiac arrhythmia, or death. So management in general for spinal cord injury, particularly in your athlete, you want to ensure that they're upright. You're going to loosen any clothing and straps, particularly in your wheelchair athletes, like rugby, basketball, they'll probably have tight leg straps to stay in their chair. You want to check for obvious injuries or skin lesions. You want to check their catheter for kinks and you should flush the catheter to ensure there is no bladder outlet obstruction. If needed, you can disimpact their bowels. And kind of the last line is to administer medication. Typically it's nifedipine or nitroglycerin paste that are used. Nitro paste is particularly useful because once the target blood pressure is achieved, you quickly wipe it off and you can avoid causing hypotension. So special considerations, particularly in the management of athletes, it's important for medical staff, coaches, and athletes to be able to recognize and treat AD to avoid those potentially life-threatening complications. Males with spinal cord injury often prescribe PDE5 inhibitors for sexual dysfunction. So this is like your Cialis and your Viagra. And you should determine recent use prior to administration of any nitrates because nitrates should not be registered within at least 24 hours since their last PDE5 inhibitor use due to risk for hypotension from two vasodilating agents. Finally, it's important to know that self-induced AD can be used to enhance performance. This is called boosting. And as I mentioned earlier, I will talk about that later on in this presentation. So moving on kind of to the other end of the spectrum, we have orthostatic hypotension. This occurs in spinal cord injury at T6 and above due to decreased sympathetic nervous system efferent activity in the vasculature below the level of injury. This results in venous pooling in the abdomen and lower extremities with position changes. OH is typically managed with compression garments and medications. Pharmacologic management includes alpha-1 agonist medications such as Midodrine, glucocorticoids such as Flutocortisone and non-selective adrenergic agonists such as Avedrin. Risk factors include the neurologic level of injury and autonomic completeness of injury. West and colleagues in 2014 evaluated 52 male Paralympic wheelchair athletes who were competing in the 2012 Paralympic Games. And they found that lower seated systolic blood pressure, a larger change in systolic blood pressure was supine to sit and more clinical symptoms of orthostatic hypertension were present in cervical spinal cord injury compared to thoracic spinal cord injury. They also looked at sympathetic skin response and how it was used to measure autonomic completeness of injury. And they found that autonomic completeness of injury is independent of their AIS classification of completeness. So that's your Asia A through D. And they also found that in addition to the neurological level, cardiovascular dysfunction after spinal cord injury is also dependent on autonomic completeness of injury. So specifically for athletes, things to consider in orthostatic hypertension is using compression garments and hydration status as a way to prevent OH in the first place. So common compression garments include stockings and abdominal binders. You should ensure your athletes are well hydrated before competition and during competition. Salt supplementation is also sometimes used. Pharmacologic agents are generally avoided because those medication classes I mentioned earlier are actually on the list of World Anti-Doping Agency banned stimulants. However, if there is an athlete who's requiring these medications regularly, there is a therapeutic use exemption that they can apply for. So taking that quick detour that I mentioned earlier to look at wheelchair sports classification, we've seen how the neurologic level of injury and autonomic completeness contribute to their risk for autonomic dysfunction. So in addition to their medical risks, the AD and OH pose for wheelchair athletes. I wanna point out that functional classifications for wheelchair sports do not directly account for neurological level of injury. AIS classification or autonomic level of completeness. For example, in wheelchair basketball classification is primarily based upon function of the upper limbs, lower limbs, trunk and hands. In wheelchair rugby classification is based primarily upon manual muscle testing, ball handling skills and observation during match play. In a wheelchair racing classification is based primarily upon function of the upper limbs, lower limbs and trunk. Jumping into boosting, I kind of alluded to this earlier. So it's defined as the intentional induction of autonomic dysreflexia to gain a performance benefit. It is considered a form of doping and has been banned by the International Paralympic Committee. Methods that athletes will use to induce AD prior to competition include bladder irritation by kinking the catheter, over-hydrating or they can apply a painful stimulus such as tightening their leg straps, sitting on their scrotum or breaking bones such as a toe. So multiple studies have been conducted to evaluate the physiological effects and performance benefits of boosting. In 2011, Schmidt and colleagues found that the dysreflexic state, there was an increased risk of epinephrine and norepinephrine release, as well as higher peak power, blood pressure and VO2 max. In 1994, Burnham and colleagues evaluated the effect of dysreflexia on race performance in tetraplegic wheelchair racers. And they found that on average, there was a 9.7% improvement in their seven and a half kilometer race times when the athletes were in a dysreflexic state. In 2010, Bonvanni and colleagues investigated the perceptions of boosting among wheelchair athletes. They conducted a confidential survey of 99 athletes, 89% of which were male. Of those athletes, 56% reported knowledge of the practice of boosting, 16.7% reported having previously boosted to improve performance. And the more alarming finding in the study was that there was poor awareness of the medical risks associated with boosting, with nearly 50% of the participants rating boosting as being only somewhat dangerous. And then about 21% thought it was dangerous and about 26% thought it was very dangerous. In 2016, the International Paralympic Committee released updated position on autonomic dysreflexia and boosting. Per those guidelines, they defined boosting as a hazard, they defined a hazardous dysreflexic state as being present when the systolic blood pressure is above 160. In order to screen for boosting, the International Paralympic Committee released a report on autonomic dysreflexia in order to screen for boosting at the Paralympic events, athletes are screened within two hours prior to the start of their event. And basically how they do it is screen the athlete if the systolic blood pressure is greater than 160, then the athlete is re-examined 10 minutes later. If that blood pressure remains above 160 again, the athlete's withdrawn from the event. And then deliberate induction of autonomic dysreflexia is forbidden, as I mentioned earlier, and that leads to an autonomic or an automatic disqualification. So the IPC, also in this statement, outlined the responsibilities of the National Paralympic Committees and the medical staff. So staff are responsible for ensuring their athletes are not dysreflexic prior to entering the competition. They're not dysreflexic prior to entering the call-up area. They're responsible for ensuring that their athletes are not using a mechanism which may cause or provoke dysreflexia. They're responsible for providing the authorized person who examines for AD a list of resting blood pressure of the athletes. Typically this is over the past 14 days. And they're also responsible for providing the authorized person who examines for autonomic dysreflexia with medical evidence at the level of spinal cord injury. So the IPC protocols aim to prevent boosting in competition. However, in 2013, Blauwet and colleagues investigated the efficacy of these IPC testing protocols. They looked specifically at testing completed during the Beijing 2008 Paralympic Games, the Guadalajara 2011 Parapan-American Games and the London 2012 Paralympic Games. They looked at 78 tests completed on 56 athletes across the three games. And the average systolic blood pressure through that testing was 135. So through this investigation, they raised the concerns that first performance enhancing autonomic dysreflexia can occur at the systolic blood pressures below that cutoff of 160. I will note that at the time of the study that the cutoff used by the IPC was actually 180 rather than the current 160. That was in the updated 2016 guidelines. They noted that it can be difficult or impossible for officials to differentiate intentional autonomic dysreflexia and unintentional AD that can result from rigorous sports. So collisions in your basketball or rugby, the use of leg straps, hold them in the chair, et cetera. And finally, they noted that screening occurs within two hours of competition start time. So athletes may still have time to induce autonomic dysreflexia after screening. So while the screening for boosting is important both to promote fair competition and protect athletes from the adverse risks of boosting, it is evident that there's still quite a bit of room for improvement. All these current protocols and the way the IPC is testing before competition. And there's also a lot of room for educating these athletes about the risks of boosting as that study showed that about 50% of the athletes they surveyed didn't think boosting was all that dangerous. So finally, I wanna leave just kind of a few key points. So individuals with spinal cord injury at T6 and above are at risk for autonomic dysregulation, including AD and OH. Autonomic dysreflexia is a potentially life-threatening condition and therefore needs to be promptly recognized and treated. And finally, boosting is self-induced autonomic dysreflexia that's used to gain an advantage in competition. It is a form of doping and is banned by the IPC. These are the references in the studies I referenced earlier. And that is all for me. Thank you so much, Dr. Briggs. That was really a great review. And bringing it home, Dr. Ullein. Hi, can every slides come up look okay? Just like before, I, great. I just, this has been so cool. Thank you so much. I am so happy to be part of this awesome team presenting tonight and I'm gonna talk about emergency management, emergency preparedness in adaptive sports. I have no relative financial interests. And let's start with the definition. Let's talk about what emergency preparedness actually is. Like, what is it? So it's an organized activity undertaken to prevent, mitigate, prepare for, respond to, recover from, actual or potential emergencies. And we're gonna look at this under Dr. Tini's umbrella of safety for the adaptive athlete in adaptive sports. And so for me, what I'm gonna do is I'm gonna present this from my experiences and my, kind of like my background with sled hockey. And so I've been lucky enough to be with the sled team for a bunch of years now, since 2012. And have learned a lot about emergency preparedness, having a plan and that learning, I tell you, has been from trial, a lot of error, a lot of mistakes, a little bit of luck, a lot of listening to other providers, to the athletes themselves. And man, you don't go on a single trip without learning something from these guys or about this. And so when we look at this and use this as kind of the background to look at an umbrella of safety, when you're going out and helping at another event or you're going to volunteer at the big cheese wheelchair basketball tournament as part of another medical group, what we're trying to do is create safety in adaptive sports. And so for me, my background is emergency medicine and I had to learn a lot about a disability medicine, basically fueled by sled hockey. Like literally it was like, whoa, I've got to learn this stuff to take care of these guys. And I always tell the residents that I'm working with now is that I'm too gray, grumpy and old to be surprised anymore. Like I don't want to be surprised by anything. So I want to be thinking two steps ahead in multiple different directions for anticipation at work and in life and when I'm at one of these events. So like at work, if someone goes, oh, this person now has a fever 102 and blood pressure is 80. I'm like, okay, we kind of expected that could possibly happen, this is our plan. Because when you're having a cross-border series with Canada in St. Louis and you watch one of the Canadians go out in this ambulance to a local hospital, you want to have all that set up to where you know where that person's going, who they're going to be potentially seeing and follow up. When their doctor goes with them, you're now responsible for any injuries for the other side. All of that is set up and discussed first. So we said that this is an organized activity. Well, what kind of activities are we going to talk about? Well, let's talk about this activities for emergency management. So we'll talk about the basics, right? We'll talk about the emergency action plan and some medical travel assessment. Now this could be as big and crazy as, you know, like multi-page, you know, things for multi-day events or you show up and you're like, what's the plan? Like someone gets hurt today, like this is what I have with me, this is what I'm carrying. Who do we call? How are we going to be notified? Where's our collection point? Where are we doing our assessments with the other people that you're with, right? Equipment knowledge, which we'll talk about, which we'll talk a lot about and just completely folds into what Dr. Tinney has already said is really important. And we'll talk about quote, building your kit. Now, what does that mean? Well, that's the medical kit that you have or the tools that you bring with you if you don't have a kit, right? But it's the true boots on the ground type of stuff. So what are our objectives? Ta-da, the same things, right? So the objectives are, we're going through this stuff so that if you're at the Tour of America's Dairyland and helping out in the adaptive side for the adaptive races or you're covering track and field, or like I said, any type of event like this, you have an idea of, you know, what to do. Because I tell you, all of us at any level of provider, like that's why we're doing this. Like we want to be able to help. And we always want to, you know, and remember, we always fall back to our highest level of training and preparedness, not rise to some magical level of, you know, performance. So with that, let's talk about emergency action plans, okay? So in general, like I said, what we really, or what I would like to really emphasize is the importance of your environment and knowledge of the local resources. So if someone comes up to you and says, I need this, I need that, I need this, I need that, or someone comes up to you and says, I need this, or I've got to look at this, or I want to take care of this, you know that, you know, the hospital that, you know, is closest is this, the pharmacy or Walgreens for ABC or Deere is this. It doesn't need an emergency department, but could use an urgent care. Well, that's here. And then how is that individual going to get there? Is it 911? Is there EMS on site? Is there a wheelchair van? And remember, if you're kind of responsible or part of this, and you're sending a wheelchair athlete to the hospital, well, they're not, the EMS a lot of times can't take that chair, right? So then you have to figure out how to get not just their sport chair to where they, you know, to home, but to get their personal chair to where they're going to be either with, you know, a friend, a co-athlete, teammate, or whatever. And then honestly, in the age of COVID-19, you have to have a plan of what to do when someone comes to you and says, I just started feeling like absolute crumb, right? Like I feel awful fever. And where do you do? How do you isolate? How do you just separate? And then where do you send that person from there? Do you bring, you know, antigen tests yourself or what do you do? And so literally tomorrow we, well, actually Wednesday, the team goes to Madison for our second training session for the year, the US National Sled Team. And this is my emergency action plan. I mean, this is it, right? And it's got the hotel, it's got the rink, the time to try and figure out an address is not when you're dialing 911. What's your address? Ah, I'm at the ice arena? You know, like what ice arena? You have all this stuff right into you. It's the same thought process as there are no math and codes and if you notice that, you know, there is non-emergent followup, emergent followup. We have multiple veterans on our team, pharmacy and our local contact. I blocked out the local contact, you know, names and, you know, our other contacts. So it's all there, right? It's all there. So when something like this happens, you know, you're like, okay, this doesn't need the ER. We're gonna go to our non-emergent followup at SportsMed and we'll be able to get dialed in. You contact your person and then boom, that happens. Or something even more complicated like this. This is from 2018 when we had a combined training camp with Norway. So this is a 16 year old Norwegian who is there with their 22 year old trainer. They didn't travel with a physician and he's changing his blades and went pink and cut his finger on the blade. And so when you close that and look at that and take care of that, that's part of your kit. So for me, we do a lot of soft tissue stuff and I'll show you kind of why. And you're evaluating, you're like, oh man, despite you able to do this and able to do this, you bagged your tendon, you can see it. So how do you get this kid help in Madison as a 16 year old from Norway with a trainer? And if you don't have that, and by the time he left, he had surgery by hand surgery. They were arranging followup with the Norwegian Paralympic Committee's doctors and orthopedic surgeon. But if you don't have that set up that you're really, like we said, the time to get that set up is not the time during the emergency. So with that, just like the time to set that up is not the time for emergency, the time to know your equipment is not the time of an emergency, right? Because each sport has obviously, I'm speeching to the choir for this one, right? But unique equipment for a unique underlying diagnosis. And I will tell you that the person and people to teach you about the equipment is the athlete using it. Hey, can you show me how to get out of this, how the best way, if you were down and you were hurt, what's the best way I can help get you out of this? Whether it be a chair, whether it be a sit ski, whether it be a sled, whether it be a race chair, right? And then, like Alex mentioned, Dr. Stank mentioned, I've been lucky enough to be with some of these guys for 10 years, right? So I understand or know and have had a chance to read up on their underlying diagnosis. But a lot of times, if you're just covering an eventual, you don't know these athletes and you have to find out the important stuff really quickly and then be able to communicate that to the EMS in a way that they understand that there could be a risk for autonomic dysreflexia, to understand that this person needs to make sure that when they get to that, in that if they're going to the emergency department without any skin issues, the EMS ride in the emergency department time shouldn't create a skin issue, right? So you have to really make sure that these are really important things, right? And the expected injury patterns. So for us, in sled, I thought it was gonna be a ton of concussion. It's been a lot less than I actually expected, but it's been upper extremity and hand because those hockey gloves, they're standup gloves. And I tell you, you do not protect people's hands very well when they're skating and banging on the ice there and then the buckles and straps. I tell you, if someone's really injured, working on getting them out of those buckles and straps, you really wanna have a good knowledge on how to do this. And of course you can always just cut them. But to have that in your kit is something important as well, because I can tell you that someone going over in a chair like this or on the right, that's, I mean, like, I mean, I had to ask someone like, hey, how do we get you out of this sit ski at the winter sports clinic? I mean, that's a pretty high tech piece of equipment or for two of our sleds here, both of these are sleds from some of our, two of our Marine Corps veterans. And one on the left is a hip disartic on the left and above knee on the right. And you can see that there's a strapping way that he actually pulls himself down in the sled. Well, if you didn't know that, or you're trying to help him get out of that, or if he was unconscious, like that's really, that's a tough position to be in, right? Like you want to know that beforehand and then you can see the buckles for the bilateral below knee amputee playing in this one. And then just to share with you guys the equipment, here's the picks. So that's a regular four pick, that's on the end of the stick with the blade end on the other. And that's what digs in the ice so they can get going. And that other thing, believe it or not, I know it looks like some crazy medieval like battle ax weapon, but it's actually our goalie pick, right? So that's the pick on the end of the goalie sticks so that they can slide post to post and they've got the track shoe glued to their glove hand. So that's why I bring soft tissue stuff because those picks, I tell you, they're picking each other all the time. So, and then you look at what the athletes are bringing and how that could create a safety issue with their own personal equipment and the decisions you make for this. So that here is, you know, one of our guys showing up to practice with that glove and you're wondering why you're pulling out fiberglass splinters out of his hand or he can't do this. So, you know, he can't play until we get him new gloves. Luckily we could get him a set of new gloves and the shoe on the right, we just got back on October 1st from two weeks in the Czech Republic for a four nation tournament. And that's one of our guys, he showed up with, that's his hockey boot. And we're like, why is there blood on your sled? Oh, it's because you didn't tell us that you took off the bottom of your boot to because you need a little more space for your feet because of the way your toes are contracted. And we're like, well, you can't play like that. So we actually had a, it's amazing what you can fix with a little bit of plastic and a lot of hockey tape to protecting them enough so they could go back and actually play. So it's, so knowing the equipment, their equipment, knowing what can go wrong with their equipment, what they actually sometimes bring as their equipment is all important and sometimes quite surprising. So now falling back to our highest level of training, let's talk about in this last five minutes, so that just are kind of our worst case scenarios, right? So we're talking about emergency preparedness and all of us have varying degrees of comfort with worst case scenarios, right? But in general, right? If we're at these events or we're caring and talking about safety of athletes, as an emergency medicine provider, we think obviously, right? You know, well, there's pattern recognition and there's, you know, problem list and active investigation, but if you, it's all under the umbrella of rule out worst case scenario, because we've got to think about the worst first. So for us in these events, like I have to be able to support the ABCs, right? Now you have to think about that yourself. Are you, you know, going to have in your kit a bag valve mask from North American Rescue that compresses down to a little, you know, little cylinder about this big and you can actually bag someone with a nasal airway or an oral airway? Or are you gonna say, listen, that's not what I'm gonna do. We're gonna wait for EMS, but I'm gonna give the best CPR only, compressions only CPR than anyone's ever seen. That's fine, right? That's absolutely fine, right? But you don't wanna decide that at that time. You wanna have that in your head first. We have to be able to control and think about bleeding. That can be as much as, you know, tourniquets and wraps to just having enough, you know, four by fours and some Dermabond to take care of bumps, scrapes, trips, falls, cause they happen too. And then cervical motion restriction, right? So that's a big thing now, cause that's changing, right? You know, in the old days when I long, even before medical school, I worked on an ambulance in Boulder and we used to call it the standing. I mean, everyone was spinal, right? Everyone was on a board or a scoop. We call it the standing takedown. Someone would have a crash. They would get out of their car, walking around, look at their car, look at the other people. We'd show up and like, you got any neck pain? They're like, maybe I'm like, don't move. Put your feet up and we'd lay him back on the board and then boom, right into the ambulance, right? But that doesn't make any sense, right? And we knew it didn't make any sense, but that was, you know, but now common sense and care is catching up to, you know, is catching up and we're able to provide the care that people need, which is basically protect the neck, right? Cervical motion restriction. And then you always want to know where your AED is if you're not carrying one. So, you know, show up at the rink and check. And I'm like, hey, where's your AED? They're like, oh, ambulance. I'm like, where's the ambulance? Oh, not here. I'm like, oh, okay, only here during the games. You know, so you're just like, well, I have to know that if something happens, I got to, you know, talk, you know, I got to get help from the rink manager or figure out if dialing 112, which is their 911 is going to actually get me the help that I need. And that's why you always have the team host to help you out as well. So, these worst case scenarios dial into what am I prepared for? Building your kit, right? So, pocket mask, bag valve mask, support the ABCs, practice good BLS, bleeding. For me, like in my kit, where we go, I have a backpack and I have two suture kits and a bunch of Dermaband because we're doing small soft tissue stuff all the time. Cervical motion restriction. Well, that's common sense. Protect the neck, nose, belly button, straight line, neutral. Can you fit a collar? We carry, I carry a collar. Do you, do you, you know, a lot of EMS aren't using boards anymore. They'll literally help someone onto the ambulance, collar them, and then use pillows, towels, you know, anything to just make sure that you are neutral and protected, protect the neck. And like I said, the AED location. So, and then you have to kind of, with that, you kind of end up expecting the unexpected. So, I just want to share with you what I mean by that because this goes into the safety aspect of it. Our underlying umbrella of being, providing the safest environment for the athletes because you realize that that a lot of times people like, well, I'm stumbling over my words right now, trying to say that it's amazing what you see happen that other people don't even think about, but these athletes have to deal with, case in point. So, this is our trip. We land in Vienna and all of the gate-checked wheelchairs are in baggage claim. We got eight of them. How do these guys get there? How do these guys get, and we can't go back to pick them up. We can't help them. We were trying to communicate with them on whatever type of WhatsApp, you know, communication, but all of our guys with some help from the airline, help in quotes, had to get to baggage claim through customs through customs and all that stuff, which was a long way to get your dang chairs, right? And then of course, the way the bus drops us off at the rink, the way everyone else is parked, they're dropping the ramp off and these guys are rolling right into the wall. I'm like, stop, wait a minute, guys, you got to do this. It's going to be a bad, they're like, no place, no other place. I'm like, guys, stop. We need a spotter here so you don't go careening off into the wall, which of course they all thought was really funny. And went off careening into the wall, but no one got injured. And then the biggest thing, and this actually comes up a lot of times with, you know, some of the, almost, there's very little research in adaptive sports, but a lot more is happening now and people are asking the questions, it's just so awesome. But in like 2012, they did a pilot survey on injury and safety concerns for sled hockey players. And yeah, there was a lot of concussion and dislocation and this and this, but a lot of it was like rink. These are the shower chairs for the shower. And so I go and I look at them. Are they stable? Are these guys going to fall? We bought, you know, physical education scooters so guys can scoot in and don't have to literally sit on the floor, right, before they, or scoot into there on the floor so they can actually, you know, not be on the shower floor there. And there's been times where, you know, they're using lawn chairs and they're so crappy, we're like, nope, that's out. You can't use that. We got to use something different, you know, because that's just dangerous, right? Someone's going to get hurt here. And none of the bathrooms there are wheelchair accessible. So you get guys having to use a chair to relieve themselves because there's no other option. So they make do, right? But at each one of these steps is a potential for someone to have a slip, trip, fall, go down, and then like the 2021, the world champions was in check, different rink. The only injury that I had to take care of, knock on wood, thank heavens for that one, was an injury, a guy literally hopping out of the shower, right, to go and get his towel. And he slipped on the floor and busted the toilet and cut up his arm on the poor slip from his toilet that I had to sew up, right? That's the only injury the entire trip. Had nothing to do with hockey. It was bathroom injury, right? So with that, that's really important. You know, I mean, that really, that awareness was really important and something that I'm more aware of every time we're together, every time we travel. So to summarize, right, have a plan. Have a plan, right? Have a personal plan, talk to the plan. You know, these plans can be as simple as a timeout, right? We do use timeout all the time before procedures, right? This is a, hey, we're gonna have a timeout. Let's talk about this. What are we gonna do? Who goes out? How do you go out? When do you need me? How are you gonna signal me? What's gonna happen? Learn the equipment and the best people that teach you the equipment are the people who are in it. Hey man, can you show me how this is? Hey, what do you like about this? Hey, do you like, you know, tell me about, tell me why do you have your buckles like this? You know, what would you like to, you know, what would you teach me about this? If you like knew, I knew absolutely nothing about this, which basically I don't, cause I'm asking you, right? And then be prepared for the worst case scenarios in your own mind, right? We do a lot of simulation in emergency medicine now, which is really kind of, which is really cool, right? But we always talk to the residents about the best simulator on the planet. It's between your ears and you can really, if you just spend a little time, you can really think to yourself, okay, if I was challenged by blank, if I was challenged by blank, what would I do? And you can just run them down. Worst case scenarios, you know, some sort of collapse or cardiac arrest, right? Then you talk about spinal, you know, motion restriction, right? Then you talk about a significant hemorrhage, right? Or significant, then you talk about, okay, skin issues. Then you talk about infection and fever, okay? And then you talk about to yourself, to the people around you, so you have that plan. And like I said, it's such, and you know, I always kind of joke that, you know, working with this team, like this team does way more for me than I ever do for the team in regards to just, you know, awareness and I just love it. And I love talking about it, teaching about it. And I hope that everyone on this call gets out there and can have the same type of experiences. And with that, I just want to thank you again. There we go. Stop sharing. Oh, did that stop sharing? Yep, it did. Thank you so much, Mike. That was great. It was really, really nice of you to share all your experiences. Appreciate everyone, you know, contributing. I know we are short on time. I want to open it up for any questions. Any of the folks listening in may have, you can either put them in the chat or feel free to just chime in. I think chiming in would probably be the best. I won't be able to figure out how to use the chat efficiently. I can moderate the chat if anyone is not feeling like, you know, unmuting their mic, but we welcome any questions, even just thoughts. Or a hearty hello. Or a hearty hello. Or even just sharing their own experiences as physicians in this space. All right, we got a thank you. You're most welcome, Johan. Thanks for listening. Well, people kind of think about their questions. I have one for you, Dr. Tinney. So when you're doing your consultation, do you ever come into a scenario where you're actually having to kind of educate the spouse or the loved one or the caregiver of the potential adaptive athlete more so to kind of help put their concerns at ease? Certainly, and I think that was really part of the reason if you look at the list of barriers of why, you know, there've been studies about barriers of why people don't participate in adaptive sports and recreation, fear, safety, you know, the family members worry that their family, that their loved one will be injured or the participant themselves may fear injury. And certainly, you know, the family is integral logistically, right? As far as support, you know, being able to facilitate the person even being involved, really having a family member there or a caregiver is really, really important and really helpful for them to understand, you know, what they might be exploring together as a team. That's why I always say, I try to tell them, you know, it's a team effort to make sure that the family knows it is an investment. But, you know, I also say you can learn a lot of things together. They can participate together in a lot of adaptive, you know, recreation activities, you know, and so it's an opportunity for the family members too. So I try to encourage that and really emphasize that. And I think them showing up and encouraging people to come to your clinic with family members does really help the process. That's a good question. Oh, I think we have, do we have anything else in the chat? No, not right now. The other thing that I forgot to include on my screening that I should have emphasized is mental health baseline. And I really, that was like kind of a big oversight. I should have included that and mentioned it in an emergency preparedness, Mike too, you know, as well. I know we both, you know, we have all, you know, especially in all of our experiences, certainly that is something that should still be, you know, as part of the toolkit. So, can I share something really quick? So before Beijing, the USOPC did a really nice job with Dr. Finof being the new chief medical officer and they had two mental health screening. Everyone had to do it. And I am telling you, we're doing our athlete health, we're going through everything. And I'm like, check, oh, you know, follow up, boop, follow up, boop, follow up. I mean, like I got halfway through going through this. I'm, you know, I'm emailing the, you know, the head clinical psychologist going, thank you, but holy cow, like unbelievable how important that is. And the other thing is that it was so awesome that they actually did it. Because you have to understand, especially with, you know, hockey and some of these other kind of, you know, more some of these other sports, like I was just sharing with you the culture, right? So we're in, this is 2013, we're in Calgary and there's two Marines and we're kind of waiting to go on the bus. And these ladies are trying to get in with the family. And he's like, hey, get out of the way, make a hole. And the guy looks at him and goes, whatever, paper cut. And he just kind of pushes, you know, goes out of the thing and I'm like, what was that? And so later on that afternoon, I go over to him, I go, hey man, you know, he called you paper cut before. Like, what's up with that? And he goes, oh yeah, paper cut. Yeah, so I got a below knee on one leg. So that's the paper cut. That's what the Marines call a paper cut. And I was like, oh, okay, okay. Okay, that's a culture, right? So the fact that all these, you know, all these hockey players, right? You know, answered all these questions accurately enough to share their mental health struggles and that they need assistance in A, B, C or D that they are now getting was amazing. And because I do, and I think that's because we're talking about it more. We know that you were reducing stigma and not only that is because I don't think that would have happened in 2013. People would have gone, yep, not doing that, move on. You know, I think that, I mean, that's really great to share then the fact that it is so effective or in your experience that you've seen. But on the other side, the thing that I have noticed is the barriers to participation, the mental health overlay. I mean, not just saying that there's fear but there's a lot there, you know, isolation, depression, et cetera. You also have some of the veterans have literally looked at you and said, hey man, if I wasn't doing this, this saved my life, you know, after an injury like this. And we hear that not uncommonly at, you know, some of the VA events, right? Wheelchair games or winter sports clinic. They'll, you know, people will share their stories and they're like, I'm so thankful to be here doing this because if I wasn't doing this, I don't know what I'd be doing. Exactly, yeah. Well, we don't have anything else in the chat. If anyone, you know, has any questions, they can certainly email us. I know they have our speaker profile. So those who are watching the recording, please reach out if you're interested in this topic and want a further discussion, we welcome it. Thank you everyone for a wonderful session and look forward to next year. This was super fun. Thank you very much. Thank you so much, everyone. I appreciate each and every one of you.

boosting

autonomic dysfunction

blood pressure

wheelchair racing

ethical implications

medical risks

sporting organizations

education

pre-competition examinations

monitoring

emergency preparedness

healthcare providers