I am Dr. Andrew Gordon with U.S. Physiatry, and I also teach for the National Capital Sports Medicine Consortium in the Washington, D.C. metro area, and I'll be talking to you today about adaptive cycling, giving you an introduction, talking a little bit about the history of adaptive cycling, looking at the design of adaptive cycles, classification of adaptive cycling events, and some technology considerations. I have no disclosures. Adaptive cycling as a sport is broad in scope in terms of participants and adaptations. From hand cycling, recumbent bicycles, traditional upright bicycles, and wheelchair systems, the cycle or wheelchair use must be designed with the patient's health and sport-specific needs in mind. There is a wide array of sports that support adaptive cycling participation, and from youth to adult, adaptive cycling may be enjoyed by para-athletes of all ages. And this session will first look at the introduction, history, design, and technology of adaptive cycling. Then Dr. Delle Lugia will be talking about common orthopedic and medical issues in adaptive cycling, after which Dr. Stephanie Tao will be discussing para-cycling considerations for youth with disabilities. And then finally, Dr. Jaya Balan will be discussing the impact of adaptive cycling on shoulder health in adaptive cycles. The adaptive sports cycle wheelchair can be classified by the sport for which they are designed to assist. We are focusing on adaptive cycling, hand cycling, tricycling, bicycling, and tandem cycling in this session, but also other sports that I can support, you know, can include tennis, road racing, basketball wheelchairs, other wheelchairs for extreme sports such as all-terrain and mountainous trails. Adaptive cycles can be used even in archery or triathlons and hunting, so, you know, the cycle is very, very much able to be used in a lot of different sports here, so. A variety of para-athletes are on the U.S. Paralympic cycling team, including athletes with limb deficiency due to amputation or congenital deformity. Those with spinal cord injuries, including paraplegia and quadriplegia, hemiplegia due to stroke or brain injury, visually impaired athletes, para-athletes with cerebral palsy or intellectual disability, and then there are tandem cyclists for those with visual impairments or for those who are intellectually disabled. Since the mid-1980s, international competitions for adaptive cyclists include the World Championships, Paralympic Games, and the World Cup. In 1999, adaptive hand cycling organized as a competitive sport and was recognized by the International Paralympic Committee as a form of para-cycling. In 2004, it became part of the Paralympic Games for the first time in Athens, and then in 2007, governance of the para-cycling was transferred from the IPC to Union Cyclists International, the UCI, which governs it still today. There are eight discrete events for both men and women composing the road and track races governed by the UCI. They include road races for men and women, individual time trial for men and women, hand cycling team relay for men and women, a mixed event. Then there are track events including the tandem sprint for men and women composed of team sprint, 500-meter time trial, or 1-kilometer time trial, individual pursuit, para-omnium, and scratch races. Impairment classes for adaptive cycling include those with impaired muscle power, impaired passive range of movement, limb deficiency or amputation, leg length differences, those with athetosis, hypertonia, ataxia, and visual impairment. This leads to a discussion on the classification of adaptive cyclists in national and international competition. There are, in general, five classes of hand cyclists, two classes of tricyclists, five classes of bicyclists, and three classes of tandem cyclists that are meant to better place each adaptive cyclist into brackets of competition with athletes of similar ability. Hand cyclists are limited in their ability to use their trunk and or lower extremities. Tricyclists are generally afflicted with coordination or balance deficits, and an adaptive tricyclist may not be an amputee. Bicyclists are capable of riding a traditional upright bicycle, however, they need accommodations or adaptations secondary to loss of muscle power or amputation. Tandem cyclists are visually impaired and ride with a side pilot cycler. Looking more closely at the hand cycle design, initially, these were actually designed for impaired military veterans after World War I to help them navigate more difficult terrain. They have four basic designs. The arm crank and on unit that attaches to the athlete's own wheelchair, the upright arm crank unit, which the athlete is positioned similar to their own wheelchair, kneeling cycles in which athletes kneel with the torso straight up or leaning forward over cranks, and then the recumbent cycle in which the athlete lies supine while manning the cranks above their chest. And the main two designs used in the Paralympics are the latter kneeling and recumbent hand cycles that you can see pictured on the right. In road racing, hand cycles are generally three-wheeled, front wheel chain controlled, and operated by the athlete using upper limb and their torso. Hand cycles are also more efficiently driven than standard push rim wheelchairs, making them more ideal for road racing. So again, hand cyclists are limited in their ability to use their trunk and their lower extremities. And there are five classes in competition that are generally understood to involve hand cyclists. The lower numbers here include those with more severe impairments. The H1 athlete is typically tetraplegic, C6 or above, with severe upper limb impairment with no ability to use their trunk or leg. The H2 athlete is tetraplegic, roughly C7, C8 level. They suffer from severe athetosis, ataxia, and or dystonia. The H3 athlete have spinal cord lesions anywhere from T1 to T10, or equivalent injury with limited trunk stability. The H4 athlete are impaired from T11 down with normal or almost normal trunk stability, but unable to kneel. Then H5 athletes are paraplegic, T11 or below, and also amputees, and distinguish themselves from H1 to H4 hand cyclists by being able to kneel and can compete on the kneeling hand cycle. So to review, a typical H1 to H4 athlete are spinal cord injured patients, those with cerebral palsy or multiple sclerosis, and generally need to be reclined in their cycle. And a typical H5 athlete has a leg amputation or general limb deficiency, paraplegia, ataxia, and are usually sitting on their knees and can use both their arms and trunk. Moving on to tricycle or bicycle design, these generally echo the standard design for able-bodied individuals with specific limited adaptations, such as attachment for lower limb prosthesis to the foot pedal. General considerations include the cyclist body segment, bicycle and tricycle components, important interface components of the body affecting reach, such as the perineum contact of the seat, the hand grip point on the handlebars, and shoe pedal interference. UCI regulations also only allow a standard diamond-shaped frame for upright bicycles during competition with various more aerodynamically frames outlawed. So there are two classes of tricyclists, and the tricyclists typically, you know, their coordination or balance is effective enough to require the tricycle for stability while riding. And the lower number corresponds to a higher degree of impairment again. The T1 athlete has severe athetosis, ataxia, or dystonia in grade 3 or above of spasticity. The T2 athlete has moderate athetosis, ataxia, or dystonia with more fluent movements. So grade 2 would correspond for hemiplegic and quadriplegic athletes, and grade 3 would correspond for diplegic athletes. The C1 athlete has five classes from C1 to C5, and these paracyclists are capable of riding a traditional upright bicycle yet need adaptations secondary to loss of muscle power or amputation. Again, the lower numbers correspond to the higher degree of impairment. The C1 athlete has grade 3 spasticity in the upper and or lower limbs with poor strength in the trunk and or extremities, single or double amputations. The C2 athlete has grade 2 spasticity throughout with more lower limb involvement. The C3 athlete has less spasticity in the upper limb, grade 1, versus the lower limb, grade 2, less athetosis, ataxia, or dystonia than C1 or C2 cyclists. And C4 athletes have grade 1 spasticity with the lower limb more involved. And C5 athletes have minimal impairment such as monoplegia spasticity with clear neurologic signs or a single amputation. C1 through C4 cyclists may be single or double amputees, whereas a C5 cyclist may only be a single amputee. And finally, here is the tandem cycle. The tandem cycle is unique in that it is a two-seat bicycle allowed into competition with a sighted pilot cycler in back behind what is usually a visually impaired adaptive cyclist. And the mechanical design of this cycle must have the riders as close as possible to optimize the aerodynamics. The pilot controls the steering, the gear changing, and the tactics, whereas the visually impaired cyclist must instantly relax to cadence increases as well as changes from standing to seated positions in purple queue. The visually impaired cyclist must be able to remain calm, composed during sudden movements of tandem cycling and changes in road slope or other race conditions. Again, the tandem cyclists are usually visually impaired, and there are three classes from B1 to B3. They all typically compete together in the same events. B1 athletes have no sight. B2 athletes recognize a shape of a hand up to visual acuity of 2 to 60 and or a visual field of less than 5 degrees. B3 athletes have visual acuity of 2 over 60 up to 6 over 60 and or visual field of more than 5 degrees and less than 20 degrees. Some more comments about adaptive cycling design. The frame must optimally fit the athlete, minimize weight, offer significant support and stability, be easily maneuverable, and simultaneously be sport specific. They are typically composed of aluminum, titanium, or other lighter composites. The light athletes typically favor the composite materials, which are more expensive, require more labor to fabricate, but they can offer more stability than their aluminum or titanium counterparts. Other variables important in adaptive cycling design include saddle height, saddle setback, saddle tilt, the length of the handlebar or hand control reach from the saddle, handlebar height drop from the seat, crank length, and saddle tube angle. Changes in cycle setup can also influence the trunk angle, which can influence muscle recruitment and intermuscular dynamics throughout the body. So ideal adjustment of these variables will obviously optimize the power output, the efficiency of the para-athlete, and race performance by the adaptive cyclist. So there is also prosthetic design and technology considerations for limb-deficient adaptive cyclists. Complications can evolve from amputee biomechanics, athlete physiology, and prosthetic design. And cycling socket should be lightweight, optimize aerodynamics as well as energy storage and return, and allow for both range of motion and stability. The custom socket for type intensity and duration activity corresponds with typical competition speeds. And in 2014, the UCI declared all prosthetic devices must be formally approved for use prior to being able to use in one of their sanctioned races. In upper-extremity limb-deficient para-athletes, they typically ride a standard upright bicycle but may also use a recumbent or kneeling hand cycle. They usually need a specific terminal device capable of hand-braking and are able to provide upper-extremity propulsion. In the lower-extremity limb-deficient para-cyclists, this encompasses a wider spectrum of options for riding with or without a lower limb prosthesis. They ride any type of cycle, including a standard one, and can still ride a standard upright bicycle. Now, trans-tibial amputees ride with prosthesis more often than trans-femoral prosthetic amputees. The standard footwork terminal device is hooked directly onto the foot pedal. So here is a trans-tibial limb-deficient amputee riding an upright bicycle. They benefit from suspension systems that cross the knee in order to best enable maximal knee flexion while cycling. A typical suction gel sleeve system are commonly replaced with pin-and-lock mechanisms for stability while cycling with a trans-tibial amputation. The athlete may still elect to use a more traditional gel sleeve that is already flexed and able to maintain suction for a good seal, and critical in keeping the posterior rim of the socket low enough so that it does not cut into the athlete's leg while in a more flexed position. Unilateral trans-tibial-deficient athletes demonstrate more asymmetry with pedaling, but healthy and more force applied in work done. And finally, a brief word on trans-femoral limb deficiency. The cycle seat must be adapted to allow proper space between the ischium and the seat so the leg may clear the seat while cycling. And trans-femoral prosthetics with knees allow freer motion, easier for the athletes to manage while riding. And with that, we will now transition to Dr. DeLuigi, who will discuss common orthopedic and medical issues in adaptive cyclists. Great. Thank you so much. I'm looking forward to talking here today on adaptive cycling and common orthopedic and medical issues that you may see. I have no disclosures. I do have some special thanks to my original mentor, Stuart Willick, who first got me involved with adaptive athletics, and then my continuation with that through USC and snowboarding, the U.S. Olympic Committee, and then when I went back to Walter Reed and started the Military Advanced Training Center with some of the personnel there that helped with the wounded warriors. Today's learning objective is to become familiar with the acute and chronic injuries that may be sustained in participation in adaptive cycling, as well as identifying common medical conditions that are related to athletes participating in adaptive cycling. Here's a picture of where I had the opportunity to travel with the U.S. Paralympics and was one of the medical providers for the Winter Games in Sochi, Russia. This was the first-ever pair of snowboarding event that they had and they went to the Olympics and the United States won and swept the podium. So we'll overall this continuation starting with Dr. Gordon was saying, you know, in general wheelchairs are utilized, you know, utilize their upper limbs for mobility and activities of daily living. So it is important to recognize when treating and preventing these upper limb injuries that can occur because, you know, it can be catastrophic to their overall mobility. And so this would be, so these injuries may be magnified when compared to the able-bodied population. Relative rest of the upper limb may be challenging or near impossible. So you have to think of other considerations when it comes to splinting, orthotics, potentially admission to an inpatient unit if rest is required, and additionally like modifications that may be performed at home or any additional assistance that may occur. In general, there's a wide variety of different wheelchairs for wheelchair sports, as Dr. Gordon mentioned, you know, but again, it's also important to know what type of wheelchair that's being used for as far as the trauma that can be related to the musculoskeletal or the overuse injuries. So, you know, so again, it's also a challenge with the rehabilitation for overall chronic disabilities, you know, a driving force for innovation and technology and practice. I've had the opportunity to work with many great personnel over time who have made significant adaptations to wheelchairs and sporting wheelchairs, and so I'm looking forward to seeing continued future advancements with them. You know, the patients learn compensatory strategies. They also transform perceptions of self, and they help build strength, flexibility, stamina, and improved outlook on life. They're getting back something that they thought that they perhaps had lost. Wheelchair sports in general create opportunities for greater community integration, especially with activities that allow people to compete with and without disabilities at the same time. That's one of the great opportunities with a lot of the adaptive cycling. A lot of the marathons and the road races are now allowing people in the adaptive cycling community to participate simultaneously, and so the wheelchair sports movement parallels the disability rights movement, and they complement each other in making advancements and promoting respect, dignity, and inclusion for persons with disabilities. So the primary focus of my portion of the talk here today is the medical care of the athletes who are participating in adaptive cycling. In general, medical conditions, or it could be things that are encountered by wheelchair athletes, are both similar to able-bodied as well as standing adaptive athletes. The main difference is there may be a different injury pattern, particularly when we're talking about upper extremity overuse injuries and mechanisms of injury with traumatic injuries. Things that you'd be looking for is overall, again, the approach is a full spectrum. They frequently may have some pre-existing trauma which led to their disability. Musculoskeletal, neurologic, vascular, cardiac, dermatologic, infectious, endocrine, GI and GU, psych and environmental aspects can impact our athletes, and so it's important to be aware of the full spectrum of what can occur to one of your competitors that you may be treating. Again, pre-existing trauma, there may be presence of hardware, screws, plates, and pins, previous musculoskeletal injuries that may appear on new x-rays. They may have had organ losses from trauma, splenectomy or nephrectomy. They may have also had a prior TBI, and so if they have a concussive injury, that would be one of those things to look for too, the importance of knowing their baseline. In general, starting with the orthopedic conditions, joint injuries, heterotrophic ossification, spasticity in that neuromusculoskeletal. There's also a different approach in the sensate athlete versus the insensate athlete. Many of our wheelchair athletes, again, may have spinal cord injury or other neurologic deficit which may impair sensation, and therefore you have to be extra diligent in looking for occult musculoskeletal injuries, fractures, dislocations, and visceral injuries, particularly if it's below the level of sensation. The sensate athlete, however, they are able to provide that feedback, and so they would be more similar to able-bodied person when you're coming up with the time for evaluation, but the injury that they have may have a greater consequence than it would for an able-bodied athlete. So shoulder injuries in wheelchair athletes, there is an increased risk for shoulder pathology, and it can be due to trauma or overuse. It can often lead to pain, rotator cuff injury, subacromial bursitis, AC abnormalities, coracoacromial abnormalities, subacromial distal clavicle osteolysis, as well as impingement syndrome. Risk factors in general are repetitive motion, so there's increased pressure in the shoulder, particularly when you're doing a wheelchair propulsion, as well as a muscular imbalance, should this shoulder girdle due to weakness. So complications that may occur, upper lumbar extremity injuries may also lead to other, you know, particular issues. You have to rely on the upper upper body for weight lift, weight transferring, and weight bearing. You know, additionally, they do pressure relief, so they would have to elevate on their shoulder, and so there's one of those things where the injury that occurs to the adaptive athlete can be more problematic than the able-bodied athlete. Despite increases in repetitive use and intensity activity, wheelchair athletes do not have a higher incidence of shoulder pain than other wheelchair users who are not participating in athletics. In fact, it seems that participation in athletics appears to be protective. It's likely due to increased strength and endurance in the athletic population. You know, there are some modifications that can be made. Shoulder complaints among wheelchair users still can, you know, be reduced by making evaluations of proper wheelchair design, as well as the idea of propulsion techniques. Elbow injuries, you know, again, the most common that you'll see is going to be an overuse injury of the ulnar nerve entrapment, most commonly in the cubital tunnel, and so it's the most common upper limb nerve entrapment syndrome, and second most behind carpal tunnel, which I'll discuss next. You know, wheelchair users have increased the ulnar neuropathy at the elbow, as noted by Groh. There's also no evidence to suggest wheelchair users are at greater risk compared to non-athletic wheelchair users. Again, there may be some protective portions, but still there's going to be a lot of overlying pathology. The symptoms are going to present similarly, in most cases, to what you would see in the able-bodied population. Numbness and tingling in the fifth digit, and the ulnar half of the fourth digit. Weakness and atrophy in the intrinsic hand muscles, as well as pain at the ulnar groove. Again, the examination will be, an evaluation will be history, physical, and electrodiagnostic testing, you know, so you want to rule out other aspects. It could be mimicking, lateral epicondylitis, osteoarthritis, electro-hombrositis, and the treatment would be the same. You know, again, you try to have relative rest, activity modification when possible, you know, maybe limited weight-bearing when you can, and then the other medications, bracing, orthotics, and injections can be of potential utilization in this patient population. Wrist injuries, the most common is going to be carpal tunnel. It's the most common nerve entrapment in the able-bodied, as well as the disabled persons. Long-tail wheelchair use does have a prevalence of carpal tunnel syndrome, between 40 and 70.5 percent, so it is something we do see frequently. Wheelchair user symptoms, again, would be similar to carpal tunnel in the majority of the cases, that would present the same in able-bodied, you know, but there may be some changes in the overall lowering of functional status as compared to wheelchair users without carpal tunnel. Again, the diagnosis, again, will be based on history, physical, and electrodiagnostic testing, but again, you want to rule out other portions that may be leading to it, you know, the querve veins, as well as guillain canal, entrapment, osteoarthritis, tendonitis, and as well as the tenosynovitis. Upper extremity fractures, again, in road crashes, their arms are not protected. Oftentimes, they'll be bracing a fall, so you're going to have frequently having fuchs injuries, fall on an outstretched hand, and so, but the overall incident is not known. Wheelchair users may be at a greater risk because of that repetitive falls, particularly in sports like basketball. In cycling, it would be a road crash or would be a crash within competition or training. Hand position can also, if you're in a collision sport, can lead to upper extremity fracture, but typically, there's still possibility to be jostling in a road race against one another where the hand could get caught in between the wheelchair, but again, there's relative high speeds that are occurring, so this would be a high-velocity trauma in most cases, and so, fractures should be treated the same as an able-bodied person, except one of those things is you have to recall that restricted upper limb weight-bearing and utilization, you know, with mobility can impair their day-to-day activities of daily living. Heterotrophic ossification, formation of bone in an area that normally does not ossify. Traditionally, this can be seen in traumatic brain spinal cord injury and burns and total arthroplasty, so again, in your wheelchair population, this can lead to people that, from spinal cord injury or some of these other pathologies, and so, this can be in a high, also seen in amputees, so if you have bilateral amputees that are participating in wheelchair races, this is something that also could be seen. So, may increase the risk of skin breakdown, may cause pain when weight-bearing. Again, following the traumatic brain injury, SCI, that usually occurs around major joints, which then can restrict range of motion and limit mobility. In contrast, with HO and amputation, usually occurs in the residual limb. Surgical excision, if medical management does not fail, may be able to restore in some more extreme cases. Spasticity, again, is velocity-dependent increase in the muscular tone that occurs with an upper motor neuron injury. So again, this is typically your spinal cord traumatic brain injury patients that may be wheelchair bound. You know, in some other sports, you know, maybe cerebral palsy or some of the other congenital, you know, perinatal injuries that may occur. So, with that, again, you're going to look at it for the increased spasticity, which can lead to other problems, so can be a part of a, can lead to other complications, and also may be exacerbated by different complications, such as if you're having increased spasticity because you are having, you know, problems with genitourinary or gastrointestinal issues. So, you're looking for any changes in the sudden increase in spasticity, you should be looking for other underlying pathology. Treatment of spasticity is oftentimes oral medications, baclofen, dantrolene, tizanidine, benzodiazepines, again, injectable medications, such as botulinum toxin, as well as intrathecal medications. Again, if spasticity is resistant to curative management, surgeries can be performed, particularly if they're hindering activities of daily living. Approach to vascular injuries, again, with adaptive cycling, you can have crashes, again, there's going to be a differentiation in a sensate versus an insensate athlete. They may not be able to, especially if it's distal or extremity, be able to tell you the typical findings you have in compartment syndrome, or if they have an arterial injury, however, they are able to provide this if they are sensitive. Looking at the cardiopulmonary system, big ones here to look at is going to be autonomic dysreflexia and orthostatic hypertension. You may see some of these other ones, but for the sake of time with here, those are the ones I'm going to be focusing on here. Autonomic dysreflexia, you know, is a condition that occurs with sympathetic outflow in response to a noxious stimuli that is unregulated due to the interruption of the neural pathways after spinal cord. And again, this is typically a T6 and above or at a higher risk for autonomic dysreflexia. The symptoms usually present as paroxysmal hypertension, bradycardia, facial flustering, and headache. If the hypertension continues without treatment, it can lead to a stroke or even death. Common noxious stimuli, you know, that may lead to it is tight clothing, urinary or fecal retention, renal or bladder stones, pressure ulcers, infections, or intra-abdominal pathologies of appendicitis. Treatment, again, would be sitting up the patient, loosening the clothing, and then inspecting and identifying any other potential noxious stimuli. For acute blood pressure control, you can use chewable nifedipine or nitro paste can be utilized. Some athletes create artificial, by artificial means, autonomic dysreflexia, in which case we call, in fact, we consider this boosting. This may be an athlete that would put either clamping their catheter, you know, sitting a tack in their seat in which they are trying to purposely create a noxious stimuli to try to get an increase in their overall, that hyperstimulation of their system. So again, this is the intentional introduction of the autonomic dysreflexia. It is a dangerous practice and should be discouraged because it may be life-threatening. Orthostatic hypotension, on the way, also occurs in spinal cord injured patients. Again, it's similar from the pathophysiology in that it may occur because, again, that decreased sympathetic afferent activity that occurs. Oftentimes, it presents as lightheaded and dizzy. And so, again, this is that, have that venous pulling and not getting enough blood flow back to the, from the lower limbs or abdomen back to the head. Prevention would be lower limb compression, stockings, abdominal binders, maintenance of hydration, in some cases, salt supplementation. There are some medications that can be utilized if they are in competition that may be banned. Metadrine for a quarter, uh, cortisone and epinephrine. Again, this is again, more commonly seen in the spinal cord injury patients. Again, dermatologic, you're going to be looking at insensate versus sensate athletes. And then if you're having the amputation athletes as well, you know, for the sake of the extent of this, this is more of an introduction aspect of it. We'll talk about some of these, but not all. So one of the big ones we'd looking at would be skin breakdown in the wheelchair athletes, particularly if you're having a longer races. Now, if you're unable to provide those pressure reliefs during a race because of the longevity, then you can get breakdown, particularly in the seated position, again, in your wheelchair athlete, sacrum and coccyx, as well as the ischial tuberosities. So again, depending on what you're looking for, these can also lead to those problems that would lead to odd numbness, dysreflexia. So with these that you want to look for, you know, assess for skin breakdown, particularly if they are having symptoms and you know, it is a longer race, this would be one of those things you'd look for. Again, uh, you try to, you and the athletes oftentimes will sacrifice pressure reliefs to continue with high performance and, and in time. So again, trying to make sure that the cushion is, you know, uh, if they have a cushion, as well as trying to provide the reliefs and, and mitigating risk as much as possible. Infection, again, can lead to a number of different things. UTI, cellulitis, septic arthritis, uh, sensate athletes usually will feel the same. These also may be anitis for odd numbness, dysreflexia. Endocrine issues, the adrenal, uh, diabetic insulin regulation, all may be impaired in these athletes, but you also have the, the disuse osteoporosis that is a nearly universal complication of, of spinal cord injury. There's decreased weight bearing, which predisposes with the osteoporosis. And these risk factors would include the severity of injury, spasticity, and time of injury. So osteoporosis may increase the risk of fracture in these athletes. So again, if they are a spinal cord athlete and they are participating in wheelchair adaptive cycling and they are in a crash, then again, there'd be insensate. So looking for occult fractures would be pertinent. So again, so the E here is prevention of osteoporosis, calcium and vitamin D supplementation, as well as consideration of bisphosphonates. Other things that may lead to problems in this, they have neurogenic bowel and bladder. Oftentimes, particularly in your upper motor neuron and spinal cord injury athletes. Again, this would be one of those things is where they're at in their bowel program before and after a race, abdominal trauma, pelvic trauma, again, may have occurred at the time of the overall injury. So psychologic, they were in a prior trauma potentially, which led to their catastrophic changes in their life, which led to the disability that they're now overcoming and adapting to. There may be cognitive side effects of medications, depending on what pathology they're dealing with. There may be PTSD, traumatic brain injury, and it may be important role of sports psychology for these athletes as well. Environmental, again, these are things that you'll see. Oftentimes, you may be in hot or cold environments. You may also be in altitude. So, and you remember that some of these patients have impaired thermoregulation. So particularly with spinal cord injured patients, it's disruption of the neuroregulatory system that helps control body temperature. Below the level of lesion, the athlete has impaired shivering to produce heat, as well as impaired sweating to dissipate heat. Tetraplegic athletes are at the highest risk compared to paraplegic, and the paraplegic and tetraplegic are also seeing greater increases in body temperature with exertion, as well as greater decreases in temperature with exposure to cold weather. So the key here is being heightened awareness and monitoring these athletes and making sure that they are not developing complications such as frostbite that may occur. So that's what I have here today. So thank you for allowing me to participate, and I'll pass it back along to Dr. Gordon. Hi, everyone. My name is Dr. Stephanie Tao, and I am currently the medical director of adaptive sports medicine and assistant professor at UT Southwestern in the Department of Physical Medicine and Rehab, and I also work at Scottish Rite and Children's Health, specializing in pediatric sports medicine, pediatric rehab medicine, and also adaptive and para sports medicine. My only disclosure is that I'm the team physician for US Paralympic swimming and get a small amount of money for international and domestic travel that I do with them, and I'm also volunteering as a national medical classifier with them. So the outline for today's presentation. So we'll be focusing on paracycling for youth with disabilities. And first, we'll briefly talk about the Paralympic movement. We'll then move on and talk about the more common barriers to participating in paracycling by children and adolescents. Then we'll go over some examples of adaptive cycles for youth, followed by an example of a long-term plan for athlete development in paracycling. We'll go over some tips on how to start training in paracycling, and then briefly discuss some special considerations for youth para athletes when it comes to classification, but hopefully it does not repeat too much of what Dr. Gordon has already mentioned in his presentation. And then I'll summarize the take-home points. So the Paralympic movement has gained significant momentum over the past century, enabling individuals with disabilities to achieve sporting excellence, to inspire and excite the world. As media attention and education about the Paralympic movement increases, there is increased interest at local levels for participation in adaptive and para sports. As a result, there has been an increase in adaptive and para sports organizations or programs leading to increased participation in adaptive and para sports, including at the youth level. Two major organizations in the para and adaptive sports worlds, sorry, para and adaptive sports world that often work with youth with disabilities are the Paralympics and the Special Olympics. While the two organizations have some overlap in their mission and the population they serve, there are three major differences. In Paralympics, each para sport has its own categories of eligible diagnoses and set of qualifications based on the athlete's impairments. Overall, Paralympics has sports that include athletes with physical, visual, and intellectual impairments. Meanwhile, Special Olympics focuses on athletes with intellectual impairments. The Paralympics has traditionally focused on elite performance in sport, while the Special Olympics has focused on including anyone over the age of eight years with any ability level. However, as we will discuss in the next slide, the Paralympics also focuses on helping youth find opportunities to develop and train into stronger athletes as they get older. And so Paralympic efforts are not just focused on elite athletes. Lastly, the IPC oversees the Paralympics across its member nations, while Special Olympics has its own set of regional involvement around the world. US Paralympic cycling has developed this nice schematic demonstrating the pipeline toward elite sport performance in paracycling. Once athletes are connected at the recreational level, they start learning more about the sport and developing the skills to improve in their sport performance, and they continue to climb up the pipeline. However, the most important thing is helping them access this recreational level. And this is not always easy as there are many barriers to consider. I also want to note that while we are focusing on youth with disabilities in this presentation, some of the topics we discuss may also pertain to adults with disabilities who are just getting introduced to paracycling. So here's a fishbone diagram demonstrating some of the more common barriers that youth with disabilities face when accessing sporting or recreational activities. I have grouped them into larger categories, including knowledge or awareness, physical factors from an individual's underlying impairment or disability, financial considerations, psychosocial factors, resources and time, and environmental factors. There are many special considerations for helping youth with disabilities to access cycling and other adaptive and parasports opportunities. For instance, what environmental factors contribute to the child participating in cycling? Are there safe areas for a child to practice paracycling? Are there any facilities willing to provide space and time and what is the cost? Has anyone educated the child or family about paracycling, such as types of equipment, where to find resources, paracycling clinics sponsored by organizations like the Paralympics or other events such as competitions if they become interested in competing? What other resources are available locally? And most importantly, what is the child's preference for involvement in sports? If a child is interested in paracycling, there are many other things to consider, some of which we can help as medical professionals. One example is developing an adaptive sports medicine program at your institution that is a collaborative effort with the adaptive sports community in your area. For example, at UT Southwestern, we developed an adaptive sports coalition in the Dallas-Fort Worth area, where we serve as the hub and manage the coalition, have partnerships with other hospital systems and collaborate with other adaptive sports organizations. Then if there are patients we see who are interested in a particular adaptive sport, we can connect them to the appropriate organization or contact in the area. We also support the various adaptive sports organizations by helping out with sports or event medical coverage, serving as a team physician, helping develop return to play protocols during the pandemic or emergency action plans, doing pre-participation physicals, seeing patients as needed in adaptive or parasports dedicated clinic slots and any other sports medicine needs. What about other barriers such as costs to play or train, equipment or prosthesis needs, motivation, or access to train personnel and supervision of activities? I like this table from this article published by Wright et al in 2018, which provides a clinical intervention guide for physical activity in youth using the trans-theoretical model of behavior change. It looks at the different stages of behavioral changes and the associated goal at the stage and really breaks down the steps for clinical support for each stage. Working with our Therapeutic Recreation Department at Scottish Rite, we have started this program to help kids with spina bifida or cerebral palsy get involved in recreational activities such as cycling. We have multiple checkpoints, but basically have a process for frequently checking in with children and their families and helping them through barriers instead of waiting until their next clinic appointment months later to find out that they weren't able to get into a certain recreational activity. Another example is a personal training model, such as the Adaptive Training Foundation founded by former NFL linebacker David Vobora in 2014. Programs like these help bridge the gap between rehabilitation programs and therapy services and adaptive and para sports, helping individuals who no longer need therapies but aren't quite involved in sports yet to maintain or increase their physical activity. This particular program is committed to keeping its services free for athletes with disabilities and relies on charity or donations. I have also seen others that are quite cost-effective. Here's a quick video of Vobora's Adaptive Training Foundation to show you an example of such a program. One of five living that lost all four limbs serving our country. I walked right up to him and I said, hey bro, when was the last time you worked out? And I realized really quickly that there was a void post-rehabilitation. We've now defined that. We've given them a new ridgeline. And even though you're working on individual goals, you're part of this collective tribe. And you realize that even though no two injuries are the same, you know, people are coming to become a better version of themselves and pulling everybody else by the bootstraps along with them. Man, I grew up just in love with football. It was clear to me that my only path was to be there on the gridiron. As I got later in my career, I started to get injuries and I realized I was not invincible. It was hard for me to say, hey, who's David without football? Matter of fact, it scared me so significantly that I began to cope. It started with injuries and prescription medicine. And then I just went out to the streets to buy what I needed to just numb myself to not face that fear. I checked myself into a hospital, went through a seven day detox, lost 34 pounds, two seizures. I mean, true rock bottom. I was playing weeks prior in the NFL. Being flat on my face in detox was the beginning of really ATF. And I felt the call to open a gym. And it sort of just shifted my passion to realize that I could create optimization for this group, the adaptive athletes, person with physical disability that at some level has been rehabilitated, but never believed in to go and do anything outside of just getting back to a new normal. And I don't like that. I think that you're either getting better or you're getting worse. There's no maintenance. There's no staying the same. When you take a group of people that have every justifiable right to say no to something, but they say yes, and that's a message for all people. USA Paracycling also recommends finding a cycle from a local bike shop or paracycling group and ensuring proper cycle fit, including appropriate adaptations and modifications, which some bike shops may be able to help with, but this depends on their education and training, working with individuals with disabilities. USA Cycling's website also has a list of clinics, seminars, and racing calendars, but local bike shops also may have more information on local events. And once introduced to local clubs, those clubs likely will have a list of other club events where one could get to know others in the paracycling community and learn more about them. Next, let's talk about equipment modifications, prostheses, and costs to play or train specific to youth athletes with disabilities. For many children with disabilities with mild or physical impairments, they may still be able to learn to bike with a balance bike, which many typically developing children are also now using to learn to bike. There are also various cycling companies or equipment vendors that now specialize in adaptive cycles. Ambucks is one company that makes Amtrikes. Their website includes this breakdown on how to choose a trike, including deciding how the rider will propel the bike, measurements needed for equipment fit, and then finding the appropriate trike. Here are examples of hand and foot trikes. These types of cycles may be helpful for a child who has weakness in a particular area as the propulsion of the cycle is spread across all four extremities. Ambucks particularly notes that these two trikes are intended for early intervention. They have a fixed drive, which may help children who might otherwise have difficulty making a full pedal rotation. They are designed to stimulate reciprocal movement and increased range of motion. This is an example of a foot trike intended for early intervention. It has a fixed drive that helps children who might otherwise have difficulty making a full pedal rotation, and there's a foot crank that is constantly in motion for full therapeutic effect. These foot trikes are designed to provide full support for riders who have low tone or truncal control and can be adapted to meet a wide range of needs. Here's an example of a recumbent recreation trike, or two of them, sorry, designed for riding on paved trails and roads. And then here's an example of a recumbent tricycle based on two forward wheels and a single drive wheel at the rear. The seat is fully adjustable and is a sling style system, and the pedal boom can be shortened or lengthened to accommodate riders of different heights. As noted in previous presentations, hand trikes or hand cycles, similar to these hand trikes, are also helpful for those who lack similar to these hand trikes are also helpful for those who lack lower limb function or need focus therapies for the upper extremities. These particular hand trikes have an adjustable easy slide wheelchair seat to ease transfers, and they also have adjustable foot platforms. Here on this slide, we have a bunch of examples of other components that could be considered for adaptive cycling, such as pedal modifications, pedal blocks, foot cups, lower leg supports, or handlebar modifications. Some other easy modifications we often recommend to patients and families interested in cycling are a stabilizer glove that is commonly used in golf for someone who, like let's say they have a little bit of dystonia or spasticity in their hand, that glove can just help with them with providing just a little bit more traction. Toe cages for bike pedals allow for an easy and cost-effective way to modify the pedals to make sure the foot stays in that toe cage, and customized upper extremity prostheses that our prosthetists are able to create for children. Fat Wheels is another company that makes different training wheels for additional support depending on the rider's needs. In terms of cost of equipment or prostheses, sometimes local organizations will have cycles that could be loaned to families. However, if a family is not able to find an appropriate cycle through such a program, other programs are getting creative. For instance, Assisted Cycling Tours, which is based out of Colorado and has bike programs for people with disabilities and their families, has a bike shop called A New Spin Bike Recyclery. This venture is a bike collective model offering internships, earn-a-bike programs, bike education classes, and supported employment training for individuals with developmental or intellectual disabilities, as well as at-risk individuals. There are also grants and funding opportunities through various organizations that support the adaptive sports equipment needs of youth. Many of these are listed on the Move United website, and so I would encourage anyone who's interested in finding some of these funding resources to check out their website. The various Paralympic national governing bodies are also starting to focus on development programs. Here's an example from Canada's long-term athlete development program in paracycling. There are a lot of details on the following slides showcasing Canada's paracycling program, but due to the time restraints of this presentation, I will briefly outline the components of their program and have provided a link to this document in my reference slide for those interested in reading and learning more about this program. Similar to the table I showed previously from the article by Wright et al in 2018, this schematic breaks down the steps that typically take place to reach different levels of participation and competition in paracycling. What is great is that they also break down the different stages of involvement in paracycling by years of experience and age, starting at first contact and gradually advancing to the next stages as they continue interest in paracycling and dependent on their skill level. For each stage of involvement in paracycling, they note key partners, programs, and organizations that would be most helpful at each level. Under each stage of training or eventually competition, they also have a lot more information categorized by definitions of each stage, the typical profile of a participant at that stage, overall objectives for each stage, para-specific objectives and support, physical development and technical development for each stage, tactical development, mental skill development, training program, competition framework, and then at each stage, who the system leaders typically are, what coaches should be working on, what sports services such as classification or sports specialist support should be sought out at different stages, and testing and talent identification. Canada's program also provides this training volume schematic broken down by the different stages of training and categorized by paracycle type, which may be quite helpful for newer paracyclers for guidance in their training. And so as you can see from the overview of this document that Canada's long-term athlete development in paracycling program showcases, it makes it really easy for someone to help guide an athlete with a disability to develop their skills in paracycling depending on what stage they're in in their training. Going back to our barriers fishbone diagram, now let's talk about helping youth with barriers perceived, youth with disabilities perceived and their perceived barriers, inability, physical factors from an individual's underlying impairment or disability, psychosocial factors such as motivation or interest, and medical support. Australia's paracycling website has provided this simple stepwise guide on how to start training in paracycling which aligns well with the early stages of Canada's long-term athlete development program in paracycling. Step one includes working on one's fitness base. Start with short rides a couple times per week and then gradually increase the distance and frequency over a number of months. Participants should be comfortable during this step and carry out a conversation without running out of breath. In step two, participants start to pick up the intensity. They should still be able to talk during the rides but in shorter sentences. In step three, now we're focusing on speed and power, particularly if the athlete is interested in competition and will need to do sprints. Some individuals may not reach this step if they would like to just cycle for leisure or it is not safe to do so due to an underlying medical condition. Step four focuses on more advanced training for the beginner such as training with a club and developing racing skills and tactics to optimize their sport performance. And then step five is recovery which is always a significant portion of training and includes sleep, good nutrition, and stretching and massage. Before ending this presentation, I also wanted to note some special considerations for classification for youth athletes in addition to what Dr. Gordon presented on his classification presentation. In the U.S., there's no minimum age specifically for classification for para sports. However, athletes need to be able to follow instructions and be actively engaged in the classification process. The athlete should also be able to successfully perform the sport before pursuing classification. Of note, within each class of classification, there is still a wide range of performance based on skill and training just like typically developing athletes within an age class have a wide spectrum of performance levels. Another thing to note is that most athletes are reclassified when they turn 18 years old and sooner if they have progressive medical conditions or changes in their medical status impacting the function. So take home points. Youth participation in paracycling or any para or adaptive sport should include a strategic process with consideration of potential barriers. Modifications and customizations of cycle equipment, accessories, and or prostheses is dependent on the children's needs and may evolve as they grow and develop. Depending on individual goals, starting paracycling or any sport should include a gradual progression of training as skills develop. And then special considerations for classification and youth para athletes mainly depend on skill level and ability to follow instructions. Here is a list of my references for anyone who is interested in some of the links that we went over today and if you have any questions please feel free to email me at stephanie.tau at utsouthwestern.edu. Thank you. Hi everyone, my name is Prakash J Balan. I'm the director of clinical musculoskeletal research at the Shirley Ryan Ability Lab. I want to thank Dr. Andrew Gordon for inviting me to be part of this session which has been very informative already for myself. And I'm a clinician scientist so a lot of the work that I do is looking at ways to optimize the performance of athletes as well as prevent against injury in individuals with primarily degenerative musculoskeletal conditions. So typically I've focused on osteoarthritis of the knee but today I'll be talking about some work that we've been doing looking at the impact of a cycling or hand cycling task on shoulder health in individuals who are hand cyclists or adaptive cyclists. And I think Dr. Gordon did a really good summation of the different types of hand cyclists. So the individuals I'll be talking about are specifically hand cyclists not bicyclists. So I do not have any disclosures. Sorry, it's the next slide. I do not have any disclosures at present. So the current evaluation as clinicians of individuals with potentially shoulder pathology is we'll typically they'll present to us with pain, we'll do a physical exam, and we may do imaging studies of those individuals. And classically until the last few years it's really been focused on probably x-ray or MRI evaluation. But definitely within the last five to ten years ultrasound has really taken off. And one of the challenges that we have as physiatrists managing many of these patients is that we don't really have information on how how a joint is potentially going to respond to an exercise regimen. So when we're talking about a physiatry management of sports medicine we're really talking about trying to individualize the prescription of exercise. But we really don't know biologically how that particular joint is necessarily going to respond to loading. And in turn how is the joint going to progress in its disease going forward. And that's really been the focus of a lot of the work that I've done in knee osteoarthritis. This really leads to the development of something called a stimulus response framework. This is where essentially you provide an individual a biomechanical stimulus similar to something like a cardiac stress test. So for example in a cardiac stress test we provide people a physiologic stimulus. In that case it's walking or running on a treadmill. And we look at EKG changes and we stratify risks for the development of coronary artery disease on the basis of that. So similar to that my lab is really focused on developing a stimulus response framework in individuals with joint disease. So for example we get individuals to walk on a treadmill. And this is in individuals with knee osteoarthritis. And then we load the joint. So that's our physiologic stimulus. And then we place an IV or take blood from them at periodic intervals. And we're able to measure certain biomarkers in their bloodstream that have some diagnostic or prognostic value for their specific condition. And that's really the goal of some of the work that we've done in knee osteoarthritis. So similar to that what we wanted to do was to look if we can take that forward and look at it in an individuals who are hand cyclists following a hand cycling task. Now important to think about the structure of cartilage. So obviously the glenohumeral joints in the shoulder does consist of cartilage. And essentially cartilage consists of a chondrocyte surrounded by an extracellular matrix. And that extracellular matrix typically consists of collagen which gives cartilage its tensile strength. And proteoglycans such as agrican which gives cartilage its compressive strength. And there are also other proteins within the extracellular matrix that we are able to measure in individuals bloodstream. So what happens is typically in osteoarthritis or any sort of cartilage injury there's release of some of these extracellular matrix proteins through the lymphatics and into the bloodstream. And we're able to measure those in the bloodstream of individuals with musculoskeletal disease. We're also able to measure some of these cartilage degradative enzymes called MMPs which I'll talk about later which essentially are important and potentiate some of the breakdown of this extracellular matrix. And we can measure those in the bloodstream of some of our patients. So what we wanted to do and no one has done in the past is to look at specifically tendon or cartilage pathology in individuals performing an upper extremity task. So one of the challenges that we have in the use of biological markers in the bloodstream is that they can't always be individualized to a particular joint. So for example if I get someone to walk on a treadmill and I'm looking at their knee osteoarthritis the hip and the ankle are also getting a load. So some of the biological markers that we measure aren't always attributable to or changes in those markers aren't always attributable to the joint of interest. So what we what we know obviously is if individuals are seated and they're doing an upper extremity shoulder task with the shoulder being the largest joint in the upper extremity it's most likely that whatever biomarker changes that we're seeing are probably most likely to be coming from the shoulder and that's what we hypothesize in this study. Also we wanted to look at specific markers of tendon pathology in response to a loading task and in this situation it was a hand cycling task in a hand cycling team. So what we wanted to do was to firstly compare sonographic and biomarker changes at baseline following a dynamic shoulder task in individuals who are manual wheelchair users versus able-bodied individuals. So essentially what we did was we took a hand cyclist these were both able-bodied and manual wheelchair users so these are manual wheelchair users in their everyday life versus able-bodied individuals who did not use a manual wheelchair in their everyday life. We included patients who were between the age of 25 to 50 and the manual wheelchair users who are defined as using 50% of their time of their mobility with manual wheelchair and our outcomes were basically to do ultrasound of these individuals and take blood from these individuals pre and post and also measured their pain pre and post using the visual analog scale. We also use the physical exam symptom scale to give us an idea of to see if physical exam had any relationship to some of these biological markers or ultrasound changes and most importantly pain in these individuals. So we essentially had three remits of markers and the biomarker three remits of outcome measures and the biomarkers that we measured are basically markers of cartilage stress so that's COMP, cartilage degradation which is MMPs, inflammatory mediators which is IL-1 beta and TNF-alpha and TMP-1 which is actually an anti-degradative marker so it actually inhibits MMPs so it's more anabolic in its function. We excluded patients who are unable to consent or had prior shoulder surgery for this study. So the sonographic measure that we actually used is something called something called the AH distance so and we also measured we also sorry we also measured biceps tendon thickness as well as supraspinatus thickness and what we wanted to do was so the age distance which is essentially a measure from the acromion to the humerus and we measured that distance has actually been shown to have a relationship to subacromial impingement as well as also shoulder pain in individuals. So the lower this distance the more it's associated with pain in individuals with potentially shoulder pathology. So those are our major major outcome measures that we looked at in these individuals. So we had 16 individuals to perform the hand cycling tasks and they did 30 minutes of hand cycling with increasing resistance and and then all of the manual wheelchair users in this study were individuals with a prior spinal cord injury and as I said we did these outcome measures pre and post and we measured their serum for some of these markers which I just mentioned. So the demographics of the individuals there was no really significant differences between these individuals unfortunately was primarily a male population that's because of our hand cycling team at our at our population but we we matched the number of male and females in each parts of the study so there were no significant differences in demographics. So the hand cycling tasks that they do and is essentially that they do a they watch they're watching a screen and they each individual hand cyclist actually gets feedback on the power which they're exerting with each of the hand cycling motions or the cycling motions. All of the individuals that were in the did perform the hand cycling tasks were pretty familiar with performing hand cycling and as described it can be a very challenging sport for individuals who are new to the sport. So pre versus post exercise where we looked at the pain scores there was no significant difference in in the visual analog scale in terms of pain and no significant difference in some of the physical exam metrics that we measured. However in terms of ultrasound in the dominant arm in the age distance in the abducted and neutral position was significantly reduced in in the adaptives or hand cyclists and also there was a significant correlation between the reduction of the age distance and the pain that these in this individuals had in their shoulders in the dominant shoulder. Next what we wanted to look at was our serum markers and what we found interestingly enough was that individuals who are manual wheelchair users actually had higher baseline inflammatory mediators but those did not significantly change post exercise and in fact the able-bodied individuals increased their overall increased their inflammatory load in their serum following the exercise. Next what we looked at was this cartilage degradative or tendon cartilage degradative enzyme and MMP1 which essentially is involved in breaking down collagen type 1 which is present significantly in tendon actually significantly increased in the manual wheelchair users following the the hand cycling task which was interesting and in terms of the anabolic marker which is anti breakdown and the manual wheelchair users at both pre and post actually had significantly higher concentrations of this marker. This may suggest that they're obviously individuals that are that have a using a manual wheelchair are likely using their shoulders much more significantly in the everyday life compared to able-bodied individuals so there's certainly some tissue remodeling that's likely occurring in these individuals that you may not see in able-bodied individuals and that may be why we see this change. The other thing that we also looked at was a breakdown marker of collagen type 1 which is present in tendons and serum CTX1 is a breakdown of breakdown molecule of collagen type 1 and what we found was that there was a significant correlation between the in all individuals between the concentration of CTX1 in their serum and their age distance so what that means is is that there was a relationship between some of the biological findings of tendon tendon breakdown or turnover and some of these sonographic changes that we saw in these individuals who perform this task. So putting all these studies together what does this mean now it's been stated that approximately 70% of all adaptive athletes, overhead athletes who play adaptive sports do have shoulder pain so shoulder pain is a significant issue that that that many of these adaptive athletes have. Hand cycling being no different and some of the biological markers that we measured did suggest that there were some biological differences between manual wheelchair users and able-bodied individuals who aren't using their shoulders in their everyday life as much. Obviously this study is limited by the sample size but it certainly gives an indication as a pilot that there may be some differences in the biological health of the shoulder in these individuals. The other interesting thing is that ultrasound was a great biomarker particularly the age distance of and in terms of the pain that individuals may have and that was very very important to think about when we're trying to institute we're trying to institute preventative strategies in our patients and so maybe this sort of evaluation involving the biology as well as sonographic measurements could be something that we think about using in patients who are at early risk of pathology. The next steps that we're performing is really to see if this is a robust response that we can follow longitudinally. We also want to look at a dose response of the biomarker change so trying to see for example the number of turns that individuals actually make with the with the hand cycle whether that has any relationship to some of the biological changes that we see as well as some of the sonographic changes that we saw and then looking at more age sex and pathologic disease severity differences in this population could be of extreme benefit to this population. So in conclusion this hand cycling task or this project produced a significant biomarker and sonographic response in manual wheelchairs users that could be useful in determining precursors to pathology in the future and my hope is and this session as a whole by educating on hand cycling and some of the issues and the pathologies that we might see by incorporating some of these methodologies for our patients we may or our athletes I should say we improve their function overall by diagnosing their disease much earlier on and providing them with biomechanical strategies that are individualized to them to optimize their function both in their sports but also in their everyday life. I'd just like to thank my funding sources and many of the residents and medical students who worked with me on this project and thank you very much for your time.

youth with disabilities

para-cycling

orthopedic conditions

spasticity

cardiorespiratory considerations

autonomic dysreflexia

Paralympic movement

training in paracycling

barriers to participating

adaptive cycles

shoulder health