Hi, everyone. Welcome to the Pediatric Adaptive Athletes session today. So we're going to talk about lots of different topics, including creating programs, promoting programs, maintaining participation, and providing medical care for pediatric adaptive athletes. So I wanted to start off by introducing our really remarkable group of faculty. I'm really excited to be working with everybody that is in this session today. And so we all come from different backgrounds, but all have really great passion for taking care of parent adaptive athletes in different ways. And particularly today, we're going to be talking about a bit of a pediatric spin. So I'm Mary Dubon. I'm a Pediatric Rehabilitation Medicine and Pediatric Sports Medicine Physician at Boston Children's Hospital and Spalding Rehabilitation Hospital. And I'm a medical director for a brand new program that's being developed called the Youth Athletes with Disabilities Program at Boston Children's Hospital. And I'm really excited to be co-session directors with Dr. Jonathan Napolitano, who's at Nationwide Children's Hospital. And he is the director for the Adaptive Sports Clinic there at Nationwide Children's Hospital, which has been in existence for quite a few years now and has been really successful. And he's also director for their Pediatric Amputation Program as well. We also have really remarkable faculty speaking with us today as well, including Dr. Erin Andrade, who is at Confluence Health. She's a general physiatrist, and she has a really great background in wheelchair tennis in terms of coaching it and putting together programs. And so she's going to be speaking a little bit about this today. We have Dr. Sherry Blauette, who has extensive experience with para sports and para sports medicine. And so she is at Spalding Rehabilitation Hospital and Harvard Medical School. And she's the director of the Adaptive Sports Program there. And she has extensive experience with the IPC and the USOC as well. Then we have Dr. Andrea Paulson, who is a Pediatric Rehabilitation Medicine Physician and Pediatrician at Gillette Children's Specialty Healthcare. And she has a really big passion for getting kids involved in adaptive sports, and herself has some experience with adaptive sports in terms of sled hockey as well. We have Dr. Stephanie Tao, who's another Pediatric Rehabilitation Medicine Physician and Pediatric Sports Medicine Physician, who is at UT Southwestern. And she is the director of the newly developed Adaptive Sports Program there for her clinic, as well as some experience that she's had with the US Paralympic Swimming Team as well. So just as an introduction, when we talk about pediatric athletes with disabilities, we don't necessarily, that's not super specific in and of itself. So it could be multiple different things. So athletes with disabilities could be participating in general sports. So just because you have a disability doesn't mean that you have to participate in a sporting organization that's specifically for youth with disabilities. But they could be athletes with disabilities to participate in para or adaptive sports that are specifically Paralympic style sports. So this is often athletes with physical disability, with blindness, low vision, and sometimes athletes with intellectual disability too. Special Olympics is specifically for athletes with intellectual disability. And then Deaflympics is actually the elite version of sports for athletes with deafness or hard of hearing, just like Paralympics is the elite version of para and adaptive sports. So today we're going to be specifically talking about para and adaptive sports. So I'm going to pass it along to Dr. Napolitano. So the, thanks Mary, I appreciate it. So the para and adaptive sports, as Mary explained, are sports in parallel. Either those that are adapted from other sports or those that are unique and specific for that population. Kind of different examples and comparisons there is something that's adapted from another sport would be wheelchair basketball, similar to basketball, but for those using a wheelchair. Another example of a complete sport in parallel that's unique to the population would be an example here on the bottom of the screen, which is a sport called goalball in the Paralympic environment, which is not a comparison that we have in the able-bodied population, but it's plenty of different examples. So why are we talking to you guys about this today? We understand the role of physical activity in youth. There are excellent health guidelines and expectations because we understand there are countless benefits of physical activity. The Department of Health and Human Services, the CDC, the AAP, American Heart Association, all have agreed that children under the age of 18 should all be involved in 60 minutes of moderate vigorous physical activity each and every day. In addition to that, they recommend about three days a week of vigorous aerobic physical activity, three days a week of muscle strengthening and physical activity, as well as three days a week of bone strengthening physical activity. So dividing this out countless different ways, we know that physical activity is possible and it's really beneficial. So what about that in the population with disabilities? The interesting thing is the recommendations are the exact same. So this came out with the Americans' Recommendations for Physical Activity. The second edition addressed the population with disabilities specifically and held the expectations the same. So understanding that that expectation is the same is a goal for all of us to get our patients active and involved in sports. So why is this important and how are we doing it? The AAP has a promotion, a position statement promoting the participation of children in sports, even those with disabilities. The Government Accountability Office has researched and found that the resources and availability of adaptive sports programs or the benefit of physical activity can extend and has countless benefits and that's currently an underserved group. So what do we do from here? There are a number of studies out that have evaluated what are these barriers, why aren't we getting involved and what can we do about it. Some common barriers to physical activity and those with disabilities, the first two that they mention are the same things for me and everybody else who's listening to this presentation. Lack of motivation and lack of time. Nothing special about that as far as, you know, a unique population. But the other things are things that I don't encounter and they become very real barriers that we need to continue to work to overcome. Poor access to transportation, financial stresses, and poor accessibility and access to various programs. But there are plenty of facilitators out there as well. Kids understand the benefits of physical activity. They know it's important. They want to be healthy and active and they believe that physical activity is fun and a good thing for them. They see their peers participating. They want to be involved as well. And as this movement expands and grows, there is more and more access to different adaptive programs. So we spoke so far about what's the benefits of physical activity in general. This study back in 2015 was a systematic review of the benefits of athletic participation in the able-bodied population. So in all kids and activities. And they identified nearly 40 different social and psychological benefits to team participation. A benefit that is not currently available for the small, for the percentage of people who are not active in sports. So this is the goal. These are the reasons to get people involved. And we're hoping today that we can outline for you some different ways to do that. The outline of our presentation, the next step is Stephanie Tao is going to talk to us about sports classification in the para-adaptive sport population. Next, we'll have Dr. Aaron Andrade speak about how to create a adaptive sports program. After that, Dr. Andrew Paulson will talk about how are you going to get your patients involved? What resources can you share and what conversations can you have? Next, we'll have Sherry Blauette talk about transitioning to the adulthood in adaptive sports. We know it starts young here, but we want to make sure that we include longevity in this movement for physical activity. Finally, Mary and I will come back on the screen and we'll talk about sports medicine for the pediatric athlete. How do we prevent and treat injuries and what are the injuries that we see? And then finally, the panel will come together and we'll review some examples of our various adaptive sports programs that we have started at our various institutions. The next step, we'll have Stephanie Tao talk about sports classification. Thanks, Dr. Napolitano for that wonderful presentation. In this session, we will talk about the classification process as it pertains to pediatric adaptive athletes. My only disclosure is that I work with U.S. Paralympic Swimming as their team physician and as a national medical classifier. Here is a general outline of our presentation today. First, we will do an overview of the classification process. Then, I'll give you some examples of classification for an individual sport versus a team sport. We will then discuss special considerations for youth adaptive athletes and then discuss some works in progress and the future of Paralympic classification. Lastly, we will summarize with some take-home points. The first known mention of classification was in a book by Joan Scrutton, Stoke Mandeville, Road to the Paralympics, when in 1955, it was discussed that the sport netball needed to be a fair competition and so they changed netball to basketball and divided the competition into two classes, one for complete spinal cord injury lesions and another for incomplete lesions. Since then, classification has evolved and its continued purpose is to ensure a fair and level playing field for all competitors while minimizing the impacts of impairments on activity. The inherent impact on the sport must be demonstrated. Classification is also seen in mainstream sports such as weight classes, gender, or age. There are three main steps in classification of para sports. First, the athlete needs to have an eligible impairment for that sport. Then, they also need to demonstrate that their impairment meets minimum criteria for the sport. That is, the impairment has enough of an impact on their sport performance. Lastly, they are assigned a sport class based on their impairment evaluation. The old classification system was based on a medical diagnosis and every one of the same diagnosis were placed within the same class. More recently, within the past decade, the classification system has evolved to be more functional based. The classification process varies by each sport since impairments may impact one sport differently from another. Classification is performed by a panel of at least one medical classifier and one technical classifier, both of whom have done training specifically for classification in a particular sport. To undergo classification, an eligible impairment is verified via medical documentation. Then, the classifier panel conducts a physical bench evaluation followed by a technical evaluation specific to the sport. Afterwards, based on the evaluation and any needed calculations, the athlete is assigned a sport class. Sport class becomes final once the athlete is observed in competition to verify the sport class assignment. An athlete may not be eligible for a sport class if they don't have a primary impairment eligible for the sport, if their impairment is not severe enough to significantly impact sport-specific activities, or they do not have a known medical diagnosis that has an underlying etiology for their impairment. This is especially tricky as some medical diagnoses are not qualifying diagnoses for classification, such as hypermobility syndromes or functional disorders like conversion disorder. In the Paralympics, there are three main eligible impairment categories, physical, visual, and intellectual. We will focus on physical impairments on our examples today. Physical impairments are then further categorized into at least one of these eight categories, and the athlete needs to demonstrate that their impairment is permanent and a direct result of the underlying health condition. Which assessment is performed for classification is dependent on the impairments that result from the health condition and the sport for which the athlete is being classified. Each sport has a different list of eligible impairments, and this table can be found on the Team USA website showing a breakdown of all the different current parasports and which diagnoses or which impairments are eligible for each sport. We will use paraswimming as an example of classification within an individual sport today. Paraswimming is one of the few parasports that is inclusive of all the physical, visual, and intellectual impairments we previously listed. As such, there are a lot of different examinations that may be performed to evaluate the underlying impairment during classification. And so as you can see, these are the different impairment types that swimming includes for for eligible impairments. Strength testing via manual muscle testing with a set protocol for positioning is performed for muscle weakness. Coordination testing is performed for hypertonia, ataxia, or athetosis and is a much more comprehensive exam than the typical coordination testing we perform as physicians. It involves having the athlete perform a series of repetitive movements at various joints in certain positions and then grading the coordination movements on a scale of zero to five. As you can see, while score zero and five are very clear, everything in between is somewhat subjective. Passive range of motion measurements with a goniometer are performed in certain positions to evaluate athletes with impaired passive range of motion. The range of motion they have is then converted to a score of zero to five based on a percentage of what is considered normal range required for each swim stroke. For athletes with limb difference or deficiency, limb length measurements are taken and then the percentage of difference is converted to a point value. If an athlete does not have an unaffected limb for comparison, then there's a much more complicated formula that is used to calculate their point values for classification. Athletes with short stature are classified by height. Athletes with leg length difference have their difference measured and then this is converted to a number of points. After the bench exam, the swimmer moves on to the technical assessment. In swimming, this occurs in the pool and we evaluate water safety, their assistance needs with getting to the starting block, starting and getting into the pool, and getting out of the pool. Sometimes the water may worsen or enhance the athlete's impairment impact on their sport performance and so this is also taken into consideration in their classification and adjustments may be made in their scoring. We also look at what exceptions the athlete should have in the water so they don't get disqualified by officials when competing. For instance, an athlete with a unilateral shoulder disarticulation should not be disqualified for a single hand touch in butterfly. Here is an example of how we score some swim starts. Once the athlete is done with the technical assessment, the scores from the bench and the technical evaluations are used to calculate the athlete's class. In swimming, the athlete receives three separate classes, an S class for freestyle, backstroke, and butterfly. They also get a separate SB class for breaststroke since breaststroke movements are quite different from the other three and then the SM class for individual medley is calculated based on the S and SB class. Here is a list of different exception types the para swimmer may need that we add as codes in the in the classification process. The final classification classes are then assigned based on where their point score falls on this table, where higher point scores mean higher functional levels. For reference, an athlete without impairments would score 300 points for the S stroke and 290 points for the SB stroke. And then, as stated before, the sport class is finalized once each stroke is observed during competition. Now to switch gears and talk about an example of classification in a team sport and we'll focus on what is different in wheelchair rugby. In wheelchair rugby, these seven physical impairment types are eligible for classification and competition and as you can see, short stature is the only physical impairment excluded from this list based off the overall eligible physical impairment types that are permitted in para sports or Paralympic sports. There are also only seven sport classes in rugby and during the game, the total value of players classes on the court cannot exceed eight points. Each sport class in rugby has a distinct profile and athletes in each class often play a specific role on the court. For instance, those in sport class 3.5 have higher levels of functioning and are expected to have higher levels of control and movement and so they are often the major ball handler and primary playmaker, while someone who is a 0.5 has much more impairment and decreased ability for controlled movements and so they often serve as a blocker. While each sport has its own rules and procedures for classification, overall in the U.S. there are special considerations for youth para athletes. There is no minimum age specifically for classification in the U.S., although once athletes go international, there is an age restriction and this depends on the sport. In order for youth para-athletes to be classified, they need to be able to follow instructions and be actively engaged in the classification process. The athlete needs to be able to successfully perform the sport prior to classification. Within each classification class, there is still a wide range of performance levels based on training and skills, as is the case in mainstream sports when categorizing athletes by gender or age, and so younger or beginner athletes may feel like they're behind other more advanced para-athletes within their class, but it is expected that their performance will improve as they train and gain more skills. And lastly, most athletes are reclassified when they turn 18 years old or sooner if they have a progressive medical condition or a change in the medical status impacting their sport function. As discussed, the Paralympic classification system has evolved significantly since it started at the Stoke Mandeville Games, but there is so much research needed to continue evolving it. For instance, in the paraswimming coordination testing example I discussed, those evaluations are still quite subjective. Another controversy in Paralympic classification is that fatigue is not taken into consideration in many of the neurologic and or muscular conditions, such as those with hypertonia, and athletes feel this is unfair as these athletes have both physiologic and pathologic fatigue, while athletes with a traumatic amputation do not typically have pathologic fatigue from a neurologic issue, yet athletes from these two impairment categories may end up competing within the same sport class depending on the sport. Therefore, there is so much research needed to further improve the classification system for many sports. Take-home points for this presentation. Classification varies by parasport and aims to ensure a fair and level playing field for all competitors. The three steps of classification include eligible impairment, minimum disability criteria, and sport class assignment. Athletes within each classification class may physically look different by their diagnosis or impairment, but have similar functional and sports performance potential. Special considerations for youth para-athletes mainly depend on skill level and ability to follow instructions. And lastly, parasport classification is still evolving and further evidence-based research is needed. Here's a list of references for this presentation, and if you have any questions, please email me at stephanie.tau at utsouthwestern.edu. Thank you, and now on to Dr. Erin Andrade, who will present on creating adaptive sports community programs. My name is Dr. Erin Andrade, and today I'm going to be talking about creation of an adaptive sports community program, including key aspects of successful examples of program creation and communities. These are my disclosures. So how did I get here? Well, I first learned to coach wheelchair tennis in about 2008, and then the below picture is a picture of me in 2016 where I was serving as a lead instructor for Seattle Adaptive Sports. And so, as I mentioned, I first learned to coach wheelchair tennis, and I went on to play collegiate tennis. I went to medical school, completed my residency training, and while I was in residency, I continued to coach wheelchair tennis. And ultimately, I completed my training and moved out to Wenatchee, Washington, where I serve as a physiatrist, and I also continue to do consultation work with the United States Tennis Association. And so some of the key ingredients to growing a successful program, the biggest thing I can emphasize is definitely forming good, strong connections in the community. Certainly luck, preparation, creativity, and passion are also important as well. So my journey began at the Veterans Affairs Wheelchair Tennis Camp, where I first connected with Dan James, who's a head wheelchair tennis coach for the USDA. And the whole purpose of the camp was to give the VA Puget Sound the tools and resources needed to start and grow a community wheelchair tennis program. And as a part of the program, the USDA provided coaching to volunteers such as recreation therapists, staff at the VA, and other volunteers. They brought in equipment including wheelchairs, tennis rackets, tennis balls, and then they brought in participants from across the country to participate. And hopefully this clinic would give us the skills to then continue to grow a program. The experience also connected me with the USDA and led toward an expanded role as a medical consultant that I'd go on to do in my future. But not everyone is fortunate enough to be gifted equipment. So where are some of the sources that we look to for equipment? Well, certainly it's important to consider applying to grants. As I talked about with connections, reach out to existing programs locally, as they may have some sport chairs that could be used for your particular sport. And then thinking about ongoing equipment maintenance, you may need to reach out to local vendors, even things outside of the box like bike shops to help with repairs, those type of things. And then now that you have your equipment, you need a facility or a place to host your event, you should make sure that it's accessible. And that's accessible in a variety of different ways. So what's the geographic location? Is it relatively central so that your participants can come there? Is there access for public transportation? Where are the bathrooms easily located close to your facility and sporting fields? What kind of first aid and safety plans are in place for those athletes or really for any athlete, you need to think about thermoregulation or making sure that people are adequately hydrated, and that there are fans and other cooling things available. And then thinking about the hours that you want to host your event, a lot of individuals may have pretty heavy care needs in the morning, so it may not be until nine or 10 o'clock, that they're able to actually come to the event. So timing your event to help accommodate for those type of things. The local Parks and Recreation Services can be a good resource as well, but I didn't end up going that route. And then you do need to recruit participants. On this slide, I have an example flyer that we posted both at local tennis facilities, as well as we handed it out to hospitals with inpatient, outpatient, pediatric facilities. Reach out to existing programs as well. For us, it was Seattle Adaptive Sports, where some of their basketball players wanted to cross-train and they became involved with wheelchair tennis. Certainly social media. And then national organizations may have a database to search for programs that are in existence, so making sure to let them know about your particular program and a good contact information. And then you do need people to help run the event, and this picture perfectly encapsulates different places to look for people to help coach. So in the picture, you have myself, who's the lead instructor. One of my friends is standing by me, who volunteered her time. We have a few medical residents, and then one of the teaching pros at the facility was also volunteering his time. And so in this picture, I'm actually coaching these coaches how to coach, and I'm talking about drills, like teaching points, that type of thing. And particularly because these type of things can't be a one man or woman show, it's really important to make sure to invest the time in coaching the coaches for the sustainability of your program, and people can be there if you're not there. And remember, it's okay to start small. It does take time to grow a program, and sometimes it's nice to start with a smaller program to get the kinks worked out. And speaking of getting the kinks worked out, when you're developing some structure to your program and a schedule, it's really important to consider certain things. So for example, this is my week three schedule, and it looked very different than week one. Most notably, I budgeted time for people to simply arrive and get into their wheelchairs. I didn't realize how much time that could potentially take. And during the meantime, for those people to get going, be it simply pushing around the wheelchair and get warmed up, or throwing a ball, or doing some more sport-specific type skills, that's important. You should also think about your participants. Some people may have a lot of experience with sport in the past and have good experience with sport-specific movement, and you can work on more advanced skills, whereas some people need to just get more comfortable with moving in a wheelchair and learning some of those fundamental movement patterns. And as I mentioned already, spend time coaching the coaches. And finally, sustainability and partnerships are important. As I've already touched upon, you cannot be the only reason the program continues, so it's important to invest that time in coaching other people who can then be the lead instructors. Partner with existing programs. They already may have liability waivers, nonprofit status, websites, resources, etc. Partner with existing facilities and continue to expand your connections. As I mentioned at the start, Dan James was one of the head coaches for the USTA, and right as I was moving out of the area, he was actually moving to the area, and he took over the program and has continued to help it grow. So finally, in summary, focus on those connections, partner with existing organizations to identify community needs, think about the sustainability of your program, make sure you have good equipment and accessible facilities, and most importantly, have fun. And these are my resources. All right, so I'm Dr. Andrew Paulson. I'm going to talk today about how do we get kids involved. And so when we think about encouraging active participation in sporting events, really the most important thing that we can do is ask kids what they're already involved in or what they want to do. This helps them understand that we think physical activity and different participation is very important, and we just can open this discussion in clinic. So it normalizes their desire to participate in organized activities, and I usually do this by just starting the conversation with, sort of, tell me what you do. What type of sports, clubs, or activities are you already involved in? And then if they actually start discussing adaptive sports, then I'll ask them more about what they're doing, what the organization they're working with is. This is often how I learn about new opportunities that are available in our community, and then I can use that information going forward with other patients. I also try to ask about what sports they may be interested in trying, because they may already know about other opportunities that they haven't found yet. And again, really it's just about starting the conversation and trying to be a resource. You definitely don't have to know everything there is about the different adaptive sports in your area. You just need to start that conversation. So I find that can be helpful to find other team members. These often are physical therapists or social workers who are familiar with some of the adaptive sports in your area, and it's helpful if you know of any adaptive sports clinic that you can refer these patients to. It's also helpful to know some of the major organizations that are involved in the adaptive sports, and you've heard about a few of those already today. But here are some more that you can, sort of, direct your patients and your families to. So one is the American Association of Adaptive Sports Programs. This one was started in 96 in Atlanta, and it works with high schools to develop the adaptive sports programs at the local community level. These programs typically are designed for grades 1 through 12, and it also helps recruit sponsors and partnerships in raising funds for the programs. Then there's the Disabled Sports USA and Adaptive Sports USA. They actually merge now, and they're called Move United. This organization helps coordinate adaptive sporting events for veterans with disabilities as well as for children and young adults with physical and intellectual challenges. And the focus of this Move United, it really is just equal access to sports activities. This program has over a hundred different community-based programs in 37 different states, and they have over 30 sports that they're involved in. Then there's also the Paralympics that we've heard about, and again, the athletes are competing in the six main categories. Special Olympics is also one of the largest, most well-known sports organizations in the world. It provides year-round sports training in several different sports. They actually have more than 35 sports that they're involved in. And then there's the Wheelchair Sports Federation that offers individual and team sports as well. And so then if you're lucky enough to have an adaptive sports clinic in your area, it can be a great resource for where you can send your patients to to also learn about other local options in addition to any injuries that they may have. I had the opportunity to participate in an adaptive sports clinic in the past that was made up of a pediatric rehab physician and a physical therapist. The clinic that I was a part of was unique in that the whole goal of that clinic really was to assess the patient's physical and intellectual function and really to discuss where their interests were with the goal of helping match them with options in the local community to try. So the goal for that clinic wasn't injury management but it was just as a place to discuss adaptive sports where it was the primary topic instead of something that was mentioned more in passing as part of an other clinic visit. We were trying to be a resource for patients and families that were interested in more participation but that either hadn't found a good option or just wasn't sure kind of what would be a good fit for them. So as part of the clinic, the physical therapist and I actually went around to a lot of different organizations in our local community to learn more about them, to meet people working in them. That way we had more sort of this firsthand knowledge of what was going on and then we would have a name and a phone number that families could contact with any questions and that we could you know get them plugged in with. The families really felt that the firsthand knowledge that we had was pretty reassuring and actually increased their likelihood of trying out those sports and participating and we were also then able to speak more intelligently about kind of what was the expectations of that organization, what was the competition like, what was the commitment, kind of all of that which they found to be helpful. And then as part of this clinic we also created a database of all the local opportunities that we tried to keep updated as best as we were able to. And so then one of the barriers that many of us have mentioned is that is significant when you're talking about participation in adaptive sports is really funding. So adaptive sports often require sports specific equipment. It can be special wheelchairs or press CC's and they're very expensive and then often this price is very prohibitive to trying a new sport since it needs to typically be custom to the individual. So there are potentials to find used equipment or to borrow something but it's much harder to find appropriate fitting equipment for these athletes than it is to say you know finding a used pair of decent soccer cleats. And so one of the most common ways that we can help families pay for adaptive sports and equipment really is through different types of grant funding. And so the image on the slide here comes from our very own Dr. Phoebe Scott Ward. So thank you for putting this together. But the organizations that are shown here as well as the ones I'm going to mention can offer some grant funding for for our patients. So one of those would be the Challenged Athletes Foundation. They have access for athletes grants that can provide funding for adaptive sports equipment. They'll do things like sport wheelchairs, hand cycles, mono skis, different sports specific prostheses, etc. There's also the Disabled Sports USA grants and they provide funding in three main categories. So that'd be youth, military, and then for training and education. There's also the High Fives Nonprofit Foundation. Then there's the I Am Able Foundation that can do grants for individuals. They also do things like hand cycles or skis and other athletic adaptive gear. There's the Kelly Brush Foundation that is specific for spinal cord injury patients and then the Travis Roy Foundation that also offers grants for patients with spinal cord injuries. And so up next you're going to hear from Dr. Blauwet. Great, thanks everyone. So for this portion of the lecture we'll be talking a little bit about the transition from pediatric to adult adaptive sport and some important considerations to keep in mind in working with this population. The image depicted on the bottom is demonstrating a transition of the international symbol of disability, which I think all of us recognize as typically appearing as the image on the left. But there's actually a global movement to transition to the image that you note on the right, designating the fact that there's really been a paradigm shift and a cultural shift in how we think about physical activity for adults with disabilities and how we depict that within a lot of our signage and in public facing imaging. A brief agenda, we'll first talk a little bit about an overview of disability and health disparities in adults related to the impact of sedentary lifestyles as well as community barriers that we know present a problem for this population. We'll talk a bit about how we can promote access and opportunity particularly through the lens of universal design. And during the end of the talk we'll talk a little bit about our model for a sports medicine clinic. So when we think about the transition from pediatric to adult adaptive sports it's really too important to consider the public health impact this could have. Adopting an active lifestyle when you're young, particularly in childhood or adolescence, translates to being active when you're adult. We know that there's fairly significant evidence that demonstrates that. When we look at the World Report on Disability published by the WHO, this notes a global prevalence of adults with disabilities at over a billion people worldwide. So when I think about this and I think about this theme that we're discussing today of pediatric adaptive sports and how we get people involved at a young age, I think a lot about how that translates into this global population of over a billion people and what a significant impact that could make. So how are we doing now? The CDC published a vital signs report in 2014 noting that inactivity is a significant problem for adults with disabilities. The infographic on the left is quite helpful with some basic facts and figures. Also concerning is that we're not doing a great job in terms of counselling adults with disabilities about the importance of physical activity. In this particular report only 44 percent of adults with disabilities received physical activity recommendations from a health professional. Well what are the barriers? There's been some good research on this topic. Jim Rimmer who's based at the University of Alabama Birmingham has really dedicated his career to think about how facilitating physical activity in adults with disabilities. This is a study where they surveyed adults with hemiplegia due to stroke and asked them about what are the barriers they were experiencing in accessing physical activity. You'll note that at the top of the list was cost of the program, also not knowing where to go, having transportation difficulties, or knowledge and expertise on how to implement an exercise program. And I state this because it's important to note that from my lens all of these things are modifiable and that's a lot of what we're talking about today in terms of barrier reduction and thinking differently about how to bring resources out into the community. Another barrier that's really important to recognize is the social determinants of health and there's been multiple studies that show in both able-bodied populations as well as in people with disabilities that if you have socioeconomic challenges it creates innumerable barriers to engaging in physical activity and certainly adaptive sport. We know that adults with disabilities across our country are less likely to be employed and are more likely to experience those socioeconomic challenges that we know can create an additional barrier. I also want to point out that our own attitudes likely need to shift and of course in PM&R we are certainly more savvy and have a progressive lens in thinking about empowering people with disabilities and thinking outside the box about developing programs and opportunities but across the medical profession in general we need to do a better job to really change our own attitudes and expectations around people and patients with disabilities engaging in physical activity so that we can try to break what is dubbed this vicious cycle of inactivity where disability and inactivity are very much interrelated and build upon one another and create additional disability and chronic disease into adulthood. It's important to note that when we then bridge to organized adaptive sports based on definitions these are opportunities that are organized competitive and rules-based which is the nuance really that separates them from just individual physical activity. It's important to note that not all adaptive sports involve a lot of physical activity so for example an adaptive fishing program which of course is great for socialization, community integration, peer mentoring probably doesn't move the needle very much in terms of someone's cardiovascular health so I think it's important to recognize that. There have been a number of cross-sectional studies though that showing that adaptive sports likely has a significant impact in things like mental health, social integration, life satisfaction and even correlations with increasing the likelihood of employment. And of course we have to recognize that when people do get active and rise to competing in the elite level of sport for example at the Paralympic Games that there are likely considerations that we have to keep in mind regarding potential risks of injury and illness related to sports participation for example things like acute versus overuse injuries, traumatic fractures, illness from the spectrum of autonomic dysfunction or difficulties with thermal regulation and skin breakdown. A lot of the work that we've done at the Paralympic level is using a longitudinal study called the Paralympic Injury and Illness Surveillance Study where we've been able to work with colleagues at the International Paralympic Committee to integrate injury and illness tracking during the Paralympic Games. Now of course this is just one small snapshot of time and it needs to be supplemented with more longitudinal work but it does show us some interesting trends. For example the upper extremity is certainly at high risk across a Paralympic athlete population and certain sports show higher rates of acute injury versus overuse injuries. So for example the sport of football five-a-side which is soccer for athletes with visual impairment demonstrates a high rate of acute injury versus a sport like powerlifting which involves of course multiple repetitive movements with the upper limb increases the risk of chronic injury. If you then dive deeper it's important to note that although we note these large trends for example the upper limb is more likely to be injured in a Paralympic athlete population that if you dig deeper in the data that this is really disability and sport specific. So for example in 2016 we published a sub analysis looking at the sport of track and field noting that there were definitely differences in injury trends between ambulant athletes versus wheelchair or seated athletes. For example the wheelchair racers or athletes involved in throwing sports like shot put and discus and the ambulant athletes who are primarily amputees or visually impaired demonstrated a higher rate of injury in the thigh knee and lumbar spine where it was really this wheelchair and seated athletes that demonstrated a high rate of injury in the shoulder for example as well as the elbow. And why do we care? Well when we think about longitudinal health this is really important for considering how we catalyze opportunities that promote athlete health from pediatrics into adulthood. One correlate that I think is sort of handy or something that's really telling is comparing shoulder injuries in the para-athlete to ACL injuries in the youth athlete in general. And we know that something like ACL tears for example is a significant concern and even a public health problem because an athlete who tears their ACL in adolescence is more likely to progress to early osteoarthritis dubbed in many cases the young athlete with an old knee. And there's likely a correlate when we think about shoulder injury in the para-athlete where when that athlete is loading the upper limb and particularly the shoulder with activities like wheelchair propulsion and transfers and then also adding load to the shoulder because of sports activity they certainly are more likely to experience those overuse injuries like degenerative rotator cuff tears at an earlier age and therefore downstream effects of that something for example like rotator cuff tear arthropathy or glenohumeral osteoarthritis. And although this isn't dubbed in the literature I question whether we need to be concerned about this phenomenon of the young athlete with an old shoulder in the para-athlete population. Autonomic dysreflexia from the medical illness standpoint is certainly a consideration in many adaptive athletes particularly those with spinal cord injury and there have been good studies that show that autonomic dysreflexia is a problem and in fact in the Paralympic lens there have been challenges in the past regarding athletes purposely stimulating a mild degree of autonomic dysreflexia for performance enhancing purposes. This is a practice called boosting. It can lead to enhanced performance and also is prohibited in sport because of course it's a very dangerous practice and this is something that is very unique to a para-athlete setting. Thermoregulation can be a challenge particularly with individuals with higher level neurologic injury like cervical complete SCI. And we have to think about strategies for both cold and hot environments particularly if athletes are transitioning into a new environment because of travel for example or going from a training venue to a competition venue where there may be new thermoregulation challenges that the athlete hasn't compensated for or is not planning for. And in those cases we really need to think about this in terms of overall illness prevention and ensuring that we're promoting safe participation and both educating athletes but also developing compensatory strategies. One strategy that I've seen be quite successful is use of something like an ice vest or a cooling vest in athletes with SCI when they know they're going to be competing in a really hot weather environment. They can be wearing it when they're in the staging area or before they compete and then take it off to compete but it keeps their core temperature down for a longer period of time and is not intrusive from the standpoint of what they have to physically wear. Bone health is certainly a consideration that's unique to a Paralympic athlete population. Many athletes with neurologic injury experience osteoporosis of the non-weight-bearing lower limbs which can create a high risk for fragility fracture with even more low speed trauma and of course with high speed trauma in certain sports like wheelchair racing for example where you see this picture of a fairly epic crash that happened at the Beijing Paralympic Games. We're going to go back to this so I'll skip this. So what's the way forward when we think about promoting participation in adult population? I really think it's important to think about the lens of universal design where we design programs and services in a way that is inclusive for everyone. This is not actually a disability specific concept but it's a concept that's very empowering because it means that we're thinking proactively about universal access from the start and we don't have to backtrack or think retroactively about how to make programs accessible for athletes with disabilities. So some quick examples of that from the standpoint of infrastructure. The US Access Board is a federally appointed board that's responsible for developing guidelines for implementation of the ADA and they've developed this really great checklist that you can take into any fitness facility and it provides just basic recommendations about how you can reconfigure or adapt that facility to make it more inclusive. And again of course this is great for adults with disabilities but also fantastic for many different people who would like to access that fitness facility in that space and again it makes it more universal and welcoming for all. Another great example is related to the concept of universal design and equipment and the crank cycle is an upper extremity spin bike essentially that you can crank with your upper limbs but the way it's designed anyone can use it so you can be a wheelchair user and push the seat to the side and wheel up and you can spin or you if you're an adult who's ambulatory but has poor balance you can use the seat just to provide a little bit of support or if you're an adult with no disability you could simply move the seat and then stand and engage your lower limbs and core while you're cranking. And there's been this push to consider whether mainstream gyms for example our YMCAs could integrate something like a crank class which everyone could access and anyone who visits the gym could decide whether on any given day they want to spin or crank it would make things far more universal and inclusive in terms of the programming offered at that facility. And finally wanted to end with the example of inclusive programs. So there's been some really innovative thinking around this the example that I like to point to is the sport of sled hockey where the way USA Hockey has set the rules of the sport at the community level teams can be integrated. So it can be a blend of athletes with disabilities but also athletes with no disability which helps to fill team rosters, create more teams, create more exciting tournament play and then when athletes get to the more sublead and elite level the rules change so that the team has to be comprised of all athletes with disabilities and that really protects that competitive experience for the elite Paralympic athlete. But in doing it in this way you know more people get exposure to sled hockey, athletes with disabilities are able to compete alongside their friends and it's just a better social experience for everyone. So I think it's really win-win and a great example of universal programming. So in sum we know that unfortunately most adults with disabilities live sedentary lifestyles and because of that are at risk of experiencing chronic disease. That's why we care about engaging young people because we know those health behaviors translate into adulthood. Active individuals demonstrate unique patterns of sport-related injury and illness that are unique to athletes with disabilities and something that we need to be aware of. And I think that moving forward universal design is a really proactive way to think about how we engage more adults and catalyze that transition from adolescence into adulthood and keep people active by designing universal programming in the community and ultimately just a call that we can really be agents for change as physiatrists. We're really trusted sources of advice and subject matter experts on this and it's great to see this session today and I hope we can continue this conversation. So next I'm going to pass it back to Dr. Dubon and Dr. Napolitano. Thanks Sherry and thanks everyone. So we're going to close our session today with what is sports medicine in this realm? What are some important things to think of when it comes to sports medicine for the physiatrist practicing in this realm? So first of all it's important to keep in mind that there are some precautions. So there are some disabilities that may require specific restrictions as far as what participation one may be able to be engaged in but ultimately our role should be to encourage participation. So instead of saying a global no is finding what is accessible. A great example is bocce. It's a great sport that involves the team environment. It does not require you know high cardio threshold events. So there's plenty of options. Keep your eyes open. Look at the various realms and really look to get involved. A big part of sports medicine though is prevention. So the PPE or pre-participation evaluation monograph just released its fifth edition this past year in 2019. And finally in this monograph they have a distinct section for evaluation for the athlete disabilities. This is really serving to form an informed access point for the sports medicine physician, for the athletic trainer, for the coaches to really understand more about the athlete. So what are the things that are covered here? Really a lot of what Dr. Blauwet has talked to us about in our last session. So it asks us about what kind of assistive device someone may use. What types of visual or hearing impairments or various of these other symptoms or symptomatology associated with disability. And the purpose here is to really keep that awareness so that a athletic trainer, a coach, a sideline provider understands who has a predisposition for joint dislocation, osteopenia, fracture risk, those type of things. So having this information filed away in your pre-participation evaluation is now helpful because there is less fear and unknown for that athletic training environment. It's important to understand the difference in the neurologic function. Specifically when we look at atlantoaxial instability there used to be a big dichotomy between where the AAP, the American Academy of Pediatrics, and the Special Olympics thought the role of radiographic evaluation of this stability of the atlantoaxial joint. Finally, everyone is on the same page and realizes that radiographs and further evaluation is only indicated when new and changes of neurologic function change with these symptoms as outlined on this slide. So I'm going to transition over here to Mary to bring us home with some other injury patterns. Yeah, thanks so much. A lot of what I'm going to be reviewing right now is a lot of the stuff that Dr. Blauwet actually has worked on and spoke to us a little bit about because so much of the information that we have has really been in recent years and has been with elite athletes, so mostly adult Paralympic athletes. And so we know that the injury rates are fairly similar to other sports. As we heard earlier, specifically for wheelchair athletes, we see a lot more upper extremity injuries. And with ambulatory athletes, we see more lower extremity injuries, sprains and strains and skin injuries are things that we definitely should be looking out for. We know there are sports specific things as well, as Dr. Blauwet mentioned. And so with winter sports, just with the fast speed, we see a lot more of the fractures and acute injuries, contusions, head injuries. And then with the summer sports, we do have to worry a lot about things like blisters and pressure sores and sunburn with exposed skin and with friction. And then in wheelchair track in particular, there is an increased rate of peripheral monorepithes, whether at the median or ulnar nerve. And so the other thing that we have to think about too, which I guess was touched upon a little bit as well, is it's not just musculoskeletal injuries and skin injuries, but we also have to worry about overheating, hyperthermia, and also hypothermia for our winter sport athletes. So what do we do to try to prevent injury? This is something that I think there needs to be a lot more work on in power sports medicine. But we know from just general studies that the wheelchair propulsion stroke pattern has been shown to be important. And then we do kind of know that there's a difference in terms of shoulder pain between athletes and non-athletes in the wheelchair user population and wheelchair athlete population. So one would expect that, given that, you know, with the wheelchair athletes having less shoulder pain, that the strength and periscopular strengthening likely does decrease those types of injuries, though we don't really have any evidence specifically what types of exercises, what types of things are going to try to prevent that young athlete with the old shoulder syndrome that Dr. Bouawet mentions. So this is an area where there certainly needs to be a lot more work. Now we talked about at the beginning of our talk, I mean, the whole focus is on the pediatric population. So now we're talking about adult Paralympic athletes. So what about the pediatric population? So one of our very own pediatric rehab medicine physicians, Dr. Wilson, did a study in the 1990s. So I believe it was 1993 when this was published. So it's been a while, but this has really been, to my knowledge, the only report specifically looking at pediatric para-adaptive athletes. And so there's certainly, it's been years since that's been done, so there certainly needs to be a lot more work. And this was just with one wheelchair athletics event. And so they kind of surveyed to try to find out injuries, and they did find out a lot of skin injuries, and certainly soft tissue injuries, as well as hyperthermia and overheating. So a lot of the same things we were talking about, the rates, I guess, again, just because of the small nature of the study, it's hard to make generalizations based on this. And certainly a lot has changed in terms of pediatric para-and-adaptive sports since then. So I think there's definitely a huge call here for us to get more information on this population. So next, we're just going to round up by talking a little bit about, fortunately, we have a group of us here who work with this population and are either in development or have developed programs to try to really support these athletes. And so I've been at Boston Children's Hospital for just about two years now. And unofficially, I've kind of had a program where I've been taking care of a lot of youth athletes with disabilities. So I see individuals like pediatric patients who come into my sports medicine clinic or my pediatric rehab clinic that kind of have that overlap between my two areas of interest with pediatric rehab medicine and pediatric sports medicine. And I've spent the last two years or so kind of collaborating with so many different individuals and departments to really optimize care for these individuals and with the plan to kind of create a program. And so about a year ago, we had a Youth Athletes with Disabilities Conference that we had as our official sports medicine conference, the McKaylee Lecture, in 2019. And actually, Dr. Blalat was our keynote speaker. And at that point, we were able to kind of join forces with so many people. And those are the people that really have helped us lay the ground for this program. So what our program is, it's led by sports medicine. So essentially, it's a list of sports medicine providers who have special knowledge or interest and expertise in taking care of youth athletes with disabilities, deafness, hard of hearing, blindness, low vision. And so I'm the medical director of this developing program, and we have two other sports medicine physicians. One is Dr. Adam Tenforty, who's a physiatrist, and then we also have a pediatric sports medicine physician as well, who did her general pediatrics residency and had so much time that she spent with children with complex medical needs. And that's Dr. Kristen Whitney. And so we're kind of the medical home for these patients. And so any of our sports medicine clinics, they can jump into. And so it's really more of an advertisement of, hey, you know, this is a population that we serve. We have an interest and an expertise in. And then we have collaboration with specific physical therapists, occupational therapists, orthopedic surgeons, optometry, ENT, neurosurgery, complex care pediatrics providers who we can kind of coordinate with. So, for instance, if I'm taking care of somebody with a traumatic brain injury and I need to run something by the neurosurgery department to make sure that they're cleared for the particular thing in sport, I have a contact there of somebody that's particularly interested in this population. And then really important to our program is we have athlete mentors, so folks that we can kind of connect our athletes with. So we're going to talk through things. If it's like, hey, we're going through something similar or I'm really hoping to get involved in this just to have that social support. And what we're hoping that they'll be able to do also is be able to do little videos and things from time to time to kind of give new pieces of information to folks. So I'm going to pass it along to Dr. Blauwet to speak about the very established Spaulding program. Great. Thanks, Dr. Duvon. So as was briefly mentioned in my previous comments, when we began to see the unique patterns of injuries and illnesses that para and adaptive athletes were developing several years ago, we decided to start a novel or develop a novel approach in which we launched an adaptive sports medicine clinic at Spaulding. This is one of the original postcards from the clinic that we used for getting the word out and advertising to both athletes as well as clinicians. And the main premise of this program was that it was interdisciplinary, and that's very similar to what Dr. Duvon just described. And you'll see a theme here where we really recognize that in order to care for the para and adaptive athlete, an interdisciplinary model is really optimal because of the unique nature of these injuries and illnesses, and particularly the way in which the injuries and illnesses often develop in a context that's part of the broader rehab context and also very much intertwined with the athlete's equipment. So when we launched our model, initially, we involved a physician, and that was me, although now other people have also joined forces with us, as well as a physical therapist and an adaptive sports medicine program expert. So someone who would literally be the person to think about how we could best evaluate the athlete in real time, and they'd bring the stationary roller or the screwdrivers and the tools that were needed in order to adjust equipment and all those really interesting aspects of the evaluation. The evaluations were interdisciplinary, so it would involve a physician visit, and then that was supplemented by a point-of-care PT eval and also an eval of the athlete and their equipment so that we could really see whether there was a problem in terms of their biomechanics or equipment fit, which is so often the case in these athletes. So it's continued to roll along quite nicely, and our main objective now is just to continue to get the word out, increase referrals, and particularly help our colleagues in physiatry remember that it's a service that's available for people with disabilities who are already involved or interested in getting involved in sport. And now I'll pass it to Dr. Tao. Thank you, Dr. Blowett. So I just started here at AUT Southwestern last month, so actually in September. And so getting the ground running, but luckily I did my residency here three years ago before I left for fellowships. And so I am just developing our program here in the adaptive sports medicine program on the pediatric side. When I, during my last year of residency, so we're in Dallas, Fort Worth, and we saw that there were so many different adaptive and parasport organizations, but some of them didn't necessarily talk with each other or some of them even competed against each other. There's a lot of politics behind that. But what we realized was, you know, we had a lot of patients who had the potential or the interest in getting involved with adaptive and parasports. And then at the same time, you know, with these organizations, well, you know, some of us in Scottish Rite to kind of build this coalition. We basically, we started with a spreadsheet. I remember I had a Google spreadsheet and we said, okay, let's start listing all the different organizations out there who are, you know, focused on adaptive and parasports. So, you know, word got out there. Everyone just started adding things on the spreadsheet. We had a big meeting and we birthed this coalition. And so it's really a two-way street or the way we see it is like kind of like a hub and then like a spoken hub model. And so we have the adaptive sports program as like the home at UT Southwestern. And then we interface with the other organizations and, you know, we have the initial access for patient care in our clinics and on the inpatient rehab unit or on our consult services. And so anytime we meet patients who have an interest in a specific sport, we are able to connect them with the organization connections that we have. And then in turn, we've been focusing this more on the adult side. And now that I'm here, we're doing this more on the youth side as well, but providing medical support for these adaptive and parasports organizations. And then each year, all of us work together. We have a planning committee of some of us on the medical side at UT Southwestern and Scottish Rite and Children's Health, and then also some leaders in the community in adaptive and parasports. And we put on an expo every year that showcases and lets people try out different sports and, you know, different activities, showing them, you know, what they're able to do. And unfortunately, because of COVID, it was virtual this year, but the past three years, it was this big in-person event, and it was just wonderful. And so as I'm developing this program, it's very similar to what you've been hearing with others. But on the clinical side of things, I plan to be seeing youth with disabilities who are already in sports and physical activity. And maybe they have, you know, an acute or chronic injury that they need to see me for, if they want to talk about injury prevention, or usually I will incorporate injury prevention into my sports or rehab evaluations, sports performance, and optimization of function. And then if any of them are interested in any new sports or needing medical guidance, you know, I'm there to provide that for them as well. For youth with disabilities who are not already in sports or physical activity, but do have an interest, I can also, you know, provide them with personalized recommendations, including customized exercise prescriptions, recommendations on resources in the DFW area, and then guidance on adaptations and ensuring safety in sport. So as I had mentioned, a lot of the stuff that I do is also out in the community, and it's a lot of volunteering, just like it is in traditional sports medicine. And so we help do pre-participation physicals, and then I do sports coverage for a lot of weekends or during the week. I've been helping a lot of the teams do some return to play protocols, especially during COVID, and trying to navigate that new territory, which has been very interesting. And then I've realized a lot of these organizations or events don't have emergency action plans. And so as a sports medicine physician, we're skilled and trained to, you know, to help organizations and events do that. And so I've been helping some of our organizations do that. And then we also have the academic and research pillars of our program here at UT Southwestern. And so I plan to kind of build that out further and collaborating with many of the others on this talk today to kind of build like a multi-center, you know, injury prevalence or surveillance, sorry, or injury prevention programs and gathering more data at a national level. In order for our program to work, similar to what Dr. Dubon was talking about, I see patients both in my peds rehab and my pediatric sports medicine clinics. That's the plan. Right now, I don't have like a designated day. Originally, I thought it'd be nice to have a designated day if I needed to see, like make it a multidisciplinary clinic, but then it makes it difficult for patients who need that acute appointment. And so I decided to start it off with just having open appointment slots for adaptive or para sports needs for my patients in both sides, both specialties. And then we partner with a bunch of different, with orthopedics, neurology. I have a sports neurologist who just started here as well, and he's interested in adaptive sports as well. And so we're talking about what we're going to be doing. And then I'm really close with the rec therapists, physical therapy, and occupational therapy. And then I also, similar to Dr. Napolitano, I also work in one of the limb deficiency clinics at Scottish Rite. And so that helps a lot too, since we see a lot of kids who are interested in adaptive sports there. And then we have a wonderful, wonderful support from our PM&R department and our leadership for our program. And now I'm going to pass it on to Dr. Napolitano. For you guys, thanks for bearing with us. First of all, this slide here, I'm going to speak on behalf of my colleague, Dr. Amy Rabatton, who is not able to join us for today's conference, but she's up at Mayo Clinic and is forming a pilot program of the Adaptive Athlete, where they will see both pediatric and adult patients for both assessment of getting involved in exploring different sports, as well as treating injuries. Their program involves a lot of collaboration, as Dr. Tao outlined, with the whole system as a whole, and they are really excited to get going. As Dr. Tao explained, we are all very excited to move forward and look to create some multi-center groups to further look at this group. As I mentioned, I'm here in Columbus, Ohio at Nationwide Children's Hospital. We started our Pediatric Adaptive Sports Medicine program, will be four years coming this January. And so this program, we market it as a specialized resource and program for athletes with physical disabilities. So there's a couple different models that you've heard about today. Primarily, our model is a model within sports medicine. So as a sports medicine provider, pediatric sports medicine provider, that's where most of my clinical time is. And therefore, I have a clinic in which I see athletes with disabilities. My sticking point of this argument was that this needed to be a weekly availability, and it needed to be completely integrated with my regular sports medicine clinic. So I have a clinic space that has accessible rooms with a high-low table for additional assessment and availability based on mobility limitations. And so in that clinic, we have two separate models. We have a model where we are looking to get kids active. I talk to them about their interests, as Dr. Paulson was talking about, in getting people connected with groups that they want to. Within our hospital as a whole, we have a unique program called the Play Strong program run by athletic trainers, which integrates with various different programs throughout our hospital. It works with our cardiologists. It works with our hemlock service. They're working on getting kids active, fighting for that physical activity that I mentioned in our introduction. And then I also see those patients who are already active, and our motto there is to stay active. I don't want an athlete who has worked hard to be involved in Paralympic sports or para-adaptive sports to sustain an injury and not know where to go, and not know how to get back to play. That's where I think my sports medicine training really comes into effect here, is that there needs to be a return to play progression. In addition to using traditional forms of physical therapy and occupational therapy, at Nationwide Children's, we have a functional rehabilitation program with our athletic trainers, and that is really focused on sports-specific movements. We've been working really hard to educate our staff on what are the different sports-specific movements in the adaptive population. So what is that wheelchair mechanic? What is that use of the prosthesis and gait training? How does that vary? And what are the ways to get back on the court, back on the field to compete? So as we said, there is a lot of collaboration with various groups within our program, and we really take advantage of some of the high-level sports performance stuff as well. So we have strength and conditioning for our adaptive athletes. We have sports nutrition for our adaptive athletes. My goal is to truly integrate this program with the rest of sports medicine at Nationwide Children's Hospital. So my wheelchair track patient on the picture here is sitting in the waiting room, waiting for his appointment next to the quarterback of his football team sitting next to him. So this is complete integration, and that's a really important part for me. But then it's also a lot of community outreach. So we work very closely with a number of those groups in the community, volunteer time, getting kids active into those groups, and then having them a place to contact when there is an injury because we know that happens. So that's our last slide. Again, thank you so much for bearing with us in this session. It's been a really enjoyable time getting to know each of my co-presenters better and learning about what we're each doing to really increase availability, inclusion, and collaboration in this unique realm. I ask that you can all join us along with this and continue to help our programs grow. And please don't hesitate to reach out to us with additional questions or comments. Thank you.

physical activity

disabilities

access

universal design

collaboration

sports medicine clinic

comprehensive care

injury prevention

adaptive equipment

positive mindset

inclusivity