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This study aimed to determine the relationship between shoulder pain, physical examination, and tissue pathology in manual wheelchair users competing in elite sport.Eighty elite para athletes who used a manual wheelchair for daily mobility were recruited from international track (n = 40), field (n = 19), and powerlifting (n = 21) competitions. Athletes were surveyed regarding shoulder pain history and symptoms (Wheelchair User's Shoulder Pain Index (WUSPI)), whereas independent blind observers measured signs (Physical Examination of the Shoulder Scale (PESS)) and tissue pathology (Ultrasound Shoulder Pathology Rating Scale (USPRS)). Relationships between measures for the total cohort and for subgroups defined by sporting discipline were calculated.A large proportion of athletes reported a history of upper limb pain (39% dominant and 35% nondominant). For the total cohort, WUSPI score was 22.3 ± 26.9, PESS score was 7.4 ± 6.7, and USPRS score was 5.2 ± 4.0. There were no USPRS score differences between athlete subgroups; however, track athletes had lower WUSPI and PESS scores, especially compared with field athletes. The first principal component explained most of the variance in the WUSPI and PESS, which were strongly correlated (r = 0.71), and the second orthogonal component explained the USPRS, which did not correlate with either the PESS (r = 0.21) or WUSPI (r = 0.20). Subgroup analysis showed that track athletes had lower symptom scores for a given physical examination score.Elite para athletes who use manual wheelchairs for daily mobility have a high prevalence of shoulder symptoms, positive signs on physical examination, and ultrasound-determined tissue pathology. Ultrasound-determined tissue pathology does not correlate with symptoms or signs. This information can help to guide clinicians in managing shoulder problems in this athlete population at high risk of injury.

ObjectivesTo adapt key components of exertional heat stroke (EHS) prehospital management proposed by the Intenational Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020 so that it is applicable for the Paralympic athletes.MethodsAn expert working group representing members with research, clinical and lived sports experience from a Para sports perspective reviewed and revised the IOC consensus document of current best practice regarding the prehospital management of EHS.ResultsSimilar to Olympic competitions, Paralympic competitions are also scheduled under high environmental heat stress; thus, policies and procedures for EHS prehospital management should also be established and followed. For Olympic athletes, the basic principles of EHS prehospital care are: early recognition, early diagnosis, rapid, on-site cooling and advanced clinical care. Although these principles also apply for Paralympic athletes, slight differences related to athlete physiology (eg, autonomic dysfunction) and mechanisms for hands-on management (eg, transferring the collapsed athlete or techniques for whole-body cooling) may require adaptation for care of the Paralympic athlete.ConclusionsPrehospital management of EHS in the Paralympic setting employs the same procedures as for Olympic athletes with some important alterations.

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic. [Abstract copyright: © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.]

Concussion is a frequent injury in many sports and is also common in para athletes. However, there is a paucity of concussion research related to para sport, and prior International Concussion in Sport (CIS) consensus papers have not substantively addressed this population. To remedy this and to improve concussion care provided to para athletes, the concussion in para sport (CIPS) multidisciplinary expert group was created. This group analysed and discussed in-depth para athlete-specific issues within the established key clinical domains of the current (2017) consensus statement on CIS. Due to the onset of the COVID-19 pandemic, the group held all meetings by video conferencing. The existing Sport Concussion Assessment Tool 5 (SCAT5) for the immediate on-field and office-based off-field assessment of concussion was evaluated as part of this process, to identify any para athlete-specific concerns. Regular preparticipation and periodic health examinations are essential to determine a baseline reference point for concussion symptoms but pose additional challenges for the interpreting clinician. Further considerations for concussion management for the para athlete are required within the remove, rest, reconsider and refer consensus statement framework. Considering return to sport (RTS), the 2017 CIS consensus statement has limitations when considering the RTS of the para athlete. Case-by-case decision making related to RTS following concussion is imperative for para athletes. Additional challenges exist for the evaluation and management of concussion in para athletes. There is a need for greater understanding of existing knowledge gaps and attitudes towards concussion among athlete medical staff, coaches and para athletes. Future research should investigate the use and performance of common assessment tools in the para athlete population to better guide their clinical application and inform potential modifications. Concussion prevention strategies and sport-specific rule changes, such as in Para Alpine Skiing and Cerebral Palsy Football, also should be carefully considered to reduce the occurrence of concussion in para athletes.

Medication use among elite athletes has received growing attention over the past decades. However, only limited studies have focused on para athletes, and trends in medication use among this cohort remain unclear. The aims of this study were (1) to describe the pattern of medication use in elite Paralympic athletes, with a particular focus on analgesics, (2) to analyze whether medications declared by athletes were included in the 2018 World Anti-Doping Agency's prohibited list and monitoring program, (3) to report on a variety of novel supplements, and (4) to review whether athlete analgesic needs will be met by the new OlympicParalympic Model Formulary.This is a retrospective, descriptive cohort study.Of all athletes who underwent doping control, 21% declared the use of an analgesic medication. Athletes with limb deficiency and para snowboarders declared the most analgesic medications in their respective categories. It was determined that 84% of the athletes' analgesic medication needs were provided from the new OlympicParalympic Model Formulary.Analgesic use among athletes who participated at the 2018 PyeongChang Winter Paralympics was high. Para snowboarders and athletes with limb deficiency declared the most analgesics. The new OlympicParalympic Model Formulary adequately addressed the medication needs of the athletes attending the 2018 games.

To describe the occurrence of imaging-depicted sports-related injuries (bone, muscle, tendon, and ligament injuries) during the Rio 2016 Summer Paralympic Games. Descriptive data on all imaging examinations by using radiography, ultrasonography (US), and MRI were collected and retrospectively analyzed centrally by five musculoskeletal radiologists according to imaging modality, country of origin of the athletes, type of sport, type of disability, and type and location of injury. We report 109 injuries in 4378 athletes. A total of 382 radiologic examinations were performed in 261 athletes, including 118 (31%) radiographic, 22 (6%) US, and 242 (63%) MRI examinations. Para athletes from Africa had the highest utilization rate (20.1%, 67 out of 333). Athletes from Europe underwent the most examinations with 29 radiographic, 12 US, and 66 MRI examinations. The highest utilization rate of imaging modalities by sport was among Judo para athletes (16.7%, 22 out of 132). Most injuries were reported in athletics discipline (37.6%, 41 out of 109). Most injuries were also reported among para athletes with visual impairment (40 injuries, 36.7% of all injuries). Bone stress injuries were most common among para athletes with visual impairment (6 out of 7). Para athletes with visual impairment were also more prone to bone stress injuries than traumatic fractures, unlike para athletes with neurologic and musculoskeletal impairments. Imaging was used in 6.0% of para athletes. MRI comprised 63% of imaging utilization. Identification of patterns of injuries may help building future prevention programs in elite para athletes. • The highest imaging utilization rates were found among para athletes competing in Judo, sitting volleyball, powerlifting, and football. • Utilization of diagnostic imaging at the Rio 2016 Paralympic Games demonstrated similar trends to what was observed at the Rio 2016 Olympic Games. • Comparison of the rate of imaging-depicted injuries between Olympic and Paralympic athletes is limited due to inherent differences between the two athlete populations and the manner in which injury risk in the Paralympic athlete varies dependent on impairment type, which is not the case for the Olympic athlete.

Physical medicine and rehabilitation requires teamwork and innovation to help patients reach their goals and to optimize their quality of life, and one way is through participation in sports ( Sports Med Arthrosc Rev . 2019;27:73-82; PM R . 2015;7(10):1081-8; PM R . 2012;4(11):851-6; Phys Med Rehabil Clin N Am . 2019;30(1):289-99). Unfortunately, people with disabilities participate in sports ~20% less than their peers, and reasons for this disparity include equipment cost and availability ( Sports Med Arthrosc Rev . 2019;27:73-82; PM R . 2015;7(10):1081-8; Pediatrics . 2008;121(5):1057-61; Res Dev Disabil . 2017;67:9-18). A unique way for physical medicine and rehabilitation clinicians to aid in overcoming these barriers is to collaborate with other fields to make adaptive equipment that meets patients' needs.A multidisciplinary team including a physical medicine and rehabilitation resident physician and biomedical engineer, physical therapist, and machinist collaborated through a local nonprofit organization to design and build adaptive equipment solutions. This team designed two types of adaptive putters that are useable by golfers of various ages and functional ranges and a removable golf club grip for a player with limited grip strength.Implementation of a design team for creating adaptive equipment solutions is possible and can be done in the community setting or as part of a hospital system. In the authors' experience, taking a multidisciplinary team approach allowed developing more innovative and diverse solutions, and the athletes benefited by being able to participate in their desired sports activities.

BackgroundA concussion is a common injury in many sports, including para sport. Aside from a more comprehensive need for concussion education, clinicians face difficulties applying concussion assessment and management guidelines to para athletes.1 At present, there is a lack of para-sport concussion research, and prior International Concussion in Sport (CIS) consensus papers have not addressed this specific population. To rectify this issue and improve concussion management provided to para athletes, the Concussion in Para Sport (CIPS) multidisciplinary expert group was created.2MethodsThe CIPS group undertook an in-depth analysis of issues specific to the para athlete within the established key clinical domains of the current (2017) Consensus Statement on Concussion in Sport.3 The existing Sports Concussion Assessment Tool 5 (SCAT5) was evaluated as part of this process and helped identify para athlete-specific concerns. Four CIPS working groups were tasked with exploring the following key clinical areas of concussion in para sport described in the most recent consensus statement of concussion in sport2: (Less)

Funder: Loughborough University; funder-id: http://dx.doi.org/10.13039/501100000857, Funder: Peter Harrison Foundation, The objective of this scoping review was to map the evidence on measurement properties of body composition tools to assess whole-body and regional fat and fat-free mass in adults with SCI, and to identify research gaps in order to set future research priorities. Electronic databases of PubMed, EMBASE and the Cochrane library were searched up to April 2020. Included studies employed assessments related to whole-body or regional fat and/or fat-free mass and provided data to quantify measurement properties that involved adults with SCI. All searches and data extractions were conducted by two independent reviewers. The scoping review was designed and conducted together with an expert panel (n = 8) that represented research, clinical, nutritional and lived SCI experience. The panel collaboratively determined the scope and design of the review and interpreted its findings. Additionally, the expert panel reached out to their professional networks to gain further stakeholder feedback via interactive practitioner surveys and workshops with people with SCI. The research gaps identified by the review, together with discussions among the expert panel including consideration of the survey and workshop feedback, informed the formulation of future research priorities. A total of 42 eligible articles were identified (1,011 males and 143 females). The only tool supported by studies showing both acceptable test-retest reliability and convergent validity was whole-body dual-energy x-ray absorptiometry (DXA). The survey/workshop participants considered the measurement burden of DXA acceptable as long as it was reliable, valid and would do no harm (e.g. radiation, skin damage). Practitioners considered cost and accessibility of DXA major barriers in applied settings. The survey/workshop participants expressed a preference towards simple tools if they could be confident in their reliability and validity. This review suggests that future research should prioritize reliability and validity studies on: (1) DXA as a surrogate ‘gold standard’ tool to assess whole-body composition, regional fat and fat-free mass; and (2) skinfold thickness and waist circumference as practical low-cost tools to assess regional fat mass in persons with SCI, and (3) females to explore potential sex differences of body composition assessment tools. Registration review protocol: CRD42018090187 (PROSPERO).

Background: Ensuring the strength of the physician workforce is essential to optimizing patient care. Challenges that undermine the profession include inequities in advancement, high levels of burnout, reduced career duration, and elevated risk for mental health problems, including suicide. This narrative review explores whether physicians within four subpopulations represented in the workforce at levels lower than predicted from their numbers in the general population—women, racial and ethnic minorities in medicine, sexual and gender minorities, and people with disabilities—are at elevated risk for these problems, and if present, how these problems might be addressed to support patient care. In essence, the underlying question this narrative review explores is as follows: Do physician workforce disparities affect patient care? While numerous articles and high-profile reports have examined the relationship between workforce diversity and patient care, to our knowledge, this is the first review to examine the important relationship between diversity-related workforce disparities and patient care. Methods: Five databases (PubMed, the Cochrane Library of Systematic Reviews, EMBASE, Web of Knowledge, and EBSCO Discovery Service) were searched by a librarian. Additional resources were included by authors, as deemed relevant to the investigation. Results: The initial database searches identified 440 potentially relevant articles. Articles were categorized according to subtopics, including (1) underrepresented physicians and support for vulnerable patient populations; (2) factors that could exacerbate the projected physician deficit; (3) methods of addressing disparities among underrepresented physicians to support patient care; or (4) excluded (n=155). The authors identified another 220 potentially relevant articles. Of 505 potentially relevant articles, 199 (39.4%) were included in this review. Conclusions: This report demonstrates an important gap in the literature regarding the impact of physician workforce disparities and their effect on patient care. This is a critical public health issue and should be urgently addressed in future research and considered in clinical practice and policy decision-making.

Adaptive sports athletes represent a growing population within the athletic community worldwide. Given potential cardiometabolic and psychosocial benefits of adaptive sports participation, the impact on bone health and injury risk in adaptive athletes is of increasing clinical interest. Impaired bone health as a result of low energy availability has been well described in able-bodied athletic women and, more recently, men as part of the female athlete triad and Relative Energy Deficiency in Sport (RED-S). However, the applicability of these models to adaptive athletes remains unclear given altered physiology and biomechanics compared with able-bodied counterparts. Thus, a literature review was completed to characterize the influence of adaptive sports participation and associated risk factors for impaired bone health in this unique population. To date, limited investigations demonstrate a consistent, positive effect of sports participation on bone health. Risk factors for impaired bone health include low energy availability and micronutrient deficiency.

This review aims to provide an overview of sports medicine principles pertaining to youth Para athletes. While little research on youth Para athletics exists, recent elite Paralympic Games data confirms a higher rate of upper extremity injuries in wheelchair athletes and lower extremity injuries in ambulatory athletes, while showing a higher rate of acute injuries in the Winter Games and skin/soft-tissue injuries in Summer Games. These summer sport findings are consistent with historic youth Para sport data. Clinicians caring for youth Para athletes should be aware of medical considerations for Para athletes with various medical conditions. While little research exists specifically on youth Para sport, we review pediatric rehabilitation medicine and sports medicine principles and data from the adult literature to help prepare clinicians caring for this population. Future research should focus on injury patterns and injury prevention in the youth Para sport population.

ObjectiveTo describe the epidemiology of sports injury at the Pyeongchang 2018 Paralympic Winter Games.Methods567 athletes from 49 countries were monitored daily for 12 days over the Pyeongchang 2018 Paralympic Winter Games (6804 athlete days). Injury data were obtained daily from teams with their own medical support (41 teams and 557 athletes) and teams without their own medical support (8 teams and 10 athletes) through two electronic data capturing systems.Results112 of 567 athletes (19.8%) reported a total of 142 injuries, with an injury incidence rate (IR) of 20.9 per 1000 athlete days (95% CI 17.4 to 25.0). The highest IR was reported for para snowboard (IR of 40.5 per 1000 athlete days [95% CI 28.5 to 57.5]; pConclusionThe new Paralympic Winter Games sport of Para snowboard requires attention to implement actions that will reduce injury risk. The shoulder was the most injured single joint—a consistent finding in elite para sport.

ObjectiveTo describe the incidence rate (IR) and illness burden (IB) at the Pyeongchang 2018 Paralympic Winter Games.MethodsA total of 567 athletes from 49 countries were monitored for 12 days over the Pyeongchang 2018 Games (6804 athlete days). Illness data were obtained daily from teams with (41 teams, 557 athletes) and teams without (8 teams, 10 athletes) their own medical support, through electronic data capturing systems.ResultsThere were 87 illnesses reported, with an illness IR of 12.8 illnesses per 1000 athlete days (95% CI 10.2 to 16.0) and IB of 6.8 days lost per 1000 athlete days (95% CI 3.4 to 13.5). The highest IR was reported for Para snowboard (IR of 19.7 [95% CI 12.0 to 32.2]). Illnesses in the respiratory system (IR of 4.1 [95% CI 2.9 to 5.9]; IB of 1.4 [95% CI 0.6 to 3.0]), skin and subcutaneous system (IR of 2.5 [95% CI 1.5 to 4.1]; IB of 0.6 [95% CI 0.1 to 2.9]), and eye and ocular adnexa (IR of 1.6 [95% CI 0.9 to 3.1]; IB of 0.5 [95% CI 0.1 to 3.3]) were the most common.ConclusionThis is the first study to report both the IR and IB in this setting. There was a high IR of illness in the new sport of Para snowboard. The respiratory system had both the highest IR and IB.

In 2020, the IOC proposed a universal methodology for the recording and reporting of data for injury and illness in sport. Para sport is played by individuals with impairment, and they have a unique set of considerations not captured by these recommendations. Therefore, the aim of this addendum to IOC consensus statement was to guide the Para sport researcher through the complexities and nuances that should be taken into consideration when collecting, registering, reporting and interpreting data regarding Para athlete health. To develop this translation, experts in the field of Para sports medicine and epidemiology conducted a formal consensus development process, which began in March 2020 with the formation of a consensus group that worked over eight phases, incorporating three virtual consensus meetings to finalise the translation. This translation is consistent with the IOC consensus statement, yet provides more detailed Para athlete specific definitions and recommendations on study population, specifically, diagnostic and eligible impairment categorisation and recording of adaptive equipment, and defining and classifying health problems in the context of Para sport. Additionally, recommendations and Para athlete specific examples are described with regards to injury mechanism, mode of onset, injury and illness classification, duration, capturing and reporting exposure and risk. Finally, methods and considerations are provided to cater to the varied needs of athletes with impairment with respect to data collection tools. This harmonisation will allow the science to develop and facilitate a more accurate understanding of injury and illness patterns for tailoring evidence-informed prevention programmes and enabling better planning of medical services for Para sport events.

The impact of mental health symptoms and disorders in elite athletes is increasingly recognised. This led the International Olympic Committee (IOC) to produce a consensus statement1 and establish a Mental Health Working Group. Members of this group have extensive experience in research and practice in the field of athlete mental health and have collectively ascertained gaps in current knowledge and practices. This editorial reflects the authors’ opinions and aims to provide researchers and practitioners with future directions relating to mental health symptoms and disorders in elite sport, focusing on prevalence/incidence, prevention, screening, assessment and treatment. The prevalence studies that are currently available have significant limitations,2 including the lack of data distinguishing mental health symptoms from disorders . The latter require a clinical assessment accounting for the intense and unique demands athletes face, which influence how symptoms and disorders may manifest. An example is the presence of mental health symptoms in overtrained athletes, how these are understood from perspectives such as low energy availability or impaired immune function and where existing classification systems may be inadequate. Studies are limited by the influence of stigma related to mental health symptoms and disorders both in and out of sporting contexts, which likely impact athletes’ responses and do not take account of additional barriers to reporting, specifically cultural barriers including sex, religion, …

There are currently no clear, evidence-based guidelines on return to play (RTP) following sports-related concussion (SRC) for athletes with impairment participating in wheelchair sports or adaptive sports. The current RTP progression from the 2017 Concussion in Sport Group (CISG) follows a graduated stepwise rehabilitation strategy that can serve as a framework for the wheelchair athlete. However, modifications may be necessary due to the unique considerations for the wheelchair athlete. An individualized approach to RTP should be utilized for all athletes following SRC.

In 2020, the IOC released a consensus statement that provides overall guidelines for the recording and reporting of epidemiological data on injury and illness in sport. Some aspects of this statement need to be further specified on a sport-by-sport basis. To extend the IOC consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sports and to meet the sport-specific requirements of all cycling disciplines regulated by the Union Cycliste Internationale (UCI). A panel of 20 experts, all with experience in cycling or cycling medicine, participated in the drafting of this cycling-specific extension of the IOC consensus statement. In preparation, panel members were sent the IOC consensus statement, the first draft of this manuscript and a list of topics to be discussed. The expert panel met in July 2020 for a 1-day video conference to discuss the manuscript and specific topics. The final manuscript was developed in an iterative process involving all panel members. This paper extends the IOC consensus statement to provide cycling-specific recommendations on health problem definitions, mode of onset, injury mechanisms and circumstances, diagnosis classifications, exposure, study population characteristics and data collection methods. Recommendations apply to all UCI cycling disciplines, for both able-bodied cyclists and para-cyclists. The recommendations presented in this consensus statement will improve the consistency and accuracy of future epidemiological studies of injury and illness in cycling.

ObjectivesTo develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders.MethodsWe conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool.Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches).ConclusionThe SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment.

To describe the occurrence of imaging-depicted sports-related injuries (bone, muscle, tendon, and ligament injuries) during the Rio 2016 Summer Paralympic Games.Descriptive data on all imaging examinations by using radiography, ultrasonography (US), and MRI were collected and retrospectively analyzed centrally by five musculoskeletal radiologists according to imaging modality, country of origin of the athletes, type of sport, type of disability, and type and location of injury.We report 109 injuries in 4378 athletes. A total of 382 radiologic examinations were performed in 261 athletes, including 118 (31%) radiographic, 22 (6%) US, and 242 (63%) MRI examinations. Para athletes from Africa had the highest utilization rate (20.1%, 67 out of 333). Athletes from Europe underwent the most examinations with 29 radiographic, 12 US, and 66 MRI examinations. The highest utilization rate of imaging modalities by sport was among Judo para athletes (16.7%, 22 out of 132). Most injuries were reported in athletics discipline (37.6%, 41 out of 109). Most injuries were also reported among para athletes with visual impairment (40 injuries, 36.7% of all injuries). Bone stress injuries were most common among para athletes with visual impairment (6 out of 7). Para athletes with visual impairment were also more prone to bone stress injuries than traumatic fractures, unlike para athletes with neurologic and musculoskeletal impairments.Imaging was used in 6.0% of para athletes. MRI comprised 63% of imaging utilization. Identification of patterns of injuries may help building future prevention programs in elite para athletes.• The highest imaging utilization rates were found among para athletes competing in Judo, sitting volleyball, powerlifting, and football. • Utilization of diagnostic imaging at the Rio 2016 Paralympic Games demonstrated similar trends to what was observed at the Rio 2016 Olympic Games. • Comparison of the rate of imaging-depicted injuries between Olympic and Paralympic athletes is limited due to inherent differences between the two athlete populations and the manner in which injury risk in the Paralympic athlete varies dependent on impairment type, which is not the case for the Olympic athlete.

Introduction The global pandemic due to SARS‐CoV‐2 has resulted in an expansion of telemedicine. Measures of quality and barriers for rapid use by patients and physicians are not well described. Objective To describe results from a quality improvement initiative during rapid adoptive phase of telemedicine during the pandemic. Design Patient and physician satisfaction with synchronous audiovisual telemedicine visits was measured during early adoptive phase (April 6‐17, 2020) within the division of sports medicine in an academic Physical Medicine and Rehabilitation (PM&R) department. Patients were invited to participate in a quality improvement initiative by completing an online survey at the end of a telemedicine visit. Physicians completed a separate survey. Primary Outcome Measures Patient measures included visit type, duration of encounter, quality, and satisfaction. Physicians reported on experiences performing telemedicine. Results Surveys were completed by 119 patients (289 telemedicine encounters, response rate 41%) and 13 physiatrists. Telemedicine was utilized primarily for follow‐up visits (n=74, 70.6%) and most common duration was 15‐29 minutes. Patients rated their telemedicine visit as “excellent” or “very good” across measures (91.6‐95.0%) including addressing concerns, communication, developing a treatment plan, convenience, and satisfaction. Value of completing a future telemedicine visit was measured at 84.9%. Most reported estimated travel time saved in excess of 30 minutes. Rate of no‐show was 2.8%. Most physicians (62%) had no prior experience with telemedicine visits, and most were comfortable performing these visits after completing 1‐4 sessions (69%). Nearly all physicians (92%) rated their telemedicine experience as very good or excellent. The key barrier identified for telemedicine was technical issues. All physicians reported plans to perform telemedicine visits if reimbursement continues. Conclusions In summary, rapid expansion of telemedicine during COVID‐19 pandemic was well‐received by a majority of patients and physicians. This suggests feasibility in rapid expansion of telemedicine for other outpatient sports medicine practices. This article is protected by copyright. All rights reserved.

Objective To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population. Data sources A comprehensive literature search was performed linking pain with terms related to different impairment types. Main results There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete. Conclusions It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.

Shoulder pain in wheelchair users that participate in competitive adaptive sports can be a troublesome condition. Shoulder pain not only affects athletic performance but also affects functional activities such as wheelchair propulsion and weight bearing during transfers. Managing pain in these athletes thus presents a unique challenge because of the difficulty in achieving relative rest and the need to modify athletic shoulder-focused rehabilitation strategies. In all athletes, it is vital to establish an early, accurate diagnosis and optimize conservative treatment before considering surgical interventions to avoid excessive shoulder-related morbidity, loss of function, and, worse, loss of independence.

ObjectiveTo investigate representation by gender among recipients of physician recognition awards presented by the American Academy of Neurology (AAN).MethodsWe analyzed lists of individual recipients over the 63-year history of the AAN recognition awards. Included were awards intended primarily for physician recipients that recognized a body of work over the course of a career. The primary outcome measures were total numbers and proportions of men and women physician award recipients.ResultsDuring the period studied, the proportion of women increased from 18% (1996) to 31.5% (2016) among AAN US neurologist members and from 18.6% (1992) to 35% (2015) in academia, and the AAN presented 323 awards to physician recipients. Of these recipients, 264 (81.7%) were men and 59 (18.3%) were women. During the most recent 10-year period studied (2008–2017), the proportion of women increased from 24.7% (2008) to 31.5% (2016) among AAN US neurologist members and from 28% (2009) to 35% (2015) in academia, and the AAN presented 187 awards to physician recipients, comprising 146 men (78.1%) and 41 women (21.9%). Although it has been more than 2 decades since the proportion of women among US neurologist members of the AAN was lower than 18%, 1 in 4 AAN award categories demonstrated 0% to 18% representation of women among physician recipients during the most recent decade. Moreover, for highly prestigious awards, underrepresentation was more pronounced.ConclusionAlthough the reasons why are not clear, women were often underrepresented among individual physician recognition award recipient lists, particularly for highly prestigious awards.

In 2014, the International Olympic Committee (IOC) published a consensus statement entitled “Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S)”. The syndrome of RED-S refers to: “impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health.”

Background Few U.S. studies have explored how children experience a parent's mobility disability and its effects on their daily lives. Objective We aimed to engage youth ages 13–17 who had at least one parent with mobility disability in describing their perceptions of their parent's disability and its consequences for their daily and family life. Methods Participants videoed and photographed their experiences following general guidelines from the researchers about topics of interest. Participants made their own choices about what they submitted. We used conventional content analysis to identify broad themes. Results The mean (standard deviation) age of the 10 participants was 15.2 (1.9) years; 5 were male; 9 participants were white. All 5 girls submitted multiple self-focused (selfie) videos made in their bedrooms; the 5 boys submitted more diverse data files. Several broad themes or topics emerged including: the effects of timing and trajectory of the parent's disability; perceptions of early maturity and responsibility; fears and frustrations relating to the parent's disability; support and emerging resilience; and sense of social justice. Participants generally felt their parents' disability made them become – compared to their peers – more mature, responsible, capable of performing household tasks, and aware of disability civil rights. Conclusions Participants raised many issues that health care providers should be aware of when youth have parents with mobility disability. A parent's mobility disability may be associated with resilience but also may pose challenges for youth. More research is needed to understand better adolescents' experiences and how clinicians might best assist these youth.

Supplemental digital content is available in the text., Objective Determine representation by gender for individual recognition awards presented to physicians by the Association of Academic Physiatrists (AAP). Design Cross-sectional survey was used. Lists of individual recognition award recipients for the 27-yr history of the AAP awards (1990–2016) were analyzed. The primary outcome measures were the total numbers of men versus women physician award recipients overall and for the past decade (2007–2016). Results No awards were given to women physicians for the past 4 yrs (2013–2016) or in half of the award categories for the past decade (2007–2016). No woman received the outstanding resident/fellow award since its inception (2010–2016). There was a decrease in the proportion of awards given to women in the past decade (2007–2016, 7 of 39 awards, 17.9%) as compared with the first 17 yrs (1990–2006, 10 of 46 awards, 21.7%). Furthermore, compared with their proportional membership within the specialty, women physicians were underrepresented for the entire 27-yr history of the AAP awards (1990–2016, 17 of 85 awards, 20%). According to the Association of American Medical Colleges, the proportion of full-time female physical medicine and rehabilitation faculty members was 38% in 1992 and 41% in 2013. Conclusions Women physicians have been underrepresented by the AAP in recognition awards. Although the reasons are not clear, these findings should be further investigated.

Background Although participation in adaptive sports offers numerous benefits for persons with disabilities, a substantial number of eligible persons do not take part. Previous studies have identified personal and environmental factors that promote or inhibit adaptive sports participation. However, these studies have considered a relatively narrow range of factors. Objective To use qualitative research techniques to identify novel factors that influence participation in a community-based adaptive sports program. Design Qualitative focus group study. Setting Community-based adaptive sports programs affiliated with a rehabilitation hospital network. Participants Participants were recruited from among 134 adults who registered for the sports program in 2013-2014. Participants with mobility or sensory impairment, absence of cognitive impairment, and English proficiency were included. The 90 former participants with adequate contact information were contacted, and 17 participated in the focus groups. Methods Two moderators led each of 3 audio-recorded focus groups using a moderator's guide. We conducted a thematic analysis of transcript data to identify perceived benefits, barriers, and facilitators of participation. Results Our analysis identified 5 themes: physical well-being and health/safety; interpersonal and social relationships; intrapersonal and beliefs/attitudes; physical environment; and access. Participants experienced participation both as physically beneficial and as transformative in terms of how they view themselves. However, programs drew on limited personal resources and sometimes presented a perceived risk of injury. Finding information about and transportation to programs was a challenge. Participants formed an informal community that modeled what athletes with disabilities are capable of, helping to overcome initial doubts. Conclusions To gain the benefits of participation, athletes overcame significant barriers, several of which may be modifiable, including transportation and difficult-to-find information about program offerings. The importance of community and raising awareness of athletes' own abilities suggests a key role for mentorship. Our study contributes to the understanding of experiential aspects that motivate participation in adaptive sports. Level of Evidence IV

Bone stress injury is a common overuse injury in athletes. Risk factors for bone stress injury in athletes include the female athlete triad (triad); this has not been evaluated in para athletes. The aim of this study was to identify risk factors, prevalence, and anatomical distribution of bone stress injury in para athletes. A cross-sectional online survey on health characteristics and previous fractures including bone stress injury was completed by para athletes training for the 2016 or 2018 Paralympic Games. Two hundred sixty para athletes completed the survey (659 invited, response rate = 40%). Half reported previous fracture, and bone stress injury was reported in 9.2% of all athletes. Twenty-four athletes (11 men and 13 women) sustained one or more bone stress injury, including 13 athletes with two bone stress injuries. No risk factors of the triad, disability type, or duration of disability were associated with bone stress injury. Injuries were most common in the metatarsals (n = 8) and hand/wrist (n = 7). In an elite para athlete population, locations for bone stress injury included both the upper and lower limbs. Clinically, para athletes presenting with pain localized to bone require further workup to evaluate for bone stress injury particularly for pain in both upper and lower limbs. Further research is required to identify risk factors for bone stress injury in para athletes.

We appreciate the comment made by Dr. Ortega, suggesting that childrearing may be the primary reason behind the underrepresentation of women among American Academy of Neurology award recipients found in our report.1 This comment speaks to the pipeline issue—that is, whether the supply of women eligible and qualified to receive these awards justifies their underrepresentation. To that end, it is critically important to use data to guide conclusions and conversations—not anecdotes, assumptions, or case studies. While childrearing may indeed affect or delay recognition and should be included in conversations about the underrepresentation of women in medicine, “the US pool of women neurology award candidates currently comprises, but is not limited to, 400+ successful and high-achieving women physicians including more than 170 full professors and more than 280 associate professors.”1,2 Given these populations, it is difficult to justify the underrepresentation found in our study. Moreover, it seems problematic to attribute underrepresentation primarily to the demands of childrearing when implicit bias has been reported to play a role in the selection of award committee members,3 as well as the nomination, evaluation, and selection of women in numerous settings.4,5

Background Studies have revealed a higher incidence of injury and illness among elite adaptive athletes when compared to able-bodied athletes in competition. However, individuals with disabilities report poorer access to health care. Objective The purpose of this study is to identify differences in healthcare access, satisfaction, and unmet needs between recreational adaptive and able-bodied athletes in all sports and within a single sport (hockey). Design Cross-sectional, survey-based study. Setting Recreation sports programs in Boston, MA and Chicago, IL. Participants Adult, recreational, competitive adaptive, and able-bodied athletes. Interventions Not applicable. Main outcome measure(s) The Short-Form Patient Satisfaction Questionnaire (PSQ-18) for healthcare access and satisfaction; percentage of athletes reporting unmet sports-related healthcare needs in the prior year. Results Sixty adaptive athletes (78% male, age 35.7 ± 12.4 years) and 65 able-bodied athletes (40% male, age 34.9 ± 11.9 years) participated. Mean access and satisfaction scores were not significantly different between groups in all sports (P = .53 and P = .19, respectively) or hockey (P = .28 and P = .55, respectively). Unmet needs were more commonly reported among adaptive athletes (18.3% all sports, 20.0% hockey) as compared to able-bodied athletes (9.2% all sports, 4.0% hockey). This reached statistical significance in the hockey group (P = .03), but not all sports (P = .12). Conclusions No differences were seen between groups in healthcare access or satisfaction scores. Adaptive athletes of the same sport reported a higher rate of unmet sports-related healthcare needs but with few doctor's visits in the preceding year, suggesting discrepancies in expectations and healthcare-seeking behavior. Level of evidence III.

ObjectiveTo describe the epidemiology of injuries at the Sochi 2014 Winter Paralympic Games.MethodsA total of 547 athletes from 45 countries were monitored daily for 12 days during the Sochi 2014 Winter Paralympic Games (6564 athlete days). Daily injury data were obtained from teams with their own medical support (32 teams, 510 athletes) and teams without their own medical support (13 teams, 37 athletes) through electronic data capturing systems.ResultsThere were 174 total injuries reported, with an injury incidence rate (IR) of 26.5 per 1000 athlete days (95% CI 22.7% to 30.8%). There was a significantly higher IR recorded in alpine skiing/snowboarding (IR of 41.1 (95% CI 33.7% to 49.6%) p=0.0001) compared to cross-country skiing/biathlon, ice sledge hockey or wheelchair curling. Injuries in the shoulder region were the highest single-joint IR (IR of 6.4 (95% CI 4.6% to 8.6%)), although total upper and lower body IR were similar (IR 8.5 vs 8.4 (95% CI 6.4% to 11.1%)). Furthermore, the IR of acute injuries was significantly higher than other types of injury onset (IR of 17.8 (95% CI 14.7% to 21.4%)).ConclusionsIn a Winter Paralympic Games setting, athletes report higher injury incidence than do Olympic athletes or athletes in a Summer Paralympic Games setting. The highest incidence of injury was reported in the alpine skiing/snowboarding sporting category. There was a similar incidence of injury in the upper and lower limbs. The joint with the greatest rate of injury reported was the shoulder joint. Our data can inform injury prevention programmes and policy considerations regarding athlete safety in future Winter Paralympic Games.

ObjectiveTo describe the epidemiology of illness at the Sochi 2014 Winter Paralympic Games.MethodsA total of 547 athletes from 45 countries were monitored daily for 12 days over the Sochi 2014 Winter Paralympic Games (6564 athlete days). Illness data were obtained daily from teams without their own medical support (13 teams, 37 athletes) and teams with their own medical support (32 teams, 510 athletes) through electronic data capturing systems.ResultsThe total number of illnesses reported was 123, with an illness incidence rate (IR) of 18.7 per 1000 athlete days (95% CI 15.1% to 23.2%). The highest IR was reported for wheelchair curling (IR of 20.0 (95% CI 10.1% to 39.6%)). Illnesses in the respiratory system (IR of 5.6 (95% CI 3.8% to 8.0%)), eye and adnexa (IR of 2.7 (95% CI 1.7% to 4.4%)) and digestive system (IR of 2.4 (95% CI 1.4% to 4.2%)) were the most common. Older athletes (35–63 years) had a significantly higher IR than younger athletes (14–25 years, p=0.049).ConclusionsThe results of this study indicate that Paralympic athletes report higher illness incidence rates compared to Olympic athletes at similar competitions. The highest rates of illness were reported for the respiratory and digestive systems, eye and adnexa, respectively. Thus, the results of this study form a basis for the identification of physiological systems at higher risk of illness, which can in turn inform illness prevention and management programmes with eventual policy change to promote athlete safety in future editions of the Winter Paralympic Games.

The 2009 IOC Consensus Statement on Periodic Health Evaluation (PHE) of Elite Athletes recommends a 12-lead ECG, but the frequency of the PHE elements is not defined.1 In 2011, the International Paralympic Committee (IPC) approved the IPC Medical Code, which describes the need for routine PHE based on the latest medical knowledge.2 However, the components and frequency of screening are also not delineated. Recent research has evaluated the cardiovascular (CV) screening practices of Olympic athletes, but there are limited data regarding CV screening of Paralympic athletes.3 4 This study aimed to investigate current practices for CV screening of Paralympic athletes. Chief medical officers (CMOs) for National Paralympic Committees of the PyeongChang 2018 Paralympic Winter Games were identified by the IPC and surveyed regarding the CV screening practices of their respective teams. The primary outcome was the utilisation of CV screening components as part of the PHE. The secondary outcomes were the frequency of performing the CV screening components. A total of 35 of the 49 (71.4%) countries …