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Episode 7: Equity in Elite Sports: The Paralympian

August 7, 2023

In this episode, we hear about the state of the science of sports medicine in the elite para athlete.

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Episode Guests

Cheri BlauwetCheri Blauwet, MD is an Associate Professor in Physical Medicine and Rehabilitation at Harvard Medical School, the Distinguished Chair in Physical Medicine and Rehabilitation at Brigham and Women’s Hospital, and the Chief Medical Officer of Spaulding Rehabilitation Hospital. She is an attending sports medicine physician at Mass General Brigham, where she also serves as Founding Director of the Kelley Adaptive Sports Research Institute.

Dr. Blauwet is also a former Paralympic athlete in the sport of wheelchair racing, competing for the United States Team in three Paralympic Games (Sydney '00, Athens '04, Beijing '08) and bringing home a total of seven Paralympic medals. She is also a two-time winner of both the Boston and New York City Marathons.

Wayne DermanProfessor Wayne Derman is the Executive Head of the Department of Exercise, Sport and Lifestyle Medicine, as well as the Head of Division: Institute of Sport and Exercise Medicine (ISEM) at Stellenbosch University. He is currently a Co-director of the IOC Research Centre in South Africa and heads up one of two FIFA Medical Centres of Excellence in Africa. His research focuses on secondary prevention of chronic diseases of lifestyle, and injury and illness prevention in athletes including those with disabilities.

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Shonali Gaudino, OT, Host, Producer, Co-Creator

Chuck Clough, Editor

This production is a collaboration between, and partially funded by, the Rehabilitation Outcomes Center at Spaulding and our Model Systems: the Boston-Harvard Burn Injury Model System (NIDILRR Award #90DPBU0008), the Spaulding-Harvard Traumatic Brain Injury Model System (NIDILRR Award #90DPTB0027-01-01), and the Spaulding New England Regional Spinal Cord Injury Model System Center (NIDILRR Award #90SIM0017-01-00).

Transcript of Episode 7

Shonali: (00:28) Not a bad deal to have a visa commercial about how cool you are. Welcome to Finding Strength. The Spaulding Rehabilitation Podcast, where we'll try to connect the dots between rehabilitation research and the people who are most impacted. So why start with a Visa commercial from 2010? It’s a fantastic introduction Dr. Cheri Blauwet, who, if you listened to our last episode, you’ve already met, but Dr. Blauwet is the Chief Medical Officer of one of our inpatient rehab facilities. She is an academic; an Associate Professor at Harvard Medical School with over 80 publications to her name. She is the Founding Director of Spaulding’s Kelley Adaptive Sports Research Institute. And she’s a person living with a spinal cord injury. As a former wheelchair racing athlete, she brought home seven medals over the course of three Paralympic Games and is a two-time winner of both the Boston and New York City marathons. It is this intersectionality of clinician, researcher, and person with lived rehab experience that makes her personal story so compelling, but also makes her a perfect person to teach us about the state of the science on elite para sport.

Shonali: (01:37) In the last episode, and in many other media platforms, Dr. Blauwet, you've shared your story of being in Iowa in the 80s. And getting exposed to wheelchair racing and how important it is that we give people opportunities early on, and for you how, you know, a lot of stars aligned in order to set you down the path to Paralympics. So, now we're gonna get to that next level of once you become to repair Olympian, what is that experience like for you? And what was your time as an athlete? You know, you were going through med school at the same time as being a Paralympian?

Cheri: (02:13) So, when I graduated high school, and started my undergrad education, I decided to go to the University of Arizona. Because at the time, it was one of the only colleges or universities in the US that offered a more fulminant adaptive sports program, meaning you could go and actually be a true student athlete, you know, pursuing your academic interests while also pursuing training and competition. And there were programs across the US, but very few of them had several different sports inclusive of wheelchair racing. So, at that time, the options were the University of Illinois or the University of Arizona, and I was a farm kid from Iowa. So, Arizona sounded a lot more intriguing. And when I made that transition, I suddenly had access on a daily basis to a much higher-level training environment inclusive of, you know, having teammates around me who were also very talented, who really pushed me and we could do a lot of pacing, also a lot of expertise on equipment, and daily coaching. And that was a much different scenario than in high school when I had been really the only person with a disability on our high school track team. So, I got better really, you know, quickly. And it was in my sophomore year of college that I qualified for my first Paralympic Games, which was in Sydney 2000. And that then really launched my international career towards competing in two more Paralympic Games in Athens, 2004 and Beijing 2008. Obviously, that was an incredible journey, and quite a wild ride, right? Being an elite athlete and competing internationally and flying all around the world, while also trying to keep up with school and take care of oneself and everything that you need to do. Reflectively, I think that the state of the Paralympic movement is in a much different stage of development now than it was at that time. You know, at that time, we were - really if I look at the team, in Sydney 2000, for example, we were really a group of talented athletes who were really left to figure a lot out on our own. And that definitely includes everything related to health, right, our healthcare and our sports medicine care. And I would say that's for a couple of reasons. Number one, at the time, we didn't have the resources and infrastructure in place that that is needed to really work directly with elite athletes and understand their needs and have clinicians there at the ready to meet those needs. And then the other aspect was that the state of the science was totally underdeveloped. There were very few publications that looked at the sports medicine and health needs of elite Paralympic athletes. And those that did exist, or, you know, frankly, very nice, but low-quality studies, you know, looking at, for example, one team over the course of the season and saying 50% of them had shoulder pain, okay, that's interesting, but it doesn't really translate into what we need to know in order to try to prevent injury and enhance performance and athletes. So, it was just a very different time. What I see now is that our athletes who, for example, are training to go to the Paris Paralympic Games next summer and 2024. That the infrastructure and resources available to those athletes here in the US, is incomparable, incomparably different than what was the case back in 2000. That said, there are still many places around the world and maybe Wayne can speak to this as well, where those services are still vastly underdeveloped.

Shonali: (05:45) Because even if the Paralympic experience has better resourcing and better medical care on site during the training process, that it's up to the country, the individual country to provide that.

Cheri: (05:56) Yeah, it really falls to the individual country and or the individual sport Federation. The other thing I would say is that, alongside that those areas of underdevelopment was just a general lack of awareness and education to athletes. We can do all the research we want and understand the injury and illness patterns, or the epidemiology of these injuries and illnesses in these athletes. But ultimately, it's about how do you take that information and translate it to being able to provide better services and educating athletes regarding what they need to know, regarding their journey through elite sport and what they should be asking about which they should be watching out for, what they can do, independently and proactively to stay healthy as an elite athlete. I would say that in my time as an elite athlete, that conversation just wasn't there.

Throughout my athletic career, I had shoulder pain and shoulder injuries throughout frankly, it wasn't a matter of — it was a matter of just I think athletes like in the sport where I competed are used to having musculoskeletal pain a lot, right? And so it wasn't, it wasn't really a matter of do you have it? Or do you not have it? It's like, if you have it, how bad is it? And so, you know, I certainly had times, especially when I would take a period of time off and then be trying to sort of ramp back up in training was always a time where I would have worsening of shoulder pain. And I would say when that happened, rather than having a team physician who was dedicated to our Paralympic track and field team that I knew and trusted and could call, rather than that, the scenario was that I was there in Tucson as an undergrad student going to Campus Health, right? Because that was the resource I had available. So I was there alongside your general undergrad student, you know, waiting for an appointment, rather than having access to elite athlete healthcare, which is, of course should be much more responsive and tailored to the needs of an elite athlete.

Cheri: (07:49) And you're right Shonali that, would you go to the Paralympics, there were usually a cadre of well-trained clinicians there at the games, but that's just the very, very peak of the athlete experience, and actually what it's important, but what matters more, is what access the athlete has through the entire rest of the year as they pursue their training cycle. And as you can imagine, the higher risk period is the month or two prior to that when you're actually going through the highest load right through your training period to your training phase. And you're stressing your body the most as opposed to at the games when you've actually reduced that stress because you want to be ready to actually perform on the field of play.

Shonali: (08:33) I’ll pause here to introduce the voice you’re about to hear — Dr. Blauwet invited her colleague Professor Wayne Derman to join us, virtually, from South Africa. Around the time Dr. Blauwet was competing on the international stage, Dr. Derman was expanding his sports medicine career to start working with para athletes.

Prof. Derman: (08:53) As Cheri said, when she started, we didn't even know what the problems were. So, you know, you first got to actually find out what are the challenges? What are the problems, and we've got wonderful ways of doing that through epidemiological methodologies that bring to the forward, here are your issues. This is what you guys need to actually look at. These are your more dangerous sport, these are your more kind of prevalent illnesses that you're going to have in various of your populations. You know, just listening to Cheri’s experience of it. I think the biggest difference between where you're sitting and where I'm sitting on the tip of Africa, it is really, you know, chalk and cheese. You are very fortunate to have wonderful resources. And yes, Paralympic sport might be increasingly resourced at this point in time, particularly in countries like North America and Europe. But we are yet to actually get to the level of some of the things that we take for granted — exposure to good equipment, adaptive equipment. The prosthetics that people have access to here in Africa is completely different. Our athletes who actually make it up to be world champions, from Africa, and this would probably apply to some countries in South America and some of the island countries as well. If they're up there, they have succeeded, not because of the structures, they have succeeded, despite the structures that are looking after them. There's some challenges that are like kind of boggles the mind, really, I'll never forget going to world athletic championships in the UK in 2017. And I watched an athlete from I think it was Uganda, competing in the hijab bare feet, and running up to the high jump and slipping in the water puddle that was there and thinking, Oh, my word, you know, we are really, with there's such a lot of work we need to do in the world generally. But we need to do even more when it comes to this whole topic of debate in our underdeveloped countries in the world to ensure a more equitable environment. I mean, Cheri you've been at these big competitions are in? Isn't it phenomenal? The differences when looking at various different countries around the world?

Cheri: (11:31) Absolutely. You know, athletes experience that as well, I think on both sides I when I was competing, for example. So, I won a gold medal in the 800 meters in Athens 2004. And obviously, that was one of the pinnacles of my athletic career, and an incredibly special moment. But I always recall thinking that, you know, when you did press interviews after reflecting on it, and people would always ask you, you know, what does it feel like to be the best in the world? And I always I would answer it one way publicly. But in my mind, I was always thinking, well, there's no way to know if I'm the best in the world, I would say I'm the best of athletes and countries that have access to these opportunities, right. But there are we know, athletes, especially from Africa, and other world regions, where the sport of running and track and field is, we know that we know that these athletes have inherent talent in that sport. And in many cases, they're not represented in the Paralympic context, because of the broader issues related to Paralympic sport development in those regions of the world, which I would say also track to the broader context of the disability rights movement in those countries around the world. Because if you don't have a foundational disability rights movement in a country, that then impacts your ability to advance sport for people with disabilities in that country. That's an interesting part of this work. think we do have a inherent belief that all athletes should have an equitable opportunity to compete in a way where we are providing them the resources that are needed to enable them to perform and not sustained injuries and illnesses that then will impact them later in life.

Shonali: (13:11) It's hard to tease apart the science from the advocacy.

Cheri:(13:14) It is it's impossible. I think it's impossible.

Shonali: (13:26) Professor German, I want to capture some of these stories about your experiences when you first started working at the Paralympics.

Prof. Derman: (13:34) Well, I've been an exercise medicine physician. I'm really since well, really goes back to about 1990. So we're going back a really long, long time. And I've been very fortunate in my career to have a whole rich experience both in Olympic sport and in Paralympic sport in Sport and Exercise medicine. This is probably the best and biggest challenge that you're going to see as a sports physician. Because you've got very elite athletes competing at the highest level of the sport with a disability or an impairment, which really is going to challenge the clinicians thinking and it is going to stretch you in this wonderful area of sports medicine. And I still think that if you have looked after a team of Paralympic athletes, it's easy to look after an NFL team after that, oh, it's easy to look after an Olympic team. It's really the ultimate challenge.

Being a team physician to a Paralympic team, does bring about a whole new group of challenges for that physician that perhaps you haven't experienced before. I think of two or three challenging cases, where all of a sudden, I thought, you know, the skin is probably the system in the body that I need to know the least about. And boy, was I wrong! Because I remember the first my exposures, I had amputee athletes, who showed me stumps with the most horrendous sores on those stumps. And I realized, Oh, my word, this is as bad as somebody who's had a fracture, because there cannot be weight through those stumps, it takes like really a, you know, a whole group of people to try and work out where pressure points are, where we can perhaps change and tweak things that pressures go differently through the residuum of that stump? And how are we going to adapt? How can I put a artificial skin layer there in the socket, that actually we can get this card through the race and worry about this afterwards. So it like really, really challenged me a lot. One of the other interesting things that I learned is about the ethics of being a sports physician. For example, visual impairment.I worked with a sprinter, who had significant muscle tear that I'd worked with for a long time. And this muscle tear was one that could have ruptured the quadricep muscle, which is the main muscle of the anterior thigh. And she's a long jumper. And while I'm speaking about this, should we be busy publishing this as a chapter in a book on ethics. I remember being in the medical room and doing an office-based ultrasound. And usually, I would, particularly to somebody who's got a visual impairment, explain what I'm seeing on the screen and explain the injury. And here was a situation where, after a long ethical dilemma, I actually chose not to tell the athlete about the extent of the injury, and actually let them jump. Because I knew that if I had described the extent of the injury, they would have inhibited and not jumped at the peak capacity that they were able to. And this was after consultation with other physicians, with the athlete’s husband with the physiotherapist and the coach and actually almost withheld information. This particular athlete was in significant pain during jumping, and the coach said to her, “All we need is one well-timed to jump. Just one.” And that jump came that athletes next jump in, she jumped to gold medal for our country with that injury. So for me, that's been a great example of ethical dilemmas that I've learned as being a team physician. And everybody takes good decisions. And sometimes you make some not good decisions. And this was one that luckily worked out well. And there are a lot of structures that one advocates now so that it gives the physicians a little bit of help with each of these steps when making a difficult return to play decision like this one.

Cheri: (18:21) Wayne, can I ask a follow up question? How did the athlete react when they learned about the injury? Later?

Prof. Derman: (18:29) Yeah. So that that's very, very interesting and important. So, Cheri, she had, you know, in how long jump works is that you actually know that you've won it. Sometimes before you have to take your last jump? And from the long jump, but we actually told the athlete, don't take the last jumps be your leg, you really want it. And to the, to our horror, we see that she's going to walk back now to do a final jump. And we she jumped? wasn't a very good jump. But we met her at the mixed zone. And he said to her, what's going on? Why did you take and put your leg at further risk? She said, Of course, I wanted the I wanted the world record. So that kind of vindicated us. But when we went back to her and said to her, Look, we took this decision after working with you for a period of five years, knowing that this was a decision, you were ending your career, you are going to have to a period of rehabilitation and rest after this, would you have done things any differently. She said to the coach, and to me, thank heavens, you didn't share that with me the time it would have upset me and I wouldn't have been able to jump and would not do it again, I would do everything again. And she's actually agreed to assist us with the writing of this chapter two actually give at each step, her feelings at this point in time.

Cheri: (19:55) That's a really interesting story when especially from the standpoint of I mean, that scenario, you could see that in a number of different types of, you know, athlete contexts, but then when you have that context, an athlete with visual impairment, and the cognitive concentration that it takes to jump as an athlete who's blind, and then how that, you know, what's the intersection of that impairment based consideration with the actual, you know, what you're seeing on ultrasound it...Yeah, it's really interesting because it adds another layer of complexity, right?

Shonali: (20:27) Dr. Blauwet, do you still treat patients with Paralympics? Are you a more sort of like an administrative role today?

Cheri: (20:34) Yeah, I'm currently in more of an administrative role in terms of the Paralympic Games, I have two different hats that I wear at the Paralympic Games. One is as a board member of the US Olympic and Paralympic Committee. And in that role, I am the leading board member around Paralympic matters for the US. Prior to that, I was working at the Paralympics as a member of the International Paralympic Committee, medical committee, which is where I have worked most closely with Wayne. Well, it's also primarily an administrative role, but it's more providing direct clinical oversight for the clinical services that are taking place at the games, and also performing research, right. So administering studies, recruiting, study participants, etc. For the research that we seek to do in a Paralympic Games context, typically, we try to design studies in a way that doesn't distract athletes from you know, what they're there to do, right, which is to compete on the world stage. So,our work tends to be more focused on gathering data and information from the clinicians themselves or more epidemiologic work and surveillance work, like Wayne described where we're collecting data based on datasets as opposed to asking athletes questions, right, or trying to interview athletes. The direct care that I provided is more, here in Boston, where Many athletes need clinical care throughout the course of their training cycle.

Shonali: (22:03) And those data sets that you're collecting at the Paralympic Games I assume have grown significantly in the past decade, they have much more data than we used to? 

Cheri: (22:12) Oh, they've grown enormously. Yeah, Wayne has been an incredible leader in this space. So, we here at Spalding our collaborator on that work. But the collection of that data and storage of that data is primarily led by Wayne's group and at the University of Stellenbosch in South Africa. And he and his university have created apart direct partnership with the International Paralympic Committee to be able to collect and store that data. And then that serves as a very rich repository of information that then all of us who work on the International Paralympic Committee, medical committee and other academic collaborators can look at that dataset and use it to ask really interesting and pertinent questions about injury and illness patterns in elite athletes with disabilities. that dataset, is really novel and rich. And it's been a game changer for the field.

Prof. Derman: (23:05) The first real academic report of the surveillance came, I think, in 2010, after the Vancouver Winter Games, and then in 2012, we invested quite a bit of money into a platform for data collection, which really uses a web portal, where the team physicians from all the different countries are able to track various different athletes injuries and illnesses and be reminded on a daily basis of how far they are falling behind in the calendar and how they're collecting data. And we've really gamified this because we believe that being involved in research should also be fun. And it's really been something that we've all enjoyed being part of. We've now in a situation where we've collected data longitudinally over three summer and three Winter Games. So we'll be able to actually see not only at a particular games if a particular athlete was ill or injured, but we're able to actually see is this somebody who is injured at every game setting and how they have been doing. We've been able to really get a good idea of how big the problems are, and which are your major problems. So for example, we've seen trends in injuries over time. And we see that there are some sports where the injury rates are high and some sports where the injury rates are really low. For example, we noticed that there's always one sport that is more dangerous than the all the others, and that is blind football, football fives. And the reason is quite clear, you've got people who can't see that are running at relatively high speeds, and that they impact each other. So, there are a lot of acute contact injuries in sport, including concussion. We know that there's other interesting sports like Goal Ball, which was really right up there in the London Games. And yet, when we followed it through into 2016, in Rio, became one of the lowest risk sports, and why those are and then we did some very interesting studies looking at going to the athletes and coaches that were at both games, asking them the differences. And what came out from that research is, the substance of the floor of the Goal Ball surface area was different in London, and Rio, that the ball itself was different in London and Rio, they were different run-in training and competition, scheduling differences between London and Rio with sometimes athletes not being able to rest and recover prior to the big competitions. So that all tells us a lot more of the richness of what we can expect. In Tokyo...

Shonali: (26:23) I’m sorry, what is Goal Ball?

Dr. Derman: (26:24) Goal Ball is a sport which is played by individuals with visual impairment, where a heavy ball is rolled with the aim of getting that ball into a wide knitted goal. So you can imagine that what happens is the ball has a bell in it, and it is rolled and then the athletes can try and prevent that ball going in the net by diving from one side to another. Yeah, that was our learning about Goal Ball and how a sport can go from a high risk to a low risk with things that we don't necessarily think about. Certainly not as, as physicians. One interesting thing is that if you have a look at what's generally happening across the games, that as time goes by from London to Rio to Tokyo, the injury rate is falling. And I think what is happening is that both us and the athletes are learning as the knowledge gets developed, about which injuries they are and how to prevent them. And then what happens is that okay, we need to make adaptations to some of the rules of some of the sports in order to mitigate these risks. But then what happens you get new sports that are introduced, for example, in Tokyo, they introduced Badminton and Taekwondo. And lo and behold, two of the highest risk sports, Badminton and Taekwondo. So, it actually backs up by theory, that the more we are exposed to the sports at Games time, the more the physios, the doctors, the multidisciplinary team, that strength and conditioning staff understand it, and are able to prevent injury, and the injury rates are coming down. So that's the kind of things that we're able to learn from studies, like the Injury And Illness Surveillance study. And I think Cheri can tell you a lot about what happens in the winter sports, as here in South Africa. We more focused on the the summer sports. But Cheri, maybe you can share some of what happened down in our findings after Sochi?

Cheri: (28:38) Yes, so I was hoping to chime in about that. Thank you, Wayne. So, another good example of the power behind this work is that you can often use this data to identify trends, and then have a data driven way to work with You sport policymakers, sport administrators, coaches to potentially augment right or modify the competition environment. And without having data, that's a much harder discussion. Right? So, one really, really clear example of that is that at the Sochi Winter Paralympic Games, we were doing this Injury and Illness Surveillance work longitudinally, as we always do. And in observing the sport of para-alpine skiing, we were beginning to just visually see that it seemed as though there were a lot of acute injuries occurring - a lot of crashes on the slope, especially in the downhill, which is the, you know, fastest and most aggressive run-in alpine skiing. Sure enough, you know, at the conclusion of the Sochi Games, we worked together, analyzed that data and saw a really sky-high incidence of injury in the sport of alpine skiing, we were able to then sit and organize meetings with the International Federation. the group that's responsible for setting the course basically everything having to do with the environment of competition. And we were able to meet with them and to work together and to say, here's the data. Look what happened in Sochi. Something's wrong. Right? Something happened here, that definitely demonstrates a risk to athlete health, you know, athletes with major traumatic injuries, fractures, lacerations, bad concussions, needing to go to the hospital and be helicoptered off the mountain, you know, something that we don't, that we know needs to change. And in talking to that team, we were able to confirm some things that that we assumed, for example, the temperatures were quite warm in Sochi. And with the warm temperatures, the snow becomes very icy. And because it's ice here, it's faster, and it's much more technically difficult. Additionally, in Sochi, they had decided to largely replicate the course that was used at the Olympic Games. And it was just, it was just a very aggressive course. And so many of our Paralympic athletes, particularly the sit-skiers, or mono-skiers, were during certain parts of the course just losing their, you know, basically, they were catching air, they were having to try to control the ski on a course that was simply too aggressive, probably too aggressive for a mono-ski, period. And so we were able to work with those administrators to say, all right now we know, right, this data, this is not great data. How can we work together to ensure that the standards that are set the course the snow conditions, that we can work together ahead of time to ensure that those conditions are much better and much safer for athletes in Pyeongchang, where the athletes, you know, they're talented, right? They want to ski aggressively so they can get out there on the slope and put in their best run. We have no problem with that. But we have to make sure that the course on which they're competing at its foundation is a safe course. And so we were able to ensure - do that in a much better way for Pyeongchang and sure enough, the data improved dramatically. So having that those objective numbers right to share with administrators and coaches is extremely helpful for implementing change that actually lowers risk for athletes and creates a safer environment for athletes.

Shonali: (32:20) I don't want to end us until we talk also about aging after being a Paralympian and do we know anything about that? And in these datasets? Are we able to follow up with those people? Dr. Blauwet — today do you feel like you have some sense of what it means to be a former Paralympian and your health what that does for your health tonight?

Cheri: (32:42) Sure. Sure. So maybe I'll answer it from a personal perspective briefly, and then we can talk about the research. So from a personal perspective, I would say that firstly, I'll start by saying that every athletes experience is different so I can speak for myself and what my experience was, but of course, you may hear, you know, different stories from different athletes. Because all sports are so different. All athletes are so different, right in the disability types are variable. And so my experience as a person with spinal cord injury, and a wheelchair user may be very different than an athlete with visual impairment or an amputee athlete, for example. I think that if I look at the overall trajectory of my athletic career, and then where I land now, that having been involved in Paralympic sport and pushing myself to compete at the elite level, has been by far and away the most positive thing for my health that I could have contemplated through my early adulthood. I say that because that journey, that athlete journey, totally reframed my expectations, and health behaviors in a way that I think has been net positive, right? So, you know, before I got involved in adaptive sport, I was quite sedentary, I certainly wasn't what you would call fit, right? And so getting involved in adaptive sport, and then learning to love it, and then gaining that competitive drive and wanting to win that whole journey, you know, brought me into a totally different level of fitness that I think has been beneficial. And once you, once you achieve that level of fitness, it changes how you think about yourself and the expectations that you set for yourself, even in retirement. So now, you know, I know that even though I'm not competing, and trying to get gold medals, I still certainly find it a very core part of who I am that I have to exercise, right? And I want to stay fit. And that's just a part of my value set. So, I think because of that journey, and because of those behaviors, and those values that I saw along the way, I think it's been net positive. That said, I certainly feel it, right? In a lot of different ways. And I think for me, the most salient thing that I experienced now on a regular basis and have to manage is shoulder pain. And that, as I said earlier, is the most common musculoskeletal injury pattern that we see in athletes of my background type, right? Wheelchair users, athletes with spinal cord injury. And that's because we, we use our shoulders for everything, right. And in athletes like me, our shoulders have become a weight bearing joints. So, when I transfer in and out of my car, when I get out of bed every day, I am putting load through my shoulder that is not normal, and an able-bodied individual, you don't bear weight through your shoulder, right? And so it just we know, through good research that that leads to early pathology and pain and, you know, sequela down the road. And so that's real for me. But, you know, looking back 20 years, would I have changed anything. No, the only thing I would have changed is that I wish that when I was an athlete, I would have known more and been more educated about what to expect. And I wish that I had known how important it was to maintain a shoulder strengthening program and to engage in the preventative aspects.

Shonali: (35:56) And through that lens, actually, the racing is probably better. I mean, even physiologically better for you. Versus like, if it's the transfers and the weight bearing that really is the etiology of the shoulder pain. Yeah, then it's not like racing tore up your shoulders worse or anything?

Cheri: (36:14) I don't know, probably not. No, I think it is, you know, at the end of the day, for someone like me, we don't really know, if my right shoulder is hurting — is that is the is 90% of the reason for that transfers in 10%. Sport, we don't know, right? We know that both probably play a role. I think more of the, the strong research is, you know, there's a wealth of research about shoulder conditions in wheelchair users writ large, you know, athletes and non-athletes. And we know through those studies in the spinal cord injury population more broadly, that the longer you have a spinal cord injury, the more years of wheelchair use and transfers that you have, as you age, you accumulate injury, right? You accumulate degenerative changes in your shoulder. And so, absolutely, I'm sure that that's the largest factor, just simply the fact that I'm, you know, a 40, something woman who experienced a spinal cord injury when I was a child. And I've used a wheelchair that whole time, and I've been bearing load on my shoulder for 40 years, by far and away, that's the largest factor. Did sport contribute to that along the way? Probably, to some extent, right. But we and we really don't know how much. So, I think I think that the question about, you know, aging as an athlete, what to expect is really, really an individualized discussion based upon the type of disability and really balancing the positive effect the positive impact of sport participation for physical and mental health, with the risk of injury and illnesses that athletes might incur along the way. And I think that balance is different for every single athlete, especially, especially the like mental health aspects, right? Where for so many, especially in Paralympic sport, so many athletes will tell you that being a part of sport being a part of an elite competitive environment, being with teammates, that athlete journey has such tremendous net positive benefits to mental health. And so, and having a positive self-identity, that, you know, they're willing to accept the risks in terms of other types of injury. So, I think, you know, we can't jump to the conclusion that sport is always bad for health. at the elite level, I think it's a very individualized and balanced discussion.

Prof. Derman: (38:31) So let me let me add my voice to Cheri’s here. So, my take on this is that actually the benefits of lifelong sport and physical activity, or are so significant on a variety of different levels? That the question isn't even it's not that the benefits totally outweigh every downside. Question is that what is the downsides? As we grow older, as one is going into retirement from elite sport, what are the challenges? And can we do anything to mitigate those specific risks? And here the risk is on the muscular skeletal system. So, one needs to focus in on that. Can we learn anything from the studies that we've conducted? Well, recently, we did an analysis, which hasn't been published yet on the older Paralympian, which looks at — because Paralympic athletes are competing far longer than the Olympic counterparts. So, we've got a group quite a large size group from 35 to 75. We didn't really find massive changes in the distribution of injuries at all. So, there was a we're going to drill down now into various different sports, but we didn't really find any earth-shattering revelations. And I think the reason for that is — one of the major limitations of the work that we're doing - is that we get what happens from Games time to Games time, the real gold lies in longitudinal studies, with groups of athletes that have followed in between games times, and then you will start to actually discern and get your cohorts and work through, with them, into hopefully groups that you can follow long term. So also, there's a very strong Olympic association of previous Olympians, where that's those studies are now being published, which shows the relative risk of osteoarthritis in people who functioned at the highest level, and they do show that there is an increased risk of joint degeneration. As one gets older, if you've been exposed to certain elite sports. There is not as developed a older Paralympian cohort that is actively followed by the IPC. And I think that's where we need to change things to actually get together a consortium of Paralympic clinicians that are interested in following up athletes into their retirement longitudinally, to actually get the histories and how those changes and examine work on a panel of tests, that one can look at the difference between those who have been exposed to lifelong physical activity in an adapted environment and those that have not. So, do I have the data to tell you this is a fantastic thing to do? Or is, in some ways dangerous for the muscular skeletal system? The answer is no. We don't have the data. But we have many reports of the very kind of rich answer that Cheri gave you about how she perceives the benefits and risks of exercise as one gets older. And would she have done anything differently? And the answer is absolutely not.

Shonali: (42:16) Dr. Blauwet, there's a particular article that you said was relatively sort of a big paper that just came out if you could talk a little bit about the consensus statement that came out of the concussion?

Cheri: (42:27) Yeah, sure. Where to begin? What do we think Wayne so... I think I would frame it this way. So, part of the benefit of this work, is that it has enabled us to create a foundational knowledge and a reasonable amount of research to understand athlete health and Paralympic athletes, it's also created a lot of connections, elevated the awareness of Paralympic athletes, and the importance of monitoring health and thinking about injury risk and Paralympic athletes. So, what I have seen as a benefit of that, is that internationally, a lot of the large consensus processes, the large consensus papers and position statements that are coming together that really guide our field are more and more so becoming inclusive of Paralympic athletes. And that's definitely a sea change. I would say that, over the years, you know, people like Wayne and I who work in this space, we would see something coming down the pike. And we'd hear about some collaboration that was happening, and we'd raise our hand or we'd send an email and we'd say, hey, are you thinking about including the Paralympic athlete in that work? And many times, the answer was no, no, the answer would be, oh, there's not enough data in that those athletes or the populations too small or oh, you know, the we already - it would be it would make the paper too big or what have you. What I've seen is a sea change such that now, when we ask that question, frankly, the culture of our field has changed. And it's now often seen as no longer acceptable to not include the Paralympic athlete in that work, similar to how it's no longer acceptable to not include female athletes in that work, or the child and adolescent athlete in that work. Because we understand that as we come together as an academic community, we really need to be thinking about all of our athletes, not just male athletes. So, so because of that culture change, which again, I think has been catalyzed by a lot of the work that Wayne and I described over the years, we were able to form a collaboration wherein the most recent international consensus statement on concussion in sport included a section on considerations for the para-athlete. And we were able to take what we know from the injury surveillance work at the Paralympics, as well as Paralympic Athletes specific position statement that was on concussion that was developed in 2020. and translate that information in a very succinct and powerful way to be included in this large consensus statement. Which is read by millions of clinicians and researchers around the world. And again, you know, the content of the of what's in the paper is important. But frankly, I think even more, just as important, maybe not even more, but just as important is that it sends a strong signal, and it tells the international sport medicine community, that this is important. And when you're doing work in concussion, that you really need to be thinking about para-athletes. And that subsequent iterations of the paper will now include this topic, right? So, I think it's an example of it's another flavor of advocacy, I think, you know, I consider one of our types of advocacy that we're advocating for better services to Paralympic athletes. But another type of advocacy is that we're, we're advocating to our colleagues in sports medicine, both in clinical care and research that these athletes can't be left behind in this really important academic work. And we've seen that pattern with Paralympic athlete inclusion now in a number of different spaces. So, for example, recent, the recent International Olympic Committee, consensus statement on athlete mental health, Included Paralympic athlete. Papers that focus on the female athlete and relative energy deficiency in sport include Paralympic athletes. So now we see that pattern replicated far more frequently.

Shonali: (46:35) Any final thing that you think we didn't cover that you think we should?

Cheri: (46:39) I think we did a great job.

Prof. Derman: (46:41) I think I think it was a great chat. And I think that yeah, I think it's a wonderful opportunity when anybody asks you questions to actually go back and review the work that one's done as you see things from novel angles, even if one's been writing on that research oneself. So, thanks for the opportunity of listening to it again through a different lens and explaining the work and I'm sure you'll find quite nice content in what you've recorded in order to really put together a great podcast. Thanks for inviting me!

Shonali: (47:17) Hopefully a good like reflective therapy session for everybody. And I will say that like, I'm the furthest thing from an athlete that there probably could be. So upcoming is what Paris you said?

Cheri: (47:31) Yeah.

Shonali: (47:32) In 24. Okay. All right. And you What are you looking forward to most in Paris, I assume you guys will see each other there.

Prof. Derman: (47:39) At the moment, what I'm looking to forward, the moment is, we're in the thick of winter, here it is freezing. Paris is in the midst of a heatwave. It's sounding appealing at this point. I think that therein lies the challenge. I think Paris is going to be very hot. The challenges of Paris, particularly for para-athletes, who some of who have impaired thermal regulation, we're going to have a potential environment that is way hotter than Tokyo. And I think that's going to be the challenge. But it's also going to be the part that one's looking forward to dealing with at the moment, and I'm fortunate to be part of a committee that's planning the heat decks, all the mitigation strategies, looking if the environment is conducive to good performances? How can we make the environments they're safe from heat perspective? And what can we do better? So I think it's a great privilege to be involved in some of those preparations. For Paris, we're going to be running the fourth iteration of the Summer Games injury and illness surveillance.

Shonali (48:54) So tune in to the 2024 Paris Paralympic games armed with the knowledge that Cheri and Wayne are there keeping an eye on the outcomes of the athletes. Remember that you can go to the episode’s resource page for links to the research we mentioned. I’ll also post a link to a YouTube video of the USA Goalball team making an exciting comeback against Brazil.

If you've enjoyed this podcast, please know that liking, subscribing and sharing is essential to sustaining our work. We release episodes the first Monday of each month, so stay tuned for more stories. The Finding Strength production is a collaboration between the Rehabilitation Outcomes Center at Spaulding and our Model Systems: the Spaulding-Harvard Traumatic Brain Injury Model System, the Boston-Harvard Burn Injury Model System, and the Spaulding New England Regional Spinal Cord Injury Model System Center, all funded by the National Institute on Disability Independent Living and Rehabilitation Research. The material presented here is for general informational purposes only.

Shonali: (49:53) I would ask you what the temperature is there. But you're going to tell me in Celsius. And I'm not going to know what that means.

Prof. Derman: (49:59) It's going down to eight to nine, seven at night. It's an interesting phenomenon. Because you guys have called the weather, but you guys are more set up to deal with a colder weather dress better, are geared up for it. Whereas we feel that our temperatures which is not as low as yours, are the most dreadful winters. I've got fellow from here with me from Norway, and another one from Switzerland. And they said the winters here are 10 times worse than they are there. Because it's like freezing here. They they've dealt with it.

Shonali: (50:34) I often visit my family in India in December and it is miserable because I feel like there's not enough hot water long enough for what I want in the shower to like regenerate my own body heat so and there's no heating in the houses, because it doesn't actually get below — well it hasn't when I've been in there — like maybe 50 or 60 Fahrenheit. So, it's still that's cold that's cold and they're just wearing like blankets and layers and they're used to it — hats inside all the time. I'm sure new construction houses — my uncle's house is from forever ago — but yeah, anyway, HVAC is important — and hot water.