Exertional Heat Stroke – Supplement for athletes with a disability

Position Statement – Exertional Heat Stroke – Supplement for athletes with a disability

There are increasing numbers of people with disabilities that participate in sporting events in the UK. Certain impairments add particular risk to the development of Exertional Heatstroke (EHS). This guideline acts as a supplement to the Faculty of Sport and Exercise Medicine (UK) Position Statement on Exertional Heat Stroke to bring these factors to the attention of medical staff.  There are a variety of factors that may make EHS more likely or may complicate assessment and management. These include:

1. Reduction of surface area for heat loss e.g. bilateral amputee.

2. Syndromic conditions where the physical impairment limits the person’s mobility but there is associated cardiac or autonomic dysfunction.

3. Medication usage more common – medications that impart a diuretic effect, or that affect blood flow, heat loss or thermoregulation (for example, anticholinergic and sympathomimetic drugs, laxatives and beta blockers) increase the risk of EHS.

4. Cerebral palsy – factors such as unsteadiness of gait or dysarthria may make assessment of an athlete unknown to the medical staff more challenging. Athletes who exhibit an unsteady gait or communication difficulties may be confused with exhibiting the early signs of EHS.

5. Spinal cord injury – the thermo-regulatory impairment that accompanies a spinal cord injury makes these athletes the most at risk from heat-related illness:

i. Thermo-regulatory impairment occurs as a  result of loss of peripheral receptor mechanism function and the loss of autonomic control on the sweating effector mechanism for heat loss and the peripheral vasculature.

ii. The extent of the thermo-regulatory impairment relates to the level of the spinal cord injury and the lowermost functioning sympathetic nervous components with athletes with injuries at T6 and above being more at risk.

iii. Spinal reflex sweating does occur below the level of the spinal lesion but this is insufficient to regulate body temperature during thermal stress or exercise.

iv. A loss of sympathetic cardiac innervation in lesions at T6 and above results in a maximum heart rate of 110–130 beats per min, which is determined by intrinsic sino-atrial activity. This must be considered in the assessment of the cardiovascular system.

vi.  Athletes with these high spinal lesions may also develop autonomic dysreflexia resulting in large rises in blood pressure with risk of seizure and cerebral haemorrhage. This should be considered if the collapse has resulted in a fall from the wheelchair resulting in injury.

It is important to ensure that athletes, sports participants and medical staff are fully educated about the additional risks of developing EHS during exercise in athletes with disabilities. Pre-cooling strategies may help prevent EHS. Prompt recognition and management are essential.

©Faculty of Sport and Exercise Medicine UK – Exertional Heat Stroke – Supplement for athletes with a disability September 2014, to be reviewed September 2017

Authors: Dr Nick Webborn, Dr Ed Walter, Dr Richard Venn, Dr Rob Galloway, Prof Yannis Pitsiladis

References: Price MJ (2006). Thermoregulation during exercise in individuals with spinal cord injuries. Sports Med36, 863–879.

Van De Vliet P. Event medical care for Paralympic athletes. In: McDonagh D, Micheli L, Frontera W, et al, eds. FIMS sports medicine manual: event planning and emergency care. Philadelphia:Lippincott Williams & Wilkins, 2012.

Webborn N, Van de Vliet P. (2012) Paralympic medicine. The Lancet. 380 (9836):65-71.

Webborn, A.D.J. (1996) Heat-related problems for the Paralympic Games, Atlanta 1996. British Journal of Therapy & Rehabilitation Vol. 3 (8), 429-436.

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