Diving with Disabilities - Part 3 of 3
This third article in the series on diving with disabilities is an excerpt from the extensive revision in progress of Dr. Michael Strauss and Dr. Igor Aksenov’s Diving Science textbook.
This three-part series is extracted from a chapter in the second edition of Diving Science by Michael B. Strauss, MD, et al. which covers special diving types, situations and environments. Part 3 of this series in the current issue of WCHM discusses previous medical problems of diving and provides resources for divers with handicaps.
Previous Medical Problems of Diving
Introduction This subject has the potential to generate much discussion. The comment if “bent” (i.e. joint pain only decompression sickness) once, the second “hit” (i.e. episode of decompression sickness) will be at the same site. Data to support this comment is not known to the authors. However, there is physiological justification for decompression sickness (DCS) to target a joint that has been previously traumatized. If the trauma was severe, it is logical that scar tissue, injured muscle and healed fracture sites will have altered perfusion. This will likely influence on and offgassing during the scuba dive and make the site more vulnerable to developing gradients sufficient to cause DCS in the joint.
Residual Disabilities and Bends Proneness If neurological disabilities remain after an episode of decompression sickness or arterial gas embolism severe enough to alter gait and/or interfere with higher brain center functions, scuba diving should not be resumed. Often times reasons for the episodes are not obvious and this raises the question, “Is the diver bends prone i.e. experienced DCS without an apparent reason?” A patent foramen ovale (see cardiovascular disabilities section of this chapter) could be considered a bends prone factor. If DCS occurs without apparent reason, disordering events, that is incidents that could have altered the offgassing of nitrogen during the dive, should be sought by a careful review of the dive history.6
Conversely, some divers appear bends resistant and do not develop symptoms of DCS even though their dives are extra-ordinary and/or exceed dive tables/dive computer guides. Coagulopathies (abnormalities of blood clotting) have not been established as a cause of DCS or conversely, a reason divers do not get “bent.” However, nitrogen bubbles in contact with endothelial surfaces (the linings of blood vessels) initiate an inflammatory reaction somewhat resembling the reperfusion injury as observed with transient interruption of the blood supply to critical organs. Hence, it is our recommendation that divers who experience decompression sickness in the 1970s, Chryssanthou proposed that smooth muscle activating factors (SMAFs) were associated with decompression sickness in laboratory animals subjected to pressurizations. He then utilized “anti” SMAFs (somewhat analogous to antiinflammatory agents), which resolved the bends symptoms. Although the information received attention and sounded enticing at the time, he was unable to obtain funding for further studies and the roles of SMAFs and anti-SMAFs “died a silent death.”18 pain only symptoms with complete resolution and an apparent deserving event is identified, should not resume scuba diving for a minimum of two weeks after the occurrence. This is the time the nitrogen bubble, endothelium inflammatory reaction would be expected to resolve. A new area of interest concerns microparticles in the blood stream which may provide a nidus for bubble enucleation.19 However, at this time, changes in ambient pressure coupled with perfusion and gradients provide the best understanding why bubbles occur in decompression sickness.20
In the 1970s, Chryssanthou proposed that smooth muscle activating factors (SMAFs) were associated with decompression sickness in laboratory animals subjected to pressurizations. He then utilized “anti” SMAFs (somewhat analogous to antiinflammatory agents), which resolved the bends symptoms. Although the information received attention and sounded enticing at the time, he was unable to obtain funding for further studies and the roles of SMAFs and anti-SMAFs “died a silent death.”18
Deserved versus Undeserved Decompression Sickness Another consideration with regard to returning to diving is whether or not the episode of decompression was deserved (for example the diver exceeded the diving tables) or undeserved (there was no apparent violation of diving practices). If deserved and there are no residuals after hyperbaric oxygen recompression treatment, we feel it is OK to allow the diver to resume scuba diving. However, we advise the diver to wait two weeks before doing such to allow the theoretically injured endothelium from the nitrogen bubble interaction to resolve. If the DCS episode was undeserved, we hesitate to allow the patient to resume scuba diving. With the above considerations, logical advice can be made regarding return to diving or not (Table 7).
Other Considerations Injuries from marine animal encounters such as jellyfish stings and spine puncture injuries impose only temporary restrictions to diving—once the problem is resolved, the patient may return to diving. After nonfatal shark bites, motivated divers have resumed scuba diving just as surfers who experienced similar injuries have done so. The unilateral loss of hearing, especially if associated with a scuba dive, is an absolute contraindication for scuba diving as was previously discussed (see Hearing Impairments under Neuropsychiatric Disorders section ). This is because the ears are such a vulnerable structure to barotrauma associated with changes in ambient pressure. Almost all the other medical problems of diving such as nitrogen narcosis, oxygen toxicity, hypothermia, sunburn, panic and blackouts impose no or only temporary restrictions for diving once the problems are resolved.
Organizations and Agencies Dealing with Divers with Disabilities
In their goals to promote scuba diving to a broader population and demonstrate that everyone can enjoy scuba diving, many diving organizations have established programs to train and certify divers with disabilities such as paraplegia, asthma, diabetes, and epilepsy/seizures. For each type of disability, it is advisable that divers are trained and well informed about the risks in advance for their conditions. Consider the following:
Handicapped Scuba Association (HSA) has started from a research program at the University of California, Irvine in the 1970s using donated equipment from the Professional Association of Diving Instructors (PADI). Adapting curricula from both PADI and the National Association of Underwater Instructors (NAUI), HSA now has their own certification programs focusing on divers with a wide range of disabilities, including visually impaired, posttraumatic stress disorder, paraplegia, quadriplegia, and those with highfunctioning intellectual disabilities.21,22 The programs are multileveled and center on the physical challenges disabled divers must overcome under water.
Even though they did not offer suggestions for a training program for divers with asthma, the Undersea and Hyperbaric Medical Society (UHMS) created a guideline on the risks and symptoms of divers with asthma at their 1995 annual scientific meeting.23 The symposium “Are Asthmatics Fit to Dive?” concluded that divers with a history of asthma are at risk of shortness of breath, panic, arterial gas embolism and drowning. Scuba diving is OK if the asthmatic’s symptoms are intermittent, is asymptomatic at the time of the scuba dive, and does not require medications to remain such. The Divers Alert Network (DAN) reported a small increase in the risk of decompression illness but there were not enough data points to accurately assess it. Another note is that divers with active asthma (requiring medications) may be diving against medical advice but are probably doing such since their symptoms are mild.
Before 1997, people with diabetes were advised against scuba diving due to the risk of becoming hypoglycemic under water. However, with proper training and planning in advance, diabetic divers can avoid this problem. DAN has issued a diving guideline for the diabetic on their website with emphasis on the diver’s physical fitness even under hypoglycemic conditions (in which some people are prone to seizures, lack of coordination, or impaired judgment).24 PADI as well as Scuba Schools International (SSI) also include the education and preparation for people with diabetes in their normal open-water diving certificates.
It is almost uniformly agreed that patients with epilepsy not scuba dive.25,26 However, epilepsy has many presentations, and some might not adversely affect the ability to scuba dive safely. In the United Kingdom, the Sport Diving Medical Committee requires people with epilepsy to be seizure-free and off of their medications for at least 5 years before diving. In the United States, scuba diving is considered the same as driving in terms of limitations and they vary from state to state, ranging from 6 months to a year’s restriction and 5 years off of their medications according to DAN. Most of the divers also need a “sign-off” from their doctors, who should be familiar with diving medicine as well as the patients’ medical conditions.
Certainly, the discussion of every possible disorder that can be considered a disability for scuba diving cannot be included in this chapter. Two thousand plus pages of medical and surgical textbooks include countless disorders that contraindicate scuba diving. Common sense needs to be used in making recommendations when patients with conditions other than those mentioned in this chapter occur in patients who would like to scuba dive. On one end of the spectrum there are dermatological conditions that temporarily prevent or minimally limited restrictions for scuba diving. In the middle are conditions like celiac disease and Crohn’s disease where relative contraindications to scuba diving can usually be mitigated. At the other end of the spectrum are decompensating conditions like liver failure, end-stage kidney disease, critical limb ischemia, advanced cancers and major wounds that are incompatible with scuba diving. This chapter, we believe, includes the 99 percent of disabilities and handicaps that are likely to be encountered in those who want to engage in scuba diving activities.
Myths and Misconceptions about Scuba Diver Disabilities and Handicaps
Myth Handicaps and disabilities are essentially the same thing
Facts Although closely related terms, handicaps usually refer to disorders that limit a particular activity while a disability is more a legal term that the problem prevents usual and customary activities. Disabilities are often rated by percentages determined by how much the patient is incapacitated. The American Disabilities Act (ADA) specifies what accommodations employers as well as new construction must make to accommodate those patients with handicaps. Education, assistive devices and therapy are typical interventions used to mitigate handicaps.
Myth Patients who have had heart attacks should not scuba dive
Fact A heart attack is not an absolute contraindication for scuba diving. Considerations of how much heart damage, if any, occurred, whether or not the heart muscle has been revascularized, and the patient’s exercise potential determine if the patient has enough cardiac reserve to scuba dive without undue risk. Likewise, low demand scuba dives such as in warm water, with absence of currents, diving off of boats with descending lines, and good visibility should be selected as the diving venues for such divers.
Myth A diabetic who has experienced a hypoglycemic episode should not scuba dive
Fact The more important consideration is the stability of the diabetic’s blood sugars. If labile, scuba diving should not be done. However, if stable and the diver is knowledgeable about his/her disease, performs blood glucose testing immediately before and after a scuba dive, carries an emergency supply of a high sugar content item on the dive, and plans the dive to reduce energy expenditures and stresses, scuba diving without undue risks is possible.
Myth It is unfair not to allow a patient with a history of adult-occurring seizures to scuba dive.
Fact Fairness is not the question! The risks of seizure occurring while on a scuba dive is compounded by the stresses of increased ambient pressures, Valsalva maneuvers to clear the ears, increased oxygen partial pressures as the diver descends, and energy demands to meet emergencies. The history of seizure disorder in contrast to asthma and diabetes is the one relative common condition that essentially all diving authorities consider a contraindication to scuba diving.
Myth The respiratory system and especially the alveoli are the ultimate “fast” tissue with respect to on and offgassing with changes in ambient pressure and correspondingly present no contraindications for scuba diving
Fact While the first part of the myth is true, respiratory conditions that interfere with the effectiveness of gas exchange in the alveoli such as asthma, emphysema, atelectasis (collapse of lung alveoli), pulmonary fibrosis and lung cancer must be considered before allowing a patient with problems of this type to scuba dive. Some such as asthma prevent relative contraindications while a spontaneous pneumothorax is a temporary (up to 5 years) contraindication. In addition, with explosive decompressions, the offgassing of gas in the alveoli may be overwhelmed with bubble formation in these structures leading to the life and death problem of lung decompression sickness, referred to as the chokes.
Myth Once a diver has experienced decompression sickness without violation of the dive computer or diving tables, he/she should not be allowed to scuba dive again
Fact Several considerations must be given to this myth. First, are there residual problems such as neurological deficits that persist after the hyperbaric oxygen recompression treatment? Second, can disordering events to offgassing be identified during the ascent phase of the dive? If there are no residuals and disordering events, for example, dehydration, interference with offgassing due to keeping an extremity in the cramped position, or a patent foramen (PFO) identified, scuba diving may be resumed after the diver is educated about the problem, and in the case of the PFO, corrected.
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- Dear GL, Pollock NW, Uguccioni DM, Dovenbarger J, Feinglos MN, Moon RE. Plasma glucose response to recreational diving in divers with insulin-requiring diabetes. Undersea Hyperb Med. 2004; 31(3): 291-301).
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