Disabled Athlete And Their Problems
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Introduction Who is the disabled athlete? The disabled athlete is the person who suffers physical, sensory, or cognitive impairment that interferes with him/her participating in sport (Fig. 1). Historical Perspective Early sports participation by the disabled was on an individual basis. The origin of organised competitive sport for the disabled was directly related to the rehabilitation of Second World War veterans with spinal cord injury. It was the renewed interest in sport as therapy in postwar hospitals in the UK and USA that led to the present day state of sport for the disabled.
1 The development of the first international competition for the disabled was in 1949. The games were held in Austria and this was the first World Winter Games for the deaf. Subsequently international competitions involving other disabled athlete, amputees and spinal cord injured have been taking place throughout the world. Organisations such as the International Sport Organisation for the Disabled (ISOD) was formed in 1964 and its objective was to coordinate sport competitions for all disabled athletes. Now the Paralympics are a major feature of all Olympic Games. Disabled groups considered: •
Sensory:
the deaf athlete the blind athlete
•
Physical:
the spinal cord injured the amputee athletes the cerebral palsied athletes
Disabled athletes with the above physical impairments are classified as either wheelchair dependent or independent. •
Cognitive:
mentally handicapped
•
Les Autres:
disabled athletes who do not fit into any of the disability groups
above, such as muscular dystrophy, multiple sclerosis, dwarfism. Athletes with Sensory Impairment The Blind Athlete •
Blind athletes have a partial or complete loss of sight. Eligibility for athletic competition is granted only to those individuals who have a visual acuity of 6/60 or less.
•
Blind athletes can compete in a wide variety of sports including baseball, bowling, cycling, marathon, racing, track and field and wrestling. The events include modification of some rules to facilitate participation by blind competitors.
•
The only specific sports medicine problem for the blind is related to falls. Falls on the outstretched upper limbs are not uncommon, leading to the same types of fractures and soft tissue injuries as in the able-bodies athletes. Sprains of the knee and ankle ligaments are also not uncommon.
The Deaf Athlete
•
The deaf athlete’s hearing impairment is often the result of sensorineural deficits caused through cochlear damage. Equilibrium deficits with a loss of balance and coordination may compound the athlete’s disability if there has been damage to the semicircular canals or vestibular apparatus. 2
•
The deaf athlete is not restricted and able to participate in any sport available to the able bodied.
•
Major dangers arise from a lack of audible warnings and potential slowness in communication. Apart from serious trauma consequent upon these problems there is little evidence to suggest that the injuries sustained by the deaf differ significantly fro those of the able-bodied.
•
The deaf athletes may compensation by maximizing their visual abilities through training powers of observation and peripheral vision.
Athletes with Physical Disability Spinal Cord Injuries
•
When the spinal cord is damaged, there is a loss of motor and sensory function below the level of the spinal cord lesion. The extent of the motor and sensory loss depends upon this level as well as upon the degree of damage of the spinal cord. Quadriplegia at the level of the cervical region, spastic paralysis at the thoracic region and flaccid paralysis at the level of the lumbar region.
•
The majority of athletes with spinal cord injury are wheelchair dependent, thus giving them the label “wheelchair athletes”.
•
Athletes with spinal cord injury compete in many sports, but track and field and swimming are the most popular (Fig. 2). Other competitive sports for such athletes include archery, basketball, fencing and marathon racing.
•
The low levels of physical activity in the wheelchair athlete predispose them to:
∙ An increased risk of cardiovascular disease by unfavourable modification of risk factors. ∙ Diabetes and other medical conditions associated with obesity. ∙ The development of osteoporosis and renal calculi.
The Cerebral Palsied Athlete
•
Cerebral palsy is a group of disorders of impaired brain and motor function with an onset before or at birth, or during the first years of life (Fig. 3). The condition has multiple aeteologies and the most obvious manifestation is impaired function of the voluntary musculature.
•
Track and field and swimming are popular sports for these athletes. Participants may be ambulatory or complete in a wheelchair depending on extent of their motor dysfunction. It should be noted that half the cerebral palsied athletes compete in wheelchairs.
The Amputee Athlete •
Amputee athletes have a partial or complete loss of one or more limbs.
•
The amputee athlete usually participates in sport with or without a prosthesis or in a wheelchair.
•
Track and field and swimming have been popular sports for amputee athletes.
•
Sport may help to prevent atrophy of the stump muscles, improve circulation of the stump and strengthen the remaining muscles in the affected limbs.
Children’s Diseases (after O-Bar-Or) Children, whether well or ill, can safety participate in physical fitness programmes. In fact, training may improve physical fitness for such diseases as bronchial asthma (but beware exercise-induced bronchospasm), cystic fibrosis (follow for signs of arterial desaturation), diabetes mellitus (improves control) and chronic renal failure (better appetite), muscular dystrophy, mental retardation, obesity and rheumatoid arthritis. There are physical and mental benefits (improved self-esteem) however the exercise prescription must be specific to the problem. Athletes with Cognitive Disability
•
Mental retardation specifies as an IQ less than 70 resulting from pathophysiologic processes affecting the cerebrum during the developmental period.
•
Mentally retarded athletes are not restricted and are able to participate in any sport available.
•
The mentally retarded, prior to systemic training, are often not as physically fit as the general population.
•
Approximately 75% of mentally retarded individuals have one or more other medical conditions.
Les Autres
•
Les Autres is the French term for “the others”. This denotes other locomotor disabilities.
•
The type of disabilities include:
•
Dwarfism
•
Multiple Sclerosis
•
Friedrich’s ataxia
•
Limb deficiencies, including absence of arms or legs
•
Conditions characterised by muscle weakness related to peripheral nerve damage (Guillain-Barre Syndrome).
•
Arthritis of major joints.
Wheelchair Athlete
•
Wheelchair athletes are those disabled by spinal cord injury, cerebral palsy, lower extremity amputation or any of the disorders included with Les Autres. The common denominator for these disabled athletes is their mobility impairment and need of a wheelchair for sports participation.
•
Wheelchair locomotion is not an efficient means of transportation. The mechanical efficiency of wheelchair locomotion is at best 5%, compared with a minimum of 0% for walking or cycling at similar velocity.
•
The design of sports wheelchairs is constantly evolving. Recent design modifications are intended to improve the mechanical efficiency of the wheelchair, facilitate a more effective wheelchair stroke and minimize the risk of upper-extremity injuries (Fig. 4).
Wheelchair Sport Injuries •
The most common injuries incurred by wheelchair athletes are soft tissue injuries, blisters, lacerations, abrasions and cuts (Fig. 4).
Figure 5
Region
Type of Injuries
Prevention
Shoulder
Direct trauma:
• adequate training in correct technique
• contusion of muscle,
• strengthening of the shoulder
soft tissue
stabilisers
• sprains
• warmup, cool down and
• capsulitis
stretching procedures
• rotator cuff problems
• equipment modification
• fractures
• early reporting and treatment of
shoulder pain
Nontraumatic:
• bicipital tendonitis due to tendon
strain caused by overuse and
Elbow Wrist Hand and fingers
inadequate warmup. • as above • lacerations and abrasions • as above • lacerations and abrasions • abrasions and lacerations particularly of the knuckles • avulsion of the nails • finger injuries related to the
• wearing of clothing on the upper arms • use of tube socks on the rim • use of padded push rims • use of gloves and padding over the wrist and heel of the hand • use of gloves and taping • padded push rims and plastic wheel covers
catching of fingers in the spokes of the • removal of sharp edges on the
wheelchair are common
wheelchair
• muscular spasm related to overuse during maintenance of trunk stability
• blistering at the top of the seat post
or the back of the wheelchair
• postural correction by specific
Upper back
strengthening exercises
• wearing a shirt and padding on
the back of the wheelchair
Figure 5 (Cont’d)
Region
Type of Injuries
Prevention
Buttock
• pressure sores and ulcers
• padding or cushion on the wheelchair seat • intermittent lifting from the seat • combination of the above preventative measures
Special Medical Problems of Wheelchair Athletes Urinary tract complications
•
Neurological control of the urinary tract is usually lot after spinal cord injury.
•
Resulting complications of significant risk include bladder and kidney infection, stones, bladder distension.
•
Kidney damage secondary to infection alone is the main cause of death in spinal cord injury
Pressure sores
•
Pressure sore are one of the most common and costly complications of spinal cord injury. Skin breakdown is usually caused by prolonged pressure and compromise of the blood supply to affected tissues.
•
Wheelchair athletes who sit in the chairs with their knee higher than their buttocks are particularly prone to pressure sores. Further risks of pressure sore development is inherit as the athlete’s skin becomes damp with sweat and other moisture.
•
Prevention of pressure sores is important in all persons with spinal cord injury. Such measures include:
•
Intermittent shifting and lifting of the buttocks fro the wheelchair’s seat relieves pressure.
•
Wearing moisture-absorbing clothing to reduce skin laceration and friction forces.
•
Frequent skin checks of the trunk, sacrum, buttocks and legs.
Autonomic hyper-reflexia (AHR)
•
AHR is a particular complication of spinal cord injury above the 4th to 6th thoracic vertebrae.
•
AHR occurs as a result of the loss of central inhibitory control over the isolated distal spinal cord. A generalised sympathetic hyperactivity may be triggered in response to numerous sensory stimuli, for example bladder distention.
•
AHR in a person with spinal cord injury presents with sudden hypertension, bradycardia, headache, anxiety and profuse sweating.
Temperature regulation disorders
•
Impairment of thermoregulatory function is a significant complication of spinal injury
•
The loss of sensory afferent inputs from the spinal cord and muscles below the level of the lesion may limit hypothalamic responses to exercise and temperature.
•
The loss of lower extremity skeletal muscle pump in disabled athletes, such as amputees reduced venous return to the heart during exercise and further compromises thermoregulatory responses.
•
Wheelchair athletes are generally at a thermoregulatory disadvantage and certain precautions must be taken to prevent the occurrence of hyperthermia and hypothermia
1 The development of the first international competition for the disabled was in 1949. The games were held in Austria and this was the first World Winter Games for the deaf. Subsequently international competitions involving other disabled athlete, amputees and spinal cord injured have been taking place throughout the world. Organisations such as the International Sport Organisation for the Disabled (ISOD) was formed in 1964 and its objective was to coordinate sport competitions for all disabled athletes. Now the Paralympics are a major feature of all Olympic Games. Disabled groups considered: •
Sensory:
the deaf athlete the blind athlete
•
Physical:
the spinal cord injured the amputee athletes the cerebral palsied athletes
Disabled athletes with the above physical impairments are classified as either wheelchair dependent or independent. •
Cognitive:
mentally handicapped
•
Les Autres:
disabled athletes who do not fit into any of the disability groups
above, such as muscular dystrophy, multiple sclerosis, dwarfism. Athletes with Sensory Impairment The Blind Athlete •
Blind athletes have a partial or complete loss of sight. Eligibility for athletic competition is granted only to those individuals who have a visual acuity of 6/60 or less.
•
Blind athletes can compete in a wide variety of sports including baseball, bowling, cycling, marathon, racing, track and field and wrestling. The events include modification of some rules to facilitate participation by blind competitors.
•
The only specific sports medicine problem for the blind is related to falls. Falls on the outstretched upper limbs are not uncommon, leading to the same types of fractures and soft tissue injuries as in the able-bodies athletes. Sprains of the knee and ankle ligaments are also not uncommon.
The Deaf Athlete
•
The deaf athlete’s hearing impairment is often the result of sensorineural deficits caused through cochlear damage. Equilibrium deficits with a loss of balance and coordination may compound the athlete’s disability if there has been damage to the semicircular canals or vestibular apparatus. 2
•
The deaf athlete is not restricted and able to participate in any sport available to the able bodied.
•
Major dangers arise from a lack of audible warnings and potential slowness in communication. Apart from serious trauma consequent upon these problems there is little evidence to suggest that the injuries sustained by the deaf differ significantly fro those of the able-bodied.
•
The deaf athletes may compensation by maximizing their visual abilities through training powers of observation and peripheral vision.
Athletes with Physical Disability Spinal Cord Injuries
•
When the spinal cord is damaged, there is a loss of motor and sensory function below the level of the spinal cord lesion. The extent of the motor and sensory loss depends upon this level as well as upon the degree of damage of the spinal cord. Quadriplegia at the level of the cervical region, spastic paralysis at the thoracic region and flaccid paralysis at the level of the lumbar region.
•
The majority of athletes with spinal cord injury are wheelchair dependent, thus giving them the label “wheelchair athletes”.
•
Athletes with spinal cord injury compete in many sports, but track and field and swimming are the most popular (Fig. 2). Other competitive sports for such athletes include archery, basketball, fencing and marathon racing.
•
The low levels of physical activity in the wheelchair athlete predispose them to:
∙ An increased risk of cardiovascular disease by unfavourable modification of risk factors. ∙ Diabetes and other medical conditions associated with obesity. ∙ The development of osteoporosis and renal calculi.
The Cerebral Palsied Athlete
•
Cerebral palsy is a group of disorders of impaired brain and motor function with an onset before or at birth, or during the first years of life (Fig. 3). The condition has multiple aeteologies and the most obvious manifestation is impaired function of the voluntary musculature.
•
Track and field and swimming are popular sports for these athletes. Participants may be ambulatory or complete in a wheelchair depending on extent of their motor dysfunction. It should be noted that half the cerebral palsied athletes compete in wheelchairs.
The Amputee Athlete •
Amputee athletes have a partial or complete loss of one or more limbs.
•
The amputee athlete usually participates in sport with or without a prosthesis or in a wheelchair.
•
Track and field and swimming have been popular sports for amputee athletes.
•
Sport may help to prevent atrophy of the stump muscles, improve circulation of the stump and strengthen the remaining muscles in the affected limbs.
Children’s Diseases (after O-Bar-Or) Children, whether well or ill, can safety participate in physical fitness programmes. In fact, training may improve physical fitness for such diseases as bronchial asthma (but beware exercise-induced bronchospasm), cystic fibrosis (follow for signs of arterial desaturation), diabetes mellitus (improves control) and chronic renal failure (better appetite), muscular dystrophy, mental retardation, obesity and rheumatoid arthritis. There are physical and mental benefits (improved self-esteem) however the exercise prescription must be specific to the problem. Athletes with Cognitive Disability
•
Mental retardation specifies as an IQ less than 70 resulting from pathophysiologic processes affecting the cerebrum during the developmental period.
•
Mentally retarded athletes are not restricted and are able to participate in any sport available.
•
The mentally retarded, prior to systemic training, are often not as physically fit as the general population.
•
Approximately 75% of mentally retarded individuals have one or more other medical conditions.
Les Autres
•
Les Autres is the French term for “the others”. This denotes other locomotor disabilities.
•
The type of disabilities include:
•
Dwarfism
•
Multiple Sclerosis
•
Friedrich’s ataxia
•
Limb deficiencies, including absence of arms or legs
•
Conditions characterised by muscle weakness related to peripheral nerve damage (Guillain-Barre Syndrome).
•
Arthritis of major joints.
Wheelchair Athlete
•
Wheelchair athletes are those disabled by spinal cord injury, cerebral palsy, lower extremity amputation or any of the disorders included with Les Autres. The common denominator for these disabled athletes is their mobility impairment and need of a wheelchair for sports participation.
•
Wheelchair locomotion is not an efficient means of transportation. The mechanical efficiency of wheelchair locomotion is at best 5%, compared with a minimum of 0% for walking or cycling at similar velocity.
•
The design of sports wheelchairs is constantly evolving. Recent design modifications are intended to improve the mechanical efficiency of the wheelchair, facilitate a more effective wheelchair stroke and minimize the risk of upper-extremity injuries (Fig. 4).
Wheelchair Sport Injuries •
The most common injuries incurred by wheelchair athletes are soft tissue injuries, blisters, lacerations, abrasions and cuts (Fig. 4).
Figure 5
Region
Type of Injuries
Prevention
Shoulder
Direct trauma:
• adequate training in correct technique
• contusion of muscle,
• strengthening of the shoulder
soft tissue
stabilisers
• sprains
• warmup, cool down and
• capsulitis
stretching procedures
• rotator cuff problems
• equipment modification
• fractures
• early reporting and treatment of
shoulder pain
Nontraumatic:
• bicipital tendonitis due to tendon
strain caused by overuse and
Elbow Wrist Hand and fingers
inadequate warmup. • as above • lacerations and abrasions • as above • lacerations and abrasions • abrasions and lacerations particularly of the knuckles • avulsion of the nails • finger injuries related to the
• wearing of clothing on the upper arms • use of tube socks on the rim • use of padded push rims • use of gloves and padding over the wrist and heel of the hand • use of gloves and taping • padded push rims and plastic wheel covers
catching of fingers in the spokes of the • removal of sharp edges on the
wheelchair are common
wheelchair
• muscular spasm related to overuse during maintenance of trunk stability
• blistering at the top of the seat post
or the back of the wheelchair
• postural correction by specific
Upper back
strengthening exercises
• wearing a shirt and padding on
the back of the wheelchair
Figure 5 (Cont’d)
Region
Type of Injuries
Prevention
Buttock
• pressure sores and ulcers
• padding or cushion on the wheelchair seat • intermittent lifting from the seat • combination of the above preventative measures
Special Medical Problems of Wheelchair Athletes Urinary tract complications
•
Neurological control of the urinary tract is usually lot after spinal cord injury.
•
Resulting complications of significant risk include bladder and kidney infection, stones, bladder distension.
•
Kidney damage secondary to infection alone is the main cause of death in spinal cord injury
Pressure sores
•
Pressure sore are one of the most common and costly complications of spinal cord injury. Skin breakdown is usually caused by prolonged pressure and compromise of the blood supply to affected tissues.
•
Wheelchair athletes who sit in the chairs with their knee higher than their buttocks are particularly prone to pressure sores. Further risks of pressure sore development is inherit as the athlete’s skin becomes damp with sweat and other moisture.
•
Prevention of pressure sores is important in all persons with spinal cord injury. Such measures include:
•
Intermittent shifting and lifting of the buttocks fro the wheelchair’s seat relieves pressure.
•
Wearing moisture-absorbing clothing to reduce skin laceration and friction forces.
•
Frequent skin checks of the trunk, sacrum, buttocks and legs.
Autonomic hyper-reflexia (AHR)
•
AHR is a particular complication of spinal cord injury above the 4th to 6th thoracic vertebrae.
•
AHR occurs as a result of the loss of central inhibitory control over the isolated distal spinal cord. A generalised sympathetic hyperactivity may be triggered in response to numerous sensory stimuli, for example bladder distention.
•
AHR in a person with spinal cord injury presents with sudden hypertension, bradycardia, headache, anxiety and profuse sweating.
Temperature regulation disorders
•
Impairment of thermoregulatory function is a significant complication of spinal injury
•
The loss of sensory afferent inputs from the spinal cord and muscles below the level of the lesion may limit hypothalamic responses to exercise and temperature.
•
The loss of lower extremity skeletal muscle pump in disabled athletes, such as amputees reduced venous return to the heart during exercise and further compromises thermoregulatory responses.
•
Wheelchair athletes are generally at a thermoregulatory disadvantage and certain precautions must be taken to prevent the occurrence of hyperthermia and hypothermia
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