INJURY IN THE DISABLED ATHLETE
With more DA athletes come more sports injuries. The field of sports medicine for the disabled athlete is growing to meet pace with the increase in participation. Among elite athletes in the 2002 Winter Paralympics, 9% sustained sports-related injuries.
Sprains and fractures accounted for more than half of the injuries, with strains and lacerations making up another 28% (74). Summer Paralympians sustained sprains, strains, contusions, and abrasions rather than fractures or dislocations (75). Retrospective studies have shown 32% incidence of sports injuries limiting participation for at least a day. Special Olympics participants encounter far fewer medical problems than their elite counterparts. Of those seeking medical attention during competition, overall incidence is under 5%, with nearly half related to illness rather than injury. Knee injuries are the most frequently reported musculoskeletal injury. Concerns regarding atlanto-occipital instability and cardiac defects must be addressed in the participant with Down's syndrome.Among elite wheelchair athletes, upper limb injuries and overuse syndromes are common; ambulatory athletes report substantially more lower limb injuries. Spine and thorax injuries are seen in both groups (76). Wheelchair racers, in particular, report a high incidence of arm and shoulder injuries. The injuries do not appear to be related to distance, amount of speed training, number of weight-training sessions, or duration of participation in racing (77). Survey of pediatric wheelchair athletes reveals that nearly all children participating in track events report injuries of varying degrees. Blisters and wheel burns are most frequent, followed by overheating, abrasions, and bruising. Shoulder injuries account for the majority of joint and soft tissue complaints. Injuries among field competitors are less frequent, with blisters and shoulder and wrist problems reported most often.
Swimmers report foot scrapes and abrasions from transfers, suggesting opportunity for improved education regarding skin protection (78).An important factor in injury prevention for the wheelchair athlete is analysis of and instruction in ergonomic wheelchair propulsion (79). Proper stroke mechanics positively affect pushing efficiency. Push frequency also affects energy consumption and can be adjusted to improve athletic performance (80). Motion analysis laboratories and Smartwheel technology can be utilized to objectively analyze and help improve pushing technique, thus reducing injury (81).
While some injuries are sport-specific, others may be more common among participants with similar diagnoses. Spinal cord-injured individuals are at risk for dermal pressure ulcer development, thermal instability, and autonomic dysreflexia. In fact, some paralyzed athletes will induce episodes of dysreflexia, known as “boosting,” in order to increase catecholamine release and enhance performance (82). Education regarding the risks of boosting is essential, as are proper equipment and positioning to protect insensate skin.
Athletes with limb deficiencies may develop painful residual limbs or proximal joints from repetitive movements or ill-fitting prostheses. The sound limb may also be prone to injury through overuse and asymmetric forces (83). Participants with vision impairments sustain more lower limb injuries than upper limb, while those with CP may sustain either. Spasticity and foot and ankle deformities in children with CP may further predispose to lower limb injury. As with all athletes, loss of range of motion, inflexibility, and asymmetric strength further predispose the DA participant to injury. Instruction in stretching, strengthening, and cross training may reduce the incidence and severity of injury.
“Evening the Odds”: Classification Systems
Sport classification systems have been developed in an attempt to remove bias based on innate level of function.
In theory, this would allow fair competition among individuals with a variety of disabilities. Early classifications were based on medical diagnostic groupings: one for athletes with spinal cord lesion, spina bifida, and polio (ISMWSF); one for ambulatory amputee athletes and a separate one for amputee athletes using wheelchairs; one for athletes with CP; one for Les Autres (International Sports Organized for the Disabled [ISOD]), and so forth. (Table 5.1). These early attempts reflected the birth of sports as a rehabilitative tool. This form of classification continues to be used in some disability-specific sports, such as goal ball for blind athletes and sit volleyball for amputee athletes. Other older systems took into account degree of function. This system unfairly penalized athletes who were more physically fit, younger, more motivated, and so forth.With the growth of elite competitive sports came the need for more impairment-based classification systems, which shifted the focus from disability to achievement. Impairment-based classifications have the added advantage of reducing the number of classes for a given sport. This results in greater competition within classes and reduces the number of classes only having one or two competitors. Impairment classifications are further utilized in sport-specific definitions, such as in basketball, quad rugby, and skiing (Table 5.2).
The issue of inclusion in elite sports has been quite controversial. Debate exists not only within
5.1
Comparison of medical and functional classifications of les autres athletes
| MEDICAL CLASSIFICATION | ||
| LEVEL | ATHLETES WITH... | EXAMPLES |
| L1 | Severe involvement of all four limbs | Severe multiple sclerosis Muscular dystrophy Juvenile rheumatoid arthritis with contractures |
| L2 | Severe involvement of three or all four limbs but less severe than L1 | Severe hemiplegia Paralysis of one limb with deformation of two other limbs |
| L3 | Limited functioning of at least two limbs | Hemiparesis Hip and knee stiffness with deformation of one arm |
| L4 | Limited functioning in at least two limbs; limitations less than in L3 | Contracture/ankylosis in joints of one limb with limited functioning in another |
| L5 | Limited functioning in at least one limb or comparable disability | Contracture/ankylosis of hip or knee Paresis of one arm Kyphoscoliosis |
| L6 | Slight limitations | Arthritis and osteoporosis Ankylosis of the knee |
| FUNCTIONAL CLASSIFICATION | ||
| LEVEL | DESCRIPTION | |
| L1 | Uses a wheelchair; reduced function of muscle strength and/or spasticity in throwing arm; poor sitting balance | |
| L2 | Uses a wheelchair; good function in throwing arm and poor to moderate sitting balance or reduced function in throwing arm with good sitting balance | |
| L3 | Uses a wheelchair; good arm function and sitting balance | |
| L4 | Ambulatory with or without crutches and braces or problems with balance together with reduced function in throwing arm | |
| L5 | Ambulatory with good arm function; reduced function in lower extremities or difficulty in balancing | |
| L6 | Ambulatory with good upper extremity function in throwing arm and minimal trunk or lower extremity impairment | |
| Source: United States Olympic Committee, 1998. | ||
Classification for Alpine Skiers
| VISUALLY IMPAIRED | |
| B1 | Totally blind |
| B2 | Partially sighted with little remaining sight |
| B3 | Partially sighted with more remaining sight |
| STANDING | |
| LW1 | Double above-knee amputees |
| LW2 | Outrigger skiers |
| LW3 | Double below-knee amputees (CP5, CP6) |
| LW4 | Skiers with prosthesis |
| LW5/7 | Skiers without poles |
| LW6/8 | Skiers with one pole |
| LW9 | Disability of arm and leg (amputation, cerebral palsy, hemiplegic) |
| SITTING | |
| LW10 | Mono skiers (high degree of paraplegia) |
| LW11 | Mono skiers (lower degree of paraplegia) |
| LW12/1 | Mono skiers (lower degree of paraplegia, double above-knee amputees) |
| Source: International Paralympic Committee, 2008. | |
5.2
sports for the disabled, but also in the inclusion of DA athletes in sports with AB competitors.
A few sports such as archery have fully integrated AB and DA competitors. However, in sports such as marathon racing, the AB athlete is at a distinct disadvantage, being unable to achieve the speeds or times of the wheelchair racer. Having classification systems and segregation in DA sports allows for achievement based on ability rather than disability. Yet, there continues to be a discrepancy between the recognition and reward for AB and for DA athletes. The issues of integration and classification continue to be refined and debated. Inclusion at the educational and recreational levels remains much more feasible through Adapted Physical Education and community-based programs.