Sport and disability

Caring for athletes with disabilities is a challenge for sports medicine practitioners. Scientific research in sport and exercise medicine for people with disabilities is surprisingly sparse considering the inspirational achievements of these athletes, says A D J Webborn

The achievements of athletes with disabilities remain largely unknown to most people. A high jump of nearly two metres by a person who has had a leg amputated, or less than an hour and a half for the wheelchair marathon, show that people with disabilities are capable of considerable athletic performance. It is important that these achievements should be recognised by the medical profession for two major reasons. Firstly, that these people are athletes in their own right who have their own sports medicine needs. Secondly, to help alter attitudes to patients with disabilities, in relation to physical activity, in which many doctors are restrictive rather than prescriptive with exercise.

General health
The beneficial effects of exercise are well established in relation to general health and in regard to prevention or management of specific disease processes--for example, non-insulin dependent diabetes. People with physical disabilities are less likely to avail themselves of these benefits for a variety of reasons that include cultural and social factors, facilities, and access. Participation in sport is not essential but it is important that people with disabilities are encouraged to remain physically active. Accumulating evidence shows that people with disabilities who are more physically active visit doctors less and have fewer medical complications and hospitalisations than their sedentary counterparts. Paraplegic athletes are more successful than non-athletes in avoiding major medical complications of spinal cord injury. The same message of the accumulation of at least 30 minutes of moderate intensity activity on at least five days of the week is equally applicable to someone with a disability. The same principles of training--that is, the graded increase in duration, intensity, and frequency apply, but more thought may be required as to the mode of exercise according to the disability. The social and psychological benefits of exercise and participation in sport are not exclusive to the able bodied and major improvements in self esteem and social integration may occur through an active lifestyle.

Choosing an activity or sport
In reality, people with disabilities can take part in virtually every sport available including high risk sports such as mountain climbing, subaqua diving, and skiing. Some sports are conventional sports in which little or no modification is required--for example, swimming. Other sports may require specific adaptation--for example, wheelchair basketball--or may be specifically developed for a certain disability--for example, goalball for the visually impaired. For those who are counselling people with disabilities regarding the potential benefits of sport it is important to establish their aims. If the aim is primarily for physical health benefits for a general health or disease modification then one has to consider the difference between exercise and sport. These terms are often incorrectly used interchangeably. Sport is not always exercise and vice versa. Sport implies competition and the physiological demands are determined by the sport--for example, wheelchair sprint racing (anaerobic) compared with wheelchair road racing (aerobic) compared with pistol shooting (skill). Sport may also involve trauma, which will be particularly undesirable in some conditions. Alternatively the focus may be on socialisation and building self esteem. Although the ability to achieve one of these aims is not necessarily exclusive of the others it is helpful to consider the person's goals. Not all sports need to be organised or competitive. The choice of sport will be influenced by various factors that include:

• The personal preference of the person--an emphasis on enjoyment and participation in a sport that stimulates the person may be important for continued participation
• The characteristics of the sport--physiological demands, collision potential, team or individual, coordination requirements
• The medical condition--beneficial and detrimental aspects
• Conditions associated with the condition--although motor dysfunction may initially appear to be the major limitation to participation there may be for example an associated cardiac condition to consider
• The cognitive ability and social skills of the person--ability to follow rules and interact with others.
• Availability of facilities
• Availability of appropriate coaching and support staff--for example, lifting and handling
• Equipment availability and cost--as disability sport has evolved, so has the technology. Specialist chairs are available for sports such as tennis, rugby, and basketball. Although sport specific chairs are not necessary for initial participation it does become a consideration as people develop their interest and feel more limited by their equipment.

Risks of participation
In general terms there are relatively few absolute contraindications to participation in physical activity for anybody, able bodied or not, if the general training principles of gradual and progressive overload are applied.

• Cardiac conditions--Sudden deaths, associated with vigorous exercise or sports participation, are predominantly related to cardiac conditions. For people with a disability it requires greater awareness from their physician of conditions that may have associated cardiac disease. Exercise intensity is an important consideration in sport selection where cardiac anomalies may be present--for example, Down's syndrome
• Environmental issues--Risks of heat or cold injury may occur due to loss of autonomic function in, for example, spinal cord injury. People who have had both legs amputated will have reduced surface area for evaporative cooling during exercise in a hot environment
• Trauma--Sports may be classified by their risk for collision potential (for example, skiing or cycling) or they may be a contact sport such as football. Bone mineral density may be reduced by the nature of the condition--for example, osteogenesis imperfecta--or secondary to immobilisation (for example, in paraplegia) and the risk of spontaneous fracture or fracture with minimal trauma exists. The risk of atlantoaxial instability in people with Down's syndrome remains an issue of contention
• Overuse injuries--The potential for overuse injury occurs in any athlete in regular training but there are certain predisposing factors which are likely to be more prevalent:
• Biomechanical factors--for example, gait in cerebral palsy or scoliosis in spina bifida
• Technical factors--coordination difficulties or restriction of movement altering correct technique.

The wheelchair athlete is prone to more upper limb overuse injuries and in particular degenerative changes in the shoulder have been noted in wheelchair users whether athletic or not. However because good upper limb function is so important for performing activities of daily living--for example, transfers from chair to bed or bath, or propulsion--the same injury occurring in a wheelchair athlete as an able bodied athlete may have significantly different consequences on quality of life.

History of competitive sport
Although sports associations for people with disabilities have existed since the 19th century the credit for the evolution of major games for athletes with disabilities is rightly attributed to the vision and efforts of Ludwig Guttmann. Guttmann was a neurosurgeon at the spinal injuries unit at Stoke Mandeville hospital near Aylesbury in England who introduced sport as part of the rehabilitation programme of his patients. Guttman believed that "by restoring activity of mind and body--by instilling self respect, self discipline, a competitive spirit, and comradeship--sport develops mental attitudes that are essential for social reintegration." The competitive spirit resulted in an archery competition on the front lawns of the hospital between 16 competitors in wheelchairs from the spinal unit and a disabled exserviceman's home in London. This was in July 1948 on the opening day of the Olympic Games in London and there started the first Stoke Mandeville Games. In the Athens Paralympic Games in 2004

PHOTOS RICHARD BAILEY

they expect to host more than 4000 competitors from 130 countries with these major disability groups:

1. Spinal cord lesions--congenital (spina bifida) or acquired (injury or disease)

   (2) Visually impaired

2. Cerebral palsy
3. Amputees
4. "Les Autres"--or "the others" is a term used for people with certain disabilities that do not fit into another category--for example, muscular dystrophy or multiple sclerosis
5. Intellectual disability
6. Hearing impaired--deaf people still maintain their own organisation, the Comité International Sports des Sourds (CISS) and games (the Silent Games).

Historically sports for people with disabilities have developed in certain sports for certain disabled groups:
Athletes are placed into different classifications according to their disability to produce fair competition. Some sports are restricted to certain disability groups--for example, judo for the visually impaired. Others allow cross-disability competition by functional assessment of sport performance as well as objective assessment by medical examination--for example, in swimming.

Sports
In élite disability sport the International Paralympic Committee are responsible for the organisation of the Paralympic Games. The games take place two weeks after the Olympic Games and this format is used for both summer and winter games. The sports represented at Paralympic Games are shown in boxes 1 and 2, but many other sports are represnted at World and Regional Championships--for example, lawn bowls and wheelchair dance. Each sport adds new challenges to understanding of the sports science and medicine demands of the sport with different injury risks through disability factors, technique or equipment. It requires the practitioner to be able to think laterally around the problems that may be presented.

Medical issues relating to the disability groups

Spinal cord lesions
The motor loss that occurs after spinal cord injury reflects the level of the lesion, but several other factors should be considered:

• Loss of intercostal muscle function with reduced ventilatory capacity
• Postural stability--scoliosis may require bracing for some sports
• Sensory loss--skin pressure--increased pressure and shear forces from sports activities may increase the risk of skin ulceration
• Autonomic impairment:Bowels and bladder--It is important that dehydration does not occur as this not only impairs sport performance and risks heat illness but also is likely to aggravate renal calculi and infection
• Thermal regulation--loss of peripheral receptor mechanism, control of the sweating effector mechanism, and control of the ability to appropriately vasoconstrict or vasodilate the peripheral vasculature. In the cold environment the muscles will not shiver and the skin responses are not appropriate and increase the rate of heat loss
• Cardiovascular--a spinal cord lesion above the level of T1 will cause an absence of sympathetic cardiac innervation producing a depressed maximal heart rate and the level is determined by the intrinsic sino-atrial activity (110-130 beats per minute)
• Autonomic dysreflexia--an inappropriate response triggered by nociceptive input below the level of the lesion producing hypertension, sweating, skin blotching, and headache. The usual causes are blockage of a urinary catheter, constipation, urinary calculi, anal fissure or ingrowing toenail. It can produce severe hypertension, cerebral haemorrhage, fits, and death and as such is treated as a medical emergency with treatment aimed at removing the nociceptive stimulus and reduction of blood pressure with sublingual nifedipine. There have been reports of athletes with a quadriplegia intentionally inducing the dysreflexic state to achieve performance enhancement. This technique is known as "boosting" and has produced increases in simulated race times of 9.7%. Athletes suspected of being in a dysreflexic state (previously deemed a banned method of doping by the International Paralympic Committee) are prohibited from competing for medical safety reasons. A hazardous dysreflexic state is considered to be present when the systolic blood pressure is 180 mm Hg or greater
• Musculoskeletal injuries--data on the true incidence and type of injury in people with spinal cord lesions are limited. Chronic and overuse symptoms in the cervical and thoracic spines and the shoulder are not uncommon, as are traumatic injuries to the forearm, hand, and fingers.

Spina bifida
Depending on the level of the motor loss people may be ambulant or require a wheelchair for activity. Those who are ambulant have relatively few limitations in sport. Those with higher lesions are more prone to significant scoliosis that may require bracing or spinal fusion. Contractures are common and stretching and flexibility should be an important part of the exercise programme. Bowel and bladder function and sensory loss may be present but not the autonomic problems of the spinally injured.

Visually impaired
Visual impairment can range from complete blindness to partial sightedness combining loss of visual acuity and field loss. Adaptations to sports include a sound emitting ball for goalball or cricket or a tandem cycle with a sighted pilot rider. In swimming, an assistant taps the head or shoulder of the swimmer with a soft ended pole to indicate the pool end to enable turning and finishing. Adaptations can be made to rifles to emit an audible tone when on target. Cross country and alpine skiing events are possible with guide skiers who give audible commands. The main problems specific to the disability include falls and collisions causing injury.

Cerebral palsy
The three primary motor disorders that characterise the condition are spasticity, choreoathetosis, or ataxia. Hypotonic cerebral palsy is less common. Commonly associated disorders that should be considered in sport selection include:

• Epilepsy
• Visual defects
• Deafness
• Intellectual impairment
• Perceptual deficits
• Speech impairment.

At élite level, half of competitors compete in a wheelchair and the others are ambulant.

Amputees
Amputees may participate in sport with a prosthesis (for example, sprinting or cycling) or without (for example, high jump or swimming) or may compete in a wheelchair (for example, basketball). The main risks to the residual limb occur from the effects of friction and compression when a prosthesis is used. Impact loading is also a concern for the residual limb with increased ground reaction forces that may lead to degenerative change in joints higher in the kinetic chain. Technological advances in prosthetic design may reduce this loading while storing energy to facilitate propulsion.

Intellectual disability
Apart from intellectual disability, other terminologies often used are including learning disability, mental handicap, mental deficiency, and mental retardation. They all refer to the same condition. One of the most difficult problems facing these athletes is poor perception of their sporting potential and also prejudice against them. From an organisational point of view classification is a difficult problem in setting the level at which someone becomes eligible to participate. The International Paralympic Association and International Sports Federation for Persons with Intellectual Disability diagnostic criteria for intellectual disability require:

1. Significant impairment in intellectual functioning, as determined by a rating that is two standard deviations below average on an appropriate/recognized assessment instrument. (This generally an IQ score of 75 or lower.)
2. Significant limitations in adaptive behaviour, as expressed in conceptual, social, and practical adaptive skills. Examples of these skills include communication, self care, self direction, and social and interpersonal skills.
3. Intellectual disability must be evident during the developmental period. This is generally considered to be from conception to 18 years of age.
4. International Paralympic Association rules require evidence that an athlete's disability has significant sport related affects, which makes it impossible for the athlete to compete "on reasonably equal terms" with non-disabled athletes.

Doping issues
The list of prohibited classes of substances and prohibited methods is the same as the Olympic Movement Anti-doping Code until the adoption of the World Anti-Doping Code list in 2004. Relatively few paralympic athletes have tested positive for banned substances and received penalties and these have been predominantly in sports normally associated with drug misuse--for example, powerlifting. A far greater proportion of athletes with disabilities will be taking prescribed drugs and the attending physician should be aware of this. For example, chronic pain, hypertension, and renal disease are more common in the paralympic athlete group and family practitioners are often unaware of the restrictions placed on prescribing for athletes.
Differences occur in the sample collection procedure:

• To ensure integrity, athletes with visual or intellectual disabilities must have an accompanying person with them to supervise throughout the doping control process
• Sample collection methods may be adapted for athletes requiring catheters, using condom drainage or having severe disabilities, when a larger collection vessel may be used. For self catheterisation, the athletes are allowed to use their own catheter but the bladder must first be emptied and the sample collected from the next available urine collection.
• Assistance during the process may be given with the athlete 's consent

Nick Webborn, sports physician, Esperance Private Hospital, Hartington Place, Eastbourne, East Sussex, The Sussex centre for sports and exercise medicine, University of Brighton
Email: nigel@uicc.org


studentBMJ 2004;12:265-308 July ISSN 0966-6494

1. Adapted from the newly revised edition of the ABC of Exercise and Sports Medicine Edition, publishing January 2005 by Blackwell BMJ Books.
   ISBN: 0727918133 Price: £25-00

       

           

Responses published this month Articles Responses EDUCATION Sport and disability       A D J Webborn (July 2004) Kaushal R Pandey (July 30, 2004) Read this response EDUCATION Sport and disability       A D J Webborn (July 2004) Kaushal R Pandey (July 30, 2004)       MBBS, fourth year Maharajgung Campus,IOM,Nepal kr_pandey@hotmail.com It is an appreciatory effort by the author to comprehensively present the problem in the field of sports for disabled people and difference with that of which we think by watching the popular versions of the game played. It is even more significant now because many people nowadays get disabled due to increase in all sorts of accidents and also as the complication of many disease processes and even physically good player can be disabled during sports partipication.Sport events can arouse the enthusiasm in disabled people for physical activities and ultimately improve their health status . But it is an irony that disabled people in the developing nations live a life of social outcast and neither they can participate nor can watch other's playing due to financial problems. So gvernments should come up with the program for these people to get involved in exercise regularly as a part of rehabilitation.