Adaptive Sports Medicine · • World War II veterans with a spinal cord injury • Stoke...
Transcript of Adaptive Sports Medicine · • World War II veterans with a spinal cord injury • Stoke...
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Adaptive Sports Medicine
Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship
Director, Sports Medicine Director, Interventional Pain
National Rehabilitation Hospital Georgetown University Hospital
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Financial Disclosures
• None to report
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Disclosure
• Stuart Willick, MD
• United States Ski and Snowboarding Association
• United States Olympic Committee
• Walter Reed Army Medical Center
• Military Advanced Training Center
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Overview
• History • Paralympic Games • Sports Governance • Disability Groups • Classifications • Adaptive Sports • Adaptive Equipment • Medical Care • Research
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History
• Inaugural Event – 1948
• Sir Ludwig Guttmann • World War II veterans with a spinal cord injury • Stoke Mandeville, England.
– 1952 • competitors from the Netherlands joined the games • international movement was born.
• Inaugural Olympic style games for athletes with a disability – Rome, 1960 – Now called Paralympics.
• Toronto, 1976 – other disability groups were added – idea of merging together different disability groups for international sport
competitions was born.
• Sweden, 1976 – First Paralympic Winter Games
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History
• Paralympic Games – Elite sport events for athletes from 6 different disability
groups
– Emphasize the participants' athletic achievements rather than their disability
• Movement has grown dramatically since its first days
• Rome 1960 – 400 athletes from 23 countries
• Beijing 2008 – 3,951 athletes from 146 countries
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History
• Paralympic Games – Always been held same year as the Olympics – Seoul 1988 Paralympic Games and the Albertville
1992 Winter Paralympic Games: • Same venues as the Olympics
– 2001: • Agreement between the IOC and the IPC securing this
practice for the future
– From 2012 onwards: • Host city chosen to host the Olympic Games will be obliged
to also host the Paralympics
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History
• International Paralympic Committee (IPC) – Global governing body of the Paralympic Movement – Organizes the Summer and Winter Paralympic Games – Founded on 22 September 1989 in Dusseldorf ,Germany
• Preceded by the ICC in 1982 • "International Coordination Committee of World Sports Organizations for the Disabled"
– IPC ‘s First Paralympic Games • The Winter Paralympics in Lillehammer in 1994
– Organization is rapidly developing • 165 member nations
– Growth is best exemplified through the phenomenal rise of the Paralympic Games.
• More countries competed at the Beijing 2008 Paralympics (3951 athletes, 146 countries) than in the Munich 1972 Olympic Games.
• In Beijing, degree of media coverage was unprecedented.
– Growing interest in and acceptance for sport for persons with a disability – Expansion of the Paralympics is most likely to continue in the future
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History
• “Paralympic” • Derives from the Greek
• preposition "para" (beside or alongside) and "Olympics"
• Paralympics being the parallel Games to the Olympics
– Originally a pun combining 'paraplegic' and 'Olympic'
• however with the inclusion of other disability groups and the close associations with the Olympic Movement
– Now represents 'parallel' and 'Olympic' to illustrate how the two movements exist side by side
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Paralympic Games
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Paralympic Games
• Sports Governance
– 20 Paralympic Summer Games
– 5 Paralympic Winter Games
– 1 Non Paralympic Sport
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Sports Governance • International Paralympic Committee (IPC)
– Serves as the International Federation for nine (9) sports
– Supervises and co-ordinates the World Championships and other competitions
• The following sports are governed by the IPC:
– Alpine Skiing
– Athletics
• Track events: Sprint (100m, 200m, 400m), Middle Distance (800m, 1500m), Long Distance (5,000m, 10,000m) and Relay races (4x100m, 4x400m)
• Road event: Marathon
• Jumping events: High Jump, Long Jump and Triple Jump
• Throwing events: Discus, Shot Put, Javelin
• Combined events: Pentathlon (track and road events, jumping events and throwing events, classification dependant)
– Biathlon
– Cross-Country Skiing
– Ice Sledge Hockey
– Powerlifting
– Shooting
– Swimming
– Wheelchair Dance Sport
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Sports Governance
• International Organization of Sport for the Disabled (IOSD) • IPC currently recognizes six IOSD sports on the Paralympic Program
– Governed by the Cerebral Palsy International Sports and Recreation Association (CPISRA) • Boccia • Football 7-a-side
– Governed by the International Blind Sports Federation (IBSA) • Football 5-a-side • Goalball • Judo
– Governed by the International Wheelchair and Amputee Sports Federation (IWAS) • Wheelchair Fencing
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Sports Governance
• International Federations (IF) – Archery (International Archery Federation) – Cycling (International Cycling Federation) – Equestrian (International Equestrian Federation) – Rowing (International Rowing Federation) – Sailing (International Association for Disabled Sailing) – Table Tennis (International Table Tennis Federation) – Volleyball (Sitting) (World Organization for Volleyball for Disabled) – Wheelchair Basketball (International Wheelchair Basketball
Federation) – Wheelchair Curling (World Curling Federation) – Wheelchair Rugby (International Wheelchair Rugby Federation) – Wheelchair Tennis (International Tennis Federation)
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Disability Groups
• Six different disability groups in the Paralympic Movement: – Amputee
– Cerebral palsy
– Visual impairment
– Spinal cord injuries
– Intellectual disability
– Les Autres • a group which includes all
those that do not fit into the aforementioned groups
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Disability Groups
• Amputee:
– partial or total loss of at least one limb
• UE/LE
• Single/multiple limbs
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Disability Groups
• Cerebral Palsy: – Athletes with non-
progressive brain damage, • Cerebral Palsy
• Traumatic brain injury
• Stroke
• Similar disabilities affecting muscle control, balance or coordination.
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Disability Groups
• Intellectual Disability:
– Athletes with a significant impairment
• intellectual functioning
• limitations in adaptive behavior.
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Disability Groups
• Spinal Cord Injury (Wheelchair):
– spinal cord injuries
– other disabilities which require them to compete in a wheelchair
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Disability Groups
• Visually Impaired:
– Vision impairment
• Partial vision
• Legally blind
• Total blindness
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Disability Groups
• Les Autres:
– Athletes with a physical disability that does not fall strictly under one of the other five categories
• Dwarfism
• multiple sclerosis
• congenital deformities of the limbs
• such as that caused by thalidomide
– (the name is French for "the others").
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Classification
• Classification is simply a structure for competition. – Not unlike wrestling, boxing and weightlifting,
where athletes are categorized by weight classes – Athletes with disabilities are grouped in classes
defined by the degree of function presented by the disability.
• Classes – Determined by a variety of processes that
include: • physical and technical assessment and observation
in and out of competition
• Classifiers – Sports certify individuals to conduct the process
of classification
• Classes are defined by each sport and form part of the sport rules – Ongoing process.
• When an athlete starts competing, they are allocated a class that may be reviewed throughout the athlete's career.
• Since the 1960's, the development of sport for athletes with a disability has produced the development of classification systems
– Continues to evolve to the present day.
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Classifications
• Classes – Determined by a variety of processes that include:
• physical and technical assessment and observation in and out of competition
• Classifiers – Sports certify individuals to conduct the process of classification
• Classes are defined by each sport and form part of the sport rules – Ongoing process.
• When an athlete starts competing, they are allocated a class that may be reviewed throughout the athlete's career.
• Since the 1960's, the development of sport for athletes with a disability has produced the development of classification systems
– Continues to evolve to the present day.
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Classifications
• Code • Classification Strategy
– Developed in 2003 by IPC
• Overall objective to support and coordinate the ongoing development of classification systems and their implementation: – Accurate – Reliable – Consistent – Credible – Sport focused
• The IPC Classification Code is a direct result of these recommendations – Framework for policies and procedures that are common to all sports
• Specific enough to achieve complete harmonization on classification issues • General enough in other areas to permit flexibility
• The Code is complemented with International Standards that provide the technical and operational requirements for classification
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Classifications: Alpine Skiing
• Visually impaired
– B1 - Totally blind participants with vision up to light perception / hand movement
– B2 - visual acuity of 2/60 and / or visual field of less than 5 degrees
– B3 - visual acuity above 2/60 to 6/60 and / or visual field of more than 5 degrees and less than 20 degrees
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Classifications: Alpine Skiing
• Standing – LW1 double above-knee amputees or similar – LW2 above knee amputee using outriggers and one ski – LW3 double below-knee amputees/ CP5, CP6 – LW4 skiers with below knee amputation using
prosthesis, two skis and poles – LW5/7 skiers with both hands / arms amputated
unable to use poles (LW5/7-1, LW5/7-2, LW 5/7-3) – LW6/8 skiers with one hand / arm amputated using
one pole (LW6/8 -1, LW6/8 -2) – LW9 disability of one arm and one leg (Amputation,
CP, Hemiplegic), (LW9/1, LW9/2)
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Classifications: Alpine Skiing
• Sitting
– LW10 mono skiers (high level of spinal cord injury), (LW10/1, LW10/2)
– LW11 mono skiers (thoracic spinal cord injury)
– LW12 mono skiers (paraplegia or double AK Amputees), (LW12/1, LW 12/2)
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Adaptive Equipment: Sports Prostheses
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Sports Prosthesis
• Everyday vs. special use
• Prosthetic weight
• High tech vs. conventional
• Prosthetic foot dynamics
• Shock absorption
• Transverse rotation
• Alignment
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Adaptive Skiing
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Adaptive Alpine Skiing
• Rules similar to Alpine Skiing – however, real time is multiplied
by a factor based on disability level to obtain official time
• Sitting • Disability Groups
– Spinal Cord Injury
– Cerebral Palsy
– Spina bifida
– Double Transfemoral amputations
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Adaptive Skiing
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Skiing
• Upper Extremity
– Outriggers
• Lower Extremity
– Standing
– Standing frame
• 4 track
– Sit Ski
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Upper Extremity
• Outriggers
– Specially adapted ski poles
– Modified Lofstrand crutches attached to ski tips
– Types:
• Flipski (flips up to walking crutch)
• Standard
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Lower Extremity Skiing Prosthesis
• Center of gravity in front of ankle
• Can place one inch heel under heel for forward cant
• Ski prosthesis
– Anterior socket brim 1 inch behind prosthetic toe
– Prosthesis length reduced to intact dorsiflexed lower limb
– SACH foot to dynamic-response feet
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3 Track Skiing
• Stand up skiing – One ski and two hand-
held outriggers. • Alternative: Two skis,
one outrigger
– Outriggers provide stability and a means for initiating the turn.
– 3 track disability groups: • Amputees, Post-polio,
and some congenital birth defects.
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2 Track Ski with Tether
• Extra help with learning to steer their skis. – Tether system leading to the
front of the ski tips
– In conjunction with a ski bra
• Allows the instructor to make the turn for the participant – Learn the feel of the turn
– Progress to making the turns for themselves.
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4 Track Skiing
• Stand up skiing – using two skis with two hand-held
outriggers for balance. – Provides student with four-points of
contact with the snow. – Designed for those with leg strength
and/or stability issues.
• Disability groups: – Cerebral palsy, Multiple
sclerosis,Post-polio, Spinal cord injury, Stroke, Muscular dystrophy, Spina bifida, Amputees.
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Sit Ski
• Seating System
• Frame
– Alignment
– Shock Absorption/Suspension
• Bindings
• Ski
– Single (Monoski)
– Double (Bi-ski)
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Seating System
• Custom Molded Orthotic Seat
• Cushion
• Removable external shell
• Alignment
– more dependant on frame
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Frame
• Variations for disability level, type of skiing, alignment
• Weights between 30-50 lbs
• Main types – Nissen
– Bramble
– HOC • “hands on concept”
– Prashberger
– Tessier
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Frames
• Nissen
– Aircraft Grade Aluminum
• Lighter weight
– Upright
• “Athletic Stance” positioning
– Suspension
• Pivot
• “like a toe”
– Shock Absorption
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Frames
• Bramble
– Stainless Steel/Aluminum
– Reclined position
– Suspension
• Dual swing
– Shock Absorption
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Frames
• HOC • “hands on concept”
– Hybrid
– Mostly aluminum with some stainless steel
– Upright positioning
– Suspension
• Lever
– Similar to Nissen
– Shock Absorption
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Frames
• Prashberger
– Stainless steel
– Agility/Speed
• Good for Slalom
– Suspension
• Linkage
– Shock Absorption
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Bindings
• Settings
– Dependant on ski level of individual
• Styles
– Dependant on ski brand
• Marker 30 – Fits Marker/Head
• Salomon 920 – Fits Salomon, Atomic
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Sit Ski
• Mono-Ski: • Sit down ski equipment
• One ski and using two hand-held outriggers
– Designed for independent skiers with good upper body strength and balance.
– Mono-ski Disability Groups:
• Brain Trauma, Double amputee, Post-polio, Muscular dystrophy, Cerebral palsy, Spinal cord injuries below the level of T4, Multiple sclerosis, Spina bifida.
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Sit Ski
• Bi-Ski: – Sit ski with a molded bucket seat – Two specially shaped skis that can be skied
independently • similar fashion as the mono-ski with hand-held outriggers
– Skied with the assistance of an instructor using stabilizing outriggers and tethers
• Bi-ski disability groups: – Cerebral palsy, Multiple sclerosis
Muscular dystrophy, Amputees Spinal cord injury, Severe epilepsy Spina bifida, Severe balance impairment
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Nordic Skiing • Sit skiing
• Additional suspension
• Lighter frame
• Shorter prosthesis for more turning power
• Appropriate terrain
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Snowboarding
• Snowboarding – Terminal Device
attached directly to the Snowboard • Trans-femoral amputee
was made possible through knees with shocks and by directly attaching the prosthesis to the board
– Bartlett Tendon • Shock Absorption • Aids Knee Extension
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Adaptive Running
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Adaptive Running
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Adaptive Running
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Running Prosthesis
• Sprinting • Jogging
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Adaptive Cycling
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Adaptive Cycling
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Adaptive Cycling
• Paralympic Cycling • Initially developed by Visually Impaired Cyclists
– Tandem Bicycle
• Now includes all 6 disability groups
• 1st became Paralympic Sport, Seoul, 1988
– Bicycle
– Tricycle
– Tandem Bicycle
– Hand Cycle
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Cycling
• Traditional (Upright)
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Cycling
• Recumbent Cycle
• Hand Cycle
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Adaptive Cycling
• Transtibial amputee:
– ride with prosthesis
• Transfemoral amputee:
– ride with or without prosthesis
• Recumbent Cycling
• Hand Cycling
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Cycling
• Lower Extremity
– aerodynamic leg with integrated clip
– Bartlett Tendon (Leftside, Inc)
• Upper Extremity
– specialty terminal devices
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Cycling
• Bartlett Tendon (Leftside, Inc)
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Adaptive Golfing
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Adaptive Golfing
• Need good balance
• Can play sitting or standing
• Add rotational component to shank
• Swivel golf shoe device
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Adaptive Golfing
• Upper Extremity – Specialty terminal
devices to maintain proper grip on the golf club.
• Lower Extremity – Torsion adapters allow
more motion and reduce stress on the residual limb and prosthetic components
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Adaptive Swimming
• Swim without Prosthesis
• Socket directly attached to fins
• Swimming Prosthesis
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Swimming Prosthesis
• Advantages
– Can exercise residual limb musculature
– Increased stability when diving
– Can climb ladder out of pool
– Some protection against injury
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Swimming Prosthesis
• Swimming Knees
– Locking knee
• Knee joint bends for walking around the pool or at the beach
• Locks to put the leg in a straight position for use in the water
– Buoyancy will have distal leg float
• Aulie Nylon Knee
– designed specifically for water use
– locking pin system
– with or without hydraulic control
– adolescent and adult swim legs.
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Swimming Prosthesis
• Swimming Ankle • Allow the swimmer to lock the foot into a pointed position
• Simulates the natural position of a foot when swimming
• Ankle is locked into one position for walking
• Changed to a pointed position for swimming
– Ortholite Leisure ankle • Lever to enable the amputee to change the foot from a walking to
a swimming position
• suitable for most swimming legs (except very young children).
– ActivAnkle and Swimankle • both enable the amputee to change the foot position from walking
to swimming
• suitable for adolescents and adults.
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Adaptive Field
• Shot Put • Discus
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Adaptive Track & Field
• Rules of Paralympic track and field are almost identical to those of its non-disabled counterpart • Certain allowances are made to accommodate certain disabilities
– For example, the blind and more severely visually impaired runners compete with guide runners, who are often attached by the wrist with a tether to the runner
• Classifications • Cerebral Palsy/Traumatic Brain Injury
– Wheelchair • T31
– Quadriplegia: Severe (High Cervical)
• T/F32 – Quadriplegia: Severe to Moderate (Mid Cervical)
• T/F33 – Quadriplegia: Functional strenght in UE (Low Cervical)
• T/F34 – Paraplegia: Severe to Moderate
• Spinal Cord Injury – Wheelchair
• T51 – Quadriplegia
• T52 – SCI affecting trunk and lower extremities
• T53 – SCI affecting abdomen and lower extremities
• T54 – Paraplegia
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Adaptive Rock Climbing
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Adaptive Rock Climbing
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Rock Climbing
• Upper Extremity • Ice climbing device
– Vacuum suspension is a robust design
– Incorporating the ice climbing pick directly into the socket
• Alternative Cable System
• Lower Extremity – Adaptive Feet
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Rock Climbing
• Lower Extremity • Specialty rock climbing feet
– allow better purchase onto the wall. • These particular legs were
designed for a bilateral amputee who desired the ability to adjust the length of the prostheses for different climbs.
– A quick disconnect (Ferrier Coupler) facilitates changing quickly back into feet designed for hiking
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Adaptive Archery
• First Paralympics – Rome, 1960
• Shooting Precision and Accuracy – Individual – Team
• Eligible Disabilities – Amputees, Autres,
Spinal Cord Injury, Traumatic Brain Injury, Cerebral Palsy, Stroke
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Adaptive Fencing
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Wheelchair Rugby/Boccia/Goalball
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Inline Skating
• Custom Device
– Light weight
– Adjustable Ankle
• Alignment adjustments
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Kayaking
• Kayaking requires stabilization of the legs inside the boat.
• Traditional prosthetic feet – difficult to fit in and out of the
kayak – slip easily off of the foot pegs.
• Monolithic design
– connects the prosthesis to the foot peg using a bungee cord
– allowing multi-axial movement – facilitate quick exit out of the
kayak
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Medical Care of Athletes with Disabilities
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Medical Conditions
• The majority of medical conditions encountered with wheelchair athletes are similar to both able bodied athletes as well as other standing adaptive athletes.
• Main difference
– Injury pattern
• upper extremity overuse
• traumatic injuries
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Medical Care
• Pre-Existing Trauma
• Musculoskeletal
• Neurologic
• Vascular
• Cardiac
• Dermatologic
• Infectious
• Endocrine
• Gastrointestinal
• Genitourinary
• Psychological
• Environmental
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Pre-Existing Trauma
• Presence of hardware (screws, plates, pins)
• Previous skeletal injuries may appear on new X-rays.
• Athlete S/P splenectomy
• Athlete S/P nephrectomy
• Prior TBI
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Neuromusculoskeletal
• Insensate athlete:
– Need to look more carefully for occult MSK injuries:
• Fractures
• Dislocations
• Visceral injuries
• Sensate athlete:
– Same as able bodied athlete but possibly with greater consequences.
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Shoulder Injuries
• Wheelchair Athletes – Increased risk for shoulder pathology
• pain, rotator cuff injuries, subacromial bursitis, acromioclavicular joint abnormalities, coracoacromial ligament thickening, subacromial spurs, distal clavicle osteolysis, and impingment syndrome
• (Brose, Bayley)
– RiskFactors • repetitive motion, increased pressure in the shoulder joint during
wheelchair propulsion, and muscle imbalances in the shoulder girdle due to weakness
• (Bayley, Silfverskiold, Donovan, Waring).
– Upper limb injuries including shoulder injuries are particularly disabling • Rely on their upper limbs for weight bearing, transfers, and
ambulation in addition to all of the demands placed on the upper limbs in the able-bodied population
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Shoulder Injuries
• Wheelchair Athletes – Despite increases in repetitive use and high-intensity
activity • wheelchair athletes do not have a higher incidence of
shoulder pain than non-athletic wheelchair users. – In fact, participation in athletic competition appears to be
protective from shoulder pain (Fullerton) » Likely due to increased strength and endurance in the
athletic population.
– Modifications • Shoulder complaints among wheelchair users can be
reduced by appropriate wheelchair design and the use of ideal propulsion techniques.
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Elbow Injuries
• Ulnar nerve entrapment – 2nd most common upper limb nerve entrapment syndrome – Wheelchair users are an increased risk for ulnar neuropathy at the elbow
(Groah). • No evidence to suggest wheelchair athletes are at a greater risk as compared with non-
athlete wheelchair users
– Symptoms • numbness and tingling in the 5th digit and the ulnar half of the 4th digit • weakness and atrophy in the hand intrinsic muscles • pain and tenderness in the ulnar groove.
– Diagnosis • history, physical examination, and electrodiagnostic testing.
– Treatment • Tailor to the individual needs of the patient, keeping in mind that many wheelchair users
will be non-mobile if they are required to restrict weight bearing or otherwise limit activity involving their upper limb.
• Elbow Pain – Other sources of elbow pain in wheelchair users
• lateral epicondylitis, osteoarthritis, and olecranon bursitis • (Paralyzed Veterans of America).
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Wrist Injuries
• Carpal tunnel Syndrome – Most common site of nerve entrapment in able-bodied and disabled persons. – Long-term wheelchair users have a prevalence of Carpal Tunnel Syndrome
(CTS) of 49-73% (Yang). – Wheelchair users with symptoms and physical examination findings of CTS
have lower functional status as compared with wheelchair users without CTS (Yang).
– Symptoms
• numbness and tingling in the radial 3 digits and the radial half of the 4th digit • weakness in thumb abduction • wrist pain, and nocturnal paresthesia
– Diagnosis • history, physical examination, and electrodiagnostic testing.
• Other Wrist Injuries
– ulnar nerve entrapment in Guyon’s canal (Groah) – osteoarthritis, tendintis, and DeQuervain’s tenosynovitis (Paralyzed Veterans
of America).
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Upper Extremity Fractures
• Incidence – Upper limb fractures in wheelchair athletes/users is not known.
• Wheelchair athletes may be at greater risk for upper limb fractures due to: – Repetitive falls associated with many wheelchair sports – Hand position during propulsion susceptible to injury from
nearby wheelchairs or collisions – Relatively high speeds achieved during certain wheelchair
sports.
• Fractures should be treated as in the able-bodied population.
• Restricted upper limb weight bearing in a wheelchair user may result in immobility.
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Heterotrophic Ossification
• Formation of bone in tissues that are not normally ossified. • Traditionally reported to occur following Traumatic Brain Injury (TBI), Spinal
Cord Injury (SCI), burns, and total arthroplasty. • Recently, Heterotopic Ossification (HO) has been reported to occur at high
rates in the residual limbs of traumatic amputees (Potter).
• Complications – May increase the risk of skin breakdown – Cause pain with weight bearing.
• Patient Populations – TBI, SCI, burns, and arthroplasty
• develops around major joints • Restricting range of motion and limiting mobility.
– Amputation • occurs in injured tissues in the residual limb • may not be in the vicinity of a joint.
• Treatment – Surgical excision of HO may be required if conservative measures fail
to restore adequate levels of function.
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Spasticity
• Spasticity – Velocity-dependent increase in muscle tone – Occurs after injury to the upper motor neuron – Common complication of SCI/TBI/CVA/CP – May limit athletic participation by interfering with voluntary movements and
restricting range of motion. – Increase in spasticity may be an indicator of a systemic or otherwise
asymptomatic condition. • For example, infections, intra-abdominal pathology (e.g. appendicitis), skin breakdown,
or bladder distension may have few symptoms that are sensed by a patient with SCI.
– Sudden increase in spasticity should lead to a search for underlying pathology
• Treatment – Oral medications (baclofen, dantrolene, tizanidine, benzodiazepines) – Injectable medications such as botulinum toxin; and intrathecal medications
such as baclofen. – Resistant to conservative treatment – Surgery for tendon lengthening
• May improve hygiene, activities of daily living, and functional activities including participation in athletics.
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Vascular
• Insensate athlete:
– Arterial Injury
– Compartment Syndrome
• Sensate athlete:
– Same as able bodied athlete but possibly with greater consequences.
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Cardiopulmonary
• DVT/PE
• Cardiovascular Effects of Injury
– SCI
– Amputee
• Pulmonary
• Exercise Induced Asthma
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Autonomic Dysreflexia
• Sympathetic outflow in response to a noxious stimulus that is unregulated due to interruption of neural pathways after spinal cord injury. – Spinal cord injuries at the level of T6 and above are at risk for AD.
• Symptoms – paroxysmal hypertension, bradycardia, facial flushing, and headache. If hypertension
continues to increase without treatment, stroke or death may occur (Pasquina).
• Common noxious stimuli that lead to AD – tight clothing, urinary or fecal retention, renal or bladder stones, pressure ulcers, infections, or
intra-abdominal pathology (e.g. appendicitis).
• Treatment – sitting the patient upright, loosening clothing, – identifying and eliminating the noxious stimulus – For acute blood pressure control, chewable nifedipine or nitropaste can be used.
• “Boosting” describes the practice of intentionally inducing AD in order to improve
athletic performance (Harris). – This dangerous practice should be discouraged and may be life-threatening.
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Orthostatic Hypotension
• Orthostatic Hypotension occurs in most SCI patients. – Symptoms include lightheadedness and dizziness, and syncope may occur if uncorrected.
• Pathophysiology – Orthostatic Hypotension occurs after SCI because of decreased sympathetic efferent activity in
vasculature below the level of the injury and also due to decreased reflex vasoconstriction. – The result is venous pooling in dependent areas (lower limbs or abdomen) that occurs with
changes in position (Krassioukov).
• Prevention – Lower limb compression stockings and abdominal binders – Maintenance of hydration – Salt supplementation.
• Treatment – Midodrine – Fludrocortisone – Ephedrine
• (Krassioukov).
• In SCI athletes, non-pharmacologic prevention should be attempted before the use of pharmacologic agents is considered.
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Dermatologic
• Insensate athlete: – Lacerations – Decubitus Ulcers – Rashes – Callous Formation
• Sensate athlete: – Same as able bodied athlete but possibly with greater
consequences.
• Amputees – Verrucous Hyperplasia – Lichinification – Epidermoid Cyst – Contact Dermatitis
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Skin Breakdown • Following Spinal Cord Injury, insensate skin leads to a risk of skin breakdown or
pressure ulcer. • Highest risk of skin breakdown regardless of the level of the injury
– Sacrum – Coccyx – Ischial tuberosities
• Specific athletic events may result in increased risk of skin breakdown in additional areas. – For example, wheelchair racers may have increased risk of skin breakdown if the medial
surface of the arm and forearm rubs against the wheelchair during propulsion. – May require customized equipment and padding to prevent skin breakdown in activity-specific
high risk skin areas.
• Athletic wheelchairs commonly sacrifice pressure relief for higher performance. – Increase vigilance in monitoring for skin breakdown, changing position frequently, and limiting
time in the wheelchair. – Particularly important when athlete transitioning to new equipment (e.g. a new wheelchair).
• Prevention is of paramount importance in this population. – At the first sign of skin breakdown or pressure ulcer, weight bearing and athletic activities
should be modified or restricted to prevent further injury.
• Pressure ulcers can be a significant cause of morbidity and mortality in the spinal cord injured population.
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Verrucous Hyperplasia
• Signs/Symptoms – “warty” condition of the
residual limb
• Etiology – proximal constriction
and vascular insufficiency
• Treatment – Modify socket
• ensure distal compression and total contact socket
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Lichinification
• Signs/Symptoms • thickened, leathery
appearance
• Hyperpigmentation
• burning, itching, or soreness
• Treatment • Realign
• Modify socket to decrease pressure
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Epidermoid Cyst
• Etiology
– Mechanical shear from the socket
• Treatment
– Modify Wear
– Modify Socket
– May need to drain
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Contact Dermatitis
• Sign/Symptoms – Erythema
– Pruritis
• Etiology – Irritation from
socket/liner
• Treatment – Modify socket/liner
– Modify wear
– Anti-per spirant
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Infectious
• Insensate athlete: – UTI
– Cellulitis
– Septic Arthritis
• Sensate athlete: – Same as able bodied athlete but possibly with greater
consequences
May be a nidus for development of Autonomic Dysreflexia
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Endocrine
• Adrenal
– Hypotestosterone
• Diabetes
• Insulin regulation
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Osteoporosis
• Osteoporosis is a nearly universal complication of SCI. • Decreased weight bearing predisposes to osteoporosis
– However many risk factors are independent of alterations in weight bearing. • These risk factors include severity of the injury, spascticity, and time since
injury (Jiang).
• Osteoporosis results in increased fracture risk of athletes with SCI. – Because of impaired sensation below the level of the injury, SCI
athletes may not immediately complain of pain after a fracture. – Other warning signs may include increases in spasticity or Autonomic
Dysreflexia.
• Prevention of osteoporosis – Calcium and Vitamin D supplementation for all athletes with SCI. – Bisphosphonates may also be used for prevention.
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Gastrointestinal Genitourinary
• Neurogenic Bowel
• Neurogenic Bladder
• Abdominal Trauma
• Pelvic Trauma
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Psychological
• Prior trauma
• PTSD
• TBI
• Sports Psychology
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Environmental
• Impaired Thermoregulation
• Heat Injuries
• Cold Injuries
• Altitude Illness
– AMS, HAPE, HACE
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Thermoregulation
• Spinal cord injuries • Disruption of neuro-regulatory systems that are involved in control of
body temperature. • Below the level of the lesion, spinal cord injured athletes have impaired
shivering to produce heat; and impaired sweating and vasodilation to dissipate heat. – Athletes with tetraplegia are increased risk as compared with paraplegia
(Price). – Paraplegic and tetraplegic athletes are expected to see greater increases in
body temperature with exertion, and greater decreases in temperature with exposure to cold weather.
• Prevention – Requires heightened awareness and monitoring, use of appropriate clothing
and equipment, availability of rehydration, and avoidance of extremes of temperature when possible.
• Complications – Frostbite is of particular concern during cold weather events.
• Athletes with spinal cord injuries have impaired sensation and require frequent visual monitoring to prevent cold injuries.
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Acute Mountain Sickness
• Constellation of symptoms – Headache, nausea, weakness, shortness of breath
• Inciting Event – Occurs with exposure to high altitudes
• Incidence – Increases with increasing altitude. – In many winter sports, competition at high altitudes increases the risk of
Acute Mountain Sickness.
• Etiology – Thought to be caused by alterations in the blood-brain barrier and cerebral
vasculature that occur at high altitudes (DiCianno). – Given their altered neurophysiology and anatomy, SCI athletes may be at
higher risk of Acute Mountain Sickness (DiCianno).
• Prophylaxis – Acetazolamide may be used as prophylaxis in high-risk scenarios.
• Treatment – Return to low altitude, acetazolamide, or dexamethasone.
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Acute mountain sickness (AMS)
• Frequent complication for athletes and travelers at high altitudes. • Symptoms may occur in individuals with less cerebrospinal fluid volume and less
ability to accommodate increased brain volume. • No studies on AMS exist in individuals with neurological impairments. • Methods:
– 64 subjects, including active and sedentary controls and those with tetraplegia, paraplegia, multiple sclerosis, and traumatic brain injury at the 2007 National Veterans Winter Sports Clinic in Snowmass, Colorado.
– Subjects completed three Lake Louise Score surveys to quantify symptoms.
• Results: – Higher than expected occurrence of AMS overall (51.6%) but no differences among groups,
and few participants sought treatment. • Fatigue and weakness were common symptoms. • High subject activity levels may explain these findings.
• Conclusion: – More research is warranted on larger sample sizes and on preventative medications and
treatments for AMS, especially since many military personnel with neurological impairments are returning to full active service.
» Dicianno BE et al. J Rehabil Res Dev. 2008;45(4):479-87.
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Research
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The Injury Experience of the Competitive Athlete with a Disability: Prevention Implications
Ferrara, MSSE 1992
Methods: • Retrospective injury
survey • 426 athletes
participating in the 1989 national championship of the NWAA, USABA, and USCPAA
• Athletes participated in track and field, weight lifting, and swimming
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The Injury Experience of the Competitive Athlete with a Disability: Prevention Implications
Ferrara, MSSE 1992
• Results:
• 137/426 (32%)
reported injury
– 37% USABA
– 37% USCPAA
– 26% NWAA
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The Injury Experience of the Competitive Athlete with a Disability: Prevention Implications
Ferrara, MSSE 1992
Results (cont): • Majority of injuries:
– USABA: 53% lower extremity
– USCPAA: 21% knee – NWAA: 57% shoulder
and arm/elbow
• Disabled athletes had about the same percentage of injuries as the their able-bodied counterparts in similar sport activities
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Snow Skiing Injuries in Physically Disabled Skiers
Laskowski, AJSM 1992
Methods • Data on disabled skier
injuries gathered from instructional programs at 4 ski resorts with large disabled-skiing programs
• Survey included total # of injuries, age, gender, type of disability, injury type, location, severity, mechanism, snow conditions, experience level.
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Snow Skiing Injuries in Physically Disabled Skiers
Laskowski, AJSM 1992
Results: • No significant difference
in overall injury rates between able-bodied and disabled skiers
• Injury rate for disabled skiers: 3.7:1000
• Injury rate for able-bodied skiers: 3.5:1000
• Types of injury were statistically different between disabled and able-bodied skiers: – Disabled skiers: more
abrasions/bruises – Able-bodied skiers: more
fractures/lacerations
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The Injury Experience and Training History of the Competitive Skier with a Disability
Ferrara, AJSM 1992
Methods:
• Survey of 68 elite disabled athletes who participated in the 1989 Winter National Games
• Data collected regarding demographics, sports training experience (# days and weeks spent per month training, also strength/weight, aerobic/anaerobic training), and injury experience
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Injuries Among Disabled Athletes During the 2002 Winter Paralympic Games
Webborn N, Willick SE, Reeser JC MSSE 2006
Methods: – Attempts were also made to distribute forms to delegation
medical personnel so that data on injuries that may not have been evaluated by venue or polyclinic physicians might also be captured in the database.
– Each day during the Games, lists of the entire list of medical encounters generated by the Salt Lake Organizing Committee (SLOC) Medical Services were scanned, looking for athletic injuries that might have been reported. If a questionnaire for the reported injury had not yet been completed, attempts were made to collect as much information as possible about the injury, either by contacting the athlete or a team official directly, or by gathering other information that had been entered into the SLOC Medical Services computerized data system
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Injuries Among Disabled Athletes During the 2002 Winter Paralympic Games
Webborn N, Willick SE, Reeser JC MSSE 2006
Results:
• 39 injuries involving 9% of the Paralympic athletes were captured
• Sprains (32%), fractures (21%), and strains and lacerations (14% each) represented the most common diagnostic categories
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• Methods
– Utilization of a questionnaire to identify the number of disabled athletes that had sustained an injury during the 2006 Winter Paralympic Games and identifying the types of injuries across the varying sports.
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• Demographics
– 474 athletes from 39 countries
– 375 (79%) were men and 99 (21%) were women
– 190 (40%) athletes competed in Alpine skiing
– 132 (28%) athletes competed in Nordic skiing
– 112 (24%) athletes participating in Sledge hockey
– 40(8%) athletes who competed in Curling
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• Results
– 40 injuries in 474 athletes were captured (8%).
– 32 injuries in 375 males (8.5%) and 8 injuries in 99 females (8%).
– Average age was 35 (19-48) among injured male athletes and 27 (19-36) among female athletes.
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• Injury Rate by Sport
– Alpine 23 / 190 = 12%
– Sledge Hockey 12 / 112 = 11%
– Nordic & Biathlon 5 / 132 = 4%
– Curling 0 / 40 = 0%
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• Sledge Hockey – No lower limb injuries in Sledge Hockey during the 2006
games as compared to 5 lower limb fractures in 2002 • Significant change and may relate to two factors.
– Multifactorial • 1) 2002 report identified a risk for lower limb fractures
– Suggestion to the sport for the improvement of the protective equipment to the lower limb.
– Response: players required to wear hockey skate boots and leg guards.
• 2) Recommendation of sledge design – The governing body of the sport brought new regulations to reduce the
chance of one sledge overriding another to cause injury
– stating that “the height of the main frame measured from the ice to the bottom of the frame shall be 8.5-9.5 cm”.
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• Chronic vs. Acute Injuries
– Trauma greater than Overuse
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• Results (Summary) – Similar injury rate between male (8.5%) and female (8%)
athletes.
– Overall incidence of injuries were higher in Alpine Skiing (12%) and Sledge Hockey (11%).
– The data suggests a slight reduction (10% to 8%) in the injury rate for all participants from 2002.
– Although there was slight increase in overuse injuries in the alpine skiing and sledge hockey participants, the majority of the injuries were of an acute traumatic nature (73%).
– The shoulder was the most common injured location (30%).
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Incidence of injuries among the participating disabled athletes during the 2006 Winter Paralympic Games.
Webborn N, Willick SE, De Luigi AJ, Reeser JC.
• There were no concussions recorded in either the 2002 Salt Lake City Paralympics or the 2006 Torino Paralympics.
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Summary
• Adaptive mechanisms enable non-impaired extremities and trunk to partially compensate for the deficit experienced as a result of an amputation or abnormal limb.
• Such adaptations may result in different injury patterns and may change over time.
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Summary
• Overall injury rates are the same for able-bodied and disabled athletes.
• Injury patterns are sport and disability specific.
• Injuries may have greater functional consequences in the disabled athlete.
• Understanding injury patterns and biomechanical issues will assist the clinician in diagnosing injuries in disabled athletes as well as designing training and rehabilitation programs.
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Summary
• Injury prevention program should include careful monitoring of volume, progression and type of training (e.g. hrs/week), and BMI.
• Need better training/protection for areas of high impact/stress in disabled athletes (e.g. UE with outriggers and thigh in hockey players).
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Summary
• Application of an injury surveillance system
can assist in understanding injuries,
implementing injury prevention interventions,
and monitoring outcomes of such programs.
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References
• 1) Harmer PA. Disability sports. In: Caine DJ, Caine CG, Lindner K (eds). Epidemiology of Sports Injuries, Chamaign, IL: Human Kinetics, 1996 161-175.
• 2) Laskowski, E. R., and P. A. Murtaugh. Snow skiing injuries in physically disabled skiers. Am. J. Sports Med. 20:553-557, 1992.
• 3) Ferrara, M. S., and W. E. Buckley. Athletes with disabilities injury registry. Adapted Physical Activity Quarterly 13:50-60, 1996.
• 4) Ferrara, M. S., W. E. Buckley, D. G. Messner, and J. Benedict. The injury experience and training history of the competitive skier with a disability. Am. J. Sports Med. 20:55-60, 1992.
• 5) Ferrara, M. S., and R. W. Davis. Injuries to elite wheelchair athletes. Paraplegia 28:335-341, 1990.
• 6) Ferrara, M. S., and C. L. Peterson. Injuries to athletes with disabilities: identifying injury patterns. Sports Med. 30:137-143, 2000.
• 7) Bernardi M, V Castellano, MS Ferrara, P Sbriccoli, F Sera, M Marchetti. Muscle pain in athletes with locomotor disability. Med Sci Sports Exerc. 2003 Feb;35(2):199-206.
• 8) Jones BH, D.N. Cowan, and J.J.Knapik. Exercise, training and injuries. Sports Med 1994 Sep ;18(3):202-14.
• 9) Hootman, J. M., C.A. Macera, B. E. Ainsworth, M. Martin, C. L. Addy, and S. N. Blair. Association among physical activity level, cardiorespiratory fitness, and risk of musculoskeletal injury. Am J Epidemiol. 2001 Aug 1;154(3):251-8.
• 10) Ferrara MS, WE Buckley, BC McCann, TJ Limbird, JW Powell, R Robl. The injury experience of the competitive athlete with a disability: prevention implications. Med Sci Sports Exerc. 1992 Feb;24(2):184-8.
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References
• 11) Nyland J, Snouse SL, Anderson M, Kelly T, Sterling JC. Soft tissue injuries to USA paralympians at the 1996 summer games. Arch Phys Med Rehabil. 2000 Mar;81(3):368-73.
• 12) Webborn N, Willick S, Reeser JC. Injuries among disabled athletes during the 2002 Winter Paralympic Games. Med Sci Sports Exerc. 2006 May;38(5):811-5. PMID: 16672831
• 13) Laskowski ER, PA Murtaugh Snow skiing injuries in physically disabled skiers. Am J Sports Med. 1992 Sep-Oct;20(5):553-7. PMID: 1443324 14) Ferrara MS, WE Buckley, DG Messner, J Benedict. The injury experience and training history of the competitive skier with a disability. Am J Sports Med. 1992 Jan-Feb;20(1):55-60.
• 15) Czerniecki JM, A Gitter, C Munro. Joint moment and muscle power output characteristics of below knee amputees during running: the influence of energy storing prosthetic feet. J Biomech 1991;24(3-4):271-2
• 16) Czerniecki JM, A.J. Gittert, J.C. Beckt. Energy Transfer Mechanisms as a Compensatory Strategy in Below Knee Amputee Runners. J Biomechanics, Vol. 29. No. 6, pp. 717-722, 1996
• 17) Harmer PA. Disability sports. In: Caine DJ, Caine CG, Lindner K (eds). Epidemiology of Sports Injuries, Chamaign, IL: Human Kinetics, 1996 161-175.
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References
• 18) Adaptations for Sports and Recreation (Chapter 24B, p623-644), Kegel B. in Atlas of Limb Prosthetics: Surgical, Prosthetics, and Rehabilitation Principles, Bowker JH, Michael JW, eds. Second Ed. Mosby Yearbook, St. Louis, 2002.
• 19) Kegel B, Webster JC, and Burgess EM. Recreational activities of lower extremity amputees: a survey. Arch Phys Med Rehabil 1980;258-264.
• 20) Michael, JW, Gailey RS, and Bowker JH. New developments in recreational prostheses and adaptive devices for the amputee. Clin Orthop and Related Research 1990;256:64-65.
• 21) Fergason JR et al. Custom Design in Lower Limb Prosthetics for Athletic Activity. PMR Clinics. 2000;11:681-699.
• www.leftsideinc.com • www.heathcalhoun.com • www.usoc.org • www.usparalympics.org • www.paralympics.org • Olympic Training Center, Colorado Springs, CO
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