1. Paralympic Spirit, Atlanta Paralympic Organising Committee, 1996.
Organised structure of international sport
Athletes disabilities may be divided into the following categories1:
1. Locomotor:
Cerebral Palsy (C.P.): Congenital or acquired brain injury or stroke. This group will include athletes with spastic or flaccid quadriplegia, hemiplegia or diplegia with or without choreiform or athetoid movements.
Amputee: Congenital or acquired limb deficiency.
Wheelchair: Congenital or acquired complete or incomplete spinal lesion, e.g., spina bifida. Some amputees and other groups compete as wheelchair athletes.
Les Autres: Poliomyelitis with paralysis
Muscular dystrophy
Rheumatoid arthritis
Multiple scleroses
Small stature (dwarf)
2. Sensory: Hearing impaired (deaf)
Vision impaired (Blind)
3. Intellectual Disability (I.D.) or Mental Handicap (M.H.), U.S.A.
6. Transplant: Organ transplant, e.g. renal, heart.
1. Goodman, S., Coaching Athletes with Disabilities: General Principles (2nd Edn.), Australian Sports Commission, 1995.
The organisations representing these bodies are listed. Many are associated with the International Paralympic Committee and others are autonomous.
Most organisations have links with International Sports Organisations (ISOs)
The following organisations are affiliated with the International Paralympic Committee (IPC):
• International Sports Organisations for the Disabled (ISOD) Les Autres, Amputees
• International Blind Sports Association (IBSA)
• International Stoke Mandeville Wheelchair Sports Federation (ISMWSF)
• Cerebral Palsy International Sports and Recreation Association (CP - ISRA)
• International Sports Federation for People with Mental Handicap (INAS - FMH)
• Disabled Skier Federation (DSF) Snow Skiing
• Riding for the Disabled International (RDI) Equestrian
• International Sailing Federation/International Foundation for Disabled Sailing (ISAF/IFDS)
The following organisations are autonomous:
• International Committee of Sports for the Deaf (CISS)
• Special Olympics International (SOI) Mental Handicap Intellectual disability
• World Transplant Games Federation (WTGF)
The athlete
General considerations in treatment of injury
Correct lifting with assistant, avoid tugging limbs to avoid subluxation of hip and shoulder Avoid pressure on insensate areas particularly hip and sacrum to prevent skin ulceration. Use cushioned bench or examine in wheelchair. Support athlete to prevent falling from chair or bench (quad, high para). Active joint motion before slow passive range to avoid increase in muscle tone, clonus or spasm. Position and secure ice packs and monitor. The athlete may not be able to hold in place due to poor dexterity. Communicate with the athlete taking time to comprehend slow or dyarthric speech. Be aware of drug interactions. The athlete may be taking multiple prescribed medications Do not assume that physical disability or communication difficulty is associated with intellectual disability.
Cerebral palsy
Definition: ‘Cerebral Palsy is a disorder of movement and posture due to damage to an area or areas of the brain that control and co-ordinate movement’. This disorder may occur in utero, intra partum or post partum (Little 1862).
Causes: (Incidence, aetiology). 2.5/1000 live births,1 cerebral hypoxia, haemorrhage, obstetric trauma, meningitis, abruptio placenta.
Diplegia 32%, Hemiplegia 29%, Quadriplegia 24%, Dyskinesia/ataxia 14% (Subtypes CP at age 7).2
Physiology: Increased muscle tone leads to risk of muscle strains. There is a higher incidence of epilepsy 30%3 and intellectual disability 50%, more likely in quadriplegia.
Primitive reflexes, i.e., Asymetric tonic neck reflexes, (ATNR) may be present.
Osteoarthritis in the neck is common with aging.
1 Blair, E., Stanley, F. J. (1982), ‘An epidemiological study of cerebral palsy in Western Australia, 1956-1975. III: postnatal aetiology’ Developmental Medicine and Child Neurology, 24, 578-585.
2 Nelson, K. B., Ellenberg, J. H., (1978) ‘Epidemiology of cerebral palsy’ In Schoenberg, B. S. (Ed.) Advances in Neurology, Vol. 19, New York: Raven Press, pp. 421-435.
3 Gage, J., Gait Analysis in Cerebral Palsy, Coaching Athletes with Disabilities, Clinics in Developmental Medicine, No. 121, MacKeith Press, 1991.
Management of injury and associated conditions:
Spasticity: Muscle strains treated with R.I.C.E. Prevention by regular stretching.
Slow prolonged 5 - 10 minutes Q.I.D. until desired range, then 1 minute BD. Maintenance stretching is more effective combined with muscle relaxation, heat, cold or massage.
Muscle relaxation medications: Dantrolene sodium 25 - 50 mg BD - QID (adult dose) monitor L.F.T.s regularly (6 weekly). Baclofen 10 - 25 mg T.D.S. (adult dose) - rarely used in cerebral spasticity Diazepam used rarely due to effect on alertness, balance and co-ordination.
Selective muscle paralysis: Botulinum toxin 3 - 6 monthly to decrease spasticity and strength, may improve function and ambulation.
Motor nerve or motor point blocks with phenol or alcohol.
Epileptic Seizures: Consider low anticonvulsant blood level, timing of medication, travel, dehydration, hyperthermia, intercurrent febrile illness. Beware recent fall, if on anticoagulant exclude extra or subdural haematoma (C.T. scan). Most fits resolve within 1 minute, place in coma position, check airway.
If status epilepticus:
Diazepam 5 to 10mg - 10mg IVI (adult dose). 1 to 5mg I.V.I. (child dose >age 5)
Clonazepam 0 - 5 mg IVI (child dose)
1.0 mg IVI (adult dose)
These medications may be given rectally if unable to administer I.V.I.
Neck: New weakness in arms/legs in older athlete with or without bladder, bowel dysfunction. X-ray neck +/- MRI to exclude cervical myelopathy due to spinal cord compression.
Common surgery in C.P.: Adductor tenotomy for scissoring gait due to adductor spasticity not responding to medication, or obturator block . Achilles lengthening for Equino varus foot, with toe walking . These procedures may be used in the future less with the introduction of selective muscle paralysis with botulinum toxin.
Assistive Devices: Ankle foot orthosis in polypropylene, resin or steel (caliper) to control ankle/foot often used with boot with medial/lateral flare for stable base of support. A lateral or medial T strap may be attached to the shoe or caliper.
Amputee
Definition: Acquired limb deficiency is described in relation to the residual limb;
Partial foot - Transmetatarsal, mid foot (Lisfranc), hind foot (Chopart), through ankle (Symes).
Common amputation sites;
Below knee - BK, Through knee TK, Above Knee AK
Partial hand, through wrist, below elbow BE
Above Elbow AE, shoulder disarticulation
Congenital limb deficiency frequently involves partial deficiency or dysplasia of elements of the limb. An international classification system has been established. (ISO.ISPO).
Causes (aetiology): congential (thalidomide), cancer (osteogenic sarcoma), peripheral vascular disease, diabetes, osteomyelitis, leprosy, traumatic (land mines, occupational, motor vehicle).
Physiology: Traumatic amputees may have phantom sensation, pain and psychological adaptation to body image. Pain may be related to poor fitting prosthesis with or without neuroma. Due to decreased surface area thermoregulation may be slower and should be considered in extreme heat and cold.
The energy cost of ambulation is greater than able bodied by 25% for BK and up to 100% for AK.1
Calculated by 02 consumption per metre walked.
1. Bowker, J. H., Michael, J. W. , Atlas of Limb Prosthetics, American Academy of Orthopaedic Surgeons, 2nd Ed., Mosby, 1992.
Management of injury and associated conditions
Lower limb stump abrasion -
Clean, antiseptic non stick dressing, e.g. silicone gel pad. If the patella tendon is ulcerated then check alignment. Walking and running alignment are different and should be adjusted prior to competition.
Recurrent or chronic stump breakdown: consider silicon stumpsock, roll on silicon socket (ICEROSS) or Polyurethylene Liner (TEC).
Above knee amputee, discuss with prosthetist rotator or vertical shock absorber type pylon.
Stump hyperkeratosis - Continual pressure and abrasion makes diagnosis difficult as lesions may not have a typical appearance. Consider the following possibilities:
(a) Tinea; fungal Scraping, clotrimazole 1% cream topical t.d.s. for three weeks
(b) Contact dematitis; If new prosthetic liner, exclude contact dermatitis from glue.
(c) Psoriasis; check other sites e.g., scalp, elbows.
(d) Verrucous hyperplasia; - warty appearance due to poor hygiene, sweating, and poor distal prosthetic contact. Any keratolytic cream e.g. Sulphur 2%, Salicylic Acid 2%, aqueous cream to 100%.
All athletes should wash prosthetic liner with soap and water and change socks daily. If all else fails then correct the problems by modifying the prosthetic socket or recasting for a new socket
Lower back pain (lower limb amputee).
Adjust height of prosthesis up or down ½ cm prior to commencing investigation unless signs of nerve root compression.
Prosthesis too tight to fit due to stump oedema.
For below knee amputee, bandage stump with 10cm elastic bandage for 30 minutes then retry. For above knee amputee, bandage stump 30 minutes then retry. Try ‘wet fit’ with aqueous cream to stump prior to donning the suction socket prosthesis.
Pain phantom or stump, exclude referred pain, infection or ischaemia. If true phantom pain - Self massage stump 10 minutes bd or q.i.d., Cetromacrogole or aqueous cream.
Physical therapy, transcutanaeous electrical stimulation (TENS) applied to popliteal fossa, sciatic nerve 15 - 30 minutes nocte.
Medication: Anticonvulsants - Carbamazepine 100 mg. Nocte.
OR Sodium Valproate 100 - 200 mg. nocte, OR Tricyclic antidepressants - Amitriptyline 25 mg. Nocte. Neuroma: Check prosthetic fit. Inject with Bupivicaine 0.25% 1 - 2 ml. Often effectivealone OR Bupivicaine 0.25% 1 - 2 mls. Mixed with Methyl prednisolone acetate ½ ml (40 mg/ml).
Assistive devices: Prostheses consist of the following components:Suspension, socket, shank, articulation, terminal device (foot or hand).
Figure 1: Examples of prostheses
Spinal
Definition: Congenital or acquired complete or incomplete damage to the spinal cord or nerve roots within the spinal cord. Athletes competing include those with cervical cord injury (quadriplegia) thoracic, lumbar cord, and cauda equina lesions (paraplegia).
Causes: Traumatic spinal cord injury frequently occurs as a result of motor vehicle and motor cycle trauma, diving, Rugby football and horse riding accident. Spina bifida occurs in 0.7/1000 births [need ref] Polygenetic factors and folic acid deficiency in pregnancy. May have associated myelomeningocele with cerebral interventricular shunt inserted.
Physiology: Altered response to exercise occur in the spinal athlete due to a number of factors -
Skeletal muscle paralysis
The active muscle mass is limited to the arms and trunk in paraplegics. The inability to utilise lower limb muscle mass will limit the maximal oxygen uptake (VO2max)7. Increases in aerobic fitness may be achieved8 particularly in low spinal with normal cardio respiratory function and approach that of a sedentary able bodied person9.
In the quadriplegic the oxygen demands of the upper limb muscles during exercise are unlikely to exceed cardiac reserve.
Peripheral rather than cardiac factors may be more important. Adaptive changes in upper limb muscles may occur with the development of a higher percentage of slow twitch fibres in long term wheelchair users compared to the normal population9.
- Sympathetic autonomic dysfunction
Complete transection of the spinal cord above T1 isolates the sympathetic from the central nervous system. This results in a loss of sympathetic regulation of heart rate and release of catecholamines from the adrenal medulla. There is a loss of innervation to the arterial and venous smooth muscle and sweating and thermoregulation is profoundly affected11.
Spinal cord injury impairs respiratory function by paralysis of accessory, intercostal, diaphragm or abdominal muscles depending on the level of lesion.
The quadriplegic is particularly at risk of pneumonia and atelactasis. Decreased tidal volume with diaphragmatic breathing may be affected by intra abdominal presssure and posture. The reduction of Forced Vital Capacity [FVC] has been implicated as a risk factor for respiratory complications. Exercise training my improve FVC in persons with quadriplegia.12
Venous return is impaired due to loss of muscle pump and sympathetic vasoconstriction.
Biomechanical limitations to exercise occur due to spasticity and contracture. Self implemented daily stretching is recommended. Ballistic stretches or passive stretches by an assistant risk muscle damage. Static sustained stretches are preferred, e.g. three repetitions of 60 seconds 2 - 3 times daily.13
Bowel management is usually daily or second daily with continence achieved between evacuation. Daily management with adequate fibre and intermittent use of peristaltic agents (e.g. Senna) to achieve rectal filling and rectal stimulation manually or by enema to achieve evacuation. The defaecation reflex is preserved when Sacral segments (S2-4) are intact. Cauda equina lesions result in a patulous anus and regular manual evacuation may be required.
Three types of bladder function occur in spinal injury
1.Disinhibited bladder. In this type of bladder voluntary control is partially retained. Filling of the bladder to a certain point results in reflex emptying and incontinence. The bladder usually fully empties and there is a minimal risk of urinary tract infection. It is managed by regular toiletting.
2. Spinal reflex bladder (Suprasacral) The person has no awareness of bladder filling. The bladder fills to a certain limit and then reflexly empties. This is initiated through the S2, S3, S4 sacral reflex arc and emptying may be initiated by tapping the abdomen. A person with this type of bladder may develop a ‘balanced bladder’ with regular toiletting and use of a collecting device, e.g. Uredome and leg bag. The reflex bladder may also be managed by intermittent self catheterisation depending on hand function. Anticholinergics, e.g. oxybutinin are frequently used to block the reflex detrusor contraction if catheterisation is the chosen management.
3. Autonomous bladder. This occurs in cauda equina lesions, e.g. spina bifida where and there is insufficient bladder contraction to result in emptying. This type of bladder is usually managed with an indwelling catheter, suprapubic catheter or intermittent self catheterisation.14,15
Factors that influence the formation of pressure sores in areas insensate to pain temperature and touch include;
1. Sustained local pressure
2. Friction
3. Shearing forces
4. Skin maceration
5. Infection, burns and poor nutrition.
Sacral and ischial pressure points are most common or any other bony prominence eg heel, toes, trochanter.
Regular lifting off buttocks (self implemented) by the wheelchair athletes at the rate of 3 times per hour and the use of a pressure relieving cushion eg air floatation or gel may prevent the problem. Regular inspection of the pressure points by the athlete should be encouraged. Medical examinations should be conducted in the wheelchair or on a cushioned couch.
Loss of sweating and vasodilation vasocontriction in the high lesion spinal athlete affects the ability to regulate core temperature. Adequate fluid intake immediately prior to and after competition16 is essential. Access to ice fans in hot conditions, and blankets and heaters in cold conditions are essential. Increase spasticity may be a symptom associated with low body temperature. Management of Associated Conditions:
- Management of autonomic hyperreflexia (dysreflexia).
This condition occurs in athletes with spinal cord injury above the splanchnic sympathetic outflow (levels higher than T6).
Distension of bladder or bowel, initiates excessive reflex activity of the sympathetic nervous system below the level of injury. This causes high blood pressure which cannot be controlled by centres in the brain. If the blood pressure becomes very high, it can cause a cerebral haemorrhage and fitting.
These spinal athletes have an altered cardiovascular response to exercise and in an attempt to increase their performance by up to 10% an illegal technique called ‘boosting’ has developed.1 This technique is initiated by placing nociceptive stimuli in the wheelchair, e.g. sharp objects, or tight leg straps. Another method is to increase the bladder volume prior to a race. The intention is to bring on a degree of autonomic hyperreflexia, which is a potentially fatal condition.
1. Burnham, R., et al., Intentional Induction of autonomic dysreflexia among quadriplegic athletes for performance enhancement: efficacy, safety, and mechanism of action, Clinical Journal of Sport Medicine, 4 : 1-10. 1994.
Symptoms
1 Pounding headache which increases in intensity as blood pressure rises.
2 Bradycardia (slow pulse rate).
3 Flushing/blotching of the skin above the level of spinal cord injury.
4 Profuse sweating particularly above the level of spinal cord injury.
5 Goose bumps
6 Chills without fever
7 Nasal stuffiness
8 Hypertension. The normal B.P. for this group of people is commonly 90/60 - 100/60
lying and lower when sitting. A B.P. 130/90 is therefore high for them. If untreated
it can rapidly rise to extreme levels e.g. 220/140.
9 Blurred vision.
10 Nausea.
Common Causes
a) Bladder irritation, e.g. distended bladder, urological procedure, urine infection
b) Bowel irritation, e.g. distended rectum, chemically irritant suppositories.
c) Skin irritation, e.g. pressure sores, infected toe, ingrowing toenail, burns.
d) Other, e.g. distended or contracting uterus, fractured bones, ingrown toenail.
Treatment
(Two people are required to control the situation unless the condition is easily reversed).
1 Place person in a sitting position with head elevated (BP is lowered by gravity) and ask if cause is known or able to be predicted.
2A For person with an indwelling catheter:
1)Empty leg bag and estimate volume. To determine whether or not the bladder is empty. Ask if volume is reasonable considering fluid intake and output earlier that day.
2)Check that catheter or tubing is not kinked or flow is not impaired by clogged inlet to leg bag or perished valve in leg bag.
3) If catheter is blocked irrigate GENTLY with no more than 30mls Sterile Water. If this is unsuccessful, recatheterise, using a generous amount of lubricant containing a local anaesthetic, e.g. lignocaiane jelly.
4)If the blood pressure declines after the bladder is emptied, the person still requires close observation as the bladder can go into severe contractions causing hypertension to recur 2B For a person with a balanced bladder (bladder trained):
1) If the bladder is distended and the person is unable to void on gentle abdominal expression or tapping, lubricate the urethra with a generous amount of local anaesthetic jelly,
e.g., lignocaine jelly, wait one to two minutes and then empty the bladder, by passing a catheter.
2C For faecal mass in rectum
1) Gently insert a generous amount of lignocaine jelly into the rectum and gently remove faecal mass - note: symptoms may be aggravated initially.
3 If the markedly elevated blood pressure does not start to subside within 1 minute of above treatment, or the cause is unable to be determined, give nifedipine (Adalat/Anpine) 10 mg capsule; the patient should bite the capsule and swallow the liquid like
water. The hypotensive response begins within 5 minutes after administration, reaches a peak at 30 minutes and persists for several hours.
Glycerol trinitrate (Anginine) can be given instead of nifedipine. It is placed under the tongue or used as an aerosol.
If nifedipine or glyceryl trinitrate do not lower the blood pressure, IV diazoxide (Hyperstat) 300 mg/20 ml ampoules can be used. The initial dose is 75 - 150 mg (5 - 10 ml) IV over 30 seconds. Further doses can be given at intervals of 5 – 15 minutes or a continuous infusion commenced at 15 mg/min [adapted from Austin Hospital emergency treatment card personal communication D Brown].
- Peripheral Nerve Entrapment
Upper extremity nerve entrapment in wheelchair athletes is very common with prevalence up to 23%.1
The commonest injuries are to the median and ulnar nerve at the wrist. The ulnar nerve may be damaged near the elbow and may occur concurrently with median neuropraxia.2
Wheeling a chair creates pressure over the carpal tunnel during the propulsive phase. The use of a glove is not totally protective of the carpal tunnel although designed with padding to reduce trauma to the wrist and palm. Repetitive trauma to the volar aspect of the wrist in extreme forced extension is an important factor.3
The ulnar nerve may be damaged at the distal aspect of the cubital tunnel possibly due to heavy repititive contraction of the flexor carpi ulnaris and/or pressure from the armrest or the outer rim of the wheel.4
At the wrist the ulnar nerve and artery enter an osseofibrous canal, ‘Guyon’s canal’. The nerve travels through a groove between the pisiform and the back of the hamate5,6 where it is susceptible to damage from repetitive trauma, ischaemia, ganglia, or fracture of the hamate.
Treatment: Conservative treatment aimed at nerve protection and avoidence of surgery which is unlikely to solve the causative biomechanical factors.
Padding to gloves and push rims should be checked.
Techniques to avoid extreme wrist extension and ulnar deviation while pushing and transferring.
Substitute alternative training, e.g. arm ergometer or swimming. Until symptoms subside.
Assess transfers and crutch use where weight bearing and forced wrist extension occurs with unprotected hands. Prevent arms hitting the outer rims.7
Consider night resting splints.
Shoulder pain occurs in more than half the number of people with spinal injury using wheelchairs.7 The shoulder becomes a weight bearing joint for transfers or if using crutches.8
This results in a high incidence of rotator cuff impingement and subacromial bursitis. Wheelchair propulsion creating overuse injury is also a factor.
Treatment: Rest may be difficult to achieve as the problem is often bilateral. Assessment of transfer techniques by a physical, or occupational therapist may assist.
Assistive Devices: [Figure 2]
Sports wheelchair.
- Burnham, R. S., & Steadward, R. D., Upper extremity peripheral nerve entrapments among wheelchair athletes: prevalence, location, and risk factors, Arch. Phys. Med. Rehabil. Vol. 75, May 1994.
- Aljure, J., et al., Carpal Tunnel Syndrome in paraplegic patients, International Medical Society of Paraplegia,23, 182-186, 1985.
- Dozono, K., Hachisuka, K., Hatada, K., amd Ogata, H., Peripheral neuropathies in the upper extremities of paraplegic wheelchair marathon racers, International Medical Society of Paraplegia, 33, 208-211, 1995.
- Burnham, R., et al., Acute Median Nerve Dysfunction from Wheelchair Propulsion: the development of a model and study of the effect of hand protection, Arch.Phys.Med.Rehabil., Vol. 75, May 1994.
- Weinstein, S. M., and Herring, S. A., Nerve problems and compartment syndromes in the hand, wrist, and forearm, Clinics in Sports Medicine, Vol. 11, No. 1, January 1992.
- Bloomquist, L. E., Injuries to athletes with physical disabilities: prevention implications, The Physician and Sports Medicine, Vol. 14, No. 9, September 1986.
- Nichols, P. J. R., Norman, P. A. and Ennis, J. R., Wheelchair User’s Shoulder, Scand. J. Rehab. Med., 11 : 29-32, 1979.
- Bayley, J. C., et al., The Weight-bearing Shoulder, The Journal of Bone and Joint Surgery, Inc., Vol. 69-A, No. 5, June 1987.
Down’s syndrome
Definition: People with Down’s Syndrome are characterised by an intellectual disability and short stature. Their facies has been described as Oriental due to the epicanthal fold of the eye partly covering the medial angle of the palpebral fissure and poor development of the bridge of the nose. They have an enlarged tongue and their hands are broad with a single palmar crease, hypoplastic middle finger and short little finger.1 They have a high incidence of cardiac abnormalities (septal defects) and atlanto axial (C1-2) instability which may has implications for sport and the risk of high cervical spinal cord injury. Most compete within the intellectual disability classification and Special Olympics
Causes: Trisomy of chromosome 21 occurring more frequently to children of mothers with increasing age of parity 1.3/1000 (age 30-34), 1.9/1000 (age 35-39).2
Management of injury and associated conditions:
Intellectual disability will affect the athletes ability to follow complicated treatment regimes, e.g. application of ice packs. Communication should be brief, simple, and clear. Safety issues and prevention are most important, particularly hydration and application of sun screens where prompting may be necessary. The doctor should be patient, tolerant, and tactful. Atlanto axial (C1-C2) instability3 occurs in 10-20% of people with Down’s Syndrome. Since 1983 athletes with Downs’ Syndrome have required a medical examination including flexion and extension Xrays of the head and neck to diagnose the condition. Athletes with atlanto axial instability or those who have not received a medical clearance are prohibited from participation in gymnastics, diving, swimming butterfly stroke, high jump, and pentathlon.4
Isselbacher K et al. Harrison Textbook of Medicine, 13th edition. Mc Graw Hill, New York. - Schimmel, M. S., et al., Increased parity and risk of trisomy 21:review of 37,110live births, B.M.J., Vol. 314,pp.720-721, March 1997.
Taylor, T. K. F., and Walter, W. L., Screening of children with Down syndrome for atlantoaxial (C1-2) instability: another contentious health question, M.J.A., Vol. 165, October 1996.27. - Bloomquist, L. E., Injuries to Athletes with Physical Disabilities: Prevention Implications, The Physician and Sports Medicine, Vol. 14, No. 9, September, 1986.
Polio
Definition: Paralytic polio myelitis is due to a loss of anterior horn cells. Muscle paralysis may result in segmental, paraplegic quadriplegic or bulbar loss.
Causes: RNA entero virus with 3 strains spread through faeco oral route. 0.1% of all infections progress to paralysis. Infections are rare in developed countries since the introduction of Salk and Sabin vacines from 1955 to 1960.
Physiology: After the initial paralysis a recovery phase occurs with neurological recovery. During this phase ‘orphaned’ muscle fibres may be reinnervated by terminal axon sprouting from unaffected motor neurones. This results in giant motor units forming with one motor nerve innervating up to five times the original number of muscle fibres.1 Loss of muscle in the extremities results in blood pooling, intolerance to cold and gait abnormalities. Many athletes require assistive devices such as wheelchair, caliper and crutches.
Management of injury:
Muscle weakness, muscle pain, fatigue and joint pain are common symptoms as late effects of polio.2 Strengthening exercises in weakened muscles may result in a decrease in strength. Aerobic fitness programmes and biomechanical efficiency and energy conservation is preferred. Compression neuropathics from crutches and wheelchairs are similar to spinal athletes. Pressure sores are less common than spinal athletes due to normal protective sensation.
- Lauro S, Halstead, MD, The residual of polio in the aged. Top Geriatr Rehabil. 1988. 3(4), 9-26, 1988 Aspen Publishers, Inc.
- Agre JC, Rodriquez AA, Tafel JA. Late effects of polio: critical review of the literature on neuromuscular function. Arch Physiotherapy Med Rehabil 1991; 72:923-31.
Management of events
1. Access:
Consider all attendees, athletes, judges and classifiers and spectators may have disabilities. Access should be available to Spectator areas, prize presentation areas, toilets and accommodation and the sporting arena. Wheelchair, ramps of 1:12 to 1:14 gradient are recommended. Extended ramps 50-100 metres requires ‘pusher’ volunteers on standby. Transport by motor vehicle may need ramped access or wheelchair lifts fitted to the vehicles. Amputees, particularly above the knee, develop knee instability on ramps and steps may be better if a handrail is fitted.
2. Staff:
Small events require a first aid officer with a good referral network. Athletes with severe disabilities often travel with well informed carers and parents who render first line treatment. For larger events, e.g. State, National, or International, where records may be set , then an organised sports medicine team is required. This should comprise:
- Medical Co-ordinator who may also be the Chief Medical Officer for medical emergencies and review of medical certificates;
- Nurse for triage and assistance to Medical Officer in an emergency
- Physiotherapists for treatment of musculo-skeletal injuries
- Massage therapists for precompetition massage of Cerebral palsy and spinal injury athletes with spasticity.
- Sports trainers/First Aiders for ‘on field’ and finish line response to injury. The ratio differs from able-bodied events due to the greater need for precompetition massage:
Doctor - 1: Nurse-1: Physio - 3: Masseurs - 4: Sports trainers/First Aiders - 5: Prosthetist/Orthotist - optional.
The greatest number of injuries are likely to occur at athletics with fewer in other sports.
3. Drug/Dope testing:
The same conditions apply as for able bodied sport. Prescribed medications taken at the prescribed dose may be acceptable on presentation of a medical certificate to the Chief Medical Officer. Evidence of prescribed medications is generally presented at least two days prior to competition, not on the day of competition. Prescribed medication should be for an existing medical condition and not prescribed for competition or increased in dose to enhance performance.
4. Additions to Standard Doctors Bag/kit:
Medication: Nifedipine capsules 5 - 10 mg. For sublingual use in dysreflexia, or
Glyceryl trinitrate aerosol
Diazepam 5 mg. For injection
Clonazepam 0.2 mg. For injection
50% Dextrose for injection
Lignocaine jelly lubricant for catheterisation
Equipment: Tube gauze for prosthetic ‘pull through’
Lubricant cream for ‘wet fit’ prostheses (aqueous cream)
Stretch stump bandage 10cm x 2 metres
Silicon gel pads
Sterile dressing tray, sterile glove, disposable gloves
Neoprene catheters x 4
Screwdriver, pliers, and Allen (hex) key, to assist prosthetist/orthotist with prosthesis and wheelchair repair.
The sports
General
Most sports can be adapted for athletes with disabilities. The rules of the International Sporting organisations usually apply. The following sports consist of those sports included in International Paralympic competition or demonstration sports.
Archery
Athletes shoot from a distance of 70 m at 122cm diameter targets. Competition scores range from 1,000 to 2,500 points. Amputees, cerebral palsy, and wheelchair athletes compete in these events.
Athletics All disability groups may compete in these events. Track (10 events): 100m, 200m, 400m, 800m, 1500m, 3000m, 5000m, 10000m, 4 x 100 relay, 4 x 400m relay and Marathon.
These events may be may be competed in as a running event, or as a wheelchair event depending on the disability. Field (9 events): Shotput, discus, javelin, club throw (cerebral palsy), long, high, triple jump, pentathlon.
Basketball
This is a wheelchair event played in accordance with the regulations of the International Basketball Federation. There are a number of rules of play. The athletes must dribble the ball after two pushes. Touching the ground with the feet or rising from the chair results in a foul.
Boccia (pronounced ‘botcha’)
The athletes throw 6 leather balls as close as possible to the target ball (jack). It is played individually or in teams. Cerebral palsy classes C1, C2, and C1 with assistive devices compete.
Cycling
These events are divided into 3 groups. Cerebral palsy in bicycle and tricycle events. Athletes with visual impairment compete in tandem with a sighted cyclist. Amputees compete with or without a prosthesis.
Equestrian
Riders of all disability groups compete in dressage competitions before 3 judges.
Fencing
All disability groups compete in wheelchairs fixed to the floor using epee, sabre and foil. The competitor may duck, lean forward, back or half turn to avoid touches without rising from the chair.
Football (Soccer)
This is open to male athletes with cerebral palsy. The game is divided into two 25 minute halves with up to 7 players on the field from each team of 11 players. Two substitutions per game are permitted.
Goalball
Athletes with visual impairments compete in opposing teams of 3 players. The ball contains bells and a goal is scored by throwing or rolling into the opposing team goal which is the width of the court.
Judo
Played by athletes with visual impairment. Touch, balance, strength, and agility are highly developed skills in these athletes.
Lawn Bowls
Disability groups who may compete are amputee, cerebral palsy, visually impaired and wheelchair. It is played on a lawn bowling court with a target ball (jack). Large wooden balls are rolled towards the jack, and balls lying closest to the jack score more points.
Power Lifting
This is a bench press starting with arms extended bringing the bar to the chest. The athlete then presses the bar back to its original position. Male paraplegics, amputees, cerebral palsy, and polio athletes compete. Classification is determined by body weight.
Quad Rugby
This is open to male and female wheelchair athletes. It is played on a basketball court by two opposing teams of 4 players. The team passes a volleyball while advancing into the opponent’s half court with the intention of crossing the goal line in possession of the ball to score. The ball must be dribbled or passed within 10 seconds.
Sailing
All disability groups may compete in the three man keel boat division. The selection of a team is based on a total points system based on functions required to compete in sailing. Theseinclude stability, hand function, moveability, visibility, and hearing.
A single handed division is developing based on the International 2.4 metre class. The sailor sits facing the bow and controls sails and steering by sheets and joystick.
Shooting (air and .22 calibre)
Men and women mixed teams compete in SH1 class if no support of the upper limbs is required or SH2 class if arms are unable to support the weight of a rifle, requiring a support stand.
Pistol shooting is a standing event and rifle shooting is in prone, kneeling and standing. Amputees and wheelchair athletes compete.
Swimming
Athletes with locomotor disabilities compete with the 10 functional classes for freestyle, backstroke, breaststroke and medley. Blind and visually impaired compete in separate competition.
Table Tennis
All disability groups compete standing or in a wheelchair. The rules are those of the International Table Tennis Federation with only minor modifications, e.g. player may grip the side of the table.
Tennis
Wheelchair athletes compete on a conventional tennis court. The ball may bounce twice before being returned. There are mens and womens singles and doubles.
Volleyball
Standing volleyball is played with standard configuration. Seated volleyball is played with a smaller court and lower net.
Classification
Classification is a process of grading athletes according to their ability to perform the functional tasks of the sport. The older system of classifying athletes by their medical diagnosis or impairment is being replaced by a functional integrated classification.
Functional classification has enabled many different disability groups to compete in the same events classified as equal to other competitors in terms of their ability to perform the tasks required for the sport.
Athletes are classified prior to an event and generally retain their classification over many years. Improvements in technique and performance related to training should not change the classification. However the athlete or the classifier may initiate a new classification if a change of function has occurred through medical or surgical intervention or based on observed performance at events which may be above or below that expected for the class.
Medical and technical classifiers require considerable training and accreditation. The systems of classification consist of three components.
- Medical: assessment by doctor or physiotherapist
- Technical: assessment often by a coach familiar with the tasks and movement potential related to the sports
- Review: Classifiers watch training and competition..
There are three basic types of classification: General
Functional, and
Team
1. General
This is the older system based on impairment, diagnosis, and disability. These classifications have little relationship to the sport. Examples are:
(a) Visually impaired
Class B1 - No light perception at all in either eye up to light perception but inability to recognise the shape of a hand at any distance or direction.
Class B2 - From ability to recognise the shape of a hand up to a visual acuity of 2/60 and/or a visual field of less than 5 degrees.
Class B3 - Front visual acuity from 2/60 up to a visual acuity of 6/60 and/or visual field of more than 5 degrees and less than 20 degrees.
Visually impaired classification groups in swimming use the standard letter ‘B’ for all strokes, while the number represents the extent of the disability.
(b) Cerebral Palsy
Class 1 - Severe involvement in all four limbs . Limited trunk control, unable to grasp a softball. Very poor functional strength in upper extremities, necessitating the use of an electric wheelchair.
Class 2 - Severe to moderate involvement in all four limbs. Able to slowly propel wheelchair with either feet or arms. Poor functional strength and severe control problems exist.
Class 3 - Moderate involvement in three or four limbs. Fair functional strength and moderate control problems in upper extremities and torso. Uses a wheelchair..
Class 4 - Lower limbs have moderate to severe involvement. Good functional strength and minimal control problems in the upper extremities and torso. Uses a wheelchair.
Class 5 - Good functional strength and minimal to moderate control problems in upper extremities. May walk with or without aids for ambulatory support.
Class 6 - Moderate to severe involvement in all limbs. Ambulates poorly. Severe co-ordination and balance problems which tend to be less noticeable when running, swimming and throwing.
Class 7 - Moderate to minimal involvement in both limbs on the same side of the body. Good functional ability in the non-affected side. Walks and runs with a limp.
Class 8 - Minimally affected athlete. May have minimal co-ordination and functional problems affecting only one limb. Able to run and jump freely. Has good balance.
(c) Amputee:
AK Above or through knee joint
BK Below knee, but through or above talo-crural joint.
AE Above or through elbow joint
BE Below elbow, but through or above wrist joint.
Class A1 - Double AK
Class A2 - Single AK
Class A3 - Double BK
Class A4 - Single BK
Class A5 - Double AE
Class A6 - Single AE
Class A7 - Double BE
Class A8 - Single BE
Class A9 - Combined lower plus upper limb amputation.
The classification for winter sports is combined for locomotor disabilities. The prefix in winter sports classification is therefore LW (Locomotor Winter).
(d) Wheelchair1:
Quadriplegics are classified as T1 or T2 for track and F1, F2 or F3 for field events. The 1 indicates the highest level of disability. Paraplegics are classified as T3 or T4 and F4, F5, F6, F7 or F8. In this system a double leg amputee would be classified as T4 for track events.
1 N.S.W. Wheelchair Sports Association. Personal communication J McCullough
2. Functional
These classifications are based on the sport and assessment of the athletes abilities related to the sport.
Athletes are classified according to:
A. A clinical assessment or ‘benchtest’ by a medical classifier (Doctor/physiotherapist) examining the following features as appropriate to the athlete:
1. Muscle strength
2. Dysfunction/co-ordination
3. Range of motion of joints
4. Limb length in amputees
5. Trunk length in dwarfs.
B. Sports related test in the pool or on the track by a technical classifier familiar with the tasks required for the sport.
(a) Swimming - Freestyle, Backstroke, Butterfly = S1-S10
- Breaststroke = SB1-SB10
- Individual Medley = SM1-SM10
The ‘1’ indicates the most disabled, through to 10 indicating minimal disability. The swimming classification system is ‘functional’ and caters for various physical disabilities. For example in one race there could be competitors with cerebral palsy, paraplegia, polio and amputations.
(b) Track and Field - designated by ‘T’ and ‘F’ with low numbers indicating a greater disability. This system is still evolving and reference is made to the older general classes as a starting point for functional classification. For example a Class 2 cerebral palsy wheelchair athlete (general) would relate to a T30, T31 and F30 (functional) classification. A T42 standing track classification would include A2 and A9 amputee (general) classifications.
3. Team
Teams are made up of a number of competitors with individual disability scores which add up to a maximum score for a team. Examples:
(a) Yachting - Points are allocated to individual crew members based on hand function, movability, stability, vision, and hearing. Total points for a crew of three may not exceed twelve points. Points for an individual crew member may not exceed 7 points.
(b) Wheelchair basketball - Competitors with a high level of disability score 1 up to 4.5 points for competitors with a low level of disability. A team is allowed a maximum of 14 points on the court.
(c) Wheelchair Rugby - Competitors are graded from 0.5 - 4.0 points and maximum 8 points are allowed on the court during play.
| 
