Injury and the disabled athlete: inspiration for all athletes

Andrew Hamilton and Sean Fyfe provide an insight into working with disabled athletes and provide guidance for coaches, trainers and physiotherapists

Although public perception is changing, the stigma of disability in sport remains. Disabled athletes at all levels, right up to Paralympians are all too often regarded by the general public as curiosities or even as objects of pity - rather than sportsmen and women who love to train hard and compete, but who also happen to have a disability. Much of this of course is down to ignorance, where the differences between able-bodied and disabled athletes are seen as more important than the physiological similarities. The research however tells us that disabled athletes can benefit just as much from vigorous activity and competition, and push themselves just as hard as able-bodied individuals.

In a 2018 published study on exercise guidelines for adults with spinal cord injury, researchers conducted a systematic review of relevant literature and held three consensus panel meetings (European, Canadian and International) to establish recommended exercise protocols⁽¹⁾. They concluded that for optimum cardiorespiratory fitness and muscle strength benefits, adults with a spinal cord injury should engage in at least 20 minutes of moderate-to-vigorous intensity aerobic exercise two times per week - AND that they should also perform three sets of strength exercises for each major functioning muscle group, at a moderate-to-vigorous intensity, two times per week. This latter recommendation was highlighted as being particularly important.

These recommendations fit with previous evidence that 2-3 sessions/week of upper body aerobic exercise at a moderate to vigorous intensity for 20-40 minutes, plus upper body strength exercise (3 sets of 10 repetitions at 50%-80% 1-repetition maximum for all large muscle groups), can improve cardiorespiratory fitness, power output, and muscle strength in athletes with this type of disability⁽²⁾.

The injured disabled athlete

With the recommendations that disabled athletes should be encouraged to train hard, and the inspiring sight of Paralympian heroes pursuing Olympic dreams, clinicians might expect to see an increasing number of injured, disabled athletes coming through their clinics!

While clinicians may be faced with particular challenges in terms of assessment and rehab of a disabled athlete (for example, a useful diagnostic test or an effective rehab technique that may not be suitable as it involves a non-functioning muscle group/limb), this should not been seen as an inherent problem. That’s because research suggests that although there may be additional physical barriers to overcome, disabled athletes - particularly those participating at elite levels - may possess mental attributes that more than make up (see box 1).

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Box 1: Mental toughness

Mental toughness is a quality that sports psychologists have studied in depth – because good evidence suggests that it is highly correlated with success in sport⁽³⁾. There’s no universal definition of mental toughness in sport; however, an individual who continues to persevere and achieve their goals in situations so adverse they would ordinarily be expected to falter and fail, would almost ubiquitously be described as demonstrating mentally tough behavior⁽⁴⁾.

Why does mental toughness correlate with sport success? This is most likely because transient exposure to adversity is now considered to be an important formative experience for talent development – so-called ‘post-traumatic growth’ (PTG). In studies of athletes, sports-based traumas such as severe injuries were universally viewed as negative experiences at the time, but were retrospectively seen by the athletes as having had a positive impact on their future development⁽⁵⁾.

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One group of athletes that exemplify PTG is Paralympic athletes. Paralympic athletes constantly have to deal with: sport overuse, risk behavior, functional limitations, psychological stressors, normalized pain, health hazards, and unequal prerequisites⁽⁶⁾. Relative to able-bodied athletes, research suggests that athletes with disabilities demonstrate stronger resiliency and self-efficacy skills than able-bodied athletes⁽⁷⁾. In short, they tend to be extremely mentally tough.

Implications for the clinician

The study of best sports science practice for disabled athletes such as Paralympians is still in its infancy. What is known however is that disabled athletes are often capable of sustaining high training loads, which means they are likely to require the input from a clinician at some point in their sporting career. Indeed, there’s solid evidence that certain categories of disabled athletes may be particularly susceptible to injury.

For example, one study of wheelchair athletes found a relatively high prevalence of shoulder complaints, ranging from 16% to 76%⁽⁸⁾. Pain was found to be a common, and researchers found that the cause of shoulder problems was difficult to identify and likely multifactorial, with increased years of disability, age and BMI all increasing risk.

In another study, 139 elite athletes with physical disabilities completed a questionnaire about sports-related injuries that resulted in at least one day off from training or competition⁽⁹⁾. All disability groups sustained soft tissue injuries in high percentages. Cerebral palsy athletes reported soft tissue injuries and lacerations in higher percentage than other disabled athletes and spinal cord injured athletes. Spinal cord injured athletes meanwhile sustained fractures and blisters in higher percentages than the other groups.

A further study by German researchers published recently analyzed the finding of the German Medical team caring for the German Paralympians at the 2016 Rio Olympics⁽¹⁰⁾. A total of 201 musculoskeletal complaints were recorded for 140 athletes (93.3%), corresponding to 1.4 musculoskeletal complaints per injured athlete. The incidence of musculoskeletal complaints in German athletes was 62.9 per 1000 athlete-days. High incidence rates were observed in wheelchair basketball (72/1000 athlete-days, 1.6 injuries per athlete) and equestrian events (72.7/1000, 1.6). Musculoskeletal complaints were mainly located in the upper extremities (37.6%) and the spine (37.6%). The most frequent diagnoses were myalgia.

Tough cookies

The limited evidence to date suggests that (per athlete-hour of training), elite disabled athletes are at a greater risk of injury than their able-bodied contemporaries. For these athletes (and their coaches, trainers and clinicians) however, the quality ‘mental toughness’ alluded to above shouldn’t be underestimated. Disabled athletes, particularly at the elite level, will have already overcome seemingly insurmountable obstacles. This quality will work in their favor during any injury rehab protocol, and is something that should be borne in mind by the trainer, coach or clinician when prescribing exercise therapy. Although the rehab of an injured disabled athlete is something of a challenge, you should relish it because there’s every chance your client will!

Andrew Hamilton

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Practical guidelines and eight key principles (by Sean Fyfe)

As an experienced clinician working with a wide range of sportsmen and women, my opinion is that it is different and challenging – but often actually more rewarding - working with athletes with a disability. If you are a coach, trainer or clinician with para-athletes in your care, here are my eight key principles that can be applied successfully when working with any individual with a disability.

1. The individual’s disability

Start any work with an athlete with a disability by developing a deep understanding of an individual’s disability, and specifically your athlete’s individual presentation of that disability. This will involve developing your own series assessment and re-assessment parameters that are important to the athlete - so that you can gauge progression - or possibly regression. Any work you do with an athlete with a disability will generally have to be in the context of that disability.

2. Understanding sport

In some instances, things may not change too much from able-bodied sport and in others there may be significant changes. If we are working with able-bodied athletes from a sport, most coaches and sports-injury practitioners will have an in-depth knowledge of that sport, and may have even played a lot of that sport, which further enhances the knowledge base. This is often not the case when it comes to sports for competitors with a disability like wheelchair rugby. If possible, try it yourself. My advice is to study the sport and understand the real physical demands. This is crucial particularly for late-stage rehabilitation, when the aim of programming is to take them as physically close to the musculoskeletal demands of that sport.

3. Make strengths stronger

Ten years ago when I was completing my level-3 tennis coaching level course, we had a very successful visiting tour coach give a guest lecture. Something very simple from this lecture still resonates with me to this day whenever I work with an athlete and I think it rings true even more so for athletes with a disability: “Know the strength and make it stronger. I spend 90% of my time working on my players’ strengths, not weaknesses”. His reasoning for this was two-fold: the first was obvious - to practice how you are going to win points and not how you are going to protect losing. And the second was all about the mind – confidence. For athletes with a disability, there are mostly going to be obvious weaknesses in physical capacity. But my message is to realize the strengths and be sure to focus on those strengths from a training, rehabilitation and communication perspective.

4. What can compensate?

One thing you will always be thinking about when dealing with athletes with a disability is how you help your athlete improve somewhere in order to overcome a limitation somewhere else. For example, with an athlete with visual impairment that impacts the usual system of integration between vision, balance and sensory information for dynamic balance control - how can I help make their other two systems even more heightened to compensate? Or for an athlete with a specific joint impairment of the knee - how can I improve the surrounding joint and muscle function of the hip and ankle to compensate?

5. Super individualized

We know every athlete is different, but this is true even more so for athletes with a disability. It is common that you may be dealing with a complex musculoskeletal condition, but having to adjust your usual techniques and programming in the context of their disability. Take for example a shoulder injury for an athlete with an incomplete spinal injury, where the athlete will have neurological strength and sensory partial limitations. The trainer/therapist must have the complete picture of shoulder function due to the disability - but then also be able to assess what changes may be happening around the shoulder based on the musculoskeletal condition. In this case, individualized testing and re-testing over time is crucial to individualized rehabilitation, injury prevention and training strategies.

6. Recovery strategies

Think about how hard the shoulders and arms have to work in a wheelchair athlete, whether on the track, in basketball, rugby or tennis. Likewise, think about the work of the dominant leg in an athlete with an amputee. Recovery strategies for these areas of the body that do a lot of the work are crucial for both injury prevention and backing up training and performance. These strategies can include targeted joint and limb compression or cryotherapy (see this article), an athlete-specific routine of soft tissue massage, trigger pointing and stretching, designated recovery sessions and cross training. These should be combined with closely monitoring workloads and fatigue from general perspective (as well as in specific body areas) to help plan training based on how the athlete is actually coping physically.

7. Be prepared to think outside the box

There are two parts to this principle. Firstly, take what you think is normal for an injury or performance target for a specific test and be prepared to throw it out and start again. Think of a below-knee amputee. How strong do the hamstrings and the gluteus maximus of the buttocks have to be to compensate for having no functioning ankle for propulsion? Or how well developed do the gluteus medius and minimus need to be as lateral stabilizers, considering there is far less contribution from single leg stabilizers down the kinetic chain? The second part is to be prepared to come up with new and inventive ways to train and rehabilitate. There will be so many occasions where you can’t use traditional training methodologies or equipment. Think outside the box to develop equipment and exercises that are effective for the individual, even if they are a bit weird and wonderful!

8. Your own beliefs

I’ll explain this principle using the example of my favorite client of all time. We’ll call him Ben. That statement is no stretch and no disrespect to all my other clients, but Ben was something special. Deprived of oxygen during his birth, he suffered a brain injury that left him with cerebral palsy. His parents were told he would never walk unassisted. He walked at unassisted 5 years old. He was told to play wheelchair tennis but he refused as he wanted play like his idle Pete Sampras. So with the help of his Dad, Ben played tennis unassisted. Watching him play tennis was witnessing the sheer will of an individual forcing himself to move in ways that often seemed impossible.

Nine months previously, Ben had a stress reaction in his knee (patella). But he had been back playing pain free for six months until going for a wide volley when his patella spontaneously fractured. The fracture was managed non-surgically with a splint until healed, but the real challenge began with the commencement of his rehab. His quadriceps strength had become close to non-existent, and we were going to have to apply all the principles above - and we did.

However, along the process I found myself having to continually check my own beliefs, my own preconceptions of what was possible and my own language. To Ben it was only a matter of ‘when’ not ‘if’ he would be back playing tennis. Very early on Ben started talking about ‘when he got even stronger, how he could improve his movement on court and the things he needed to improve in his movement so he could execute certain shots better’. I had to make sure that my language matched his confidence, as in the back of my mind I had my doubts about whether any of this was going to be possible. I had to ensure that I was planning his training and rehab that allowed him to take the baby steps and helped him see how he was actually going to achieve his goals.

It was a lesson I will never forget. I am convinced that probably the most mentally tough and determined athletes are athletes with a disability, and as Andrew has reported above, the science bears this out. I’m also convinced that athletes with a disability provide possibly the greatest challenge to both strength and conditioning and rehabilitation in our industry. And in my experience can be the most rewarding. Seeing Ben back playing tennis is certainly one of the most satisfying moments in my professional career!

Sean Fyfe

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