Whether prompted by the changing healthcare environment from volume to value, Population Health, Healthy People 2020, celebration of the 25th anniversary of the Americans with Disability Act, increased prime time television coverage of Paralympic Sports, or the request of your client to return to a once-loved sport or participate in a new leisure sport, rehabilitation professionals are showing an increased interest and participation in adapted sports as a tool for remediating deficits, restoring function, and improving overall health. Adapted sports and recreation has well-established roots in therapeutic recreation due to the proven benefits in the areas of community reintegration, improvements to activities of daily living, and social integration. Increasingly, occupational therapists and physical therapists are incorporating it into inpatient and outpatient therapy treatment plans and discharge recommendations.
According to the United States Census Bureau in 2010, approximately 56 million people living in the US have a disability. Of these, approximately 30.6 million have difficulty walking or climbing stairs, or use a wheelchair, cane, crutches, or walker. Individuals who have sustained injuries, such as amputation, spinal cord injury, or brain injury or medical conditions, such as stroke, are at a greater risk for developing secondary medical conditions such as high cholesterol, hypertension, diabetes, and obesity due to limitations in their mobility status. Additionally, due to changes in their lifestyle, they are at increased risk for depression and social isolation. Despite the abundance of studies regarding the positive impact of physical activity, less than 38% of individuals with a disability follow recommended levels of physical activity, compared to 49% of US adults without a disability.1 Barriers to participation for individuals with a disability include mobility limitations, physiologic decline, lack of access or awareness of accessible physical activity programs, and lack of transportation.2,3
What are Adapted Sports?
In rehabilitation, activity adaptation is the process of modifying the activity in order to enable performance, which would not have otherwise been possible. Adapted sports are sports that have been adapted through the use of specialized equipment or rules that allow individuals with impairments in mobility, vision, or cognition to compete in recreation or competitive sports. Adapted sports include adapted golf, wheelchair basketball, goalball, power soccer, wheelchair rugby, boccia, judo, sled hockey, skiing, wheelchair tennis, track, rowing, wheelchair curling, swimming, and table tennis.
Organizations such as US Paralympics, a division of the United States Olympic Committee, dedicated to becoming the world leader in the Paralympic movement and promoting excellence in the lives of people with Paralympic-eligible impairments, including physical disabilities and visual impairments, provide a pathway for elite athletes to represent the USA in the world of international sports. There are 22 summer sports and six winter sports. US Paralympics partners with a network of community-based clubs to expand opportunities for individuals and to provide training and competitive events. This provides the aspiring athlete with local opportunities to develop their talents before trying out for the national team.
On September 7, 2016, the Paralympic Games will begin in Rio de Janeiro, Brazil. More than 4,350 athletes from 160 countries are expected to participate in 22 sports, including the Paralympic debut of para-canoe and para triathlon. Prime time media coverage for the event is planned to be at a record high of 66 hours, and TeamUSA.org as well as USParalympics.org are scheduled to provide online streaming of the games. The growing interest in adapted sports, fueled by the excitement of the games, benefits all adapted sports programs by demonstrating the level of achievement and benefits that participation provides.
Who Can Participate?
Individuals who have visual, motor, or cognitive deficits as a result of congenital or acquired mechanisms are able to participate in adapted sports. Diagnoses such as spina bifida, traumatic brain injury, amputations, blindness, spinal cord injury, cerebral palsy, and stroke are examples of qualifying conditions. Impairments can vary with some athletes able to play standing soccer or volleyball while others may require powered mobility and play power soccer, utilizing a guard on their power chair to move the ball on the court or seated volleyball where athletes sit directly on the floor. With the diversity in types of sports offered and physical requirements, a motivated individual is likely to find a niche.
Preparation and Injury Prevention
The prevalence of injury, location, and severity is dependent on the sport. Certainly, contact sports—those requiring high speed, repetition, or adapted equipment—may increase the risk of injury due to the additional stressors on joints.4 Athletes that use assistive devices for mobility place increased burden on their shoulders, arms, and hands during everyday activities, and participation in sports compounds that. Therapists play a vital role in educating their patients regarding preconditioning prior to full engagement in sports that includes conditioning of unimpaired extremities, addressing muscular imbalance, efficiency of movement, bracing, and providing for rest. Individualized programs mitigate soft-tissue injuries that will impact time away from the sport or longevity of ability to play.
It is important that coaches follow training and conditioning principles that in many ways are parallel to principles applied to able-bodied athletes. It is essential that training programs include strength, flexibility, endurance, technical skills, and knowledge of the game, teamwork, and nutrition. Therapists may provide consultation for the coach, who may be a volunteer and is not a healthcare professional. It is important that the coaching plan challenges the athlete but that it is also developed with safety of the athlete in mind. Athletes must understand that they increase their risk of injury if they do not prepare to play. This includes warming up, participating in on-the-court and off-the-court exercise, and conditioning programs and stretching.
It is important that athletes and coaches are educated regarding injury prevention, such as the need for breaks that include hydration, the need for pressure relief for wheelchair users, conditions that are commonly seen in individuals who have had a spinal cord injury such as autonomic dysreflexia, inability to regulate blood pressure effectively, reduced control of body temperature, and inability to sweat below the level of injury.5 An increasing area of concern is the incidence of concussion. For example, studies have revealed similar occurrence of concussion in wheelchair basketball to ambulatory basketball, and in some cases higher incidence. Athletes are equally reluctant to self-report suspected concussion for fear of being removed from the game. It is imperative that adapted sports programs require coaches and trainers to be trained in identifying signs and symptoms of concussion and to have policies in place that address return to play. This is important as it removes the emotional component and the inclination to minimize symptoms in an effort to remain in the game or return to the game too soon.6
It is also important for the coach and athlete to be aware that their medical condition can lend itself to performance advantages that may ultimately have negative health impacts. For instance, athletes with a spinal cord injury may experience performance benefits from competing in a dysreflexic state. They may experience increased
peak power, heart rate, and oxygen uptake. This is referred to as “boosting,” and clinical impact is potentially elevated arterial blood pressure that can cause a stroke, seizure, cardiac arrhythmia, or worse. Athletes may intentionally or unintentionally cause this condition by applying binders or shoes too tightly or not emptying their bladder timely. Due to safety concerns, boosting has been banned by the International Paralympic Committee.7
As is the case with all athletes, nutrition plays a vital role in the overall health of the athlete as well as their performance. It is advised that athletes speak with their physician or a registered dietician to provide recommendations regarding caloric intake, specific food suggestions, and dietary supplements as appropriate.8
Adapted Sports and Technology
Technology, whether it is a sport-specific wheelchair or prosthetic device, plays a major role in the success of an adapted sports athlete. While many individuals can use their everyday wheelchair and prosthetic device to participate in adapted sports, the demand for increased sophistication and specialization dramatically increases as the athlete enters the competitive arena. Advancements in design have improved athlete performance and reduced injuries.9,10
Participation in sports is an activity of daily living that should be discussed early in the rehabilitation process. For individuals who have sustained dramatic changes in mobility as a result of a traumatic injury or as the result of disease process, rehabilitation is a journey. It is imperative that therapists promote the short-term goals related to mobility and function but also expose the patient to adapted sports and allow them the opportunity to return to sports or be first-time participants. It is important to discuss this early in the rehabilitation process so that when appropriate, prescribed adapted equipment may meet all of the patients’ goals.11 It is recommended that the therapist contact existing sports team managers or coaches, associations for specific sports such as United States Quad Rugby Association, US Paralympics, and sport-specific equipment manufacturers.
For individuals who have an upper- or lower-extremity amputation, it is important to work closely with the prosthetist. There can be significant differences between prosthetics that are intended for everyday use versus those that are for sports. Minor accommodations may be made that allow increased versatility of the prosthetic for leisure walking as a precursor to one designed specifically for track.10
Some sports require minimal modifications to existing adapted equipment, such as power soccer that utilizes a guard, also referred to as a shroud that is mounted to the front frame or a center post of a power chair. This protects the athlete’s feet, legs, and chair, but also allows athletes to advance a ball down the court and score a goal. For safety reasons, large front or mid wheels are not recommended as there is an increased likelihood of the chair flipping during play. While the guard is not covered by most insurance companies, ensuring that the chair can accommodate the guard is easily accomplished.
Other sports such as wheelchair tennis, basketball, racing, and quad rugby require a specialized wheelchair. While the characteristics of each chair are largely specific to the sport it is designed for, there are common considerations for all sport chairs. Design is based on optimal speed, maneuverability, and specific regulations of the sport. Sports chairs are typically constructed out of aluminum, titanium, or composite materials. The number, size, and type of wheel provide different advantages. For example, front and rear swivel casters allow the main wheels to be placed closer to the center of gravity to maximize propulsion and turning efficiency. Smaller wheels allow for quick turns and a fast start, whereas larger wheels require more effort to start but easier-to-maintain momentum.
With an increased camber, athletes have greater side stability and turning efficiency. In most sports chairs, the footplates are positioned under the seat, shortening the length of the chair, making turns quicker. For quad rugby chairs, low-pointer chairs or defensive chairs have pickers on the front of them that are used to hook the chair of an offensive player and prevent them from moving. Alternately, high pointer chairs or offensive chairs have a shroud that makes it difficult to be hooked. Ratchet straps are used to secure the athlete to the chair. They are often located at the hips and feet. It is important that sport chairs are fitted specifically to the athlete, affording a snug fit so that the athlete and the chair move fluidly as a unit. Finally, the angle of the seat, or dump, and the height of the back of the chair can be adjusted to provide more support or greater mobility depending on the athlete’s strength and balance.9
Developing an Adapted Sports Program
For those interested in developing a program or hosting an event, it is important to look at what is currently being offered in the local area and what resources currently exist. Frequently, programs are developed because there is a staff interest and a patient or community need. With resources being slim, and the demand being high, it is critical that we do not duplicate services that are meeting the community’s needs. Forming partnerships with existing resources to provide new programs or referring individuals to existing programs is essential.
At the University of Maryland Rehabilitation & Orthopaedic Institute, we have partnered with many other organizations to bring adapted sports programming to our patients and the community. For example, we partnered with Baltimore City Recreation and Parks to provide an instructional wheelchair basketball clinic. With the expertise of our staff member Mike Henley, CTRS, organizing and running the clinic, the use of the adapted sports court on the hospital grounds and wheelchairs from Baltimore City Recreation and Parks, we are able to provide participants with an opportunity to gain basic skills that allow them to joint local teams.
When patients expressed interest in adapted skiing, staff members at the institue evaluated what was offered locally. A local adapted recreation and sports organization offers adapted skiing for all skill levels and age groups, and the interested patients were referred to them. Our quad rugby team, Maryland Mayhem, began with the support of Magee Rehabilitation loaning wheelchairs until we obtained funding through our hospital and grants from a philanthropical foundation. Many programs are challenged to find a gym for court sports. To help the Maryland Mayhem, Baltimore County Department of Recreation and Parks has provided access to a gym for weekly practices.
Many adapted sports programs rely on support from volunteers. While a hospital or program may fund the team manager or coach position, programs rely on volunteers to assist with transferring athletes in and out of chairs, and assisting with drills. Many times the staff of the hospital volunteer, but volunteering for adapted sports is a great opportunity for occupational, physical, and recreation therapy students to get exposure to adapted sports and the positive impact it has on the lives of the athletes. RM
Resources for identifying existing programs in your area or guidance for developing your own program:
• www.usparalympics.org: US Paralympics
• www.blazesports.org: Blaze Sports
• www.disabledsportsusa.org: Disabled Sports USA
• www.pva.org: Paralyzed Veterans of America
Lori Patria, MS, OTR/L, is the director of therapy services at the University of Maryland Rehabilitation & Orthopaedic Institute and adjunct faculty at Towson University and Community College of Baltimore County. With 26 years of experience in adult rehabilitation in both clinical and administrative roles, she has seen the physical and psychosocial benefits of participation in adapted sports in individuals who have sustained spinal cord injury, stoke, traumatic brain injury, and amputation. In order to increase access and participation, she facilitated a partnership between US Paralympics and UM Rehab to offer Paralympic Sport Club Maryland. For more information, contact [email protected].