Abstract
Sports as medicine has been a specialty within medicine since the time of Galen (130–200 AD) when injured and disabled gladiators were returned to competition.[1] Over the course of history, sports have been a favorite pastime and a form of rehabilitation for soldiers wounded in war. The modern age of sports for people with disabilities has been attributed to Sir Ludwig ‘Papa’ Guttman and rehabilitation work at Stoke Mandeville Hospital, Buckinghamshire, UK. To restore the spirit of achievement and self-esteem in returning Second World War soldiers, he integrated sports and competition as part of the rehabilitation program. By 1952, the Stoke Mandeville Games had become an international event for athletes with disabilities. By 1960, Guttman had founded the British Sports Association and instituted the first International Games for the Disabled in Rome, which would become known as the Paralympics.[2] Between 1960 and 1980, international and national organizations worldwide would be created for athletes with spinal cord injury, amputations, cerebral palsy, blindness, hearing loss and Les Autres (French for ‘the others’).
Starting in 1932, Harry Jennings, an engineer, worked with his friend Herbert Everest to design a ‘fold-up’ metal wheelchair that would replace his current wooden wheelchair. Various generations of their lightweight wheelchairs would become the sports wheelchair of the 1950s and through the 1970s. In 1975, Bob Hall (time 2:58) became the first official wheelchair competitor in the Boston Marathon. His first marathon was in a modified standard fold-up wheelchair, but he would go on to design aerodynamic wheelchairs that reduced the risk of injury and improved performance. Soon after, in 1978, George Murray would be the first wheelchair athlete to finish ahead of the first able-bodied runner in the Boston Marathon.[3]
Soldiers and athletes with amputations have always found ways to return to battle or sports, regardless of the quality of their prosthesis. During the 1970s, lower limb amputees would tape one inch wide strips of spring steal to the soles of their rubber prosthetic feet to increase the stiffness and increase running speed. It was not until the 1980s that specialized prosthetics and athletics began to emerge. During the 1988 Paralympic Games in Seoul Korea, the first amputees ran with a ‘sports prosthesis’ featuring the carbon fiber J-shaped foot, which was originally designed as a walking foot. In 1991, the first prosthetic foot specifically designed for running was introduced at the United States Paralympic trials in New York. The foot was to be mounted on the front of the socket. Interestingly, when an early model Cheetah Flex-Foot® was sent to a sprinter in Australia without instructions, he had it mounted on the back of the socket. During the next international competition, he had the winning performance. The foot has been mounted posteriorly ever since.
Sports for people with disability.
As the 2008 Olympic Games drew near, there was controversy concerning the equity of competition where a young athlete from South Africa with bilateral transtibial amputations, Oscar Pistorius, was accused by the International Association of Athletics Federation (IAAF) of having ‘an advantage over an able-bodied athlete’ when competing with the Cheetah Flex-Foot®. The ruling by the Court of Arbitration for Sport ruled in Mr Pistorius's favor stating that no advantage could be determined after testing was performed in two sports performance laboratories.[4]
Past Olympians with disabilities.
The unfortunate reality is that when compared to other healthcare professions who specialize in sports medicine, the specialty of sports prosthetics and orthotics is to a great extent still in its infancy. What is apparent from the Pistorius case is that little evidence exists with regards to sports prosthetics. The universal problem that exists today is that when an athlete is accused of using an orthotic or prosthetic device to enhance performance, there is little evidence to support either side of the debate. For example, currently there are less than five variations of prosthetic running feet available to athletes and yet few scientific publications have reported on their performance capabilities and limitations.[5] Furthermore, there is a paucity of information with regards to the interaction of socket design, suspension, skin, soft tissues, muscle action and performance during athletic performance.
There are many reasons for the lack of scientific evidence in respect to sports for people with disabilities. First, the population is considerably smaller than the able-bodied population. Likewise, within each impairment grouping, there are numerous levels of physical abilities making it difficult to make generalizations across even one group. Small populations and geographic distribution of elite athletes with disabilities can create logistical problems when attempting to recruit adequate sample size to determine statistical differences between groups. Second, technology developments can occur at a comparatively fast rate, resulting in the dilemma of a finished study publishing data on technology that may no longer be current. While the majority of wheelchair and prosthetic designs have remained constant, small variations in product design may have an impact on overall performance. Third, the cost of performing a well designed research study is often considerable and difficult to justify to traditional funding sources. The need for evidence in sports for people with disabilities is great; however, because of the numerous research obstacles, a real body of evidence may not be available for some time.
The development of sports orthotics has been robust with regards to orthopedic injuries of joints and soft tissue injuries. Countless orthotics are currently available for prophylactic care, post-surgical care, acute and chronic injuries with a reasonable body of research to assist clinicians in determining the validity of orthotic application with a variety of injuries. However, there is no certification for sports medicine specialist, especially with the fabrication of custom designed orthotics.
Similarly, there has been an explosion of new adaptive sports and recreation technology. Many people with disabilities are able to participate in a wide variety of activities through technology that helps to meet their needs. Although there has been steady progress into the research and development of adaptive sports and equipment, the outcomes have been hampered by inadequate access to funding support, the geographic dispersion of people with disabilities participating in sports/recreation, and the lack of sports/exercise facilities and programs. Despite these limitations, wheelchair and hand-cycling athletes have made tremendous accomplishments. An important goal to set is for greater participation in sports/recreation by people with disabilities as part of their normal routine.
Athletes need to have prosthetic devices, orthotic devices, and/or adaptive sports equipment technology fabricated for sports today so that they can train and compete, even in the face of limited research evidence. Worldwide, there are numerous prosthetists, orthotists, and rehabilitation engineers that have become extraordinarily skilled in the fabrication of adaptive sports technology (i.e., prostheses, orthoses, and adaptive equipment), primarily based on trial and error. The results have produced a new generation of accomplished athletes with disabilities. There are also clinicians with modest experience fitting adaptive sports technology that may be limiting performance rather than enhancing performance. Currently, there is no mechanism for the athlete with disability to determine their clinician's experience or expertise. The current limitations of scientific knowledge and the translation of the existing knowledge into clinical practice may be limiting the accomplishments of people with disabilities.
Healthcare professionals in other disciplines specializing in sports medicine must demonstrate a knowledge of diagnosis and treatment, injury prevention and rehabilitation, sideline coverage, preseason evaluation, performance assessment and be available to the athlete on an expedited basis should they become injured or require assistance.[6] To become a ‘sports medicine specialist’, most professions require additional training and a mechanism to certify competency. The majority of sports medicine specialists obtained their certification not only to work with professional or elite athletes, but to care for the ‘weekend warrior’ or the recreational athlete, ultimately, giving their clients the opportunity to remain physically active and healthy.
As athletes with disabilities demand sports equipment technology for better fitness, recreational pursuits and competition, the time is now to institute a specialization certification that will ensure that each athlete is being cared for by a knowledgeable clinician who has demonstrated a minimal level of competency. The notion of establishing a sports medicine competency is not novel as most healthcare professions such as surgeons, physicians, physical therapists, psychologists and several other professions currently offer credentialing programs.
Specialization would require knowledge of injury prevention, treatment of injuries typically associated with athletic activity, sports physiology, sports performance and other related topics. Most specialization credentialing bodies require general clinical experience, evidence of specialization practice, additional course work and some form of competency examination. The benefits to the profession include the acknowledgement that further training is required to obtain specialization competency within the profession, qualifications are recognized by a professional organization and that clinicians within the professions have skills that distinguish them from general healthcare professions. Colleagues and allied healthcare professions would be able identify specialists within the community where they could refer patients who are need of specialized services. Ultimately, the consumer has a mechanism to assist them when making healthcare choices.
In summary, sports for athletes with disabilities have matured over the past half century. The number of athletes participating has grown worldwide, the number of sports have increased as have the venues for competition. The assistive technology used in sports has also developed significantly as materials and designs continue to aid the athlete is reaching their athletic potential. Together with the use of improved assistive technology and contemporary training methods the Paralympic athletes' performances are continuing to improve, in some instances to the level of Olympic athletes. On a larger scale, people with disabilities who have no aspirations for Paralympic competition are participating in recreational sports and physical fitness programs. Both the elite and recreational athlete with disabilities requires clinicians with specialized knowledge of the complexities and unique needs of athletes who use assistive technologies, including prosthetic and orthotics. Therefore, the time is now for the profession of orthotics and prosthetics to join the other allied healthcare providers by creating a certification program acknowledging qualified sports medicine specialists.