Abstract
Dear Dr Curran,
It is widely reported that the South African double amputee sprinter, Oscar Pistorius, known as the ‘Blade Runner’, could possibly compete among non-disabled athletes during the 2012 Olympics in London.
Pistorius was born without fibulae and had a bilateral transtibial amputation when he was 11 months old. At the 2004 Athens Paralympics, he used J-shaped carbon-fibre Össur Cheetah Flex-Foot prosthetics to enable him to win the gold medal in the 200 m and bronze in the 100 m. In 2008, confident of his potential to compete against non-disabled athletes, Pistorius intended to run in the Olympic 400 m and 4 x 400 m relay which generated considerable debate about whether the use of his prosthesis was a technical aid that gave him an unfair advantage and that contravened the International Association of Athletics Association (IAAF) competition rule 144.2. For example, some within the sporting community believe that his prosthetics make him taller than he would have normally been and therefore give him an increased stride length. Based on biomechanical experiments, it was reported that he was able to run at the same speed as able-bodied athletes with lower energy consumption.1–3 Although the IAAF announced that he was ineligible for competitions conducted under its rules, by banning technical aids rather than prosthetic limbs, Pistorius successfully appealed against this decision to the Court of Arbitration for Sport (CAS) in Lausanne, Switzerland based on another scientific study. 4 Although the panel went on to emphasize that its decision was limited to the eligibility of Pistorius and to his use of the specific prosthesis, 5 it did not exclude the possibility that with advances in science and technology, and with the help of a testing regime designed and carried out to the satisfaction of all parties, the IAAF might in the future be in a position to explore this further. The decision by the CAS panel then opened serious debate on the future use of prosthetics and other assistive aids in sport.6–9 While the wording of the ruling was clear and did not create ‘opportunities’ for others to follow suit, Pistorius himself did not qualify for the 2008 Olympics. However, it has been claimed that there is a clear need for a scientific consensus on ‘unfair advantage’, and the use of technological assistive devices such as prosthetics in sport. 6 With respect to scientific studies themselves, the basic findings were similar and they both seem to agree that the running style is completely different to any other form of non-disabled sprinting. While the initial study indicated that the knee joint makes a considerable contribution to mechanical work production, 3 the subsequent study in support of Pistorius concluded that physiological aspects were similar to those of any other non-disabled athletes. 4 From a clinical point of view, one might argue that specific parts of a prosthesis, for example the socket, are based on the skill of the prosthetist and the effective training of the individual supported by the rehabilitation specialists in its use. Although the material and design aspects of the prosthesis might have a mechanical advantage over the ‘human leg’, it is difficult to quantify these ‘skills’ and ‘clinical intervention’. Furthermore, the ‘performance’ will also be based on the clinical condition or the pathogenesis.
What needs to be established is: what is deemed to be an advantage and on what basis is that so? Is it the mechanics or the physiology? Although we agree that these two are interconnected in terms of biomechanics, there should be some kind of limit or a regulation as to what can be influenced by a prosthetic designer or manufacturer. Moreover, to what extent is the use of prosthetic aids similar to the use of performance-enhancing drugs or, perhaps more importantly, the use of technology in sporting equipment and accessory design/manufacture (for example, swimsuits, footwear, footballs)?
The question that perhaps has not yet been answered is that of the mechanics of the devices themselves. While debate continues surrounding the mechanical advantage of these devices, the question of definition has yet to be addressed. If ‘artificial limbs’ are true prostheses then they should fulfil the criteria as a ‘replacement of a missing body part’ and Pistorius should be able to wear them for everyday activity; if they are not, and he wears them specifically for the event, then they are by definition another type of device – a performance enhancer perhaps?
It should also be noted that when an athlete loses a limb later in life, it is imperative that they relearn all the motor control patterns for normal locomotion, which minimizes the chances of running to their full potential. In the case of Pistorius, he learned to walk and run on prostheses and hence it is not a comparison. While it appears that Pistorius is regarded as a higher profile and more successful athlete when compared to other transtibial amputees, and he wants to compete against best athletes in the world, this raises another key issues in this debate: the ethics. While several authors have discussed this issue,6,10–12 it is beyond the scope of the current letter. However, the ethical issues raised in this respect lead to another issue which relates to the basic clinical intervention and the ethical position of the clinician involved in the design and construction but, more importantly, the fitting of the prostheses. Should a clinician who is duty bound to safeguard the health and wellbeing of their patient also be responsible for devices that are essentially designed for only one function from which athletes will not benefit in their daily living?
While debates have continued to rage, Pistorius has continued to race. In July 2011, he ran the 400 m in 45.07 seconds in Lignano, Italy, passing the qualifying standard that allowed him to race for South Africa alongside the best non-disabled athletes at the 2011 World Championships in August 2011. Perhaps most controversially, his performances have also enabled him to be considered for selection at the 2012 Olympic Games in London.
Should the use of prosthetics, such as those used by Pistorius, be seen as a technological form of obtaining an unfair advantage, that is as ‘cheating’, similarly perhaps to the use of performance-enhancing drugs in sport? In that connection, should prosthetists consider their role in designing and supplying a ‘performance-enhancing’ device? Rules governing sports equipment and accessory design have been set out by various national and international sport governing bodies but we are entering a new era and an unknown territory. Is this the right time to debate the role of prosthetists, bioengineers and rehabilitation specialists in defining the basic biomechanical and performance requirement in prosthetic design? What future role, if any, will prosthetists play in a related and equally contentious feature of modern disability sport: the classification of athletes’ impairments? These are among the many important questions that the circumstances surrounding Pistorius’s case are likely to raise in this extremely complex and difficult area, not only in terms of the medical practice of prosthetists, but also in the management and organization of sport and the future policy decisions to be taken by those within the sports world.