Abstract
Background:
Participation in sport and exercise training, while aiding in the reintegration and confidence building of wounded service personnel, also has potential to prepare them for elite sport competition. It is this encouragement of the war injured to use sport and recreational physical activity as a means of rehabilitation back into civilian life, which has become the worldwide phenomenon of Paralympic sport.
Objectives:
This paper evaluates existing research relating to the incidence of types of war injuries and the use of sport within the rehabilitation process.
Study Design:
Literature review.
Methods:
Initial searches were conducted in the electronic databases EBSCOHost, ScienceDirect and Pubmed using the keywords ‘veterans’ and ‘sport’ or ‘physical activity’. These searches were then supplemented by tracking all key references from the appropriate articles identified. A narrative literature review methodology was employed.
Results:
Although it is clear from the reported literature that further development of available rehabilitation services is necessary to provide the required level of care for the types of mental and physical injuries and the concept of ‘therapeutic recreation’ is becoming popular, there is still a need for the development of specific protocols to identify individuals who can participate and excel in a specific sport at an elite level.
Conclusions:
Drawing on the US military experience it can be argued that sport in the UK and other parts of the world should be more widely recognized as a component of rehabilitation. This is not just for the role that sport can play as a tool for rehabilitation but also for the intrinsic and extrinsic benefits that participation in elite sport can offer.
Clinical relevance
Based on the findings, a clear protocol for the inclusion of elite sport training within rehabilitation process should be implemented. This protocol development and implementation should encompass a team of multidisciplinary rehabilitation professionals including rehabilitation medicine specialists, bioengineers, prosthetists, orthotists and physiotherapists along with sports and exercise scientists and Paralympic administrators.
Background
While sport and outdoor activities have been shown to be useful in the physical rehabilitation of veterans, they have also provided a foundation for the development of a positive self-image and outlook on life. Previous reports indicate that adventurous training and sport offer significant opportunities during the latter stages of rehabilitation and beyond to aid re-integration and confidence building for wounded service personnel. Historically, as indicated by Eldar and Jelic, 1 the rehabilitation services were developed largely as a result of the impact of war and specifically the care of people with brain injury following World War II. However, recent reports indicate that further development of available rehabilitation services is warranted in order to provide high level care for the mental and physical injuries regularly sustained through more recent conflicts. 2 Other research reports illustrate that the incidence of blast-related injuries has been particularly high in the recent campaigns. 3 Fergason et al. 4 indicate that 56% of injuries in the Iraqi and Afghan conflicts were related to fragmentation and blast trauma and that, up to July 2009, 723 personnel had experienced lower extremity limb loss. Furthermore, between 2001 and 2005, during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), Melcer et al. 5 noted that 382 US service personnel suffered major limb amputations after combat. By 2009, referring to major amputation rates, 22% of the US troops had lost arms in Iraq and Afghanistan compared to 4% in Vietnam (Contemporary Rehab June 09). Although, Dillingham 6 highlights that amputations account for 7%, brain injuries 8% and spinal cord injuries 3%, a recent report by Vanderploeg et al. 7 notes that the incidence of brain injuries is higher in recent combat operations and that knowledge about appropriate rehabilitation is essential.
In addition, these recent military campaigns have resulted in a wide diversity of other non-fatal injuries.3,8 Dillingham et al. 6 provide data on the prevalence of specific injuries sustained in the Persian Gulf War (for example, orthopaedic, musculosketal, peripheral nerve damage, penetrating wounds, fractures and burns). However, there is a clear paucity of research outlining the numbers of war injured currently undergoing physical rehabilitation. Furthermore, there is a lack of information on the success or failure of scientific and clinical protocols followed during the rehabilitation process using the advancements in science and technology. In addition to injuries sustained during ‘battle’, it is also important to remember the role that rehabilitation and other associated allied health professionals play in maintaining the fitness of service personal during their training programmes and treating injuries sustained as a result of the military lifestyle and sports participation. 9 According to Dharm-Datta and Nicol, 10 45% of medical discharges occur from such injuries and the role of sports specific conditioning has been recognized within rehabilitation programmes. However, previous reports indicate that greater attention is needed in order to improve the preventative care and advice necessary to reduce the rates of injuries recorded in non-combat situations. 11 Therefore the purpose of this review is to provide a historical perspective to Paralympic sport and to evaluate existing research and outline the incidence of types of war injuries and the use of sport within the rehabilitation process.
Method
Initial searches were conducted in the electronic databases EBSCOhost, ScienceDirect and Pubmed using the keywords ‘veterans’ and ‘sport’ or ‘physical activity’ No date limits were set and the searches were supplemented by tracking all key references from the appropriate articles identified. A narrative literature review methodology was employed. This was deemed most appropriate as it allows for a comprehensive overview of the review topic to be produced as opposed to other methods, such as systematic reviews, which focus on a specific question.
The emergence and development of elite disability sport
While there is a potential for rehabilitated personnel to compete in elite sport, it is also noteworthy that it was the encouragement of the war injured to use sport and recreational physical activity as a means of rehabilitation back into civilian life, which led to what has become the worldwide phenomenon of Paralympic sport.
The use of physical activity as ‘therapeutic recreation’ became prominent in hospitals and schools initially in the USA and later in the UK. It was from this early involvement in therapeutic recreation using sport and other forms of physical activity that more organized competitive sporting opportunities emerged. Despite the activities of organizations concerned with sport for deaf people, 12 it was not until the competitive international events organized in the 1940s, specifically for physically impaired people, that disability sport began to enjoy the significant growth that was to follow over the next 60 years.
The origins of sport and competition specifically for disabled people, and in particular those with physical impairment, is often traced to Sir Ludwig Guttmann, a neurosurgeon who opened a National Spinal Injuries Centre (NSIC) at Stoke Mandeville Hospital.
13
The NSIC was opened after the end of the World War II to help with the treatment and rehabilitation of severely war-injured ex-servicemen returning to the UK with a wide range of physical injuries. While providing recreation as a form of therapy was Guttmann’s original intention – as he saw the psychological and physical benefits enjoyed by war-injured patients – he soon realized the significant potential of competitive sport for disabled people. Guttmann
14
believed that sport was:
invaluable in restoring the disabled persons’ physical fitness i.e.: his strength, co-ordination, speed and endurance… restoring that passion for playful activity and the desire to experience joy and pleasure in life, ….promoting that psychological equilibrium which enables the disabled to come to terms with his physical defect, to develop activity of mind, self confidence, self dignity, self discipline, competitive spirit, and comradeship, mental attitudes….to facilitate and accelerate his social re-integration and integration.
Consequently, according to Thomas and Smith, Guttmann, and the International Stoke Mandeville Games Federation (ISMGF), which he subsequently formed, is acknowledged as instrumental in the emergence and early development of disability sport. 15
One of the earliest international competitive events for physically impaired people was held in 1948 when sports clubs and hospitals were invited that year to Stoke Mandeville, the same year as the Olympic Games were being held in London. The first Paralympic Games were held in 1952 where a total of 130 athletes with spinal cord injury, representing the UK and the Netherlands competed in six sports: archery, lawn bowling, table-tennis, shot putt, javelin and club throw.
Since 1952 the Paralympic movement has grown dramatically, with the number of athletes participating in Summer Paralympic Games increasing from 400 athletes from 23 countries in Rome in 1960 to 3,951 athletes from 146 countries in Beijing in 2008. The summer Paralympics 2012 in London includes 20 sports, namely, archery, boccia, track cycling, road cycling, equestrian, five-a-side and seven-a-side football, goalball, judo, power-lifting, rowing, sailing, shooting, swimming, table tennis, sitting volleyball, wheelchair basketball, wheelchair fencing, wheelchair rugby and wheelchair tennis and will involve athletes with cerebral palsy, spinal cord injury, amputation, visual impairment and also those in a category known as ‘les autres’ to accommodate athletes with other forms of disability such as multiple sclerosis. The potential for war injured to benefit from the opportunities afforded by paralympic sport have significantly increased.
Elite sport competition for disabled people such as Paralympic Games uses a system of athlete classification to establish fair competition and is often cited as the central and defining characteristic of disability sport.16,17 Between the 1940s and 1990s elite level competitions such as the Paralympics were organized using a medical classification system which placed athletes with similar impairments into groups. From 1992 – to improve fairness and reduce the number of events – the emphasis shifted towards sport-focused classification systems which groups athletes based on their functional ability in each sport. The shift away from impairment-specific forms of classification is supported by the International Paralympic Committee (IPC). Unfortunately however, according to the IPC, current Paralympic classification systems are ‘still too often based on the judgement of a small number of experienced classifiers, rather than empirical evidence’. In addition, and of interest to this paper, the classification an athlete is assigned has a significant impact on the degree of success that they are likely to achieve and the type of prosthetics and orthotics that they are allowed to use while competing.
Recently, sport, including Paralympic disciplines, is part of a rehabilitation programme recognized in current recreational therapy at Headley Court, the main armed forces rehabilitation centre in the UK. It is acknowledged as a way to develop ‘leisure-related skills’, ‘leisure independence’ and ‘social benefits’ for those with long-term or permanent disability. 8 In the USA, it is expected that 15% of the Paralympic team will be made up of veterans by 2012. In contrast, while the UK government has demonstrated its support for the war injured, 18 to disabled people more generally as well as the GB Paralympic teams (DCMS, 2010), there appears to be no explicit policy which encourages veterans into elite disability sport. There is, however, some indication that the American military support is being recognized as beneficial in the UK. Reports indicate that British Olympic coaches have been involved in recruiting war veterans and that army chiefs have agreed to retrain injured soldiers to enable them to participate in the 2012 Paralympics. In addition, the Battle Back scheme, run by the Ministry of Defence, was reported to have enabled former military personnel to gain places in blind football, skiing, athletics, wheelchair basketball and pistol shooting squads. 19
The US Army has developed a holistic approach to caring for service personnel that extends beyond the normal medical care. It is reported that it has developed 29 Warrior Transition Units (WTUs) throughout the USA and Europe for soldiers who require at least six months of complex medical management. Each individual in a WTU is provided with a personalized transition plan that includes specific goals relating to physical fitness. While this setup helps equip the individuals with the tools that they need for the next stage of their lives, whether they return to the force or transition to civilian life, the service personnel have a further opportunity within this initiative to participate in adaptive sports programmes coordinated by the US Paralympic Military Program. After qualifying as elite-level athletes, wounded warriors can train for the US Paralympic team through the Army World Class Athlete Program. 20
Before looking at the rehabilitation programmes that include advanced physical fitness or sport, it is important to highlight the pattern and rate of various injuries. As such, there are no scientific or structured clinical reports relating various sports to specific injuries in armed conflicts or the rehabilitation process after clinical intervention. However, various case studies and clinical reports outline the emerging pattern of injuries in the recent conflicts.
Pattern of injuries
Amputations
Studies have commented on the higher rates of US military personnel who are suffering amputations as a result of combat compared to previous campaigns. 21 Melcer et al. 5 studied 382 service personnel who had received major limb amputations in OEF and OIF between 2001 and 2005. In addition to the physical ramifications, two thirds suffered mental health disorders, and further complications were twice as likely among those with lower limb amputations. The study concluded that a varied set of services were required to serve diverse needs and that the majority of injured personnel accessed physical and occupational therapy, prosthetic and orthotic services and psychiatric care. Although there is some consistency with the symptoms experienced by lower limb amputees (namely risk of developing cardiovascular disease, blood pressure and onset of later life obesity, lower extremity amputees at risk for joint pain and osteoarthritis, transfemoral amputees report a higher incidence of low back pain than transtibial amputees and 50–80% have phantom limb pain), 22 Wetterhahn et al. 23 indicate that regular physical activity can lead to improved body image, and Yazicioglu et al. 24 note the emotional role that physical activities can play. There is no denying the complexity of injuries and the rehabilitation required, Pasquina and Fitzpatrick (2006) 21 argue that ‘combat injuries with amputations present unique medical, surgical and rehabilitation challenges’ and ‘application of multiple tools is required’. It can be argued that any rehabilitation programme needs to take this into account and should consider the contribution that sport can make in improving the physical and mental outcomes for these personnel.5,25
Although some reports indicate that the fitness levels of amputees deteriorate after an endurance training programme (when tested against an able-bodied control group, results show that fitness is lower in the areas of VO2max, anaerobic threshold and maximum workload they can produce), it is clear that pain and disability in amputees is not limited to the amputated limb. 26 It is reported that individuals felt pain in their intact limb twice as frequently as those without an amputated limb and that this was most likely for transfemoral amputees. The difficulties experienced by individuals adapting to movement with a prosthesis should not be underestimated. The stresses that are placed on other areas on the body impact on range of movement achieved during rehabilitation stages as well as levels of pain felt. This highlights the need for the development of a comprehensive, scientifically based clinical protocol to identify the physical capabilities of an individual to participate in a specific sport or exercise regime.
Lower limb and upper limb injuries
High rates of lower limb injuries have been recorded in recent wars with the ankle and foot often severely damaged. While Tintle et al. 27 recommend attempting to keep the limb wherever possible, amputation of the lower limbs has been common due to the severity of injury and blast-related damage. A range of studies have illustrated that lower limb amputation results in a loss of muscle strength and balance and have emphasized the importance of balance for walking. 28 Previous research carried out on World War II veterans showed that much higher rates of osteoarthritis (OA), hip OA and osteopenia was recorded for above-knee, compared to below-knee amputees and that bone density was reduced as a result of amputation. 29
While, sport and physical activity appears to have a positive effect on some rehabilitation outcomes of those with lower limb amputations, Yazicioglu et al.
24
tested a range of outcomes for unilateral below-knee amputees playing football, including the impact on balance, muscle strength, locomotor capabilities and health-related quality of life. Statistically significant results (
Velzen et al. 28 found there was only clear evidence for a relation between balance and walking ability, stating that there was not enough evidence for any other elements of physical capacity. However, he argued that lower limb amputees should be encouraged to include training of physical capacity as well as walking ability during rehabilitation. Although several measured parameters have been shown to be reduced after amputation there is still a paucity of information relating to the ability to regain efficient gait. If one could screen these individuals using a multi- and interdisciplinary comprehensive protocol, they could be incorporated into a sport routine which would prove beneficial both during rehabilitation and reintegration into the society.
Other injuries
Vanderploeg et al. 7 compared the impact of cognitive didactic and functional experiential traumatic brain injury (TBI) rehabilitation approaches to state that ‘the current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments’. In a group of 360 participants with moderate to severe TBI they found that those treated with cognitive treatment saw improvements in their short-term functional cognitive performance. It is important to remember that some TBI patients do have the potential to return to active duty and research has designed and tested rehabilitation techniques appropriate for these moderately TBI personnel. Activities to improve fitness cognitive skills were included in Braverman et al.’s 30 work which suggested it was a useful tool to use as part of a rehabilitation programme.
Another important area to consider is spinal injuries. Rukovansjki 31 indicated that during the East Croatian conflict, out of 4,805 casualties 32 people were treated for injuries to the spine. This study reports that the average clinical and rehabilitation intervention lasted for 5.5 months and 40% of those wounded remained severely disabled.
Sports rehabilitation
Due to the injuries seen as a result of OEF, more specialized care has been developed in some US rehabilitation centres, such as Walter Reed and Brook Army Medical Centres. 32 Smurr et al. 25 state that a ‘five-phased upper-extremity amputee protocol of care was developed (including) acute management; preprosthetic training; basic prosthetic training; advanced prosthetic training; and discharge planning’. The plan takes into account long-term rehabilitation requirements and supports advanced prosthetic tasks, including sports activities. The authors note that the armed services personnel are ‘young, athletic, and competitive, so harnessing this desire has been incredibly successful’. Providing support to maintain participation in home communities is recognized as an essential part of the programme and various sports have been introduced to the participants of the scheme, including snow skiing, water skiing, rafting and kayaking, hunting and shooting and rock climbing.
Research has also been carried out that discusses the use of sports within rehabilitation programmes in general.33,34 Although not tested on military personnel, the results can illustrate the differences in physical ability of various disability groups and the role that sport can play in developing and maintaining physical skills. In their study of anaerobic work capacity for wheelchair athletes, Woude et al. 35 underline the importance that any rehabilitation or fitness programmes should not generalize the disability population but must develop activities relevant to the individual athlete with that disability. A 30-second sprint test on a computer-controlled wheelchair ergometer was used with elite wheelchair athletes at the World Championships and Games for the Disabled in Assen (1990). In addition to gender variations, the hours of training undertaken, functional muscle mass, coordination and phenomena of cardiovascular dysfunction affected the work capacity that was reached. Individuals with cerebral palsy demonstrated a low sprint power while female basketball players, amputees and the two male field athletes achieved relatively high outputs.
Sherman and Jacobs 36 provide evidence that paraplegics can benefit from aerobic exercise and that low and medium intensity work can be useful for those with spinal cord injuries. Participating in planned sporting programmes 37 has also been found to have a benefit for those with spinal cord injuries. Goktepe et al. 38 compared wheelchair basketball players with sedentary paraplegics and found improved bone density in distal radius for the active group (although not for the areas below the injury).
Lovell et al. 39 interviewed 118 competitors with spinal injuries, attending the First International Ex-Service Wheelchair Games, held in July 1993 and highlighted the role of sport in rehabilitation. They found that there was a mean delay of 38.3 months from injury until return to sport and that only 11.8% of participants returned to sport in the initial rehabilitation period, highlighting that ‘if we believe in the benefits of sport and elite sport competition this needs to be considered as an integral part of the rehabilitation process’.
More recently, the United States Olympic Committee (USOC) – Paralympic Military and Veteran Programs aims to provide post-rehabilitation support and mentoring to US service personnel who have sustained various injuries. This initiative provides Paralympic sports as a part of the rehabilitation process and has resulted in the sports participation rates of the wounded service personnel throughout the USA to increase from 31% to 54% over the past two years. (http://usparalympics.org/military-and-veteran-programs). One of the success stories of this program include John Register, who is quoted saying ‘Sport opens doors’, ‘It’s powerful’ (http://abilitymagazine.com/Paralympic_Military.html). However, it appears that the veterans are referred to specialist centres after their initial clinical intervention and rehabilitation rather than identifying the people early and including elite sport training as a part of their rehabilitation programme.
Role of prosthetists and orthotists
While previous studies and anecdotal evidence suggests that sport participation will help in the rehabilitation process, the physical rehabilitation and the restoration of body movements where possible to participate in sport can only be achieved by a team of rehabilitation professionals that includes prosthetists, orthotists and bioengineers. The injured population will need an appropriate, well designed and effective prosthetic and/or orthotic support. Although it is not the purpose of this manuscript to outline or review all the inventions in this area, it is important to note that there have been several advances in scientific/technological developments. New materials and designs have been developed and adopted with effective input from all clinical rehabilitation professionals.
Although there might be a wide selection of prosthetic and orthotic designs available which again are made from a variety of suitable materials, they would only be useful and effective if the prosthetist or the orthoist prescribing/fitting can make an accurate clinical assessment (and fine adjustments) of the patients’ medical, functional and perhaps sporting needs. Currently, the rehabilitation process for most war-injured personnel whether amputees or otherwise, does not normally include consideration of their sporting potential or needs. In the discussion that follows we explore the potential of a broader more multidisciplinary approach to rehabilitation.
Discussion
While knowledge of the particular injury and disability experienced is important, any rehabilitation programme must start with the individual. Rehabilitation programmes based on generalized assumptions of the medical condition or injury will not take into account individual health, fitness or experience of sport prior to injury. The American military experience suggests that with support, injured military personnel can channel the psychological and physical traits that they had before the injury into sport and that, in some cases, elite sport can provide a positive avenue for improving fitness and psychological health (http://abilitymagazine.com/Paralympic_Military.html). The importance of skilled rehabilitation medics and other health professionals, including sport and exercise scientists, is essential to this process as is the role of prosthetists and orthotists.
The authors recognize the role that rehabilitation services play in maintaining the fitness of service personal during their training programmes and treating injuries sustained as a result of sports participation. 9 According to Dharm-Datta and Nicol, 9 45% of medical discharges occur from such injuries and research has also highlighted that training injuries, sports, falls and motor crashes cause significant rates of death as well as the fitness and readiness of service personnel.40,41 The role of sports specific conditioning has also been recognized within rehabilitation programmes, 10 but greater attention needs to be given to improving the preventative care and advice provided in order to reduce the rates of injuries recorded in non-combat situations. 11
Weaver et al. 42 notes that, in addition to spinal cord injuries, rehabilitation can often be delayed while treatment is carried out for fractures, tissue and muscle injuries, pressure ulcers, TBI, posttraumatic stress disorder and resistant infections. In addition, loss of hearing can affect the rehabilitation process. For any rehabilitation programme to work the daily care provided by family and other non-medical carers can be essential and the role that they will need to play in long-term rehabilitation or life-long care must be recognized. Accordingly they must understand how to support the injured person when they are participating in sports rehabilitation activities and their skills must be developed by the appropriate rehabilitation and sport professionals. It is readily acknowledged that sport and disability sport has the potential to aid physical and psychological rehabilitation as well as provide a worth-while and meaningful pursuit (or career) following rehabilitation (http://abilitymagazine.com/Paralympic_Military.html).
The emergence and growth of disability sport opportunities and, in particular, opportunities for competitive sport within the international Paralympic infrastructure 12 has raised levels of interest and expectations of those with congenital and acquired disabilities. For example, according to Sherman 36 the number of people with paraplegia continues to increase but with the increasing accessibility to facilities, clubs, training and coaching, so does their demand for recreational and competitive sport.
Evidence is clear on the positive role sport can play in the physiological and psychological rehabilitation of injured and disabled people.36,43,44 According to Sherman ‘after medical rehabilitation is completed, sports have an invaluable therapeutic value in renewing the paraplegic’s lost powers, helping coordination, and maintaining stamina’. 36 However, if well managed by a partnership of professionals (clinicians, physiotherapists, prosthetists, orthotists, paralympic classifiers and coaches) this appetite for competitive sport by disabled veterans could not only aide the process of rehabilitation but also identify, and prepare, them for elite athletic competition.
However, it must be noted that disabled people have been highlighting for many years that sport is not just a useful means of rehabilitation for the war injured (and others with acquired or congenital impairments) but also an activity that can be enjoyed by disabled people in all the same ways as non-disabled people. In that connection, advocates of the Paralympic movement and disability sport more generally have suggested a shift from a therapeutic to a recreative view of sport, and to regard sport primarily as a means of participation and competition and not as a means of rehabilitation.12,45 This reflects the shift in understanding from a medicalized to a social view of disability. 15 Since the 1960s disabled people have lobbied against a medical perspective of disability in which they are oppressed by a dominant non-disabled hegemony. Notwithstanding the significance of this context and the wider implications of ‘disability politics’ 46 for those recovering from war injury it would be of most benefit to the injured and the Paralympic movement, if their disablement was considered from both a ‘therapeutic’, as well as ‘recreative’, perspective, in which their medical and sporting needs were considered equally and at the same time.
That is to say, rehabilitation after injury and integration back into sport or into sport for the first time may be most successful when a combination of expertise is offered. Knowledge of the patient, their injury, their sporting aspirations and the opportunities available for participation, performance and elite representation can only be provided by a range of professionals. This partnership approach to rehabilitation established at the outset of any treatment may be essential if the individual is to reach their full sporting potential and gain similar levels of achievement to those enjoyed prior to their disablement.
Conclusion
Drawing on the US military experience it is possible to argue that sport in the UK and other parts of the world should be more widely recognized as a component of physical and mental rehabilitation. To achieve this, as a first step there is clear need for the development of specific protocols to identify injured individuals who can participate within a specific sport discipline at an elite level. This protocol development and implementation should be carried out by a team of multidisciplinary rehabilitation professionals including rehabilitation medicine specialists, bioengineers, prosthetists, orthtotists and physiotherapists along with Paralympic administrators and sports and exercise scientists.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors