Paralympics 2012: creating a foundation and determining success

‘There are no secrets to success. It is the result of preparation, hard work, and learning from failure’.

Colin Powell

There is no doubt that the Paralympic Games represent the pinnacle of sporting achievement and showcase exceptional levels of talent. The journey taken to reach this level is characterised by relentless training regimes and unflinching drive to succeed. While it is fair to assume that the majority of clinicians and researchers will not be involved in the management of a Paralympian, many will deal with individuals with a disability who express an interest in participating and/or competing in sport. This view is supported by the significant impact sport has on society as a whole, with ever-increasing numbers leading an active and healthy lifestyle. From the family out jogging in their local park to a well-disciplined Olympian/Paralympian, all levels of ability and commitment find an expression in sport. The arrival of the London 2012 Olympic and Paralympic Games will be a defining moment for many, and with the supporting media coverage and abundance of analysis, it is hoped that it will stimulate interest in sport and active participation. This vision applies equally to the disabled as well as the able-bodied.

Although it is known that participation within sport in individuals with a disability dates back to the eighteenth and nineteenth centuries, ¹ the opportunities that exist today have evolved greatly. Many, however, would argue that this is not universal with limited progress and opportunity for people with disability to participate in sport in developing countries. With more than one billion people worldwide currently living with some form of disability, ² this figure is set to increase with an ageing population, complications associated with a rise in chronic disease (e.g. diabetes mellitus, peripheral vascular disease), road traffic incidents and the current war conflicts. This increase will place further financial burden on governments and health-care systems. Sport, however, can be considered as a cost-effective and valuable method of rehabilitation, which in turn can cultivate a positive approach to an active and healthy social lifestyle.

The number of individuals with a disability taking part in sport has grown substantially over the last 60 years. One of the main influencing factors associated with this increase is the rehabilitation of personnel injured in the Second World War and the vision and dedication of Sir Ludwig Guttmann, a professor of neurosurgery. Guttmann believed that sport undertaken by individuals with disability could be competitive and exciting, and perhaps more importantly, he considered it as playing a vital role in rehabilitation. In 1948, on the same day as the opening ceremony of the London Olympic Games, the first Stoke Mandeville Games were held in England and involved an archery competition between patients from Stoke Mandeville and the Star and Garter Home, Richmond, Surrey. ³ From 1949, the Stoke Mandeville Games became an annual event and grew in stature in terms of competitors; the First International Stoke Mandeville Games were held in 1952. A year later, the term ‘Paralympic’ was introduced to the media (Bucks Advertiser and Aylesbury News), ⁴ and while the exact origin of the term is vague, it is thought to derive from combining the words ‘paraplegic’ and ‘Olympic’. Although officially known as the Ninth International Stoke Mandeville Games, the First Paralympic Games were held in Rome, Italy, in 1960, but was reserved for spinal cord injury competitors only. The games expanded in 1976 and included competitors who were visually impaired, amputees and les autres (other conditions that result in disorders of the locomotor system). That same year also saw the inaugural Winter Paralympic Games, which were held in Örnsköldvik, Sweden. The evolution of the Paralympic Games represents the appetite for sport among the disabled, and this rapid growth suggests that the challenges faced by early disabled athletes should serve as an inspiration for new generations of disabled athletes who can find life-affirming challenges and satisfaction through participation in sport. Readers with a keen interest in the history of the Paralympic Games Movement are therefore referred to comprehensive texts of Bailey, ³ Gold and Gold, ¹ Goodman ⁵ and Vanlandewijck and Thompson. ⁶

While Guttmann is regarded by many as the ‘Father of the Paralympic Movement’, his vision of the Paralympic Games running in tandem with the Olympics remains unfulfilled. Some may argue that such synchronisation would undermine the Paralympians and that it should continue to stand alone to better represent the talent, dedication and devotion of arguably more inspirational athletes, their coaches and support teams. Whatever your thoughts, as a reader, a clinician and a researcher, while heroes will be made during the Olympics, the same will be true of the Paralympics, which will certainly capture the imagination of many with the true talent and determination on show. It also remains to be seen how many of the 279 world records set at the 2008 Beijing Paralympic Games ⁷ will be recreated.

Technology, sport and disability

‘Technology is a queer thing. It brings you gifts with one hand, and it stabs you in the back with the other’.

CP Snow, New York Times, 15 March 1971

Technology is a word ingrained within modern life that enables progress and development within daily and social activities. As technology progresses, the demands, capabilities and expectations increase. Within the context of sport and disability, advances in technology are regarded as the foundation, particularly when prostheses, wheelchair and its related devices are considered.^8–10 The application of technology can, however, be contentious with the key argument based on the potential to create an unfair advantage of one athlete to the next. ¹¹ The most well-known and reported example relates to Oscar Pistorius, also known as the ‘Blade Runner’. While there is no doubt of Pistorius’s skill and talent, the use of state-of-the-art prosthesis technology (J-shaped carbon-fibre Össur Flex-Foot Cheetah) is regarded by some authors to have assisted his qualification for the 400 m, London 2012 Olympic Games. In a ‘Letter to the Editor’, Chockalingam et al. ¹² argued that if a true prosthesis serves to replace a missing body part, then it should be worn for daily activities, everyday, and this by definition includes participation in sport. While this explanation appears theoretically sound and logical, present day prostheses and perhaps the more cost-effective devices worn by an amputee do not have the ability, robustness and adaptability to allow the individual to participate in sport. Furthermore, this debate is limited in other sports such as swimming where individuals will remove their prosthesis since it hinders their technique and performance. ¹³ However, as Burkett ¹⁴ points out, a key issue in the role of technology and in the context of disability and sport is whether it is essential for performance or enhances performance. It is beyond the scope of this editorial to debate this issue in detail; however, it is likely that following London 2012, further demands and challenges will be placed on the international sporting bodies, such as the International Paralympic Committee, to reach a scientific consensus on the use of technology and its devices in sport.

Within any sport, there are athletes who characterise true technical brilliance, and this is no more apparent than in a Paralympian. Present and past examples include the previously mentioned Oscar Pistorius (South Africa), Louise Sauvage (Australia, wheelchair Paralympian – now retired), Dame Tanni Grey-Thompson (Great Britain, wheelchair Paralympian – now retired) and Evan O’Hanlon (Australia, T38 (cerebral palsy), 100 and 200 m). These athletes are automatically recognised within their sport for their efficiency in motion and performance. However, in order to achieve this, the athlete must possess a physical stature that can cope with the demands of the sports biomechanics. Moreover, their neuromusculoskeletal system must coordinate in an effective manner, and the physiological system must be able to maintain the performance of the sequences of motion. These features are combined with the psychological skills required to focus the mind and effort. This is challenging enough for the able-bodied athlete, but the demands for integrated function and compensation for athletes with a disability are even greater. This and the repetitive nature of training and high performance can predispose the athlete to acute and chronic injuries. Recognition of this fact by the clinician beyond the rehabilitation phase and optimising technique and performance to minimise the risk of injury in terms of prevention is therefore an important aspect of comprehensive sports management.

While earlier discussion may be biased to the Paralympian, it is at the foundational level that more recognition, assistance and support from clinicians, coaches and researchers are required. Developing and optimising a technique within a particular sport in an athlete with a disability is based on a series of building blocks, which integrate balance, stability, mobility and symmetry. For many individuals who have a disability, however, their recreational needs are not always considered, particularly during the rehabilitation phase. For example, a new transtibial amputee who prior to the loss of his/her limb was a keen recreational runner expresses a desire to continue with this activity. The initial rehabilitation team, which in an ideal world would be multidisciplinary, should discuss the expectations of the patient and the long-term functional goals. In general, for many sporting activities, running appears to be the basis. This in turn identifies the need for the rehabilitation team to acknowledge this and incorporate programs and assistive technology for active individuals. Perhaps the key message here is the need to recognise that the health benefits associated with exercise apply to the disabled, every bit as much as to the able-bodied. In fact, due to the many psychological issues that the disabled may be faced with and the potential for sport and exercise to manage these, it is eminently desirable that sport is promoted within this group. This will only happen when the impediments to participation are removed – setting forth the true challenge for modern researchers and clinicians. In essence, optimising function should not just be for activities of daily living, but for sport that should be seen as an essential activity of daily living to which the disabled have a right.

Objectives of this Special Issue

The London 2012 Paralympic Games provides a timely and exciting opportunity to explore and present informative research that has clinical relevance from the foundational level of the novice sports person with a disability to the elite Paralympian. This Special Issue contributes to the understanding and development of clinical perspectives and science of sport and disability from around the world. By the time this particular issue of Prosthetics and Orthotics International is in print, the London 2012 Olympics will have been completed, and the Paralympics will already be well underway with new records and role models being created.

This Special Issue begins with four reviews, the first of which by Deans et al., explores the motivations that inspire and the barriers that face prosthesis users in sport . Of the 12 articles examined, they note that only a small number of individuals who have had an amputation are participating in some form of physical activity/sport. When compared with motivation, they highlight the dominance of barriers and attempt to reinforce the need for daily physical activity/sport for all. The role of elite sport participation as part of the rehabilitation strategy for war-injured veterans is examined by Chockalingam et al. in the second review. Their analysis of the existing literature suggests that while ‘therapeutic recreation’ is gaining in popularity, there is a clear need for incorporation of protocols, which are multidisciplinary in nature, to facilitate the identification of individuals with potential to participate at elite level. They also point out that the United Kingdom and other areas of the world can learn from the experiences of the US Army that endorse participation in sport at an elite level as an important aspect of the rehabilitation phase. In a systematic review, the psychological attributes and well-being of the Paralympic athletes are explored by Jefferies et al. This article points to a number of limitations of the existing literature on the topic area. In particular, the authors highlight the need to foster a holistic view by integrating a psychological profile of disabled athletes in order to optimise performance. The final review is provided by Bragaru et al., who examine the use of sport prosthesis for upper and lower limbs. They note that the majority of the existing literature is descriptive in nature, which is typically based on expert opinions and technical notes. Although not inclusive of Paralympic events, they present a range of sports such as swimming, cycling, running, basketball, fishing, skiing and golf. While this latter sport can challenge the best of us in terms of skill and technique, it is a sport that can be played from young through to old, with excitement (as well as frustration!). In considering this point, and in terms of disability, there is potential scope for golf to be included as an event in future Paralympic Games, and would echo the reintroduction of golf (last included in 1904) as an Olympic sport at Rio de Janeiro in 2016. Perhaps more importantly, it may allow more direct comparisons to be drawn between the Olympics and Paralympics, which can only enhance credibility, exposure, talent, opportunities and funding.

In keeping with the traditional format of the journal, the reviews are followed by a series of original research reports, the first four of which are focused on running, jumping and sprint abilities of amputees. Using two-dimensional, sagittal plane kinematics, Nolan et al. examined the take-off technique for the long jump of Paralympians with a unilateral transtibial amputation and carbon-fibre prosthesis. They show how the prosthesis limb acts similar to a ‘springboard’ that conserves horizontal velocity. The authors note the importance of an alternative and correct technique needed for those individuals expressing a desire to take-off using their prosthetic limb. The questionable role of fairness concerning sprint prostheses at the Paralympics is explored by Dyer et al. This article builds on from previous research and examines the proposed use and pilot testing of a unilateral jump technique for athletes with unilateral amputation. Using the RS Footscan (RScan Ltd, Ipswich, UK), they show that six jumps are required to obtain reliable findings. While further research is required to determine the influence of fatigue, this assessment provides a method of determining fairness for use in lower limb sprint prostheses.

Running in amputee sprinters is the focus of the article by Hobara et al. Using a spring–mass model to determine leg stiffness, they compared and calculated body mass, ground contact and flight times during a one-legged hopping action. They show that both transtibial and transfemoral amputees had a higher leg stiffness compared with the non-amputees. Their analysis also demonstrates that the sprint ability of an amputee can be predicted from leg stiffness during the one-legged hopping task, which can aid the planning of training of athletes. The contribution of Strike et al. compares the influence of a shock-absorbing pylon with a rigid condition in recreational transtibial amputees during running. Their findings question the use of the pylon in reducing the impact forces during a flat level speed of 4.0 m·s^–1.

Differences in upper body kinematics of children who are experienced and inexperienced wheelchair users are examined by Starrs et al. They note that during three functional propulsive assessments, the inexperienced user performed better demonstrating a larger shoulder flexion angle. This differed from the experienced wheelchair users, who showed a larger elbow range of motion, and lends support that the shoulder is a key joint for an efficient propulsive technique. The role of core stability, (a popular topic within the sporting world in general), balance and strength in amputee football (soccer) players is explored by Aytar et al. Their analysis shows a relationship between core stability and sacroiliac mobility and suggests that this should be evaluated as part of performance analysis in amputee soccer players. In a slightly alternative approach, the role of functional improvement and social participation in sports of children with mild to moderate mental retardation is investigated by Ghosh and Datta. This article is written from the perspective of a developing nation (Kolkata, India), and the authors demonstrate how participation in sport activities aided the functional well-being, but note the community anxieties of their participation. The last of the original research reports is by Frossard, who presents the performance dispersion for evidence-based classification of female and male shot-put throwers. This data was gathered from the 2008 Beijing Paralympic Games which allowed the formulation of comparative matrices, performance continuum and dispersion plots that can be used to understand the classification of related variable.

The four running-related articles previously described are complimented by a case study by Waetjen et al., who show how a change from rearfoot to a forefoot strike can reduce ground reaction forces at impact and loading at the knee of the intact limb in a runner with transtibial amputation. This case study lends support to the current debate with strike patterns in able-bodied runners.^15–17

It is clear that the Paralympic Games will incite various interests from around the world, each of which can have an impact from a social and cultural perspective. In a technical note, Lee et al. report on an innovative design of an adaptive seating system. Although presented for dragon boating, the set-up mechanism of action in terms of stability for athletes with trunk and lower limb weakness is appealing for other forms of boating.

The Paralympics Games have gained a high public profile, which is fundamentally driven by the commercial marketplace. While funding opportunities from sporting bodies are limited even for able-bodied athletes, further challenges exist for athletes with a disability. The companies that design and create prostheses and other assistive devices for sport remain central to the development of facilitating the inclusion of disabled athletes in sport from the novice to the elite Paralympian. In recognition of this contribution, this Special Issue provides a series of short papers based on Clinical Perspectives in Research and Product Development. The four papers, which include contributions from Össur (UK), Adaptive Sport Ankle Prosthesis (USA), novel Gmbh pressure systems (Germany) and performance analysis in sport (Canada), are clinically based. The first two papers represent dialogue that is product centred, which focuses on the contributions of innovative prosthesis design. The remaining two papers are analysis driven, the first of which is based on novel Gmbh, a company which incorporates pressure analysis into the assessment of amputees and wheelchair users with their pliance^® and in-shoe (pedar^®) systems. The final paper of the series represents a comprehensive discourse integrating the use of biomechanics, performance analysis in athletes with a disability. The discussion focuses on a wide range of issues and highlights the complexity of modern training of athletes with a disability that can be used to analyse the novice through to the elite Paralympian.

This Special Issue attempts to address and contribute to the scientific literature in terms of progression, performance and rehabilitation of athletes with a disability. Perhaps more importantly, from a clinical perspective, it serves as a timely reminder that as clinicians, we have a duty to treat individuals with a disability – to enable them to participate in sport and lead a healthy lifestyle in spite of their disability. The London 2012 Paralympics Games will represent an accumulation of intense, unique and exciting opportunities for many. Whichever nation you are from (or support), it is hoped that each athlete, a medal winner or not, will obtain the recognition they truly deserve and inspire the champions of tomorrow. Happy reading and viewing!