An overview of common injuries to individuals with disabilities.

Athletes in wheelchairs have broken the four-minute mile and can run marathons well under two hours (Mangus, 1987). In Barcelona, sell-out crowds of over 55,000 were present for opening and closing ceremonies at the 1992 Paralympic Games. Presently, as many as two to three million United States residents with disabilities compete in recreational and organized sports (Ferrara, Buckley, McCann, Limbird, Powell, & Robl, 1992). Though many of their injuries are similar to those occurring with non-disabled athletes, there are still injuries unique to athletes with disabilities (Peck McKeag, 1994). In addition, certain groups with disabilities pose special medical risks which must be appreciated and accounted for to ensure safe and healthy participation. The better our understanding of these injuries and conditions, the better we can succeed in treating and preventing them. Our knowledge, care, and consideration of these issues can make the difference between an optimal, wonderful, rewarding experience, or one fraught with frustrating injuries, serious emergencies, and even death. Thus--

* What types of injuries can we expect to see in individuals with disabilities who engage in physical activities and sport?

* In whom are these injuries occurring? What types of injuries are common to individuals with what types of disabilities?

* What are the causes of these injuries?

* In what body regions are these injuries occurring?

It is the purpose of this article to address these questions. Hopefully this information will enable us to minimize the frequency and severity of these injuries, as well as help athletes with disabilities reach their optimal levels of performance.

To begin, in what types of sports are individuals with disabilities participating? A better question is, In what types are they not participating, for the list is virtually endless. In Sports and Recreation for the Disabled: A Resource Manual, Paciorek and Jones (1989) presented 57 different sports and recreational opportunities in which individuals with disabilities participate. Since the list expands yearly, these authors recently published a revised, even larger, and more comprehensive edition. Regarding injuries, it is not surprising that sports posing the highest risks to athletes with disabilities are also high risk sports for non-disabled athletes. Moreover, athletes with disabilities have invented some very high risk sports of their own! So, it is not surprising that sports posing risks for injuries include goal ball, quad rugby, mountain climbing, sky diving, and SCUBA diving. Again, consistent with non-disabled athletes, researchers identified road racing, basketball, track, and tennis to be sports resulting in highest risks for injuries. Sports with moderate amounts of injuries include weight training, field events, swimming, and archery. Sports with lower frequencies of injuries are table tennis, slalom, billiards, and bowling (Curtis & Dillon 1985).

Common Injuries

Ferrara et al., (1992) conducted surveys of 426 athletes who competed in the 1989 national competitions of the National Wheelchair Athletic Association (NWAA, now Wheelchair Sports USA), United States Association of Blind Athetes (USABA), and United States Cerebral Palsy Athletic Association (USCPAA). Definition of injury encompassed any trauma to a participant occurring during practice, training, or competition causing an athlete to stop, limit, or modify competition for one day or more--329 of 426 respondents reported at least one-time loss injury. By organization, 26% were from NWAA, and 37% from both USABA and USCPAA. Shoulders, arms, and elbows accounted for 57% of NWAA injuries; the lower extremities accounted for 53% of USABA injuries; and for USCPAA, injuries were distributed among knees (21%), shoulders 16%), arms and wrists 16%), and legs and ankles (15%) (see Table 1). Not surprisingly, these injury rate distributions were consistent with the most active body parts by disability. The authors concluded that athletes with disabilities demonstrated approximately the same percentage of injuries as non-disabled athletes in similar sport activities. According to Peck McKeag (1994), in the 1988 Paralympics, 60% of athletes reported injuries/illnesses compared to the 1988 Olympics where 75% of non-disabled athletes reported injuries/illnesses. Furthermore, in 1989, an injury rate of 32% was reported for athletes with disabilities, while 24-40% was reported for sports involving non-disabled athletes.

Table 1
Injuries by Disability Area (i.e., Sport Organization)
   Sport       Percent   Body Part
Organization   Overall   Affected by Percent
NWAA            26%      Shoulders & elbows     57%

USABA           37%      Lower extremities      53%

USCPAA          37%      Knees                  21%
                         Shoulders              16%
                         Arms & wrists          16%
                         Legs & ankles          15%

Common injuries seen in athletes with disabilities have included muscle strain, abrasions, elbow tendinitis, plus upper respiratory tract infections (Peck McKeag, 1994). The more common injuries seen in wheelchair sports included soft tissue injuries, blisters, abrasions, and lacerations (Arnheim, 1989; Curtis Dillon, 1986). Wrist injuries, especially carpal tunnel syndrome, were reported in 23% of all athletes using wheelchairs studied by Burnham and Steadward (1994). Of all athletes using wheelchairs tested, with or without wrist pain, 64% demonstrated positive electrodiagnostic tests for this syndrome. In an earlier study by Burnham et al., (1993), rotator cuff impingement syndrome was seen in 26% of athletes using wheelchairs. Table 2 summarizes this information and identifies specific causes for injuries (percentages exceed 100 as data are reflective of multiple studies, as previously noted). Most causes involved inadequate protective padding and training considerations, especially overuse.

[TABULAR DATA 2 OMITTED]

In addition to looking at injuries by frequency, Mangus (1987) reported injuries by body regions (see Table 3). As noted in Table 1, causes were suggested for injuries. Not surprisingly, both injuries and their causes (inadequate training techniques and protective equipment) are similar to those presented in Table 2.

[TABULAR DATA 3 OMITTED]

Special Medical Health Conditions and Risks

The purpose of this section is to identify special medical health risks unique to individuals with disabilities. Even if an injury is similar to those sustained by non-disabled athletes, often, because of the nature of the disability, the injury deserves special consideration. If special needs are ignored, many of these injuries could prove fatal. Thus, to provide necessary health care, as well as optimal training opportunities for these athletes, it is imperative these special conditions be understood and appreciated, including decreased healing times, decubitus ulcers, temperature regulation disorders, heart rate differences, drug interactions, contractures and spasms, blood pressure and autonomic dysreflexia, problems with urination and defecation, weight management, osteoporosis, communication deficiencies, ketoacidosis, hypogly-cemia, and postural and exercise hypotension. In addition, athletes with mental retardation often have special health risks, such as atlanto-axial instability, cardiac lesions, cerebral palsy, and asthma (Robson, 1990).

Due to a variety of skeletal, circulatory, and even neuromuscular impairments, healing time for injuries takes significantly longer for athletes with disabilities. Also, due to a disability, there are often fewer choices available for alternative exercise activities while in the process of undergoing rehabilitation. Decubitus ulcers (pressure sores) account for 25% of all medical costs for patients with spinal cord injuries (Mangus, 1987). Soft tissue can break down all the way to the bone; infections are unavoidable. Alternative body positions to relieve the stress are limited when ability to stand up is already eliminated. These sores occur due to pressure and friction. An individual's lack of sensation and decreased circulation are an invitation to frustrating situations. Sores on the buttocks and sacrum are common in athletes who use wheelchairs and are exacerbated by the new knees up elevated) racing positions obligating the athlete to sit in one position for long periods of time. Sweat and moisture cannot evaporate well with the knees held tightly against the chest.

Temperature regulation disorders are to be expected in athletes with lesions of T6 or higher. The nervous system is not intact to afford shivering or sweating responses. The body becomes poikilothermic; i.e., it assumes the same temperature as the environment (Schmidt Chan, 1992; Sherrill, 1993). Exposure to heat and cold without adequate clothing or environmental modifications is an invitation to thermal emergencies. An individual with quadriplegia, or high paraplegia, cannot move as vigorously to warm up as can others. Inadequate hydration exacerbates temperature regulatory problems. In addition, regardless of disability, very lean individuals have special risks for hypothermia; and their less lean counterparts are at greater risk for hyperthermia.

Due to less gross muscle function compared to non-disabled athletes, athletes using wheelchairs have significantly lower maximum oxygen consumption. Along with this, athletes using wheelchairs have comparatively higher heart rates. This is due to the fact that less venous return from the lower extremities enters the heart, thus resulting in lower stroke volumes. To make up for needed cardiac output, the heart rate increases; therefore, these athletes are more vulnerable to fatigue and stress, including thermal stresses, than their non-disabled counterparts.

Drug interactions play important roles in complicating and exacerbating existing injuries and conditions, (Peck McKeag, 1994). For example, medications for seizures, asthma, spasms, and arthritic pain have side effects, which, to say the least, are anti-ergogenic for optimal sport performances. Some of these side effects include dizziness, nausea, vomiting, stomach ulcers, fatigue, weakness, and loss of appetite Theophylline, a drug often taken for asthma, taken simultaneously with the antibiotic erythromycin, can result in increased theophylline in the blood to toxic levels. Asthma medications can cause unsteadiness. Seizure medications can decrease reaction time and cause sedation (Peck McKeag, 1994). Seldane, an antihistamine, when taken with many antibiotics, can cause fatal heart arrhythmias.

Muscle contractures occur when the joints are not moved through their normal ranges of motion. Contractures limit activities of daily living (ADL) needs, not to mention optimal sport performances. Muscle spasms occur due to excessive reflex activity below the lesion level. Individuals with spastic cerebral palsy do not have cerebral control to inhibit overactive peripheral afferents causing the motor afferents to fire (resulting in hypertonicity). People with complete spinal cord lesions above the L1 level also experience muscle spasms. Again, ordinarily the brain coordinates and controls this activity (Sherrill, 1993), yet this communication is impossible with an intervening spinal cord lesion present, Stimuli causing spasms include tactile input, such as touch, hot, and cold, as well as input from pathologies, such as a bladder infection or a pressure sore. Although frustrating, spasms are not dangerous unless they interfere with transfers or other activities of daily living. They are good for circulation and help to slow limb atrophy.

Baseline blood pressure in persons with lesions above T6 is typically low (Sherrill, 1993). Blood pressure responses to exercise must be interpreted in light of this fact. Autonomic dysreflexia, or hyperreflexia, is a life-threatening pathology that can occur in these individuals. Blood pressure becomes high, and heart rate becomes low. Sweating and goose bumps occur, even though they are not possible as temperature regulation responses (Schmidt Chan, 1992). A severe headache can also occur. A distended bladder or colon is often responsible for this reflexive condition. Cause must be identified promptly and solved, as this results in a complete shutdown of the autonomic nervous system, with death imminent. Some elite athletes using wheelchairs purposely invoke this condition to maximize blood circulation during track and swimming events (Sherrill, 1993). Peck McKeag (1994) reported a 9.7% improvement in race times with this procedure! Nonetheless, this is extremely dangerous and must be vigorously discouraged!

Urination and defecation require special attention in individuals with lesions at S2 or above; at least some dysfunction exists in nearly all athletes with paralysis. Holding urine and feces is contraindicated and can be fatal acutely due to autonomic dysreflexia, or chronically due to infections). Signs of infection can be a flushed face or elevated temperature, as well as a general feeling of malaise.

Weight control is harder for individuals with fewer moving muscles. Obesity is a major health risk to persons with paralysis because their hearts are already under greater stress due to venous insufficiency from non-functioning lower limbs. Sedentary life-styles lead to early and more severe osteoporosis. This makes the bones more vulnerable to fractures Sherrill, 1993). Participation in sports and recreational activities helps significantly in combating obesity and osteoporosis.

Communication deficiencies between coach and athlete often occur due to visual, hearing, or mental impairments which may be present. These communication problems can easily result in injuries. For example, according to Wilson and Washington (1993), 91% of all injuries in the 1990 Junior National Wheelchair Games were due to transfer injuries, foot scrapes, and hypothermia... and this was in swimming, a sport of supposedly moderate injury risk. Clearly improved communication, not to mention implementation of proper handling and environmental protocols, could serve to decrease this injury rate substantially.

Obesity and inactivity are also risk factors for diabetes. Ketoacidosis and hypoglycemia are problems associated with diabetes. Ketoacidosis can lead to diabetic coma and death; in contrast, hypoglycemia can lead to insulin shock and death. Postural and exercise hypotension can occur in persons with spinal cord injuries and other central nervous system (CNS) involvements. Proper training techniques, good nutrition, and adequate communication with the athlete and appropriate medical authorities help minimize occurrences of these events.

Athletes with mental disabilities, especially Down syndrome, often have atlanto-axial instability. Robson (1990) found this condition in 7.1% (24 of 336 tested) of athletes with Down syndrome participating the 1989 Special Olympics Games from the United Kingdom. Of the 1,512 competitors, 88 had cardiac lesions, mostly septal defects; 33 had cerebral palsy; 24 had asthma; 22 had hypothyroidism; I I had severe visual impairments; and 10 had diabetes. Athletes with mental disabilities tend to have more associated health risks than their non-disabled counterparts. Participation in most forms of exercise is still indicated; however, it is important to secure proper medical clearance, as with any medical disability.

In conclusion, athletes tend to experience similar types and frequencies of injuries as their non-disabled counterparts. In addition to these predictable injuries, many athletes with disabilities also pose health risks unique to their specific disabilities. Though some are life-threatening, essentially all should be preventable with knowledge and appreciation of their unique needs. In the event any of these injuries occur, expeditious management is crucial. This is to be addressed in a succeeding article.

Selected References

Arnheim, D.E. (19). Modern principles of athletic training. St. Louis: Mosby, 105-108.

Burnham, R.S. (1993). Shoulder pain in wheelchair athletes. American Journal of Sports Medicine, ](2), 238-242.

Burnham, R.S., & Steadward, R.D. (1994). Nerve entrapments in wheelchair athletes. Archives of Physical Medicine and Rehabilitation, 75, 519-524.

Curtis, J.A., & Dillon, D.A.(1986). Survey of wheelchair athletic injuries-common pattems and prevention. In Sherrill, C. (Ed.). Sports and disabled athletes. Champaign, IL: Human Kinetics.

Ferrara, M.S., Buckley, W.E., McCann, B.C., Limbird, T.J., Powell, J.W., & Robl, R. (1992). The injury experience of the competitive athlete with a disability: Prevention implications. Medicine and Science in Sports and Exercise, 24(2), 184-188.

Mangus, B.C. (1987). Sports injuries, the disabled athlete, and the athletic trainer. Athletic Training, 22(2), 305-310.

Paciorek, M., & Jones, J. (1989). Sports & recreation for the disabled: A resource manual. Indianapolis: Benchmark Press.

Peck, D.M., & McKeag, D.B. (1994). Athictes with disabilities: removing barriers. The Physician Sportsmedicine, 2(4), 59-62.

Schmidt, K.D., & Chan, C.S. (1992). Thermoregulation and fever in normal persons and in those with spinal cord injuries. Mayo Clinic Proceedings, 67:469-475.

Sherrill, C. (I 993). Adapted physical activity, recreation sport: Cross disciplinary and lifespan. Dubuque, IA: Burgess, 565-569.

Wilson, P.E. & Washington, R.L. (1993). Pediatric wheelchair athletics: Sports injuries and prevention. Paraplegia, 31, 330-337.

Christine Stopka is an associate professor in the Department of Exercise & Sport Sciences at the University of Florida where she directs the Exercise Therapy Program, as well as the graduate program in Special Physical Education. She is an NATA certified trainer, a licensed athletic trainer in the State of Florida, and an NSCA certified strength and conditioning specialist.