8 key principles for rehab with para-athletes

Thankfully, people of all abilities can participate in some form of meaningful movement as part of a healthy lifestyle. Whether in recreation or competition, those with disabilities suffer injuries just as typically-abled athletes do. They may then visit a physiotherapist seeking help for their injury and training to return to sport. The eight key principles outlined by Sean Fyfe help guide the therapist's treatment plan for a more successful outcome.

The history of disabled athletes participating in sport dates back to the late 1800s with sports clubs for the hearing impaired in Berlin, Germany. After World War II, Dr. Ludwig Guttmann opened a spinal injury rehabilitation unit at Stoke Mandeville Hospital in England and integrated sport into the recreation program. To coincide with the opening of the  1948 Olympic Games in London, Dr. Guttmann held a wheelchair archery competition between disabled veterans and called the event the Stoke Mandeville Games. Before long, international teams competed in the games, which eventually became known in 1960 as the Paralympic Games.

Today, the games take place every four years in the same city as the Olympics and are governed by the International Paralympic Committee (IPC). They include athletes of all nationalities and varying abilities. The IPC defines para-athletes as any person who's impairment impacts their sports participation (1). To participate in the Paralympic games, athletes must meet the minimum disability criteria and be classified according to the impact of their disability (see Box 1).

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Box 1: Minimum disability criteria

Each sport’s Paralympic classification rules describe how severe an eligible impairment must be for an athlete to be considered eligible. These criteria are referred to as minimum disability criteria. Examples of minimum disability criteria could be a maximum height for short stature or a level of amputation for athletes with limb deficiency.

Minimum disability criteria should be defined on the basis of scientific research, which assesses the impact of impairments on the sport’s activities. In this, it can be guaranteed that an impairment impacts performance in a certain sport. The minimum disability criteria are sport specific because the activities are different. As a consequence, an athlete may meet the criteria in one sport, but may not meet the criteria in another. If an athlete is not eligible to compete in a sport, this does not question the presence of a genuine impairment.

The IPC recognizes ten eligible impairment types:
1.     Impaired muscle power
2.     Impaired passive range of joint movement
3.     Limb deficiency
4.     Ataxia (lack of muscle coordination due to problems in the central nervous system)
5.     Athetosis (repetitive and more or less continual involuntary movements)
6.     Hypertonia (abnormal increase in muscle tension)
7.     Short stature
8.     Leg length difference (minimum of 7cm)
9.     Visual impairment
10.   Intellectual impairment

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With a high level of inclusion and performance comes high probability of injury. While lacking stats for para-athlete injuries, one should assume they are at least equal to those of typical athletes. When working with a para-athlete, keep in mind the following eight key principles.

1. The individual’s disability

Start any work with an athlete with a disability by developing a deep understanding of an individual’s disability, and specifically your athlete’s individual presentation of that disability. This will involve developing your own series assessment and re-assessment parameters that are important to the athlete - so that you can gauge progression or possibly regression. Any work you do with an athlete with a disability will generally have to be in the context of their disability.

2. Understand the sport

In some instances, things may not change from the able-bodied sport and in others, there may be significant changes. Most sports-injury practitioners have an in-depth knowledge of a sport and may have even played that sport, which further enhances the knowledge base. This is not the case when it comes to sports for competitors with a disability, like wheelchair rugby. If possible, try it yourself. Study the sport and understand the physical demands. This is crucial during late-stage rehabilitation when your aim of programming must ready them to meet the demands of returning to sport.

3. Make strengths stronger

Ten years ago when I was completing my level-3 tennis coaching level course, we had a very successful visiting tour coach give a guest lecture. Something very simple from this lecture still resonates with me to this day whenever I work with an athlete and I think it rings true even more so for athletes with a disability:

“Know the strength and make it stronger. I spend 90% of my time working on my players’ strengths, not weaknesses”.

His reasoning for this was two-fold: the first was obvious - to practice how you are going to win points and not how you are going to protect losing. And the second was all about the mind – confidence. For athletes with a disability, there are mostly going to be obvious weaknesses in physical capacity. But my message is to realize the strengths and focus on them in training, rehabilitation, and communication.

4. Look for what can compensate

One thing you will always be thinking about when dealing with athletes with a disability is how you help your athlete improve somewhere in order to overcome a limitation somewhere else. For example, with an athlete with visual impairment that impacts the usual system of integration between vision, vestibular and somatosensory information for dynamic balance control - how can you help make their other two systems even more heightened to compensate? Or for an athlete with a specific joint impairment of the knee - how can I improve the surrounding joint and muscle function of the hip and ankle to compensate?

5. Plan highly individualized treatment

We know every athlete is different, but this is true even more so for athletes with a disability.  Take for example a shoulder injury in an athlete with an incomplete spinal injury, where the athlete will have neurologically intact strength but partial sensory limitations. The therapist must have the complete picture of shoulder function due to the disability - but then also be able to assess what changes may be happening around the shoulder based on the musculoskeletal condition. In this case, individualized testing and re-testing over time are crucial for individualized rehabilitation, injury prevention, and training strategies.

6. Implement effective recovery strategies

Think about how hard the shoulders and arms have to work in a wheelchair athlete, whether it be on the track, basketball, rugby or tennis. Likewise, think about the work of the dominant leg in an athlete with an amputee. Recovery strategies for these areas of the body that perform the lion's share of the work are essential for injury prevention.  These strategies can include targeted joint and limb compression or cryotherapy, an athlete-specific routine of soft tissue massage, trigger pointing and stretching, designated recovery sessions and cross training. These should be combined with closely monitoring workloads and fatigue from the general perspective (as well as in specific body areas) to help plan training based on how the athlete copes physically.

7. Be prepared to think outside the box

Firstly, take what you think is normal for an injury or performance target for a specific test and be prepared to throw it out and start again. Think of a below-knee amputee. How strong do the hamstrings and the gluteus maximus have to be to compensate for having no functioning ankle for propulsion? Or how well developed do the gluteus medius and minimus need to be as stabilizers, considering there is far less contribution from single leg stabilizers down the kinetic chain?

The second consideration of this principle prepares you to implement new and inventive ways to train and rehabilitate. On occasions when you can’t use traditional training methodologies or equipment, think outside the box to develop equipment and exercises that are effective for the individual, even if they are a bit weird and wonderful!

8. Check your own beliefs

I’ll explain this principle using the case study of a young male client. Deprived of oxygen during his birth, he suffered a brain injury that left him with cerebral palsy. Despite the fact that his parents were told he would never walk, he walked unassisted at five years old. Though professionals recommended he play wheelchair tennis, he refused as he wanted to play like his idol, Pete Sampras. With the help of his father as his coach, the subject played tennis unassisted.

Nine months before coming to our clinic, the patient suffered a stress reaction in his patella. He continued to play tennis for six months until his patella spontaneously fractured when going for a wide volley. The fracture was managed non-surgically with a splint until healed. The real challenge began with the commencement of his rehab to address the deficits the forced rest inflicted - mainly significantly reduced quadriceps strength.

While applying the seven principles above, I found myself having to continually check my own beliefs, my own preconceptions of what was possible, and my own language. To the patient, it was only a matter of ‘when’ not ‘if’ he would return to playing tennis. Very early on, and to my surprise, he started talking about how improving his strength could improve his movement and performance on the court.  I had to make sure that my language matched his confidence, as in the back of my mind I had doubts about whether any of this was going to be possible. I had to ensure that I was planning rehab that allowed him to meet his goals, not my preconceived notions about his ability.

In my experience, athletes with disabilities display more mental toughness and determination than typical athletes. As Andrew Hamilton reported previously, the science bears this out. Helping this client achieve his goal of returning to tennis was certainly one of the most satisfying moments in my professional career. Watching him play tennis, I witnessed the sheer will of an individual forcing himself to move in ways that often seemed impossible.

Reference

1. Explanatory Guide to Paralympic Classification. 2015 Sept. www.paralympic.org