Focused Review

Sports and Disability

Pamela E. Wilson, MD, Gerald H. Clayton, PhD

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Medicine &n’s Hospital,80045. Ad-ail: Clayton.

Abstract: Participation in recreational and competitive sports at an early age has ltouted as a positive influence on growth and development, and for fostering lifelonlifestyles. The benefits of an active lifestyle include not only fitness, but the promosense of inclusion and improved self-esteem. These benefits are well documentpopulations, and their importance has been summarized in the recent Healthy Peoguidelines. The American Academy of Pediatrics has recently produced a summament on the benefits of activity for disabled children. They note that childdisabilities tend to have an overall lower level of fitness and an increased level of obthis population, developing a lifelong desire to be active can be a simple means forillness and much of the morbidity associated with sedentary lifestyles often associadisability. For disabled youth, participation in disabled sports programs available nand internationally can be an effective means to promote such precepts. The gofocused review is to improve the learner’s knowledge of the positive impact thlifestyles can have on overall health in the disabled youth population and, as a resultheir practice by incorporating recreational and competitive sport activities aimproving overall patient care.

PM R 2010;2

INTRODUCTION

In examining the impact that sports and recreation can have on habilitation and retion, consider a very talented young athlete who woke up one morning unable to mlower extremities. She was diagnosed with transverse myelitis and was devastateimpact this diagnosis would have on her life. During the day she was upbeat, but atreality of her situation was apparent. Her body and spirit were devastated, and hopprevious life was stripped away. Interestingly, however, during the rehabilitationshe was able to recapture part of her old self.

One of the crucial elements in this rebirth was her reintroduction to sprecreational activity. It gave her the strength and courage to move forward with a neClinicians need to understand the power that sports and recreation can have on thdisabilities. This is extremely important for adults who have been injured and perhmore so to children born with a disability [1, 2]. Sports, recreation, and play actiwhat ground young athletes and expose them to a different aspect of their lives.

THE ROOT OF DISABLED SPORTS

Before the 20th century, individuals with disabilities often were viewed as nonprmembers of society and often left to fend for themselves. The concept of survival ofwas used to justify infanticide and neglect. The large numbers of survivors of regiworldwide conflict appear to be a major impetus for the social reform necessary tocreation of organized disabled sports as a concept. Formal programs for thdisabilities can be traced back to 1888, when the first sports programs for the dstarted in Berlin. The actual deaf Olympics were formed in 1922. Sports for thphysical disabilities were introduced during World War II by Dr. Ludwig GuEngland, a neurosurgeon and director of a spinal cord injury program at Stoke MHospital. The clinicians in this program used physical activity as part of the

process, which evolved into competition among those in their rehabilitation programs

PM&R © 2010 by the American Ac1934-1482/10/$36.00

Printed in U.S.A.S46

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P.E.W. Department of PhysicalRehabilitation, B-285, The Childtal, Aurora, CODisclosure: nothing to disclose.

G.H.C. Department of PhysicalRehabilitation, B-285, The Childre13123 E. 16th Avenue, Aurora, COdress correspondence to G.H.C.; e-mjerry@tchden.orgDisclosure: nothing to disclose

[3].Submitted for publication May 12, 2009;accepted February 9, 2010.

ademy of Physical Medicine and RehabilitationSuppl. 1, S46-S54, March 2010

DOI: 10.1016/j.pmrj.2010.02.002

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S47PM&R Vol. 2, Iss. 3, Supplement 1, 2010

By 1948, as the Olympics were opening in LonGuttman introduced the first Stoke Mandeville Gamgames developed an international flavor when the Da team to compete in 1952 and, thus, the birtInternational Stoke Mandeville games. These gameheld today. In recognition of the need for an intecompetitive venue for disabled athletes, the Olymevents termed the Paralympics were first held in1960 [4]. Four hundred athletes with paralysis,countries, were present and competed in 8 sports.

The need to include multiple groups with dibecame apparent and the International Sports Orgfor the Disabled was formed in 1964 to includeathletes with spinal cord injuries (SCIs), but athlwere blind, who were amputees, and those with mdisorders. The Olympic games in 1976 were the firgames that merged multiple disabilities into a singleitive event. This is also the year during which the firParalympic events were held in Sweden.

The Paralympics have always been held in the samthe Olympics, but not until Seoul 1988 and Albertvwere they included in the same venues. Duringseveral decades, the Paralympics have evolved intolevel of competition. In the most recent games in(2008), 4000 athletes from 147 countries participDuring the 12 days of competition, 279 world recoset by these highly trained athletes. The next Paevents will be held in London, and a large group opants are expected to come from those young adultin recent years in military actions.

Before 1984, junior-age athletes could only coadult venues, which often placed them at a significavantage. During this same year, however, the first Uwheelchair sports meet was held in Delaware as aprovide young disabled athletes a venue at which thtruly compete with their peers. The event has since byearly, and to meet the needs of all disabilities, it hainto a multidisabled event analogous to the Pamovement. Disability groups include not only wathletes, but children/adolescents with amputations

Table 1. Prominent individuals with disabilities break

Athlete S

George Eyser Gymnastics: Olympics 1904Peter Gray Baseball: St. Louis Browns 19Liz Hartel Dressage: Olympics 1952, s

combined male female dWilma Rudolf Track: Olympics 1956 and 1Eddie Gadeal Baseball (St. Louis): 1959 heTom Dempsey Football: field goal kicker se

from 1970-2007 until it wasNeroli Fairhall Archery: Olympics 1984, firsMarla Runyon Track: Olympics 2000 1500John Curtis Pride Baseball: LA outfielder 2008

Natalie du Toit Swimmer: Olympics 2008 10,000 m

r.he

entthetillnalylein23

iesonnlyhoentialet-ter

as92astliteing5].erepicci-ed

ind-iortold

eldedpicairral

palsy (CP), visual impairments, and les autre (a mother disabilities). Athletes are not only classified byity but also by age. Opportunities for disabledadolescents to compete in sports have grown as sevegoverning bodies around the world have developprograms. Basketball now has youth as well as colltournaments.

A move toward disabled athlete inclusion in all aghas been adopted by several sports organizationssports such as fencing, archery, shooting, and tableinclude disabled groups/categories within their comso that able-bodied and disabled athlete alike can bethe event. Practical considerations, however, mayadoption of this philosophy because of time andconsiderations when large numbers of athletesacross many classifications.

As one reviews the history of sports for those withities, it is interesting to reflect on individuals whoabilities and participated and succeeded in sportnon-disabled athletes. Table 1 lists a few key individhave crossed these barriers.

ORGANIZATIONAL STRUCTURE OFDISABLED SPORTS

There have been many changes to the governing bdisabled sports during the years. The current organigrassroots and elite sports is under the doctrine of tnational Paralympic Committee, which develops posupervises the conduct of summer and winter eventswho impact decision-making policy include theParalympic committees, international sports federatthe 4 disability groups under the direction of InteSports Organization for the Disabled:

● Cerebral Palsy International Sports and Recreatioation;

● International Blind Sports Federation;

rriers in sports

Disability

on 6 medals Amputee competed with a pUpper extremity amputee

edal winner in a Polio

gold medals, 1 bronze Poliod one game Short stature (3 feet, 7 inchesrd 63 yard which stood

led by ElamPartial foot amputee

plegic in the Olympics Spinal cord injuryVisually impairedHearing impaired

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S48 Wilson and Clayton SPORTS AND DISABILITY

● International Federation for Sport for PersonsIntellectual Disability; and

● International Wheelchair and Amputee Federatio

CLASSIFICATION FOR DISABLED SPOR

Classification is a method to place individuals witdisabilities in a group that will provide for equitabletition. Classification systems have evolved and canwhat controversial. Different disability and sporthave different classification strategies. Originally ction was on the basis of a medical/anatomic model, bin philosophy has emerged on the basis of a fustrategy. This strategy combines different disabilmay have similar athletic performance. The athletlyzed as to his or her capacity to compete in a pevent. The classifier has to define what an athlete is cperforming, not just what he or she is demonstratprocess includes both bench testing and athleticmance. Swimming is an example of a fully integrathat uses 3 different steps to properly place an athclass [6]. These include a bench test, a water test, ancompetition.

Different disability groups continue to have sepasification and competition in the majority of events.sports, the classification system and rules allow athla given disability to compete either in one class or(but not both) as long as their abilities do not pdistinct advantage. For example, lower extremity

Table 2. Disability competition for Paralympic sports

Paralympic Event Wheelchair Amp

Archery xAthletics xBocciaCycling xEquestrianFencing xFootball, 5 vs 5Football, 7 vs 7Goal ballJudoPower Lifting xRowing xSailing xShooting xSitting volleyball xSwimming xTable tennis xWheelchair basketball xWheelchair rugby xWheelchair tennis xAlpine skiing xIce sledge hockey xNordic skiing x

Wheelchair curling x x

an

lare-e-ps

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arts

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track athletes could compete as ambulatory runnbecause of issues with their stump/prostheses, optpete in the wheelchair division (ie, crossover tocompetitive division). Their functional abilities wreevaluated as appropriate to their wheelchair clcrossover athlete would then be competing against ials with different disabilities (eg, SCI) but overall witfunctional limitations. There is no perfect classificatem, but the essential elements in any ideal systemprovide for fair and equitable competition, onlyfunctional limitations caused by the physical disauser-friendly so that they can be applied in a consisin every participating country, and be sports specificnatural talents of athletes, training effects, and bodyshould not be factored into the process.

CURRENT PARALYMPIC SPORTS

The scope of sports options available for elite-calibehas increased during the last few decades. Originawere 8 sports (fencing, track, field, snooker, baskechery, table tennis, and pentathlon). It was not unthat those with quadriplegia and visual impairmeincluded in competition. As with the Olympics, Pasports are added and removed on the basis of comand trends of the population. Table 2 contains a list owinter and summer events and what disability grofficially participate [8].

er and winter) [8]

Cerebral Palsy Les Autre Blind/Visual Imp

x xx x xx xx x xx x xx x

xx

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S49PM&R Vol. 2, Iss. 3, Supplement 1, 2010

TECHNOLOGY AND DISABLED SPORTS

Technology has been used as an “enabling” force foruals with disabilities ever since the first use of a canedeveloping enabling technologies has grown intofield, Assistive Technology. Wheelchairs, prosthetand other assistive devices such as crutches and whave seen significant advancement during the yearssurprising therefore that such changes have playedrole in the advancement of disabled sports. A few eare discussed in this section that demonstrate howogy has had an impact on disabled athletes.

Wheelchairs

Perhaps the most obvious disabled sports technolodevelopment of the racing wheelchair. Its historytraced back to the early days of wheelchair racing inat the “Stoke Mandeville” games. These games werfor veterans of World War II who had been hospitawere seeking a way to satisfy their competitive desiras recreate. The standard “hospital wheelchair” soway to modifications that lessened the weight and sthe chair. Such changes became “the competitive adand change has been going on ever since. In thStates, the first wheelchair patent was granted in 1mass production commenced in the 1930s undergranted to Herbert Everest and Harry Jennings [9,story goes that Everest, an engineer, built the firstubular steel wheelchair for his disabled friend, JMany will recognize the “E&J” moniker seen on wharound the world today. E&J, as well as many othenies, now mass produce not only standardized,everyday chairs but also sport and recreation wheelcthe masses.

An analogy for the evolution of wheelchair racing tecan be found in cycling. Because cyclists continually seetages to improve their speed, new materials (eg, carband titanium) and innovative design provide the athaerodynamic design and efficient transmission oThere are now an estimated 20 manufacturers dewheelchairs uniquely adapted for each sport. Tennprovide quick turning and enhance agility on the cowheelchairs for basketball and rugby also must beare much more strongly built to withstand the cinherent to the sport. Disabled athletes have their owmagazine, Sports n’ Spokes, which details athletic comand covers the latest wheelchair technology with thereviews.

Of recent note has been the development of thcycle.” Hand cycles, 3-wheeled devices propelled bthe arms, are different from the current 3-wheeledchair” in that they incorporate the advantages ofwhich has been adapted from cycling. Not only

cycling competition found around the world, this technolo

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is readily available to the recreational, weekend athmerely wants to go for a ride with friends and famporting an “active lifestyle.” In a way, the hand cyclean adaptation of the “recumbent” cycle more commonowadays for able-bodied riders.

The snow-skiing community has long fostered tsion of disabilities in their sport. The most recodisabilities on the slopes are the amputee skiers anchair users. For single-amputee skiers, the prosthettypically left in the locker, and they ski “3-track”crutches with ski tips on the bottom called outrigglimited technology gives the skier amazing grace aon the mountain. For competition each skier modifiher outriggers and tinkers with bindings and waxany other competitive skier.

The CP athlete and the double-amputee athlete m2 options: (1) ski upright (ie, 4-track) with the useand 2 outriggers (the amputee would need to use hprosthetic limbs in this case); or (2) use a sitting skiincalled a “sitski.” The sitski comes in 2 basic fomonoski and biski. Both use a frame made from alusteel hybrids, carbon fiber, and/or titanium. A seavided that can enables the skier to “fit” snuggly so thbody movement can weight and set ski edges as neaddition, a shock absorber adapted from motorcycleattached to the frame and the seat to absorb shockthe same way that knees function. The skis havesingle ski attached or 2 if balance is more of a conmore adaptations to the biomechanics of skiing neprovided. In skiing there is huge overlap with ski deadditional technology functions to adapt the skiefunctional limitations to the biomechanics of skiinskiers use.

Prosthetics

Another area of technological innovation has beenprosthetics. Amputees have sought more lightweefficient limbs to make their daily lives easier and praesthetic sense to make the missing limb less recoToday, however, sports limbs are high-tech, engmarvels designed for maximizing function rather thing for natural-like appearance. Now, prostheticsflaunted by the wearer rather than hidden by cpainted to look like flesh.

Advances in biomechanics and materials engineeprovided the athlete with very sports-specific adThe characteristics of materials such as titaniumfiber, and other “space-age” developments provideneer with the capability to create a limb/joint withbility and energy storage/release characteristics spdesigned for a given sport (eg, running, high jumpiskiing). In 2008, double amputee Oscar Pistorius fro

gy Africa petitioned the International Amateur Athletic Federa-

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S50 Wilson and Clayton SPORTS AND DISABILITY

tion to allow him to compete in the able-bodied O(not Paralympics), attempting to fight an earlier rulcating that his carbon fiber prosthetics provided aadvantage. It was posited that his “flexfoot” prosthsuch energy storing and releasing characteristics thvided him with an advantage. He won his petitionwill attempt to meet the elite qualifying standard inmeters for the 2012 Olympics [11, 12]. He did comwin a gold medal in the 2008 Beijing Paralympics. Itthat technological development has gone from enabple to participate in normal everyday activitiesconsidered too much of an advantage in competitioable-bodied competitors.

Sports Wear

Swimming is one sport that seems to be a greatwhen it comes to the ability of technology to prathletic advantage. One of the technological marveat both the able-bodied Olympics and Paralympicsand 2008 was the prevalence of “fish scale” swimmcodeveloped with NASA. Improvement in race timeto be available to those athletes wearing thesemarvels. The suits feature a lycra fabric with a herrfishscale texture plus innovative coatings that limsaturation and enhance shedding and buoyancy.[13] has estimated that this technology has prodaverage racetime improvement of at least 1%.

However, these suits may be particularly advantathose Paralympic athletes, whose disability inhercreases drag or whose generalized weakness makes ito move through the water. For example, the SCoften has difficulty efficiently moving through tbecause denervated limbs drop down below theincreasing drag. With these new low-drag suits,some race time may be reclaimed. Here the technoloto provide universal assistance; however, the advanbe more useful to those in the pool whose disabiliently increases drag. These types of suits may albenefit outside the competitive arena in recreationsports but, at this time, cost is a prohibitive factor.

These limited examples are only a few that shtechnology has had an impact on disabled sportfuture, innovative minds and new technology will uedly make new advances. An athlete with a need tomodate to a given sport will undoubtedly be ableuseful technologies found throughout science andFor instance, metallurgy of the space/aircraft induundoubtedly continue to provide the disabled athlighter and stronger racing chairs. As our understathe biomechanics of sport-specific movement improur understanding of the etiology of the physiologtations of individual disabilities grows, adaptationsing technology also will have an impact on disable

performance.

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SPORTS FOR CHILDREN WITH DISABIL

Sports and recreation are important for all children,or not. Sports help children to develop skills, exerlearn team play and how to get along with othbenefits of exercise are well documented. When consports programs, one needs to examine sports readdisabled children, this not only includes developmalso motor skills and coordination. Children withdisabilities may achieve these milestones at differintervals, and modifications need to be used (Table

Children who have a cognitive component mayslower, and modifications to instruction may nedifferent. Children with spina bifida and CP are khave nonverbal learning disorders, which will neincorporated into a sports plan. Disabilities with uncoordination problems require repetition to learnmotor activities. Children who have muscle weaknevery structured program to improve performancebreakdown muscle. Each disability group needs tsessed on the basis of the physical needs of the sporand the physical limitations of the individual.

PARTICIPATION IN HIGH SCHOOL TEASPORTS

High school sports programs for students with divary from state to state. Title 9 legislation entitlestudents to be included in sports activities openstudents, but no national legislation mandates inclthose with disabilities. Individual education plans mvide for adaptive physical activity, but some studentbeing excluded from school-based athletic progrillustrative case is that of Tatyana McFadden, a Parcaliber wheelchair athlete with spina bifida who justo “run” on her high school team as a fully included[15]. She was forced to compete alone and could npoints as a team member. In fact, she was a token athcould compete, but not with her able-bodied peers.much legal discussion, she was eventually alloweduring the same events and was given proportionpoints [15]. There are now several states that havethis dilemma with an equitable plan for full inclusio

SPORTS AND THE PERSON WITH A SEVDISABILITY

There is very little information available on sportspersons with very severe disabilities. This group inclhigh-level SCIs, and les autre (neuromuscular diHistorically, this population has been excluded froable activities because of resources and education oers. So what sports are available for this group o

individuals to participate in competitively?

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S51PM&R Vol. 2, Iss. 3, Supplement 1, 2010

Swimming can be performed by almost anygroup on both a recreational and competitive basis.disabled individuals with spastic quadriplegia, htetraplegia, and other significantly disabled athletes“les autres” in the older CP classification system) cothe lowest swimming classes.

Boccia can be played at a recreational or competitThe game itself is based on getting your balls as ctarget, “the Jack,” as possible. The boccia balls can bor rolled, and adaptive equipment such as ramps ancan be used. Athletes with severe CP class 1 and 2, alother severe disabilities, are eligible for Paralympiction. This is an ideal sport for not only CP athletes, bwith muscle disease and high SCI, including thoselators.

Power soccer was first developed in 1982 as an oa team sport for those players who use power wheelis played on a basketball court, and the rules arescoring is accomplished by getting the 22-inch ballgoal line. Basically anyone in a power wheelchair is eplay, and it is an upcoming sport.

LEGISLATION AND DISABLED SPORTS

Several key legislative directives have improved the csports for the disabled. The 1973 Rehabilitation Athat anyone receiving federal funds could not exclsons from programs or activities and that programs saccessible. Then, in 1978, the Amateur Sports Ac1998 the Olympic and Amateur Athletic Act both iand supported athletes with disability as part of themovement. The Steven Amendment mandated mo

Table 3. Developmental considerations for children

DevelopmentalAge [14] Typical Children [14]

2-5 years ● Introductory skills● Short attention span● Limited motor skills● Limited ability to

understand sports6-9 years ● Learning more

fundamental skills● Improving understanding of

game● Body control improving

balance and reaction time10-12 years ● Skills acquisition is improved

● Better motor skills● Better understanding of

game13-15 years ● Has fundamental and

advanced skills● Team sport● Competitive sports

sion of disabled athletes into high-level sports.

ityelyveledin

el.o awntesithti-seti-

for. Itle:

theto

ofteder-beined

piclu-

SPORTS MEDICINE FOR CHILDREN WITDISABILITIES

Participation in recreational and competitive sportshas inherent risks. People with have disabilities cothese risks with a unique set of conditions specifidisability. Table 4 lists conditions and relevant cations for sports participation [16-21].

EXERCISE AND ACTIVE LIFESTYLES FORPEOPLE WITH DISABILITIES

The benefits of an active lifestyle for both adults andare myriad, ranging from regulation of blood sumoderation or prevention of diabetes to improvecardiovascular health. Immune enhancement andments in psychological health (eg, depression, sdence) also have been well documented in the liter23-28]. Older adults appear to reap major benehaving an active lifestyle [29], including the followregular activity delays loss of independence; (2)indicates a reduction in fall-related injuries; (3) actireduce pain associated with arthritis; (4) activityprove sleep; (5) activity reduces symptoms of deand (6) activity may help reduce age-related cogncline.

The benefits of instituting a physically active prexercise at an early age are more difficult to emdocument. Long-term studies necessary to test sucheses require very lengthy follow-up, making them dimplement. There is, however, a significant amounrect evidence that supports this concept. In studying

isabilities

Goals for Children WithDisabilities Sports Consideratio

rk on mobility skills, wheelchairwalking.

rk on motor control anddamental skills such asing, pushing, and throwing.

● Introduction of variable sp● Emphasize fun and partic

not competition

rk on sports fundamentals.ntinue to work on adaptedbility skills and rulesdification.urance

● Emphasis on all sports andexposure concepts includtrack, field, swimming, baskiing, table tennis etc

● Introduction to individualteam sports.

re focused skills development.uranceerstanding game

vancing mobility skills

● Entry-level team and indivsports

rts-specific activities can bephasized such as basketball,nis, swimming.

● Ready for team sports anintense work out

● Competitive sports

with d

● Woand

● Wofunkick

● Wo● Co

momo

● End

● Mo● End● Und● Ad● Spo

emten

groups across varying age ranges, Bouchard [22] found evi-

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S52 Wilson and Clayton SPORTS AND DISABILITY

Table 4. Unique disability-associated conditions influencing sports participation

Disability Type Associated Conditions Implications/Recommendations

Down syndrome (DS) Atlantoaxial instability (AAI) ● All children with DS who participate in sports should have scervical spine radiographs (flexion, extension and neutral).

● Movement of more than 4.5 mm, restriction in sports is adv● It is not required to repeat normal cervical films.● Persons with atlantoaxial subluxation or dislocation and ne

signs should be restricted from contact/collision sport activ● Persons with DS who have no evidence of AAI may particip

all sports [13].Spina bifida (SB) Hydrocephalus and VP shunt ● Variable opinions exist about contact/collision sports activi

although reported shunt malfunctions with sports are unco● Restrictions in football, wrestling and Lacrosse have been

suggested [14,15].Latex allergies ● Common in children with SB.

● Need to consider equipment that contain latex, eg, baskeswim goggles, tires

Neurogenic bladder ● Common in SB and SCI● There may be at increased risk for UTI with different position

as in a track wheelchair.● Athletes with indwelling catheter are required to use a coll

device.Traumatic braininjury

Permanent neurologic sequelaeor parenchymal brain injuries

● Recommend no contact/collision sport activity

Spinal cord injury Temperature regulation ● Risks of heat or cold injury may occur from the loss of autocontrol.

● Monitor environmental temperature, hydration, medicationsymptoms [16].

Level of injury ● Impact on responses to exercise and cardiovascular respocervical injuries cannot increase heart rate to same extentlevels.

Autonomic dysreflexia ● Those individuals with spinal lesions above T6 present withhypertension, sweating, skin blotching, and headache. Sevsymptoms may progress leading to death if untreated.

● Effective treatment includes addressing elevated blood pr(eg, upright sitting position, sublingual nifedipine) and eliminociceptive stimulus.

● Athletes with higher lesions may use this response to enhanperformance (ie, “boosting”) [17]

Pressure ulcers are common inSB and spinal cord injurybecause of sensoryabnormalities below the levelof the lesion.

● Pressure area common in sports equipment and requireappropriate pads.

● Any open sore has to be covered in any athletic venue.

Cerebral palsy Musculoskeletal injuries arecommon from underlyingspasticity, ataxia and motorcontrol issues.

● Proper training and stretching may reduce injuries.● Use of proper equipment.

Seizures (applies to any personwith seizures)

● Well-controlled seizures should not restrict participation andcontact/collision sports are allowed.

● High-risk activities such as hand gliding, scuba diving, andclimbing are not recommended.

● Supervision for swimming, gymnastics, and rock climbing wsafety ropes [15,18].

Amputee Skin problems, including frictionand pressure

● Prosthetics and interface material should be optimally fit toshear and pressure

Musculoskeletal injuries ● Abnormal biomechanics can lead to overuse injuries.Les autre Multiple disability categories fall

into this group● A complete understanding of the disorder and its impact o

exercise and function should be done to identify potential

Muscular dystrophy ● Low-intensity exercise

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S53PM&R Vol. 2, Iss. 3, Supplement 1, 2010

dence that exercise may reduce morbidity andassociated with diseases affecting a variety of organAmong the short-term changes noted were: (1) anment in body mass index; (2) lower resting blood(3) improved lipid profiles; and (4) greater bonedensity, which may continue into adulthood.

The link between childhood physical activityfound in adulthood is strongly suggested. Dwyer ansuggest that an early active lifestyle either directlyrectly improves adult health as active children becomadults, which in turn improves adult health [25, 30know that sedentary adults are susceptible to morand associated morbidity, whereas there is a significof evidence indicating that experiences in early childtied to health in adulthood [22, 25]. In recent yearsand mind benefits of not just competitive sport partibut of recreational activities and moderate exercise ling or doing chores, have been noted to have aimpact on health. The key to efficacy appears to bregularity of activity.

Such knowledge has had a major impact on thetion of exercise and individuals with disabilities.older individuals can benefit from limited levels ofwithout undergoing the stresses of vigorous workousuggests that disabled individuals with limited aparticipate in really stressful exercise can benefit fromefforts within their abilities. For those who are capinclined, sports training can improve performanwithin the limits of one’s disability.

Early encouragement of an active lifestyle can thmajor impact on the quality of life of children with di[31]. They are at increased risk for poor health,diabetes, cardiovascular disease, and musculoskelettions. The office on Disability, United States DeparHealth and Human Services has developed a progpromotes more active lifestyles and inclusion in schildren with disabilities, analogous to the Presidenon Physical Fitness and Sports for able-bodied childThe need for development of programs that promoteactivity for youth with disabilities is perceived to b[32].

Training Options

Sport-specific exercise can improve cardiopulmonaities (eg, VO2 max) and cardiovascular endurance (ieand anaerobic capacities) and strengthen even abactivated muscle groups as in the CP population [example, one study of children with CP has showeekly training resulted in an increase of 35%aerobic power [34]. Strength and circuit training schildren with CP have also shown that biweeklyimproves muscle imbalances, increases strength

70%, increases walking speed, and provides long-last

itys.

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results [35]. These results suggest that exercise capositive impact on overall function for childrenIndeed, studies suggest that the high incidence of ossis in individuals with CP may be lowered by particiwell-defined exercise programs. It is likely that gainsthe result of exercise can be maintained into adultcontinuing to be involved in physical activity.

Not all disabilities benefit from exercise in the samthe same degree. For example, several studies havthat peak heart rates during exercise for children wisyndrome (DS) are approximately 15% lower thandren who did not have DS but had similar mental[36]. Cardiac malformation associated with DS maythe predominant reason for this. Regardless, limitpeak heart rate likely limits VO2 max. Such issuecertainly have an impact on sport performance.

CONCLUSION

The tenets of sports medicine for children still holdthose with disabilities. The clinician needs to thunderstand how a child’s disability alters his or her fuabilities and to realize that access to physical activitiesports is an important and very accessible modalitproving and maintaining optimal health. Changes inattitudes and technology over the decades have grproved access to the benefits of sport for the disabl

APPENDIX: LIST OF SPORTSORGANIZATIONS PERTINENT TO CHILDWITH DISABILITIES

● Athletes Helping Athletes● American Amputee Soccer Association● America’s Athletes With Disabilities, Inc.● Blaze Sports● Cerebral Palsy International Sport and Recreation

ation (CP-ISRA)● Disabled Sports, USA● Easter Seals● International Amateur Athletic Federation (IAAF● International Olympic Committee (IOC)● International Paralympics Committee (IPC)● International Swimming Federation (FINA)● ISMWSF: International Stoke Mandeville Wheelcha

Federation● Lakeshore Foundation● Mesa Association of Sports for the Disabled● National Center on Physical Activity and Disabili● National Sports Center for the Disabled● National Wheelchair Basketball Association● The Steadward Centre for Personal & Physical

ment (was Rick Hansen Center)

ing ● United States Adaptive Recreation Center (USARC)

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S54 Wilson and Clayton SPORTS AND DISABILITY

● United States Power Soccer Association● United States Quad Rugby Association (official)● Wheelchair Sports, USA● Winners On Wheels (WOW)

REFERENCES1. Park MJ, Brindis CD, Chang F, Irwin CE Jr. A midcourse re

healthy people 2010: 21 critical health objectives for adoleyoung adults. J Adolesc Health 2008;42(4):329-334.

2. Murphy NA, Carbone PS. Promoting the participation of chdisabilities in sports, recreation, and physical activities. Pedia121(5):1057-1061.

3. DePauw KP, Gavron SJ. Disability sport. Champaign, IL: Huics; 2005.

4. DePauw KP, Gavron SJ. Disability and Sport. Champaign,Kinetics; 1995.

5. International Paralympics Committee. Beijing 2008 Medal2009. Available from: http://www.paralympic.org/release/MainMenu/Paralympic_Games/Past_Games/Beijing_2008/index.essed February 12, 2010.

6. IPC. Disabled Sports Classification Systems: Swimming [cAvailable from: http://www.paralympic.org/release/SummSwimming/Classification/index.html. Accessed February 12

7. IPC. Disabled Sports Classification [cited 2009]. Available frwww.paralympic.org/release/Main_Sections_Menu/Classificcessed February 12, 2010.

8. IPC. International Paralympic Sports [cited 2009]. Avaihttp://www.paralympic.org/. Accessed February 12, 2010.

9. Bellis M. History of the Wheelchair [cited 2008 November 2008from: inventors.about.com/library/inventors/blwheelchair.htmFebruary 12, 2010.

10. Paraplegia News. Three million chairs . . . and still grow(Everest and Jennings’ 3-millionth wheelchair rolled off theline). Paraplegia News 1989;43:50-52.

11. Payne Cheetah legs Oscar Pistorius bound for Olympics.Mirror (Mirror.co.uk) MGN Ltd., London, 2008.

12. Peterson C, Steadward RD. Paralympics: Where Heroes Comton, Alberta: One Shot Holdings; 1999.

13. Stager JM, Brammer C, Tanner D, Kojima K, Scofield W. Ustive Modeling of Recent Swim Performances and SwimAssess the Impact of the Newest Generation Swim Suits on CSwimming. Bloomington, IN: Indiana University; 2008.

14. Harris SS. Readiness to Participate in Sports. In: Sullivan JASJ, eds. Care of the Young Athlete. Rosemont, IL: American AOrthopaedic Surgeons: American Academy of Pediatrics; 20

15. Associated Press. After legal wrangle, teen wheelchair raceagainst peers [2006]. http://www.usatoday.com/sports/preps/04-19-wheelchair-racer_x.htm. Accessed February 12, 2010.

16. Sanyer ON. Down syndrome and sport participation. CurrRep 2006;5(6):315-318.

17. Blount JP, Severson M, Atkins V, et al. Sports and pediatricnal fluid shunts: Who can play? Neurosurgery 2004;54(5):1discussion 1196-1198.

18. Miele VJ, Bailes JE, Martin NA. Participation in contact osports in athletes with epilepsy, genetic risk factors, struc

lesions, or history of craniotomy. Neurosurg Focus 2006;21(4):E9

theand

ith08;

et-

an

itedns_cc-

09.rts/

p://Ac-

om:

ablesed

ng!ion

aily

on-

dic-to

tive

sony of24.etes06-

ed

spi-96;

ionrain

19. Wilson PE, Washington RL. Pediatric wheelchair athleticsjuries and prevention. Paraplegia 1993;31(5):330-337.

20. Patel DR, Greydanus DE. The pediatric athlete with disabilitClin North Am 2002;49(4):803-827.

21. Dubow JS, Kelly JP. Epilepsy in sports and recreation. S2003;33(7):499-516.

22. Bouchard C. Physical Activity, Fitness and Health. ChamHuman Kinetics Publishers; 1994.

23. Giannini MJ. National initiative on physical fitness for childrenwith disabilities. In: Office on Disability Office of the SecDepartment of Health and Human Services, editor: HHS New

24. US Department of Health and Human Services. National IPhysical Fitness for Children and Youth with Disabilities 2able from: http://www.hhs.gov/od/physicalfitness.html. Accruary 12, 2009.

25. Bar-or O. Health benefits of physical activity during chiladolescents. President Council on Physical Fitness and Spical Activity and Fitness Research Digest. 1995;2(4):1-8at: http://www.fitness.gov/childhood.htm. Accessed Fe2010.

26. Grange RW, Call JA. Recommendations to define exercise presDuchenne muscular dystrophy. Exerc Sport Sci Rev 2007;35(

27. Wilson PE. Exercise and sports for children who have disabMed Rehabil Clin N Am 2002;13(4):907-923, ix.

28. Clark MW. The physically challenged athlete. Adolesc Med491-499, vi.

29. Centers for Disease Control and Prevention. Physical AEveryone. In: Division of Nutrition, Physical Activity anNational Center for Chronic Disease Prevention and Heation. Atlanta, GA: US Centers for Disease Control and P2008.

30. Dwyer T, Magnussen CG, Schmidt MD, et al. Decline in phyfrom childhood to adulthood associated with increased oinsulin resistance in adults. Diabetes Care 2008;32:683-68

31. Groff DG, Lundberg NR, Zabriskie RB. Influence of adaptequality of life: Perceptions of athletes with cerebral palRehabil 2009;31(4):318-326.

32. Rimmer JA, Rowland JL. Physical activity for youth with dicritical need in an underserved population. Dev Neuroreh11(2):141-148.

33. Mockford M, Caulton JM. Systematic review of progressitraining in children and adolescents with cerebral palsy wbulatory. Pediatr Phys Ther 2008;20(4):318-333.

34. Verschuren O, Ketelaar M, Takken T, Helders PJ, Gorter JWprograms for children with cerebral palsy: A systematic reliterature. Am J Phys Med Rehabil 2008;87(5):404-417.

35. Verschuren O, Ketelaar M, Gorter JW, Helders PJ, UitTakken T. Exercise training program in children and adolecerebral palsy: A randomized controlled trial. Arch Pediatr A2007;161(11):1075-1081.

36. Aguilar LC, Islas A, Rosique P, Hernandez B, Portillo E, HCortes R, Cruz S, Alfaro F, Martin R, Cantu JM. Psyanalysis in children with mental retardation due to peroxia treated with fibroblast growth factor (FGF) and shprovement in mental development. J Intellect Disabil Re

. 521-31.