Risks in Adapted Physical Activity 5. 3.

Author: Ladislav Mesarič, Jasna Vešligaj Damiš, Zvonka Novak

Keywords: risk factors, prevention of injuries, regulation of temperature, risk assessment, risk management plan

Fifteen percent of the world’s population lives with disabilities, many of whom decide to engage in sports. There are numerous obstacles to the participation of athletes with disabilities in sports activities, and sports injuries can have a major impact on everyday life. Therefore, prevention of their sports injuries is extremely important (Weiler, Van Mechelen, Fuller & Verhagen, 2016). The number of athletes with disabilities who participate in organized sports and the popularity of the Paralympic Games are constantly increasing all over the world. Despite the growing interest and the fact that participation in sports exposes athletes to certain risks of injury, there is little research about the types of injuries, risk factors and injury prevention strategies for athletes with disabilities (Fagher & Lexell, 2014)

Risk factors and injuries

Traditionally, risk factors are divided into two main categories: internal risk factors and external environmental risk factors. It is important that we can divide the risk factors into dependent and independent variables or factors. Although independent factors such as gender and age can be interesting, it is important to consider factors that can change with exercise, such as power, balance or mobility. However, this is not enough to determine internal and external risk factors for sports injuries. For a complete understanding of the causes, the mechanisms of occurring must be identified. Sports injuries are due to the complex interaction of several risk factors and events, of which only some are known (Bahr, Holme, 2003).

Therefore, studies on sports injuries require a dynamic model that takes into account several factors of sports injuries, and considers the sequence of events that eventually lead to an injury. One of these dynamic models, describing how injuries occur as a result of several factors, is the one adapted according to Meeuwisse 1994 (Bahr & Holme, 2003). The model is tested on population without disability, but without special adaptations can be used for the population of athletes with disabilities. Only specific definitions of individual expressions are needed.

Figure 7 : Risk factors for injury (Meeuwisse, 1994)

Figure 7 : Risk factors for injury (Meeuwisse, 1994)

The internal risk factors for persons with disabilities are mainly the type and degree of disability. This defines the choice of sports activities and risk prevention measures during sports activity. Among the external risk factors is sports equipment. For persons with disabilities, the risk factor is the adequacy of equipment adjustments. During the activity, it is necessary to pay due attention to the adapted program of sports training and competitions.

Prevention of injuries

Many factors influence the prevention of injury or reduce the risk of injury. Some are general and do not depend on the type and degree of disability. The instructions for Special Olympics contain the following actions:

  • An appropriate assessment of the fitness of athletes - the coaching staff must determine the baseline for each athlete established on his/her fitness and skill. The type and complexity of the sport activities that are taking place depends on this.
  • The sports performance must be the backbone of the appropriate long-term preparation of athletes. The coach cooperates with the athlete, healthcare staff, the family and other factors that influence the long-term development of the athlete. Individual must develop specific skills and fitness for the chosen sport.
  • Special healthcare guidelines and coordinated activities must be available for each individual.
  • A first aid kit should always be available at all trainings and competitions.
  • It is recommended for the athlete to adapt to the environment. Athletes must gradually adapt to exercise at an elevated temperature. At the beginning, they should practice in light clothing in the cooler parts of the day. They gradually expose themselves to heat for a short time and carry out activities even in the hotter part of the day, at the time when the competition takes place. If sport involves the use of heavier clothing and equipment, they must first adapt to wearing clothing under normal conditions only then in hot conditions. For all games and competitions proper hydration must be maintained.
  • They should also get gradually adapted to low temperatures. They must learn to layer their clothes so that they can adjust their outfit to the temperature. If necessary, wear caps and gloves.
  • Competitions at higher altitudes require gradual adjustment that lasts 10 to 14 days. Exercise should be gradually increased in duration and intensity. Without gradual adaptation they may experience altitude sickness, such as nausea, dizziness and shortness of breath.
  • In order to prevent sun and snow blindness due to strong sun athletes need to wear dark glasses with side shields during outdoor activities. Glasses must have an ultraviolet blockade.
  • If during sports activity athletes are exposed to the sun, they must wear shades and t-shirts with long sleeves. On exposed parts of the body, such as the nose, ears, face, baldness, lips, sun protection must be applied.

Temperature Regulation

Dysfunction of the sympathetic nervous system, especially important for athletes with spinal cord injury above the eighth thoracic vertebra, can cause significant problems in regulating internal body temperature. These athletes cannot sweat effectively or have difficulty in vasodilation below the level of injury. This can lead to difficult body thermoregulation, or the body is more difficult to cool by sweating or warm up by shaking and vasodilation.

Athletes with a significantly reduced body surface, such as those with bilateral amputation, should also be considered. Medicines commonly used by individuals with disabilities, such as anticholinergics, sympathomimetics, diuretics, muscle relaxants, and medicines that improve thyroid function, can cause greater sensitivity to heat (Richter, Sherrill, McCann, Mushett and Kaschalk, 1998).

Risks related to sports activities by type of disability

Different types of disability are classified into wider categories, such as motor impairment, sensory impairment, and intellectual disability. Disability can be congenital (present at birth) or acquired (not present at birth resulting from acquired injury or disease). Coaches should try to understand the disability of athletes they train.

A plan or risk assessment should be made for each athlete, including one’s disability, illness, relevant characteristics and behavioural disorders (e.g. epileptic seizures) and other important information which may have a significant impact on the sport performance of the persons involved.

Basic information about specific safety aspects according to the type of disability (Coaching Association of Canada, 2005)

Athletes with intellectual disabilities

Close co-operation between athletes, parents, guardians, trainers and assisting staff regarding the characteristics and needs of the athlete is crucial. People with Down’s syndrome often have orthopaedic problems due to too much loose joint envelopes and reduced normal muscular tension (i.e., muscle tone). People with DS often have foot problems. Hallux valgus is 2.5 times more common than in the general population and presents an increased risk of subsequent arthrosis of the underlying joint of the thumb. Due to the flat feet of 2- 6% of children with DS, they are more likely to get tired of walking, reporting pain in the tibia. Difficulties can occur on all joints due to increased mobility for example on knee joint, unstable kneecap, hip, spine (Leshing, 2003). It is necessary to determine if they have atlanto-axial instability. The instability in the joints between the nasal bone and the first and second cervical vertebrae is due to loss of bonds. It is present in 80% of people with DS, but for the vast majority of them (90%) it does not cause any problems. If they have not performed this examination or if instability is found, it is necessary to avoid activities such as contact sport, diving, gymnastics, especially sports activities with intense neck movements (Büchler, 2003). Congenital heart defects, underdeveloped vascular system and low respiratory capacity are also possible.

Athletes with physical disabilities

These are athletes with impaired mobility caused by a spinal cord injury that prevents the transmission of nerve signals below the level of injury. Spinal cord injury is usually due to traumatic injury. The trainers must pay attention to their feet and toes while pulling on various surfaces because people with this type of injury feel poorly or do not feel legs. For the same reasons, we must be mindful of the surface on which activities are taking place. Particular care must be taken that the surface is not too hot (in the summer) or too cold (in the winter). Individuals with tetraplegia have limited ability to control body temperature, so they need to be protected against heat and cold. Due to limited access to sanitary facilities they have difficult access to water. Assisting staff must ensure adequate hydration during sports activity.

Athletes with mobility disadvantages (amputated limbs)

This group includes athletes with amputated limbs and athletes born without limbs. Caring for the remaining part of the limb is the key daily activity of athletes with amputated limbs. Sport activity can cause additional wear on the remaining limb and orthosis. In particular, it is necessary to monitor the skin of the wound to prevent possible infections. Suitable socks must be used for remaining limb to keep it dry and to prevent irritation, scabies and other injuries. Athletes in wheelchairs should use helmets when beginning with sport.

Athletes with cerebral palsy

Injuries to different parts of the brain during pregnancy, at birth or in childhood are manifested in muscle weakness, paralysis, poor coordination and uncontrolled movement of the limbs. Individuals may also have intellectual disabilities. As there are usually balance problems, falls are a common risk that we must consider. It is necessary to remove all potential obstacles from the environment in which they are moving. We need to avoid situations requiring demanding movement control, and avoid contact with other people and objects or perform these with the extreme attention of the trainer. We approach slowly to activities, such as climbing, bicycle riding and similar consistently using protective equipment.

Athletes with sensory impairments

Athletes with vision or hearing impairment need accurate and well-established instructions in case of a danger. In particular, they must clearly understand the signal for the immediate cessation of the activity that will protect them from continuing and reduce the possibility of injury. Athletes with hearing impairment cannot receive verbal instructions from the trainer or co-athletes. Therefore it is necessary to establish an appropriate alternative communication strategy. For activities starting with an acoustic signal, it is necessary to replace the acoustic signal with a visual one.

Athletes with acquired brain injury (ABI)

The consequences of traumatic or non-traumatic brain injuries are manifested in different ways. Because, as a rule, two people do not have the same abilities, it is the task of the coach / facilitator of the sports activities to determine what a person can or cannot do. Activities are carried out slowly by gradually increasing the intensity, duration and complexity of the exercise. It is important to follow the needs, abilities and wishes of individual athletes with ABI, and that we can adapt the activities accordingly during the activity. In the chronic period after brain injury, the lack of awareness and insight often impedes the involvement in activities. However this should not be an obstacle to one’s cooperation, as it can reasonably be expected that the state of awareness and insight can be improved over time. Together with an athlete with ABI, we shape realistic expectations during setting goals that he/she can actually achieve. We must also consider all the clinical problems and disorders that are present in people who suffer from brain damage. For this purpose in Center Naprej, we have designed recommendations for sports activities (within the framework of the ReSport project) and a risk assessment form, which we complete prior to including an athlete with ABI in sports activity (Vešligaj Damiš, 2017). It is important for all facilitators to familiarize themselves with ABI athletes and consider them during all sports activities.

Risk assessment in Adapted Physical Activity

An example of a risk assessment for people with brain injury in the Center Naprej

When we include users with ABI in sports activities, we must be aware that the latter are often accompanied by various risks of someone or something get injured, of a physical or emotional nature, etc. To this end, we complete a risk assessment process.

When making a risk assessment, we identify all the hazards and anything that could cause damage. Based on this, we decide how serious the risks are and how we will manage these risks. We assess the risk for each sport activity for all athletes with disabilities in order to prevent possible complications or negative impacts of the sport to the individual. The benefits of sports activities must be greater than the risks that sport presents to the person. The facilitator of sports activities must know and respect the limitations of each individual - athlete with disabilities.

The risks that we know and are aware of can be assumed as part of the real possibilities. It is important that we understand the risk as something that is not negative. We are not at risk because we expect negative outcomes and consequences, as we expect positive results involving people with disabilities in sports activities.

In order to complete a risk assessment, we prepared a risk assessment form at the Center Naprej. It assesses the risk areas with a risk matrix, which helps us to evaluate the degree of risk with regard to the impact of the threat in relation to the likelihood of the risk.

If the risk or impact of the threat and the likelihood of risk is high (the red field), we should ask ourselves whether it is worth risking or whether such a high risk for the user is still appropriate. Therefore, for such an area / areas we prepare a RISK MANAGEMENT PLAN, which reduces the risk and damage and protects the athletes with disabilities. The plan must include measures to reduce the risk. There are a number of measures that we need to define clearly: how, who and what we will do to reduce the risk.

In the process of risk assessment and the preparation of a risk management plan, an individual who is included in sports activity (athlete with disabilities) must be actively involved. We help him/her to understand the risks and take responsibility for his/her actions. If necessary, relevant expert people are included in the Risk Management Plan. If the risk of inclusion of a disabled athlete is greater than his benefit of sports activities, if it is harming the athlete or others, and also with various measures and adjustments, we do not achieve sufficient safety for all, we do not include him in sports activity.

The problem arises when an individual (athlete with a disability) wants to make a decision without consent of facilitator and latter thinks that the individual who has made such a decision does not fully understand the decisions and its consequences. The task of the sports activities facilitator and other participating experts is to ensure that the athlete fully understands the consequences of his/her decision and that such decisions can lead him to a situation in which he/she can be emotionally and physically injured. It is important that we work together with an athlete with disabilities in looking for suitable solutions to the situation, considering different options, goals or find possible adaptations.

Figure 8: Risk assessment form (Center Naprej)

Figure 8: Risk assessment form (Center Naprej)

References

Bahr, R., Holme, I. (2003). Risk factors for sports injuries — a methodological approach. British Journal of Sports Medicine, 37(5), 384–392. http://doi.org/10.1136/bjsm.37.5.384

Büchler, G. (2003),Atlanto-axiale Instabilität Leben mit Down-Syndrom Nr. 43, September 2003 https://www.ds-infocenter.de/d... Association of Canada (2005). Coaching Athletes with a Disabilityhttps://www.coach.ca/files/Coa... K1, Lexell J. (2014). Sports-related injuries in athletes with disabilities. Scand J Med Sci Sports. Oct;24(5):e320-31. https://onlinelibrary.wiley.co...

Leshing, L. (2003) Orthopädische Probleme. Leben mit Down-Syndrom Nr. 43, September 2003 https://www.ds-infocenter.de/d... K.J., Sherrill C, McCann C.B., Mushett C.A. & Kaschalk S. (1998). Recreation and sport for people with disabilities. In JA DeLisa and B Gans (Eds.). Rehabilitation Medicine: Principles and Practice. Third Edition (pp. 853-871). Philadelphia, Lippincott-Raven

Special Olympics (2003) COACHING GUIDE Sport Safety and Risk Management for Coaches http://media.specialolympics.o... Damiš, J., Čeh, M., Majcenovič Cipot, D. (2017), Priporočila izvajalcem »ReSport« aktivnosti, interno gradivo Center Naprej, Maribor

Weiler, R., Van Mechelen, W., Fuller, C., & Verhagen, E. (2016). Sport Injuries Sustained by Athletes with Disability: A Systematic Review. Sports Medicine (Auckland, N.z.), 46, 1141–1153. http://doi.org/10.1007/s40279-016-0478-0