As the Beijing 2008 Paralympics
demonstrated, disability sport is growing rapidly in terms both of
participation and achievement levels, yet very little practical guidance is
available for those who work on rehab and sports conditioning for people with
disabilities. This article serves as an introduction for coaches, trainers and
therapists who are looking to work with disabled athletes. It also draws on my
own experience to provide a range of baseline conditioning exercises for
wheelchair athletes at any level.
My own introduction to working with
disabled athletes came in 1999, when I was asked to deliver a workshop on
flexibility to a group of paralympians competing in archery. I was more than a
bit nervous, as up to that point I’d had very little professional contact with
people with physical disabilities. The athletes, of course, turned out to be
just the same as any others I had worked with: same dreams and ambitions, and
my role as a strength and conditioning coach was to help them unlock their
potential just as for my able-bodied athletes.
Over the years since then I have
worked with a range of disabled athletes, including those with cerebral palsy,
amputations and spinal cord injuries, competing across sports that
include wheelchair basketball, wheelchair rugby, archery, dressage,
athletics and swimming. Many have picked up international sporting
honours.
This experience has reinforced my
belief that conditioning and rehabilitation programmes for athletes with
disabilities but who do not have health complications, should largely be the
same as those developed for their able-bodied peers. This view is supported by
other authorities (1).
Below, I outline the main groups of disabilities you may encounter as a
conditioning or rehabilitation specialist in either a sports or health and
fitness environment. I then offer some practical training advice that I have
picked up through my work as lead strength and conditioning coach for
wheelchair basketball in the UK.
Limitations
While the training approach is the
same as for anyone else, when you take on clients with disabilities, it is
nonetheless important to understand the nature and extent of the disability you
are dealing with, so you can tailor your programme accordingly.
The wide range of disabilities can seem daunting, so for sport and activity programming
purposes, it is helpful to group these within three broad categories. Table 1
(above) gives an overview.
State 1: static
Someone with a static disability
undergoes no physical changes to that condition during physical activity or
exercise. This makes training relatively straightforward for coach and athlete.
You will not make the condition worse as a result of training (though you
should screen your client carefully for increased vulnerabilities or altered
responses to exercise – see below).
State 2: dynamic
A dynamic disability can change
during physical activity, making life a little more tricky. If, for example,
you are working with an athlete with cerebral palsy, factors such as fatigue,
temperature and emotional distress can all bring about changes in the
condition, for example increased tonicity (not something you want if you are
trying to improve the athlete’s flexibility).
State 3: progressive
There is a gradual reduction in
physical functioning over time, secondary to the disorder. This has obvious
implications if your athlete is involved in periodised training over a three-
or four-year cycle. The condition could get worse with time, so be aware that
you may not always see improvements in conditioning and performance. Your job
as a coach may simply be to try and maintain physical function/performance,
rather than improve it.
Physical preparation
My experience of developing
conditioning and rehabilitation programmes has been mainly with amputee,
cerebral palsy and wheelchair/spinal injured athletes. I have found that
athletes with disabilities generally have the same, or very similar, responses
to training as their able-bodied peers, as long as they don’t have any
health-related complications.
That said, with some categories of
disability – such as spinal cord injury – health complications are quite likely
and you will need to take account of any restrictions that these may suggest,
as well as the possible effects of medications and altered responses to
exercise.
Athletes with higher and more complete
damage to the spinal cord above T6 place increased strain on their
cardiovascular systems and temperature regulation. A less effective circulatory
response may cause hypotension during exercise. There is a greater tendency to
overheat and to cool rapidly because of a lack of sympathetic vasomotor control(2),
particularly in more extreme environments. The compromise to the nervous system
can also cause a potentially hazardous sudden rise in blood pressure during
exercise (watch out, for instance, with heavy weight training), known as
autonomic dysreflexia.
It is important to realise when dealing with wheelchair athletes that postural
control may be compromised because of a loss of abdominal function. This is not
to say that you don’t train the abdominal area, just that you should be mindful
of how much improvement you can realistically expect to see. Don’t always think
only about traditional exercises, either. We have occasionally used portable
EMS (electromagnetic stimulation) units to stimulate abdominal musculature
passively where the athlete could not voluntarily recruit those muscle fibres.
Just as with your non-disabled
clients, you need to adopt an individualised approach to the training
programme. Get to understand your client and their disability thoroughly, and
at all costs avoid ‘cookie cutter’ training regimes based purely on a client’s
official disability type.
Exercising from the wheelchair
I learned early on that it is
pointless and too restrictive to try to programme all exercise to be done in
the chair. The trainer or therapist should prescribe exercises that get the job
done and that challenge the individual – and if that means the athlete has to
get out of their chair and on to the floor or a bench, they should just get on
with it!
Ideally, the athlete should
undertake their own transfers to and from the wheelchair. It allows them to be
independent; also, they know which transfer method is safest and best suits
them and will not place the helper/lifter at risk of injury.
Where lifting and carrying an
athlete is legally permissible and necessary, always avoid one-person lifts
unless the athlete can offer considerable weight-bearing assistance
during the transfer. With a two-person transfer:
- Lift with the legs (flat back, bend from the knees)
- Keep the athlete’s centre of gravity as close to your
body as possible
- Lift smoothly without jerking.
Some readers, I am sure, will find
this viewpoint controversial. Surely, they will argue (and many people have),
the training principle of ‘specificity’ means that wheelchair athletes should
train in their chairs? I don’t hold with this. For sure, there is benefit from
some work being completed in a chair to correct faulty movement patterns, but I
believe there are further benefits to be gained by taking these athletes out of
the chair:
- It adds to the variety of available training methods
and removes the restrictions imposed by the chair (dimensions,
stability and centre of gravity) or of machine exercises using the chair
- A bench or floor will allow you to incorporate a wider
range of free weights exercises into the programme, increasing its
functionality
- It takes the athlete out of their comfort zone and
presents a challenging training environment.
Training in a different setting will force
the individual to balance and
control the resistance and their body, thus helping them to develop confidence
in their own physical capabilities. I’ve worked with CP athletes who rarely got
out of their motorised wheelchairs, mainly because they lacked confidence in
their ability to move. Over the course of their training with myself and my
colleague, they developed the strength and confidence to get in and out of the
chair with increasing ease.
Conditioning priorities
Among wheelchair athletes, the
combination of a lot of pushing with poor sitting posture is a recipe for
overuse injuries, leading to chronic shoulder problems, and many of the players
in the basketball team suffered from these. Note, also, that those who did not
spend most of their time in the chair but who played from the chair were just
as vulnerable to these problems.
Working closely with the
physiotherapist, we identified priority weaknesses. I believe that the two
areas of muscle balance and postural correction should always be addressed
early on for a wheelchair-based athlete, and we introduced a number of
exercises, some of which are featured here, to help in both areas.
Muscle balance
Good muscle balance will give
stability, flexibility and mobility. The players tended to have very tight
anterior musculature (pec major, pec minor, anterior deltoid) and weak,
overstretched back muscles. These imbalances are largely the result of the
day-to-day overuse of anterior musculature arising from pushing the wheelchair
(our upper bodies have not evolved to withstand that level of repetitive use).
Typically, wheelchair athletes will develop:
- weak and overstretched connective tissue and
musculature on the back side of the spine
- stiff and shortened tissues on the front side of the
spine
- stiff and shortened tissues around the trunk.
All this can result in excessive thoracic
kyphosis, a slouched, rounded-back posture that reduces the spine’s normal
mobility and prevents ideal upright posture.
This compromised posture in turn
repositions the shoulder blades further from the spine and increases their
forward tilt, making it much harder for the athlete to learn to activate the
necessary scapular stability muscles (3). Not only will they experience upper
back pain, they will develop poor scapular positioning/stability, leading to
shoulder instability, weakness in the rotator cuff and shoulder impingement.
Arguably most important, this lot also leaves the athlete with limited overhead
reach – bad news if you are a basketball player.
The exercises we introduced focused
on developing strength, flexibility and mobility in the back and posterior
shoulder muscles. Here are some of my favourites.
The exercises
Exercise 1: YTWLs (See Fig
1 above)
Aim: A great sequence that target scapula retraction and
depression movements (1). The movements are performed prone (on floor or bench).
Start positions:
- Y – Arms extended at between 45 and 90 degrees above
shoulder level, straight, with thumbs pointing up (to help external
rotation)
- T – Arms at 90 degrees to the torso, thumbs pointing
up. Maintain 90 degree angle at the shoulder throughout (Note to trainer:
If the scapulae are weak, the athlete will tend to overuse their lats,
which in turn will result in them pulling their arms down to the sides)
- W – Humerus (upper arm) at 45 degree angle to the
torso, elbow flexed at 90 degrees
- L – Upper arm is as close as possible to the side,
elbow flexed 90 degrees. This combines retraction and external rotation.
Technique:
- In each case, slowly lift the arms an inch or so
straight upwards off the ground by moving the scapulothoracic joint
– not glenohumeral joint – then lower down again under control. These are
scapula-stabilisation (not deltoid) exercises, so the activation work is
primarily scapular retractors and depressors. The range of movement
involved in all cases is small.
- Start with 8 reps (no weight) in each position, moving
smoothly into next position with no rest. Progress difficulty by adding
another complete set; then add 2 reps per position until you can achieve 2
sets of 16 reps in each position (64 movements per set).
Exercise 2: Scapular
control
Aim: To help improve activation of the scapular retractors and
depressors (3).
Technique:
- Sit upright with ‘tall’ posture, arms by
- your sides
- Turn palms to face forwards (for external rotation of
arm)
- Pull the shoulder and shoulder blades downward and back
until you feel a contraction between the shoulder blades
- Hold for 5 then relax back to start position
- Repeat for up to 10 reps.
Exercise 3: Dynamic
Blackburns (see Fig 2)
Aim: Targets internal and external rotation of glenohumeral
joint; improves upward and downward rotation of scapula (3).
Technique:
- Lie prone on a flat bench or floor, with hands behind
your back (as if handcuffed!). Hands should be near buttocks, palms facing
upwards
- Abduct
the arms in wide sweeping arcs
- to the sides of your body, rotating as they go, so that
palms move from upwards- to downwards-facing. Finish at about 45
degrees in a Y shape in front of your body, thumbs pointing upwards
- Return to the starting position following the same path
- Keep head and chest down throughout.
Exercise 4: Wall slides
Aim: Improves upward and downward rotation of the scapula; will
work scapula depression as well as activation and strength in the lower
trapezius fibres (3). Can be done in or out of a chair.
Technique:
- Place upper back and buttocks against a wall or against
chair-back (arm rests off if possible)
- Extend arms to 90 degrees at either side, with elbows
and wrists against the wall (or just maintaining sagittal plane
positioning)
- Pull elbows down and into your sides
- Squeeze elbows inwards for a moment at the bottom
position, then slide the arms back up the wall as high as they will go
with your hands maintaining contact
- Once the hands can no longer maintain contact, reverse
the movement back to the start position
- Avoid rounding upper back or increasing the arch in
your lower back
- Perform 1 set of 8 reps and build up to 2 sets of 15.
Exercise 5: Truck drivers
(see Fig 3 above)
I first came across this exercise when
I visited the National Strength and Conditioning Association’s (NSCA)
Collegiate Strength and Conditioning Coach of the Year, Robert dos Remedios, at
his facility in southern California. I am assuming the name refers to the fact
that it looks like you are at the steering wheel of a big truck.
Aim: Shoulder flexion with internal and external rotation; goes a
long way to building a strong and stable shoulder complex (4).
Technique:
- Hold a weight plate at arm’s length with elbows
slightly bent
- Lift the weight straight out in front of the body until
you can look through the hole in the plate
- Rotate the weight as far as possible to your right,
keeping trunk still, and then as far as possible to your left
- Lower the weight plate back down to start position for
one repetition
- Work up to 2 sets of 8 reps.
Postural correction
The next group of exercises helps to
address some of the problems that wheelchair athletes face as a result of their
daily postures and training. Life lived mainly in a wheelchair produces its own
postural problems, such as the development of progressive adaptations in the
spine, shoulder complex and upper extremity (3).
Bill Hartman and Mike Robertson, two
US conditioning coaches, have developed a very useful postural correction
technique, which they call high frequency postural correction (HFPC). They use
a number of drills to try and ‘break’ the poor posture. Why do I love it?
Because it is so simple!
High frequency postural correction
Central to HFPC is to get the
athlete to adopt the corrective posture whenever they check the time of day!
Initially this will be a very short-lived adjustment, but as they keep on doing
the small, frequent corrections, their postural endurance will develop.
Technique:
- Sit as tall as possible, arms by your sides
- Turn your palms forward.
HFPC fidget
Hartman and Robertson have a second
key recommendation, which is: fidget. Moving around in the chair reduces the
likelihood of getting stuck in a single, posturally bad position.
The following exercises are not strictly
part of HFPC but are great for conditioning that helps to break poor postural
patterns.
Exercise 6: Head nods
Aim: Targets the sub-occipital muscles at the base of the skull.
Technique:
- Sit upright in a ‘tall’ posture
- Nod the head by focusing movement at the uppermost part
of the neck, just below the base of the skull
- Hold the stretch for a count of 5, gently returning the
head to its balanced, upright position
- Complete 10 repetitions.
Exercise 7: Upper
trapezius stretch
Technique:
- Sit upright in a tall posture
- Place left arm behind your back
- Bend neck to the right (ear to shoulder) and place
right hand on the side of your head, just above left ear
- Apply pressure with your hand until a comfortable
stretch is felt in the left side of the neck and shoulder
- Hold for 15 seconds
- Repeat on other side.
Exercise 8: Seated
rotations (see Fig 4 above)
Aim: It is important to develop good movement ability in the
chair. This drill develops rotational range of motion and mobility in the
thoracic spine.
Technique:
- Sit upright in a tall posture
- Cross arms in front, elbows raised to shoulder height
- Maintaining tall posture, turn shoulders to the left as
far as comfortable, hold for a count of 2, and return to centre
- Repeat up to 10 times
- Perform exercise turning to the opposite side.
Exercise 9: Thoracic
mobility (see Fig 5)
Aim: To maintain thoracic spine mobility into extension.
Depending on the level of disability, the client can mobilise different parts
of the thoracic spine by shifting their buttocks forward or backward in the
chair and making contact with a different point of the thoracic spine against
the top of the back-rest.
Technique:
- Sit tall and clasp hands behind your head
- Your back should be against the back of the chair, with
top of chair back about level with the lowest point of your shoulder
blades
- Bring elbows together and push them upwards
- Lean back over the chair and pause for a count of 2,
then return to start position
- Repeat up to 10 times.
Conclusion
This article is meant as a practical
introduction to the world of disability sport and exercise for coaches, trainers
and rehab specialists. Clearly it is well beyond our scope here to cover
everything you would need to know, but it should open up possibilities and
underline how physical disability need not mean physical inactivity.
References
1. Goodman S. Coaching Athletes With
Disabilities: General Principles (2nd Ed) 1995. Australian Sports Commission.
2. Shephard RJ. Fitness in special populations. Human Kinetics 1990. Champaign.
3. Hartman B, Robertson M. Inside Out – The Ultimate Upper Body Warm-Up 2006.
4. Remedios R. Power Training: Build Bigger, Stronger Muscles through
Performance-Based Conditioning 2007. New York: Rodale.
