Paralympic sport: working with disabled athletes

Paralympic training routines

Nick Grantham gives an overview of Paralympic sport and some practical advice for those working with wheelchair athletes.

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.