By David Hill
David Hill is an Assistant Editor at Training & Conditioning. He can be reached at dhill@MomentumMedia.com.
Training & Conditioning, 15.8, November 2005, http://www.momentummedia.com/articles/tc/tc1508/readyserve.htm
Assessing a deaf football player for a possible concussion years ago drove home for Hal Hilmer what it means when disabilities and sports mix. Hilmer, LAT, ATC, Head Athletic Trainer at John Hersey High School in Arlington Heights, Ill., was running through the standard assessment of the 220-pound nose tackle when he realized there was a problem.
“One of the questions was, ‘Do you have any ringing in your ears?’” Hilmer recalls. “Well, he didn’t hear anything. So I couldn’t ask that question.”
Luckily, Hilmer had been educated in working with athletes with a disability, and aided by a sign language interpreter, he completed the assessment. The nose tackle was held out for a week with a mild concussion.
For athletic trainers and strength and conditioning specialists who’ve done it, working with athletes with physical, developmental, or intellectual disabilities can be highly rewarding. But it takes a willingness to educate yourself and the flexibility to think outside of the routine.
BEFORE YOU DO ANYTHING
A college sophomore who’s missing a limb. A 13-year-old who could outrun you any day of the week but struggles with a question about how much something hurts. A wheelchair athlete participating in a sport you’ve never heard of before. Athletes with disabilities are a diverse group.
But no matter the specific disability of the athlete you’re serving, a few fundamental steps will get you off to the right start. The first is to learn as much as possible about the disability—and the strengths and weaknesses of the particular athlete.
Linda Platt Meyer, EdD, ATC, PES, Associate Professor in the Duquesne University Department of Athletic Training, has been a Special Olympics volunteer for nearly 20 years and has attended five Special Olympics World Games. Before working with athletes with any type of disability, she says you may need to abandon your own expectations and biases about what it means to have a disabling condition. This was made clear early in her involvement with disabled athletes, when she was treating a teenager with cerebral palsy and made a rookie mistake.
“I assumed that he had cognitive difficulties and kept asking, ‘Do you understand?’” Platt Meyer says. “He said, ‘Yes, I understand you.’ I hadn’t known he was literally a genius. He was 16 years old and going into his junior year of college, and he wanted to learn to swim. I was the person who looked really stupid. Don’t assume that if a person has multiple sclerosis or cerebral palsy that they also have a cognitive dysfunction, because most times they do not.”
Ideally, you should also do some research on how the specific conditions of the disability are likely to affect athletic participation. For example, people with Down syndrome, Platt Meyer explains, are more prone to joint laxity, which can leave them vulnerable to sprains and unable to gain strength as quickly as many other people. The condition may also come with a predisposition to diabetes, cardiac conditions, foot deformities that lead to tendonitis, and atlantoaxial instability, which is a laxity in the upper spine that can preclude certain athletic activities.
Or, if you’re working with an athlete who has a spinal cord injury, you’ll need to find out more specifics of the injury and how it affects the athlete’s movement. “Even the same level of spinal cord injury can be very different, depending on the individual. While one person may be able to do a chest press, that might be impossible for another person, depending on their specific disability,” says Heather Pennington, MA, CSCS, ACSM H/FI, Strength and Conditioning Specialist for the Lakeshore Foundation in Birmingham, Ala., a rehab center for people with disabilities and a USOC Paralympic training site.
To learn as much as possible about an athlete who has a disability, Lori Glover, MS, ATC, Community Sports Medicine Manager for the Institute for Athletic Medicine in Eden Prairie, Minn., turns to the athlete’s parents for advice since they are often much more involved than other parents. “They are used to being a big part of their children’s lives, and that carries over into everything they do,” Glover says. “I’ve had instances where I’ve called to say, ‘This happened,’ and the parent says, ‘Okay, that’s normal. Give it five minutes, and this will happen.’ The communication has to work really well, because the kid might not be able to tell you what’s going on.”
Regardless of the disability, it’s also important to understand the social implications of injury to an athlete with a disability. Alison Talley, MS, ATC, who works in clinical and high school settings for the Institute for Athletic Medicine in the Minneapolis-St. Paul area, which has an extensive adaptive sports system, says that an injury can cut a young person off from not only teammates, but daily involvement with disabled peers.
“Most of these kids stay together as a team through all three seasons—they play soccer, floor hockey, and softball,” Talley says. “This is their group of friends, this is what they can do, and they’re accepted doing this. So if one of them can’t play, suddenly he or she loses that aspect of their life.”
Another big-picture consideration is that, for athletes with physical disabilities, a relatively minor injury may affect their everyday life in drastic ways. “If you or I sprain or break a finger, we might not be too upset,” says Hilmer. “But for someone who is deaf, that’s their means of communication. So it’s really quite traumatic and scary to be unable to use that hand or finger.
“When I get deaf kids who injure a finger, I know I have to work a little harder to get mobility back in that injured digit quickly,” Hilmer continues. “Normally, you’d tape the two fingers together to get them through. Well, with a deaf person I devise something to support it differently so the finger is free and can be used to communicate with people.”
Another example of how an athletic injury can affect life is the athlete whose mobility depends on maneuvering his or her wheelchair. “If an athlete who uses a wheelchair has a shoulder injury, should we go ahead and put it in a sling, or can we do something else, since they use that shoulder for mobility?” Hilmer says. “You have to make some accommodations, do things a little differently, because of how they spend their day.”
“For someone who relies on their arms for mobility, you also have to jump on it a little bit faster—make sure they’re icing, stretching, and strengthening the rotator cuff and all the little muscles they might not realize they’re using,” Talley says. “This helps the bigger muscles rest and get back into shape so the athlete is pain-free faster and able to maintain their daily life activities.”
Along with general guidelines for working with athletes with disabilities, there are specific considerations that vary depending on whether the athlete’s disability is physical or mental. Athletes with physical disabilities—which may range from a single amputee to a quadriplegic—require some unique considerations.
An advantage in working with athletes with physical disabilities is that they are often highly attuned to their own bodies and understand how to talk to medical professionals. “We can often get a quicker reaction than with a lot of able-bodied people, because they’ve had to develop communication skills with the medical community,” Talley says. “They know what’s wrong, and they know how something is supposed to feel. They’re focused on it because they have to be.”
Injury assessment and healing aren’t very different between disabled athletes and their able-bodied peers except for one main consideration, says Chris Schroer, ATC, who works with Olympic and US Paralympics athletes at the USOC Training Center in Colorado Springs. “Depending on the injury, you may not be able to compare it to the contralateral side,” he says. “If the athlete is an above-the-knee amputee and you’re working on the remaining knee, you don’t have a comparison, whereas in the able-bodied athlete you’re able to compare side to side.”
In terms of rehab and strength work, the biggest change from working with an able-bodied athlete is dealing with safety and balance. Strapping and spotting require extra care because a person missing or without use of their lower extremities may need help maintaining balance. And core work is crucial because lower abdominal muscles have often gone unused and ignored.
Andrea Kushman, MEd, ATC, CMT, is Athletic Trainer for the New England Bruins sled hockey team, a sport in which players are strapped on specially made sleds and use a pair of shortened sticks with picks on the end to move about and control the puck. When she wanted an amputee with a prosthetic leg to do single-leg squats to strengthen his hips, she put him in a corner. “When he did wall squats, he sagged to one side, so I had to get him to push against that side to straighten himself out,” she says. “I put him in a corner so he could put his arm out to push himself back upright when he started leaning over. Little considerations like that make a big difference.”
Pennington suggests taking a close look at how the athlete’s body already compensates and works before designing a rehab or strength program. “For example, some people might have a prosthetic leg that allows them to do a two-leg press, but others might not have as high-tech a prosthetic leg,” she says. “We might just do a one-legged leg press, then to work the other leg, we might use some tubing with their prosthetic leg, or use a one-legged squat to simulate the exercise and get the same load without challenging that prosthetic leg to the point where we might damage it.”
Because other muscle groups must compensate for what’s not available, overuse injuries are a major concern. “With wheelchair athletes, everything they do is pushing forward. So the more I can get them to do pulling and rowing motions, such as lat pull-downs, the more I can protect their shoulders from injury,” Pennington says. “I emphasize back strength—the shoulder girdle and the posterior deltoid and all parts of the back muscles. We’re training those areas nearly two-to-one compared to chest muscles.”
Athletes with physical disabilities will often benefit from modifications to traditional strength training equipment. Pennington has worked with two quadruple amputees—including a player in “Murderball,” a prize-winning documentary about wheelchair rugby—and that has presented challenges. But with the use of prosthetic limbs, hooks, and cuffs on the stumps of their arms, quadruple amputees are able to work out on cable-column machines and with barbells and dumbbells.
Less severely disabled athletes also benefit from modified equipment, including a machine with a pad against which wheelchair athletes can press their chests to stabilize the trunk when they work out. “We could hold their shoulders steady, but then they’re not getting the full strength gains because we’re doing some of the work for them,” Pennington says. “So that machine is great.”
Cardiovascular training also requires some adjustments. Research is ongoing into precisely how loss of limbs affects oxygen use and efficiency, but Pennington has begun making adjustments based on preliminary results. “When I’m working with a paraplegic on an ergometer, their heart’s having to work just as hard whether they’re working their arms or legs,” she says. “But they don’t have as many muscles to get their heart rate up as someone who’s working all four limbs, so I alter their target heart rate accordingly. Sometimes I’ll drop it 10 or 20 beats, based on conversations I’ve had with our research director.”
Working with athletes with mental disabilities takes an understanding of the specific athlete’s cognitive abilities. It also requires tailoring your communication practices. Using simple terms and repetition, without being patronizing, is often what’s needed.
“Patience is totally different from patronizing,” Glover says. “You explain something to them and realize they’re going to have questions. If they look totally lost, you just have to do it again. Keep it simple, and keep the medical terms out of it. It can help to slow down—I talk fast, so I know I have to slow down my speaking a bit.”
Platt Meyer tries to get an understanding of the athlete’s cognitive abilities from the start. “If I say, ‘How much pain are you in, and they say ‘Number 10,’ am I sure they know the difference between a number-one level pain and 10?” she says. “You need to talk to the caregiver, parent, guardian, or physician ahead of time so you understand where this athlete is coming from.
“I’m not going to talk baby talk, though,” Platt Meyer adds. “If it’s a 13-year-old student-athlete, that’s how I’m going to treat him or her. If I know it’s a 13-year-old working at an 8-year-old’s level, I have to back that down to how I’d treat an 8-year-old. It’s looking at the athlete as a whole person and deciding how I can best serve him or her.”
One condition that can take great finesse is autism. The parent of a child with autism, Glover says that when these athletes are injured, it often helps to have a familiar face present, such as a coach or parent, and to approach them empathetically. “There are some autistic kids who are very touch-sensitive,” she says. “You have to get them calm and settled, then work slowly. You try compressions to get them used to having the affected area touched, and gradually work your way up the leg area.”
Some autistic children don’t like to be touched at all. “Make sure you talk to an autistic child before you do anything, and ask, ‘Okay, can I touch your ankle now?’” Talley adds. “You want them to know it’s coming. Don’t assume that they expect anything. Sometimes you can’t touch them, and you have to just do whatever you can.”
In addition, Glover says pain is not always an effective guide to the severity of an injury. “Some autistic children don’t feel as much pain as a person typically would because their sensory system is all off-key,” she says. “So they might have a more severe injury than it appears because they’re tolerating it at a higher level.”
It pays to be aware of less severe cognitive conditions as well. “One of the common tests for concussion is having the athlete count backward by threes or sevens. There are some people with learning disabilities who just can’t do that,” Glover says. “So it’s important to know their mental status before they were concussed. And in rehab, if they are a visual learner, make sure they have a picture of the exercise you want them to do.”
It boils down to patience, and not just with the athlete, Talley says. “Everybody has the same basic anatomy, so all the skills you learn in athletic training are applicable to athletes with disabilities,” she says. “It’s just that when you’re dealing with a population out of the ‘norm,’ you have to adapt your style, skills, and ability to theirs. So the patience is more of a personal patience with yourself and realizing what you have to adapt to.”
A REWARDING PATH
Once they get the hang of it, most athletic trainers and strength coaches find working with this population very meaningful. In fact, Kushman’s paying job is Head Athletic Trainer for the Reggie Lewis Track and Athletics Center in Boston, and her work with the sled hockey team is voluntary.
“The sled hockey guys I work with never wanted to associate with anybody else with a disability until they started playing,” says Kushman. “But a person needs a peer support group, and sports provide that for them. Now they wear hockey gear and USA Hockey shirts, and they’re proud to say, ‘Yeah, I play ice hockey.’ And then they watch people’s mouths drop.”
Her performance-enhancement and rehab work involves a lot of trial and error, but that seems okay with the players, who appreciate the help and attention. Much of the feeling, Kushman believes, results from their gratitude—and surprise—at having someone go beyond rehab that allows them to merely carry out basic daily life to being able to play and excel at a sport.
“They tell me, ‘I’ve never been sore in the muscles I was sore in, ever. You had me using stuff I have never used before,’” she says. “One amputee told me, ‘My butt was killing me! I can actually feel my low back now.’”
Pennington has found similar rewards in her work. “You see people with disabilities who go from being totally depressed and thinking, ‘My life is yuck,’ to, ‘Oh my gosh, there are other people like me and they can compete at an elite level,’” she says.
“I wish that more athletic trainers would become involved, because it’s a population that absolutely could utilize our services,” Platt Meyer adds. “And speaking selfishly, we get so much more out of it than we can ever imagine delivering.”